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Root of Some Tooth Pain is not in The Tooth

NEW ORLEANS, Louisiana – Sometimes the best way treat a toothache is to not treat the tooth, according to an endodontist speaking here at the 58th Annual Session of the American Association of Endodontists (AAE). "Not all toothaches come from teeth," said Stephen Cohen, DDS, Professor of Endodontics at the University of the Pacific School of Dentistry, San Francisco, and an endodontist in private practice in San Francisco.

"Sometimes we best serve our patients by not doing dental work. Our job is to listen to the patient, relieve the pain and either treat the tooth or involve other doctors to treat the source of the pain."

Endodontists are dentists who specialize in root canal procedures and have special training and expertise in diagnosing and relieving oral pain. Endodontists often see patients with pain that is difficult to diagnose and pain that may be caused by conditions ranging from a sinus infection to a neurological disorder and, in rare cases, cancer. Because of the complex network of nerves in the head, face and neck, conditions in this part of the body often cause referred pain that turns up in or around a tooth. Consequently, some patients with toothaches may have unnecessary dental procedures and the pain continues unrelieved. Some patients return to the dentist numerous times, but relief from the pain remains elusive.

"As dentists, we should think of ourselves as doctors practicing oral medicine, not just excellent technicians," Dr. Cohen said.

One of the most common non-dental causes of tooth pain - and sometimes unnecessary dental treatment - is a sinus condition called acute maxillary sinusitis (AMS), usually caused by a bacterial infection. Through a series of non-invasive tests - X-rays, pressing and tapping on the teeth and gums, along with thermal tests - a dentist can accurately determine if the toothache is caused by a sinus infection or a dental problem. If it appears that the tooth and gums are healthy and not causing the pain, the dentist would then prescribe a medication regimen that includes analgesics, antihistamines, antibiotics and nasal sprays.

"If it's AMS the patient should feel noticeably better within 24 hours. We then advise patients that if the pain recurs - and sometimes it will - they should go to an ear, nose and throat specialist instead of a dentist," Dr. Cohen said.

Factors that help the patient and dentist determine if the pain is sinus, rather than dental-related, include chronic allergies, pain when bending over, having recently had a cold and having recently flown on an airplane. It's important that the patient report this information to the dentist.

"There's a saying in medicine, 'listen to the patient, the patient will tell you the diagnosis,'" Dr. Cohen said.

Another common type of non-dental pain in a tooth is called Atypical Facial Pain (AFP), which is a term for a certain type of facial nerve disorder; sometimes AFP can cause a "roaring toothache," he said.

Another neurologic disorder patients may first report in the dentist's office is Trigeminal Neuralgia. "These patients are in exquisite pain that can be triggered by the lightest touch," Dr. Cohen said. "We don't know exactly what causes the pain, but we do know it's a neurologic disorder. The patient wants something done right away but we have to recognize that the "toothache" is not a dental problem and refer the patient to a neurologist."

A much less common, but potentially more serious, type of non-dental condition dentists see is a tingling or numbness in the mouth that may be an early sign of cancer.

"It's not common but we have diagnosed a few cancers," Dr. Cohen said. "This early detection can save the patient's life."

Endodontists have always diagnosed various types of non-dental pain; new, more effective medications are making diagnosis and treatment easier, Dr. Cohen said. He also said that although there is no hard data to prove this, it seems like the frequency of these cases might be increasing.

"It seems I'm seeing more of these cases and I assume my colleagues are as well," he said. "It may be that we're more aware of them."

Of course sometimes a toothache really is a toothache. There are many dental causes of tooth pain, but a classic toothache usually occurs when the tooth's soft inner tissue, containing nerves and blood vessels, is damaged, usually by deep decay. A root canal procedure relieves the pain and saves the tooth by removing this tissue, called the pulp, and cleaning, filling and sealing the root canals. An estimated 17 million teeth are saved with root canal procedures each year.

The tooth's pulp also can be damaged by oral trauma; endodontists treat these emergency cases, sometimes even replanting a tooth that has been knocked out of the socket. [ Format imprimable Format imprimable ]
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