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Orofacial Pain QUINTESSENCE INTERNATIONAL OROFACIAL PAIN Noboru Noma Cracked tooth syndrome mimicking trigeminal autonomic cephalalgia: A report of four cases Noboru Noma DDS, PhD1/Kohei Shimizu DDS, PhD2/Kosuke Watanabe DDS3/Andrew Young DDS, MSD4/ Yoshiki Imamura DDS, PhD5/Junad Khan BDS, MSD, MPH, PhD6 Background: This report describes four cases of cracked All cases mimicked trigeminal autonomic cephalalgias, a group tooth syndrome secondary to traumatic occlusion that mim- of primary headache disorders characterized by unilateral icked trigeminal autonomic cephalalgias. All patients were facial pain and ipsilateral cranial autonomic symptoms. referred by general practitioners to the Orofacial Pain Clinic at Trigeminal autonomic cephalalgias include cluster headache, Nihon University Dental School for assessment of atypical facial paroxysmal hemicrania, hemicrania continua, and short-lasting pain. Clinical Presentation: Case 1: A 51-year-old woman unilateral neuralgiform headache attacks with conjunctival presented with severe pain in the maxillary and mandibular injection and tearing/short-lasting neuralgiform headache left molars. Case 2: A 47-year-old woman presented with sharp, attacks with cranial autonomic features. Pulpal necrosis, when shooting pain in the maxillary left molars, which radiated to caused by cracked tooth syndrome, can manifest with pain the temple and periorbital region. Case 3: A 49-year-old man frequencies and durations that are unusual for pulpitis, as was presented with sharp, shooting, and stabbing pain in the max- seen in these cases. Conclusion: Although challenging, dif- illary left molars. Case 4: A 38-year-old man presented with ferentiation of cracked tooth syndrome from trigeminal intense facial pain in the left supraorbital and infraorbital areas, autonomic cephalalgias is a necessary skill for dentists. which radiated to the temporoparietal and maxillary regions. (Quintessence Int 2017;48: 329–337; doi: 10.3290/j.qi.a37688) Key words: cracked tooth syndrome, orofacial pain, trigeminal autonomic cephalalgias Cracked tooth syndrome (CTS) was described by Cam- 1 Associate Professor, Department of Oral Diagnostic Sciences, Nihon University School of Dentistry; and Division of Clinical Research, Dental Research Center, eron1 as “incomplete fracture of a vital posterior tooth Nihon University School of Dentistry, Tokyo, Japan. involving dentin and possibly pulpal tissue.” Patients 2 Assistant Professor, Department of Endodontics, Nihon University School of Dentistry, Tokyo, Japan. complain of pain when consuming cold or hot foods or 3 Research Student, Department of Oral Diagnostic Sciences, Nihon University beverages, or while chewing, particularly hard foods.2,3 School of Dentistry; and Division of Clinical Research, Dental Research Center, Nihon University School of Dentistry, Tokyo, Japan. Dentinal tubular fluid flow may explain the presence of 4 Assistant Professor, Department of Dental Practice, Arthur Dugoni School of Dentistry, University of the Pacific, San Francisco, California, USA. pain when the cusp is loaded during movement 4 5 Chief and Professor, Department of Oral Diagnostic Sciences, Nihon University between fracture sites. The pulpal tissue of affected School of Dentistry; and Division of Clinical Research, Dental Research Center, Nihon University School of Dentistry, Tokyo, Japan. teeth may become inflamed because of irritation 6 Assistant Professor, Department of Diagnostic Sciences, Rutgers School of Den- caused by microleakage, which can induce thermal tal Medicine, 110 Bergen Street, Newark, New Jersey, USA. sensitivity. Eventually, crack propagation leads to Correspondence: Dr Noboru Noma, Department of Oral Diagnostic Sciences, Nihon University School of Dentistry, and Division of Clinical necrotic pulp or irreversible pulpitis. Other potential Research, Dental Research Center, Nihon University School of Dentistry, causes are parafunctional habits such as clenching and 1-8-13, Kandasurugadai, Chiyoda-ku, Tokyo 101-8310, Japan. Email: [email protected] damage caused by dental preparations.5 Previous stud- VOLUME 48 • NUMBER 4 • APRIL 2017 329 QUINTESSENCE INTERNATIONAL Noma et al ies showed that presence of an extensive preparation CASE PRESENTATION or amalgam restoration and parafunctional habits increased the risk of crack line development. However, Case 1 other studies reported that 60% of teeth with cracks A 51-year-old woman presented to the Orofacial Pain had no restoration.6,7 Clinic at Nihon University with severe pain in the maxil- Diagnosis of CTS is not always straightforward. lary and mandibular left molars. The maxillary left molar Incomplete tooth fracture is sometimes easy to identify pain had begun 10 years previously but was sporadic. with conventional testing, such as selective bite tests, Approximately 2 weeks before seeking treatment at the staining solutions, and transillumination. In other cases, clinic, the patient had seen a neurologist, who pre- however, such fractures can be difficult to localize and scribed neurotrophin, which did not result in significant diagnose when pain symptoms mimic conditions such relief. One week later, she saw a general dentist for as sinusitis, temporomandibular joint disorders, head- what had become severe dental pain, in the mandibu- ache, ear pain, or atypical orofacial pain.8,9 Dentists lar left region. The dentist diagnosed possible trigemi- must therefore be familiar with various odontogenic nal neuralgia and prescribed loxoprofen. The severe and nonodontogenic causes of orofacial pain, so that pain gradually spread superiorly. When severe, the pain they can differentiate CTS from other conditions. occasionally radiated to the periorbital region. While The trigeminal autonomic cephalalgias (TACs) are a eating noodles, the patient felt what she described as a group of primary headache disorders characterized by “hot, burning poker in the eyes.” During exacerbations, unilateral symptoms, namely, prominent headache and the pain would reach an intensity of 9 to 10 out of 10. ipsilateral cranial autonomic features such as conjunc- Exacerbations occurred three times per day. They tival injection, lacrimation, and rhinorrhea. In the Inter- lasted from a few minutes to a few hours but were national Headache Society Classification (ICHD-3-beta) superimposed on constant pain. The periorbital loca- the TAC category includes cluster headache (CH), par- tion and “hot” quality in the eye suggested CH. oxysmal hemicrania (PH), short-lasting unilateral neu- ralgiform headache attacks with conjunctival injection Clinical examination and tearing (SUNCT)/short-lasting neuralgiform head- Intraoral examination revealed extensive tooth wear. ache attacks with cranial autonomic features (SUNA), The maxillary left second molar was sensitive to percus- and hemicrania continua (HC).10 These conditions can sion and bite testing. Electrical pulp testing (EPT) be differentiated by their attack duration and fre- showed hyposensitivity in the maxillary left second quency, and by response to treatment. HC is continu- molar (Fig 1a). No fracture or decay was seen in intra- ous and responsive to indomethacin. CH is character- oral radiographs of the maxillary and mandibular left ized by excruciatingly painful attacks that occur in molars (Figs 1b and 1c). At this point, CTS and CH were discrete episodes lasting 15 to 180 minutes, at least considered in the differential diagnosis. CH was once every 2 days. PH is more frequent and of shorter included because of the periorbital location, the “hot” duration than CH and, like HC, is responsive to indo- quality in the eye, the frequency and duration of pain, methacin. SUNCT/SUNA has the shortest duration and and the absence of obvious dental pathology. highest frequency; attacks can occur more than 100 A diagnostic anesthetic block eliminated the pain. times a day. Patients often present to dentists for symp- The patient was therefore referred to the endodontic toms associated with these types of headaches.10 department, for root canal treatment (RCT). An incom- This report describes four cases of CTS that mim- plete fracture was observed in the maxillary left second icked TACs. molar (Fig 1d). The patient has been followed for more than 2½ years and is currently pain-free. 330 VOLUME 48 • NUMBER 4 • APRIL 2017 QUINTESSENCE INTERNATIONAL Noma et al Fig 1a Percussion stimulation and bite tests showed high sen- b sitivity in the maxillary left second molar (circle), but no cracks or decay were observed (mirror view). c Fig 1d An incomplete fracture was seen in the distal wall of the Figs 1b and 1c Dental radiographs show no cracks or decay in left maxillary second molar (arrow). the maxillary and mandibular left second molars. Case 2 Clinical examination A 47-year-old woman presented with a chief complaint The patient appeared healthy and responsive, and her of sharp, shooting pain in the maxillary left molar area, medical history was noncontributory. She was not which radiated to the temple and periorbital region. using any medications. A musculoskeletal examination The intensity was rated as 9 to 10 out of 10, and the revealed no abnormalities except in the left masseter frequency and duration were 10 times per day for muscle, which produced slight discomfort on palpa- approximately 5 to 10 minutes each episode. The tion. However, this was localized and did not reproduce patient reported that the pain occasionally woke her the chief complaint. Intraoral examination revealed while sleeping. Approximately
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