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Atypical Odontalgia
Chapter 15 ATYPICAL ODONTALGIA
ICD-9 CODE 525.9 ICD-10 CODE K08.9 The Clinical Syndrome Atypical odontalgia (also known as persistent orodental pain syndrome) describes a heterogeneous group of pain syndromes that share in common the fact that the odontalgia cannot be classified as classic trigeminal neuralgia. The pain is continuous but may vary in intensity. It is almost always unilateral and may be characterized as aching or cramping rather than the shocklike neuritic pain typical of trigeminal neuralgia. The vast majority of patients suffering from atypical odontalgia are female. Atypical odontalgia can occur at any age, but has a peak incidence in the fifth decade of life. The pain is felt in a single tooth or its surrounding area and occurs most commonly in the maxillary region (Figure 15-1). Headache may occur with atypical odontalgia and is clinically indistinguishable from the tension type of headache. Stress is often the precipitating, or an exacerbating, factor in the development of atypical odontalgia. Depression and sleep disturbance are also present in a significant number of patients. A history of dental or facial trauma, including dental extractions, root canal treatment, infection, or tumor of the head and neck may be elicited in some patients with atypical odontalgia, but in many cases no precipitating event can be identified.
to identify a tumor or bony abnormality. Magnetic resonance imaging (MRI) of the brain and sinuses can help the clinician identify intracranial pathology such as tumor, sinus disease, and infection (Figure 15-2). A complete blood count, erythrocyte sedimentation rate, and antinuclear antibody testing are indicated if inflammatory arthritis or temporal arteritis is suspected. Injection of the painful tooth with small amounts of local anesthetic can serve as a diagnostic maneuver to determine whether the tooth or adjacent structures are the source of the patient’s pain. Differential neural blockade can help distinguish primary tooth pathology from atypical odontalgia and reflex sympathetic dystrophy of the face (Table 15-2). Complete relief of pain after injection of the painful tooth with local anesthetic suggests a local pathological process, whereas incomplete pain relief suggests the pathological process is more central. Thus the diagnosis of atypical odontalgia is a strong possibility of underlying pathological condition of the trigeminal nerve, adjacent bone, brain, or brainstem. Complete relief of pain after ipsilateral stellate ganglion block is highly suggestive of reflex sympathetic dystrophy of the face. Psychological
Signs and Symptoms Table 15-1 compares atypical odontalgia with trigeminal neuralgia. Unlike trigeminal neuralgia, which is characterized by sudden paroxysms of neuritic shocklike pain, atypical odontalgia is constant and has a dull, aching quality but may vary in intensity. The pain of trigeminal neuralgia is almost always within the distribution of one division of the trigeminal nerve, whereas atypical odontalgia invariably involves just a single tooth, its surrounding gingival tissue, or underlying bone. The trigger areas characteristic of trigeminal neuralgia are absent in patients with atypical odontalgia. Most important, no findings of pathological condition of the painful tooth or adjacent gingival tissues are seen on physical examination.
Testing Radiographs of the head are usually within normal limits in patients suffering from atypical odontalgia, but they may be useful
Figure 15-1 Patients with atypical odontalgia often rub the affected area; those with trigeminal neuralgia do not.
37
38 SECTION 1 • Headache and Facial Pain Syndromes TABLE 15-1
Comparison of Trigeminal Neuralgia and Atypical Odontalgia Atypical Odontalgia
Pain Factor
Trigeminal Neuralgia
Temporal pattern of pain
Sudden and intermittent
Constant
Character of pain
Shocklike and neuritic
Dull, aching, cramping
Pain-free interval
Usual
Rare
Distribution of pain
One division of the trigeminal nerve
One tooth and surrounding area
Trigger areas
Present
Uncommon
Underlying psychopathology
Rare
Common
evaluation should be considered if significant coexistent depression or sleep disturbance is present.
Differential Diagnosis The clinical symptoms of atypical odontalgia may be confused with pain of dental or sinus origin or may be erroneously characterized as trigeminal neuralgia. Careful questioning and physical examination usually allow the clinician to distinguish these overlapping pain syndromes. Tumors of the zygoma, maxilla, and mandible, as well as posterior fossa and retropharyngeal tumors, may produce ill-defined pain that is attributed to atypical odontalgia. These potentially life-threatening diseases must be excluded in any patient with odontalgia (see Figure 15-2). Reflex sympathetic dystrophy of the face should also be considered in any patient with ill-defined odontalgia after trauma, infection, or central nervous
A
B
C
D
Figure 15-2 Computed tomography (CT) scan and magnetic resonance imaging (MRI) of the lesion. CT shows a well-defined expansile lesion with thin cortical margin and high-density area (A). MRI of the lesion revealed the well-circumscribed lesion (B) to be homogeneously and relatively hypointense on T2-weighted imaging (C). The lesion was weakly enhanced by gadolinium (D). (From Nozaki S, Yamazaki M, Koyama T, et al: Primary extracranial meningioma of the maxillary sinus presenting as buccal swelling, Asian J Oral Maxillofac Surg 23:134–137, 2011.)
15 • Atypical Odontalgia 39 TABLE 15-2
Differential Nerve Block in the Diagnosis of Atypical Odontalgia 1. Record the patient’s pain level on a visual analogue scale of 0 to 10. 2. Isolate the painful area with cotton rolls and cheek retractor. 3. Dry the painful area with gauze. 4. Apply 20% topical benzocaine gel to the painful area. 5. Record the patient’s pain level on a visual analogue scale of 0 to 10 every 3 minutes for 15 minutes. 6. If the patient experiences incomplete pain relief, perform localized block of the painful tooth with 1% lidocaine 1.5 mL. 7. Record the patient’s pain level on a visual analogue scale of 0 to 10 every 3 minutes for 15 minutes. 8. If the patient experiences incomplete relief, perform ipsilateral stellate ganglion block with 0.5% preservative-free lidocaine 7 to 10 mL. 9. Record the patient’s pain level on a visual analogue scale of 0 to 10 every 3 minutes for 15 minutes. 10. Repeat this sequence on a separate visit to confirm the results.
system injury. As noted, atypical odontalgia is dull and aching, whereas reflex sympathetic dystrophy of the face causes burning pain and significant allodynia is often present. Stellate ganglion block may help distinguish these two pain syndromes; the pain of reflex sympathetic dystrophy of the face readily responds to this sympathetic nerve block, whereas atypical odontalgia does not. Atypical odontalgia must also be distinguished from the pain of jaw claudication associated with temporal arteritis.
Treatment The mainstay of therapy is a combination of drug treatment with tricyclic antidepressants and physical modalities such as oral orthotic devices and physical therapy. Trigeminal nerve block and intraarticular injection of the temporomandibular joint with small amounts of local anesthetic and steroid also may be of value. Antidepressants such as nortriptyline at a single bedtime dose of 25 mg can help alleviate sleep disturbance and treat any underlying myofascial pain syndrome. Orthotic devices help the patient avoid jaw clenching and bruxism, which may exacerbate the clinical syndrome. Management of underlying depression and anxiety is also mandatory.
Complications and Pitfalls The major pitfall in caring for patients thought to have atypical odontalgia is failure to diagnose underlying pathology that may be responsible for the patient’s pain. Atypical odontalgia is essentially a diagnosis of exclusion. If trigeminal nerve block or intraarticular injection of the temporomandibular joint is being considered as part of the treatment plan, it must be remembered that the region’s vascularity and proximity to major blood vessels can lead to an increased incidence of postblock ecchymosis and hematoma formation, and the patient should be warned of this potential complication.
Clinical Pearls Atypical odontalgia requires careful evaluation to design an appropriate treatment plan. Infection and inflammatory causes, including collagen-vascular diseases, must be ruled out. Stress and anxiety often accompany atypical odontalgia, and these factors must be addressed and treated. The myofascial pain component of atypical odontalgia is best treated with tricyclic antidepressants such as amitriptyline. Dental malocclusion and nighttime bruxism should be treated with an acrylic bite appliance. Opioid analgesics and benzodiazepines should be avoided in patients with atypical odontalgia.
SUGGESTED READINGS Clark GT: Persistent orodental pain, atypical odontalgia, and phantom tooth pain: when are they neuropathic disorders? J Calif Dent Assoc 34:599–609, 2006. Marbach JJ: Is phantom tooth pain a deafferentation (neuropathic) pain syndrome? Oral Surg Oral Med Oral Pahtol 75:95-105, 1993. Marbach JJ: Orofacial phantom pain: theory and phenomenology, JADA 127:221–229, 1996. Marbach JJ, Raphael KG: Phantom tooth pain: a new look at an old dilemma, Pain Med 1:68–77, 2000. Matwychuk MJ: Diagnostic challenges of neuropathic tooth pain, J Can Dent Assoc 70:542–546, 2004. McQuay HJ, Tramér M, Nye BA, et al: A systematic review of antidepressants in neuropathic pain, Pain 68:217–227, 1996. Melis M, Lobo SL, Ceneviz C, et al: Atypical odontalgia: a review of the literature, Headache 43:1060–1074, 2003. Pertes RA, Bailey DR, Milone AS: Atypical odontalgia: a nondental toothache, J N J Dent Assoc 66:29–31, 33, 1995.
ICD-9 CODE 525.9 ICD-10 CODE K08.9 The Clinical Syndrome Atypical odontalgia (also known as persistent orodental pain syndrome) describes a heterogeneous group of pain syndromes that share in common the fact that the odontalgia cannot be classified as classic trigeminal neuralgia. The pain is continuous but may vary in intensity. It is almost always unilateral and may be characterized as aching or cramping rather than the shocklike neuritic pain typical of trigeminal neuralgia. The vast majority of patients suffering from atypical odontalgia are female. Atypical odontalgia can occur at any age, but has a peak incidence in the fifth decade of life. The pain is felt in a single tooth or its surrounding area and occurs most commonly in the maxillary region (Figure 15-1). Headache may occur with atypical odontalgia and is clinically indistinguishable from the tension type of headache. Stress is often the precipitating, or an exacerbating, factor in the development of atypical odontalgia. Depression and sleep disturbance are also present in a significant number of patients. A history of dental or facial trauma, including dental extractions, root canal treatment, infection, or tumor of the head and neck may be elicited in some patients with atypical odontalgia, but in many cases no precipitating event can be identified.
to identify a tumor or bony abnormality. Magnetic resonance imaging (MRI) of the brain and sinuses can help the clinician identify intracranial pathology such as tumor, sinus disease, and infection (Figure 15-2). A complete blood count, erythrocyte sedimentation rate, and antinuclear antibody testing are indicated if inflammatory arthritis or temporal arteritis is suspected. Injection of the painful tooth with small amounts of local anesthetic can serve as a diagnostic maneuver to determine whether the tooth or adjacent structures are the source of the patient’s pain. Differential neural blockade can help distinguish primary tooth pathology from atypical odontalgia and reflex sympathetic dystrophy of the face (Table 15-2). Complete relief of pain after injection of the painful tooth with local anesthetic suggests a local pathological process, whereas incomplete pain relief suggests the pathological process is more central. Thus the diagnosis of atypical odontalgia is a strong possibility of underlying pathological condition of the trigeminal nerve, adjacent bone, brain, or brainstem. Complete relief of pain after ipsilateral stellate ganglion block is highly suggestive of reflex sympathetic dystrophy of the face. Psychological
Signs and Symptoms Table 15-1 compares atypical odontalgia with trigeminal neuralgia. Unlike trigeminal neuralgia, which is characterized by sudden paroxysms of neuritic shocklike pain, atypical odontalgia is constant and has a dull, aching quality but may vary in intensity. The pain of trigeminal neuralgia is almost always within the distribution of one division of the trigeminal nerve, whereas atypical odontalgia invariably involves just a single tooth, its surrounding gingival tissue, or underlying bone. The trigger areas characteristic of trigeminal neuralgia are absent in patients with atypical odontalgia. Most important, no findings of pathological condition of the painful tooth or adjacent gingival tissues are seen on physical examination.
Testing Radiographs of the head are usually within normal limits in patients suffering from atypical odontalgia, but they may be useful
Figure 15-1 Patients with atypical odontalgia often rub the affected area; those with trigeminal neuralgia do not.
37
38 SECTION 1 • Headache and Facial Pain Syndromes TABLE 15-1
Comparison of Trigeminal Neuralgia and Atypical Odontalgia Atypical Odontalgia
Pain Factor
Trigeminal Neuralgia
Temporal pattern of pain
Sudden and intermittent
Constant
Character of pain
Shocklike and neuritic
Dull, aching, cramping
Pain-free interval
Usual
Rare
Distribution of pain
One division of the trigeminal nerve
One tooth and surrounding area
Trigger areas
Present
Uncommon
Underlying psychopathology
Rare
Common
evaluation should be considered if significant coexistent depression or sleep disturbance is present.
Differential Diagnosis The clinical symptoms of atypical odontalgia may be confused with pain of dental or sinus origin or may be erroneously characterized as trigeminal neuralgia. Careful questioning and physical examination usually allow the clinician to distinguish these overlapping pain syndromes. Tumors of the zygoma, maxilla, and mandible, as well as posterior fossa and retropharyngeal tumors, may produce ill-defined pain that is attributed to atypical odontalgia. These potentially life-threatening diseases must be excluded in any patient with odontalgia (see Figure 15-2). Reflex sympathetic dystrophy of the face should also be considered in any patient with ill-defined odontalgia after trauma, infection, or central nervous
A
B
C
D
Figure 15-2 Computed tomography (CT) scan and magnetic resonance imaging (MRI) of the lesion. CT shows a well-defined expansile lesion with thin cortical margin and high-density area (A). MRI of the lesion revealed the well-circumscribed lesion (B) to be homogeneously and relatively hypointense on T2-weighted imaging (C). The lesion was weakly enhanced by gadolinium (D). (From Nozaki S, Yamazaki M, Koyama T, et al: Primary extracranial meningioma of the maxillary sinus presenting as buccal swelling, Asian J Oral Maxillofac Surg 23:134–137, 2011.)
15 • Atypical Odontalgia 39 TABLE 15-2
Differential Nerve Block in the Diagnosis of Atypical Odontalgia 1. Record the patient’s pain level on a visual analogue scale of 0 to 10. 2. Isolate the painful area with cotton rolls and cheek retractor. 3. Dry the painful area with gauze. 4. Apply 20% topical benzocaine gel to the painful area. 5. Record the patient’s pain level on a visual analogue scale of 0 to 10 every 3 minutes for 15 minutes. 6. If the patient experiences incomplete pain relief, perform localized block of the painful tooth with 1% lidocaine 1.5 mL. 7. Record the patient’s pain level on a visual analogue scale of 0 to 10 every 3 minutes for 15 minutes. 8. If the patient experiences incomplete relief, perform ipsilateral stellate ganglion block with 0.5% preservative-free lidocaine 7 to 10 mL. 9. Record the patient’s pain level on a visual analogue scale of 0 to 10 every 3 minutes for 15 minutes. 10. Repeat this sequence on a separate visit to confirm the results.
system injury. As noted, atypical odontalgia is dull and aching, whereas reflex sympathetic dystrophy of the face causes burning pain and significant allodynia is often present. Stellate ganglion block may help distinguish these two pain syndromes; the pain of reflex sympathetic dystrophy of the face readily responds to this sympathetic nerve block, whereas atypical odontalgia does not. Atypical odontalgia must also be distinguished from the pain of jaw claudication associated with temporal arteritis.
Treatment The mainstay of therapy is a combination of drug treatment with tricyclic antidepressants and physical modalities such as oral orthotic devices and physical therapy. Trigeminal nerve block and intraarticular injection of the temporomandibular joint with small amounts of local anesthetic and steroid also may be of value. Antidepressants such as nortriptyline at a single bedtime dose of 25 mg can help alleviate sleep disturbance and treat any underlying myofascial pain syndrome. Orthotic devices help the patient avoid jaw clenching and bruxism, which may exacerbate the clinical syndrome. Management of underlying depression and anxiety is also mandatory.
Complications and Pitfalls The major pitfall in caring for patients thought to have atypical odontalgia is failure to diagnose underlying pathology that may be responsible for the patient’s pain. Atypical odontalgia is essentially a diagnosis of exclusion. If trigeminal nerve block or intraarticular injection of the temporomandibular joint is being considered as part of the treatment plan, it must be remembered that the region’s vascularity and proximity to major blood vessels can lead to an increased incidence of postblock ecchymosis and hematoma formation, and the patient should be warned of this potential complication.
Clinical Pearls Atypical odontalgia requires careful evaluation to design an appropriate treatment plan. Infection and inflammatory causes, including collagen-vascular diseases, must be ruled out. Stress and anxiety often accompany atypical odontalgia, and these factors must be addressed and treated. The myofascial pain component of atypical odontalgia is best treated with tricyclic antidepressants such as amitriptyline. Dental malocclusion and nighttime bruxism should be treated with an acrylic bite appliance. Opioid analgesics and benzodiazepines should be avoided in patients with atypical odontalgia.
SUGGESTED READINGS Clark GT: Persistent orodental pain, atypical odontalgia, and phantom tooth pain: when are they neuropathic disorders? J Calif Dent Assoc 34:599–609, 2006. Marbach JJ: Is phantom tooth pain a deafferentation (neuropathic) pain syndrome? Oral Surg Oral Med Oral Pahtol 75:95-105, 1993. Marbach JJ: Orofacial phantom pain: theory and phenomenology, JADA 127:221–229, 1996. Marbach JJ, Raphael KG: Phantom tooth pain: a new look at an old dilemma, Pain Med 1:68–77, 2000. Matwychuk MJ: Diagnostic challenges of neuropathic tooth pain, J Can Dent Assoc 70:542–546, 2004. McQuay HJ, Tramér M, Nye BA, et al: A systematic review of antidepressants in neuropathic pain, Pain 68:217–227, 1996. Melis M, Lobo SL, Ceneviz C, et al: Atypical odontalgia: a review of the literature, Headache 43:1060–1074, 2003. Pertes RA, Bailey DR, Milone AS: Atypical odontalgia: a nondental toothache, J N J Dent Assoc 66:29–31, 33, 1995.