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Non-Odontogenic Sources of Tooth Pain: Demystifying the Mystery of Phantom Tooth Pain

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Non-Odontogenic Sources of Tooth Pain: Demystifying the Mystery of Phantom Tooth Pain 4/23/21 Non-Odontogenic Sources of Tooth Pain: Demystifying the Mystery of Phantom Tooth Pain SEENA PATEL DMD, MPH ASSOCIATE PROFESSOR, ASSOCIATE DIRECTOR OF ORAL MEDICINE ARIZONA SCHOOL OF DENTISTRY & ORAL HEALTH, A.T. STILL UNIVERSITY, MESA, AZ SOUTHWEST OROFACIAL GROUP, PHOENIX, AZ DIPLOMATE, AMERICAN BOARD OF ORAL MEDICINE DIPLOMATE, AMERICAN BOARD OF OROFACIAL PAIN 1 Financial Disclosure u I have no financial conflicts of interest to disclose. 2 Objectives u Describe the non-odontogenic sources of tooth pain u Implement diagnostic techniques in the evaluation of non-odontogenic tooth pain u Successfully manage each type of non- odontogenic tooth pain 3 1 4/23/21 4 Why is it important? Courtesy of Dr. Brad Gettleman 5 Mr. Jones, 80 yo male: “I feel like I have a headache in my tooth.” Pain History u Step 1: Rule out dental causes Onset A few weeks prior to this consultation Location Lower right jaw, #30 area Quality Dull ache, throbbing Intensity 4/10 Frequency/duration Daily, constant May 28th, 2020 6/4/2020 Modifying factors Chewing worsens pain, Vicodin helps 6 2 4/23/21 Exam Findings u MSK palpations: all 0 pain level EXCEPT the right superficial masseter which radiates downward u TMJ noises: crepitus on right u CBCT: mild osteoarthritis of the right TMJ Patient report complete pain relief. Dx: myofascial pain-induced toothache Diagnostic trigger point injection 7 Pain Mechanisms: Terminology u Afferent nerve fibers: u Nociception u A-beta u Pain u A-delta u Suffering u C fibers u Pain behavior u Silent nociceptors 8 Pain Mechanisms: Nociception u Trigeminal nerve: sensory input to the anterior head and intraoral structures u Trigeminal nucleus: sensory processing center in the CNS u Trigeminal spinal tract nucleus: u Subnucleus oralis, interpolaris, and caudalis u Subnucleus caudalis: nociceptive specific, wide dynamic range neurons, and low-threshold mechanoreceptors u Wide Dynamic Range Neurons u Receive convergent sensory input from primary afferent nociceptors and low-threshold mechanoreceptors u Can lead to expansion of receptive fields and cause radiation of pain Merrill RL. Central mechanisms of orofacial pain. Dent Clin North Am. 2007;51(1):45-59. ! 9 3 4/23/21 Nociceptive Pain 10 1) Why does pain become chronic? ! Hargreaves et al. Orofacial pain: Peripheral mechanisms. In Fricton JR and Dubner RB (eds): Orofacial Pain and Temporomandibular Disorders. New 2) Why can pain York: Raven Press, 1995: 36. occur without a local cause? First-order neurons Merrill RL. Central mechanisms of orofacial pain. Dent Clin North Am. 2007;51(1):45-59. Second-order neurons 11 Peripheral and Central Sensitization -Expansion of receptive fields -Activation of NMDA receptors -Decreased inhibition Allodynia Hyperalgesia Chronic Pain 12 4 4/23/21 Sensitization and Convergence https://pocketdentistry.com/introduction-to-orofacial-pain/ 13 The Challenges of Non-Odontogenic Toothache u How do we deal with these challenges? u ALWAYS ensure an accurate diagnosis u Know the different types of pain: u Nociceptive Protective pain u Inflammatory u Neuropathic Chronic pain u Dysfunctional 14 International Classification of Orofacial Pain, 1st edition (ICOP) u 1) Orofacial pain attributed to disorders of dentoalveolar and anatomically related structures u 2) Myofascial Orofacial Pain u 3) Temporomandibular joint pain u 4) Orofacial pain attributed to lesion or disease of the cranial nerves u 5) Orofacial pains resembling presentations of primary headaches u 6) Idiopathic Orofacial Pain International Classification of Orofacial Pain, 1st edition (ICOP). (2020). Cephalalgia, 40(2), 129–221. https://doi.org/10.1177/0333102419893823 15 5 4/23/21 Odontogenic Cardiac pain referral Musculoskeletal Sinus pain referral Neuropathic Neurovascular 16 Step 1: Rule out local causes Pulpal, Periodontal, Gingival Oral mucosal, salivary gland, alveolar Step 2: Check for other sources of infection in the surrounding region Sinus infection Ear infection Step 3: Check for myofascial sources of pain Trigger points Joint pain Step 4: Check for neuropathic sources Neuralgia PTTN Step 5: Check for neurovascular sources Orofacial migraine Trigeminal autonomic orofacial pain 17 Case 1: 35 yo female with pain on #10 u Subjective: “pressure-like pain around #10” Trauma to the • Describes face, a mild subsequent tenderness observation to #10 •Pain Endo #1 persists Endo #2 •Pain persists Extraction and implant 18 6 4/23/21 Pain History Onset 18 years ago Location #10 u Medical History: Quality Severe pressure unremarkable Frequency Began episodically, now daily u ROS: unremarkable Attack duration Constant u Sleep Hx Severity 9/10 u Family Hx Ameliorating factors Ibuprofen u Social Hx Exacerbating factors Bruxism u Habits Associated symptoms L TMJ clicking, day- and night-time parafunctional habits Wakes with her jaw clenched 19 Diagnostic Process Exam Imaging Diagnostic tests Accurate Diagnosis 20 Musculoskeletal examination Anterior and MedialUpper and and Lateral TemporalisSternocleidomastoidSuperficialPosterior Tendon shoulderDeepPterygoids Masseter trapezius TemporalisMasseter 4 lbs of pressure 21 7 4/23/21 TMJ examination u Examination of the TMJs u A) Palpation: 2 lbs of pressure u Lateral side u Dorsal side u B) Range of motion u Pain-free, active, passive u Lateral movements u C) Joint sounds u Single vs. reciprocal click 2 lbs of pressure u Crepitus 22 Case R L Lateral 3 3 Report: Condyle (TMJ) Exam Dorsal 2 3 Findings Condyle Superficial 3 3 (referred Masseter down the jaw) Anterior 3 3 (referred temporalis down the head, into her anterior teeth; replicated her CC) SCM 3 3 Upper trap 3 3 Shoulder trap 3 3 23 Case Report: Exam Findings Range of motion Pain-free 27 mm Passive 40 mm, pain on left superficial masseter, soft-end feel Protrusive 8 mm R Lateral 11 mm L Lateral 12 mm 24 8 4/23/21 Musculoskeletal Sources u Myofascial Pain: u Regional pain disorder characterized by localized muscle tenderness and limited range of motion u Defined by the presence of myofascial trigger points u Masticatory muscle involvement can be a source of tooth pain u Described as dull, achy, tiring, deep, pressure-like Kim ST. Myofascial pain and toothaches. Aust Endod J 2005;31(3):106-110. 25 Myofascial Pain u Clinical Features: u Spontaneous dull, aching pain and localized tenderness u Muscle stiffness u Sustained muscle function causes fatigue easily u Upon palpation: hyperirritable spot within a taut band that exhibits referral u Trigger point (TP): motor endplate with spontaneous firing u Decreased ROM u Weakness w/o atrophy or neurological deficit Fricton J. Myofascial Pain: Mechanisms to Management. Oral Maxillofac Surg Clin North Am. 2016;28(3):289-311. 26 Muscle referral patterns: Masseter Simons DG, Travell JG, Simons LS. Travell & Simons’ myofascial pain and dysfunction: the trigger point manual: upper half of body (Vol. 1). Philadelphia: Lippincott Williams & Wilkins, 1999. 27 9 4/23/21 Muscle referral patterns: Temporalis 28 Muscle referral patterns: medial pterygoid 29 Muscle referral patterns: lateral pterygoid 30 10 4/23/21 Muscle referral patterns: digastric 31 Myofascial Pain u Causation: u Direct muscle trauma u Adverse effect of medication u Secondary pathology-induced trismus u Parafunctional habits u Stress-induced hypoperfusion u Secondary neurogenic effects Fricton J. Myofascial Pain: Mechanisms to Management. Oral Maxillofac Surg Clin North Am. 2016;28(3):289-311. Graff-Radford SB & Bassiur JP. Temporomandibular disorders and headaches. Neurol Clin. 2014;32(2):525-537. 32 Diagnostic Tests u A trigger point is a hyperirritable within a taut band of skeletal muscle that is not only painful upon palpation but can cause referred pain and autonomic phenomena Kim ST. Myofascial pain and toothaches. Aust Endod J 2005;31(3):106-110. 33 11 4/23/21 Trigger Point Injection: Superficial Masseter 34 Orthotics Treatment • Flat, hard acrylic stabilization splint • May consider a day-time splint if needed Plan Pharmacologic • Muscle relaxant: cyclobenzaprine, methocarbamol, metaxalone, baclofen, chlorzoxazone, tizanidine *Often involves a • Adjuvant analgesics: serotonin modulators (TCAs, SNRIs) multidisciplinary Interventional approach • Series of trigger point injections Physical medicine, Lifestyle Education • Home-based myofascial and avoidance protocols • Physical therapy Kreiner M, Betancor E, Clark GT. Occlusal stabilization appliances. Evidence of their efficacy. J Am Dent Assoc. 2001;132(6):770-777. De Rossi SS, Greenberg MS, Liu F et al. Temporomandibular disorders evaluation and management. Med Clin NM 2014;98(6):1353-1384. 35 Case 2: 57 yo male with an electric, shock- like pain on #30 Pain History Onset May 2013 Location LR, #30 Quality Sharp, stabbing, electric-shock Frequency Daily, several attacks in a day Duration 1-2 seconds (bursts, jolts) Severity 10/10 Ameliorating factors Not moving the jaw Exacerbating factors Chewing, talking, brushing Associated Symptoms Pain radiates into the tongue, chin, sinus 36 12 4/23/21 Exam findings Musculoskeletal exam TMJ exam Dental exam Cranial nerve exam Imaging Shintaku W, Enciso R, Broussard J, Clark GT. Diagnostic imaging for chronic orofacial pain, maxillofacial osseous and soft tissue pathology and temporomandibular disorders. Calif Dent Assoc. 2006;34(8):633-44. 37 Trigeminal Neuralgia (TN) u IASP defines TN: u “Sudden, usually unilateral, severe, brief, stabbing, recurrent episodes of pain in the distribution of one or more branches of the trigeminal nerve” u Annual incidence: 4-5/100,000 people u Classical
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