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Clinical / August 31, 2023

In focus: atypical odontalgia

by Patrick O'Beirne

atypical odontalgia

Patrick O’Beirne discusses atypical odontalgia – its symptoms, diagnosis and treatment – and answers some frequently asked questions.

Imagine the scene: it’s a Monday morning, your inner battery is low and you are just getting charged up for the day ahead. A new patient presents complaining of pain. They have previously attended several dentists, but nobody has been able to help. The patient explains they have ‘a mouth full of root canals’ and still they are in pain (Figure 1).

Figure 1: Initial presentation – radiograph.
Figure 1: Initial presentation – radiograph.

‘What’s going on here?’ you ponder.

When you come across a case such as this, and you will at some point in your career, the first thing to do is stop and think. Do not lift a handpiece! Don’t try to be the next in a long list of ‘heroes’ to this patient.

Atypical odontalgia

Atypical odontalgia, also known as atypical facial pain, phantom tooth pain or neuropathic orofacial pain, is characterised by chronic pain in a tooth or teeth. It may also occur in a site where teeth have been extracted or following endodontic treatment, without an identifiable cause.

Over time, the pain may spread to involve wider areas of the face or jaws.

The pain is called ‘atypical’ because it is a different type of pain than that of a typical toothache. 

Typical toothache comes and goes and is aggravated by exposure of the tooth to hot or cold food or drink, and/or by chewing or biting on the affected tooth.

There is an identifiable cause, such as decay, periodontal disease or injury to the tooth and the pain is predictably relieved by treatment of the affected tooth.

With atypical odontalgia, the pain is described as a constant throbbing or aching in a tooth, teeth or extraction site that is persistent and unremitting, and which is not significantly affected by exposure to hot or cold food or drink, or by chewing or biting.

The pain may or may not be relieved by the injection of local anaesthetic.

The intensity of the pain can vary from very mild to very severe. Typically, there is no identifiable cause to explain the pain and it often follows or is associated with a history of some type of dental procedure, such as having a root canal or tooth extraction.

On occasion, the pain can occur without any reason. The pain is felt in a tooth or teeth and persists despite 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.

The diagnosis of atypical odontalgia is made after a thorough history, clinical examination and radiographic assessment fail to identify a cause for the pain. Once the diagnosis is made, medications can be used in an effort to reduce the level of pain.

Frequently asked questions 

What causes atypical odontalgia?

The cause of atypical odontalgia is not known, and therefore, some clinicians refer to the pain as ‘idiopathic’. 

In all likelihood, it is probably due to a variety of factors, which may include genetic predisposition, age, and sex. It is more common in women than in men, and is found most often in the middle-aged to older age group.

Some studies have found an association between atypical odontalgia and depression and anxiety. However, the significance of this association is unclear.

The actual pathologic mechanism seems to be dysfunction or ‘short-circuiting’ of the nerves that carry pain sensations from the teeth and jaws that is triggered by some type of dental or oral manipulation. Areas of the brain that process pain signals appear to undergo molecular and biochemical changes that result in a persistent sensation of pain in the absence of an identifiable cause of the pain.

Why doesn’t dental treatment cure the pain?

In most cases, dental treatment doesn’t help. In some cases, it may temporarily lessen or change the severity of the pain, but it will inevitably return. This is because the pain is not caused by any pathology in the teeth or gums, but rather it is due to dysfunction of the nerves or a portion of the brain that processes pain sensation. 

It is important to recognise this in order to prevent unnecessary and ineffective dental treatment.

How is atypical odontalgia treated?

Atypical odontalgia is a chronic pain condition that is treated by using a variety of medications, including local anaesthetics, steroid injections or tricyclic antidepressants. Although these are antidepressant medications, they are primarily used for their pain relieving properties and not for their antidepressant effects.

Other medication that may be prescribed include gabapentin, baclofen and duloxetine.

Generally, treatment is successful in reducing the pain but not eliminating it.

Is this a permanent condition?

Since the exact cause of this problem is not known, it is difficult to say whether atypical odontalgia is a permanent condition. There are cases in which the pain goes away spontaneously as well as cases in which the pain gradually subsides and disappears after prolonged treatment with medications. 

There are many cases, however, that persist and require the continued use of medications.

Why are many dentists unaware of this problem?

While atypical odontalgia is not rare, it is uncommon enough that many dentists have not seen the problem and are not familiar with it. 

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