The per radicular and pulp of the tooth are the most common culprit when it comes to tooth pain. When it comes to a pulpal verdict, the correct answer would be symptomatic irreversible pulpitis. As for a periapical diagnosis, you would be looking at symptomatic apical periodontitis. If pus and swelling are present, it would be an acute apical abscess. While these are the most common causes of tooth pain, there are other issues that could be causing the pain. For people with chronic pain condition like myofascial pain, this can be the cause of pain in the teeth. When it comes to neuropathic pain like trigeminal neuralgia, it can yield pain that exudes to the teeth. Most of these conditions are determined when a patient has long term tooth pain with no improvement. We will go into more detail with chronic pain, and dig deeper into myofascial pain.
Odontogenic Pain
The patient usually visits the dentist and complains of a simple toothache. The toothache is most commonly a sign of an issue with the pulp. If it is left untreated, more pain is likely. Once the enamel is disturbed, the acidity from certain bacteria cause a breakdown of minerals and collagen.
If this process proceeds quickly and supersedes the natural pulpal defenses, including the creation of various dentins, destructions will continue on to the pulp tissue. As a result, cell necrosis begins, which could continue on to become irreversible pulpitis. When the pulp tissues break down, the inflammation causes pain. Even though symptomatic irreversible pulpitis, acute apical abscess, and symptomatic apical periodontitis, are the most common, there are other issues that could be causing the typical toothache.
Non-Odontogenic Pain
Tooth pain that does not meet the criteria to be diagnosed as odontogenic pain fall into three focal groupings.
- Chronic pain conditions that create pain to teeth.
- Neuropathic conditions that radiate pain to different sources, included teeth.
- Non-odontogenic sources that make for long term tooth pain with no pulpal or per radicular diagnosis.
Before the start of any treatment process, it is important to diagnose the issue properly. For pulpal or periapical diagnoses, the most successful form of treatment has proven to be endodontic treatment. There is a five year survival rate topping at 98.1%. A significant amount of data comes with a limitation for those with pain. Preoperative pain arises from the anesthetic injections, and the difficulty of achieving proper pulpal anesthesia. It is associated even more with postoperative pain following treatment that can be long term.
If a diagnosis can’t be determined, or if the criteria of diagnosing pulpal or per radicular diagnosis can’t be achieved, exodontia and endodontic therapy would not be the ideal choices. One of the other three groupings would have to be considered. Review your particular patients pain history and determine if additional imaging and testing would be beneficial.
Most Typical Non-Odontogenic Tooth Pain Causes
Chronic pain conditions are the most common causes of pain that are non-odontogenic. Chronic conditions act very differently than acute conditions, in that it lasts much longer. Pulpitis is usually and acute inflammatory based condition that occurs as a result of tissue damage. Inflammation is a result of the healing process and creates the signs and symptoms that the patient states exist. When the issue heals, the pain goes away.
On the other hand, chronic pain is caused by trauma to the nervous system that results in changes as to how the central nervous system processes pain. It is usually multifactorial and not inflammatory. Chronic pain can start from simple event that occurs, but can remain even after the healing process. Chronic disorders present themselves clinically with some classic signs and indications.
- Spreading Pain. Pain spreads to certain areas with no diagnosis. There is usually a broader area of pain associated with this symptom.
- Temporal Summation. Increasing pain is reported during masticatory or palpation structured. It may feel as if everything is painful.
- During palpation or any small change in pressure, the client will feel pain even with the lightest touch. Sensory nerve fibers that don’t usually associate themselves with pain begin to do so.
- Maintained Pain. Pain that is painful becomes increasingly painful or maintains the same pain level, instead of getting better.
When discussing the central nervous system, it is important to note that it can often become so sensitized that even the smallest background stimulation can be interpreted as pain. The clinical term for this is Central Sensitization and happens between the brain stem and brain itself. This is responsible for the four symptoms above. Pain thresholds are minimized long term, and normal pain barring safe guards are lost. Correct pharmacotherapy can help the patient’s central nervous system go back to normal thresholds.
There are a lot of patients and clinicians that are not aware of the clinical implications of chronic pain and how it shows up very differently than acute pain. This lack of knowledge can lead to misdiagnosis, so it is important to take the time to get it right the first time. Prescribed treatments may not provide relief for the patient, and cause them to lose faith in their provider.
Myofascial Pain
The most common chronic pain condition, when it comes to teeth, is Myofascial Pain. There are two subcategories to this type of pain.
- Myofascial Pain
- Myofascial Pain with referral.
Both of these diagnoses have the following symptoms:
- The patient states that the pain is in the jaw, ear, temple, or preauricular areas
- The patient reports that the pain seems to be occurring in the jaw, ear, temple, or preauricular areas.
- The patient reports that the pain intensity varies over time and seems to increase with chewing, or stretching the jaw.
- The patient reports that the muscles hurt during examination.
Different trigger points will be assessed during the appointment with the patient, and during the examination the patient will be able to tell the provider when the most pain occurs. Myofascial pain varies from pain in a specific muscle because the pain spreads and is usually described as “achy” or “sore” by the patient. The pain is usually constant, but intensity can vary.
Pain Referral to Teeth
In patients that are diagnosed with Myofascial Pain, the masseter and temporal muscles have been said to intensify the pain in teeth. Other muscles, such as cervical muscles, have been found to refer pain to the teeth.
Various regions of muscles have been proved to refer pain to teeth. The superior aspect of the temporalis muscle could refer to maxillary anterior teeth. If the region in pain is more inferior on the muscle, the referral sites can migrate to the maxillary region and then continue on to the molar region.
The superior region of the superficial masseter muscle has been proven to refer pain to the maxillary molar and premolar teeth. The inset of the masseter is proven to refer pain to the mandibular molars. Patterns may be consistent over time but will vary in intensity with the back and forth of the overall pain level.
Muscles aren’t the only body parts that have been proven to create pain in teeth. The maxillary sinus, temporomandibular joints, heart, and submandibular glands, all can also cause tooth pain.
Myofascial Pain Management
Managing chronic pain is much different than managing acute pain. Because the pain is most likely non-inflammatory, medications like non-steroidal anti-inflammatory medications only help a little bit as an analgesic. There has to be a multidisciplinary response in order to manage the pain, as it is multifactorial in nature. The patient has to be educated and involved in order to get the best result. They have to understand that their condition is chronic, and be in tune with management strategies.
Myofascial Pain Prognosis
Myofascial pain is a chronic condition, which means that treatments are meant to manage the pain, not cure it. There is no guarantee of remission after trying certain strategies, and not every treatment will work for everyone.
This type of pain is cyclical and the pain is variable. It may recede, and then come back with little to no inclination of its return. As soon as a patient successfully learns management strategies, they will know when to implement them.
This type of pain may not be diagnosed immediately, and many patients go through extractions and endodontic treatments that are unnecessary. Patients and doctors must both understand chronic pain, its effects, and how to treat it.
