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?

1. DDS watch if pain goes away
2. Refer endodontist for 2^nd opinion
   a) Hope pain goes away
   b) 2nd root canal, miss nerve
   c) Apicoectomy-cut root tip-surgery
3. Surgeon for extraction

If a root canal is recommend on tooth w/ no good reason for tooth abscessing, you ask for 2^nd 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:

1. Not associated with inside nerve
2. Not caused by cavity
3. Comes and goes
4. Mild-moderate level pain
5. Not relieved by root canal
6. Symptoms grind/clench

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: 6 Sources pain feels like inside nerve

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

Orofacial Specialty: diagnose and treats these conditions

1. Outside nerve: nerve in periodontal ligament holds tooth in bone,
2. Muscle refer: trigger points in chewing muscles
3. Joint loading-loss joint space=complete displaced disc = loading molars
4. Trigeminal Neuralgia-5^th nerve has a trigger near teeth
5. Atypical Odontalgia -neurovascular pathology of teeth
6. Miscellaneous (Sinus, tumors, MS, heart attack)

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

1. Atypical toothaches not taught in dental school
2. 6 causes AT is taught in Orofacial Residency
3. Diagnostic testing for AT diagnosis
4. Differentiation between 6 pains
5. Save teeth w/o unnecessary dental care
6. Insurance ignores need for extensive testing
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/ 3^rd molar proceeding to 2^nd  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-3^rd 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. 12 % of toothaches, outside nerve is primary source pain
2. Outside nerve caused hidden grind/clench

Treatment:

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

Chasing pain ghost with dental treatment:

1. root canal
2. 2nd root canal
3. extraction
4. 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

Pain	Location	Cause
Inside nerve	Pulp	Cavity
Outside nerve	Ligament	Grinding/clenching

Diagnosis of Atypical Toothache

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. Sharp & shooting

OUTSIDE NERVE

1. Earliest symptoms of outside nerve irritation is Sensitivity
2. Unexplained sensitivity w/o cavity, crack, recession
3. Tooth sensitivity is a outside nerve symptom
4. Outside nerve becomes hyper sensitive
5. Another example: skin sensitivity to a sunburn
6. Diagnostically it should be 2^nd likely cause
7. Most dentist default to inside nerve and do root canal
8. Cervical erosion adds to credibility of clench/grind
9. Repetitive wiggling tooth causes inflammation in outside ligament

Hints it is outside nerve:

1. progressive sensitivity
2. dull ache
3. mobility
4. wear
5. microfractures & cracks
6. history broken teeth
7. teeth shift or move
8. retainer is tight insertion
9. frequent crown adj
10. frequent root canals

Hints that it is not from inside nerve:

1. Tooth pain:
   a) virgin tooth
   b) decay not near pulp
   c) 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. Inside nerve 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: a) Delivery feels like back pain b. Heart attack feels like indigestion 
3. Trigger points refer to other sites: a) Masseter refers 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) joint, 2) joint, 3) set teeth

1. One legs of stool losses height
2. Stool will lean to that side
3. Load on the teeth increases
4. Loads teeth on side of loss
5. Tooth pain in outside nerve
6. Tooth reports discomfort or pain in outside nerve

Trigeminal Neuralgia:

1. Severe pain near tooth triggered by light touch-brush-wind
2. Damage by pulsating artery over the trigeminal nerve
3. Cranial arteries lengthen with age
4. Increase probability with age
5. Severity causes patients to demand quick fix: root canal or extraction
6. Dental treatments no effect on pain
7. Source pain is in 5^th nerve in middle cranial fossa
8. TN is tested with TN medication or refer to neurosurgeon

Atypical Odontalgia:

1. Nerve associated with muscle to blood vessel
2. Moderate to severe pain
3. Old term was “tooth migraine”
4. Neurotransmitter malfunction tells blood vessel to constrict-painfully
5. Nerve to blood vessel travel same nerve as inside nerve
6. Requiring Orofacial Specialist for test
7. Neurovascular pathology looks like toothache
8. Treat medication, then sympathetic system is managed
9. 3 to 6 % of patients develop OA after root canal procedure
10. Diagnose of exclusion=rule out all 5 of pathologies

Miscellaneous:

1. Sinus: 1) Maxillary sinus Infection: sits on 2^nd premolars & 1^s 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 2^nd premolars and 1^st molars and maxillary sinus. Can simmer for months and years, come and go, and flare in odd times.
2. 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.
3. 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
4. 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
5. MS: unilateral presentation of MS in early onset disease can looklike jaw-tooth-face pain w/ neurological symptoms