Endodontic Pain or TMD?

Differential Diagnosis
Gary D. Klasser Orofacial Pain

You must understand function before you can understand dysfunction Dr. W. Bell A clinician can not treat a disorder until he or she has a sound understanding of order

Dr. W. Bell
You can not diagnose what you do not understand Unknown

Introduction
Toothache - most common complaint
12.2% of the general population report a toothache within the last 6 months (Lipton, Ship and Larach-Robinson) Diagnosis can be challenging and complicated Pain from one tooth may be referred from another tooth or from other orofacial structures Other facial pain disorders may mimic the symptoms of toothache Proper Diagnosis is critical

Clinical Characteristics of Odontogenic Pain

Mainly inflammatory
2 Tissues: Pulp and Periodontium Functionally and embryologically distinct

Pain is perceived differently

Teeth are visceral tissues that function as part of the musculoskeletal system

Pulpal pain = visceral pain

Periodontal pain = musculoskeletal pain

Pulpal Pain
Types:

Reversible or Irreversible

Reversible: brief, non-spontaneous, provoked pain that is present only as long as a stimulus is in contact with the tooth Irreversible: prolonged pain provoked by a stimulus or occurring spontaneously

If pain is prolonged and intense, central excitatory effects may produce pain referral

Pulpal Pain
Deep, dull, aching pain of a threshold nature
Often difficult to localize Occurs irrelevant to biomechanical (masticatory) functions

Common Characteristics of Pulpal Pain

1. Quality of pain is dull, aching, throbbing and occasionally sharp

2. An identifiable condition that reasonably explains the symptoms

3. Response to local noxious stimulation is proportionate and predictable 4. Pulpal pain tends to get better or worse, but rarely stays the same over time

5. Local anesthesia of the suspected tooth eliminates the pain

Odontogenic pain can be extremely versatile and have the propensity to mimic many other pain disorders

Rule of Thumb
Consider all pains in the mouth and face to be of dental origin until proved otherwise.

Periodontal Pain
Deep somatic pain of the musculoskeletal type (Okeson) It is related to the biomechanical (masticatory) function It responds to provocation proportionately and in graduated increments Precise localization of the stimulus therefore the offending tooth is readily identifiable

Common Characteristics of Periodontal Pain

1. Pain is dull and aching 2. An identifiable periodontal condition explains the symptoms

3. Response to local mechanical pressure is proportionate to the amount of force applied, rather than a threshold response (as in pulp) 4. During chewing, the tooth feels sore or elongated. Discomfort is often felt when biting pressure is released rather than while it is sustained***(GARY, see notes section of this slide) 5. Local anesthesia of the suspected periodontal tissue eliminates the pain

Site of Pain vs. Source of Pain

Site of Pain
The location where the patient feels the pain Easily located by asking the patient to point out the region of the body that is painful

Source of Pain
That area of the body from which the pain actually originates

Primary Pain
Site (where it hurts) = Source (where it originates) Eg./ cut finger

Heterotopic Pain
Site Source
Eg./ cardiac pain

Rule of Thumb
Successful therapy is achieved by treating the Source of pain, not the Site of pain

Non-Odontogenic Toothache
TYPES 1. Myofascial toothache 2. Neurovascular toothache 3. Cardiac toothache

4. Neuropathic toothache
Episodic Continuous 5. Sinus toothache 6. Psychogenic toothache

Myofascial Toothache
1. Pain is non-pulsatile 2. Typically more of a constant ache than pulpal pain 1. Variable , intermittent over months or years 2. Pain tends to increase with emotional stress 3. Not responsive to local provocation of the tooth 4. Pain increases with function of involved muscle (Trigger points) 5. Local anesthetic of the tooth does not affect the toothache 6. Local anesthetic of the involved muscle (trigger point) reduces the toothache

Neurovascular Toothache
1. Pain is spontaneous, variable and pulsatile; simulates pulpal pain 2. Has periods of remission. Episodes of pain may pose a temporal behavior appearing at similar times during the day, week or month 3. Lack of reasonable dental cause of pain 4. Effect of local anesthesia is unpredictable 5. May follow illness, sinusitis, dental treatment, surgery or trauma, appearing to be a complication of a former experience 6. Very frequently initially felt in a tooth (maxillary canine and premolar usually) as a toothache so convincingly that dental treatment may be undertaken , even when only minor dental cause can be located

7. May undergo remission following dental treatment, but recurrence is a characteristic of neurovascular pains.
8. May spread to adjacent teeth, opposing teeth or the entire face 9. If the pain experience is protracted, it may induce autonomic symptoms 10. With time, the complaint spreads to involve wider areas of the face, neck or shoulder and may evoke muscle pain and restricted movement 11. Pain may respond to ipsilateral carotid pressure or migraine medications

Cardiac Toothache
1. Presence of aching pain that is cyclic 2. Toothache is increased with physical exertion or exercise 3. Toothache is associated with chest pains 4. Toothache is decreased with nitroglycerin tablets 5. Local provocation of the tooth does not alter the pain

6. Local anesthetic does not arrest the toothache

Neuropathic Toothache: Episodic

1. Unilateral, sudden, sharp, severe, lacerating and shock-like (paroxysmal) 2. Provoked by relatively innocuous peripheral stimulation of a trigger zone or may occur spontaneously 3. Local anesthetic at the tooth will not reduce the pain unless it also represents the trigger zone (very rare)

4. Local anesthetic at the trigger zone will reduce the attacks

5. Patient is typically asymptomatic between the episodes

Neuropathic Toothache: Continuous

1. Persistent, ongoing and unremitting 2. May be increased by local provocation such as touching the tooth and surrounding gingiva, which adds confusion to the diagnosis 3. Presence of other neurologic complaints such as hyperesthesia, hypoesthesia, anesthesia, paresthesia, muscular tics, weakness and paralysis as well as autonomic and special sense aberrations, depending on the fiber content at the site of neuropathy

Neuropathic Toothache: Continuous

Types of neuropathic conditions
Neuritis

Deafferentation
Sympathetically maintained pains

Neuropathic Toothache: Continuous

1. Neuritis
Inflammatory condition in the peripheral distribution of the nerve due to trauma, chemical, viral or bacterial causes 1. Arises in the maxillary or mandibular division of the trigeminal nerve along with other neurological symptoms

2. Neuritis of the superior dental plexus due to extension from maxillary sinusitis may cause a toothache in and around one or more of the maxillary teeth 3. Neuritis of the inferior alveolar nerve in the mandibular teeth from direct trauma, dental infection or surgery

Neuropathic Toothache: Continuous

2. Deafferentation
Crushing or cutting of a peripheral nerve (Traumatic Neuralgia)
1. May follow an injury such as external trauma, pulp extirpation, extraction or major oral surgery 2. Often mistaken for a post-traumatic or postoperative complication

Neuropathic Toothache: Continuous

2. Deafferentation

(Contd)

Atypical Odontalgia (Phantom Toothache)

Graff-Radford et al
1. Pain is felt in a tooth or tooth site (maxillary canine and premolar are most common) 2. Pain is continuous or almost continuous 3. Pain persists more than four months 4. No sign of local or referred pain

5. Local anesthetic of the painful tooth provides equivocal results

3. Sympathetically Maintained Pains

Deafferentation tooth pains may be influenced by the efferent activity of the sympathetic nervous system 1. Normal sympathetic activity (sympathetic tone) can be responsible for maintaining the pain 2. An increase in sympathetic activity could increase the pain condition 3. Increased levels of emotional stress could aggravate this condition

Sinus Toothache
1. Patient reports pressure or pain below the eyes *** See notes 2. Toothache is increased with lowering of the head 3. Toothache is increased with applied pressure over the involved sinus 4. Local anesthetic of the tooth does not eliminate the pain 5. Diagnosis can be confirmed by air/fluid level seen in appropriate imaging

Psychogenic Toothache
1. Patient reports that multiple teeth are often painful with frequent change in character and location 2. A general departure from normal or physiologic patterns of pain 3. Patient presents with chronic pain behavior 4. Lack of response to reasonable dental treatment 5. Unusual or unexpected response to therapy 6. No other identifiable pain condition that can explain the toothache

Non-Odontogenic Toothaches
Warning Symptoms- Summary
1. Spontaneous multiple toothaches
2. Inadequate local dental cause for the pain 3. Stimulating, burning, non-pulsatile toothaches

4. Constant, unremitting, non-variable toothaches

5. Persistent, recurrent toothaches 6. Local anesthetic blocking of the offending tooth does not eliminate the pain 7. Failure of the toothache to respond to reasonable dental therapy

Case 1
Chief Complaint:
Lower left mandibular pain and toothache.

History:
61 yr-old male with mild, continuous but variable, dull aching pain diffusely located in the left mandible and teeth. Mandibular movement did not increase the pain. The pain was preceded by left shoulder discomfort. The shoulder pain began 3 days ago. He went to his physician and was diagnosed as bursitis. NSAIDs were prescribed. Two days later, the left toothache pain began even though he had been edentulous for 20 years. He went to his dentist thinking that he had a problem with his lower denture.. His dentist took a periapical of the lower left area and discovered an impacted third molar. He was referred to the oral surgeon for extraction of the tooth.

Examination:
Intraoral: A normal appearing edentulous mouth with satisfactory dentures. There is no palpable discomfort in the area of the impacted tooth. Radiograph revealed a complete bony impacted third molar in the left submandibular triangle without any pathology. Mandibular functions are normal. There is no dental, oral or masticatory cause for the complaint. TM joints: Normal. Muscles: Negative for any cause of pain.

Cranial nerves: Within normal limits.

Diagnostic Tests: Inferior alveolar nerve block in the left did not arrest the pain.

Diagnosis???

Cardiac muscle pain referred as mandibular toothache

Case 2
Chief Complaint: Left mandibular toothache

History:
A 42 yr-old female with mild continuous protracted steady bright
burning pain located in the left mandibular teeth and accompanied by paresthesia described as a sensation of high teeth and recently as gingival swelling. The complaint began 5 years ago following the surgical removal of an impacted left third molar. After a few months, dental pain began in the left mandibular first molar which was extracted and replaced by a fixed bridge that felt too high despite repeated occlusal adjustments and finally refabrication of the prosthesis. A year later, the left mandibular second molar was treated endodontically because of pain and later the left mandibular first and second premolars as well.

The bridge was replaced after the second premolar and second molar were extracted and replaced by a removable partial denture. She could not tolerate the prosthesis due to pain. Then some diffuse temporal discomfort began which lead to muscle therapy by first a Periodontist and then an Oral Surgeon unsuccessfully. Presently, she has an excellent prosthesis but she can not wear it because of pain and a sensation of gingival swelling. It feels no better when she leaves it out.

Examination:
Intraoral: The missing left mandibular teeth were replaced with an excellent removable partial denture which she does not wear. No dental cause is evident either clinically or radiographically. There is an acute tender spot to finger pressure located in the mucosal scar residual to the surgery for removal of the left mandibular third molar.

TM joints: Normal.
Muscles: Minor tenderness in the left Temporalis. Local anesthetic of that muscle arrested only the muscle pain. Cervical: Normal.

Cranial Nerves: Hyperalgesia, paresthesia and dysesthesia were noted at the gingival tissue over the former extraction sites.
Diagnostic Tests: Local anesthetic into the mucosal scar provided immediate relief of pain and, therefore, it was presumed to represent a painful Neuroma. Excision, however, provided only a transitory relief and after a few weeks the pain returned as before.

Diagnosis???

Continuous neuropathic pain (Deafferentation) caused by a previous nerve injury