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The findings in 30 cases diagnosed as atypical odontalgia are presented. The clinical characteristics of these cases are compared with other cases reported in the literature. Three cases are described in detail. Patient understanding and treatment with tricyclic antidepressants are discussed together with medication side effects and interactions. The importance of deferring invasive procedures is emphasized.
The purpose of the present study is to update the reader on atypical odontalgia and to present some preliminary data on the long-term follow-up of a subsample (n = 28) of these patients. Data based on 120 patients tend to support earlier findings that indicate that primarily women (81%) between the ages of 23 and 60 have this condition. Pain is generally localized in the teeth but may involve several areas of the oral cavity. On the basis of this larger sample size, the relationship between atypical odontalgia and migraine does not appear to be as strong as initially reported. Psychologic disturbance also may play a less significant role than initially thought. Follow-up data on 28 patients suggest that many patients will continue to experience episodes of pain. Antidepressant medication still appears to be the treatment of choice for this condition.
The symptoms of phantom tooth pain are often considered to be of psychological origin by those unfamiliar with its clinical characteristics. Part of the problem is that phantom tooth pain is often confused with atypical facial pain. Extensive literature exists for the latter that suggests a psychological cause. Many studies of atypical facial pain, however, suffer from one or more of four methodologic problems. In the present study, 115 phantom tooth pain cases are compared with a contrast group of 151 facial pain cases and 137 nonpain controls on a variety of personality characteristics. Only one trait personality factor, locus of control, statistically differentiates the three groups. The chief psychological difference of the phantom tooth pain sample compared with the control and contrast groups was higher scores on a measure of demoralization. Demoralization can be interpreted as a consequence as well as an antecedent of the chronic pain state. Evidence for each opinion is presented. Suggestions for obtaining informed consent of prospective endodontic patients are suggested. This study has not demonstrated that phantom tooth pain cases are characterized by a specific premorbid personality.
A young female with severely uncontrolled hypertension suspected to result from malignant pheochromocytoma underwent combined medical and dental care for the treatment of acute dental pain. The dental treatment was performed with the patient under intravenous sedation and careful perioperative management with the use of high doses of alpha and beta receptor blocking agents. The procedure was completed without intraoperative problems and an uneventful posttreatment course.
It has been recommended that the prescription of dental radiographic examinations be based on a series of selection criteria. This study evaluated the usefulness of the presence of a large or deep restoration as an indicator for the need for a radiographic examination. Patients in need of routine examinations were questioned regarding pain in restored teeth. The radiographs of 2269 restored teeth in 209 patients were evaluated for depth of restoration and presence or absence of periapical pathosis. Another 1306 nonrestored teeth in 100 patients were evaluated similarly. There was an association between pain and periapical pathosis and between depth of restoration and periapical pathosis (p < 0.001 in each case). Radiographic yield for positive apical findings was low in restored teeth, especially when the restoration was shallow. The radiographic yield may be increased if other factors such as pain or integrity of the restoration are used to help make the decision regarding the need for radiographs.
The study was carried out to determine the risk of acute disease of third molars in young adult patients. The subjects in this case-control study were 100 consecutive university students who complained of third molar problems when making an appointment. The third molars were mostly mandibular, partly erupted, and distoangularly oriented. Severity of discomfort and interference with daily activities were graded by the patients on average as 5.0 (SD +/- 2.7) and 3.6 (SD +/- 2.9), on a scale from 0 through 10. Distoangular lower third molars caused the most discomfort and interfered most with activities of patients. The risk of acute disease in patients with distoangularly oriented third molars was 3.6 times that in other patients. Bivariate analysis showed that if the follicle of a distoangular third molar were enlarged, the risk of acquiring acute disease was 44 times that in other patients. It was concluded that early removal of partially erupted and distoangularly oriented lower third molars is recommended, especially when they are associated with an enlarged follicle.
Several authors have asserted that psychological factors are the underlying cause of atypical odontalgia. However, objective evidence is lacking to support this claim. In this study, the Minnesota Multiphasic Personality Inventory was used to assess psychological functioning of an atypical odontalgia population. Means of the standard scores for each Minnesota Multiphasic Personality Inventory scale were within normal ranges. Standard scores for atypical odontalgia profiles compared with standard scores for a chronic headache group (matched for age, sex, and chronicity) were similar and scales for both groups were within normal ranges. These findings fail to support psychological dysfunction as a primary condition associated with patients suffering from atypical odontalgia.
The diagnosis of dental pain that results from a pulpal pathosis may prove to be a confusing and complex issue for both dental students and experienced clinicians alike. A computerized diagnostic expert system, COMENDEX, was developed to aid in the clinical diagnosis of pulpal pathosis and to provide a rapid, accurate second opinion when a human consultant is not readily available. The vast majority of diagnostic expert systems use a single reasoning methodology as their inference mechanism. COMENDEX is a prototype hybrid expert system that combines and exploits the best aspects of both rule-based and statistical reasoning methodologies. The COMENDEX endodontic diagnostic system was tested to determine the validity and accuracy of its diagnoses by the use of a variant of Turing's test and weighted kappa statistic. The promising result obtained from the initial tests suggests that an expert system using this type of hybrid reasoning methodology is well suited to the area of endodontic diagnosis and may prove highly successful if expanded to include other problem areas in oral diagnosis.
Phantom tooth pain is a syndrome of persistent pain or paresthesia in teeth and other oral tissues that may follow dental or surgical procedures such as pulp extirpation, apicoectomy, tooth extractions, or exenteration of the contents of the maxillary antrum. It can also occur when nerves are injured after trauma to the face or even after routine inferior alveolar nerve blocks if the needle pierces the nerve sheath. In the case of tooth extraction, the pain is found in the edentate area. After periodontal surgery, pain or paresthesia is located in the gingiva. The incidence of phantom tooth pain after extirpation may be as high as 3% of cases. Clinically, phantom tooth pain is similar in many essential characteristics to deafferentation pain syndromes also known as phantom pain syndromes. A limitation to this taxonomy is the lack of definitive information with respect to the pathophysiology of deafferentation pain in the trigeminal nerve. This article amplifies previous clinical descriptions of phantom tooth pain. Current concepts in the pathophysiology of neuropathic pain are reviewed as they pertain to phantom tooth pain. Treatments are described that use three routes of drug administration: oral, nerve blocks by injections, and intranasal applications. Reasons are discussed for the high rates of morbidity after dental and neurosurgery in attempts to treat phantom tooth pain.
Research conducted in the last 10 years has increased our knowledge on pain mechanisms substantially. Although many local tissue mediators, including neuropeptides, are known to exert pro-inflammatory effects, comparatively little is known about the actual tissue levels of these inflammatory mediators and their pharmacologic regulation. This article describes two new methods, clinical microdialysis and superfusion of dental pulp, which provide data on the pharmacology of peripheral neuropeptide and inflammatory mediator release. Collectively, these methods provide a biochemically based approach toward determining the mechanisms and management of orofacial pain.
A study of the willingness of 363 general dental practices in Brazil to accept a patient infected with human immunodeficiency virus for treatment of dental pain and the provision of routine dental care showed only 44% of dental practices to be willing to provide dental care. Willingness was influenced neither by financial factors nor the local prevalence of human immunodeficiency virus disease.
The role of microorganisms in the cause of endodontic lesions has been intensively investigated. Bacterial components such as endotoxin and other cell wall components are implicated in the development of pulpal and periapical inflammation. Newer anaerobic microbiologic techniques have facilitated accurate and reproducible identification of endodontic pathogens, some of which have been reclassified. This article reviews and correlates newer microbiologic findings with clinical symptoms.
The ability of intracanal use of two nonsteroidal anti-inflammatory agents--diclofenac and ketoprofen--with and without hyaluronidase to control posttreatment pain was compared with that of a placebo control in a double-blind study of 760 subjects. The study was carried out on originally asymptomatic and symptomatic teeth that required endodontic therapy. Endodontic treatment was completed in three visits during which medications were placed into the canal either at the end of the first visit (postextirpation) or the second visit (postinstrumentation). Patients subjectively rated their pain on a scale of 1 to 4 as none, mild, moderate, and severe. The ratings were done preoperatively and at 2, 4, 8, and 12 hours postoperatively on the first day as well as on the second and third days. Statistical analysis of the data revealed that both diclofenac and ketoprofen significantly reduced the mean pain score in originally asymptomatic and symptomatic cases and were significantly superior to the placebo until the end of the study. Postendodontic pain occurred with less frequency when the teeth were treated with diclofenac, but diclofenac-treated and ketoprofen-treated cases were not significantly different at controlling postendodontic pain. An increase in the number of patients who reported complete absence of pain was recorded when hyaluronidase was added to the study medications. However, the difference between the medications and medications-hyaluronidase was not of statistical significance.
Neuropathic pain may be a major cause of pain in the head and neck. Trigeminal neuralgia may appear as intraoral pain. This article reviews a series of 24 consecutive cases of oral pain treated with topical capsaicin. Complete remission of neuropathic pain was seen in 31.6% of patients; partial remission was achieved in 31.6% of patients. Trigeminal neuralgia with an intraoral trigger was less responsive to topical therapy than neuropathic pain. Further study is needed to clarify the efficacy of topical capsaicin in neuropathic and neuralgic pain and the effect of differing dosages and frequency of application. On the basis of the findings in this open-label clinical trial, controlled clinical study of capsaicin in neuropathic oral pain states appears warranted.
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A simple method for bipolar electrical stimulation of the tooth pulp for evaluating pain modulating procedures is described. Stimulation selectivity has been studied by means of cortical evoked potentials before and after gum anaesthesia. Results obtained by constant current and constant voltage stimulation have been compared. Constant voltage stimulation has proved to be more stable in time. This technique is able to differentiate the analgesic effect of a single dose of i.v. lysine acetylsalicylate from saline. Threshold sensation was judged as painful by about half of the subjects.
A verbal and a visual scale to assess pain, the McGill Pain Questionnaire and the Visual Analogue Scales, were administered to 50 patients suffering from pulpitis and 50 patients suffering from pericoronitis. The results show that words chosen to describe dental pain of different etiologies include throbbing, sharp, aching, and annoying. Additional descriptive words used by patients with pulpitis, pericoronitis, and postoperative dental pain are sore and shooting and tender. Women who have pulpitis and pericoronitis report higher levels of pain than do men. The greater sensitivity of the scores obtained from the variables, number of words chosen, and pain rating intensity scale not only showed a significant difference between males and females, but also could distinguish between the two dental conditions. The value of the MPQ as a diagnostic tool in cases where it is difficult to elucidate the cause is limited.
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