LAS VEGAS—Whether called “atypical” facial pain, or “phantom tooth pain,” if edentulous—which Peter Foreman, DDS, consultant, Orofacial Pain, New Zealand, called “useless terms”—clinicians should be alert to pain that may precede or follow dentistry.

The signs and symptoms of oral neuropathies are aching, stabbing, burning, and throbbing, mostly in the upper molar/premolar region. Pain may be intermittent or prolonged, and worse with temperature changes. Hyperesthesia and allodynia may occur.

Neuropathic pain can follow deafferentation, defined as elimination or interruption of sensory nerve transmission due to nerve injury. For example, exodontia, third molar surgery, and endosseous dental implants can all create nerve injuries and neuropathic pain.

“Posterior mandibular implants may result in 5% to 15% of postoperative problems, with permanent neurosensory disorders occurring in approximately 8%,” he said to attendees at PAINWeek 2014. “‘Nerve lateralization’ risks perineural damage from ischemic stretching. Implant compression and drill punctures may result in neuroma formation, which can result in permanent pain.”

Orofacial pain occurs more often in females (at a 2:1 ratio to males) and in those primarily older than 40 years of age. Incidence of neuropathy following endodontia ranges from 3% to 6%. Some patients appear to be at risk of whenever endodontia is performed. What remains unknown, however, is whether there is a genetic predisposition. There are few pathological or radiographic signs; for that reason, patients may see many physicians without success.

“Patients with unrelenting pain often visit numerous dentists, dental and medical specialists, and others in search of relief,” Dr. Foreman said. “Many undergo multiple extractions and/or irreversible and often harmful procedures, yet they still have pain.” In fact, he added, many patients continue to suffer but avoid further treatment due to fear of more pain and treatment costs.

He said few dentists and maxillofacial surgeons consult with colleagues such as pain specialists or neurologists. On the contrary, “69.7% rated the efficacy of their procedures highly, despite ongoing problems.” Oral surgeons and endodontists are more likely to see persistent pain patients due to referrals. “Caution is wise if the pain history is long standing. It is a warning that diagnosis and management may prove difficult,” he advised.

Some common responses of dentists to complaints of chronic orofacial pain are summarized in the Table.

Table. Common Dentist Responses to Chronic Orofacial Pain Complaints

 That leaky filling needs replacement
 It must be a “cracked tooth syndrome”
 You need a root canal filling
 I’ll have to do an apicectomy
 Let’s explore that “bone cavity”
 You’ve got “TMJ syndrome”
 Your occlusion needs adjustment
 You need a bite splint
 You need an arthrogram
 Sorry I’ll have to extract the tooth
 I’ll have to refer you to an oral surgeon