non odontogenic tooth ache- referred pain, sinus pain, cardiac tooth ache, muscle pain, neuropathic pain, neurovascular pain, atypical facial pain,

2. Pain is perfect misery, the worst of evils
and excessive, overturns all patience –
John Milton, Paradise Lost

3. Pain is not a simple sensation but rather a complex neurobehavioral
event involving at least two components.
First is an individual’s discernment or perception of the stimulation of
specialized nerve endings designed to transmit information
concerning potential or actual tissue damage (nociception).
Second is the individual’s reaction to this perceived sensation (pain
behavior). This is any behavior, physical or emotional, that follows
pain perception.

5.  Odontogenic pain is generally derived from either one of two
structures associated with the tooth: pulpal or periodontal tissue.
 Pulpitis is the most common cause of odontogenic pain
 As a visceral organ, pain of the dental pulp is characterized by
deep, dull, aching pain that may be difficult to localize
 It may present as intermittent or continuous, moderate or severe,
sharp or dull, localized or diffuse and may be affected by the time
of day or position of the body

6.  Periodontal pain is more readily localized and identifiable because
of proprioceptors located within the periodontal ligament.
 Therefore, periodontal pain will follow the characteristics of pain
of musculoskeletal origin.
 The periodontal receptors are able to accurately localize the pain
whether they are lateral or apical to the tooth

7. Non odontogenic pain

8.  The cardinal warning symptoms of nonodontogenic toothache are as
follows
 spontaneous multiple toothaches
 inadequate local dental cause for the pain
 stimulating, burning, nonpulsatile toothaches
 constant, unremitting, nonvariable toothaches
 persistent, recurrent toothaches
 local anesthetic blocking of the offending tooth does not eliminate the
pain
 failure of the toothache to respond to reasonable dental therapy.

9.  The extent of pain may vary from very mild and intermittent pain
to severe, sharp, and continuous
 Pains that are felt in the tooth do not always originate from dental
structures
 In ‘primary’ pain, the site and source of pain are coincidental and in
the same location
 Pain with different sites and sources of pain, known as heterotopic
pains, can be diagnostically challenging

10. Heterotopic Pain
Central pain Projected pain Referred pain
Constant
nociceptive input
from deep
structures

11.  Central pain is simply pain derived from the central nervous system
(CNS) resulting in pain perceived peripherally
 An example of central pain is an intracranial tumor as this will not usually
cause pain in the CNS because of the brain’s insensitivity to pain but
rather it is felt peripherally
 Projected pain is pain felt in the peripheral distribution of the same nerve
that mediated the primary nociceptive input.An example of projected
pain is pain felt in the dermatomal distribution in post-herpetic neuralgia
 Referred pain is spontaneous heterotopic pain felt at a site of pain with
separate innervation to the primary source of pain
 Pain referred from the sternocleidomastoid muscle to the
temporomandibular joint is an example of referred pain

12. CNS pain – intracranial
tumour
Projected pain in post herpetic
neuralgia
Referred pain inTMJ
disorder

13.  Pain arising from deep tissues, muscles, ligaments, joints, and
viscera is often perceived at a site distant from the actual
nociceptive source.
 Convergence-projection theory:This is the most popular theory.
Primary afferent nociceptors from both visceral and cutaneous
neurons often converge onto the same second-order pain
transmission neuron in the spinal cord.
 The brain, having more awareness of cutaneous than of visceral
structures through past experience, interprets the pain as coming
from the regions subserved by the cutaneous afferent fibers

15.  Convergence-facilitation theory: This theory is similar to the
convergence-projection theory, except that the nociceptive input from
the deeper structures causes the resting activity of the second-order pain
transmission neuron in the spinal cord to increase or be “facilitated.”
 The resting activity is normally created by impulses from the cutaneous
afferents.
 “Facilitation” from the deeper nociceptive impulses causes the pain to
be perceived in the area that creates the normal, resting background
activity.
 This theory tries to incorporate the clinical observation that blocking
sensory input from the reference area, with either local anesthetic or
cold, can sometimes reduce the perceived pain

17.  Careful and exhaustive history
 Physical examination
 Diagnostic studies
 Pulp testing
 Nerve blocks
 Radiographs
 Blood tests
 Appropriate referrals

18.  The myofascial toothache is described as non-pulsatile and aching pain
and occurs more continuously than pulpal pain
 Patients are unable to accurately locate the source of the pain
 Pain tends to be associated with extended muscle use and exacerbated
with emotional stressors, rather than direct provocation of the affected
tooth
 Palpation of the trigger point is able to reproduce the toothache, even
modulate the pain by increasing or eliminating it altogether
 Alleviation of the toothache is often achieved when local anesthetic is
administered to the strained muscle (source of pain) rather than the
tooth (site of pain)

21.  Warm or cold compresses
 Muscle stretching
 Massage, and a restful sleep may alleviate both the muscle
and tooth pain.
 Elimination of the trigger point and pain of the muscle
should be the aim of the treatment rather than the tooth
itself

22.  Ear pain is typically seen with disorders such as otitis media, otitis
externa, and mastoiditis and may be associated with headache
 The ear is innervated by cranial nervesV,VII,VIII, IX, X, and XI
 Therefore, pain can be referred to the ear from inflammatory or
neoplastic disease of the teeth, tonsils, larynx, nasopharynx,
thyroid, TMJ, and cervical spine, as well as from inflammation or
tumors in the posterior fossa of the brain
 Patients with otitis externa (inflammation of the external auditory
canal) may present themselves to the dentist first because this
pain is aggravated by swallowing

23.  The dentist must carefully examine the dentition for pulpal
disease and the oropharyngeal mucosa for inflammation to rule
out referred ear pain from oral or dental sources.
 MyofascialTrPs (trigger points) in the lateral and medial pterygoid
muscles frequently refer pain to the ear as well.

24.  Cardiac ischemia more commonly presents with substernal pain and
radiation to the left shoulder and arm
 When cardiac pain presents in the orofacial region commonly affected
areas include pain(s) in the neck, throat, ear, teeth, mandible and
headache
 The mechanism of cardiac pain likely involves multiple nociceptive
mediators with bradykinin being the most important, evoking a
sympathoexcitatory reflex and inducing a sympathetic response of the
heart
 Pain may be episodic, lasting from minutes to hours, and varies in
intensity, although almost invariably is precipitated by exertional
activities and alleviated with rest

25. Cardiac nociceptive input
travels into CNS
Ascends to higher centers for processing in region of
convergence
Adjacent nociceptors are activated
Misinterpreted in cortex – unintentional
pain input
Heterotopic pain

26. These
symptoms
may radiate
upward from
the
epigastrium
to the
mandible the
left more
frequently
than the
right.

27. The pain of angina pectoris is often felt in the left arm or the jaw, and diaphragmatic
pain is often perceived in the shoulder or neck

28.  Since the roots of the maxillary dentition are in intimate contact with,
and often protruding into, the sinus cavity, it is comprehensible that the
dentition could be a potential source of sinus inflammation and infection.
 Patients may present with facial pain and pressure in the maxillary
posterior region.
 constant but rather mild pain in a number of posterior maxillary
teeth on one side is almost pathognomonic
 Other symptoms such as headache, halitosis, fatigue, cough, nasal
discharge/drainage or congestion and ear pain may be more identifiable
as being associated with sinus disease
 Sinus pain can also present as a continuous dull ache or diffuse lingering
pain in the maxillary teeth with sensitivity to percussion, mastication,
and/or temperature

29. .The pain, mild but deep and nonpulsating, radiates out of this area onto the face,
upward toward the temple, and forward toward the nose. A referred frontal
headache and cutaneous hyperalgesia along the side of the face and scalp may also
be present

30.  Pain may be elicited by palpation of the infraorbital regions or
maneuvering the head to below the levels of the knees, initiating
gravitational shifting of fluid in the sinus
 The absence of an offending tooth or gingival inflammation upon
intraoral examination may further lead to the conclusion that there is
sinus inflammation or infection.
 The sinuses may appear cloudy, opacified, and congested on the
panoramic radiograph.
 Most cases of acute sinusitis are of viral origin and require nasal
decongestants, a therapy targeted at reducing the soft tissue edema to
allow drainage of the sinus through the ostium into the middle meatus of
the nasal cavity

31. The canaliculi of the teeth often open toward the sinus, and pulpal nerves may
be in direct contact with the inflamed mucoperiosteum of the sinus lining.
Their direct irritation may cause dental symptoms.

32.  The typical symptom picture includes pain over at least one lobe
of the thyroid gland or pain radiating up the sides of the neck and
into the lower jaws, ears, or occiput. Swallowing may aggravate
the symptoms.
The thyroid gland may be visibly
enlarged and will be tender to
palpation with nodularity . If
thyroiditis or other thyroid disease
is suspected, referral to the
patient’s physician should be made
for a complete medical workup.

33.  Headache may also present as a variant involving the orofacial region
mimicking toothache
 Two primary headache types that may present as toothache are migraine
and trigeminal autonomic cephalalgia
 Migraines are typically unilateral, moderate to severe pains of pulsatile
and throbbing quality that are often disabling
 Migraine is often accompanied by nausea, vomiting, phonophobia and/or
photophobia and may present with (20%) or without aura
 Trigeminal autonomic cephalalgias (TACs) are a collective term that
refers to a group of headaches characterized by unilateral head and/or
face pain with accompanying autonomic features

36. The most common sites are either around and behind the eye radiating to the
forehead and temple or around and behind the eye radiating infraorbitally
into the maxilla and occasionally into the teeth, rarely to the lower jaw and
neck.

38.  Neuropathic pain refers to a pain that originates from
abnormalities in the neural structures and not from the tissues
that are innervated by those neural structures
 There are two types of neuropathic pains that can be felt in teeth:
episodic and continuous
 Episodic neuropathic pain is characterized by sudden volleys of
electric-like pain referred to as neuralgia. The most typical
example of this type of pain is trigeminal neuralgia
 The clinical presentation of an episodic neuropathic toothache is a
severe, shooting, electric-like pain that lasts only a few seconds

40.  The pain is not altered by intraoral thermal stimuli
 The most common branch of the trigeminal nerve involved is the
mandibular followed by the maxillary and least involved is the
ophthalmic
 With trigeminal neuralgia there is often a trigger zone that, when lightly
stimulated, provokes the severe paroxysmal pain.
 Anesthetic blocking of the trigger zone will completely eliminate the
toothache and paroxysmal episodes during the period of anesthesia.
 Patients with trigeminal neuralgia frequently receive endodontic
treatment for their dental pain
Trp

42.  Continuous neuropathic pains are pain disorders that have their
origin in neural structures and are expressed as constant, ongoing
and unremitting pain
 Continuous neuropathic pains that can be felt in teeth have been
referred to as atypical odontalgia or sometimes phantom
toothache
 Patients with continuous neuropathic toothache often report a
history of trauma or ineffective dental treatment in the area
 It is not unusual for patients with continuous neuropathic
toothache to have received multiple endodontic treatments or
extractions for their dental pain

43.  The following characteristics of continuous neuropathic toothache can
be used to differentiate it from odontogenic pain:
 a) diffuse pain
 b) pain not always restricted to a tooth (e.g., the area may be
edentulous)
 c) pain that is almost always continuous
 d) a pain quality often described as a dull, aching, throbbing, or burning
 e) pain that may or may not be relieved by a diagnostic intraoral local
anesthetic block
 f) pain that often lasts more than 4 months
 g) pain not altered by intraoral thermal stimuli
The molars are most commonly involved, followed by premolars

44. The vast majority of patients present
themselves with unilateral pain
Onset of the pain may coincide
with the dental treatment
A more probable cause of atypical odontalgia is
deafferentation (partial or total loss of the afferent
nerve supply or sensory input) with or without
sympathetic involvement
The current treatment of
choice is the use of tricyclic
antidepressant agents
such as amitriptyline or
imipramine.
If the pain has a burning
quality, the addition of a
phenothiazine, such as
trifluoperazine, may be
helpful

45.  Primary squamous cell carcinoma (SCC) of the oral mucosa may present
with pain and sensory disturbances that mimic toothache symptoms
particularly when located on the gingiva, vestibule or floor of mouth.
 Nasopharyngeal cancers may present with signs and symptoms that
have been confused with, and treated as, temporomandibular disorders
parotid gland lesions ,and odontogenic infections with trismus
 Systemic cancers such as lymphoma and leukemia may have intraoral
manifestations that mimic toothache like symptoms
 Orofacial pain has also been reported in patients with distant non-
metastasized cancers, most commonly from the lungs

46.  Orofacial pain may be associated with metastatic malignancies
and when metastatic orofacial tumors occur, they affect the jaw
bones more often than the oral soft tissues
squamous cell carcinoma

47.  Psychogenic pain is pain that is associated with psychologic
factors in the absence of any physiologic cause.
 Pain descriptors are often diffuse, vague, and difficult to localize
 Pain may be sharp, stabbing, intense, and sensitive to
temperature changes, all of which are similar to pain symptoms of
odontogenic origin
 The pain is inconsistent with normal patterns of physiologic pain
and presents without any identifiable pathologic cause
 Patients should be referred to a psychiatrist or psychologist for
further management.