Download What is the Relationship Between the Misdiagnosis of

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
(Cont’d)
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