Diagnostic challenges of nonodontogenic toothache
A 57-year-old female was referred for evaluation of pain on #26, the upper left first molar. She complained dull pain on #26 when chewing. The patient reported a history of pain on #26 five months ago. To resolve her discomfort, she visited her general dental practitioner and root canal therapy was performed on this tooth. The patient had some relief of pain for approximately 2 weeks after root canal treatment of #26 was completed, but the pain returned. The patient was subsequently referred when the pain did not abate.\nClinical examination revealed that tooth #26 was restored with gold crown. Percussion and bite testing of #26 were positive and periodontal probing depths of #26 were less than 3 mm. All adjacent teeth responded within normal limits for percussion, palpation, bite test and vitality when tested with cold and electronic pulp tester. Radiographic examination revealed tooth #26 had root canal treatment and no noticeable pathologies were observed (). On the basis of clinical findings and history of pain, a diagnosis of acute apical periodontitis was suspected. Root canal retreatment was performed on this tooth. During the treatment, missing canal MB2 of #26 was found. After canal enlargement and canal dressing with calcium hydroxide on MB2 canal of #26, the pain was relieved and root canal retreatment was completed () on assumption that acute apical periodontitis because of untreated canal, MB2 of #26 was the source of her pain.\nThe patient visited again 9 months later complaining that the pain returned to the area of tooth #26. The patient reported spontaneous dull pain and gingival pain of #26. The patient also wanted removal of gold crown on #26 because she felt odd taste of crown. Percussion, palpation and bite testing of #26 were negative. A Radiograph was taken, which revealed no noticeable pathologies () As well, all adjacent teeth responded within normal limits for percussion, palpation, bite test and vitality when tested with cold and electronic pulp tester. Intraligamental injection on this area was not effective in reducing the pain. A definitive diagnosis could not be made from the clinical findings, the following treatment options were discussed with the patient: (1) no treatment and follow-up check for monthly, (2) apical surgery, or (3) extraction. The patient was told that the pain may be referred from another source or from another tooth. The patient elected to have no treatment and follow-up check for monthly.\nOn follow-up 1 month later, the patient reported continued pain in the area of the treated tooth. The dull pain on #26 was exacerbated and tingling on the right maxillary posterior area and burning sensation of left lateral side of tongue were appeared. The patient insisted that treated tooth #26 was the source of the pain. Radiographic examination revealed that no noticeable pathologies were observed on #26 (). There were no mucosal abnormalities and the patient is a postmenopausal woman. A possible diagnosis of burning mouth syndrome was suspected. The patient was referred to the Department of Oral Medicine, Kyungpook National Dental Hospital. Further questioning revealed that the onset of pain was spontaneous and the burning sensation often occurred in more than one oral site, those were the left posterior palate, buccal gingiva and left lateral side of tongue. Alterations in taste also occurred. The presenting complaint was diagnosed as burning mouth syndrome. 10 mg of benzodiazepine (Rivotril, a chlonazepam, Roche, Basal, Switzerland) taken twice daily, was prescribed. This provided a reduction in pain from 8 of VAS scale to 4 after four weeks and to 1 after ten weeks, this was effective in controlling the symptoms.