When a Toothache is Not

By Dr. Steven D. Bender

A 60-year-old female presents to your clinic with a chief complaint of a “sharp pain in (her) face in the area of the left maxillary second bicuspid”. She indicates that her complaint began approximately one year prior to her consultation with you today. Her symptoms seem to be getting worse over time. She lists previous consultations with numerous providers including her general dentist, a periodontist and a neurologist. Her general dentist suggested that she may have trigeminal neuralgia, but the consulted neurologist disagreed and felt that her complaint was odontogenic in nature.

This scenario is probably not atypical of the average endodontic specialty practice. It is well known that pain is the primary reason people seek care from their health care providers especially in an endodontic practice. An estimated 25% of the population has experienced some form of oral and/or facial pain, with the highest prevalence in the 18- to 25-year-old age group (1). Oral pains can be primary in presentation or secondary due to referral from other sources, such as muscles, joints or intracranial structures. The diversity of the numerous structures related to the oral cavity along the complex innervation and vascularization is at least partially responsible for the sometimes-puzzling symptoms these patients present with. Also, the convergence of afferent information received from these structures into the central nervous system may serve to further confound the pain presentation. It should also be noted that failure to consider the pain patient’s psychological and social conditions, sleep health, and comorbid systemic factors will often lead to less than desirable outcomes (2).

Returning to our patient: When asked to describe her pain, she uses the terms shooting, sharp, and dull and aching. Her average pain level on a 0 to 10 scale is 7/10 with her worst pain being a 9 out of 10. She reports to you that if she manipulates the area above tooth number 13, it will aggravate her primary complaint. Fortunately, there have been no previous therapies attempted to alleviate her pain. Taking a non-steroidal anti-inflammatory agent will reportedly help to decrease her pain symptoms. Your clinical exam provides no positive symptoms that would help you diagnose an odontogenic problem: Now what?

Myofascial pain with referral is a sub classification of myalgia, or pain of muscle origin, characterized by pain in a muscle group that when palpated, will refer pain beyond the boundary of the muscle being palpated (3). This entity is often considered to be the most common of muscle pain disorders. Travell described very characteristic referral patterns resultant from what are commonly termed trigger points (4). These are focally tender spots found in taut bands of muscle tissue, often described as “knots”. An active trigger point, when provoked, will refer pain to distant sites; often to non-muscular tissues.

As your exam progresses and the lack of significant clinical findings begins to stress you (just a little), you ask your patient to show you how she elicits a painful response. She places her finger in her mouth and pushes on the buccal vestibule area approximating tooth number 13. Thinking back to your days in gross anatomy, you recall that the origin of the masseter muscle is the lateral and inferior surfaces of the zygoma. When your patient reports that she is manipulating her area of concern, she is actually provoking the masseter muscle origin. As previously described by Travell, an active trigger point in this area will commonly refer pain to the ipsilateral maxillary bicuspids.

Myofascial pain with referral is considered to be the most common cause of secondary “toothache” and the masseter muscle is the most common painful muscle in temporomandibular disorders (5, 6). Tooth pain of muscle origin will typically present as constant and non-pulsatile with a dull aching quality. There may be exacerbations of the pain with movement or provocation. The pain will not respond to provocation of the tooth where the pain is felt. Also, a local anesthetic block or infiltration of the tooth will not provide any relief. However, anesthetic placed at the muscle trigger point will often provide relief.

As clinicians, one the most important and rewarding services that we can provide for our patients with oral and facial pains is an accurate diagnosis. Many patients with pain, especially chronic pain, have previously consulted with numerous providers and have often received ineffective and in some cases, inappropriate treatment, based on the lack of an accurate diagnosis. It is important not to “try” therapies. To effectively diagnose and triage these patients, a systematic approach to the examination process is necessary. Obtaining a good history and performing a systematic clinical evaluation is necessary to avoid missing critical data. Additional laboratory tests and imaging studies should be ordered only when necessary to confirm a differential diagnosis. Ultimately, it is important to remember that no two patients are alike. Each individual will present with very unique aspects to their disorders based on their biologic, psychologic and social attributes.

Steven D. Bender, D.D.S., is Diplomate, American Board of Orofacial Pain; clinical assistant professor, Department of Oral and Maxillofacial Surgery; and director of facial pain and sleep medicine, Texas A&M College of Dentistry, Dallas.

1.Lipton JA, Ship JA, Larach-Robinson D. Estimated prevalence and distribution of reported orofacial pain in the United States. J Am Dent Assoc 1993;124(10):115-21.

2.Turner JA, Dworkin SF. Screening for psychosocial risk factors in patients with chronic orofacial pain: recent advances. J Am Dent Assoc 2004;135(8):1119-25; quiz 64-5.

3.Schiffman E, Ohrbach R, Truelove E, et al. Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: recommendations of the International RDC/TMD Consortium Network* and Orofacial Pain Special Interest Groupdagger. J Oral Facial Pain Headache 2014;28(1):6-27.

4.Travell JG, & Simons, D. G.   Lippincott Williams & Wilkins. Myofascial pain and dysfunction: the trigger point manual: Lippincott Williams & Wilkins; 1983.

5.Wright EF. Referred craniofacial pain patterns in patients with temporomandibular disorder. J Am Dent Assoc 2000;131(9):1307-15.

6.Benoliel R, Birman N, Eliav E, Sharav Y. The International Classification of Headache Disorders: accurate diagnosis of orofacial pain? Cephalalgia 2008;28(7):752-62.