Atypical Toothache

Atypical toothache is one most expensive pathologies to diagnose and treat in todays dentistry. Chasing the pain ghost can take decades of dental reconstruction and can cost as much as small house. The quicker one gets referred to Orofacial Pain Specialist the quick pain relieve and less waste money and tooth structure.

A toothache not associated with inside nerve or pulp of tooth, not caused by cavity or gum disease, episodic not progressive, mild to moderate level pain, not relieved by root canal or crown.

Source of confusion:

  1. In 88 % toothaches, the inside nerve (pulp) is source of pain
  2. In 12 % toothaches, the source pain is 6 other pathologies

Atypical Toothache: 7 Sources pain

  1. Tooth
  2. Muscle
  3. Joint
  4. Outside nerve
  5. Trigeminal Neuralgia
  6. Atypical Odontalgia
  7. Miscellaneous-sinus, heart, cancer, MS

I. Tooth:

  1. cracks,
  2. cavities,
  3. gum disease

II. Orofacial Pathologies

  1. Outside ligament-parafunctional damage to periodontal ligament and nerve
  2. Muscle refer-trigger points in chewing muscles (masseter-temporalis) refer pain to posterior teeth
  3. Joint loading-loss joint space by complete displaced disc or bone loss causes loading molars

III. Medical Pathologies:

  1. Trigeminal Neuralgia-trigeminal nerve damage
  2. Atypical Odontalgia -neurovascular pathology
  3. Miscellaneous (Sinus, tumors, MS, heart attack)

Orofacial Pain Specialist serves public as diagnostic clearinghouse for Atypical Toothache:

  1. Serves diagnostic clearinghouse
  2. Knowledge of other 6 causes of AT
  3. Diagnostic testing for atypical toothache
  4. Differentiation between other 6 pains
  5. Save teeth from dental care that will not relieve pain
  6. Dental & medical insurance try not to over these test
  7. Diagnosis before treatment is holy grail of health care

Atypical toothache: Cases: Examples

  1. Case I: Series of root canal-crown-extraction on lower right, starting w/ 3rd molar proceeding to 2nd premolar.- when dentist would question not dental pathology-he would go to another dentist, being engineer he was sure it was tooth-each dental procedure reduce pain short period then pain returned. Diagnose Muscle referred pain
  2. Case II: remaining LL wisdom tooth w/ major interference-moderate grinder. Years later, cementing crown on that tooth, the huge interference set up pain. Dental Tx w/ 2 full equilibration and 11 refinement adjustments,  chasing pain ghost. Dull bite with parafunction
  3. Case III: ongoing lower left molar toothache in 2000. Treatment w/ biteguard-nightguard-3rd extraction, history intermittent restricted opening, pain increasing w/ each lock, finally locked-stayed lock.Complete displace disc
  4. Case IV: sharp shooting pain lasting seconds, a series of pains for days, then go away for weeks, then return, 69-year-old female, no history trauma, dental work, or event prior onset. Trigeminal Neuralgia

OUTSIDE NERVE

OUTSIDE NERVE

  1. Nerves: inside nerve = pulp, outside nerve=ligament
  2. 12 % of toothaches, outside nerve is primary source pain
  3. When outside nerve is source, destructive grind/clench is primary cause

Treatment:

  1. Endodontist =root canal treats inside nerve
  2. Orofacial pain specialist treats outside nerve

Chasing pain ghost with dental treatment:

  1. root canal
  2. crown
  3. 2nd root canal
  4. extraction
  5. implant

Why root canal does not always treat the source pain, the outside nerve ?

  1. Test for inside nerve are not conclusive
  2. Root canal treats inside nerve
  3. If outside nerve is source pain, root canal ineffective
  4. Nerves travel in same bundle to same area brain
  5. Only good test for outside nerve is night guards
PainLocationCause
Inside nervePulpCavity
Outside nerveLigamentGrinding/clenching
Diagnosis of Atypical Toothache

TOOTH = INSIDE NERVE

  1. 60% of neurotic pulps do not reflect pain
  2. Inside tooth does not have collateral circulation
  3. High levels inflammation inside tooth cause necrosis
  4. Pulp highly innervated
  5. Nerve damage produces inflammation chemicals
  6. Anxiety nerves couple to pain nerves
  7. 40% tooth pain’s increase w/ anxiety (Journal Oro Fac Pain-HA, 2019:33:226-233, Dr. Sivakami Rethnam Houg, & Mihaela Marthinussen)

SENSITIVITY IS SIGN DESTRUCTIVE GRIND-CLENCH;

  1. One of earliest symptoms of outside nerve irritation is sensitivity,
  2. Unexplained sensitivity, no cavity, no crack, no gum
  3. The tooth sensitivity is a neuropathic symptom
  4. It is an alloydnia, like skin sensitivity to a sunburn.
  5. Diagnostically it should be included list possible causes
  6. Irritation to outside nerve is most likely cause
  7. Powerful repetitive wiggling tooth in socket causes inflammation in outside ligament.
  8. Cervical erosion adds to credibility of clench/grind

Hints of outside nerve:

  1. progressive sensitivity
  2. dull ache w/o cavity
  3. mobility
  4. wear
  5. micro fractures, cracks
  6. broken filling-tooth
  7. tooth shifts
  8. partial/retainer not fit
  9. frequent crown adj
  10. frequent root canals

Hints that it is not from inside nerve:

  1. Tooth pain:
    1. virgin tooth,
    2. decay not near pulp,
    3. small filling
  2. Mod to severe wear on tooth
  3. No cracks
  4. No deep pockets or  gum disease
  5. Dull ache, not sharp shooting
  6. Jaw function aggravates pain
  7. Some test are inconclusive
  8. Worse upon awakening
  9. Not a progressive pain, like infection

Muscle Referred Pain:

  1. Muscles damage causes enlarge or trigger points a) Trigger points refer pain b) Enlargement muscle
  2. Referred pain is not new: a) Delivery feels like back pain b. Heart attack can feel like indigestion
  3. Trigger points refer to other sites a) Masseter tr pt refer lower 2nd molars b) Temporalis refers upper 2nd molars
  4. Trigger Point Manual written by Dr. Janet Travell

Joint Load Pain

Loading of last tooth in arch by loss tissue in joint space:

  1. Sudden disc displacement
  2. bone loss in condyle

Physics of 3 legged stool:

  1. If one of legs of 3 legend stool losses height,
  2. the stool will lean to side of loss
  3. The load on the shorten leg increases
  4. If the tile below leg measured pressure it would go higher
  5. Loading of last tooth on side of loss height condyle reports extra load
  6. Tooth reports discomfort or pain in outside nerve
  7. Gets misinterpreted as inside nerve damage; thus, root canal, extraction

Trigeminal Neuralgia:

  1. A severe pain in and around tooth that is triggered by light touch-brush-lip movement-wind on face-food moving in mouth
  2. A central brain damage by pulsating artery over the top of the trigeminal nerve that supplies the tooth-gum-bone of maxilla or mandible
  3. Increase probability with age
  4. Severity of the pain causes patients to demand quick fix:  crown, root canal, extraction
  5. Dental treatments have little to no effect on pattern or severity of pain
  6. Source pain is in middle cranial fossa (blood vessel irritates tooth nerve-ganglion)
  7. Suspected TN is tested with TN medication w/ great track record, if successful then TN is managed short term until referral to neurosurgeon for Janetta procedure.

Atypical Odontalgia:

  1. Nerve associated with muscle to blood vessel
  2. Moderate(+) to severe pain
  3. Old term for this pathology was “tooth migraine”
  4. Neurotransmitter malfunction telling blood vessel near tooth to constrict-painfully
  5. Nerve tooth & blood vessel travel same nerve bundle
  6. Difficult to differentiate requiring Orofacial Specialist to test
  7. Neurovascular pathology looks like toothache
  8. Treat medication, thentitrated sympathetic system is managed
  9. 3 to 6 % of patients develop OA after root canal procedure
  10. Diagnose of exclusion after ruling out all 7 of other pathologies

Miscellaneous:

Sinus: 1) Maxillary sinus Infection: sits on 2nd premolars & 1s molars, mod to sev infection put pressure on root tips of these teeth causing pain. Typically, URI symptoms are somewhat present.2) Endo/Sinus Connections: cross over infection between root tips of 2nd premolars and 1st molars and maxillary sinus. Can simmer for months and years, come and go, and flare in odd times.

Parotid: salivary stone blocking Stenson duct on side cheek, hydrologic pressure canrefer pain into the posterior teeth in the area of this duct. Other symptoms of swelling side face-dry mouth-pain on eating sour candy.

Tumors: occasionally or rarely a tumor can be in or near tooth, itslocation makes it a likely cause of tooth symptoms, most are discovered by endodontist

Heart: a heart attack has been known to refer pain in rare occasions to left angle mandible and to lower posterior teeth, yes, muscles can refer pain to distant sites

MS: unilateral presentation of MS in early onset disease can looklike jaw-tooth-face pain w/ neurological symptoms

Chasing pain ghost: hammer sees nails, plumber sees pipes, dentist sees teeth

Atypical toothache is one most expensive pathologies to diagnose and treat in todays dentistry. Chasing the pain ghost can take decades of dental reconstruction and can cost as much as small house. The quicker one gets referred to Orofacial Pain Specialist the quick pain relieve and less waste money and tooth structure.

A toothache not associated with inside nerve or pulp of tooth, not caused by cavity or gum disease, episodic not progressive, mild to moderate level pain, not relieved by root canal or crown.

Source of confusion:

  1. In 88 % toothaches, the inside nerve (pulp) is source of pain
  2. In 12 % toothaches, the source pain is 6 other pathologies

Atypical Toothache: 7 Sources pain

  1. Tooth
  2. Muscle
  3. Joint
  4. Outside nerve
  5. Trigeminal Neuralgia
  6. Atypical Odontalgia
  7. Miscellaneous-sinus, heart, cancer, MS

I. Tooth:

  1. cracks,
  2. cavities,
  3. gum disease

II. Orofacial Pathologies

  1. Outside ligament-parafunctional damage to periodontal ligament and nerve
  2. Muscle refer-trigger points in chewing muscles (masseter-temporalis) refer pain to posterior teeth
  3. Joint loading-loss joint space by complete displaced disc or bone loss causes loading molars

III. Medical Pathologies:

  1. Trigeminal Neuralgia-trigeminal nerve damage
  2. Atypical Odontalgia -neurovascular pathology
  3. Miscellaneous (Sinus, tumors, MS, heart attack)

Orofacial Pain Specialist serves public as diagnostic clearinghouse for Atypical Toothache:

  1. Serves diagnostic clearinghouse
  2. Knowledge of other 6 causes of AT
  3. Diagnostic testing for atypical toothache
  4. Differentiation between other 6 pains
  5. Save teeth from dental care that will not relieve pain
  6. Dental & medical insurance try not to over these test
  7. Diagnosis before treatment is holy grail of health care

Atypical toothache: Cases: Examples

  1. Case I: Series of root canal-crown-extraction on lower right, starting w/ 3rd molar proceeding to 2nd premolar.- when dentist would question not dental pathology-he would go to another dentist, being engineer he was sure it was tooth-each dental procedure reduce pain short period then pain returned. Diagnose Muscle referred pain
  2. Case II: remaining LL wisdom tooth w/ major interference-moderate grinder. Years later, cementing crown on that tooth, the huge interference set up pain. Dental Tx w/ 2 full equilibration and 11 refinement adjustments,  chasing pain ghost. Dull bite with parafunction
  3. Case III: ongoing lower left molar toothache in 2000. Treatment w/ biteguard-nightguard-3rd extraction, history intermittent restricted opening, pain increasing w/ each lock, finally locked-stayed lock.Complete displace disc
  4. Case IV: sharp shooting pain lasting seconds, a series of pains for days, then go away for weeks, then return, 69-year-old female, no history trauma, dental work, or event prior onset. Trigeminal Neuralgia

OUTSIDE NERVE

OUTSIDE NERVE

  1. Nerves: inside nerve = pulp, outside nerve=ligament
  2. 12 % of toothaches, outside nerve is primary source pain
  3. When outside nerve is source, destructive grind/clench is primary cause

Treatment:

  1. Endodontist =root canal treats inside nerve
  2. Orofacial pain specialist treats outside nerve

Chasing pain ghost with dental treatment:

  1. root canal
  2. crown
  3. 2nd root canal
  4. extraction
  5. implant

Why root canal does not always treat the source pain, the outside nerve ?

  1. Test for inside nerve are not conclusive
  2. Root canal treats inside nerve
  3. If outside nerve is source pain, root canal ineffective
  4. Nerves travel in same bundle to same area brain
  5. Only good test for outside nerve is night guards
PainLocationCause
Inside nervePulpCavity
Outside nerveLigamentGrinding/clenching
Diagnosis of Atypical Toothache

TOOTH = INSIDE NERVE

  1. 60% of neurotic pulps do not reflect pain
  2. Inside tooth does not have collateral circulation
  3. High levels inflammation inside tooth cause necrosis
  4. Pulp highly innervated
  5. Nerve damage produces inflammation chemicals
  6. Anxiety nerves couple to pain nerves
  7. 40% tooth pain’s increase w/ anxiety (Journal Oro Fac Pain-HA, 2019:33:226-233, Dr. Sivakami Rethnam Houg, & Mihaela Marthinussen)

SENSITIVITY IS SIGN DESTRUCTIVE GRIND-CLENCH;

  1. One of earliest symptoms of outside nerve irritation is sensitivity,
  2. Unexplained sensitivity, no cavity, no crack, no gum
  3. The tooth sensitivity is a neuropathic symptom
  4. It is an alloydnia, like skin sensitivity to a sunburn.
  5. Diagnostically it should be included list possible causes
  6. Irritation to outside nerve is most likely cause
  7. Powerful repetitive wiggling tooth in socket causes inflammation in outside ligament.
  8. Cervical erosion adds to credibility of clench/grind

Hints of outside nerve:

  1. progressive sensitivity
  2. dull ache w/o cavity
  3. mobility
  4. wear
  5. micro fractures, cracks
  6. broken filling-tooth
  7. tooth shifts
  8. partial/retainer not fit
  9. frequent crown adj
  10. frequent root canals

Hints that it is not from inside nerve:

  1. Tooth pain:
    1. virgin tooth,
    2. decay not near pulp,
    3. small filling
  2. Mod to severe wear on tooth
  3. No cracks
  4. No deep pockets or  gum disease
  5. Dull ache, not sharp shooting
  6. Jaw function aggravates pain
  7. Some test are inconclusive
  8. Worse upon awakening
  9. Not a progressive pain, like infection

Muscle Referred Pain:

  1. Muscles damage causes enlarge or trigger points a) Trigger points refer pain b) Enlargement muscle
  2. Referred pain is not new: a) Delivery feels like back pain b. Heart attack can feel like indigestion
  3. Trigger points refer to other sites a) Masseter tr pt refer lower 2nd molars b) Temporalis refers upper 2nd molars
  4. Trigger Point Manual written by Dr. Janet Travell

Joint Load Pain

Loading of last tooth in arch by loss tissue in joint space:

  1. Sudden disc displacement
  2. bone loss in condyle

Physics of 3 legged stool:

  1. If one of legs of 3 legend stool losses height,
  2. the stool will lean to side of loss
  3. The load on the shorten leg increases
  4. If the tile below leg measured pressure it would go higher
  5. Loading of last tooth on side of loss height condyle reports extra load
  6. Tooth reports discomfort or pain in outside nerve
  7. Gets misinterpreted as inside nerve damage; thus, root canal, extraction

Trigeminal Neuralgia:

  1. A severe pain in and around tooth that is triggered by light touch-brush-lip movement-wind on face-food moving in mouth
  2. A central brain damage by pulsating artery over the top of the trigeminal nerve that supplies the tooth-gum-bone of maxilla or mandible
  3. Increase probability with age
  4. Severity of the pain causes patients to demand quick fix:  crown, root canal, extraction
  5. Dental treatments have little to no effect on pattern or severity of pain
  6. Source pain is in middle cranial fossa (blood vessel irritates tooth nerve-ganglion)
  7. Suspected TN is tested with TN medication w/ great track record, if successful then TN is managed short term until referral to neurosurgeon for Janetta procedure.

Atypical Odontalgia:

  1. Nerve associated with muscle to blood vessel
  2. Moderate(+) to severe pain
  3. Old term for this pathology was “tooth migraine”
  4. Neurotransmitter malfunction telling blood vessel near tooth to constrict-painfully
  5. Nerve tooth & blood vessel travel same nerve bundle
  6. Difficult to differentiate requiring Orofacial Specialist to test
  7. Neurovascular pathology looks like toothache
  8. Treat medication, thentitrated sympathetic system is managed
  9. 3 to 6 % of patients develop OA after root canal procedure
  10. Diagnose of exclusion after ruling out all 7 of other pathologies

Miscellaneous:

Sinus: 1) Maxillary sinus Infection: sits on 2nd premolars & 1s molars, mod to sev infection put pressure on root tips of these teeth causing pain. Typically, URI symptoms are somewhat present.2) Endo/Sinus Connections: cross over infection between root tips of 2nd premolars and 1st molars and maxillary sinus. Can simmer for months and years, come and go, and flare in odd times.

Parotid: salivary stone blocking Stenson duct on side cheek, hydrologic pressure canrefer pain into the posterior teeth in the area of this duct. Other symptoms of swelling side face-dry mouth-pain on eating sour candy.

Tumors: occasionally or rarely a tumor can be in or near tooth, itslocation makes it a likely cause of tooth symptoms, most are discovered by endodontist

Heart: a heart attack has been known to refer pain in rare occasions to left angle mandible and to lower posterior teeth, yes, muscles can refer pain to distant sites

MS: unilateral presentation of MS in early onset disease can looklike jaw-tooth-face pain w/ neurological symptoms

Chasing pain ghost: hammer sees nails, plumber sees pipes, dentist sees teeth

Atypical Toothache Navigation

Pearls of Pain

Side effects Appliances
a) soft biteguard: increase grinding, bulky, decrease airway space b) soft-hard guards (Hybrids): increase clench, can’t repair-retread-tighten c) hard nightguard: tighter insertion, loose retentiveness, can be adapted d) ARS (worn 24/7): major changes bites, requires cost Ortho or CR/BR e) Orthotic: requires use other orthopedic tools
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