When a toothache isn't really a toothache

A patient comes into your practice complaining of a toothache, so you perform a careful examination and take radiographs. But what happens next puzzles you. There is no clinical evidence that something is wrong with the tooth, yet the patient is still in pain. Is the person crazy?

Not always, according to Kenneth Moore, DDS, and John Orsi, DDS, two orofacial pain and sleep medicine experts from the University of California, Los Angeles (UCLA). They shared what the red flags are for identifying pain that isn't dental in nature at the recent California Dental Association's CDA Presents 2018 meeting in Anaheim, CA.

"Where does it hurt?" Dr. Moore said. "We've been using this philosophy to fight tooth decay, gum disease, and occlusal disease. It works for many people, but it doesn't work for everybody."

The dual nature of pain

The first thing dentists need to know about pain is its definition, Dr. Moore said. He defined pain as an unpleasant sensory and emotional experience.

"Pain is a physical sensation and an emotional experience," Dr. Moore said. "Whether it's physical pain or a broken heart, it's all pain to the brain."

That's why hidden traumas, such as childhood abuse, post-traumatic stress disorder, sexual assault, or drug abuse, can sometimes trigger tooth and jaw pain.

"Patients that have multiple pain issues ... what happens is that it's like a traffic jam in there, and the pain gets shot out to other areas," Dr. Orsi said.

Stress can even cause dental pain, and Dr. Moore notices an uptick in stress-related toothaches around the beginning and end of the school year.

"Anytime around the beginning of a school year and the end of the school year, we get a flood of healthy 20-something-year-olds complaining about jaw and tooth pain," he said. "But when it's around spring break, we never hear from them."

But even other physical conditions can present as dental pain. For instance, pain in the lower left quadrant of the mouth may indicate the patient has a heart condition, while chin numbness may indicate metastatic cancer.

"Hunt for signs and symptoms with intensity as a team," Dr. Orsi said. "It deserves attention because our patients are literally trusting us with their lives."

How to correctly identify nondental pain

Certain red flags can distinguish odontogenic and nonodontogenic pain, and by doing your due diligence, you may prevent inappropriate treatment and make timely, potentially lifesaving referrals. And the first step is to get a thorough patient history.

"Although helpful, I don't need a patient history when I see a big hole or a big abscess," Dr. Moore said. "But patient history in nonodontogenic pain is critical. It is the thing."

Some things to look for in a patient history include a history of trauma or excessive stress, both of which can cause the body's natural pain modulation system to malfunction. Furthermore, if patients have chronic pain, migraines, limb movement disorders, or restless leg system, it can be a sign that the problem may be originating elsewhere.

"One of the red flags is if they've had this pain for three months," Dr. Orsi said. "They're not going to live with endodontic tooth pain for three months."

They also recommend that dentists and hygienists know the keywords that distinguish nonodontogenic pain from odontogenic pain. If the following words come up, it's a red flag that you're dealing with pain that doesn't originate in the mouth:

• Burning
• Tingling
• Electric
• Searing
• Stabbing
• Numb
• Bilateral

"Sometimes the patients won't say that," Dr. Moore said. "You have to ask them."

You should also do your due diligence to rule out something systematic, Drs. Moore and Orsi said. This includes taking your patients' vitals and asking about neurological symptoms. In addition, suddenly experiencing a new type of headache, and neurological symptoms all may indicate a serious, nondental problem.

"Did you take vital signs: blood pressure, temperature, pulse, SpO2 [blood oxygen saturation]?" Dr. Orsi said. "Did you perform a neurologic screening? Did you get a headache and sleep history?"

Finally, when diagnosing a patient, trust your gut instinct but also use all testing modalities available to you to verify that your instincts are correct. Any inconclusive findings could be a red flag that the pain isn't originating where you think it is, and that patient may need a referral.

"Say you're doing a root canal on tooth #20, and their lip is profoundly numb, and there's no change in the tooth pain," Dr. Orsi said. "Stop there. That's not a normal root canal."