Persistent Toothache Despite Multiple Dental-related Treatments: How Could this Be?

Patients with recurrent or persistent dentoalveolar pain usually believe that endodontic treatment or extracting a tooth will alleviate it, and most cannot conceive that the pain might not be tooth related. Understanding that dental procedures of any kind will be ineffective when a tooth-related pathology is ruled out and that a nonodontogenic etiology best explains the "toothache" pain goes against their beliefs. In this article, we present an overview of basic concepts to help manage such cases by briefly outlining possible causes of nonodontogenic pain as well as diagnostic pitfalls that may lead to questionable treatments. The decision to provide dental treatment is justified only when definitive peripheral mechanisms driving the pain are uncovered and the multitude of factors that might contribute to the various presentations of persistent dental pain have been considered. Otherwise, patients might be managed with treatments that are not the norm for those with unremitting tooth pain in general dental practice. We also make suggestions for clinicians to assure that patients with recurrent or persistent dental pain receive a thorough work-up that considers odontogenic and nonodontogenic sources to arrive at the correct diagnosis before treatment, taking psychosocial factors into account when devising the treatment plan.

Diagnostic Accuracy of a Temporomandibular Disorder Pain Screener in Patients Seeking Endodontic Treatment for Tooth Pain.

INTRODUCTION: This study assessed the accuracy of a TMD Pain Screener questionnaire in identifying patients with temporomandibular disorder (TMD) pain among those seeking endodontic treatment for tooth pain. It also investigated whether the screener accuracy could be improved by adding questions regarding putative predictors of TMD status. METHODS: One hundred patients seeking endodontic treatment for tooth pain were enrolled. Participants completed the 6-question TMD Pain Screener before treatment. A board-certified orofacial pain specialist/endodontic resident conducted endodontic and TMD examinations using validated Diagnostic Criteria for TMD (DC/TMD). The sensitivity (Se), specificity (Sp), and positive/negative predictive values (PPVs/NPVs) were calculated for the 6-question and 3-question versions of the TMD Pain Screener. Logistic regression and receiver operating characteristic curve (AUROC) analyses were performed to determine the screening accuracy. RESULTS: At the screening threshold of ≥3, TMD Pain Screener's sensitivity was 0.85, specificity 0.52, PPV 0.68, and NPV 0.75 for the 6-question version and 0.64, 0.65, 0.69, and 0.61, respectively, for the 3-question version. The AUROC was 0.71 (95% CL: 0.61, 0.82) and 0.60 (95% CL: 0.48, 0.71) for full and short versions, respectively. Adding a rating of current pain intensity of the chief complaint to the screener improved the AUROC to 0.81 (95% CL: 0.72, 0.89) and 0.77 (95% CL: 0.67, 0.86) for full and short versions, respectively, signifying useful overall accuracy. CONCLUSIONS: The 6-question TMD Pain Screener, combined with the patient's rating of current pain intensity of the chief complaint, could be recommended for use in endodontic patients with tooth pain for detecting painful TMD.

Expression of Selected Inflammatory Mediators with Different Clinical Characteristics of Pulpal Inflammation.

INTRODUCTION: Accurately diagnosing the state of dental pulp is crucial when addressing tooth pain to determine the best treatment approach. This study aimed to investigate the concentration of inflammatory mediators in the dental pulp of mature teeth that have been exposed via caries but show no signs of apical periodontitis. METHODS: Samples of pulpal blood from adults with mature teeth responsive to pulp testing and have carious pulp exposures were obtained. These samples were analyzed for 12 inflammatory cytokines and other inflammatory proteins using the Luminex assay platform. Clinical factors were correlated with cytokine levels, and statistical analysis was performed to evaluate the impact of these factors on cytokine expression. RESULTS: Of the 36 patients that were included, 44.44% took pain medications, 33.33% had prolonged pulpal bleeding, 41.67% felt spontaneous pain, and 72.22% were diagnosed with symptomatic irreversible pulpitis. Significant correlations existed between presenting pain scores and levels of interleukin (IL)-1α, IL-6, and IL-8 (P < .05). Factors like analgesic medication intake, pain to percussion, pain to thermal testing, spontaneous pain, and nocturnal pain were significantly associated with higher levels of specific inflammatory proteins. No significant associations were observed with pain to palpation, bleeding time, or pulpal diagnosis. CONCLUSIONS: Inflammatory proteins, including cytokine levels may play a critical role in characterizing pulpal inflammation. Future studies should investigate the role of these potential biomarkers in determining the diagnosis of pulpitis and the prognosis of vital pulp therapy.

A Patient with Herpes Zoster of the Maxillary Division of Trigeminal Nerve Presents for Oral Evaluation and Toothache.

Herpes zoster (HZ) is an acute and painful neurocutaneous infection caused by the reactivation of a latent varicella-zoster virus in the dorsal root or cranial nerve ganglia. It is characterized by 3 stages: prodromal, acute, and chronic. During the prodromal stage, reactivation in the maxillary branch of the trigeminal nerve closely mimics odontalgia, and HZ should be in the differential diagnosis. Patients with HZ develop painful lesions following the affected dermatome. Laboratory testing confirms the diagnosis; treatment is with antiviral agents. Early detection and treatment shorten the course of the infection and lessen the severity of the associated postherpetic neuralgia.

Review of visceral throat and chest disorders causing nonodontogenic orofacial pain.

BACKGROUND: The purpose of this narrative review was to show that referred orofacial pain can be the chief symptom or a prominent symptom of visceral diseases of the chest and throat, with implications for dental and medical practice. TYPES OF STUDIES REVIEWED: A search of PubMed was performed to identify dentally relevant clinical case reports and case series using the following terms: jaw pain, orofacial pain, toothache, temporomandibular disorders, otalgia, neuralgia, and neuropathicpain crossed with angina, myocardial infarction, carotid artery, esophagus, mediastinum, thyroid, heart, pericardium, aorta, lung, thymus gland, and stomach. RESULTS: Numerous acute, visceral disorders of the throat and chest have been reported to produce pain in the orofacial region, which may be difficult to distinguish from dental-related diseases on the basis of symptoms alone. Chest organs and structures reported to cause such pain include the heart, aorta, esophagus, stomach, lungs, and mediastinum. Throat organs and structures reported to cause pain in the orofacial region include the thyroid gland, carotid arteries, and vagus and glossopharyngeal nerves. Coronary artery diseases, aortic and carotid dissection, mediastinal tumors, subacute thyroiditis, and gastroesophageal reflux disease have a predilection for referring pain orofacially. CONCLUSIONS AND PRACTICAL IMPLICATIONS: Misdiagnosis of referred visceral orofacial pain can lead to delayed diagnosis and unnecessary treatment. Dentists can play a key role in the management of these conditions by means of ruling out odontogenic facial pain, promptly referring patients to medical specialists, and educating patients. Future research is needed to determine the incidence and mechanism of orofacial pain in these disorders. Visceral pain referred to the orofacial region may not be as rare a phenomenon as is sometimes assumed.

Bilateral occurrence of bimaxillary bi-rooted primary canines: a rare case report with review of the literature.

Multiple roots in anterior teeth are very rarely reported in the literature. The occurrence of multi-rooted canine in primary dentition is an infrequent entity. This unusual abnormality is an accidental finding on routine examination. Radiographic examination plays a significant role in the identification of this anomaly. This rare anomaly has been reported very infrequently reported and has not been published in a Saudi Arabia population. Therefore, the purpose of the present case report is to describe a case of an 8-year old Saudi boy presented with the bimaxillary occurrence of bi-rooted primary canine. This report discusses this unique occurrence in the context of the published literature.

Atypical odontalgia and trigeminal neuralgia: psychological, behavioral and psychopharmacological approach in a dental clinic - an overview of pathologies related to the challenging differential diagnosis in orofacial pain.

Orofacial pain represents a challenge for dentists, especially if with a non-odontogenic basis. Orofacial neuropathic pain is chronic, arduous to localize and develops without obvious pathology. Comorbid psychiatric disorders, such as anxiety and depression, coexist and negatively affect the condition. This article presents one case of atypical odontalgia and one of trigeminal neuralgia treated with psychological and psychopharmacologic tailored and adapted therapies, after conventional medications had failed.  In addition, an overview of the pathologies related to the challenging differential diagnosis in orofacial pain is given, since current data are insufficient.   A 68-year-old male complained of chronic throbbing, burning pain in a maxillary tooth, worsening upon digital pressure. Symptoms did not abate after conventional amitriptyline therapy; psychological intervention and antianxiety drug were supplemented and antidepressant agent dosage incremented; the patient revealed improvement and satisfaction with the multidisciplinary approach to his pathology. A 72-year-old male lamented chronic stabbing, intermittent, sharp, shooting and electric shock-like pain in an upper tooth, radiating and following the distribution of the trigeminal nerve. Pain did not recur after psychological intervention and a prescription of antidepressant and antianxiety agents, while conventional carbamazepine therapy had not been sufficient to control pain. Due to concern with comorbid psychiatric disorders, we adopted a patient-centered, tailored and balanced therapy, favourably changing the clinical outcome.  Comorbid psychiatric disorders have a negative impact on orofacial pain and dentists should consider adopting tailored therapies, such as psychological counselling and behavioural and psychopharmacologic strategies, besides conventional treatments. They also need to be familiar with the signs and symptoms of orofacial pain, recollecting a comprehensive view of the pathologies concerning the differential diagnosis. A prompt diagnosis prevents pain chronicity, avoiding an increase in complexity and a shift to orofacial neuropathic pain and legal claims.

New International Classification of Orofacial Pain: What Is in It For Endodontists?

Pain is a common symptom in endodontic conditions, but differential diagnostic procedures are often needed to exclude other pain origins. Thus, general dentists and endodontists need to be aware of alternative painful orofacial conditions and be able to identify them. The new International Classification of Orofacial Pain (ICOP) is the first comprehensive classification that uniquely deals with orofacial pain. The ICOP is a hierarchical classification modeled on the International Classification of Headache Disorders and covers pain in dentoalveolar and anatomically related tissues, muscle pain, temporomandibular joint pain, neuropathic pain affecting cranial nerves, pain resembling primary headaches, and idiopathic pain in the orofacial region. A description of each condition is given, and structured diagnostic criteria for each condition are proposed based on research data when available. This narrative review aims (1) to give an overview and brief explanation of the ICOP system, (2) to describe and give examples of how it can be of use to general dentists and endodontists with special attention to differential diagnosis of tooth pain, and (3) to highlight how endodontic research can contribute to validation and improvement of the classification. A comparison to other classification and diagnostic systems is also included.

Does Virtual Reality Affect Children's Dental Anxiety, Pain, And Behaviour? A Randomised, Placebo-Controlled, Cross-Over Trial

ABSTRACT Objective: To evaluate the effect of virtual reality (VR) on dental anxiety, pain, and behaviour at different time points among children undergoing dental treatment under local anaesthesia. Material and Methods: This randomised, two‐armed, within-subject, cross-over, placebo-controlled trial included 76 children. Eligible participants were treated in two dental visits using the following methods: with protective glasses only, without distraction (attention placebo-controlled - APC); and with the treatment condition (i.e., VR). Primary outcomes were dental anxiety and pain; secondary outcome was dental visit behaviour. Heart rate scores were recorded as an objective measure to evaluate dental anxiety and pain. Subjective measurements for each variable were also performed. Results: Significant reduction in dental pain and anxiety was observed in the VR group, according to the heart rate scores; however, no statistical differences were observed according to the self-reported measures. Decreased dental anxiety and pain were associated with the first visit sequence with VR. Dental pain and anxiety scores were lower during local anaesthesia in the VR group than in the APC group. Conclusion: Virtual reality significantly reduced pain and anxiety during local anaesthesia in children undergoing dental treatment; therefore, it may be recommended during dental treatment in school-age children.

Exposures to Dental Products, Stomatological Preparations, and in Dental Care and Toothache reported to the PIC Erfurt (1997 to 2017).

We examined human exposures to dental products (EDP), stomatological preparations (ESP), and in the context of dental care (EDC) or toothache (ETA) registered by the Poisons Information Centre (PIC) Erfurt from 1997 to 2017. Dental products like dental technical and filling materials belong to medical devices. Stomatological preparations were classified according to the ATC code and symptom severity to the Poisoning Severity Score (PSS). In total, 156 cases of EDP (136 cases with different tooth filling materials), 1167 cases of ESP (55.6% fluoride containing products), 979 cases of EDC, and 331 cases of ETA were registered. Symptom severity in EDP and ESP were asymptomatic or mild. In ETA and EDC, however, 35 cases with moderate and 5 cases with severe symptoms were detected. 5 moderate and 3 severe cases were caused by prolonged paracetamol overdose. Severe bleeding occurred following tooth extraction in a 41 year-old phenprocoumon treated patient after self-medication with acetylsalicylic acid and metamizole. Gingival injection of lidocaine plus epinephrine in a 37 year-old healthy woman resulted in severe bradycardia and cardiac arrest. Acute toxicity of EDP and ESP appears to be low. Prolonged paracetamol overdose because of toothache, and some dental treatment can result in severe symptoms.

Community pharmacy staff oral health training, training needs and professional self-efficacy related to managing children's dental problems.

OBJECTIVES: Few studies have explored the oral health training needs and professional self-efficacy (PSE) in both pharmacy support staff and pharmacists related to managing children's dental problems. This study assessed community pharmacy staff perceptions of their (i) training experiences and interests; (ii) PSE; and (iii) whether this was influenced by the pharmacy being part of a minor ailment scheme (MAS), where staff could directly offer advice and issue prescription medications without patients seeing a doctor. METHODS: All of the 1851 community pharmacies across London, UK, were invited to participate in an online questionnaire. Staff rated their prior training, perceived need for further training and confidence in giving parents advice related to three dental problems in children (dental pain, mouth ulcers and dental trauma). Information was collected about staff roles and whether the pharmacy was a MAS. KEY FINDINGS: From 752 community pharmacies, 846 community pharmacy staff participated. Positive experiences of training were variable but interest in further training for all three dental problems was high. Pharmacy support staff had significantly lower PSE scores than pharmacy professionals (P = 0.009). A significant interaction showed that pharmacy staff who had poorly rated prior training on advising parents about managing their child's dental pain and who did not work in a MAS had lower PSE scores than staff who had highly rated training and who worked in a MAS (P = 0.02). CONCLUSIONS: Minor ailment scheme pharmacies may be an optimal environment for frontline pharmacy support staff to develop higher PSE when combined with good quality oral health training.

Orbital AL amyloid.

Amyloidosis and lymphoma localized to the ocular adnexa are rare, and their presentation may resemble more common inflammatory conditions such as autoimmune disease or infection, which can protract diagnostic evaluation and delay eventual therapy. In a patient with recalcitrant facial and tooth pain and ophthalmoplegia, evaluation should include careful histopathologic analysis of biopsy specimens. We report a case of orbital AL amyloidosis associated with localized lymphoma that presented with intractable dental pain and progressed to bilateral complete ophthalmoplegia.

Tooth-Related Pain or Not?

Dental pain is the most common acute pain presenting in the orofacial region; however, chronic pain conditions are also frequent and include; temporomandibular joint disorders (TMDs), primary headaches (neurovascular pain), painful post-traumatic trigeminal neuropathy (PPTTN) and less commonly referred pain and idiopathic or centralized pain conditions. All of these conditions can mimic toothache and vice versa. Many of these conditions are comorbid with high levels of tension headache and migraine reported in patients with TMD; however, dentists remain unfamiliar with headaches and medics unfamiliar with toothache's multiple presentations. The anatomical complexity of the region, the potential exhaustive differential diagnoses and the multiple siloed training of specialties, leads to incorrect and delayed diagnosis and often results in patients undergoing inappropriate surgical and medical treatments. The continued inappropriate interventions may also complicate the later presentation of the patient with pain, by changing its phenotype, preventing a timely and correct diagnosis. Due to the variable presentation of toothache, which can mimic many different chronic pains including; episodic throbbing pain of migraine, the dull continuous pain of myofascial and arthrogenous TMDs or centralized facial pain, diagnosis can be complex. Neuralgic pain occurs in the dentition in health and with disease, mimicking conditions like PPTTN, trigeminal neuralgia (TN), and trigeminal autonomic cephalalgias (TACs), many patients are inappropriately diagnosed and treated, either by general medical practitioners assuming that the neuralgia is due to TN rather than more commonly presenting toothache or by a dentists or other surgeons continuing to treat TN or TACs with routine surgical care. Many patients are prescribed countless courses of antibiotics and undergo multiple surgical interventions simply as a result of poor education due to siloed specialty training. This must be addressed to improve patient safety.

The central nucleus of the amygdala lesion attenuates orthodontic pain during experimental tooth movement in rats.

INTRODUCTION: Orthodontic pain is the most common adverse side effect reported in the context of tooth movement. Given its central role in processing pain and negative emotion, the central nucleus of the amygdala (CeA) is thought to be a key site involved in orthodontic pain sensation. METHODS: In the present study, we therefore explored whether the CeA is involved in contributing to orthodontic pain in a rat model of tooth movement. For this study, we utilized adult male rats with bilateral sham or electrolytic CeA lesions (400 µA; 25 s), and then we analyzed face grooming behavior as a measure of pain sensation. RESULTS: Through this approach, we found that there were time- and force-dependent factors influencing pain levels in these rats. We further found that bilateral CeA lesions markedly reduced tooth movement-induced orofacial pain and that unilateral CeA lesions did so to a lesser extent. CONCLUSIONS: As such, these results suggest the CeA is a key area of orthodontic pain, with the results of this study highlighting potential avenues for achieving pain relief in those suffering from orthodontic pain.

Chronic migraine headache and multiple dental pathologies causing cranial pain for 35 years: the neurodental nexus.

We report a case that illustrates how chronic migraine headaches and multiple dental pathologies caused severe and long-standing cranial pain that affected the quality of life of a man for more than 35 years. His case was investigated at several settings including the neurology outpatient clinic of the hospital without a definitive diagnosis or resolution. After investigations, multiple oral pathologies including two occult dental abscesses were diagnosed. Once both affected teeth and associated abscesses were surgically removed, with subsequent antibiotic therapy the headaches resolved.

Revealing a rare inflammatory oral manifestation in a 6-year-old child.

A 6-year-old child with an episodic history of ulcerations over buccal mucosa was found to have severe inflammation on the palatal aspect of permanent first molars with grade 2 mobility bilaterally. Radiographical features were suggestive of bone loss around permanent molars extending to the distal aspect of the deciduous first molars. The clinical and radiographical findings were indicative of periodontal degeneration without any apparent cause visible intraorally. Further biopsy was done from the rashes present on the malar prominences, which showed nodular aggregates of atypical cells in superficial dermis. These large histiocytic cells with vesicular nuclei and nuclear grooves were immunopositive for CD1a and S100, concluding the diagnosis of Langerhans cell histiocytosis. For treatment, patient was referred to Department of Haemato-oncology and chemotherapy was suggested as per protocol.

Sensory testing associates with pain quality descriptors during acute dental pain.

BACKGROUND: Pain descriptors capture the multidimensional nature of pain and can elucidate underlying pathophysiological mechanisms. This study determined whether the pain descriptors chosen by subjects experiencing acute dental pain associate with the outcomes of two commonly performed dental sensory tests. The goal of the study is to clarify whether pain descriptors are useful in discriminating the underlying biological processes contributing to dental pain. METHODS: Participants (n = 228) presenting with acute toothache underwent standardized clinical dental sensory testing and described their pain in reference to 22 pain quality descriptors. Univariate and two-way ANOVA determined the relationship between groups defined by cold detection (positive or negative) and percussion hypersensitivity (painful or not) on the affected tooth, and pain descriptor reporting. RESULTS: Subjects experiencing painful toothache most frequently reported evoked pain to temperature and chewing, and pain descriptors such as "throbbing" and "aching." They also reported neuropathic pain descriptors such as "tingling" and "electric shock." Subjects who detected a cold stimulus (thermal) on the affected tooth, frequently reported high intensity paroxysmal shooting pain compared to those that did not detect cold. By contrast, patients with percussion (mechanical) hypersensitivity on the affected tooth, reported higher levels of global pain intensity at rest and in function, and reported significantly higher intensity "radiating" and "throbbing" pain, than subjects with non-painful percussion. CONCLUSIONS: The reporting of neuropathic pain descriptors by subjects experiencing acute toothache was more frequent than expected, suggesting that neuropathic mechanisms could contribute to typical toothache pain. Subjects experiencing toothache with mechanical hypersensitivity experience more intense pain overall. SIGNIFICANCE: In subjects experiencing acute toothache, specific pain descriptors associate with the responses to routine clinical sensory tests performed on the injured tooth. The frequent reporting of neuropathic pain descriptors suggests that neuropathic mechanisms could create a diagnostic challenge to differentiate toothache from intraoral neuropathic conditions. Persons experiencing toothache with mechanical hypersensitivity experience more intense pain overall, suggesting patients with this clinical feature will have distinct clinical pain management needs.

Chronic Pain and Overview or Differential Diagnoses of Non-odontogenic Orofacial Pain.

Orofacial pain is defined as pain arising from the regions of the face and mouth. Dental pain is the most common inflammatory pain presenting in this region; however, chronic pain conditions presenting frequently, including temporomandibular joint disorders (TMDs), primary headaches (neurovascular), neuropathic pain and idiopathic pain conditions, can often mimic toothache. Dentists are familiar with TMDs but have no training or experience in diagnosing or treating headaches that mainly present in the first trigeminal division. The anatomical complexity of the region and the potential possible diagnoses, mean that correct diagnosis is often delayed resulting in patients often undergoing inappropriate surgical and medical treatments that themselves may complicate the presentation of the pain by changing its phenotype and further complicating diagnosis and appropriate management.
Due to the variable pain presentation of toothache, it can mimic many different chronic episodic orofacial pain conditions, resulting in many inappropriately prescribed courses of antibiotics and surgical interventions. Dentists are not the only profession to fall foul of the misdiagnosis but ear, nose and throat (ENT) and maxillofacial surgeons fall into the same trap.