Research Spotlight: Insight Track 2023

Foundation-funded research highlights the importance of differential diagnoses of persistent dental pain

Among the highlights of AAE’s mid-year Insight Track 2023 conference on Pain, a presentation by Iryna Daline, DMD, MSD, MS on “Differential Diagnosis of Tooth Pain” underscored a significant concern for patients and providers alike.  Based on Foundation-funded research published in the JOE in 2020 and a new article released just last month, Dr. Daline asserts that patient complaints of persistent pain can disrupt a practice through revenue lost to the time and expenses of re-evaluations, additional imaging and unnecessary re-treatment if the source of the pain is actually nonodontogenic or of mixed origin.  

Additionally, perceptions of a negative patient experience can result in complaints to the referring dentist and negative reviews questioning the efficacy of endodontic treatment which can take on a life of their own in the freewheeling forums of social media. 

“The Foundation’s support for identifying causes of persistent pain after RCT is an important role the Foundation plays not only in research but also in educating our endodontists and other colleagues within the profession about the importance of looking at a full diagnosis and differential diagnoses before we treat patients,” says AAE past president Alan Law, DDS PhD, a co-author of Dr. Daline’s 2020 study.  “We determined that a lot of the pain that patients present with at six months may be TMD in origin and may be misdiagnosed.  If you misdiagnose that pain, you can mismanage it.”  

Studies show that while only 5-10% of patients experience persistent pain after RCT and 11-28% of new patients have non-odontogenic or mixed causes of pain upon initial evaluation,

more than half (53-62%) of returning patients complaining of persistent oral pain are actually suffering from a non-endodontic cause. 

In her presentation, Dr. Daline reviewed the most common non-odontogenic etiologies for musculoskeletal, neuropathic neurovascular and idiopathic diagnoses, emphasizing the importance of determining the presence of TMD, which occurs in more than 10% of the general population, and is the most common condition mistakenly referred for RCT.  In fact, more than half of patients with dental pain seeking RCT have TMD.   Dr Daline’s 2023 study found 8% of patients with tooth pain actually had TMD as the sole cause for their discomfort.     

Simply asking patients how long they have experienced pain, its duration, time of occurrence and catalysts for onset can indicate the probability of TMD.  Dr Daline’s 6-question TMD Pain Screener expounded in the 2023 study demonstrated useful overall accuracy. 

Dr. Daline concluded that even in the presence of obvious pulpal-periapical pathosis, a significant proportion of patients have mixed sources of pain.  If the non-odontogenic component of that pain is overlooked, the patient is very likely to attribute the discomfort to “tooth” pain after a successful endodontic treatment.  It is therefore critical to screen for the presence of non-odontogenic pain, especially TMD, and further use validated diagnostic criteria for TMD if initial screening is positive.