Case Report: An Implant Resolution to Idiopathic Pain

INTRODUCTION
Dental facial pain of unknown origin has been reported in 5% of our patients.¹ This article chronicles an 18-month case that began with conventional crown and bridge and ended with the extraction of the abutment teeth and restoration with a implant-fixed prosthesis. Specifically, a pre-existing 4-unit PFM bridge from teeth Nos. 7 to 10 was replaced with the addition of 2 single PFM units on the adjacent cuspids. Unresolved pain resulted in multiple consultations, several endodontic procedures, a computed tomography (CT) scan, 2 extractions and a final restoration, with an implant-retained fixed prosthesis.
Since oral facial pain of unknown origin can be so difficult to diagnose, a brief review of 3 common etiologies follows.

Cracked Tooth Syndrome
Some articles have reported almost 10% of the patients referred for endodontic therapy had a cracked tooth.2 Many etiologies have been postulated from steep cuspal molars to parafunctional habits, though none have been proven.2 Diagnosing the cracked tooth, especially under fixed-restorative work, is vexing. Neither radiographs nor sensitivity testing are useful. Transillumination offers the most information. It should be used on marginal ridges, the floor of the preparation, and all proximal surfaces. The presence of crown and bridge restorative work obviated the use of this diagnostic tool for the patient presented here.²
There exists abundant literature on this subject, clearly posing a diagnostic challenge to the dentist. Most articles conclude the following:

• Treatment depends on the degree of pulpal involvement and extent of the crack
• Cuspal coverage is required of cracked posterior teeth that are considered restorable
• If symptoms persist after restoration (unless symptoms dictated endodontic treatment prerestoratively), endodontic therapy is indicated
• Cracks that are diagnosed to the osseous crest have a poor prognosis.³

Trigeminal Neuralgia
This is an episodic neuralgia affecting the orafacial region. It is the result of one or more components of the nervous system: peripheral, central, or autonomic.
It does not require the presences of noxious stimuli (excessive heat, cold, or pressure). The pain can be intense and out of proportion to stimuli. The pain is real and relativity unresponsive to low doses of narcotics.⁴

Atypical Odontalgia
This malady remains one of the most challenging diagnoses for both dentists and patients. Atypical odontalgia (AO) has been defined as severe throbbing pain in a tooth without apparent major pathology. The primary site is in a tooth or tooth site that may spread with time. Other parameters consistent with AO are females, mid 40s, previous endodontic treatment, and no pain during sleep.⁴
There is an absence of any pathological, clinical, or radiological findings. It often follows tooth extractions, endodontic procedures, although it can be idiopathic. Treatment with local anesthetic injections, direct nerve blockers are inconclusive.⁵ There is no objective evidence to support some claims that its etiology is psychological in nature.⁶
The treatment of choice is a tricyclic antidepressant, 20 mg to 75 mg of amitriptyline. The dosage is regulated according to pain control and adverse reactions, which can include dizziness, headaches, drowsiness, nausea, nervousness, and diarrhea.⁷ The dosage is tapered and sometimes discontinued after pain control is achieved.

CASE REPORT
Diagnosis and Treatment Plan
A 44-year-old female presented in October of 2005 to replace a 10-year-old, 4-unit PFM-fixed bridge (Figure 1). Although uncommon, when lateral incisors have long roots and crowns, they are considered suitable abutements to replace maxillary central incisors.⁸
The new treatment plan would include single PFMs on Nos. 6 and 11. This patient’s medical history was unremarkable and her oral exam yielded no contraindications to treatment.

Initial Treatment
In December 2006, teeth Nos. 6, 7, 10, and 11 were prepared with 360° shoulder preparations. Final impressions (Impregum [3M ESPE]), a face-bow (SAM 2P Articulator [Great Lakes Orthodontics]), and acrylic provisionals were cemented with Temp Bond NE (Kerr).

Figure 1. A 10-year-old PFM fixed bridge.	Figure 2. Teeth Nos. 7 to 10 with a 4-unit PFM bridge and teeth Nos. 6 and 11 with single PFM units (2006).
Figure 3. Postoperative photo of teeth Nos. 10 and 11 (July 30, 2007).	Figure 4. Computed tomography (CT) scan; negative for any pathology.
Figure 5. CT scan, axial view.	Figure 6. CT scans, panoramic view.

Six weeks later, a 4-unit PFM bridge and 2 single PFMs for the cuspids were cemented with Rely X (3M ESPE) (Figure 2). During the next 5 months, the patient reported occasional discomfort that was increasing with intensity and frequency. Attempts to relieve the symptoms with equilibration failed.
The patient continued to report pain bilaterally, on and around the bridge and adjacent teeth. It was described as “throbbing” 24-hour pain. Between June and July 2007, endodontic therapy first for teeth Nos. 6 and 11, then teeth Nos. 7 and 10, was provided by the author. After the endodontic treatment was completed, there was no significant reduction of symptoms.
In August of 2007, the patient was referred to an endodontist. (Teeth Nos. 12 to 15 all responded within normal limits). Retreatment was provided for teeth Nos. 10 and 11 (Figure 3). The endodontic retreatment therapy provided no significant relief, so the patient was then referred to an ear, nose, and throat specialist to evaluate any sinus involvement. Examination along with a CT scan proved unremarkable (Figures 4 to 6). The report concluded “no significant” abnormal findings. The radiographic findings of labially portioned roots and extrusion of the endodontic filling material are generally not associated with the clinical symptoms.
Thirteen months following initial treatment (preparation of the teeth for fixed prosthesis), the patient presented for a consult for continual pain. The patient stated it was continuous and driving the patient “crazy.”

Another Treatment Plan
A treatment plan that would remove the offending teeth and replace them with an implant-retained bridge was accepted. One year and 4 months following the initial preps, treatment was provided to remove teeth Nos. 10 and 11, and 3 implants were placed in the position of 8 (4.3 x 13), 10 (3.5 x 13), and 11 (4.3 x 15) (Replace Select [Nobel Biocare]) (Figures 7 and 8). The patient wore a provisional removable partial following extraction. The patient reported an immediate and significant decrease in pain, although there was still some “soreness.” She also reported the complete absence of headaches. Five months following implant placement, Zirconia (Atlantis) abutments were torque in positions of teeth Nos. 8, 10, and 11. A cementable zirconium oxide bridge (Lava [3M ESPE]) was placed with a self-etching dual-cured resin cement (Rely X Luting Cement [3M ESPE]) (Figures 9 to 11).
It has been 24 months since this visit. Although the author notes the implant prosthesis is not as aesthetic as the original prosthesis, the patient remains completely without symptoms.

Figure 7. Implant placement in positions of teeth Nos. 7, 10, and 11.

Figure 8. Panorex radiograph of implant placement.

Figure 9. Zirconia abutments.	Figure 10. Retracted view of the final restorations.

Figure 11. The completed restorations.

CLOSING COMMENTS
This article has chronicled a case of probable AO. The pain may spread with time to involve the entire maxilla or mandible.⁹ The literature reveals that the most important clinical approach is careful diagnosis to differentiate among AO, pulpal pain, myofacial pain, and trigeminal neuralgia. The literature further deduces that dental procedures should be avoided in the treatment of AO and tricyclic antidepressants alone or with phenothiazines can be effective.⁹
The case report presented here did not follow the aforementioned approach to AO treatment. In fact, the author’s approach fell into the conventional approach of chasing the patient’s symptoms…even in the absence of obvious pathology. The treatment of endodontics and occlusal equilibration proved unsuccessful. Though extraction and subsequent implant treatment provided a resolution, it is possible the patient could have avoided significant treatment if an AO treatment protocol had been employed.

References

1. Marbach JJ, Hulbrock J, Hohn C, et al. Incidence of phantom tooth pain: an atypical facial neuralgia. Oral Surg Oral Med Oral Pathol. 1982;53:190-193.
2. Rivera EM, Williamson A. Diagnosis and treatment planning: cracked tooth. Tex Dent J. 2003;120:278-283.
3. Benenati FW. Coping with cracked tooth syndrome. J Okla Dent Assoc. 1996;83:16-18.
4. Conti PC, Pertes RA, Heir GM, et al. Orofacial pain: basic mechanisms and implications for successful management. J Appl Oral Sci. 2003;11:1-7.
5. Marbach JJ. Orofacial phantom pain: theory and phenomenology. J Am Dent Assoc. 1996;127:221-229.
6. Graff-Radford SB, Solberg WK. Is atypical odontalgia a psychological problem? Oral Surg Oral Med Oral Pathol. 1993;75:579-582.
7. Lacy CF, Armstrong LL, Gold MP, et al; American Pharmaceutical Association. Drug Information Handbook. 7th ed. Hudson, OH: Lexi-Comp; 1999:62-64.
8. Shillingburg HT Jr, Hobo S, Whitsett LD, et al. Fundamentals of Fixed Prosthodontics. 3rd ed. Chicago, IL: Quintessence Publishing; 1997:112.
9. Melis M, Secci S. Diagnosis and treatment of atypical odontalgia: a review of the literature and two case reports. J Contemp Dent Pract. 2007;8:81-89.

Dr. Rasner is a general practitioner from Bridgeton, NJ. In 1998, he founded Realizing the Dream, a collection of professional management tools, including speaker services, books, and in-office training videos. He has won numerous speaking awards internationally. He can be reached at (800) 337-8435 or at realizingthedream.com.

Disclosure: Dr. Rasner reports no disclosures.