Cynthia R. Biron, RDH
Sooner or later, dental professionals will meet a patient who is experiencing facial or tooth pain which cannot be resolved or even diagnosed with the usual procedures. The patient blames the dentist for being so incompetent in diagnosing the problem. All too frequently, the dentist or his staff blame the patient for being a problem patient who has a pain which is "all in her head."
Here, in the form of an essay, is the testimony from a patient with atypical odontalgia:
"I am your worst nightmare, the patient from dental hell. I am the patient who suffers intense, unrelenting agony after a routine dental procedure. A root canal, a filling, or even a prophylactic cleaning causes months of distress that you cannot explain. My undiagnosed pain perplexes you. I sense your frustration at being unable to determine the cause of my condition. When I tell you that months of unresolved, acute pain are debilitating and depressing, you suggest my pain is mental, not dental. I tell you I want to buy a handgun. You think I am going to shoot myself. I think I am going to shoot you.
"Who am I? I am a patient with atypical odontalgia (AO), the non-dental toothache described by Bailey et. al. (Journal of the New Jersey Dental Association/Winter 1995). Although I have no medical or dental training, my perspective as a patient with undiagnosed AO may be useful. I offer some practical hints for helping your patients with possible AO understand and cope with their condition.
"When we talk about differential diagnosis, include AO as a possibility. Proceed with the differential diagnosis quickly. As a patient in pain, I want the differential diagnosis to take days or weeks, not months. Explain sympathetically maintained pain to me.
"Do not ask me to `be patient` or to `learn to live with the pain.` I need an explanation and relief NOW. Please do not judge how I am handling the pain. Unless you have experienced chronic pain, you simply have no idea how devastating it can be.
"Understand and accept my anger. I have suffered a loss in the quality of my life, and anger is part of the grieving process.
"Do not be defensive. If I did not trust you and have faith in your ability, I would not continue to turn to you for help. If AO is a possibility, discontinue dental treatment.
"Make pain relief a priority. When traditional palliative methods fail, seek non-traditional methods. (Note: With acupuncture, I can manage the pain on less than half the dosage of Elavil that I took previously.)
"If you have no experience with AO, refer me to someone who does."
The essay is written by Anne B. Ciemnecki, and she has titled it, "It`s Dental, Not Mental: The Patient From Hell Offers a Few Practical Hints for Reducing Patient Stress When Diagnosing Atypical Odontalgia."
Ms. Ciemnecki`s battle with AO (also called phantom tooth pain, atypical facial pain, atypical facial neuralgia, migrainous neuralgia, idiopathic toothache, traumatic neuralgia, chronic orofacial pain, or psychogenic pain) has been estimated to afflict some 5 to 7 million Americans. This phenomenal condition cannot be remedied by dental procedures or routine pain-relieving medications. The nature of the various disorders that manifest themselves is one that must be brought to the awareness of all dental health professionals.
Endodontic procedures and extractions apparently may be performed unnecessarily as a last resort for pain relief, only to discover that the pain is still present after the procedure is completed and healed. Ms. Ciemnecki`s initial experience is a classic example of the common treatment of AO. It was not until she was referred to Dennis R. Bailey, DDS, clinical assistant professor at the Center for TMJ Disorders and Orofacial Pain Management at the University of Medicine and Dentistry in New Jersey (UMDNJ) was she relieved of AO.
Dr. Bailey has been involved with AO in a multidisciplinary approach at the TMD/Facial Pain Center at UMDNJ where differential diagnosis of AO is assessed by a diagnostic block of the stellate ganglion to determine if the pain is being maintained by the sympathetic nervous system. Having made such a diagnosis on Ms. Ciemnecki, Dr. Bailey was able to relieve her pain by using amitriptyline (Elavil) at doses too low to be of therapeutic value for depression.
A neuromatrix theory explains the perplexing pain known as atypical odontalgia, and alternate treatment modalities are proving most effective in situations where routine treatments are useless. Joseph J. Marbach, DDS, professor in algesiology, University of Medicine and Dentistry of New Jersey, describes the pain as "Orofacial Phantom Phenomenon" and divides the phenomena into three categories:
- Phantom tooth pain.
- Intraoral stump pain, such as pain experienced in edentate tissue.
- Phantom bite syndrome, a sensation often associated with the inability to adapt to changes in dental occlusion.
Dr. Marbach theorizes that trauma from dental treatments, especially endodontic and apicoectomy procedures alters peripheral tissue and the central nervous system processing, resulting in "deafferentation pain syndromes." Physical trauma is the precursor to AO and injured tissue in the area of such an injury, endodontic, apicoectomy, or extraction site may take days, months or even years to manifest itself. The neuropathic pain is maintained by the sympathetic afferent nerves that have a predominantly central "generator" comprised of the so-called deafferentation pain syndrome. There is also the possibility that the root apices may have a lesion after endodontic treatment and such a lesion would have an effect on the nervous system.
Pain in edentulous areas is similar to stump pain experienced by amputees who still experience the pain of cramping of the hand that was amputated along with their arm. The phantom bite syndrome (described by Dr. Marbach as the pain associated with one`s "loss of recognition of self") relates to the inability to adjust to a change in occlusion that occurred from orthodontic or prosthodontic changes.
Clinical characteristics of AO
AO is most common in women in the fourth decade of life, and their pain is usually in molar or premolar regions. The pain occurs some time after dental procedures - especially pulp extirpations, apicoectomies, or extractions. The time it takes for the AO to occur may vary from days, weeks, months, or even years.
Graff-Radford and Solberg clinical characteristics include:
1. Continuous or almost continuous pain in a tooth or alveolar bone.
2. Pain present for more than four months.
3. No obvious local cause.
4. Normal radiographs.
5. No evidence of referred pain.
6. Diagnostic nerve pain is equivocal.
Patients have described their pain to Dr. Bailey and his colleagues as dull, throbbing aches, or burning, as well as being more or less constant. There is increased sensitivity to finger pressure on the tooth or alveolar bone as well as a feeling of unpleasant abnormal sensation.
Pulp testing, thermal testing, percussion, and other standard clinical dental diagnostic procedures are inconclusive. Radiographs show no abnormalities, and pain-relieving medications including CNS depressants, NSAIDS and corticosteroids are ineffective.
AO is not mental
The theory that AO is a mental condition led Drs. Graff-Radford and Solberg to conduct a study using the Minnesota Multiphasic Person-ality Inventory (MMPI) to assess psychological functioning of an atypical odontalgia population. Means of the standard scores for each MMPI scale were within normal ranges. The standard scores for AO profiles were within normal ranges.
Such findings fail to support psychological disorders as a primary association with AO. In another study, AO patients were surveyed and 52 percent of them indicated that a clinician told them their pain was imaginary. These patients felt alienated and labeled as "psychologically flawed."
It seems that, when a patient presents with a tooth pain that cannot be diagnosed with clinical examination and radiographs, many clinicians assume the problem is mental and not dental. With all that we learn in our schooling of personal perception of pain, it seems rather incongruous and indifferent of a clinician to arbitrarily pass off a patient`s pain as imaginary. Yet 52 percent of patient`s clinicians do.
Ms.Ciemnecki states emphatically: "If AO is a possibility, discontinue dental treatment." In other words, "Let`s not get the patient into painful or expensive treatment or unnecessary loss of teeth."
Dr. Bailey and his associates do not consider tricyclic antidepressants to be an "alternative" form of treatment for orofacial pain since they have overwhelming evidence of its effectiveness in AO patients. Dosages as low as 25 to 30 mg per day were completely effective in relieving pain in less than 10 days. According to The Drug Facts And Comparisons, the normal therapeutic dose of amitriptyline for maintenance in relief of depression is 40-100 mg per day with relief of depression taking three to four weeks for optimum blood level of the drug. Amitriptyline (Elavil) is thought to provide pain relief by increasing serotonin levels at neural synapses.
A study on patients with myofacial pain that was conducted by Johansson and colleagues showed no significant difference in improvement of acupuncture patients than splint therapy patients. It is believed that pain relief with acupuncture is accomplished by producing an increase in endorphins as well as the production of other non-opioid effects.
The U.S. FDA states that an estimated 9 to 12 million acupuncture treatments are provided yearly, and some insurers pay for acupuncture treatments of certain disorders. The testimony given by so many patients who have experienced pain relief has made acu-puncture increasingly popular among pain specialists in the United States. The best feature of providing acupuncture for AO is that professional administration of acupuncture will not cause iatrogenic effects.
Pain and tooth loss to a patient whose condition has been incorrectly diagnosed could result in legal ramifications that could be quite costly to the clinician. Patients who are inaccurately advised and accused of a mental condition can become socially estranged as a result of being labeled as such by their clinician.
The number of AO cases will increase as more patients can afford expensive procedures such as endodontics and prosthodontics.
We cannot afford to prejudge patients who are experiencing a pain we cannot perceive or relieve. When routine diagnostic procedures cannot isolate the cause of tooth or facial pain, refer the patient to the appropriate specialists. We owe it to our patients, our professions, and ourselves the right to treatment in specialized care where clinicians have an expertise in alleviating the crucial pain so frequently experienced in the orofacial regions of dental patients.
The first priority in dental treatment is alleviating pain. Prioritize accordingly.
Cynthia R. Biron, RDH, is chair of the dental hygiene program at the Tallahassee Community College. She is also a certified emergency medical technician.