More information in the form of a detailed case history is necessary before commenting. Describe the pain in all its dimensions - nature, severity, location, duration, frequency, relieving factors, aggravating factors and perhaps also use a pain scale as well.

In my opinion, it is not good to interpret unexplained pain presentations like this based on the minimal clinical data presented here. But it can be anything from atypical neuralgia, atypical facial pain to pain in a hypochondriac to nutritional deficiencies!

Also, trying to pin a systemic cause for her gingival pain may result in more unnecessary investigations and inappropriate treatments / medications. If you have a concern that it is related to some systemic issue, get her assessed by a medicine specialist in detail (ideal to discuss and convey your concerns personally or atleast via phone to the doctor else she'd be given a battery of tests again and a prescription with no real benefit!)

What is the patient's chief concern ? May be one must restart from there !

Such unexplained pain needs a thorough and detailed assessment to avoid unnecessary treatments (like this patient herself who underwent two gingival surgeries!!!).

One thing I tell my patients who come with complaints of pain ... if it doesnt affect your day to day activities and if it doesn't spoil your sleep, one should not give it too much attention. I am not implying that she is making it all up but even that should not be ruled out. Many times. all the patient requires is assertive reassurance and nutrition with lifestyle modifications which help people live through a lot of chronic pain disorders.

I would not venture trying to guess what systemic conditions she might have in view of her gingival pain. But if there are no clinical signs / symptoms what systemic disease would you attribute to it ? Phantom gingival pain ? Psychosomatic pain in gingiva ? These may be true ....!!! But before that, I'd like to rule out a lot of issues clinically before I even start her on any other medicine / treatment.

I wrote a lot more with considerations starting from hyposalivation, but then deliberately cut them off as consider all those factors without the actual clinical data of the patient may only lead to bias and that may cause the patient to have more unnecessary treatments / medications. May be I will post it, when more pertinent data is made available on the patient's case.

Regards,

Dr. Akilesh. R

Chennai, India

Can you give us details about the patient, Age, Sex, marital status, Some time the psychological condition have an impact, Best Regards

Age/sex- -44 /F

marital status- - married with children

chief complaint- - pain in gingival region since 2 years not relieved with analgesics

HOPI- -pain moderate to severe  , intermittent pain, aggravates in morning and reduces in intensity as day goes on

pain in night, pt can not sleep due to pain

shown to many doctors such as dentists , endodontists, periodontists,psychiatrists and neurologists. 

no one has diagnosed cause of pain

patient not satisfied. reports pain persists

investigations- - complete hemogram, thyroid function tests, 

x rays- orthopantomogram - - image attached normal

all blood test reports within normal limits. 

treatment undergone- -patient has undergone two periosurgeries in a span of one year followed by apicectomy in lower anterior teeth. 

on examination- - no caries with teeth, no pockets with teeth. 

no abrasions,erosion or attrision with teeth, 

TMJ function normal, no tenderness with any teeth, gingiva appears healthy

no muscle tenderness

diagnosis- - neurologist have ruled out nerve involvement, neurological status normal

pt has undergone pyachiatric treatment for some time during these past two years

but pt reports no relief from gingival pain

I guess that possible cause of pain could be psychological, based on the histroy you collected from the patiend, and 44/F as well passing a hormonal change period which may increase my expectation, Also, do she have night Bruxism or not?

if everything regarding oral cavity is Ok, I would consider atypical orofacial pain, referral to neurologist although she went and amytriptiline.maybe to  consult the book : Orofacial pain by Joanna Zakrzewska,

Atypical odontalgia could have a play here.

Does the patient have a wish? What was their desire at first presentation?

The case seems to be one of those that have a psychosocial background and may be also related to bruxism. As can be seen from the X-ray (lower molars....) there is tooth wear so maybe the patient is a bruxer, especially suspect for clenching. This may cause TMJ problems, Periodontal overloading but also cracked teeth. However, the case makes me very conservative to intervention. clearly someone tried to do something on a (this?) complaint in the past, looking at the three endodontic treatments in the lower incisors. what is the reason for that treatment in the past? These RCT cannot be explained from the situation of the dentition! did the RCT help in the past? People with stress and psycological problems tend to clench more on their teeth, but that does not mean that the treatment should be doing something on the bruxism. We have to be aware of the classic functional complaint......

My advise would be:

1. A thorough anamnesis, including the psychosocial and medical history. Were there any life events at the same time that the complaints started?

2. Test for possible cracks (if this hasn't been doen yet)

3. don't start any irreversible intervention if you are not sure on the diagnosis! But a splint to test if complaints improve or become worse might give insight.

4. Explain the difficult situation to the patient. Be aware that a demand for help resulting in an unnecassary treatment without proper diagnosis is not gonna help!

Lot's of wisdom!

Cannot be sure, blood flow. Disturbances in blood vessels supplying those gingiva.

I feel it to be a case of Atypical odontalgia/gingival pain. Consider Nuclear imaging as in some cases, an increased uptake of the radionuclide has been found. Also, a therapeutic diagnosis can be arrived at by administering antipsychotic medications. Further, non invasive therapeutic modality like TENS can be helpful. 

I have recently discovered that wifi, bluetooth and telecommunication signal reception from electronic devices, eg. computers, roulters, mobile phones could induce similar sort of presentation. Moreover, electronic monitors and screens, eg. computer screens, smart phone screens, also have similar effects, including xerostomia, gingivitis, ...

You didn’t mention exactly which teeth, but I would presume that it was in the area of the RCT’s.

Some information to obtain from the treating Doctor would be:

Were all teeth treated at one time?

If not, which tooth or teeth were treated at what appointments and the time between appointments?

Did the treating Doctor have trouble establishing anesthesia with these teeth?

Were they vital?

What area of the gingival tissues are painful; Buccal/Facial only? Or are the Lingual tissues involved too?

Pain which expresses in the buccal/facial gingival tissues may be related to an inflammatory hyperalgesia of the sensory nerve supplying the teeth in the immediate area. The Waxman study (1999) showed that up regulation of tetrodotoxin resistant sodium channels (Nav 1.8) is the basis of spontaneous pain, along with up regulation of the HCN ion channels are also involved along with other things we don’t understand yet.

A good diagnostic test is to place a topical anesthetic and have the patient report any pain change at the 3, 6, 9, 12 minute marks and repeat with local anesthetic with the same time intervals. Total block of pain would suggest peripheral only pain, where as equivocal pain reduction would point to some of both and no pain relief would indicate wholly centralized pain.

Neuropathic change happens in pulpal tissues and it is extremely likely that these changes are also present in periapical, periodontal and gingival tissue nerves associated with the hyperalgesic tooth. The trigeminal nerve supplies innervation both inside and outside the tooth and this would explain continuing pain in a tooth and associated buccal/facial tissues. What nerves are involved with innervation of tooth pulpal tissue and the buccal/facial gingiva? In the maxillary arch it is the posterior, middle and anterior superior nerves and in the mandible the inferior alveolar, all supplying the pulpal tissues and associated buccal/facial gingiva. The lingual gingiva are innervated by completely different nerves and would not be affected by the hyperalgesia of the tooth pulpal tissues.

If the pulpal tissues were involved in this case, successful RCT’s would not necessarily reverse the neuropathic pain. Polycarpou et al (2005), reported persistent pain after successful RCT at 12% and persistent pain after apical surgery at 45%. Removal of damaged pulpal tissue will not stop the spontaneous firing of a hyperalgesic nerve (periapical/periodontal/gingival nerves). Polycarpou postulated three important risk factors that potentiate pain after RCT’s:

Duration of preoperative pain greater then three months (OR=8.6).

Previous chronic pain problems (OR=4.5).

Female gender (OR=4.5).

Another contributor mentioned the possibility of a clenching/bruxing problem. This area must aways be addressed, as everyone clenches/bruxes to some extent. The question then is; “Is there a disorder called clenching induced pulpitis?” There are several studies that would suggest that sustained occlusal loading, over time, can cause pulpal inflammation. A well developed, comfortable appliance would reduce tooth trauma, trigeminal sensory input/tone and be helpful in obviating, to some extend, the types of pain this patient is experiencing.

Israel et al, (2003) has an interesting study on the percent of patients with orofacial pain (32%) undergoing previous dental treatments in an attempt to “fix” the pain. The studies conclusions were: Misdiagnosis and multiple failed treatments were common. Surgical treatment was rarely indicated as a treatment for pain relief in these patients, In fact, it exacerbated and perpetrated pain symptoms in some of the patients.

Waxman SG. The molecular physiology of pain: abnormal expression of sodium channel genes and its contribution to hyper-excitability of primary sensory neurons. Pain. 1999 Aug-Sept; Suppl 6:5133-40.

Renton T, et al. Sodium channel Nav 1.8 immunoreactivity in painful human dental pulp. BMC Oral Health. 2005 Jul 7;5(1):5.

Warren CA, et al. Quantification of neural protein in extirpated tooth pulp. J Endod. 2008 Jan; 34(1): 7-10. Epub 2007 Nov 26.

Polycarpou N, et al. Prevalence of persistent pain after endodontic treatment and factors affecting its occurrence in cases with complete radiographic healing. Int Endod J. 2005 Mar; 38(3): 169-78.

Edward C. Emery, Gareth T. Young, Esther M. Berrocoso, Lubin Chen, and Peter A. McNaughton. HCN2 Ion Channels Play a Central Role in Inflammatory and Neuropathic Pain. Science, September 9, 2011, 1462-1466.

Israel HA, Horrell B, Scrivani SJ. Oral and maxillofacial surgery in patients with chronic orofacial pain. J Oral Maxillofac Surg. 2003 Jun;61(6):662

Regards,

hello:

i can give you my experience with one of my patients. who has seen 16 dentist and physian 

she had continuous pain in the gingiva over  the buccal upprer right molars area   she had filings and even extracted a molar but and root canal but no relief.

she complained in the beginning of pain  which she could not localized and thought it is a TM j. i referred  her to a friend of mine who is a neurologist  and he first prescribed Amitriptyline she liked it and then she hated it for side effects ,to make the story Short he the neurologist prescribed for her alcohol injection of the  maxillary nerve. although g i did-not get  the details from that  neurologist i presume he injected the posterior superior alveolar nerve..i also think he diagnosed her with Trigeminal neuralgia (peripheral nerves )

she is ok now

cheers

Prof  galil

Did you make a CT or better a MRT of the brain?

@Cyyj Yeung

I agree with your blood flow theory. My patient has hypertension and sjogren syndrome. She has xrostomia problem also. What is your opinion for increasing blood flow for the effected area?