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Toothache Pain Beyond The Dental Pulp

Author: Donald Tanenbaum DDS MPH - Board-Certified Orofacial Pain Specialist at New York TMJ & Orofacial Pain

Date: April 13, 2021

Restorative dental practices and dental specialty groups are commonly confronted with familiar patient presentations. The same holds true in my practice, where I focus on orofacial pain and temporomandibular disorders.

Many of the challenges I face specifically relate to the complaint of toothache pain that does not have origin in the dental pulp. Therefore, the pain complaints do not respond to routine dental procedures. It is not unusual for patients to present with persistent tooth or tooth site pain despite the fact there are no obvious clinical or x-rays/imaging findings.

In this newsletter, I will focus on three specific types of neuropathic pain problems within the trigeminal system that can produce toothache complaints. Each of these neuropathic pain problems is slightly different, particularly in their origin. The treatment options available are somewhat similar but variable in terms of the timeframe and capacity to address the pain being experienced in a predictable and satisfying manner.

Scenario #1: Toothache Pain of Trigeminal Neuralgia (TN) Origin

Studies have revealed that 30 to 40% of all patients diagnosed with trigeminal neuralgia first seek care at a dental office because of toothache pain. Toothache pain is common particularly when trigeminal neuralgia is in the early stages of its emergence. The toothache pain of TN may seem like a typical toothache – but careful listening reveals distinct characteristics.

These patients will report pain that is manageable to miserable all within the same day or even within a five to thirty-minute period of time. In fact, the pain that brought the patient to the dental office may vanish before they arrive and may not be provocable when in the dental chair.

The patient may report pain events prompted by speaking, experience sharp pain immediately at the first bite of a meal, and describe total avoidance of toothbrushing in and around the tooth pain site. In addition, the pain may come on spontaneously in an acute radiating, nerve-like pattern and then stop totally, with this pattern repeating itself throughout the day. These characteristics, coupled with an inconclusive exam and unrevealing x-rays/imaging, should prompt you to consider TN as a working diagnosis.

However, a common toothache may still be suspected because a local anesthetic block can eliminate the pain. This could, therefore, justify tooth-directed treatment inclusive of a root canal procedure. The fact that TN-mediated tooth pain, therefore, can be eliminated with an anesthetic injection complicates the diagnostic process.

As a result, my firm belief is that one mistake is allowable when it relates to TN toothache pain. However, after the first failure this diagnosis needs to be considered.

Scenario #2: Toothache/Tooth Site Pain After Dental Or Surgical Intervention

Although our diagnostic acumen and treatment proficiency has evolved as a profession, it is possible that the trigeminal nerve can become irritated or injured in the delivery of care. This, of course, is not a comfortable realization. Nor are these occurrences common for dental or dental surgical practitioners.

As a result, when patients experience unexpected pain or sensory disturbances after dental or surgical treatments, follow-up assessments in the treating practitioner’s office often prompts comments such as “everything looks fine” when an exam and imaging are unrevealing. However, for the patient all is not fine, and their concern is often at a high level.

Some patients present to my office being referred from the treating doctor, while others find their way through independent searches when time and reassurance fall short. When seen in my office, the common complaint is pain accompanied by a sensory alteration called dysesthesia following a tooth extraction, implant placement, grafting procedure, tooth scaling or endodontic procedure. By definition, dysesthesia is a feeling of pressure, achiness, fullness, burning or altered sensations along with pain – but not necessarily numbness.

For many of these patients, there was no pain or any concerning symptom prior to the procedure. For others who had pre-treatment pain, the character of the lingering pain or dysesthesia is often described as different and more distressing.

The history and symptoms reported, along with unremarkable exam findings, suggest that the trigeminal nerve (commonly in the second or third division) has been irritated or injured during the procedure or as a result of subsequent inflammation at the treatment site. A course of steroids or NSAIDs may produce transient benefit, but symptoms will thereafter linger.

A recent case with a similar history involved the placement of implants in the non-symptomatic tooth sites of #20 and #21. The preliminary planning clearly identified the mental foramen and the surgical guides assured adequate distance between the apical extent of the implant and the mental foramen. However, the patient experienced acute pain after the anesthetic wore off. And then, as pain eased, dysesthesia was experienced in the lip and chin on that side. Although this is an unexpected outcome, it can and does occur.

As long as there are anatomic variants that cannot be imaged or planned for, peripheral nerves (“twigs,” so to speak) can be compressed, irritated, or traumatized – despite the best planning and clinical competence. As a result, the extraction of teeth, the placement of an implant, and periodontal and endodontic procedures can, unfortunately, lead to troubling symptoms.

What, then, is the next step? Once a neuropathic pain condition is suspected, a regimen of medications may be essential to both diminish neural discharge and reduce inflammation. The sooner medications are started, the better the potential outcome.

However, these nerve-stabilizing medications may be needed over an extended period of time as long as side effects can be avoided. In the case of implants being suspected as the cause of the neuropathic pain, quick removal is probably the right decision. However, this decision is often debated by the surgeon, who fears more potential injury while the implant is being removed.

In all of these cases, there are difficult decisions to be made. However, acknowledgment by the provider of what has likely occurred is the most important first step.

Scenario #3: Co-Morbid Medical Problems, Trauma, Anxiety, Autoimmune Conditions & More

Unlike the first two scenarios, toothache pain unrelated to the dental pulp may be the end result of co-morbid medical problems such as persistent migraines, systemic inflammatory diseases, fibromyalgia, early life traumas, uncontrolled anxiety and autoimmune conditions that predispose to lower pain thresholds in the trigeminal system.

In addition, medications such as those used for ADD and ADHD and medical treatments inclusive of chemotherapy can cause dysregulation in the autonomic and central nervous system, lowering pain thresholds, tightening muscles and upsetting glial cells, which play an intimate role in regulating nerve excitation in both the peripheral and central nervous system.

This subset of patients may initially seek care for toothache pain but are often told that examination and x-ray findings are inconclusive and treatment needs to be deferred. Unfortunately, if this patient continues to complain of pain and revisits the dental office on multiple occasions, it is likely that care will be delivered based upon suffering – rather than objective evidence of a problem.

This is also the subset of patients that have fillings replaced or other minor procedures performed on an asymptomatic tooth and then begin to experience pain for no clear reason. In both these scenarios, the more treatment that is provided – the worse the outcome.

So, if this sounds familiar, re-explore what I call the “back story” to see if the patient may have features in their medical, social, or emotional history that could predispose the trigeminal system to excessively fire without obvious provoking factors. Solutions here are challenging and likely will require collaboration with other health care providers.

In Conclusion

Amidst all the successes achieved in the rendering of traditional dental and dental surgical care, there are instances when it will be necessary to recognize that “things are not what they seem to be.” Hopefully, this summary, based upon patients that seek care in my office, provides insights that may be relevant as you continue to care for patients.

I welcome your thoughts.


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