Atypical odontalgia

Atypical odontalgia A report of twenty-two

cases

Ralph I. Brooke, B.Ch.D., L.D.S., M.R.C.S., L.R.C.P., F.D.S.R.C.S., London, Ontario, Canada DEPARTMENT

OF ORAL

MEDICINE,

FACULTY

OF DENTISTRY,

UNIVERSITY

F.R.C.D., OF WESTERN

ONTARIO

The findings in twenty-two cases of a condition that causes pain in the teeth and gingivae are presented. Two cases are described in detail. The importance of recognizing the probkn and avoiding unnecessary dental treatment is stressed. The most effective treatment appears to be reassurance and the use of antidepressant drugs.

Pain may occur in normal teeth. This pain may be

induced by very cold food, such as, ice cream, which can cause pain in the lower incisors. As Mumford has pointed out, the crowns of these teeth are small, which means that contact with cold food or drink produces a

greater decreasein temperature than occurs in larger teeth. In addition, the distance from the outer surfaceto the pulp is not very great and the temperature at the pulpodentinal junction falls rapidly. Even cold air encountered upon leaving a warm building

may cause

dental pain in some persons. Another cause of pain in normal teeth is sensitive dentine or sensitive cementum. This pain can be very severe and may be brought on by touching or brushing the teeth. If it is a great problem for the patient, desen-

sitizing agents may have to be used. The purpose of this article is to outline the findings in

twenty-two casesof a much more serious condition in which pain occurred in apparently normal teeth and to present two typical case histories. The significance of this condition is that if it is not recognized it may lead to extensive dental treatment which is not only unnecessarybut always fails to give permanent relief of pain. CASE 1 (PATIENT 22) The patient, a 32-year-old registered nurse, had a long history of dental pain. At the age of 17, while recovering from a throat and ear infection, she beganto have episodesof sharppain on the right side of the face. These sharp, lancinating pains over the left cheekwere severeand were brought on by chewing or touching the face or by a breezeblowing over the face. They occurred many times during the day, and the patient was admitted to a hospital for investigation, which included a normal pneumoencephalogram.She was treated with steroids and experienced almost immediate relief of the pain within 5 or 6 days of its onset. 196

The patient was free of pain until 1 year before she was seen in the Oral Medicine Clinic. She stated that she had begun to have an ache in all the upper teeth bilaterally, plus intermittent sharp,jabbing pains in isolated teeth. Thesepains becamemore severeand appearedto be localized to the upper left incisor region. Apparently, some dental radiographic changes had been seen and these led to root canal therapy being carried out on the upper left secondincisor. The patient was pain free for a month, but subsequentlythe pain returned and root canal therapy was then carried out on the upper right first molar, the upper left second molar, and the lower left first incisor over the next 3 months. When questionedabout the nature of the pain, the patient statedthat it often occurred in “all the teeth and gums.” She describedit as a constant pain which occasionally “jumps.” It started at any time of the day or night and frequently occurred bilaterally and was aggravatedby cold food or chewing or even touching the teeth. She statedthat she often had a burning sensation in the upper right jaw which “feels like something crawling through the bone.” The pain had become quite widespread and had not responded to a variety of analgesics and other medications including Tegretol, 1,600 mg. per day. The patient had undergonea lumbar laminectomy in 1973. She previously had a tonsillectomy and adenoidectomy and two other “tonsil” operations. In 1967 she developed pain and numbnessin the right little finger and ulnar border of the right hand. After several months without relief, she had the right anterior scalenemuscle divided, with immediate relief. In 1976, after 4 years of similar but less pronounced symptoms on the left side, she had a similar operation with less satisfactory relief. In 1973 she had low back pain radiating into the left leg, which led to a myelogram and subsequent laminectomy. The patient had a history of right-sided headachesassociatedwith “flashing lights” since 1973. In addition, she had had multiple breast biopsies and a reduction mammoplasty. Physical examination findings were essentially normal. No abnormalities of the cranial nerveswere detected,except that 00304220/80/0301%+04$00.40/0

0

1980 The C. V. Mcsby Co.

Atypical odontalgia

Volume 49 Number 3 sensation to pin prick was questionably slightly diminished over the left cheek. Oral examination revealed no gross abnormality apart from sensitivity to percussion of the upper teeth, especially the right first molar and left second molar. This patient was informed that it would be inadvisable for her to undergo further surgical treatment unless there was absolute evidence of pathosis. She was seen by a psychiatrist; who believed that elements of depressive neurosis were present. The patient was put on a regimen of Etrafon-D and, when seen after 1 month, stated that she was still having pain which she could “live with.”

Table I. Clinical features of twenty-two patients with atypical odontalgia

Patient

Age when condition was diagnosed

DISCUSSION Harris2 described a condition which he called idiopathic periodontalgia in which patients complain of intolerable sensitivity of the teeth to any stimulus, be it pressure or thermal. The pain may be unilateral and localized or, more frequently, generalized and bilateral. The patient may have undergone a dental proce-

Duration symptoms

4 5

37 43 65 64 37

7 yr. 19 yr. 8 yr. 2 yr.

6

36

18 mo.

7

8

54 36

7 mo. 1 yr.

9 10 11 12 13

14 54 35 39 49

7 yr. 4 yr. 4 mo. 13 mo.

14 15 16 17 18 19 20 21 22

54 56 41 46 45 32 67 34 32

19 mo. 2% yr. 10 yr. 12 yr.

2

CASE 2 (PATIENT 16) The patient, a 4%year-old woman, was seen in the Oral Medicine Clinic on Feb. 20, 1978. She had a long and complicated history of facial pain which dated back approximately 18 months, when the upper left first and secondpremolars had been ground clear of the bite in order that a bridge could be constructed. She began to be bothered about the occlusion following placement of the bridge and further occlusal equilibration was carried out. Three or 4 months later she began to have pain in the region of the bridge, and this spread to involve all the upper teeth and eventually the lower teeth. She consulted a number of practitioners, and further occlusal equilibration was carried out as well as fabrication of an occlusal splint. The patient was never comfortable with the splint and continued to complain about her occlusion. Approximately 6 months after this, while she was on holiday in Florida, she developed an abscessed upper left first premolar. The root canal was opened and there was relief of pain, but this returned a couple of days later, when the patient requested that the upper left second premolar and lower left first premolar also be opened. This too was done, and the patient then began to experience severe swelling of the left side of the face. She was hospitalized and given antibiotic therapy and was discharged on this therapy. Approximately 1 week later she saw another practitioner, who told her that she had acute sinusitis and prescribed antihistamines and tetracycline. She became somewhat better with this therapy but continued to have facial pain. When seen in the Clinic, she was experiencing pain in all parts of her mouth from time to time. No overt pathosis was seen, either clinically or radiographically, except that associated with the previous root canal treatment. She was extremely preoccupied with her condition and described her symptoms in an almost hysterical fashion. After neurologic consultation, she was firmly assured that no pathologic condition existed in her mouth, but she continued to seek endodontic therapy for the “abscessed” teeth.

197

8 mo.

I5 yr.

18 mo. 4 yr. 6 yr.

of Medical

history

‘Thyrotoxicosis Migraine Depression Migraine, family problems Anxiety; cystic fibrosis Bruxism ‘Tension headaches; severe family problems Depression

Depression Severe headaches Migraine; bruxism Migraine; asthma; severe allergies Depression Depression Migraine

Depression Depression

18 mo.

Depression -

15 yr.

Depression

dure which appears to have precipitated the problem. Sometimes there are emotional problems, and other patients give a history of migraine. Harris goes on to suggest that the condition is a state of hyperalgesia of periodontal pain receptors, and its association with migraine suggests a vascular disturbance . More recently Rees and Harris3 have renamed the condition atypical odontalgia, as they believe it is one variety of atypical facial neuralgia. They have seen patients who have had the problem for 2 months to 20 years and believe the condition to be a symptom of an underlying disorder of affect, associated with a temporary or permanent biochemical defect producing vascular changes, rather than a local disease. Thus, a persistent vasodilatation in the microcirculation of the affected tissue occurs secondary to impairment of catecholamine activity. The site of the pain may be determined by local factors (for example, trauma) or impulses of central origin. Rees and Harris believe that the correct treatment for these patients is the avoidance of surgery, reassurance, and the use of a tricyclic antidepressant or, if this fails, a monoamine-oxidase inhibitor. Patients with marked

198 Brooke

Oral Surg. March, 1980

All the patients were fully investigated from a neurologic point of view. TREATMENT

AGE IN YEARS Fig. 1. Histogramshowingagesof twenty-twopatientsat time of onsetof atypicalodontalgia.

emotional problems or those who do not respond to drug therapy should be referred for a psychiatric opinion. The chief findings in the patients we have seen are summarizedin Table I. It will be noted that the duration of symptoms was from 4 months to 19 years, with an average of 5.6 years. The age range at the time of diagnosis was from 32 to 74 years. The age range for the time symptoms first appeared is shown in Fig. 1. All the patients were female; 23 percent had a past history of migraine, and 41 percent had a history of depression. Other patients had stress-relatedconditions such as bruxism or tension headache. All the patients had undergone a great deal of dental treatment in an attempt to relieve the pain, and in most casesthe obj,clive clinical evidence for the diagnosis upon which the treatment was basedwas very weak. Frequently, it was the patient’s insistence that “something should be done” that prompted endodontic or surgical treatment. Significantly, there was never any permanent relief of symptoms. On the contrary, the more treatment that was carried out, the more problems appearedto have been created. Thus, a tooth may initially have been restored, later treated endodontically, then subjectedto an apicectomy, and finally extracted, each stagebeing a prelude to the next. DIFFERENTIAL DIAGNOSIS

Differential diagnosis included all other causes of tooth pain of nondental origin. Localized causes, such as sinusitis, ear and eye problems, and myofascial pain dysfunction, would have accompanying clinical signs. The primary neuralgias (for example, trigeminal neuralgia) are characteristic enough in presentationto have been easily differentiated. The secondary neuralgias would have shown spread to continguous areas and objective changes in sensation, motor function, etc. Other vascular causesof facial pain (for example, migrainous neuralgia, giant-cell arteritis) were excluded,

When the diagnosis of atypical odontalgia was made, despite the protestations of the patient (and often the family), no further active treatment(for example, restorations or root canal therapy) was permitted unless there was clear evidence of organic diseasethat warranted this. The presenceof pain alone is not sufficient reason to give such treatment, which invariably leaves the patient in worse pain. After careful neurologic and psychiatric evaluation, the patient was treated by firm reassurancethat no further dental treatment was required, together with the use of antidepressant and tranquilizer drugs. OUTCOME

Fifty percent of our patients obtained permanent relief from pain with the use of antidepressantand tranquilizer drugs. The superior results obtained by Reesand Harris (75 percent obtained complete relief or had only occasional brief, mild attacks over a period of 3 months) were probably due to the antidepressanttherapy being continued longer. Harris4 believes that this therapy may be required for as long as 8 weeks before remission is induced. DISCUSSION

The main features of atypical facial neuralgia were reviewed by Gayford in 1969. LateP he put forward the view that atypical depressionwas a major etiologic factor in this condition. Although several series of casesof atypical facial neuralgia have been reported, it is not possible to determine how many of the patients describedhad pain in the teeth as well as the face. Rees and Harris believe that the description of the condition and its relationship to depression is sufficient to consider “atypical odontalgia” a localized form of the more diffuse atypical facial neuralgia. They do not, however, consider the condition to be a local disease entity but a symptom of an underlying disorder of affect. They also stressthat, just as depressionis characterized by remissionsand exacerbations,the odontalgia might recur with the return of the depression.The fairly long interval of time between commencementof antidepressant therapy and the relief of pain has been referred to earlier. Our findings are substantially the same as those of Reesand Harris. We believe, too, that this condition is a form of atypical facial neuralgia and should be treated as such. It cannot be stressedtoo strongly that much mental anguish and unnecessarytreatment can be pre-

Atypical odontalgia

Volume 49 Number 3

vented by the recognition of this condition and the avoidance of dental treatment based on no findings other than the presenceof pain.

5. Gayford, J. J.: Atypical Facial Pain, Practitioner 202: 657-660. 1969. 6. Gayford, J. J.: The Aetiology of Atypical Facial Pain and Its

Relation to Prognosisand Treatment, Br. J. Oral Surg. 7: 202207. 1970.

REFERENCES 1. Mumford, J. M.: Toothache and Related Pain, Edinburgh, 1973. Churchill Livingstone. 2. Harris, M.: PsychogenicAspects of Facial Pain, Br. Dent. J. 136: 199- 202, 1974. 3. Rees, R. T., and Harris, M.: Atypical Odontalgia, Br. J. Oral

Surg 16: 212-218, 1979. 4. Harris, M.: PersonalCommunication.

199

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Dr. Ralph 1. Brooke Department of Oral Medicine Faculty of Dentistry The University of Western Ontario London. Ontario. CanadaN6A 587

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