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Is Phantom Tooth Pain Normal After Dental Surgery?
If you’ve recently gotten dental surgery and now feel a persistent pain in the place where the oral surgery was performed, you might be suffering from phantom tooth pain. Here, we’ll explain what that is, what symptoms are associated with it, whether it’s normal to experience after dental surgery, how you diagnose it, and what your treatment options are for phantom tooth pain.
What Is Phantom Tooth Pain?
Phantom tooth pain is a constant, chronic, lingering pain in your mouth in an area where you just had dental work done. For example, after an extraction you feel pain in the space where there is no longer a tooth. This phenomenon is similar to its more commonly known cousin phantom limb syndrome, where amputees feel pain where their amputated limb used to be. This is not a physical issue, but a neurological one.
Phantom tooth pain most often comes about after dental surgery. Whether it’s a root canal, extraction, or filling, phantom tooth pain is the result of a damaged or dysfunctioning nerve that sends signs to the brain saying that there is pain in a tooth that may no longer be there.
What Are the Symptoms of Phantom Tooth Pain?
The common symptoms of tooth pain are described as mild to severe throbbing or aching tooth pain. The pain can vary from one end of the spectrum to the other throughout the span of a single day. While the phantom tooth pain may start in the one area, it can also spread throughout to other parts of your mouth and even your jaw. Phantom tooth pain symptoms differ from those of a typical tooth ache because the specific cause of pain is not identifiable. With normal tooth pain, there is often a specific cause that leads to the specific symptoms such as tooth decay, gum disease, or a knocked out tooth.
How Do You Diagnose Phantom Tooth Pain?
Because there is no one identifiable cause of phantom tooth pain, diagnosis can take a while because there is no external symptom. To diagnose phantom tooth pain, a dental health professional will observe the patient over time and work through eliminating any other dental health issues. Misdiagnosis is not an uncommon occurrence.
What Is the Treatment for Phantom Tooth Pain?
Because phantom tooth pain is not the result of an identifiable, physical oral health issue, treatment often means managing the pain by medication. There are a number of antidepressants, steroids, NMDA receptor antagonists, anticonvulsants, and narcotics that can manage the pain, while treatments like acupuncture and nerve stimulation have also shown that they can help diminish the phantom tooth pain.
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What Is Phantom Tooth Pain?
By Laulani Dental Care
Have you ever felt pain in a tooth that is no longer in your mouth? If so, you may be experiencing phantom tooth pain. Here, we’ll explain what phantom tooth pain is, what the symptoms are, what causes it, and how you can treat it.
Phantom tooth pain, also known as atypical facial pain or atypical odontalgia, is chronic and constant pain in your teeth or in an area where teeth have been pulled or extracted. You may have heard of a similar phenomenon when people with amputated limbs still feel pain where the limb used to be. Over time, the pain can even extend to other parts of the mouth or the jaw.
What Are the Symptoms of Phantom Tooth Pain?
The pain associated with phantom tooth pain is often described as a persistent aching or throbbing at the site of extraction. It’s different from regular tooth pain because an average tooth pain usually has an identifiable cause such as injury to the tooth or tooth decay or gum disease and can be solved in a specific treatment. Unlike regular tooth pain, phantom tooth pain is not affected by hot or cold food or drink, or grinding or chewing. Sometimes the pain is intense and severe, while other times it is mild. It may take a while to diagnose the issue because there are no real external signs of pain and therefore diagnosis is done mostly through observation over a time and by eliminating any other oral health issue.
What Causes Phantom Tooth Pain?
Phantom tooth pain is caused by a root canal or extraction or other dental procedure such as these. It is thought to be a type of neuropathic pain disorder and therefore is believed to be due to nerve endings sending signals to the patient’s mind telling it that it feels pain. This error in processing the pain between the nerves and brain means that phantom tooth pain won’t go away unless treated by a dental professional.
What Is the Treatment for Phantom Tooth Pain?
Treatment for phantom tooth pain is typically done in the form of medication. Because phantom tooth pain is a neurological disorder, any type of topical solution or surgical procedure won’t do anything to stop the pain. Medications like antidepressants, anticonvulsants, narcotics, and NMDA receptor antagonists have known to improve the pain associated with phantom tooth pain. There are also some non medication treatments like acupuncture and nerve stimulation.
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Treating Phantom Tooth Pain
Phantom tooth pain, also known as Atypical Odontalgia, occurs in an area of the mouth where tooth extraction has recently taken place. Though the tooth itself is gone and the actual source of pain removed, the gum and jaw area where the tooth was located can continue to ache, similar to the way a patient with an amputated limb may feel pain in the area where the limb used to be.
Signs of Phantom Tooth Pain
This can be due to the nerve ending in the area sending signals of pain to the patient’s brain, though no physical cause for the pain exists within the mouth. There may be an existing issue with the way the patient’s brain interprets pain signals, or this issue may be isolated to the nerves in the tooth area. A dentist or endodontist may take some time to diagnose a patient with phantom tooth pain, as there are no external signs of the pain. Diagnosis is typically done through observation over time and process of elimination to ensure there is no physical cause for the pain. The pain itself is reported as a chronic, repeated dull ache in the area where a tooth was extracted, which can spread to the surrounding area of the face and jaw bone. Since it is caused by an error in the processing of pain between the nerves and the brain, phantom tooth pain does not typically get better or stop without some form of treatment by a professional.
Treatment of Phantom Tooth Pain
Visit your Houston endodontist to treat phantom tooth pain. As this pain is tied to the association between nerve endings in the gums and the part of the brain that receives pain signals, treatment for the pain is typically done through medication as opposed to topical treatments on or around the site of the extraction.
Antidepressants can be an effective treatment for the symptoms of phantom tooth pains. Patients may find that the phantom tooth pain does not subside naturally and medications have to be taken indefinitely to control phantom tooth pain.
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Introduction, putative mechanisms for phantom pain, definitions and subgroups, conclusion and future research, acknowledgments.
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Phantom Tooth Pain: A New Look at an Old Dilemma
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Joseph J. Marbach, Karen G. Raphael, Phantom Tooth Pain: A New Look at an Old Dilemma, Pain Medicine , Volume 1, Issue 1, March 2000, Pages 68–77, https://doi.org/10.1046/j.1526-4637.2000.00012.x
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The aim of this paper is to review the current knowledge of phantom tooth pain, a neuropathic facial pain disorder, thought to result from peripheral nerve injury. Phantom tooth pain is a deafferentation pain disorder of persistent toothache in teeth that have been denervated (usually by root canal treatment) or pain in the area formerly occupied by teeth prior to their extraction. The pain usually extends to the facial structures adjacent to tissues that have undergone deafferentation. The clinical characteristics, differential diagnosis, epidemiology, and treatment of phantom tooth pain are reviewed. Suggestions for further research include the need for controlled treatment trials and modification of current criteria.
Conclusions. Phantom tooth pain has much in common with other phantom pain disorders. In the absence of controlled clinical trials specifically directed to phantom tooth pain, treatment should be guided by standards used for other neuropathic pain disorders. Revised diagnostic criteria for phantom tooth pain are proposed.
Throughout the past half century, those concerned with the classification of facial pain disorders have struggled with many attempts to bring order to the field. In the absence of a generally accepted classification system for facial pain, numerous labels are employed to describe essentially the same conditions. In addition, ‘wastebasket’ categories such as ‘atypical facial pain’ (AFP) are commonly used. Here heterogeneous facial pain conditions are placed in one category. The common thread among these heterogeneous neuropathic disorders is that they can not be explained by one etiology or anatomic lesion, and that treatment response remains unpredictable.
We present a review of the clinical characteristics for one disorder frequently labeled as AFP, namely phantom tooth pain (PTP), and propose revised diagnostic criteria for PTP. PTP is a syndrome of persistent pain and paraesthesia in the face, teeth, and other oral structures. The onset usually follows nerve injury to the face often accompanying dental or surgical procedures. In the case of tooth extraction, the pain is found in the edentate area. This latter condition is analogous to stump pain following limb amputation [1-3] .
Phantom pain is customarily associated with limb amputations  . However, phantom pain is not confined to limbs. For example, phantom phenomena are reported in 20-25% of post mastectomy cases, 50% of them painful  . Data suggests that an individual surviving the amputation of any anatomic structure can experience phantom pain phenomenon. Yet, despite the fact that teeth are probably the most commonly amputated structures among members of industrialized societies, relatively little attention has been paid to orofacial phantom pain. Moreover, teeth are unique in that the neural structures that serve them can be entirely eliminated routinely without amputating the entire part. One could argue quite legitimately that the term “phantom” should not apply to postendodontic neuropathic pain. Rather than attempting to introduce a unique term to describe this situation, subsuming this clinical state under the rubric of phantom pain appears to be the most parsimonious approach. There is precedent in the literature for other unusual manifestations of “phantom pain” [6-9] . While a similar process may accompany spinal cord injury, for example, with PTP, elimination of neural tissue occurs in the course of root canal therapy. In spinal cord injury, phantom-like pains appear to develop  and are readily identifiable as stereotypical phantom pain, given the extreme alteration in function and sensation that accompany such an injury. In the case of PTP, the idea of phantom pain may be much less apparent to the clinician and patient alike.
Although the past decade has witnessed wider recognition of PTP  , its systematic study is a relatively recent phenomenon. The term PTP was first used in the English-language literature in 1978  . At virtually the same time, the term PTP appeared in French  and German publications  . In all, Medline lists 23 papers using the term PTP since 1975. In the same period, Medline lists 175 papers under the heading “atypical facial pain,” 70 of which have been published since 1990. Despite the heterogeneity and ambiguity implicit in the term atypical facial pain, it continues to be used. In contrast, we advocate the use of terms that imply greater homogeneity of clinical presentation and etiology, such as PTP. This approach lends itself to the goals of establishing reliable diagnoses, providing more specific treatment, and facilitating research on pathogenesis. Classification systems are important to clinicians. They help them in the selection of treatments, provide a gauge for prognostication, direct the search for risk factors, and alert one to comorbid conditions. To be useful, a taxonomy system must reliable  ; different examiners applying the diagnostic standard should reach the same conclusions. To be reliable, the system must possess operational criteria and use inclusion and exclusion criteria. It should also be comprehensive, applying to milder, more diagnostically subtle cases as well as the more obvious, severe ones. Nevertheless, the taxonomy of facial pain continues to be problematic for reasons that will become apparent.
The identification of those at high risk for PTP needs further exploration. Vulnerability to phantom pain has been demonstrated to be genetic in animals [15-17] and hypothesized to be so in humans [15,18] . Given the universal loss of deciduous teeth, perhaps evidence for the neuromatrix theory can be found in children. Humans appear to experience no lasting sensory sequellae from the loss in contrast to adult dentition
While acknowledging the frequent use of the term “atypical facial pain” (AFP), Merskey singles out and “deliberately rejected” AFP from the International Association for the Study of Pain taxonomy  . He suggests that such patients can better be served by attempting to define them by other, more specific diagnoses, e.g., temporomandibular pain syndrome, atypical odontalgia, etc. Despite his advice, the diagnoses atypical facial pain (AFP) and atypical facial neuralgias persist in the literature and frequently appear on clinical charts. AFP continues to be used as a euphemism for medically unexplained chronic facial pain  . However, like other heterogeneous diagnostic labels, such as temporomandibular disorders (TMD)  , AFP leads to confusion regarding the specific nature of the complaint and often results in inconsistent approaches to treatment. For example, Ford  writes that “treatment for patients with atypical face pain is essentially the treatment indicated for depression.” As we will see, Ford's conclusion was based on a body of literature that predates modern criteria for various facial pain disorders.
Phantom limb phenomenon following amputation is almost universal  . Most individuals report the vivid impression that the amputated member is still present and, less often, painful. Mounting evidence from animal and now human studies identify long-term cortical reorganization of the somatotopic arrangement can follow alterations of peripheral input.
Neurophysiologic mechanisms of phantom pain
Fields and colleagues  describe three different, but nonmutually exclusive, mechanisms to explain neuropathic deafferentation pain. In the first type, they speak of an “irritable nociceptor.” Here an anatomically intact but physiologically abnormal primary afferent nociceptor results in mechanical allodynia due to central sensitization of pain transmission neurons. In other patients, extensive degeneration of C-fibers is present with the allodynia. A third mechanism accounts for both constant pain and sensory loss without allodynia, i.e., anesthesia dolorosa. Here deafferentation may result in changes in the activation state of central nervous system (CNS) pain transmission neurons. Although based largely on animal studies, indirect evidence from humans suggests that more than one of these mechanisms can cooccur in the same individual, and even change in time by means of synaptic reorganization.
Melzack [18,24,25] has posited a provocative hypothesis regarding phantom phenomenon. He suggests that: (1) the bodily sensations that we perceive in our brain are started and maintained, typically, by input derived directly from our bodies. However, because phantom sensations feel so vivid, they too are probably subserved by the same neural processes; (2) All sensations we feel from our bodies, such as pain, can be felt without input from the body. From this we conclude that the sensory experiences lie innately in the neural “hardware” of the brain because external stimuli may trigger the sensations but do not create them. They are produced by the brain itself. Other examples of physiologic responses that appear to occur without external stimulation include the vivid sexual responses to dreams; (3) The sense of self is generated in the CNS, not from the sensations derived though the peripheral nervous system (PNS). The uniqueness we perceive physically as ourselves (not someone else) takes place in the brain; (4) The CNS processes that regulate the recognition of the body are genetically specified, though probably modified by experience. These four elements comprise Melzack's theory of the “neuromatrix.”
In summary, the neuromatrix theory of Melzack posits that loss of input to the CNS by deafferentation following injury or amputation produce localized abnormal neural activity. Tissues near the site of injury, visceral sensory nerves, from small afferents in the sympathetic chain, and from higher psychoneural processes trigger prolonged firing, resulting in chronic pain in discrete areas of the denervated body parts and even more remote body sites. The neuromatrix provides an intriguing theoretical framework for understanding one of the most perplexing of pain disorders, phantom pain, and associated phenomena.
An extensive literature exists regarding the controversy as to whether phantom pain has a psychological or physical basis  . Many attribute the etiology of phantom pain and of AFP to psychological factors [27-29] . A standard neurology textbook associates AFP with women, depression, anxiety, and hysteria  . Indeed, as with many other phantom pain disorders, most PTP patients could meet DSM-IV criteria for somatoform pain disorder  . A psychological attribution to the diagnosis is not surprising when the patient's symptoms appear to fit no known physical disorder, the symptoms are notoriously recalcitrant to traditional dental and surgical treatment, and examination discloses high rates of psychiatric symptomatology  . Nevertheless, it remains plausible that psychological abnormalities observed in phantom patients are a consequence of the stress associated with the pain, as this explanation has recently been confirmed for other orofacial pain conditions  . There is no evidence currently that PTP is characterized by a premorbid personality  . Few pain clinicians now raise the specter of a psychological basis for PTP.
Phantom Tooth Pain
The most common form of orofacial phantom pain is PTP. There are reports of other facial phantoms involving eyes, noses, ears, and tongues. Like phantom pain due to spinal cord injury, teeth can be denervated yet still be attached to the individual. What is obviously ‘missing’ in the case of many other phantom pains, such as limb amputation or mastectomy, may be much less obvious with PTP.
PTP is a deafferentation syndrome of persistent toothache in teeth that have been denervated (root canal) or in the area formerly occupied by teeth before their extraction. The pain often extends to the facial structures adjacent to the tissues that had undergone deafferentation. Table 1 presents a revision of the 1992 criteria for PTP. These revised criteria are distinguished from the earlier published version  in that they attempt to aid differential diagnosis rather than simply provide a comprehensive description of the syndrome.
Diagnostic Criteria for PTP
Note: Prevalence does not differ by sex. The loss of deciduous teeth does not result in phantom tooth pain.
Usually PTP follows dental or surgical procedures such as root canal therapy, apicoectomy, or tooth extraction. Other facial traumas and surgical procedures may precede the onset of PTP. PTP is characterized primarily by persistent pain. Neither repeated endodontic treatment, apicoectomy, nor more tooth extractions render the affected area free of pain. On the contrary, procedures and other surgical interventions, such as trigeminal rhizotomy and microvascular decompression, frequently exacerbate pain severity and, in addition, may increase the distribution of pain in the trigeminal nerve  . Animal data suggest that dental pulp amputation not only result in a lesion at the tooth apex, but consistent with other nerve injuries, also alters the CNS to generate ongoing pain  . This central “generator” could account for the lack of response to analgesic measures taken at the PNS. Some suggest that those neuropathic pains that have a predominantly central “generator” comprise the so-called deafferentation pain syndromes  . This theory does not exclude the possibility that a peripheral lesion is required to sustain the pain resulting from the central generator [35,36] .
Because PTP is often incessant, incapacitating, and inscrutable, the patients present a vexing problem for clinicians. Complicating matters for the clinician are difficulties regarding differential diagnoses. PTP is mistaken frequently for temporomandibular joint disorder (TMJ) or trigeminal neuralgia, sinusitis, or even ill-fitting dentures (see section on differential diagnosis, below). All too often, chronic facial pain disorders appear superficially similar one to another. Moreover, the clinician cannot turn to a ‘gold standard.’ Confirmatory diagnostic laboratory and radiographic tests are unavailable. While a physician with a specialty pain practice is sensitive to this, many dentists are used to relying on ‘objective’ signs to make a diagnosis. Dentists are trained to depend strongly on radiographs. Like all radiographs, dental radiographs are open to interpretation and can lead to equivocal treatment interventions. This frequently compounds frustrating, expensive, and lengthy delays in arriving at the correct diagnosis while diagnostic tests and treatments are pursued and repeated.
In the absence of a diagnostic gold standard, accurate differential diagnosis of PTP is dependent upon history, physical examination, and such often overlooked tools as epidemiology [37,38] . While only limited information about the epidemiology of PTP is currently available [see below], the epidemiology of other orofacial pain conditions, e.g., TMJ  , TN  is better known. The demographic distribution of these other orofacial pain conditions provides a source of clues for other possible diagnoses. For example, the underlying condition for recent onset facial pain in a 60-year-old male is unlikely to be a TMJ because TMJ is much more likely to be found in younger women  . Trigeminal neuralgia, temporal arteritis, or PTP remain possible explanations, with the latter especially likely when a symptom onset was shortly after root canal therapy.
Epidemiology of PTP
Epidemiologic data concerning chronic pain disorders such as PTP are difficult to obtain. Crombie and Davies  note that exploring the epidemiology of a disease requires a formal definition of a diagnostic group. PTP is still undergoing revision of its criteria (Table 1) to establish a relatively homogeneous group with diagnosis that is likely to be replicated by different clinical research teams. For example, the International Association for the Study of Pain  could identify only PTP because intraoral stump pain syndrome was only conceptualized in 1996 [1,3] . Because no available data on the prevalence of intraoral stump pain exists, the current discussion focuses on PTP, drawing in part from what is known about other types of phantom pain.
As reviewed by Kalauokalani and Loeser  , the prevalence of nonorofacial phantom pain following amputation is reported to range between 53% and 72%. These rates remain fairly constant for the five years following amputation. Jensen  reported a rate of 59% at two years post amputation. Sherman  reported a rate of 78% in a large (n = 2694) survey that varied widely in time since amputation. Several investigators report a gradual decline in the prevalence of postamputation phantom pain with the passage of time [43,45] . Preamputation pain is agreed to be the major risk factor predicting postamputation phantom pain  . As most root canal procedures are preceded by preamputation pain, it would appear that the risk of post-root-canal pain should be relatively high. Although healthy teeth provide relatively little sensory feedback, toothache can occupy a great deal of one's attention.
There are two common dental procedures that appear to increase the risk of PTP, tooth extraction and endodontic therapy. Thus, it is surprising that PTP is not more frequently reported in the literature. Several explanations are possible. Underreporting due to lack of recognition is a likely explanation. Alternatively, the quantity of neural tissue associated with a tooth compared with a limb may explain the difference in rates. Melzack's neuromatrix theory predicts that the general lack of awareness of teeth, unless diseased, would also result in relatively low rates of phantom tooth pain.
Reports of PTP following tooth extraction are unavailable. In a single study  of 436 individuals who underwent root canal therapy, 7% reported continued pain more than one month after treatment. Eight of the 11 subjects who were directly examined meet criteria for PTP. Extrapolating from the subsample on whom follow up physical examination was possible, the postendodontic therapy rate of PTP was 3 to 6%, with no significant differences in rates for men versus women. All those with verified PTP following endodontic treatment reported tooth pain before endodontic therapy, vs. 75% of the entire sample undergoing endodontic therapy. This is consistent with other studies showing that pain before amputation is a risk factor for nonorofacial phantom pain.
If one generalizes to the U.S. population of 260 million people and assumes conservatively that 5%, or 13 million members of the U.S. population, have undergone endodontic treatment and 5% of this group result in PTP, then 650,000 cases of PTP secondary to endodontic therapy would potentially exist. Rates are potentially even higher when accounting for other potential risk factors such as tooth extraction.
The risk of more severe and widespread PTP increases for the individual undergoing multiple endodontic treatments, particularly when the additional therapies are misdirected attempts to treat the unrecognized PTP. Per capita endodontic treatment in the U.S. will likely increase with the aging of the population. With more elders eager and able to afford the services, the rates of PTP are bound to rise.
PTP is often confused with the typical neuralgias and myofascial pain. The most common of the typical neuralgias is trigeminal neuralgia (TN) [38,40] . Both TN and PTP patients complain of pain in the face, often specifically in teeth. Here the resemblance ends. The paroxysmal, sharp, sudden, electrical-like stabbing recurrent pain is unlike the dull uninterrupted pain of PTP. The age of onset of TN is usually after the fourth decade with a peak onset in the fifth and sixth decade. Other typical neuralgias are associated with acute herpes zoster, post herpetic neuralgia, and geniculate neuralgia.
In addition, myofascial face pain is often confused with PTP. Myofascial face pain, also known as ‘TMJ’ or myofascial TMD  , like PTP, but unlike TN, presents as a constant, dull aching face pain. Although myofascial face pain can be comorbid with, and may be secondary to PTP, when the dull aching pain is restricted to the facial muscles, a diagnosis of PTP is excluded.
While not technically a matter of confusion, as stated earlier, PTP is frequently labeled AFP. AFP is a diagnosis made, traditionally, after excluding other possibilities for which the clinician has a physical explanation. In the absence of specific criteria and considering the recent developments in pain disorder taxonomy, the term AFP might best be relegated to one of historic interest.
The need for more homogeneous groups of neuropathic pain subjects is a recurrent theme among those attempting to interpret the treatment literature. By focusing attention on PTP, it is hoped more researchers will conduct controlled trials. Meanwhile, to date there are few controlled clinical trials for treatment of PTP to act as a guide. Thus, although the following section on treatment focuses on the PTP, we are required to make inferences from controlled studies of more extensively studied neuropathic pain disorders such as trigeminal and post herpetic neuralgia.
The past decade has witnessed the availability of many new adjuvant analgesic drugs and formulations for the treatment of neuropathic pain. Nevertheless, progress in the treatment of PTP has been mixed because of the long delay in diagnosis. Earlier detection of more patients would certainly result in avoiding the more aggressive and egregious errors of the past, namely unnecessary root canal treatments, tooth extractions, and neurosurgical procedures.
With the exception of trigeminal neuralgia, physicians have traditionally relegated the treatment of most chronic facial pain disorders to dental and oral surgeons. Even in the case of trigeminal neuralgia, many patients undergo unnecessary dental procedures before obtaining proper diagnosis and treatment  . Ostensibly, the decision to refer patients for dental care is based on the notion that these disorders require special dental expertise outside the scope of conventional medical training. There is little evidence to support this viewpoint. Moreover, physicians assume treatments used by many dentists for other facial pain problems, i.e., bite plates or bite adjustment, are reasonably effective. There is no literature, either anecdotal report or controlled clinical trial, to suggest their efficacy for PTP. Once the correct diagnosis and implicit knowledge of pathophysiology underlying PTP is made, it becomes clear that there is no logic for traditional dental treatment approaches.
Centrally acting drugs are meant to influence afferent impulses that culminate in central synaptic excitability. This includes the administration of both oral, transdermal, and certain topical drugs. A second approach is directed to the changes in the chemistry of transported substances in the PNS by means of nerve block injection.
Recently, Virani and colleagues  reviewed drug interactions in neuropathic pain. They observed that in clinical practice neuropathic pain patients are often treated with multiple drug “cocktails.” This leads to ambiguity about the effect of any given drug and the potential for side effects, e.g., fatigue, depression, or insomnia.
Centrally acting agents
Uncontrolled studies make up the majority of the available data on treatment of phantom pain in general and PTP specifically. Nonetheless, such studies often provide clues to etiology and differential diagnosis. Meanwhile, we will refer to non-PTP phantom pain studies if they may be relevant. Specific references below to treatment for PTP come from clinical experience and do not have the authority derived from controlled trials. Unfortunately, this is the only information available currently.
Anticonvulsants (ion channel blockers)
Carbamazipine, gabapentin, phenytoin, clonazepam, and lamotrigine have all been used and studied in the treatment of many neuropathic pains [for reviews see 49, 50 ]. Their mechanism of action is not well understood. In an adequate dose, carbamazipine is reported to be effective for more than 70% of trigeminal neuralgia patients [51-53] . If carbamazipine is effective in a patient with suspected PTP, one should consider amending the diagnosis to trigeminal neuralgia. For reasons that are still unclear, carbamazipine does not produce analgesia for PTP. Phenytoin is only rarely effective.
Although there are no randomized controlled clinical trials for PTP, gabapentin has been used successfully to treat phantom limb pain in controlled trials  . It is considered the drug of choice for PTP. Gabapentin's presumed action is that of a membrane stabilizer. Gabapentin influences both axonal conduction and synaptic transmission. Its site of action may be at the abnormal peripheral nerve or within the central nervous system.
GABA-B receptor agonist
Baclofen has been used in a variety of neuropathic disorders. It is helpful in PTP as an adjunct to other medications.
Sedatives and tranquilizers
Generally, barbituates, nonbarbituate hypnotics and minor tranquilizers have little analgesic activity in PTP, with one exception. Clonazepam, a benzodiazepine derivative, in doses of 1-3 mg/daily, often reduces PTP. A variety of mechanisms that include increased brain serotonin and enhanced GABA binding has been investigated to explain these analgesic effects in a variety of neuropathic pains.
Tricyclic antidepressants (TCA) have been used for many years in the treatment of various deafferentation pain syndromes. McQuay and colleagues  conclude from their meta-analysis that, among patients with various forms of neuropathic pain, 30% achieved at least a 50% reduction in pain. Their efficacy is well established but their site of action is unknown  . Questions have been raised as to whether TCAs act as analgesics or work by altering mood. Recent evidence supports an analgesic effect  . Phenothiazines potentiate the analgesic effects of TCAs in PTP. In severe cases, the author of this article (JJM) has prescribed a combination of TCA and phenothiazines (i.e., perphenazine and amitriptyline, Triavil) with excellent results. The clinician should monitor the patient for signs of tardive dyskenesia.
A good deal of controversy focuses on narcotic drug therapy for neuropathic pain. In his review of opioids and neuropathic pain, Dellemijm emphasizes that some inconsistencies in reported response can be attributed to a lack of agreement regarding nomenclature  . For example, studies including patients with AFP may include subjects with somatic pain disorders, which confounds results. At present, there are insufficient controlled clinical trials to provide a definitive opinion regarding opioid efficacy for PTP. However, because opioids are frequently prescribed as the only means of pain control, several concepts are clinically useful. Effective treatment and efficacy are not the same. ‘Efficacy’ refers to the activation of the receptor by the opioid. The balance between pain relief and side effects is referred to as ‘effective treatment.’ This implies the need for individual dose titration that targets interindividual variability  . Until recently, narcotics were deemed relatively ineffective in the treatment of PTP  . There is, however, animal experimental  and clinical [35,58] evidence suggesting the contrary. The authors now believe that the use of narcotics has a role in chronic PTP. Subsets of patients suffering from chronic benign pain find relief with a fixed daily dose of oral narcotic analgesic. The author ( JJM) prescribes controlled-release oxycodone, controlled-release morphine, fentanyl  , ketamine  , and methadone in selected cases. Patients selected for this therapy recognize that these drugs rarely result in addiction in chronic pain patients, but may result in chemical dependency. Nevertheless, patients are screened for addiction-proneness and medical suitability.
In addition, with one exception, intranasal application of drugs is just beginning to be recognized as useful. The intranasal application of cocaine has been used for analgesic purposes for more than a hundred years  . In a controlled double blind study, cocaine has been shown to abolish PTP temporarily. Cocaine, unlike opioids, apparently does not show affinity for specific receptor sites  , although the mechanisms of these two properties are not necessarily related. The receptor site for cocaine's action is unclear. In addition to its long recognized local anesthetic effects, cocaine has been reported to show central analgesic effects  . Moreover, a large loss of opioid binding sites has been shown to occur after deafferentation  . This may explain why cocaine is more effective than opioids in the treatment of PTP. The difference in analgesic effects in of the two types of drugs suggests research approaches to the etiology of PTP. Like the chronic use of opioids, cocaine possesses complex management issues that society has yet to address adequately.
Peripherally applied agents
The author employs local anesthetic injections routinely for the relief of PTP. They are also effective when combined with steroids. Local injection of dexamethasone with various combinations and strengths of local anesthetics is clinically effective. In rats, local steroid injection to the site of nerve compression facilitated recovery of nerve conduction blockade when compared to saline injected and noninjected control groups  .
Success rates of steroid injection appear to be dependent on two factors. First, to avoid side effects, the proper site of injection must be determined as low doses of steroid are necessary when repeated injections are contemplated. Some are at the site of the teeth intraorally and others are on the face at the terminal points of the divisions of the trigeminal nerve. Still others are at sites associated with other neuralgias, e.g., trigeminal and occipital. Repeated clinical trials help to establish the correct injection sites for each patient.
The second factor in success with steroids is early treatment, when possible. Steroids apparently best facilitate peripheral nerve recovery when the injury is fresh  . Recall the sequence of physiologic responses detected following injury of a peripheral nerve. After the initial shock and a brief shutdown of neural activity, the injured axon puts forth sprouts. These new sprouts differ from the parent nerve in an essential way. They readily generate action potentials either spontaneously or following mechanical, chemical, thermal or metabolic, (i.e., ischemic) stimulation. If these sprouts connect with the appropriate receptor, more stable electrical characteristics are likely to be established and the hyperexcitability state recedes  . Of course in the case of endodontically treated teeth, contact with the appropriate receptors is forever prevented. Deafferentation is the permanent state. Fortunately, as Wall noted, all neuropathies do not always result in pain  .
Topical and transdermal drugs
Topical drugs are usually formulated as a liquid, cream, or gel. They are applied directly to the skin. They act by penetrating the skin and influencing peripheral tissues, including nerves, directly underlying the site of application.
Transdermal drugs are also applied to the skin, but may act at distant sites, by way of the bloodstream. Transdermal delivery systems are usually patches containing a pooled reservoir. Other drugs are directly applied to skin but act as transdermal vehicles.
Patients are often reluctant to use topical drugs and certainly transdermal patches on the face. Topical capsaicin [66,67] and clonidine applied with a transdermal patch  in selected neuropathic pain disorders have been tested. In clinical practice, few PTP patients have continued to use a capsaicin. Several find topical ketamine analgesic. We are presently testing drugs in a topical intraoral delivery system that permits the vehicle to stay attached to the oral mucosa, gradually releasing the drug. At present there is a lack of consistent results from many studies of topically applied drugs  . Nevertheless, topical and transdermal therapy has intrinsic advantages and will no doubt continue to undergo investigation.
There are occasional indications for surgical treatments for PTP. A thorough appraisal of surgical treatments is not a chief priority of this article.
It follows logically that if local anesthetic blockade of a nerve relieves pain temporarily, surgical interruption at the same site, or central to it, would yield lasting relief. Clinical experience has amply demonstrated, quite to the contrary, that the reverse is more often than not the case  . The literature on this subject is too vast to review here; however, a brief summary will be attempted.
Many neurosurgical and dental approaches have been tried on PTP, mostly with extremely poor results. Rawlings and Wilkins  reviewed the neurosurgical treatment of pain syndromes of the trigeminal system. Their findings were not encouraging. Clinical experience suggests that postneurosurgical patients make up the most recalcitrant group of facial pain patients.
The most common treatment for PTP is further endodontic therapy followed by apicoectomy and tooth extraction (Fig.1) . The logic is apparent to any clinician familiar with endodontics. There are two patterns to the clinical histories of PTP cases. In the first case, a dentist or dental specialist examines a patient already suffering deafferentation pain, the result of an injury, illness, or surgery (e.g., Cladwell-Luc, rhinoplasty, silicon injection in the face). If a “suspicious” tooth is found in the area of pain distribution, endodontic treatment may be performed. If no tooth is found, the patient may urge treatment of a sound tooth in the mistaken belief that the pain is of dental origin. In the second scenario, routine endodontic treatment is performed expertly but pain persists or is worse than it was preoperatively. An assumption is made that either additional endodontic treatment is necessary or the wrong tooth was treated. Apicoectomy and tooth extraction are also logical sequella of this approach to pain management. Clinicians who consider PTP in the differential diagnosis of unusual dental pain complaints will participate in fewer of these two scenarios.
Radiograph of a 22-year-old woman suffering phantom tooth pain of four years' duration. All teeth have been treated by root canal therapy and apicoectomy. Severe pain persisted at the time this radiographic was taken.
The specific purpose of this article is to review current knowledge on PTP based on clinical observation. Beside the obvious need for controlled clinical trials, one other major information gap is apparent. There is a need to refine further the diagnostic criteria for PTP. As Merskey [17,19] emphasizes, the evolution of a taxonomic system is a work in progress. However, before progress can be made in refining criteria for a specific disorder, a critical mass of clinicians and researchers must bring their attention to the problem. The first step is recognition that the disorder exists, is a distinct one, and can be identified reliably. This is why we have presented newly revised criteria for PTP. Our hope is that others will investigate and improve both the taxonomy and treatment of PTP. As these criteria are applied in practice, further revisions and specifications will likely follow.
This research was supported in part by grants from the National Institutes of Health (NIH) National Institute of Dental and Craniofacial Research (NIDCR) Grants # R01 DE05989 and R29 DE11714. We wish to thank the anonymous reviewers for their many thoughtful suggestions.
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- differential diagnosis
- facial pain
- phantom limb
- root canal therapy
- neuropathic pain
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What Is Phantom Tooth Pain?
- December 31, 2018
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If you’re suffering from pain that just doesn’t go away after a tooth extraction or endodontic procedure, you may be experiencing phantom tooth pain. In this blog post, we’ll tell you what we know about this tricky form of oral pain.
Identifying Phantom Pain
In some instances, people who have a limb amputated report feeling pain, burning, itching, tingling or pressure where that limb used to be, even though it’s no longer there. It’s called “phantom limb pain”. A similar phenomenon has been known to happen after tooth extractions and endodontic treatments, such as root canal therapy. While phantom tooth pain is considered to be uncommon, it is definitely a real condition.
Phantom tooth pain can cause confusion for both patients and their dentists. The perception of pain lacks an identifiable and treatable physical cause, such as irritation or infection, and is instead thought of as a mix-up in how the brain is processing its memory of the senses from the area. It can be chronic or intermittent and has variable levels of intensity. While not much is known about phantom tooth pain, it is more often seen in women and people in middle-age, according to the American Academy of Oral Medicine.
If you have the unfortunate luck to be struck with these ghost sensations, consult with our team here at Signature Smiles Dental. There are things we can do to help you manage the pain, such as prescribing certain medications. We will do all we can to help you find a treatment that works for you.
If you are experiencing dental discomfort in the wake of a procedure, please let us know. If it happens to be phantom tooth pain, we’ll help you find a solution to the pain that is best for your unique needs.
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Phantom tooth pain: a new look at an old dilemma
- 1 University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Dept. of Psychiatry, and New Jersey Dental School, School of Oral Biology, Pathology, and Diagnostic Sciences, Newark 07103, USA. [email protected]
- PMID: 15101965
- DOI: 10.1046/j.1526-4637.2000.00012.x
The aim of this paper is to review the current knowledge of phantom tooth pain, a neuropathic facial pain disorder, thought to result from peripheral nerve injury. Phantom tooth pain is a deafferentation pain disorder of persistent toothache in teeth that have been denervated (usually by root canal treatment) or pain in the area formerly occupied by teeth prior to their extraction. The pain usually extends to the facial structures adjacent to tissues that have undergone deafferentation. The clinical characteristics, differential diagnosis, epidemiology, and treatment of phantom tooth pain are reviewed. Suggestions for further research include the need for controlled treatment trials and modification of current criteria.
Conclusions: Phantom tooth pain has much in common with other phantom pain disorders. In the absence of controlled clinical trials specifically directed to phantom tooth pain, treatment should be guided by standards used for other neuropathic pain disorders. Revised diagnostic criteria for phantom tooth pain are proposed.
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What is phantom tooth pain.
Phantom tooth pain—also variously known by the technical names "atypical facial pain," "atypical odontalgia," and "neuropathic orofacial pain," is one of the most mysterious conditions in the field of oral health. Chronic pain in a tooth or teeth is the defining characteristic. However, unlike the typical toothache, there is no evidence of decay, periodontal disease, injury, or other identifiable cause.
Constant throbbing or aching in a tooth, teeth, or extraction site that is persistent and unremitting is how phantom tooth pain is usually described. In addition, hot or cold sensations do not significantly affect the pain, and even local anesthetic often cannot relieve it. The intensity ranges from mild to severe.
What Causes It & Who Is Most Likely to Get It?
It is theorized that phantom tooth pain is caused by changes in parts of the brain that process pain signals, causing a persistent sensation of pain even when an identifiable source of pain does not exist. Why this happens, however, is not known. Genetics, age, and gender seem to play a role, with women and those older than middle-age being the most affected.
How Is It Diagnosed & Treated?
If a review of the patient's history, a thorough clinical examination, and radiographic assessment cannot identify the source of pain, a diagnosis of phantom tooth pain is often made. Various medications have been used in an attempt to treat it, with tricyclic antidepressants being the most common. Generally, treatment is successful in reducing the pain but not eliminating it completely.
If you have any symptoms of phantom tooth pain, be sure to contact us at North Richland Hills Dentistry right away so Dr. Desai can evaluate your specific situation and help you determine the best course of action.
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Phantom Tooth Pain – Atypical Odontalgia
November 18, 2014 By Larsen
It is diagnosed as atypical pain because it doesn't present like typical tooth pain. Typical tooth pain comes and goes. The pain is precipitated by hot or cold food or drink, and/or by chewing or biting on the affected tooth. It is usually caused by decay, periodontal disease, or injury to the tooth and the pain is predictably relieved by treatment of the affected tooth.
With Phantom Tooth Pain – Atypical Odontalgia the pain is described as a unremitting constant throbbing or aching in a tooth, teeth, or extraction site and it is usually not affected by exposure to hot or cold food or drink, or by chewing or biting. With no identifiable cause, patients might seek treatment aimed to relieve the pain such as a filling, a root canal, or even an extraction. This often presents a frustrating and confusing situation for both the patient and the dentist, and can lead to more and more dental treatment, none of which is effective at relieving the pain.
Endodontists are experts at the diagnosis of atypical odontalgia. After a thorough history, clinical examination, and radiographic assessment fails to identify a cause for the pain, the diagnosis can be made and medications can be used to reduce the level of pain.
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Phantom Tooth Pain or Serious Problem?
April 30, 2022 By Taylor Cosmetic Dental Leave a Comment
There isn’t much more annoying than tooth pain. If you’ve experienced tooth pain , you probably realize it’s not one of those things you can easily ignore. Sometimes it can be hard to pinpoint what is causing your mouth pain, but understanding your specific symptoms may give insight into what is going on.
Let’s look at what your pain may be telling you.
Some people experience generalized tooth sensitivity to cold or hot temperatures. Usually, this type of sensitivity comes when exposed to extreme temperature changes, but symptoms often go away when the irritating source is taken away. This type of sensitivity is not usually serious, although it can be annoying.
If you have generalized tooth sensitivity, you can try replacing your regular sensitivity with sensitive toothpaste such as Sensodyne. Simply brushing with this toothpaste twice a day may help alleviate sensitive teeth symptoms. Also, avoid toothpaste geared toward whitening your teeth, as many of these kinds of toothpaste are highly abrasive and will worsen your symptoms.
A Dull Ache
A dull, nagging toothache is the most common type of toothache. A dull ache is typically a mild one, but it tends to be persistent. Consult your dentist to get to the core cause of this dull ache. Most people will try painkillers to alleviate pain, but it is only a temporary solution.
Sharp Tooth Pain
Sharp tooth pain usually comes and goes pretty quick. A common cause of acute tooth pain can be recession, but it can also be a symptom of having a fracture line in your tooth. When you bite down on your fractured tooth, it will cause the tooth to splay.
When you release and open your mouth back up, you may notice a sharp pain. The pain will feel like a zinger radiating from your tooth. Ouch!! This is your fractured tooth squeezing back together and pinching the nerve in the center of your tooth, sending the message to your brain.
If this is the pain you feel, call your dentist as soon as possible. They will want to take a look to avoid further cracking and more pain.
Throbbing Tooth Pain
Have you ever experienced a throbbing headache? You know that it feels as though your head is in sync with your heartbeat if you have. This is also not a pain to be ignored as a tooth infection can lead to a very similar feeling. Call your dentist and let them know of your symptoms as soon as possible.
Debilitating Tooth Pain
Tooth pain that wakes you up from a deep sleep or that keeps you from your daily activities is what we consider to be debilitating tooth pain. This tooth pain is most often related to a painful, infected tooth.
An infected tooth often builds up pressure, and eventually, a fistula may form. The infection may drain out through this fistula, initially offering some relief to you. You might notice the pressure and pain subside for a while, but it usually doesn’t last long as the infection continues to fester and build. A few days later, you might be back in the debilitating pain stage.
I Had A Root Canal. Why Does My Tooth Still Feel Weird?
It may seem crazy, but it’s possible that you’ve had a root canal, and you still feel pain in the place where oral surgery was performed. This is commonly referred to as phantom tooth pain.
Symptoms of phantom tooth pain may be described as being mild to severe, and the pain is neurological rather than physical, so it can be more challenging to diagnose. There are many different treatments available such as acupuncture and nerve stimulation, that have been shown to help diminish phantom tooth pain.
Tooth pain, especially tooth infection, is never something to mess around with. Infection in one body area can spread to other regions, so treating and eliminating the disease is of most significant importance.
As you can see, tooth pain can mean many different things. Dentists have the knowledge and technology to evaluate your situation and get you back on your feet again!
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- v.5(4); 2011 Dec
Persistent Dento-Alveolar Pain Disorder (PDAP): Working towards a Better Understanding
Assistant Professor, Division of TMD & Orofacial Pain and Department of Neurology, University of Minnesota, 515 Delaware Street SE, Minneapolis, MN 55455 USA
Graduate Student, Center for Neurosensory Disorders, School of Dentistry, University of North Carolina, Chapel Hill, NC, USA
- New terminology, persistent dento-alveolar pain disorder (PDAP), and diagnostic criteria have been put forward to address the shortcomings of existing nomenclature, which are associated with unclear criteria.
- Arriving at an accurate diagnosis of PDAP is based on excluding other possible aetiologies, and may involve different care providers.
- Synthesis of published data suggests that PDAP has a frequency of occurrence following root canal therapy of around 1.6%.
- The putative risk factors involved in PDAP are largely unknown, but seem to be similar to those being identified with other post-surgical chronic pain disorders.
- The underlying mechanisms involved in the development of and/or perpetuating PDAP are unknown and the approach to treatment remains empiric in nature.
Pain in the orofacial region is very common to the human condition, and tooth-related pain is the most prevalent of such pains ( 1 ). Most often this pain is a symptom of dental disease and as such is effectively addressed by dental professionals, as reviewed in this journal ( 2 ). However, persistent pain perceived in teeth or adjacent dento-alveolar tissues may occur without any readily identifiable local dental aetiology; this pain can be referred to as non-odontogenic ‘tooth’ pain ( 3 ).
Non-odontogenic pain presents a complex problem for care providers for two reasons: Firstly, the challenge to arrive at an accurate diagnosis for the symptom of intraoral pain, and secondly the subsequent ability to provide an effective treatment for such pain – which is highly predicated on the success of the first step. Despite the fact that chronic non-odontogenic pain has been observed and reported in academia for centuries ( 4 ), treatment for this disorder continues to be empiric and often involves at some point a deafferenting dental procedure, such as root canal therapy or tooth extraction ( 5 – 7 ).
The purpose of this narrative is to review current literature regarding persistent dento-alveolar pain in order to i) highlight recent developments in the field and ii) identify areas requiring further research, with the ultimate goal of improving patient care. We will point out the challenges in the definition of the disorder and that the research community has now reached an accepted case definition. Given various previous case definitions, we will describe how frequent the disorder is, present which risk factors have been explored, and describe the mechanisms suggested to be involved. Finally, we present an overview about patient management.
Difficulties with diagnosing PDAP
Problems within pain taxonomy.
At present, diagnosing chronic pain disorders is based mainly on clinical signs and symptoms, since the mechanisms underlying the pathophysiological processes are largely unknown. This also applies to conditions that present as chronic pain within the orofacial tissues. Unfortunately, except for temporomandibular disorders (TMD), there is a lack of research assessing the validity of such diagnoses and classification systems. It is therefore unclear how various disorders relate to each other, since there is no over-arching taxonomy, and this is likely to perpetuate discipline-based diagnostic thinking.
The absence of taxonomical data does not however imply an absence of knowledge or theory about taxonomy of orofacial pain conditions. An international collaboration, building from the experience of TMD diagnostic research, has attempted to conceptualise how various orofacial pain disorders may be related and therefore most appropriately defined, with a view to leading eventually to a functional taxonomy (see http://www.rdc-tmdinternational.org/default.aspx ).
One group chose to address the topic of non-odontogenic ‘tooth’ pain as a working example. This group applied ontological principles to the classification of one type of orofacial pain disorder, using the descriptive name persistent dento-alveolar pain (PDAP), and produced initial diagnostic criteria ( Figure 1 )( 8 ). The key concepts behind this effort were to specify unambiguous terminology without conflations, and to produce diagnostic criteria that could then be tested and refined in the future. The aim was to improve the clinical phenotyping of the disorder so that more extensive epidemiological research and more accurate mechanism-based research could follow. All members of the group readily admitted that the criteria were expert-derived and not evidence-based, and as such were less than ideal. The main reasons for opinion-based criteria included lack of consensus in the literature, and the lack of research data to support previously proposed criteria. Therefore the expert panel's proposition was thought to be the best next step towards garnering discussion on the topic and developing a workable taxonomy.
Diagnostic criteria for PDAP
Multiple terms and various diagnostic criteria
Intertwined with the problems involving ontology is the multiplicity of classification systems proposed to define chronic orofacial pain perceived intra-orally ( 9 – 12 ). The different terms and varying criteria provide great confusion among clinicians and scientists alike, as well as fodder for disagreement. A previous article in this journal provided the background for all chronic orofacial pain conditions and presented the most widely accepted classification ( 13 ). The author presented the groups of orofacial pain conditions and used the term ‘persistent idiopathic facial pain (PIFP)’ to classify PDAP, which is an apt description that highlights previous thinking. Dental professionals seem to agree that there is a distinct clinical entity that patients seek care about, that has a chronic continuous pain symptom located in the dento-alveolar region that cannot be explained within the context of other diseases or disorders ( 8 ). The list of diseases or disorders that need to be ruled out include local or adjacent dental pathosis, referred pain from regional structures (e.g. sinus ( 14 ), muscles of mastication ( 15 ), heart ( 16 ), vascular ( 17 ) or brain ( 18 )), or headaches presenting in the orofacial region (CN V2 & V3 distribution ( 19 ) as opposed to fronto-orbital V1 or parieto-occipto-cervical (cervical 1–3) distribution).
Looking through the literature one can get a sense that many different terms have been used to describe this clinical scenario, such as: atypical odontalgia, phantom tooth pain, neuropathic tooth pain, and also as a subgroup within persistent idiopathic or atypical facial pain to name a few. Even though it is unlikely that all these terms refer to the same disorder characterised the same way, it seems safe to assume that these conditions share more commonalities than not, hence the move to rename the entity to PDAP ( 8 ).
Practical considerations regarding the diagnostic process
Diagnosis of PDAP is dependent of the ruling out of all other potential sources for the symptom of pain (i.e. referred pain from another site) and other pain disorders with such an anatomic presentation (i.e. TMD, headache disorders). Therefore the process to arrive at a diagnosis of PDAP includes more than a traditional dental evaluation and intraoral imaging. Given this, and the low sensitivity of dental radiographs, some researchers have assessed the diagnostic yield when three-dimensional radiography is used to image the dento-alveolar region involved in PDAP pain. The authors reported that the addition of advanced imaging improves the ability to ascertain the absence of local bone destruction ( 20 ), something that would exclude the presence of local disease and suggest that dental interventions are not indicated.
Besides local disease interacting with the primary afferent neurone resulting in pain, chronic orofacial pain mimicking PDAP has been reported to be referred from intracranial structures ( 18 ). A case-series of brain MRIs taken of a mixed group of chronic facial pain revealed that 7 of the 38 patients imaged (18%) had structural lesions impinging on the 5th cranial nerve ( 21 ). This is not a trivial proportion, and has prompted the authors of this article to routinely obtain brain MRIs on their patients, resulting in the anecdotal experience that between 5 and 10% of PDAP patients have similar structure lesions.
How big is the problem, and who is at risk of getting it?
In general, epidemiological evidence for PDAP is largely unknown. Given that local dental disease, sensory perception of pain, and presence of irreversible treatments are inexplicitly related, recent research on this topic has focused on the combined presentation of these three factors within the provision of root canal therapy. This seems like a reasonable initial approach to exploring PDAP since root canal therapy is a common procedure with over 20 million performed every year in the United States ( 22 ). Furthermore, root canal therapy is provided for patients with diverse characteristics (i.e. age, gender, socioeconomic status, health status) and thus allows for the exploration of a number of risk factors in a broad patient population.
Research on the prevalence of PDAP
Evidence of the true prevalence of PDAP is still lacking since all known studies have used convenience sampling from clinical populations, which is not representative of the population at large. One could argue that this is the appropriate strategy for such research given that: a) PDAP is at present intertwined with the pre-existence of local disease, the symptom of pain, and the provision of deafferenting procedures; and b) such a sampling strategy recruits a high percentage of those seeking care. Initial reports, their limitations notwithstanding, suggested that PDAP is not an uncommon outcome following root canal therapy with historic estimates ranging from 2.5 to 3.1% ( 23 , 24 ).
A recent systematic review assessing the presence of non-odontogenic pain six months or longer following root canal therapy, to give an upper limit estimate for PDAP, found that 3.4% of patients reported pain that was unexplained by local disease ( 25 ). Given that most studies were not designed specifically to capture PDAP and other non-odontogenic pain, such as referred muscle pain and headache disorders presenting in the dento-alveolar region, this is likely to be a high estimate and can be considered an upper limit.
Since these early articles by Marbach et al ( 24 ) and Campbell et al ( 23 ), there have been three articles investigating the frequency of PDAP (see Table 1 ). Pöllmann, in 1993, published an article in which he evaluated people prior to employment ( 26 ). Consistent with the idea of sensory disturbances following deafferentation as a consequence of limb amputation ( 27 ), he identified 44 people with such alteration in feeling, of whom 25 had a painful component and 19 reported no pain. Since 2,620 people of the entire sample (N=3,126) had a missing tooth, they were considered the ‘at risk’ group since the others had not undergone a deafferenting dental procedure and therefore presumably did not have the combined presentation of dental disease and interventional treatment.
Prevalence data abstracted from available articles that clinically confirmed diagnosis of PDAP
Jacobs et al in 2002 reported on 500 dental patients treated with either root canal therapy or tooth extraction ( 28 ). Of the 176 questionnaires returned they identified 10 with altered perception in the treated dento-alveolar area that was clinically evaluated; 8 were painful and 2 were painless.
Polycarpou et al in 2005 reported on 400 dental patients receiving tertiary endodontic care ( 29 ). This prospective study followed up 175 patients, and identified 12 as having PDAP.
All these studies had limitations, including omissions of reported data (i.e. baseline pain status, duration of symptoms, dental diagnoses) and/or significant loss in follow up. Nonetheless, pooling the data across those studies allowed us to estimate the frequency of occurrence of PDAP. Using a conservative calculation, which is the total of clinically determined cases of PDAP (68) divided by the total number of patients enrolled and receiving care (4,370), an estimate for occurrence of PDAP in these five studies was calculated to be 1.6% ( Table 1 ). Given the frequency of root canal therapy being performed, this is not an insignificant number of patients experiencing this painful outcome.
Risk factors for the development of PDAP
As expected, given the few epidemiological studies reporting on PDAP, the understanding of risk factors involved in the development of this chronic pain state are lacking. Only one study calculated odds ratios and it found that extended duration of pre-operative pain, presence of other chronic pain problems, female gender, and a history of painful treatment in the orofacial region are statistically significant risk factors for PDAP following root canal therapy ( 29 ). These are interesting findings, especially in the face of a selected population sample with more than 50% loss to follow-up, because they are consistent with risk factors observed in other surgical procedures that assessed for the outcome of persistent pain ( 30 – 33 ). Exploring the long-term outcome of patients with PDAP, one study followed a cohort over a 9 to 19 year period and reported that 10 of the 45 (22%) subjects followed did not report orofacial pain ( 34 ). The authors further reported that patients continuing to obtain dental interventions faired worse than those who did not, but potential diagnostic misclassification in this study could hinder the certainty of such an inference. Clearly, more epidemiological research is needed to understand basic questions on putative risk factors for PDAP.
Proposed mechanisms underlying PDAP
As a consequence of the lack of adequate epidemiological data that identify the causal pathway(s) involved in PDAP, existing research into the systems underlying the disorder has been based on clinical observations. Studies have therefore focused on the phenomenology of PDAP, exploring the presumed mechanisms that largely investigate either a psychological aetiology ( 35 ) or neuropathic aetiology ( 36 ). Besides the long-term goal of elucidating mechanisms, which this approach cannot fully realise until employed prospectively, this research approach has value in improving the characterisation of the disorder such as identifying intermediate or endophenotypes.
In the last decade there have been three articles published that assessed psychosocial factors in patients with PDAP, all employing a case-control study design ( 28 , 37 , 38 ). The first study used the SCL-90 questionnaire to assess this domain for ten cases plus ten matched controls. They found no differences with individual scales between those with pain and their pain-free controls, but when combined as an assessment of overall psychological distress slightly higher values were observed in the group with PDAP ( 28 ).
The second study used the SCL-90 and the SF-36 questionnaires to assess 46 cases plus 35 matched controls ( 37 ). With the SCL-90 they observed a significant difference in both somatisation and depression domains, and with the SF-36, four of the eight domains were found to be significantly different from pain-free controls (bodily pain, role physical, social functioning, and vitality).
The third study was restricted to patients being referred from psychiatric facilities and compared patients with PDAP to those with burning mouth syndrome (BMS), but with no pain-free controls ( 38 ). Of the 36 patients with PDAP and pre-existing records, the referring clinic had given the following diagnoses: 19 (53%) had a somatoform disorder, 8 (22%) a mood disorder, and 14 (39%) had no psychiatric diagnosis. Given that all three studies assessed psychosocial variables in patients with PDAP that had been experiencing intra-oral pain for some extended period of time, it is impossible to draw a conclusion regarding causation. Furthermore, over one third of PDAP patients not receiving a psychiatric diagnosis suggest that their symptom of pain may result in increased rating on these non-specific questionnaire-based instruments. This notion is partly supported by a follow-up study that compared the same 46 PDAP patients with a cohort of patients with TMD pain and found no difference in the psychosocial domains between these two groups of patient with orofacial pain disorders ( 39 ). The inconclusive data assessing psychosocial factors in relationship to PDAP prevents any conclusions regarding their role in the development and/or maintenance of this chronic pain disorder.
The category of potential neuropathic factors is vast and includes a wide range of possible peripheral and central mechanistic changes that have been hypothesised to occur with peripheral nerve injury ( 40 ). To date the various articles investigating the potential differences in the somatosensory function between cases of PDAP and pain-free controls can be grouped in studies assessing: i) the psychophysical response to a variety of presented stimuli, and ii) the pain response to a pharmacological challenge. Six articles have explored the psychophysical to some degree, ranging from the application of a single provoking stimulus ( 41 , 42 , 43 ) to the systematic application of a battery of stimuli ( 28 , 37 , 44 ) applied in an attempt to characterize those with PDAP ( 45 ). Baad-Hansen and colleagues observed no differences in blink reflex, a measure of trigeminofacial brainstem function, between the affected and pain-free sides; it was not altered by the application of capsaicin ( 41 , 42 ) but was delayed when compared to matched pain-free controls ( 42 ). Moana-Filho and colleagues observed that a dynamic pressure pain stimulus over dento-alveolar tissues evoked greater pain in cases of PDAP compared to matched pain-free controls and had significant discriminative ability in separating cases from controls (area under a ROC curve of 0.99) ( 43 ).
Zagury and colleagues observed that the after-stimulus sensation of pain following application of cold to the alveolar mucosa was significantly longer for cases of PDAP than controls and that the test was able to differentiate these groups ( 44 ). The electrical pain threshold was elevated for both sides in cases of PDAP, while electrical detection, warm detection and heat pain detection thresholds of the face were similar ( 44 ). Other researchers observed increased sensitivity to light-touch in PDAP cases, but not to two-point discrimination or thermal discrimination intra-orally, suggesting only A-beta fibre hyper-function at the site of pain ( 28 ).
List and colleagues observed a range of hypersensitivity, hyposensitivity, and normal sensitivity in cases of PDAP compared to matched controls with multiple stimuli and found minimal group-wise differences ( 37 ). When comparing the absolute difference between sides, these researchers observed greater variability in PDAP cases for light-touch threshold, pin-prick pain threshold, pressure pain threshold, wind-up ratio, dynamic mechanical allodynia, and vibration detection threshold but not warm detection, heat pain detection or cold detection thresholds ( 37 ). Despite the modest number of studies involving psychophysical stimuli and the variety of stimuli applied, their results suggest that PDAP cases present greater amounts of intra-group variability and increased pain evoked by supra-threshold stimuli. Assessments of different challenges to pharmacological agents revealed a modest increased pain response to capsaicin ( 42 ), lack of pain reduction to fentanyl or ketamine ( 46 ), and mixed pain reduction to injected local anaesthetic agents ( 44 ) – even when administered in a double-blind randomised fashion ( 47 ). Given the variation in these study findings, it seems that PDAP may very well involve several different psychophysical characterisations, similar to that being observed in other chronic pain conditions, and as such warrants a profiling approach to its characterisation ( 48 ).
Patient management and treatment
Diagnosis of PDAP is not straightforward, given the possibility of multiple different tissues being involved and the interaction with psychosocial variables. Expert opinion suggests an inter-disciplinary approach to the management of patients with PDAP similar to other chronic pain conditions, which includes diagnostic work-up and treatment implementation ( 49 – 53 ). Furthermore, experts agree that earlier recognition and initiation of therapeutic modalities is more beneficial than delayed diagnosis and treatment ( 54 , 55 ). Given the uncertainty of the mechanisms, diagnosis, and treatment of PDAP, these ideas seem reasonable but remain to be substantiated with evidence.
A recent review of treatments for neuropathic orofacial pain conditions did not find any randomised controlled trials for conditions consistent with PDAP and ultimately concluded: ‘Based on available evidence from other neuropathic pain conditions, TCAs or gabapentin would be the first drugs indicated’ ( 56 ). Case-series data suggest that some patients may respond to peripherally applied medications ( 57 – 59 ) and several sets of observational data recommend against interventional procedures, such as root canal therapy or extraction ( 34 , 60 , 61 ). Together, it seems that the best course of action is to follow the NICE guidelines for the treatment of neuropathic pain with oral medications ( 62 ), try topical medications when practical, and avoid irreversible treatments that involve local tissue injury. From a clinician's perspective, as well as someone suffering from PDAP, this scant data regarding treatment is unacceptable, difficult to admit, and yet not surprising.
Confusion in diagnostic criteria and terminology prompted the recent development of consensus-driven diagnostic criteria for persistent-dento-alveolar pain disorder (PDAP). The diagnostic process may involve multiple care providers to rule out various conditions that may refer the symptom of pain to the dento-alveolar region; the diagnosis of PDAP is in essence one of exclusion. Due to the often presentation of pre-existing dental disease, frequent report of pre-operative pain sensation, and surgical deafferentation as treatment to address both, the outcome of PDAP following root canal therapy needs to be cautiously interpreted. The frequency of prevalence for PDAP associated with root canal therapy is estimated to be around 1.6%, but methodological issues limit the validity of these results. Initial epidemiological research suggests that similar risk factors are involved with the development of PDAP as with other post-surgical chronic pain disorders. The mechanisms underlying the disorder are largely unknown, with psychosocial and neuropathic factors being the most commonly explored, whilst treatment at present time remains to be based on empirical evidence.
Supported by National Institutes of Health grants K12-RR023247 and U01-DE016747 (DR Nixdorf).
Orofacial Pain (Part two) Multiple Choice Questions
Burning mouth syndrome (BMS)
More than one answer may be correct. Select all that apply
- b) 3 months
- d) 6 months
- e) 12 months.
- a) Elicited pain with spicy foods
- b) Intermittent neuralgia
- c) Constant dull ache
- d) Awakening at night
- e) Cold allodynia.
- a) Amitriptyline
- b) Pregabalin
- c) Nortriptyline
- d) Baclofen
- e) Citalopram.
- a) Dose at 10mg nocte for 3 months
- b) Step up weekly (nocte) 10mg, 20mg, 30mg, 40mg maintenance at highest possible dose for 12 weeks
- c) Dose at 20mg nocte for 3 months
- d) Step up weekly (nocte) 20mg, 40mg, 60mg maintenance at highest possible dose for 12 weeks
- e) Dose at 30mg nocte for 2 months.
Primary headache disorders: Focus on migraine
- a) High dose aspirin
- b) Rizatriptan
- c) Tramadol
- d) Low dose aspirin
- e) Co-codamol.
- b) Topiramate
- c) Gabapentin
- d) Sodium valproate
- e) Coenzyme Q10.
- a) Ibuprofen 200mg od daily
- b) Ibuprofen 800mg bd twice a week
- c) Ibuprofen 400mg od four times a week
- d) Ibuprofen 600mg od once a week
- e) Ibuprofen 800mg tds twice a week.
- a) Tension-type headache
- b) Cluster headache
- c) Migraine
- d) No headache
- e) Hemicrania continua.
- a) Neck pain
- b) A need to remain active during the attack
- d) Sensitivity to chocolate
- e) Yawning.
Persistent dento-alveolar pain disorder (PDAP): Working towards a better understanding
Select the most correct response
- a) pulpitis and apical periodontitis associated with teeth in the region
- b) headache disorders with the symptom of pain perceived peri-orally
- c) intra- and extracranial lesions that may impinge upon or alter trigeminal somatosensory system
- d) trigeminal neuralgia
- e) all of the above.
- a) pre-existing dental disease
- b) post-procedural chronic pain
- c) idiopathic chronic pain
- d) all of the above
- e) none of the above.
- a) 10% and 2%
- b) 15% and 5%
- c) 5% and 2%
- d) 3% and 1.5%
- e) 5% and 1.5%.
- a) Psychological mechanisms
- b) Neuropathic mechanisms
- c) Inflammatory mechanisms
- d) Two of the above
- e) None of the above.
- a) prescribe non-steroidal anti-inflammatory and antibiotic medications
- b) extract the tooth closest to the painful area
- c) surgical exploration of the involved area
- d) prescribe the newest anti-epileptic drug available that the patient has not heard of
- e) follow the most recent guidelines for idiopathic chronic pain management.
Burning mouth syndrome
- 3 b, d and e
- 4 a, b, c, d and e
- 4 a, c and e
Donald Nixdorf, Assistant Professor, Division of TMD & Orofacial Pain and Department of Neurology, University of Minnesota, 515 Delaware Street SE, Minneapolis, MN 55455 USA.
Estephan Moana-Filho, Graduate Student, Center for Neurosensory Disorders, School of Dentistry, University of North Carolina, Chapel Hill, NC, USA.
Diagnosis - Trigeminal neuralgia
As the pain caused by trigeminal neuralgia is often felt in the jaw, teeth or gums, many people with the condition visit a dentist before going to a GP.
The dentist will ask you about your symptoms and give you a dental X-ray to help them investigate your facial pain. They'll look for common causes of facial pain, such as a dental infection or cracked tooth.
Trigeminal neuralgia is often diagnosed by a dentist, but if you have seen a dentist and they could not find an obvious cause of your pain, you should visit a GP.
Seeing a GP
There's no specific test for trigeminal neuralgia, so a diagnosis is usually based on your symptoms and description of the pain.
If you've experienced attacks of facial pain, the GP will ask you questions about your symptoms, such as:
- how often do the pain attacks happen
- how long do the pain attacks last
- which areas of your face are affected
The GP will consider other possible causes of your pain and may also examine your head and jaw to identify which parts are painful.
If your GP does think you could have trigeminal neuralgia then they may refer you to a specialist for further testing.
Ruling out other conditions
An important part of the process of diagnosing trigeminal neuralgia involves ruling out other conditions that cause facial pain.
By asking about your symptoms and carrying out an examination, the GP may be able to rule out other conditions, such as:
- jaw or dental problems
- cluster headaches
- post-herpetic neuralgia – a type of nerve pain linked to shingles
The GP will also ask about your medical, personal and family history when trying to find the cause of your pain.
For example, you're less likely to have trigeminal neuralgia if you're under 40 years old. Multiple sclerosis (MS) may be a more likely cause if you have a family history of the condition or you have some other form of this condition.
However, trigeminal neuralgia is very unlikely to be the first symptom of MS.
A MRI scan is often used to help with the diagnosis of trigeminal neuralgia.
An MRI scan uses strong magnetic fields and radio waves to create detailed images of the inside of your body.
It can help identify potential causes of your facial pain, such as inflammation of the lining of the sinuses (sinusitis) , tumours on one of the facial nerves, or nerve damage caused by MS.
An MRI scan may also be able to detect whether a blood vessel in your head is compressing one of the trigeminal nerves, which is thought to be the most common cause of trigeminal neuralgia .
Page last reviewed: 27 January 2023 Next review due: 27 January 2026
Phantom Tooth Pain and Your TMJ Disorder
Phantom tooth pain is very real. It can be a chronic pain existing in an actual tooth, or in an area where a tooth has been removed. Sometimes there is no clear cause of the pain, and yet, over time, the pain can spread to other areas of the face, jaw and neck. This week we will discuss basic facts about this condition and its relationship to TMJ disorders.
Many other names for phantom tooth pain exist. It is also known as phantom pain syndrome, neuropathic oral facial pain and atypical odontalgia.
The Frustrating Diagnosis
Phantom tooth pain is often a frustrating experience for patients. This is because tooth pain is present and very real, and yet exam and x-rays reveal no damage or decay in a tooth. The pain may also be present long after a dental procedure has been performed. Sometimes patients start to experience phantom tooth pain six months after a procedure was performed. This adds to the frustration. How can there be pain in an area where the body part, or tooth, is no longer present?
The pain experienced can be slight or severe. It may also be triggered by hot or cold pressure. Pain may also exist not only in one area, but throughout the entire mouth. And what’s worse, some patients feel a sense of despair and start to believe unnecessary dental procedures were performed that did nothing to alleviate their discomfort.
What’s Going On?
Phantom tooth pain was likely triggered by a dental procedure, including a filling, a root canal or removal of a tooth. Unfortunately, damage already existed in the surrounding nerves and the procedure simply exacerbated the nerve endings. This is why many patients experience high levels of frustration. They anticipate feeling better after a dental procedure, and instead they only feel worse.
Getting the Diagnosis You Deserve
If you are experiencing phantom tooth pain, don’t put off treatment. You need to undergo another exam. It may be determined that other tests should be ordered, including x-rays, MRI scans, CT scans or possibly i-CAT scanning.
The Connection to TMD
You are experiencing nerve pain. But it may start to feel like it has spread to other parts of your body. Perhaps there is pain in the peripheral nerves, such as the limbs and torso. It may also be present in the central nervous system, affecting the brain and spine.
A number of therapies are available. But the first step is meeting with Dr. Ronald C. Auvenshine . He can help pinpoint the true source of your discomfort and determine if phantom tooth pain or another ailment is to blame.
Image Source: en.wikipedia.org/wiki/File:Panoramicfilm.JPG
Original Source: https://www.medcentertmj.com/dental-health/ phantom-tooth-pain-tmj /
Tooth pain and Neuropathy
Every evening my front teeth, top and bottom, become very sensitive, like a toothache. Within a few hours my feet begin tingling, throbbing-classic neuropathy pain. Could this be related? I have my first set of appointments at Mayo next week for this, and other pain issues. I am really hoping for answers.
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- Report discussion
Interested in more discussions like this? Go to the Neuropathy Support Group.
Hello @jayneedbj , Welcome to Connect, an online community where patients and caregivers share their experiences, find support and exchange information with others. It's good to hear you have an appointment at Mayo next week to find the cause of your tooth pain. The symptoms sound similar to those of Trigeminal Neuralgia. I wasn't familiar with tooth pain caused by neuropathy but I found an article that talks about it occurring after dental treatment which may be unrelated in your case. Here's the abstract and the article linked at the end:
"The head and neck regions are the most common sites of the human body to be involved in chronic pain conditions. Neuropathic pain is a chronic pain condition, and refers to all pain initiated or caused by a primary lesion or dysfunction or transitory perturbation in the peripheral or central nervous system (CNS). Trigeminal neuralgia, atypical odontalgia (phantom tooth pain), burning mouth syndrome, traumatic neuropathies, postherpetic neuralgias and complex regional pain syndrome are neuropathic pain conditions in the orofacial region that can be encountered in pain and dental clinics. The majority of the time this problem is misdiagnosed by the dentist, which can lead to unnecessary treatments. These treatments may include endodontic treatment and extraction of the tooth or teeth in the region. In this review, only post-traumatic peripheral pain neuropathies seen after dental treatments will be discussed." — Neuropathic pain after dental treatment: https://pubmed.ncbi.nlm.nih.gov/23588863/
You might want to plan your visit and write down your questions for the doctors at Mayo – they love it when a patient advocates for their own health! Here's a site with some tips and tools to help you plan your visit – https://patientrevolution.org/visit-tools
You mentioned wanting answers for the tooth pain and other pain issues at your appointment next week. Can you share what other pain issues you are having and let us know what you find out at your appointment?
- Report comment
Thank you, I will post a follow up!
Jump to this post
I have been dianosed with Peripheral Neuropathy and I am recovering one from diabetes. My a1c is 5.9 blood gulcouse is 106. I don't have burning in mouth just dry mouth issues and strange feeling in mouth. Per my Deniest i have no problems gum or teeth issues
I had type 2 Diabetes 2 years ago. my A_C was 15.98 my Gulose was 600 amost dies. Went to work and lost 79 lbs. NOw mt AC is 5.5 and glouse is 106. I was dismissed from Adult Encorngy in march 2022. Now i Have Peripheral Neuropathy and haveing problems with teeth, dry mouth and strange feeling around upper teeth on right side. Been to OMS dental surgry and the DR says teeth and gums great shape. Refered me to a Neurologist said nothing dental wise can be done. Any feed back will be apprecieated
My upper teeth ache when my CIPN acts up. Started 6 years when treated with Venclaxata for NHL
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- Diseases & Conditions
Dry socket is a painful dental condition that sometimes happens after you have a tooth removed. Having a tooth removed is called an extraction. Dry socket happens when a blood clot at the site where the tooth was removed does not form, comes out or dissolves before the wound has healed.
Usually a blood clot forms at the site where a tooth was removed. This blood clot is a protective layer over the underlying bone and nerve endings in the empty tooth socket. Also, the clot contains cells that are needed for proper healing of the site.
Intense pain happens when the underlying bone and nerves are exposed. Pain occurs in the socket and along the nerves to the side of the face. The socket becomes swollen and irritated. It may fill with bits of food, making the pain worse. If you get a dry socket, the pain usually begins 1 to 3 days after the tooth removal.
Dry socket is the most common complication following tooth removals, such as the removal of third molars, also called wisdom teeth. Medicine you can buy without a prescription usually will not be enough to treat dry socket pain. Your dentist or oral surgeon can offer treatments to relieve your pain.
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Symptoms of dry socket may include:
- Severe pain within a few days after removing a tooth.
- Loss of part or all of the blood clot at the tooth removal site. The socket may look empty.
- Bone that you can see in the socket.
- Pain that spreads from the socket to your ear, eye, temple or neck on the same side of your face as the tooth removal.
- Bad breath or a foul odor coming from your mouth.
- Bad taste in your mouth.
When to see a doctor
A certain amount of pain and discomfort is typical after a tooth removal. But you should be able to manage the pain with the pain reliever your dentist or oral surgeon prescribed. The pain should lessen with time.
If you develop new pain or the pain gets worse in the days after your tooth removal, contact your dentist or oral surgeon right away.
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The exact cause of dry socket is still being studied. Researchers think that certain issues may be involved, such as:
- Bacteria that gets into the socket.
- Injury at the surgical site when tooth removal is difficult. This can happen with irregular wisdom tooth development or position, called an impacted wisdom tooth.
Factors that can increase your risk of developing dry socket include:
- Smoking and tobacco use. Chemicals in cigarettes or other forms of tobacco may prevent or slow healing. These chemicals can get into the wound site. Also, the act of sucking on a cigarette may cause the blood clot to come out too early.
- Birth control pills. High estrogen levels from birth control pills may cause problems with healing and increase the risk of dry socket.
- Improper at-home care. Not following home-care instructions and having poor mouth care may increase the risk of dry socket.
- Tooth or gum infection. Current or previous infections around the area where the tooth was removed increase the risk of dry socket.
Even though a dry socket can be painful, it rarely causes an infection or serious complications. But healing in the socket may be delayed. Pain may last longer than usual after a tooth removal. Dry socket also may lead to an infection in the socket.
What you can do before surgery
You can take these steps to help prevent dry socket:
- Look for a dentist or oral surgeon with experience in removing teeth.
- Practice good oral care by brushing your teeth twice a day and flossing once a day. Good oral care before surgery keeps your teeth and gums clean and removes bacteria.
- If you smoke or use other tobacco products, try to stop smoking before your tooth is removed. Smoking and using other tobacco products increase your risk of dry socket. Talk to your doctor or other health care professional about a program to help you quit for good.
- Talk to your dentist or oral surgeon about any prescription medicines, medicines you can buy off the shelf, herbs, or other supplements you're taking. Some may cause problems with blood clotting.
What your dentist or oral surgeon may do
Your dentist or oral surgeon can take steps to help with proper healing of the socket and prevent dry socket. These steps may include recommending one or more of these medicines, which may help prevent dry socket and infections:
- Dressing with medicine to put on the wound after surgery.
- Antibacterial mouthwashes or gels immediately before and after surgery.
- Antiseptic solutions to put on the wound.
- Oral antibiotics, usually only if you have a weakened immune system.
What you can do after surgery
Your dentist or oral surgeon can give you instructions about what to expect during the healing process after a tooth removal and how to care for the site. Proper at-home care after a tooth removal helps with healing and prevents damage to the wound. To help prevent dry socket, instructions will likely include:
- Activity. After your surgery, plan to rest for that day. Follow instructions from your dentist or oral surgeon about when you can return to your usual activities. Also follow instructions about how long to avoid vigorous exercise and sports that might cause the blood clot to come out of the socket.
- Pain management. Put cold packs on the outside of your face on the first day after tooth removal. After the first day, warm packs may help. Cold and warm packs can help decrease pain and swelling. Follow instructions from your dentist or oral surgeon about putting cold or heat on your face. Take pain medicines as prescribed.
- Beverages. Drink lots of water after the surgery. Avoid alcoholic, caffeinated, carbonated or hot beverages for as long as recommended. Do not drink with a straw for at least a week. The sucking action may cause the blood clot to come out of the socket.
- Food. Eat only soft foods, such as yogurt or applesauce, for the first day. Be careful with hot and cold liquids or biting your cheek until the numbness wears off. When you feel ready, start eating foods that do not need a lot of chewing. Avoid chewing on the surgery side of your mouth.
- Cleaning your mouth. After surgery, you may gently rinse your mouth and brush your teeth, but avoid the site where the tooth was removed for the first 24 hours. After the first 24 hours, gently rinse your mouth with warm salt water several times a day for a week after your surgery. Mix 1/2 teaspoon (2.5 milliliters) of table salt in 8 ounces (237 milliliters) of water. Follow the instructions from your dentist or oral surgeon.
- Tobacco use. If you smoke or use tobacco, do not do so for at least 48 hours after surgery and as long as you can after that. Using tobacco products after oral surgery can slow healing and increase the risk of complications.
- Daly BJM, et al. Local interventions for the management of alveolar osteitis (dry socket). Cochrane Database of Systematic Reviews. 2022; doi:10.1002/14651858.CD006968.pub3.
- Chow O, et al. Alveolar osteitis: A review of current concepts. Journal of Oral and Maxillofacial Surgery. 2020; doi:10.1016/j.joms.2020.03.026.
- Ghosh A, et al. Aetiology, prevention and management of alveolar osteitis — A scoping review. Journal of Oral Rehabilitation. 2022; doi:10.1111/joor.13268.
- Adekunle AA, et al. Effectiveness of warm saline mouth bath in preventing alveolar osteitis: A systematic review and meta-analysis. Journal of Cranio-Maxillofacial Surgery. 2021; doi:10.1016/j.jcms.2021.09.001.
- dos Santos Canellas JV, et al. Intrasocket interventions to prevent alveolar osteitis after mandibular third molar surgery: A systematic review and network meta-analysis. Journal of Cranio-Maxillofacial Surgery. 2020; doi:10.1016/j.jcms.2020.06.012.
- Buttaravoli PM, et al. Dental pain, postextraction alveolar osteitis (dry socket, septic socket, necrotic socket, localized osteitis). In: Minor Emergencies. 4th ed. Elsevier; 2022. https://www.clinicalkey.com. Accessed March 30, 2023.
- Hupp JR, et al., eds. Postextraction patient management. In: Contemporary Oral and Maxillofacial Surgery. 7th ed. Elsevier; 2019. https://www.clinicalkey.com. Accessed March 30, 2023.
- Postextraction problems. Merck Manual Professional Version. https://www.merckmanuals.com/professional/dental-disorders/dental-emergencies/postextraction-problems?query=postextraction%20problems. Accessed March 30, 2023.
- Zhou MX (expert opinion). Mayo Clinic. April 28, 2023.
- Azher S, et al. Antibiotics in dentoalveolar surgery, a closer look at infection, alveolar osteitis and adverse drug reaction. Journal of Oral and Maxillofacial Surgery. 2021; doi:10.1016/j.joms.2021.04.019.
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Unmasking the Mystery of Phantom Tooth Pain with Dentures
How Does Phantom Tooth Pain Occur with Dentures?
For many people, dentures are a godsend. They provide the ability chew food properly, speak more clearly and restore the confidence that was lost with missing teeth. However, while dentures offer many benefits there is one peculiar problem that some wearers encounter – phantom tooth pain.
Phantom tooth pain is not unique to people who use dentures. It’s a phenomenon that often occurs in individuals who have lost natural teeth or have undergone oral surgery. The condition describes sensations of aching, burning, itching or shooting pains in areas where teeth used to be– despite having no teeth in the affected region.
Now you might be asking yourself how it’s even possible to feel pain in an area where there are no nerves left? Well, brace yourselves – it’s all down to the wonders of the brain!
Our brains are wired so intricately that they can send signals for sensations of discomfort even when nothing is physically present. In situations where our bodies experience trauma such as tooth loss or surgery, our brain becomes hyper-focused on those areas immediately after or during healing. This then creates memories of nerve impulses and pain sensation leading to phantom pain long after these initial sensations have ceased.
So, why do denture wearers also experience this curious phenomenon? Dentures are essentially dental prosthetics designed to replace your missing teeth which can impact your gums the same way losing natural teeth will influence tissues in your mouth resulting in their gradual shrinking over time which affects areas surrounding implantation sites These changes affect skin pressure receptors (mechanoreceptors) located on gums causing them to react differently than originally intended by mimicking similar sensations that would occur during decay-like infections since atrophied soft tissue leads to easily disrupted skin; issues like ulcers show up from this as well – leading some people believing their ache is attributed back towards an old tooth rooted within these gumline nerve endings still sending signals for discomfort years later.
But don’t worry – there are ways to cope with phantom tooth pain. Firstly, it is important to remember that while the pain sensation is real and uncomfortable, it’s not a symptom of anything necessarily harmful or life-threatening. If the sensation persists for an extended period, seek advice from your denture provider or dentist who can provide certain treatments aimed at alleviating the discomfort .
Additionally, practicing good oral hygiene by keeping your gums healthy and having regular dental check-ups may also help reduce such sensations as it reduces gum irritation caused by bacterial build-up which makes things worse. And finally using over-the-counter analgesics (painkillers) such as ibuprofen – though limited in use due budget constraints – can be helpful towards treating more severe cases than basic remedies like salt water cleansing or massaging moderate pressure into sinuses behind gums which has been shown effective according to some anecdotal accounts.
In conclusion, phantom tooth pain is just another one of those bizarre experiences that come along with wearing dentures. But understanding the importance of maintaining a clean environment in your mouth through good oral hygiene and check-ups with professionals can help you feel more comfortable when experiencing any unwanted sensations down there!
Managing Phantom Tooth Pain with Dentures: Step by Step Approach
Dentures are a great solution for people who have lost one or more teeth due to various reasons such as periodontal disease, aging, injury or any other dental trauma. They not only restore the functionality of your teeth but also give you back your smile and confidence. However, like everything else in life, they come with their own set of challenges.
One common issue that some people face after getting dentures is phantom tooth pain. This is when you feel pain or sensitivity in a tooth that is no longer there. It can be disturbing and inconvenient, but there are steps that you can take to manage it effectively .
1. Understand why phantom tooth pain happens
Phantom tooth pain occurs because your brain has not adapted to the new reality of having missing teeth. Even though the physical teeth have been removed and replaced with dentures, your brain may still remember the sensation of the original teeth being there. This is what causes the sensation of pain or sensitivity.
2. Try using anesthetic gel
When at home experiencing phantom tooth pain, try applying anesthetic gel directly onto the affected area where you are feeling discomfort. These gels have a numbing effect which will counteract any nerve activity stimulating pain within these areas giving relief from discomfort.
3. Schedule regular dental visits
Stay on top of dental appointments as scheduled intervals may advise adjustments should they be required from ill-fitting dentures causing discomforts very similar to symptoms related to phantom tooth pains.
4. Practice Tongue Awareness 101:
Tongue awareness simply refers to training yourself by reminding yourself about any sensations or negative feelings related to any part of your oral cavity such as tongue, gums, cheek mucosa before proceeding to agitation causing potential harm.
5: Consult with Your Dentist:
Should all other suggested measures seem ineffective schedule an appointment with your dentist who will focus on methods proven through experience such as adjusting or resizing these prosthetic devices based upon the best methods available to be rid of these discomforts.
In conclusion, while dentures present a viable option for restoring one’s dental aesthetics and functionality. It can take time for the individual to fully adjust due to multiple factors causing irritations and aggravations such as food particles, surfaces touching etc. Phantom tooth pain is among them. Do not hesitate to seek professional assistance if these recommended managing steps prove unsuccessful in alleviating this annoying quirk.
Frequently Asked Questions about Phantom Tooth Pain with Dentures Frequently Asked Questions about Phantom Tooth Pain with Dentures If you are one of the millions of people worldwide who rely on dentures to chew your food and maintain a healthy oral hygiene routine, then you may have experienced phantom tooth pain at some point in your life. This is a strange phenomenon that many denture wearers experience, and it can leave them feeling frustrated and confused. Here are some frequently asked questions about phantom tooth pain with dentures. What exactly is phantom tooth pain? Phantom tooth pain is essentially the sensation of having a toothache in a tooth that isn’t actually present. It’s called “phantom” because the sensation exists only in your mind, rather than in reality. Why do people experience phantom tooth pain? There are several reasons why someone might experience phantom tooth pain after losing their teeth or getting dentures. One possibility is that it could be related to muscle memory – your brain remembers what it felt like when you had natural teeth there and continues to send signals even though they’re no longer needed. Another potential reason has to do with nerve damage. When you lose teeth or get dentures placed, the nerves in your gums become less active because they’re no longer being stimulated by the presence of teeth. This can result in sensations that feel like they’re coming from the area where the missing teeth used to be. Is phantom tooth pain really serious? While it can be concerning to experience any kind of dental discomfort, phantom tooth pain itself isn’t usually a cause for alarm. In most cases, it will go away on its own over time as your mouth adapts to life without certain teeth. However, if you find that the sensation persists for an extended period of time or becomes more severe over time, it’s always best to consult with your dentist or healthcare provider to make sure there isn’t an underlying issue that needs to be addressed. Can phantom tooth pain be treated? There is no single cure for phantom tooth pain, but there are several things you can try in order to alleviate the discomfort. Some people find relief from massaging the gums around where the missing teeth used to be, while others opt for relaxation techniques like deep breathing or meditation. If the sensation becomes too intense, your dentist may also be able to prescribe medication or offer other forms of symptomatic relief . The bottom line Phantom tooth pain can be a strange and frustrating experience for denture wearers, but it’s important to remember that it’s a relatively common phenomenon that isn’t usually harmful. With a little patience and some key coping strategies, you can learn to manage these sensations and get back to enjoying your life without constantly worrying about mysterious dental discomfort. Top 5 Facts to Know About Phantom Tooth Pain and Dentures
Phantom tooth pain is a strange and often misunderstood phenomenon that affects many denture wearers. This discomfort typically occurs in the area where the natural teeth have been extracted, even though the nerves that typically carry pain signals have been severed during the extraction process . If you’re experiencing phantom tooth pain after getting dentures, here are five important facts you should know:
1. Phantom tooth pain is real.
Even though there’s no nerve connection between your mouth and your brain in the former site of your natural teeth, it’s common for people to report feeling a sensation of pain or discomfort in this area. The reason this happens isn’t really understood by science, but it’s thought that the brain is simply sending confused signals to your nerves because it’s used to receiving pain sensations from this part of your body.
2. There are ways to treat phantom tooth pain.
Because everyone experiences phantom tooth pain differently, there’s no one-size-fits-all approach when it comes to treatment options. However, some people have had success with medication like aspirin or ibuprofen to alleviate their symptoms. Others swear by using hot or cold packs on their jaws, taking warm baths or doing other relaxing activities that reduce stress levels.
3. It can be caused by wearing ill-fitting dentures.
If you’re experiencing persistent phantom tooth pain, it could be a sign that your dentures aren’t fitting properly. When dentures don’t fit correctly, they can put pressure on areas of your jawbone that don’t normally receive pressure (because they were previously occupied by natural teeth). This can cause inflammation and irritation which contribute to phantom tooth pain.
4. Over time, most people develop coping strategies.
For some people with dentures who suffer from phantom tooth pain regularly over long periods of time develop their own coping mechanisms which mean they hardly notice any more – sort of ‘a new normal’. These may include things like mindfulness meditation exercises, distracting themselves with hobbies, talking to support groups of other denture wearers or simply trying to maintain a positive outlook despite discomfort.
5. Consult your dentist if the pain persists If you’re suffering from Phantom tooth pain , it’s important to remember that you’re not alone – this is a common phenomenon among denture wearers. However, if your pain persists or becomes severe, don’t hesitate to reach out to your dentist for advice and possible treatment options . They will be able to help you determine the root cause of your pain and work with you to find an appropriate solution that works for you. After all, the goal is always going to be to make sure dentures are comfortable in every way possible so they can just melt away into the background and do their job of making eating and speaking easy – without any phantom reminders of what was left behind.
Prevention Tips for Dealing with Phantom Tooth Pain and Dentures
Suffering from phantom tooth pain can be a frustrating and painful experience for anyone, especially for those who have dentures. Phantom tooth pain is an abnormal sensation of discomfort or pain that seems to come from a tooth that is no longer present in the mouth. This phenomenon can become an issue for people with missing teeth who rely on dentures as a solution. However, several steps can be taken to prevent phantom tooth pain when using dentures.
One practical preventative measure is regularly brushing your gums and tongue with a soft-bristled brush. It helps remove any debris or bacteria buildup and stimulates blood flow in the gums, reducing the chances of developing any phantom pains . Also, use warm saltwater rinses to clean your mouth’s interior surfaces; it will help soothe any irritation, washing out harmful bacteria preventing infection.
Another important tip is ensuring proper-fitting dentures by scheduling routine check-ups with your dentist and keeping them up-to-date with any discomforts you may experience. Loose dentures can create pressure points resulting in tissue soreness which psychosomatically causes phantom pain may seem real!
Moreover, avoiding extreme hot or cold foods/drinks also reduces sensitivity/nerve damage around your gums/gums line that usually affects those adjusting new/deformed device fondled in oral cavity after losing their original teeth.
Tooth extraction creates a sudden gap where once were roots studded gems having their respective nerves surrounded by artery vein network supplying them nutrients/oxygen needed to continue the process—less oxygenated areas tend to develop lesser workable surroundings known as inflammation inflaming nerve endings producing poorly localized petrifying feeling residing long without medical attention spiking suicidal tendencies during worst-case scenario situations panic attacks due to increased heart rate suffocated breathing turning deadly promptly.
Lastly, adopting healthy lifestyles like avoiding smoking/drink intake habits helps strengthen bone health encouraging quicker healing minimizing dental surgeries needs fewer chances of feeling phantom pains post-removal.
In summary, phantom tooth pain can be unbearable, but with careful measures such as routine dental checks, using a soft-bristled brush for gum undulations stimulation and proper precaution-taking procedures about one’s oral health, we can take care of the sensitive nerves in our gums and get rid of discomforts that might come from them. Stick to these tips to prevent unwanted pain and live a comfortable life!
Coping Strategies for Dealing with Phantom Tooth Pain and Dentures
Living with tooth pain can be a real nightmare, especially when you have dentures. Phantom tooth pain is a type of discomfort that originates in the nerves and surrounding tissues of your mouth, even though there is no logically apparent cause or source of pain. Coping strategies for phantom tooth pain aim to help alleviate this discomfort and improve your quality of life.
First and foremost, it’s important to identify the cause of your phantom tooth pain. Consult with your dentist or primary healthcare provider, who will determine whether there are any underlying health conditions contributing to the issue.
Once you’ve addressed any underlying medical issues, there are other strategies that you can pursue to help manage phantom tooth pain:
1. Regular cleaning: Keeping dentures clean and well maintained plays a crucial role in reducing phantom toothache. Cleaning them twice daily using specialized products improves oral hygiene, prevents infection and reduces inflammation.
2. Use Denture Adhesive: Most denture wearers experience slipping or looseness at some point which disrupts gum stimulation around teeth. The absence of stimulation causes nerve irritations and contributes towards sensation unevenness in one’s mouth which often leads to phantom pains . Fixodent adhesive provides strong hold all day long thus helping prevent gum irritation which signals danger agonizing sensations may occur.
3. Meditation and deep breathing exercises: It’s essential to learn how to relax and soothe yourself amidst struggling times mentally or physically – this is where meditation comes into play especially during dental visits when fear sets in . Simple deep breathing exercises helps combat anxiety hence preventing further exacerbation by taking charge on one’s own emotions .
4.Consider alternative therapies like Acupuncture/pressure therapy has been promoted as an effective treatment for phantom dental agony among conventional medicine enthusiasts globally. On the other hand, home remedies such as peppermint oil promote desensitization while ice cubes relieve nerve stimulation attributed by clove oil application soothingly while targeting sore spots within hours of application – both remedies are simpler and more within reach than acupuncture.
Last but not least, remember that it’s essential to practice good oral hygiene, including brushing and flossing often. Eating a healthy diet rich in vitamins, minerals and fibre can also significantly help boost dental health. Practicing these coping strategies will go a long way towards reducing phantom tooth pain while improving your overall well-being.
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