Referred Pain and Diagnosis

Claudia Hoffman, D.D.S.
Referred Pain and Diagnosis

Claudia Hoffman

HIS CASE seems basic, but when the symptoms are poorly localized and a patient feels strongly that a certain tooth is involved diagnosis can be a challange for a practioner.
    A 35-year-old male presented to our office with pain in an endodotically treated #14. The mesial buccal canal had been transported, and the apex had not been reached. There was a PAR evident on the mesial buccal root. The patient had pain on percussion and palpation on #14. I tried to retreat the mesial buccal canal and locate an MB2, but I was unsuccessful in reaching the apex, because the transportation and perforation prior to the apex was too severe. The patient was referred to an oral surgeon for an apicoectomy on the mesial buccal root. The patient tolerated the procedure well and was pain-free afterwards.
    The patient returned to our office one year later complaining of pain in the upper left quadrant related to hot and cold. Tooth #14 was asymptomatic; #15 tested positive to pain on cold, but #15 was a virgin tooth. The patient was insistent that #15 was the problem. I was suspicious of #14 due to the history, but that tooth was totally pain-free. I re-applied cold and hot to #15 and got a short painful response that did not last longer than ten seconds. The patient was sure that the pain he felt from #15 was the pain he had been feeling recently, but I was not convinced.
    I asked the patient to describe his pain specifically. He described a pain that woke him up at night and radiated to his ear. This was the alarm bell I needed, and I immediately examined the lower quadrant. There were no visible clinical symptoms on the bottom left, and no pain in response to percussion or palpation, so we took a radiograph. The radiograph revealed a large carious decay under an old amalgam on #18.
    This case illustrates what we all know about referred pain, it can go from top to bottom and vice-versa, but usually does not cross the midline unless it arises from a more central tooth. The few words “radiated to my ear” were my clue. This case reminded me of two things that I know: always examine the opposite arch first, and what seems obvious may not be the case.
    Here are some other characteristics of pain that may help with your diagnosis (note that these are just guidelines):

Dull, gnawing, aching: pain usually is of bony origin
Throbbing, pounding, pulsing: describes a vascular response to tissue inflammation
Sharp, electric, and stabbing: pathosis of pulp root anatomy, ireversible pulpitis

I hope this helps with your tough diagnosis of referred pain. It is a great feeling when the patient finally feels better after a difficult diagnosis.

November - December 2007

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Use Ti-Core White to close the access. Just etch for twenty seconds and syringe directly into the access cavity. Light-cure for twenty to forty seconds. Done.