Toothaches That Don’t Go Away

Recently I had the opportunity to present a lecture that touched upon the challenging problems that face us when tooth pain lingers after one or multiple interventions. Amongst the many diagnostic possibilities that were discussed, one particular theme stood out.

The majority of pain problems that pass through dental offices are due to tissue injury associated with the dental pulp or the musculoligamentous structures of the Orofacial region. However,??pain problems can and do occur in the absence of tissue injury. As a result, specific dental treatments will not work and can in many instances exacerbate and spread the initial pain complaint. This is called?non-nocioceptive pain: a situation characterized by normal somatic tissues but abnormal functioning of the peripheral and central nervous system.

The origins of non-nocioceptive pain are not always clearly understood, but clues to a possible existence are often revealed if we take a thorough history.

Consider the?case of Jane:

A 44-year old female who initially presented to her dentist with diffuse, but at times sharp, pain in the upper right maxillary posterior teeth. Initial clinical examinations, X-rays and provocative testing did not predictably reproduce the pain. After a few weeks of intermittent pain symptoms, evaluation with an endodontist did not add additional diagnostic certainty to the situation.

At one point in time an oral surgeon was able to prompt percussion pain from tooth #1, which had been previously crowned but had no opposition tooth as #32 had been removed years ago. As a result of the patient’s continued pursuit of an answer, the percussion pain, and the recognition that losing #1 would not lead to occlusal disharmony, tooth #1 was extracted.

Following the extraction, unfortunately, Jane’s pain intensified and changed in character and frequency. Although she had hours during the day with no pain (similar to pre-extraction), when present the pain was broader in its location, more frequent, and felt “deeper” in its origin.

Now Jane’s pain was often experienced in her face and jaw muscles. She would find herself rubbing her face throughout the day. Unable to take NSAIDs due to an irritable bowel problem, the pain at times compelled her to stay at home.

Follow-up visits to the oral surgeon did not identify any concerning findings and a “wait and see” approach was suggested. Suffering prompted her to return to the endodontist who once again declined to provide care based on symptoms alone without supportive clinical findings.

With the recognition that Jane’s symptoms were never classic and may never have been due to an odontogenic source, the question to consider is whether there were elements in her history that could have prompted the consideration of an alternative diagnosis.

Consider the following:

Three years prior, Jane had?wrist surgery?to address persistent pain. At that time it was symptoms, not findings, which prompted the surgical intervention. Subsequent to the surgery, pain lingered at a high level for over two years before abating to a tolerable level. Jane also reported having?ulnar nerve surgery?within the past 18 months that led to more acute pain at a different location in the elbow. This pain landed her in the care of an interventional pain anesthesiologist who, after failing to decrease her suffering with local steroid injections, offered regional nerve blocks as the next option.

Jane’s history was also inclusive of a?chronic irritable bowel, insomnia and multiple personal stresses.

With her history now revealed, one must wonder if Jane’s toothache symptoms were due to a malfunctioning neural system. Her history suggested that other pain symptoms, which prompted surgical interventions, also lingered and changed in character. Could this not have also been true for her toothache?

Jane’s history of insomnia, chronic IBS and stressors also would have also put her?neural systems?at risk, likely lowering pain thresholds and creating opportunities for allodynia and hyperalgesia in the Orofacial arena.

This history coupled with the inconclusive examination could have provided a clue not to treat, despite symptoms and cries for help.

Presently our understanding of pain that occurs despite the absence of tissue injury is still in its infancy. At the same time, however, we as dentists are pretty good at identifying true somatic/nocioceptive pain. When scenarios arise then that do not allow us to diagnose an odontogenic problem with certainty, the patient’s medical history must be scrutinized.

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Summary:

• Though it is difficult to deny care to a patient with a painful toothache, if a clear-cut diagnosis cannot be made it is important to stand your ground and?avoid interventions?that can potentially make the problem worse.
• It is important to remember that pain can arise in the?absence of tissue injury, infection and/or compromise. This is not uncommon in the Orofacial region.
• Know your patient. When a simple diagnosis is elusive, go back into the patient’s?medical profile?and search for clues that may suggest why the patient is suffering beyond the tooth and investing structures.