Quality Resource Guide

Assessing Orofacial Pain 5th Edition

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each other and may even be in opposing dental

arches. If the practitioner has difficulty identifying

the location of the source, or if the patient requires

proof that the painful tooth is not the pain’s source,

injections of local anesthetic are often used.

When a patient complains of tooth pain, a host of

diagnostic approaches may be indicated, including

radiographs, percussing teeth, evaluating teeth for

an incomplete tooth fracture, placing heat or cold

on teeth, and probing periodontal pockets. If no

tooth or periodontal pathology is identified, but

multiple teeth are tender to percussion, especially

if bilaterally or in opposing dental arches, the

clinician should consider that the tooth pain may

be secondary to excessive parafunctional habits.

Practitioners must also be cognizant that tooth

pain may arise from sources other than dental

structures. This was not considered when a

patient, whose panoramic radiograph is shown in

Figure 1

, complained of painful teeth. Her pain

was referred from masticatory musculoskeletal

structures, but the patient most predominately felt

the pain in her teeth, and had been treated for that

pain with endodontic therapy. Further assessment

demonstrated that her tooth pain could be

aggravated or reproduced by palpating various

musculoskeletal structures. If a practitioner

is preparing to perform root canal therapy to

alleviate tooth pain and the pain is still present

If other potential causes for this pain have been

ruled out, then treating the masseter muscle

through TMD therapies has a high probability of

being beneficial for the tooth pain.

Similar to how pain from musculoskeletal

structures can be perceived as tooth pain, pain

from a tooth may be perceived as TMD pain. If

the patient presents with TMD symptoms, but

also has symptoms that could be associated

with a pulpitis (pain that occurs or intensifies

upon drinking hot or cold beverages, throbbing

pain occurring spontaneously), the practitioner

should evaluate whether the TMD symptoms

could be from a pulpitis. Percussion and thermal

testing is initially indicated. If the thermal test

aggravates the patient’s TMD pain or causes

lingering tooth pain, a ligamentary injection of the

tooth is recommended. If the injection dramatically

reduces or eliminates the patient’s pain, the

pulp is likely causing or contributing to the TMD

symptoms.

Local Anesthetic Challenges

(Diagnostic Somatic Blocks)

It may be difficult to identify the source of pain

for some individuals, making local anesthetic

challenges necessary to identify or rule-out

locations of the pain. These challenges begin by

anesthetizing the smallest region possible that has

the greatest suspicion of being the source of pain.

If anesthesia fails to provide significant reduction

in the patient’s pain, then the challenges progress

to the region that has the next greatest suspicion.

Larger regions are sequentially anesthetized.

For

example, if a single tooth is suspected as the

source for the pain, a ligamentary injection of that

tooth is generally performed (a buccal infiltration

of a tooth may allow anesthesia to diffuse to other

teeth and perhaps muscles, negating the ability to

identify them as the source of pain). When using

a ligamentary injection, the practitioner must be

cognizant that it may also anesthetize adjacent

teeth. If the practitioner desires to rule-out all

mandibular posterior teeth as the contributing

source for the patient’s pain, he/she may perform

an inferior alveolar block.

after the tooth is anesthetized, it is recommended

that he/she reevaluate the patient for an alternate

source of the pain.

Fortunately, referred pain patterns are fairly

consistent from individual to individual. One

study palpated the masticatory and cervical

musculoskeletal structures of 230 TMD patients,

confirmed the consistency of referred pain, and

provided maps of the locations responsible for

producing referred pain to the different regions

of the head (

Figure 2

Referred pain patterns

to the maxillary and mandibular dentition, and

their sources are shown in the bottom drawings of

Figure 2

. The superficial locations that cause

tooth pain are highlighted on the drawing and the

intraoral palpation locations are listed below the

drawing.

Please see the maxillary and mandibular dentition

drawings of

Figure 2

. When a patient has pain in

one or more maxillary teeth, and no identifiable

pathology for the pain is found in the area,

palpating the superior portion of the masseter

muscle has the greatest probability of reproducing

the patient’s tooth pain. Similarly, if the patient has

mandibular tooth pain, no local pathology is found,

then palpating the inferior portion of the masseter

muscle has the greatest chance of reproducing the

patient’s tooth pain. If the palpation reproduces

the patient’s pain, it suggests the masseter muscle

could potentially cause or contribute to this pain.

Figure 1 - Panoramic Radiograph of Patient with TMD Whose Primary Complaint

Was Painful Teeth

Source:

Wright EF. Manual of Temporomandibular Disorders. 4th ed. Ames, IA, Wiley-Blackwell

Publishing Co, 2020, pg 89.