A tooth has two sets nerves. Tooth pain can be inside or outside nerve
Be sure dentist proves it is the inside nerve before root canal is done
Typical treatment for toothache is root canal ? 7 to 12 % of time it is not effective
Why does root canal not stop pain? A root canal treats inside nerve and pain is from outside nerve !
If root canal doesn’t stop pain?
DDS watch if pain goes away
Refer endodontist for 2nd opinion a) Hope pain goes away b) 2nd root canal, miss nerve c) Apicoectomy-cut root tip-surgery
Surgeon for extraction
If a root canal is recommend on tooth w/ no good reason for tooth abscessing, you ask for 2nd opinion.
Many times an endodontist will request 2 opinion on any tooth that does not have conclusive evidence that inside nerve is cause of pain?
Once inside nerve is amputated you cannot put it back, that is why a second opinion will save you money and teeth.
The root canal may not be quick fix you had hoped for especially when you do not get out pain ?
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. After root canal, retreat root canal, and then extraction and you still have pain. The better choice would been second opinion by Orofacial Pain Specialist. An ole saying, Measure twice cut once!
Atypical toothache:
Not associated with inside nerve
Not caused by cavity
Comes and goes
Mild-moderate level pain
Not relieved by root canal
Symptoms grind/clench
Source of confusion:
In 88 % toothaches, the inside nerve (pulp) is source of pain
In 12 % toothaches, the source pain is 6 other pathologies
Atypical Toothache: 6 Sources pain feels like inside nerve
Outside nerve
Muscle
Joint
Trigeminal Neuralgia
Atypical Odontalgia
Miscellaneous-sinus, heart, cancer, MS
Orofacial Specialty: diagnose and treats these conditions
Outside nerve: nerve in periodontal ligament holds tooth in bone,
Trigeminal Neuralgia-5th nerve has a trigger near teeth
Atypical Odontalgia -neurovascular pathology of teeth
Miscellaneous (Sinus, tumors, MS, heart attack)
Orofacial Pain Specialist serves the public as diagnostic clearinghouse for Atypical Toothache:
Atypical toothaches not taught in dental school
6 causes AT is taught in Orofacial Residency
Diagnostic testing for AT diagnosis
Differentiation between 6 pains
Save teeth w/o unnecessary dental care
Insurance ignores need for extensive testing
Diagnosis before treatment is holy grail of health care
Atypical toothache: Cases: Examples
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
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
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
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
12 % of toothaches, outside nerve is primary source pain
Outside nerve caused hidden grind/clench
Treatment:
Endodontist = treats inside nerve
Orofacial pain specialist treats outside nerve
Chasing pain ghost with dental treatment:
root canal
2nd root canal
extraction
implant
Why root canal does not always treat the source pain, the outside nerve ?
Test for inside nerve are not conclusive
Root canal treats inside nerve
If outside nerve is source pain, root canal ineffective
Nerves travel in same bundle to same area brain
Only good test for outside nerve is night guards
Pain
Location
Cause
Inside nerve
Pulp
Cavity
Outside nerve
Ligament
Grinding/clenching
Diagnosis of Atypical Toothache
INSIDE NERVE
60% of neurotic pulps do not reflect pain
Inside tooth does not have collateral circulation
High levels inflammation inside tooth cause necrosis
Pulp highly innervated
Nerve damage produces inflammation chemicals
Sharp & shooting
OUTSIDE NERVE
Earliest symptoms of outside nerve irritation is Sensitivity
Most dentist default to inside nerve and do root canal
Cervical erosion adds to credibility of clench/grind
Repetitive wiggling tooth causes inflammation in outside ligament
Hints it is outside nerve:
progressive sensitivity
dull ache
mobility
wear
microfractures & cracks
history broken teeth
teeth shift or move
retainer is tight insertion
frequent crown adj
frequent root canals
Hints that it is not from inside nerve:
Tooth pain: a) virgin tooth b) decay not near pulp c) small filling
Mod to severe wear on tooth
No cracks
No deep pockets or gum disease
Dull ache, not sharp shooting
Jaw function aggravates pain
Inside nerve test are inconclusive
Worse upon awakening
Not a progressive pain, like infection
Muscle Referred Pain:
Muscles damage causes enlarge or trigger points a) Trigger points refer pain b) Enlargement muscle
Referred pain: a) Delivery feels like back pain b. Heart attack feels like indigestion
Trigger points refer to other sites: a) Masseter refers lower 2nd molars b) Temporalis refers upper 2nd molars
Trigger Point Manual written by Dr. Janet Travell
Joint Load Pain
Loading of last tooth in arch by loss tissue in joint space:
Sudden disc displacement
bone loss in condyle
Physics of 3 legged stool: 1) joint, 2) joint, 3) set teeth
One legs of stool losses height
Stool will lean to that side
Load on the teeth increases
Loads teeth on side of loss
Tooth pain in outside nerve
Tooth reports discomfort or pain in outside nerve
Trigeminal Neuralgia:
Severe pain near tooth triggered by light touch-brush-wind
Damage by pulsating artery over the trigeminal nerve
Cranial arteries lengthen with age
Increase probability with age
Severity causes patients to demand quick fix: root canal or extraction
Dental treatments no effect on pain
Source pain is in 5th nerve in middle cranial fossa
TN is tested with TN medication or refer to neurosurgeon
Atypical Odontalgia:
Nerve associated with muscle to blood vessel
Moderate to severe pain
Old term was “tooth migraine”
Neurotransmitter malfunction tells blood vessel to constrict-painfully
Nerve to blood vessel travel same nerve as inside nerve
Requiring Orofacial Specialist for test
Neurovascular pathology looks like toothache
Treat medication, then sympathetic system is managed
3 to 6 % of patients develop OA after root canal procedure
Diagnose of exclusion=rule out all 5 of 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
If you have toothache ?
A tooth has two sets nerves. Tooth pain can be inside or outside nerve
Be sure dentist proves it is the inside nerve before root canal is done
Typical treatment for toothache is root canal ? 7 to 12 % of time it is not effective
Why does root canal not stop pain? A root canal treats inside nerve and pain is from outside nerve !
If root canal doesn’t stop pain?
DDS watch if pain goes away
Refer endodontist for 2nd opinion a) Hope pain goes away b) 2nd root canal, miss nerve c) Apicoectomy-cut root tip-surgery
Surgeon for extraction
If a root canal is recommend on tooth w/ no good reason for tooth abscessing, you ask for 2nd opinion.
Many times an endodontist will request 2 opinion on any tooth that does not have conclusive evidence that inside nerve is cause of pain?
Once inside nerve is amputated you cannot put it back, that is why a second opinion will save you money and teeth.
The root canal may not be quick fix you had hoped for especially when you do not get out pain ?
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. After root canal, retreat root canal, and then extraction and you still have pain. The better choice would been second opinion by Orofacial Pain Specialist. An ole saying, Measure twice cut once!
Atypical toothache:
Not associated with inside nerve
Not caused by cavity
Comes and goes
Mild-moderate level pain
Not relieved by root canal
Symptoms grind/clench
Source of confusion:
In 88 % toothaches, the inside nerve (pulp) is source of pain
In 12 % toothaches, the source pain is 6 other pathologies
Atypical Toothache: 6 Sources pain feels like inside nerve
Outside nerve
Muscle
Joint
Trigeminal Neuralgia
Atypical Odontalgia
Miscellaneous-sinus, heart, cancer, MS
Orofacial Specialty: diagnose and treats these conditions
Outside nerve: nerve in periodontal ligament holds tooth in bone,
Trigeminal Neuralgia-5th nerve has a trigger near teeth
Atypical Odontalgia -neurovascular pathology of teeth
Miscellaneous (Sinus, tumors, MS, heart attack)
Orofacial Pain Specialist serves the public as diagnostic clearinghouse for Atypical Toothache:
Atypical toothaches not taught in dental school
6 causes AT is taught in Orofacial Residency
Diagnostic testing for AT diagnosis
Differentiation between 6 pains
Save teeth w/o unnecessary dental care
Insurance ignores need for extensive testing
Diagnosis before treatment is holy grail of health care
Atypical toothache: Cases: Examples
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
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
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
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
12 % of toothaches, outside nerve is primary source pain
Outside nerve caused hidden grind/clench
Treatment:
Endodontist = treats inside nerve
Orofacial pain specialist treats outside nerve
Chasing pain ghost with dental treatment:
root canal
2nd root canal
extraction
implant
Why root canal does not always treat the source pain, the outside nerve ?
Test for inside nerve are not conclusive
Root canal treats inside nerve
If outside nerve is source pain, root canal ineffective
Nerves travel in same bundle to same area brain
Only good test for outside nerve is night guards
Pain
Location
Cause
Inside nerve
Pulp
Cavity
Outside nerve
Ligament
Grinding/clenching
Diagnosis of Atypical Toothache
INSIDE NERVE
60% of neurotic pulps do not reflect pain
Inside tooth does not have collateral circulation
High levels inflammation inside tooth cause necrosis
Pulp highly innervated
Nerve damage produces inflammation chemicals
Sharp & shooting
OUTSIDE NERVE
Earliest symptoms of outside nerve irritation is Sensitivity
Most dentist default to inside nerve and do root canal
Cervical erosion adds to credibility of clench/grind
Repetitive wiggling tooth causes inflammation in outside ligament
Hints it is outside nerve:
progressive sensitivity
dull ache
mobility
wear
microfractures & cracks
history broken teeth
teeth shift or move
retainer is tight insertion
frequent crown adj
frequent root canals
Hints that it is not from inside nerve:
Tooth pain: a) virgin tooth b) decay not near pulp c) small filling
Mod to severe wear on tooth
No cracks
No deep pockets or gum disease
Dull ache, not sharp shooting
Jaw function aggravates pain
Inside nerve test are inconclusive
Worse upon awakening
Not a progressive pain, like infection
Muscle Referred Pain:
Muscles damage causes enlarge or trigger points a) Trigger points refer pain b) Enlargement muscle
Referred pain: a) Delivery feels like back pain b. Heart attack feels like indigestion
Trigger points refer to other sites: a) Masseter refers lower 2nd molars b) Temporalis refers upper 2nd molars
Trigger Point Manual written by Dr. Janet Travell
Joint Load Pain
Loading of last tooth in arch by loss tissue in joint space:
Sudden disc displacement
bone loss in condyle
Physics of 3 legged stool: 1) joint, 2) joint, 3) set teeth
One legs of stool losses height
Stool will lean to that side
Load on the teeth increases
Loads teeth on side of loss
Tooth pain in outside nerve
Tooth reports discomfort or pain in outside nerve
Trigeminal Neuralgia:
Severe pain near tooth triggered by light touch-brush-wind
Damage by pulsating artery over the trigeminal nerve
Cranial arteries lengthen with age
Increase probability with age
Severity causes patients to demand quick fix: root canal or extraction
Dental treatments no effect on pain
Source pain is in 5th nerve in middle cranial fossa
TN is tested with TN medication or refer to neurosurgeon
Atypical Odontalgia:
Nerve associated with muscle to blood vessel
Moderate to severe pain
Old term was “tooth migraine”
Neurotransmitter malfunction tells blood vessel to constrict-painfully
Nerve to blood vessel travel same nerve as inside nerve
Requiring Orofacial Specialist for test
Neurovascular pathology looks like toothache
Treat medication, then sympathetic system is managed
3 to 6 % of patients develop OA after root canal procedure
Diagnose of exclusion=rule out all 5 of 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
Atypical Toothache Navigation
Pearls of Pain
Assist neurologist w/ migraines
Assist neurologist w/ migraines by reducing inflammation in chewing system, adding orofacial specialty to headache team especially difficult cases