what is the relationship between the misdiagnosis of

8/13/2019 What is the Relationship Between the Misdiagnosis Of

1/40

Endodontic Pain or TMD?Differential Diagnosis

Gary D. Klasser

Orofacial Pain


2/40

You must understand function before you can understanddysfunction

Dr. W. Bell

A clinician can not treat a disorder until he or she has asound understanding of order

Dr. W. Bell

You can not diagnose what you do not understand

Unknown


3/40

Introduction

Toothache - most common complaint

12.2% of the general population report a toothache withinthe last 6 months (Lipton, Ship and Larach-Robinson)

Diagnosis can be challenging and complicated

Pain from one tooth may be referred from another toothor from other orofacial structures

Other facial pain disorders may mimic the symptoms oftoothache

Proper Diagnosis is critical


4/40

Clinical Characteristics of Odontogenic Pain

Mainly inflammatory

2 Tissues: Pulp and Periodontium

Functionally and embryologically distinct

Pain is perceived differently

Teeth are visceral tissues that function as part of the

musculoskeletal systemPulpal pain = visceral pain

Periodontal pain = musculoskeletal pain


5/40

Pulpal Pain

Types:

Reversibleor Irreversible

Reversible: brief, non-spontaneous, provoked pain that ispresent only as long as a stimulus is in contact with the tooth

Irreversible: prolonged pain provoked by a stimulus or

occurring spontaneously

If pain is prolonged and intense, centralexcitatory effects may produce pain referral


6/40

Pulpal Pain

Deep, dull, aching pain of a threshold nature

Often difficult to localize

Occurs irrelevant to biomechanical (masticatory) functions


7/40

Common Characteristics of Pulpal Pain

1. Quality of pain is dull, aching, throbbingand occasionallysharp

2. An identifiable conditionthat reasonably explains thesymptoms

3. Response to local noxious stimulation is proportionate andpredictable

4. Pulpal pain tends to get better or worse, but rarely stays

the sameover time5. Local anesthesia of the suspected tooth eliminates the pain


8/40

Odontogenic pain can be extremely versatileand have the propensity to mimic many other

pain disorders

Rule of ThumbConsider all pains in the mouth and face to

be of dental origin until proved otherwise.


9/40


10/40

Common Characteristics of Periodontal Pain

1. Pain is dull and aching

2. An identifiable periodontal condition explains the symptoms

3. Response to local mechanical pressure is proportionatetothe amount of force applied, rather than a threshold

response (as in pulp)

4. During chewing, the tooth feels sore or elongated.Discomfort is often felt when biting pressure is releasedrather than while it is sustained***(GARY, see notes section

of this slide)

5. Local anesthesia of the suspected periodontal tissueeliminates the pain


11/40

Site of Pain vs. Source of Pain

Site of Pain

The location where the patient feels the painEasily locatedby asking the patient to point out theregion of the body that is painful

Source of PainThat area of the body from which the pain actually originates


12/40

Primary Pain

Site (where it hurts) = Source (where it originates)

Eg./ cut finger

Heterotopic PainSite Source

Eg./ cardiac pain


13/40

Rule of Thumb

Successful therapyis achieved bytreating the Source of pain, notthe

Site of pain


14/40

Non-Odontogenic Toothache

TYPES

1. Myofascial toothache

2. Neurovascular toothache

3. Cardiac toothache

4. Neuropathic toothache

Episodic

Continuous

5. Sinus toothache

6. Psychogenic toothache


15/40

Myofascial Toothache

1. Pain is non-pulsatile

2. Typically more of a constant ache than pulpal pain

1. Variable , intermittentover months or years2. Pain tends to increase with emotional stress

3. Not responsive to local provocationof the tooth

4. Pain increases with function of involved muscle (Triggerpoints)

5. Local anesthetic of the toothdoes not affect the toothache

6. Local anesthetic of the involved muscle (trigger point)

reduces the toothache


16/40


17/40


18/40


19/40

Neurovascular Toothache1. Pain is spontaneous, variable and pulsatile; simulates pulpal

pain

2. Has periods of remission. Episodes of pain may pose atemporal behavior appearing at similar times during the day,week or month

3. Lack of reasonable dental causeof pain

4. Effect of local anesthesia isunpredictable

5. May follow illness, sinusitis, dental treatment, surgery or

trauma, appearing to be a complication of a former experience

6. Very frequently initially felt in a tooth(maxillary canine andpremolar usually) as a toothache so convincingly that dentaltreatment may be undertaken , even when only minor dental

cause can be located


20/40

7. May undergo remission following dental treatment, butrecurrence is a characteristic of neurovascular pains.

8. May spread to adjacent teeth, opposing teeth or the entireface

9. If the pain experience is protracted, it may induceautonomic symptoms

10. With time, the complaint spreads to involve wider areasof the face, neck or shoulder and may evoke muscle painand restricted movement

11. Pain may respond to ipsilateral carotid pressure ormigraine medications


21/40

Cardiac Toothache

1. Presence of aching pain that is cyclic

2. Toothache is increased with physical exertion or exercise

3. Toothache is associated with chest pains

4. Toothache is decreased with nitroglycerin tablets

5. Local provocation of the tooth does not alter the pain

6. Local anestheticdoes notarrest the toothache


22/40

Neuropathic Toothache: Episodic

1. Unilateral, sudden, sharp, severe, lacerating and shock-like(paroxysmal)

2. Provoked by relatively innocuous peripheral stimulation of atrigger zone or may occur spontaneously

3. Local anestheticat the tooth will not reduce the pain

unless it also represents the trigger zone (very rare)4. Local anesthetic at the trigger zone will reduce theattacks

5. Patient is typically asymptomatic between the episodes


23/40

Neuropathic Toothache: Continuous

1. Persistent, ongoing and unremitting

2. May be increased by local provocationsuch as touching thetooth and surrounding gingiva, which adds confusion to thediagnosis

3. Presence of other neurologic complaintssuch ashyperesthesia, hypoesthesia, anesthesia, paresthesia,muscular tics, weakness and paralysis as well as autonomicand special sense aberrations, depending on the fiber content

at the site of neuropathy


24/40


Types of neuropathic conditions

Neuritis

Deafferentation

Sympathetically maintained pains


25/40


1. Neuritis Inflammatory condition in the peripheral distribution of the

nerve due to trauma, chemical, viral or bacterial causes

1. Arises in the maxillary or mandibular division of thetrigeminal nervealong with other neurological symptoms

2. Neuritisof thesuperior dental plexusdue to extensionfrom maxillary sinusitismay cause a toothache in andaround one or more of the maxillary teeth

3. Neuritis of the inferior alveolar nervein the mandibularteeth from direct trauma, dental infection or surgery

N thi T th h C ti


26/40


2. Deafferentation

Crushing or cutting of a peripheral nerve (TraumaticNeuralgia)

1. Mayfollow an injurysuch as external trauma, pulpextirpation, extraction or major oral surgery

2. Often mistaken for a post-traumatic or postoperativecomplication

N thi T th h C ti


27/40


2. Deafferentation (Contd)

Atypical Odontalgia (Phantom Toothache)Graff-Radford et al

1. Pain is felt in a tooth or tooth site(maxillary canine and

premolar are most common)2. Pain is continuous or almost continuous

3. Pain persists more than four months

4. No sign of local or referred pain5. Local anestheticof the painful tooth provides equivocal

results


28/40

3. Sympathetically Maintained Pains

Deafferentation tooth pains may be influenced by theefferent activity of the sympathetic nervous system

1. Normal sympathetic activity (sympathetic tone) can beresponsible for maintaining the pain

2. An increase in sympathetic activity could increase the paincondition

3. Increased levels of emotional stresscould aggravate this

condition


29/40

Sinus Toothache

1. Patient reports pressure or pain below the eyes *** Seenotes

2. Toothache is increased with lowering of the head

3. Toothache is increased with applied pressure over theinvolved sinus

4. Local anesthetic of the tooth does not eliminate the pain

5. Diagnosis can be confirmed by air/fluid level seen inappropriate imaging


30/40

Psychogenic Toothache

1. Patient reports that multiple teethare often painful withfrequent change in character and location

2. A general departure from normal or physiologic patterns ofpain

3. Patient presents with chronic pain behavior

4. Lack of responseto reasonable dental treatment

5. Unusual or unexpected response to therapy

6. No other identifiable pain conditionthat can explain the

toothache


31/40

Non-Odontogenic Toothaches

Warning Symptoms- Summary1. Spontaneous multiple toothaches

2. Inadequate local dental cause for the pain

3. Stimulating, burning, non-pulsatile toothaches

4. Constant, unremitting, non-variable toothaches

5. Persistent, recurrent toothaches

6. Local anesthetic blocking of the offending tooth does noteliminate the pain

7. Failure of the toothache to respond to reasonable dentaltherapy


32/40

Case 1

Chief Complaint:

Lowerleft mandibular pain and toothache.

History:

61 yr-old male with mild, continuous but variable, dull aching pain diffusely

located in the left mandible and teeth. Mandibular movement did notincrease the pain. The pain was preceded by left shoulder discomfort. Theshoulder pain began 3 days ago. He went to his physician and wasdiagnosed as bursitis. NSAIDs were prescribed. Two days later, the lefttoothache pain began even though he had been edentulous for 20 years. He

went to his dentist thinking that he had a problem with his lower denture..His dentist took a periapical of the lower left area and discovered animpacted third molar. He was referred to the oral surgeon for extraction ofthe tooth.


33/40

TM joints: Normal.

Muscles: Negative for any cause of pain.

Cranial nerves: Within normal limits.

Diagnostic Tests: Inferior alveolar nerve block in the left did not arrest thepain.

Diagnosis???

Examination:

Intraoral: A normal appearing edentulous mouth with satisfactory dentures.There is no palpable discomfort in the area of the impacted tooth.

Radiograph revealed a complete bony impacted third molar in the leftsubmandibular triangle without any pathology. Mandibular functions arenormal. There is no dental, oral or masticatory cause for the complaint.


34/40

Cardiac muscle pain referred asmandibular toothache


35/40

Case 2

Chief Complaint:

Left mandibular toothache

History:

A 42 yr-old female with mild continuous protracted steady bright

burning pain located in the left mandibular teeth and accompanied byparesthesia described as a sensation of high teeth and recently asgingival swelling.

The complaint began 5 years ago following the surgical removal of animpacted left third molar. After a few months, dental pain began in the

left mandibular first molar which was extracted and replaced by a fixedbridge that felt too high despite repeated occlusal adjustments andfinally refabrication of the prosthesis. A year later, the left mandibularsecond molar was treated endodontically because of pain and later theleft mandibular first and second premolars as well.


36/40

The bridge was replaced after the second premolar and second molar wereextracted and replaced by a removable partial denture. She could not toleratethe prosthesis due to pain. Then some diffuse temporal discomfort began

which lead to muscle therapy by first a Periodontist and then an Oral Surgeonunsuccessfully. Presently, she has an excellent prosthesis but she can notwear it because of pain and a sensation of gingival swelling. It feels no betterwhen she leaves it out.

Examination:

Intraoral: The missing left mandibular teeth were replaced with an excellentremovable partial denture which she does not wear. No dental cause isevident either clinically or radiographically. There is an acute tender spot tofinger pressure located in the mucosal scar residual to the surgery for removalof the left mandibular third molar.


37/40

TM joints: Normal.

Muscles: Minor tenderness in the left Temporalis. Local anesthetic of thatmuscle arrested only the muscle pain.

Cervical: Normal.

Cranial Nerves: Hyperalgesia, paresthesia and dysesthesia were noted atthe gingival tissue over the former extraction sites.

Diagnostic Tests: Local anesthetic into the mucosal scar providedimmediate relief of pain and, therefore, it was presumed to represent apainful Neuroma. Excision, however, provided only a transitory relief andafter a few weeks the pain returned as before.

Diagnosis???


38/40

Continuous neuropathic pain

(Deafferentation) caused by a previousnerve injury


39/40


40/40

what is the relationship between the misdiagnosis of

Documents