Systematic review and recommendations for nonodontogenic toothache
Hirofumi Yatani, DDS, PhD a, Osamu Komiyama, DDS, PhD b, Yoshizo Matsuka, DDS, PhD
c
, Koichi Wajima, DDS, PhD d, Wataru Muraoka, DDS, PhD d, Masako Ikawa, DDS, PhD e,
Eiji Sakamoto, DDS, PhD f, Antoon De Laat, LDS, GHO g , Gary Heir, DMD h
a Department of Fixed Prosthodontics, Osaka University Graduate School of Dentistry,
Osaka, 1-8 Yamadaoka, Suita, Japan
b Department of Oral Function and Rehabilitation, Nihon University School of Dentistry at
Matsudo, 2-870-1 Sakaecho-nishi, Matsudo, Chiba, Japan
c Department of Fixed Prosthodontics, Institute of Health Biosciences, The University of
Tokushima Graduate School, 3-18-15 Kuramoto-cho, Tokushima, Japan
d Department of Dentistry and Oral Surgery, School of Medicine, Keio University, 35
Shinanomachi, Shinjuku, Tokyo, Japan
e Orofacial Pain Clinic, Department of Oral Surgery, Shizuoka Municipal Shimizu Hospital,
1231 Miyakami, Shimizu-ku, Shizuoka, Japan
f Department of Dental Anesthesiology, Faculty of Dental Science, Kyushu University, 3-1-1
Mumade, Higashi-ku, Fukuoka, Japan
1
g Department of Oral Health Sciences, KU Leuven & Dentistry, University Hospitals, Oude
Markt 13 - bus 5005 3000 Leuven, Belgium
h Center for Temporomandibular Disorders and Orofacial Pain, Rutgers School of Dental
Medicine, Rutgers, the State University of New Jersey, 110 Bergen Street, Newark, NJ,
USA
Address for correspondence: Yoshizo Matsuka
Department of Fixed Prosthodontics, Institute of Health Biosciences, The University of
Tokushima Graduate School, 3-18-15 Kuramoto-cho, Tokushima, 770-8504, Japan
TEL: +81-88-633-7350, FAX: +81-88-633-7391, e-mail: matsuka@tokushima-u.ac.jp
2
ABSTRACT
Aims：Nonodontogenic toothache is a painful condition that occurs in the absence of a
clinically evident cause in the teeth or periodontal tissues. The purpose of this review is
to improve the accuracy of diagnosis and the quality of dental treatment regarding
nonodontogenic toothache. Methods: Electronic databases were searched to assess the
best scientific evidence regarding related primary disorders and the management of
nonodontogenic toothache. We evaluated the level of available evidence in the scientific
literature. Results: There are a number of possible causes of nonodontogenic toothache
and they should be treated according to these causes. Nonodontogenic toothache was
categorized into eight groups according to primary disorders as follows: 1) myofascial
pain referred to tooth/teeth, 2) neuropathic toothache, 3) idiopathic toothache, 4)
neurovascular toothache, 5) sinus pain referred to tooth/teeth, 6) cardiac pain referred to
tooth/teeth, 7) psychogenic toothache or toothache of psychosocial origin and 8)
toothache caused by various other disorders. Conclusion: We concluded that
unnecessary dental treatment should be avoided.
Key
words:
nonodontogenic
toothache,
myofascial
pain,
neuropathic
pain,
neurovascular pain, idiopathic toothache
Clinical Relevance: This review discusses etiology and management of nonodontogenic
toothache based on the available scientific evidence. This review addresses all medical
personnel involved in dental treatment.
3
INTRODUCTION
Nonodontogenic toothache, as its name suggests, is a painful condition that occurs in
the absence of any clinically evident cause in the teeth or periodontal tissues 1, 2. 88% of
patients with toothache-like pain visit a dental office; 3% of these patients have
nonodontogenic toothache and 9% have a mixed condition of odontogenic and
nonodontogenic toothache. It has been gradually recognized that nonodontogenic
toothache is not rare 3. However, general dentists and specialists may not be familiar
with diagnostic criteria or managements for nonodontogenic toothache 1,3.
Toothaches are a frequently observed condition in regular dental practice and
the diagnosis and treatment of primary toothache are not difficult; however,
nonodontogenic toothache is not routinely studied. The current approach to
nonodontogenic toothache often involves ineffective or irreversible dental procedures
such as pulpectomy and/or tooth extraction 1,3. Since nonodontogenic toothache is a
condition with multiple pathophysiological causes 4-11, some patients may suffer from
long-lasting pain of unknown origin after undergoing dental treatments. Dentists are
required to reduce the use of irreversible dental treatments in patients with toothache in
the absence of clinically evident causes. The purpose of this review is to improve the
accuracy of diagnosis and the quality of dental treatment regarding nonodontogenic
toothache.
MATERIALS AND METHODS
The inclusion and exclusion criteria for selecting papers were established prior to
conducting the literature search. The inclusion criteria consisted of English written
clinical studies: systematic reviews, randomized controlled trials (RCTs), controlled
4
clinical trials (CCTs) or case series in which the diagnosis and treatment of
nonodontogenic toothache were described. Treatment guidelines and systematic reviews
for the diagnosis and treatment of a primary condition or diseases underlying
nonodontogenic toothache (e.g. trigeminal neuralgia,) were also included. Furthermore,
case reports were considered to include “Toothache caused by other various conditions
or diseases” because the conditions and diseases may be rare. The exclusion criteria
were studies without human patients or articles written with authors’ opinion.
Both electronic and manual searches were undertaken to identify all clinically
relevant studies written in English. The electronic search was conducted by two authors
(OK, YM) using PubMed (Medline) on October 30th 2013 with the following retrieval
style: “non-odontogenic toothache OR nonodontogenic toothache OR atypical
odontalgia OR toothache non dental OR (toothache AND neuralgia) OR (toothache
AND (headache OR vascular OR neurovascular OR neurovascular orofacial pain)) OR
(toothache AND (myofascial pain OR muscle pain OR myalgia OR musculoskeletal
orofacial pain))) OR (toothache AND cardiac) OR (toothache AND neuropathic OR
neuropathic orofacial pain)) OR (toothache AND maxillary sinus) OR (toothache AND
nasal mucosa) OR (toothache AND (psychogenic OR psychological)).” A total of 891
studies were found. The reference lists of all the relevant studies, existing reviews and
personal reprint collections of the authors were screened for additional relevant
publications.
Each publication was initially assessed for relevance by two authors (YM,
WM) using the information presented in the abstract. When an abstract was not
available or failed to provide sufficient information, a reprint of the full paper was
obtained. When papers or abstracts reported different stages of clinical trials, only the
5
longer-term study was included in the review. Then all publications were reviewed by 7
authors (HY, OK, YM, KW, WM, MI, ES).
REVIEW OF LITERATURE
Many variable primary conditions or diseases cause nonodontogenic toothache 12-15, and
there are some reports illustrating that pulpectomy 3 or tooth extraction
16
failed to
relieve pain. Since in most cases of idiopathic toothache, the pain increases following
tooth extraction, spreading to adjacent teeth and continuing to the residual alveolar ridge,
it is important to avoid pulpectomy or tooth extraction 3, 16. In 100 nonodontogenic
orofacial pain patients referred to orofacial pain specialists, 44% received tooth
extraction or root canal treatment prior to referral 16.
Understanding the primary problem underlying nonodontogenic toothache
helps to identify pathophysiology and is important for achieving a diagnosis and
selecting a treatment plan. It is possible that nonodontogenic toothache may arise from a
primary condition or from multifactorial etiologies. Following the literature search,
nonodontogenic toothache was categorized into eight groups according to primary
disorders as follows: 1) Myofascial pain referred to tooth/teeth, 2) Neuropathic
toothache, 3) Idiopathic toothache, 4) Neurovascular toothache, 5) Sinus pain referred
to tooth/teeth, 6) Cardiac pain referred to tooth/teeth, 7) Psychogenic toothache or
toothache of psychosocial origin, and 8) Toothache caused by various other disorders
(Table 1).
Nonodontogenic toothache is a heterotopic pain. It consists of projected nerve
pain which is felt throughout the peripheral distribution of the affected nerve (trigeminal
neuralgia, cluster headache, post herpetic neuralgia etc.) or referred pain as a result of
6
convergence and central sensitization (myofascial pain referred to tooth/teeth, toothache,
sinus pain referred to tooth/teeth, cardiac pain referred to tooth/teeth, etc. ) 17.
Myofascial pain referred to tooth/teeth
Myofascial pain of the masticatory muscles is a frequently observed primary disorder
associated with nonodontogenic toothache and symptoms including spontaneous and
continuous dull pain 18. It was reported that 11% of myofascial pain patients complain
of nonodontogenic toothache, and the masseter muscle often appears as the causal
muscle 18. An important part (49.6-85%) of cases of myofascial pain of the head and
neck muscles involves nonodontogenic toothache induced by referred pain
18
. A
diagnosis of nonodontogenic toothache caused by myofascial pain can be effectively
made based on the fact that five seconds palpation of the trigger points of the involved
muscle increases the pain 19. The guidelines of the American Academy of Orofacial Pain
(AAOP) 17 indicate that trigger point injection is useful for diagnostic decision making
as well as for treatment. There are several scientifically verified papers regarding the
reproducibility of sites of referred pain originating from trigger points 20, 21.
Treatment: Since toothache is caused by myofascial problems, behavioral modification
(soft food diet, resting the jaw, self-massage, hot packs, etc.) is beneficial 17. Physical
therapy is effective for treating toothache and includes the following treatments:
stretching exercises, massage, thermotherapy and posture correction. Muscle relaxants
are used for pain relief
17
, but their use should be limited to a few weeks
17
.
Pharmacologic therapies that demonstrated efficacy for myofascial pain causing
nonodontogenic toothache involved ibuprofen and low-dose amitriptyline 17. Occlusal
splint therapy has only a few reliable studies that sufficiently support its efficacy for
7
treating myofascial pain
22-25
. Acupuncture has a statistically significant effect on
temporomandibular disorders compared to a placebo 26, but the actual specific effect is
controversial 27, 28.
Neuropathic toothache
Episodic neuropathic toothache
Trigeminal neuralgia (TN) is a disorder associated with episodic neuropathic toothache
15, 29
. The paroxysm of trigeminal neuralgia is provoked by relatively innocuous
peripheral stimulation of a “trigger zone” at intra-oral or extra-oral sites. TN must be
differentiated from pulpitis and local anesthesia with 8% xylocaine spray administered
at the trigger zone intraorally reduces the episodes of paroxysmal pain 29. The absence
of dental pathological findings should be confirmed using radiographic and clinical
examinations (e.g. percussion pain of the tooth 29 ).
The pathophysiology of trigeminal neuralgia is categorized as classical or
secondary. In cases of vascular compression of the trigeminal nerve root, demyelination
may occur resulting in classical trigeminal neuralgia. Tumors or other demyelinating
disorders such as multiple sclerosis or other autoimmune diseases may be the cause of
symptomatic secondary TN 30.
Treatment: According to the guidelines developed by the American Academy of
Neurology (AAN) and the European Federation of Neurological Societies (EFNS), there
is strong evidence to support the use of carbamazepine as a first-line drug for trigeminal
neuralgia
31
. These societies recommend oxcarbazepine as the second choice and
baclofen and lamotrigine as third choice 32. Toothache may disappear concurrently with
improvements in paroxysmal neuralgia; however, it may be difficult to make a
8
diagnosis in cases of comorbidity with odontogenic pathology
procedures
30
. The surgical
include microvascular decompression, radiofrequency thermocoagulation
and stereotactic radiosurgery (gamma knife surgery) for classical trigeminal neuralgia
33
.
Continuous neuropathic toothache
Herpes zoster (HZ) of the face may also be associated with toothache and pulpitis-like
pain suddenly appears in healthy teeth and becomes intense within a few days. Painful
posttraumatic trigeminal neuropathy (PTTN) developing as a result of nerve injury that
occurs during dental treatment is also a cause of persistent neuropathic toothache 34.
Treatment : Pharmacological therapy for continuous neuropathic pain should be
administered according to the guidelines developed by the National Institute for Health
and Clinical Excellence (NICE)
35
, the IASP
36
and the EFNS
37
. Tricyclic
antidepressants, serotonin noradrenaline reuptake inhibitors, the anticonvulsants
gabapentin and pregabalin, and opioids are the drug classes for which there is the best
evidence for a clinical relevant effect 38. Patches with a local anesthetic have also been
shown to provide relief when applied to affected areas 39.
Idiopathic toothache
There are no multidisciplinary studies on idiopathic toothache (i.e. persistent
dentoalveolar pain: PDAP) since the diagnostic criteria for the condition is unclear 40, 41.
Some reports define idiopathic toothache as characterized by continuous pain in the
teeth and/or periodontal tissues without objective pathophysiological or radiological
findings at the site of pain, and with an unknown etiology that lasts over four or six
9
months
42, 43
. Neuropathic and idiopathic toothaches are closer to each other, since
studies from the last decade indicate that patients clinically diagnosed with atypical
odontalgia (AO) may in fact suffer from “definite” or “probable” PTTN, if
somatosensory disturbances can be demonstrated and if other confirmatory tests can be
applied
44-46
. The new IHS classification
30
refers to this entity as PIFP (persistent
idiopathic facial pain) 47 and classifies it as a painful trigeminal neuropathy 45, while the
term “atypical odontalgia” used in this paper as a historical reference, is no longer in
common use.
85% of patients with atypical odontalgia exhibit abnormal qualitative
somatosensory responses
48
. The most frequent somatosensory abnormalities in AO
patients were somatosensory gain with regard to painful mechanical and cold stimuli
and somatosensory loss with regard to cold detection and mechanical detection 44. As
mentioned, QST is useful in diagnostic decision making of atypical odontalgia within
each patient
49-51
. Atypical odontalgia patients complain of increased pain intensity
following the application of topical capsaicin cream 52, and have diminished blink reflex
R2 waves in comparison with normal subjects 53.
Treatment: The efficacy of tricyclic antidepressants was shown to be 60-75% 54 for
idiopathic toothache with most common reports using amitriptyline. Tricyclic
antidepressants are considered to have a high efficacy; however, the reports are only
case series or case-controlled studies, and the evidence level is not high
55, 56
.
Anticonvulsants are frequently used, as a considerable proportion of these patients may
have neuropathic mechanisms underlying their pain
chronic neuropathic pain have been reported 47, 57, 58.
10
47
. Other topical treatments for
Neurovascular toothache
The relationship between toothache and neurovascular headaches such as migraines 14,
cluster headaches and other trigeminal autonomic cephalalgias (TACs) cannot be denied,
since patients with neurovascular headaches commonly visit dental clinics with a chief
complaint of toothache 14, 59. Migraine without aura, which arises in the mid face, has a
throbbing and persistent quality similar to toothache. Van Vliet et al. showed that 34%
of 1163 cluster headache patients visited a dental clinic 60.
Regarding cluster headaches, continuous intense pain occurs in the maxillary
molar region for 15 to 180 minutes, and then suddenly disappears 60. It is important to
examine the available diagnostic criteria for various headaches following the
International Classification of Headache Disorders (ICHD) 30.
Treatment: Treatment for neurovascular toothache following migraine, cluster
headaches paroxysmal hemicranias, and SUNCT is administered in accordance with the
ICHD 30, and affected patients are referred to a neurologist, neurosurgeon or headache
clinic 14. Pharmacologic therapy for migraines normally includes triptans which are used
for the acute phase as abortive therapy. Topiramate, valproic acid or amitriptyline are
used for prophylactic treatment 17, 61. Regarding cluster headache, oxygen inhalation,
triptans, and dihydroergotamine were used for abortive therapy, while verapamil,
corticosteroids (short term), lithium, divalproex sodium, and topiramate were used for
prophylactic therapy 62, 63.
Sinus pain referred to tooth/teeth
Sinus pain referred to tooth/teeth is due to referred pain from acute sinusitis. Toothache
due to acute sinusitis frequently occurs in the maxillary premolar and molar regions, but
11
it is rare that chronic sinusitis is accompanied by toothache; it typically induces nasal
congestion and dull headaches 64. Pain occurs in the maxillary molar teeth induced by
cold stimulation or mastication, and dysesthesia arises with tooth clenching. The pain
increases when the patient bends over. Sinus pain referred to tooth/teeth is diagnosed
using computed tomography (CT) and histopathological examinations showing sinusitis
or malignant fibrous histocytoma 65.
Treatment: The patients with toothache due to acute sinusitis are referred to an
otorhinolaryngologist for treatment of nonodontogenic sinusitis.
Cardiac pain referred to tooth/teeth
There are many reports regarding toothache caused by ischemic heart diseases such as
angina 66-69. Kreiner et al. reported that 71 (38%) of 186 ischemic heart disease patients
experienced facial pain during heart attacks with a significantly higher frequency in
females. Eighty-five percent (60/71) experienced chest and facial pain simultaneously,
while 11/71 (15%) experienced facial pain only 70. Dentists need to be aware of the
possibility of ischemic heart disease in patients who visit the clinic with complaints of
toothache only.
Referred pain caused by ischemic heart disease is described as “tight” and
“burning” in contrast to the “throbbing and “tingling” of odontogenic toothache. The
common characteristic features of ischemic heart disease (aggravation induced by
exercise, improvement at rest, bilateral symptoms, etc.) are considered in diagnostic
decision making 71. An Echocardiogram is considered to be used to diagnose aortic
dissection.
12
Treatment: Patients with cardiac pain referred to tooth/teeth must be referred to the
cardiologist or other internal medicine specialists for treatment of the primary disease.
Treatment includes anti-angina drugs (beta-adrenoreceptor blockers, nitric acid, etc.)
and antithrombotic drugs (antiplatelet drugs, anticoagulants, etc.) .
Psychogenic toothache or toothache of psychosocial origin
Biopsychosocial factors affect pain, and chronic pain is closely related to psychosocial
problems 72, 73, but there is no convincing evidence that psychological or emotional
issues in itself can induce pain. Pain descriptors are often diffuse, vague, and difficult to
localize. When the somatoform pain disorder is felt in the teeth, multiple teeth are often
involved. Pain may be sharp, stabbing, intense, and sensitive to temperature changes, all
of which are similar to pain symptoms of odontogenic origin. However, the pain is
inconsistent with normal patterns of physiologic pain and presents without any
identifiable pathological cause. When accompanied by other psychiatric features such as
hallucinations or delusions, there is a greater possibility that the pain is of psychogenic
origin.
Treatment: Patients with psychogenic toothache caused by mental disorders need to be
referred to neuropsychiatrists or liaison treatment specialists and treated with
pharmacological therapy (antidepressant or antipsychotic drugs, etc.). Given that
psychogenic toothache is a somatoform disorder, dental treatment will not resolve
symptoms of pain and may potentially elicit an unexpected or unusual response to
therapy. Patients should be referred to a psychiatrist or psychologist for further
management. We must mention that chronic pain can cause depression or somatization
as well 74.
13
Toothache caused by other various conditions or diseases
Life-threatening diseases such as metastasis in the oral and maxillofacial area and breast
carcinoma have been reported as primary diseases of toothache 75. Angioleiomyoma and
methemoglobinemia may also be a primary disease of nonodontogenic toothache 76, 77.
The most common cause for mental nerve neuropathy was dental treatment followed by
malignant metastasis 78.
Chemotherapy-induced toxicity injuries to the peripheral nerve might
manifest as pulpitis-like toothache
79
. One of seven patients with temporal arteritis
complains of toothache and gingival pain 80. An erythrocyte sedimentation rate (ESR)
greater than 50 mm and the findings of a biopsy of the temporal artery are used to
differentiate temporal arteritis 80. It is recommended that toothache caused by temporal
arteritis be treated with steroid therapy by a rheumatologist or neurologist 80. Pain-like
trigeminal neuralgia and numbness of the gingiva and buccal mucosa have been
reported in cases of pontine infarction 81 or tumor 82. CT or MRI are used to confirm the
primary diseases of adult T-cell lymphoma, jaw bone tumor, cervical disc herniation,
cholesterol granuloma, brain tumor (meningioma), etc. Histopathologic examinations
are used to diagnose cholesterol granuloma 83.
SUMMARY
This review outlines clinical practice guidelines for treating nonodontogenic toothache
based on the available basic scientific knowledge and treatment systems and is
addressed to all medical personnel involved in dental treatment. The literature was
searched with regard to nonodontogenic toothache and its related primary diseases.
14
However,
since
nonodontogenic
toothache
is
a
condition
with
multiple
pathophysiological causes and the process was difficult because high quality literature is
still sparse. Further studies with appropriate evidence levels will be needed in the future.
15
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27
Table 1
Representative causes of nonodontogenic toothache with clinical features,
diagnostic testing and a summary for treatment of each entity.
Cause of
Clinical features
Diagnostic
nonodontogenic
testing
toothache
(After ruling out
Treatment
primary dental
pathology)
Myofascial pain referred Dull, aching, and
Provocation of
Behavior
to tooth/teeth
diffuse. Worsened
myofascial trigger
modification.
by masticatory,
points and
Physical therapy
head and neck
reproduction of
NSAIDs
movements.
referral patterns.
Muscle relaxants
Diagnostic
TCAs
injection
eliminates pain.
Neuropathi
c toothache
Episodic
Paroxysms are
Local anesthesia
Carbamazepine is
provoked by
with topical
the first choice,
relatively
anesthetic
oxcarbazepine as
innocuous
administered at
the second choice
peripheral
the trigger zone
and baclofen and
stimulation of a
intraorally reduces
lamotrigine as third
“trigger zone” at
the episodes of
choices
intra-oral or
paroxysmal pain.
28
extra-oral sites
such as the buccal
mucosa above the
molars, the lips,
chin, nares and
nasiolabial fold.
Pain is described as
excruciating,
electric-like and
brief
Continuou
Continuous
Continuous
Neuropathic pain,
s
persistent pain
neuropathic pain
such as reported
(toothache-like)
may be
during the acute
and associated
accompanied by
phase of a herpes
symptoms
sensory
zoster infection
abnormalities such responds to
Paresthesia may be
as hypersensitivity valaciclovir
reported
and/or allodynia.
hydrochloride,
aciclovir,
vidarabine, etc.
29
First–line drugs for
other continuous
painful conditions
include application
of topical
anesthetics and
the oral
administration of
TCAs or
anticonvulsants
second-line drugs:
nonopioids or SNRI
Idiopathic toothache
Continuous pain in
The most frequent
TCAs
the teeth and/or
somatosensory
SDA antipsychotic
periodontal tissues
abnormalities
drugs
without objective
were
topical treatments
pathophysiological
somatosensory
or radiological
gain with regard
findings at the site
to painful
of pain, and with
mechanical and
an unknown
cold stimuli and
etiology that lasts
somatosensory
over four or six
loss with regard to
30
months.
cold detection and
mechanical
detection
Neurovascular
Migraine:
Migraines:
toothache
Administered in
accordance with the
Spontaneous,
May accompanied
ICHD, and affected
throbbing
by nausea,
patients are referred
maxillary pain
vomiting,
to a neurologist,
photophobia,
neurosurgeon or
phonophobia, etc.
headache clinic.
Made worse by
physical activity
Pharmacologic
Attacks last 4-72
therapy for
hours
migraines normally
includes
acetaminophen and
NSAIDs. Triptans
are used for the
acute phase, and
topiramate, valproic
acid or amitriptyline
as prophylactic
treatment.
31
TACs (trigeminal
Dysautonomic
Oxygen inhalation,
aytonomic
accompaniments
triptans, and
cepharalgia):
of cluster
dihydroergotamine
Cluster headaches:
headache include
were used for
lacrimation,
abortive therapy,
Episodic, intense
rhinorrhea, scleral
velapamil,
periorbital and
injection,
corticosteroids
maxillary pain
pupillary miosis,
(short term),
lasting 15 to 180
as seen in
lithium, divalproex
minutes 82).
Horner’s
sodium, and
Syndrome. There
topiramate were
are no signs or
used for
symptoms
prophylactic
between
therapy
32
paroxysms,
although
neurovascular
toothache may be
induced by
histamines and/or
alcohol
TACs: chronic
Paroxysmal
paroxysmal
Acute, episodic
hemicrania had a
hemicranias (CPH)
periorbital and
100% response to
maxillary pain
indomethacin.Topir
associated with
amate appears to be
dysautonomic
promising .
features
Sinus pain referred to
Pain occurs in the
Computerized
Sinus toothache
tooth/teeth
maxillary molar
tomography (CT)
patients are referred
teeth induced by
and
to an
cold stimulation or
histopathological
otorhinolaryngologi
mastication, and
examinations
st
dysesthesia arises
showing sinusitis
with tooth
or malignant
33
Decongestants may
clenching
fibrous
be helpful.
histiocytoma
Cardiac pain referred to
“Tight” and
Reduction of pain
Echocardiogram
tooth/teeth
“burning”
is observed
Refer to the
following the
cardiologist.
induced by
administration of
Treatment includes
exercise,
sublingual tablets
anti-angina drugs
improvement with
of glyceryl
(beta-adrenorecepto
rest, bilateral
trinitrate
r blockers, nitric
Aggravation
symptoms
acid, etc.) and
antithrombotic
drugs .
Psychogenic toothache
An inconsistent site Referral to a neuropsychiatrist, mental
or toothache of
of pain in the
health professional or liaison treatment
psychosocial origin
anatomical
specialist. Treatment may include
innervation area,
pharmacological therapy (antidepressant
bilateral symptoms, or antipsychotic drugs, etc.)
continuous and
persistent pain
34