Orofacial Nonodontogenic Pain – Ache Not Coming From the Tooth
Table of Material
Orofacial discomfort can be split into odontogenic discomfort (diseased teeth is evoking the distress) and nonodontogenic discomfort. Nonodontogenic discomfort may be the tenderness that will not result from the teeth or its encircling tissues. It could appear in the top, neck and mouth regions. Nonodontogenic pain as a subspecies of orofacial discomfort might have many causes and various clinical manifestations. There are a variety of circumstances and disorders of nonodontogenic character that can imitate odontogenic discomfort. As a result of this, appropriate diagnosis of the condition can often be difficult, difficult and time-consuming and needs excellent medical understanding and going for a comprehensive medical and oral history.
How exactly to recognize nonodontogenic discomfort?
Using the occurrence of the condition, you can find no apparent etiological factors directing for an odontogenic discomfort such as oral caries, bad fillings and trauma or fracture of teeth that are typical for odontogenic pain.
According to Keiser and Hargreaves, nonodontogenic pain has the following characteristics:
- after administering local anesthesia discomfort persists, it does not go away neither uniformly nor completely,
- there is a distress on both edges or more tooth are painful at exactly the same time,
- discomfort is definitely chronic (endures long time frame) and may not be decreased despite the dental care.
More or less specific characteristics of nonodontogenic pain that can assist in the diagnosis are:
- soreness description as burning sensation, dull ache, aching tenderness or shooting anguish,
- discomfort occurs simultaneously with the appearance of headache,
- touching of “trigger points” or some muscles intensifies the discomfort,
- discomfort is increased with emotional stress, physical activity and changing the position of the head.
Classification and causes
There are lots of classifications of the condition. In the favorite and most frequently classification, based on the origin, this problem is split into: musculoskeletal, neuropathic, neurovascular, inflammatory, systemic and psychogenic.
Musculoskeletal (myofacial) discomfort occurs because of bruxism, temporomandibular joint disorders or myofascial discomfort (muscular discomfort in face area).
Neuropathic discomfort can be categorized as: trigeminal neuralgia (extreme, typically intermittent discomfort along the span of a trigeminal neural in the facial skin area), atypical odontalgia (atypical toothache) so when glossopharyngeal neuralgia (extreme pain across the span of a glossopharyngeal neural in the head and mouth region).
Headaches and migraine are examples of neurovascular nonodontogenic pain.
This condition of inflammatory origin is most often manifested as allergic or bacterial sinusitis.
Some systemic diseases and conditions can cause ache in the orofacial region and be recognized as causes of nonodontogenic pain. In this case the issue may be heart pain, herpes zoster infections, sickle cellular anemia and specific neoplastic disorders (such as for example harmless or malignant tumors).
Occasionally nonodontogenic could be psychogenic origins, for instance Munchausen symptoms.
Myofascial discomfort manifests being a local, dull, muscular discomfort in face area. In addition, there are specific “trigger factors” whose coming in contact with causes irritation in distant parts of the body. These are sensitive areas of the body, activation or irritation of which causes a specific effect in another part, especially a soft area inside a muscle that causes generalized musculoskeletal pain when overstimulated. These activates points are very important in analysis of the pain and can become active or latent (existing but not yet fully developed or manifested). Active are those in which the pain happens at every contact, while when coming in contact with latent ones discomfort does not at all times occur, but just sometimes.
“Activate factors” whose coming in contact with can cause irritation in the region of dental program are:
- masseter muscles (lat. musculus masseter ) – coming in contact with this trigger stage in the zygomatic arch could cause discomfort that is felt as pain of upper back teeth; touching result in point in the angle of the lower jaw causes pain of the lower back tooth,
- central winged muscle mass (lat. pterygoideus medialis ) – is a trigger point similar to that of the masseter muscle tissue in the angle of the lower jaw and sensation of ache is similar to the sore throat symptoms,
- temporal muscle mass (lat. musculus temporalis ) – touching the front of the muscle that is on the lateral surface area from the skull along a temporal series could cause an ache within the higher front teeth and in addition painful sensation much like headache can show up
- trapezius muscles (lat. musculus trapezius ) – touching this muscle can cause discomfort in the angle of the lower jaw and in the area around the ear.
The temporomandibular joint disorders
The temporomandibular joint (TMJ) disorders are common in adults and it is regarded as that at least one-third of mature population has experienced the symptoms connected with disturbances with this joint at least once in their lifetime. These symptoms usually include pain in the jaw and neck, headache and snapping and scraping in the joint. Disorders in the temporomandibular joint can also cause pain that can be reflected in different parts of the orofacial system and the skull.
Bruxism may be the involuntary, unconscious and extreme breaking and clenching of tooth that most frequently occurs during the night during sleep. It could be diagnosed in every age groups, so when the main cause are believed psychological states such as stress, stress and tension. For many people, bruxism is transient and usually disappears when stress stops. Bruxism can cause damage and hypersensitivity of teeth, pain in the temporomandibular joint and muscle stiffness of the jaw, headaches and bites to the cheeks. They are all circumstances that cause some type of pain within the orofacial region, which may be referred to as nonodontogenic discomfort.
The most frequent cause of neuralgia in face region is usually trigeminal neuralgia, which, according to Matwychuku, affects 4-5 patients per 100,000 people. It is much more common in women older than 40 years. In presence of trigeminal neuralgia unilateral, sudden, severe, sharp pain occurs. Furthermore, patients frequently feel paresthesia, burning up and lightning feelings in affected area of encounter. The pain expands along a number of branches from the trigeminal neural. It takes a couple of seconds to several a few minutes for discomfort to vanish and it generally does not show up until the following attack.
There are particular activate points – arousal points which coming in contact with causes serious trigeminal discomfort. These activate points located throughout the nose and mouth are characteristic for trigeminal neuralgia. In addition, seizures also can become provoked by chewing, brushing tooth, light touch and even when speaking. The intensity of pain is usually disproportionate to the intensity of stimulus because actually mild stimulus is sufficient enough to induce severe pain. Local anesthetic injected into the area of result in point causes tooth pain relief.
Atypical odontalgia, also known as idiopathic or phantom toothache, is usually characterized by constant toothache after pulp extirpation (performed underlying canal therapy), apicoectomy (medical removing of teeth apex), teeth extractions or face trauma. Studies show that in 3-6 percent of sufferers after endodontic treatment (main canal therapy) atypical odontalgia shows up. All age range (except kids) could be affected, whereby it really is more regular in ladies in their forties.
With atypical odontalgia you can find periods of extented and constant pulsations and burning up sensations within the teeth and alveolar procedure (surrounding bone tissue) despite the fact that you can find neither medical nor radiographic indications that can show a disorder related to the tooth. It can be difficult for individuals to localize the pain, which is usually more intense on the side where the stress occurred or where dental care process was performed. The pain may spread into adjacent areas by one or both sides of face, and most often are affected top premolars and molars. Local anesthesia may or may not alleviate the pain. Regrettably, it is often thought that atypical odontalgia is a normal response of organism after dental procedure or a complication after facial trauma.
According to Horowitz and associates, glossopharyngeal neuralgia is a rare disorder that manifests as pain in the throat, which commonly occurs during chewing and swallowing. Pain (usually one-sided) may also occur in the pharynx, on back of the tongue and in the area of the ear. It is estimated that the occurrence of glossopharyngeal neuralgia can be 70-100 times less than the occurrence of trigeminal neuralgia.
When the scientific evaluation determines that there surely is no existence of pathological adjustments in one’s teeth or in the region from the ear being a potential resources of pain, it’s possible glossopharyngeal neuralgia can be causing the discomfort. It is regarded that disorder can be from the compression of glossopharyngeal neural and/or upper elements of the vagal neural. During the examination, dentist should follow the symmetry of movement of the soft palate and uvula when the patient speaks the voice “A”. In addition, by touching the back of the throat it should be possible to provoke vomiting reflex. Any asymmetry in the movement of the soft palate and uvula or absence of vomiting reflex should arouse suspicion in the involvement of glossopharyngeal nerve.
Migraine is the most common kind of headaches with neurovascular origins. It’s estimated that 15 to 20 percent of the populace is suffering from migraine. Clinically, it really is popular that discomfort which takes place in a migraine strike can be shown in certain areas of the facial skin and oral buildings and thus imitate odontogenic discomfort (toothache). There are lots of descriptions from the discomfort due to migraine, which is most often referred to as pounding and pulsating discomfort. This sort of face discomfort takes place in isolated regions of top of the and lower jaws.
Perhaps one of the most common resources of orofacial discomfort are sinus disease of maxillary sinus (sinus located inside higher jaw) from the higher jaw and irritation from the connected nasal mucosa which can be very sensitive and painful. Unfortunately, many of the top teeth are unneeded removed due to misdiagnosis, whereby sinusitis was misdiagnosed as toothache.
Symptoms of chronic sinusitis are bloating and pressure in the middle part of the face – in the top jaw, the top teeth and the area of the eye. The pain from sinusitis could be one-sided (unilateral) or both-sided (bilateral). This discomfort is not positioned in the region of only 1 higher tooth, however in the entire higher teeth area. When testing the teeth show signals of vitality (pulp of top teeth is not affected). The pain usually raises when lying down or when folding the body.
Center pain (cardiac pain) can manifest being a toothache. The most frequent causes of heart pain, which may be shown and mistakenly defined as a toothache, are angina pectoris and coronary attack (myocardial infarction). Angina pectoris generally contains symptoms as feeling of “weight in the chest”, nausea, choking and stabbing pain in the center of the sternum (breastbone) which can range from gastric area to the lower jaw. Heart attack is characterized by a variety of symptoms offering sudden, gradually conditioning upper body pain along with a feeling of choking, nausea, symptoms of shock such as for example sweating, cool and sticky pores and skin, and in the advanced stage of unconsciousness and cyanosis (blue color of pores and skin). The discomfort is comparable to that in angina pectoris and may also spread to the lower jaw. Researchers Sandler and colleagues found that in about 10 percent of patients with heart pain (especially the elderly), that pain transmits in the area of the lower jaw. The most frequently affected may be the lower remaining area of the jaw, however the pain could be both-sided. When assessment teeth show symptoms of vitality (pulp of lower tooth isn’t affected). The ache could also spread left glenohumeral joint, arm and back. At physical stress pain increases in the chest area.
In patients with herpes zoster (acute viral infection caused by the varicella zoster computer virus) sudden attacks of pain are possible in the area of the facial skin that are protected with vesicular allergy (the current presence of the tiny blisters on your skin). These episodes can last from a long time to several times. The usage of analgesics relatively alleviates soreness. The diagnosis is very complex because the feeling of pain can mimic the characteristics of pain that occurs with toothaches of pulp origin (pulp of the tooth is affected). Researchers have not however developed the correct laboratory exams for unambiguous verification of the ultimate diagnosis. Acute strike of herpes zoster could be accompanied by ache from neuralgia along a span of a face nerve.
Sickle cellular anemia
In the teeth whose pulp demonstrated outward indications of ache the lifetime of sickle cellular material was motivated. In 68 percent of sufferers experiencing sickle cell anemia it was found that orofacial or toothache can occur without presence of any pathological disorders. Namely, sickle cell anemia leads to necrosis of the tooth pulp, as it has a direct effect on the microcirculation of the pulp. Consequently, the pulp necrosis happens without any additional etiological factors.
Metastatic tumors within the jaws are fairly rare pathological adjustments. However, the introduction of nonspecific symptoms, such as for example toothache and/or orofacial discomfort can in a few sufferers warn of the current presence of neoplastic disease in the torso. Based on Pruckmayer’s research that is feasible in lung, breasts, prostate and kidney malignancy and in adenocarcinoma. Though it may seem pointless, in any individual who feels orofacial pain or ache in the jaw dental professional should also suspect the living of neoplastic disease or cancer. This applies particularly to the people patients with a family history of cancer, or those that for a long period do not react to the dental care that is common and effective in similar instances.
Munchausen symptoms was first referred to in 1951 and called based on Baron von Munchausen, who resided in the 18th hundred years in Germany, and was known for his amazing stories and existence experiences. This symptoms is seen as a three particular features: pathological lying (pseudologia fantastica), the existence of simulated diseases and walking/moving from place to place.
Patients suffering from this syndrome are constantly seeking medical attention due to a combination of symptoms that range from deliberate self-harm to the false guidance of pathological changes and conditions. According to Blyer, possible manifestations of this syndrome are stomach ache, bleeding and neurological symptoms. Kounis in 1979 added a 4th feasible manifestation – cardiovascular complications. Blyer’s study shows that we now have patients experiencing this symptoms who explain their medical complications as ache that is clearly a consequence of disorders from the temporomandibular joint and toothache.
Nonodontogenic discomfort, like a subspecies of orofacial discomfort, might have many causes and various clinical manifestations. Proper diagnosis of this condition can sometimes be tricky, complicated and time-consuming and requires excellent medical knowledge and taking a thorough medical and dental history. Incorrectly identified nonodontogenic pain can have many harmful consequences for the life and health of the patients.