Original Contributions

Pain Update
Mismanagement of dentoalveolar pain
What are the clinical consequences?
Charles S. Greene, DDS; Daniele Manfredini, DDS, PhD, Dr Ortho
JADA 2021:n(n):n-n
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F
or many medical and dental conditions, it is relatively easy to conclude that a particular
clinical situation was managed properly, on the basis of the existence of clear standards of
practice established over the years via a combination of clinical trials and scientific studies.
Taken together, this combination is referred to as evidence-based care, in which diagnoses are well
established and treatment procedures have been clearly delineated and shown to be effective. For
many conditions, the standards of practice are published and endorsed by the appropriate profes-
sional organizations. Some good examples are provided in several dental fields.1-3
However, the phenomenon of toothache does not fall into that simple and straightforward category.
Despite being one of the most common painful conditions, it often is misdiagnosed, leading to a variety of
inappropriate treatments. Because the term toothache is merely a popular term used by patients to describe
their pain, in the remainder of this article we will use the more accurate and comprehensive term den-
toalveolar pain (DAP).4 DAP refers to pathologies involving all elements of the dentoalveolar complex,
including the dental pulp, periodontal tissues, and surrounding alveolar bone. The pain reported by patients
when any of these elements are affected usually will be described as a toothache, but all of those conditions
can be treated successfully by means of 1 or more well-established dental procedures.
Although most DAP symptoms are of odontogenic origin and respond well to conventional
dental treatments, a variety of other orofacial pain (OFP) and systemic conditions can produce
similar symptoms (Table).5 Misdiagnosis of those conditions by treating them as ordinary tooth-
aches not only fails to resolve the clinical problem but, in many cases, the treatments provided can
lead to more severe and chronic problems.
Some have argued that dentists should not be judged negatively when these situations arise; they
are trying to do the right thing, and alternative diagnoses are difficult to separate from conventional
DAP.6 The symptoms associated with pulpal pathology, cracked teeth, periapical inflammation, and
regional aching pain are shared by several other OFP problems; therefore, it is not unreasonable to
provide dental treatments (and retreatments) when symptoms persist. However, the opposing
argument is that dental clinicians should have learned enough about those other conditions to at
least suspect an alternative diagnosis when conventional dental treatment fails. Meanwhile, it is the
patients who experience the consequences of this clinical dilemma, because they are not able to
determine how to resolve their conditions or whom to turn to when things are going badly.
On the academic side, there are both OFP and oral medicine graduate training programs in many
universities around the world focusing on managing potential sources of facial pain. The experts in
these programs often function as faculty of dental colleges while also practicing in their commu-
nities, but overall their numbers are small. As a result, the average patient is not likely to be seen by
such experts unless referred to them by his or her primary care dentist. Nevertheless, both general
and specialized dentists should be aware of the common OFP conditions, even if they are not
prepared to manage them specifically. If no dental oral pain experts are available in their com-
munities, they should consider referral to other health care professionals who can make appropriate
decisions about what to do next.
Although it might be possible to defend an initial mistake in diagnosing and treating an apparent
toothache, at some point a dentist should realize that a problem case is evolving. Similarly, if the ª 2021 Published by
patient goes to a second or third dentist with a report of continuing pain, that practitioner should Elsevier Inc. on behalf of
the American Dental
avoid moving directly toward routine dental interventions (for example, retreatment of
Association.

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 Table. Overview of main orofacial pain conditions producing toothachelike symptoms.

OROFACIAL PAIN
CONDITIONS* MAJOR FEATURES* COMMENTS*
Classic Trigeminal Neuralgias Brief episodes of sharp shooting Spontaneous onset typically
(V2 and V3) pain

Primary Neuropathic Pain, Also May include phantom tooth pain, Nomenclature issues; pain
Known as Persistent painful neuropathy (nontraumatic), usually dull, aching; feels like it
Dentoalveolar Pain atypical odontalgia is in dentoalveolar area; usually
idiopathic in origin

Posttraumatic Neuropathy and Pain development within 3 months Can be either spontaneous or
Pain of trauma elicited; pain usually sharp,
shooting neuralgiform type

Temporomandibular Muscle Should meet diagnostic criteria for Myogenous pain can refer to
and Joint Disorders temporomandibular disorders maxillary and mandibular
dentition

Migraine Headache Throbbing and aching in V1 area; May feel like pulpitis toothache
classic symptom patterns symptoms, especially throbbing

Midface Migraine Headache, Throbbing and aching in V2 and V3 May feel like pulpitis toothache
Also Known as Neurovascular areas symptoms, especially throbbing
Orofacial Pain or Lower-Half
Migraine Headache

Secondary Trigeminal Neuralgia Symptoms similar to classic form but Requires medical workup with
caused by space-occupying lesion, emphasis on imaging
multiple sclerosis, or other
intracranial pathology

* For all the listed conditions, psychological burden is a common feature.

endodontically treated teeth, curettage of surgical sockets, providing dental treatment to 1 or more
neighboring teeth, and adjustment of dental occlusion) and instead have a high level of suspicion
that a nonodontogenic problem is occurring.7,8
In this article, we present 2 cases of obvious dental malpractice. The first is an unusual case of
multiple dentists mismanaging the treatment of a patient who had an OFP problem treated and
retreated over a 3-year period before any nonodontogenic differential diagnoses were considered. This
case led to a lawsuit involving 5 dentists and a large number of experts testifying for both sides. The
second case involves a patient who received endodontic treatment and crowns on 28 teeth from 1
dentist. Despite the persistence of her pain over such a long period, the patient did not consider
pursuing any legal remedies. These 2 cases will be used as the basis for discussing some clinical criteria
for deciding when mistakes can become malpractice in the management of toothachelike pain.

CASE 1
A middle-aged woman reached up for a small plastic box of facial wipes from a closet shelf. It slipped
out of her hand and struck her upper lip. There was no bleeding either externally or on the
mucogingival tissue over teeth nos. 9 and 10. There was a localized pain that she believed was a
toothache in no. 9. Within a few days, she saw her primary general dentist (dentist no. 1). His
examination found that the tooth was vital and responded normally to testing; that is, radiograph,
electric pulp testing, tapping with blunt instrument, and manual palpations. He advised waiting to
see what would happen, and the patient continued to have fluctuating symptoms of pain.
Over the next 6 months, the patient was referred back and forth to dentist no. 2, an endodontist,
who could not reach a diagnostic conclusion about tooth no. 9. He eventually was persuaded to
perform a nonsurgical root canal therapy (RCT) on that tooth and found a vital pulp that might
have been slightly hyperemic; the procedure was completed in 1 visit. After the endodontic
treatment, the patient developed more severe pain, and the endodontist was unable to explain this
outcome. He advised her to wait it out with the help of prescription analgesics. A limited field of
view cone-beam computed tomography (CBCT) study of the area failed to show any cracks or other
radiographic findings that could explain the etiology.
At this point, the patient became frustrated with these 2 dentists and decided to search for a
more expert practitioner. Online she found a prosthodontist (dentist no. 3) who had been a part-

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time faculty member at a local dental college. He examined her approximately 2 months after the
RCT was performed. He examined her by tapping on tooth no. 9 with a blunt instrument and
found her responses to be indicative of a DAP problem, so he referred her to a periodontist
(dentist no. 4). This led to the following series of evaluations and treatments by these 2 dentists
and 3 other colleagues within 2 dental group practice offices. First, dentist no. 4 concluded that
tooth no. 9 was cracked, and he extracted it; an immediate implant was placed during that visit.
Afterward, a temporary crown was placed by dentist no. 3. Because the pain persisted, the patient
was seen by an endodontist (dentist no. 5) within that same group practice, and he performed
RCT on tooth no. 10. The same cycle of events as described for no. tooth 9 was repeated as the
pain was getting worse, and extraction was recommended. Also, owing to a questionable radio-
graphic finding around the tip of implant for tooth no. 9, that implant was removed during the
same visit. At this point, the patient went to a different dental office to see another periodontist
(dentist no. 6), who asked the endodontist in his practice (dentist no. 7) to evaluate the completed
RCT on tooth no. 10. Together they decided to extract this tooth on the basis of a cracked root. An
implant was placed, and it has not been removed to date.
Throughout all of this treatment, provided over a 3-year span, the patient’s symptoms
steadily worsened. During this entire 3-year period, not 1 of the 7 dentists ever mentioned an
alternative diagnosis other than toothache or cracked root, nor was it ever suggested that the
patient should consult with an OFP or oral medicine specialist or with a physician of any kind.
Finally, the patient sought an opinion at the Mayo Clinic, where within 30 minutes a
diagnosis of atypical odontalgia was offered; this diagnosis has changed nomenclature over the
succeeding years, but essentially it was a correct description of a neuropathic pain problem. A
first attempt to treat with gabapentin did not help. The patient returned home and began a
cross-country odyssey seeking treatment. One neurologist in New York suggested a microvas-
cular decompression surgical procedure to treat what he diagnosed as trigeminal neuralgia, but
another neurologist warned her against it. She saw oral surgeons in a Midwestern state who
advertise treatment for neuralgia-inducing cavitational osteonecrosis (NICO) (also described as
holes in bone), for which they recommended performing a surgical excavation procedure of the
dentoalveolar bone.
At this time, the patient was referred to this article’s first author (C.S.G.) and was advised to
avoid that NICO procedure. An oral stent containing a custom-compounded mixture of various
medications for neuropathic pain (that is, pregabalin, cortisone, and lidocaine) was fabricated;
this was inserted over the painful area, and that was moderately helpful for some time, but
ultimately it did not provide adequate relief. The patient then was referred for neurologic care,
and a series of medications for neuropathic pain was tried with limited success. Ultimately, after
failing to improve with stellate ganglion blocks for a supposed sympathetically maintained pain
disorder, she was prescribed opioid medications to be taken 4 times per day combined with
other centrally acting medications. Somehow, she has managed to continue working as a
teacher most of this time.
The patient understandably was distressed and consulted with an attorney. She wanted to sue all
7 dentists but ultimately was persuaded that dentist no. 1 had done the best he could with vague
symptoms and no findings and that his 6-month collaboration with the endodontist (dentist no. 2)
was acceptable. Performing the RCT on no. 9 also seemed reasonable at the time, but it is un-
fortunate that the endodontist did not understand the negative outcome; instead, he attempted
prescribing medications and hoping for resolution of the pain.
Clearly, it is fair to think that dentist no. 3 erred by failing to consider a nonodontogenic
diagnosis when this new patient with 1 year of progressively increasing DAP sought treatment at his
office. Instead, he initiated the cycle described above, and the following 6 years of pain could be
attributed to the combination of omissions (failure to diagnose or refer) and commissions (ex-
tractions, implant placement and removal, etc.) committed by him and his 4 colleagues. Therefore,
a malpractice suit was brought against all 5 of those dentists; the outcome of that action is still
pending.

CASE 2
A 27-year-old woman sought treatment at the office of an OFP expert (D.M.) showing the oral
condition depicted in Figures 1-3. She recalled her initial problem as pain in the maxillary right

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 arch, in the area of premolars, approximately 5 years earlier. Her general dentist attributed the pain
to pulpal inflammation of the first premolar, tooth no. 5 and performed an endodontic treatment.
After an initial improvement, the pain soon reappeared, and the dentist attributed the pain to
sensitivity of the neighboring teeth. He proceeded with additional sequential RCTs of teeth nos. 2
through 4 to provide possible relief from pain, which was migrating from 1 tooth to another.
The patient reported that because of persistence of pain, the dentist suggested progressive RCTs
of all teeth, ending up with all 28 of her teeth being subjected to endodontic procedures. After these
extensive procedures, her overall pain increased, with alternating periods of slight remissions and
worsening episodes. Pain was described by the patient as feeling like an electrical stimulus that is
never too intense but sometimes reaches 7 of 10 on a numeric rating scale. The location of the pain
was variable from time to time, primarily in the original quadrant but also migrating to the other
quadrants. The patient was not able to identify any particular trigger for the pain but described some
occasional associated symptoms, such as a burning sensation in the gingiva as well as a bad taste in
the mouth. She reported headaches with a frequency of no less than 7 days per month.
The patient stated that she never lost trust in her dentist over the years, not even when he
advised her to “cover all teeth with crowns.” According to the patient, prosthetic treatment was
proposed to adjust her occlusion and exclude any cause for pain related to misalignment of the
teeth. Time passed without any improvement, and her dentist suggested an escalation to a third step
of treatment: full-mouth extractions and provision of an implant-supported prosthesis. At that point
the patient, frightened over the prospect of this extensive proposed surgical intervention, decided to
ask for a second opinion, 5 years after the first appointment with the first dentist.
The second dentist referred her to this article’s coauthor (D.M.), who attempted to convince the
patient that there was nothing wrong with her occlusion. Instead, he recommended a treatment
plan combining psychological interventions and pharmacologic therapy, on the basis of a working
diagnosis of combined peripheral and centralized neuropathic pain. Despite the efforts and time
spent counseling her and explaining the plausible neurologic nature of her pains, the patient was
never fully convinced that she did not have a problem with her occlusion. She was prescribed
gabapentin and diazepam, but she communicated by phone her decision to suspend the treatment
after only 2 weeks because she felt it was not the correct approach for her. The patient never
returned for a second consultation and communicated that she would instead continue her search
for someone who might be able to correct her occlusal problem or to make her pain disappear
without any centrally acting drugs. This decision has implications for the discussion of this clinical
case. Indeed, although the diagnosis of neuropathic pain appears to be logical, the failure of
resolving it with medications and therapy does not allow confirming it. Thus, patients’ noncom-
pliance and nonacceptance of the likelihood of a working diagnosis of neuropathic pain is a factor
that must be considered when discussing the etiology of nonodontogenic OFP.

Figure 1. Clinical photograph of the patient in case report 2, showing full crowns on all 28 teeth (right-side view).

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Figure 2. Clinical photograph of the patient in case report 2 (left-side view).

DISCUSSION
We chose the 2 cases above for their representation of how badly an OFP situation can be managed
when the treating dentists fail to consider alternative diagnoses while treating what they believe is a
patient with DAP. The 2 scenarios also show how difficult the dentist-to-patient relationship can be
in these cases. Indeed, although the first patient avoided the cycle of multiyear continuous dental
procedures by deciding to seek a medical opinion, the second patient was not willing to accept any
nondental explanation and continued pursuing dental solutions. The ultimate outcome of what
happened to both of these patients is unknown. However, the length and severity of their chronic
pain make it unlikely that their problems could be totally resolved by current treatment protocols
for such conditions. This is well documented in both the medical and dental literature.9,10
Below, we will attempt to present a clinical rationale for initial mismanagement of what appears
to be a DAP, because to some extent those initial mistakes may be quite defensible. But at some
point, a line may be crossed that could have been avoided, and the rationale for making that
judgement must be carefully considered.

Difficulties in diagnosis of DAP

Because toothaches commonly are reported and successfully managed every day in dental
offices around the world, the public has come to believe that this must be an easy and routine
matter for the dental profession. However, diagnosing DAP is a relatively low-tech procedure
that involves 1 subjective component (that is, patient’s report) and some objective compo-
nents (that is, clinical and radiographic assessments), with some new technical modalities (for
example, laser Doppler, pulse oximetry) emerging as potential complementary diagnostic tools
for use in the near future.11 Whereas many other areas of medicine and dentistry have a

Figure 3. Orthopantomogram radiograph of the patient in case report 2, showing full-mouth endodontic treatments.

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 variety of high-tech methods available for aiding in diagnostic decisions, the differential
diagnosis of a toothache begins simply with a history about the nature and location of the
painful symptoms. But as every dentist knows, there are many factors that complicate the
possibility of obtaining clear answers even if the questions are well phrased. For instance, the
patient may point to an area that includes more than 1 tooth, there may be complex res-
torations in that quadrant, and the symptoms may fluctuate and seem to move from 1 place to
another, even from maxillary to mandibular areas, owing to the phenomenon of referred
pain.12 Clinicians must be able to appreciate the possibility that the site of a patient’s pain
may be different from its source and to consider possible central aspects of pain, not only the
local or peripheral ones.
Next, the dentist must conduct an objective and comprehensive examination, using several
methods such as the application of hot, cold, or electrical stimulus applied to the enamel
surface; palpation of the area; tapping on occlusal surfaces with metal instruments; periapical
radiographs; and even CBCT. Various technical advances have improved the diagnostic value
of CBCT imaging, and as a result it can detect more subtle changes in surrounding tissues
earlier than conventional radiography methods. All of these tests are of reduced value if the
teeth are heavily restored, especially with full-coverage crowns. Nevertheless, most dentists are
able to put these elements together and establish a correct diagnosis in most of the cases they
encounter, but many cases may prove to be challenging.

How successful are treatments for DAP?

One of the most gratifying aspects of being a clinical dentist is that DAP generally is managed
successfully at high rates. The success rates reported by the endodontic profession for pain relief after
initial endodontic therapy of vital teeth is in the range of 90% to 95%, and it is only slightly less for
teeth with necrotic pulps.13,14 Even if periapical infection is present, the combination of mechanical
therapy and antibiotics usually resolves the problem; the success rates in such cases are approxi-
mately 5% through 10% lower than those reported for vital tooth treatments.15 Vital teeth also may
be treated successfully with certain procedures (that is, vital pulp therapy) that do not require total
pulpal removal.16
When endodontic failure does occur, it is often due to anatomic problems within the canals, such
as branching at the apical end or the difficulty in reentering a canal that was already filled with
sealing cement. These problems usually can be solved by means of a retrograde surgical procedure
that amputates and seals the root tips.17,18 However, problems such as internal resorption or cracked
roots will occur occasionally, and, although some of them can be managed with more heroic
procedures, many cases simply cannot be resolved.19
The other primary approach to the resolution of DAP is extraction of the offending tooth.
Although the trauma of that procedure may produce some postoperative pain, it is usually of short
duration unless the removal process is complex.

What are the reasons for and consequences of failure in treating DAP?
The most obvious reason for an unsuccessful outcome in treating a toothache symptom is that the
patient never had a DAP in the first place; instead he or she had pain due to another OFP
condition, as described in the table.20 However, in addition to the technical challenges
mentioned above, there is another issue to consider when a patient with true DAP reports
continuing pain. That issue involves the sensory nerves, which transmit pain signals from the
periphery to the central nervous system. In certain susceptible patients, invasive dental procedures
used to treat the original problem may produce neuroplastic changes in the peripheral and central
nervous systems that do not revert to normal even though the initial pathology is resolved.21 It is
helpful to remember that every pulpectomy is an axotomy, whereas every extraction is an
amputation; combined with other operational procedures, these activities can increase the original
pain. Over time, the higher centers in the central nervous system can become irreversibly acti-
vated through a process described as central sensitization, and the patient could develop the
equivalent of phantom limb syndrome. For more detailed discussion of these phenomena, see The
Journal of the American Dental Association Pain Update articles by Greene22 and Greene and
Murray.23

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Crossing the line into malpractice
Given all of the above information, which has been available in the dental literature for more than
30 years, the clinical dentist has a responsibility to avoid excessive and repeated dental treatment
approaches to the management of nonresponding DAP situations. Failing to carry out that re-
sponsibility can be divided into 2 categories:
 omission: the failure to be aware of alternative OFP diagnoses (Table), to stop dental treatment
despite continued negative results, to refer for another opinion, and to listen carefully when
patients are reporting negative outcomes with escalating pain;
 commission: relying on crude examination techniques, for example, palpation of the area and
tapping on the sore tooth; moving from 1 tooth to the next in trying to solve the problem;
escalating to more aggressive procedures, for example, apical surgeries, socket curettage, NICO
procedures, and occlusal adjustments; and finally, allowing the patient to dictate treatment, for
example, when he or she says, “I’m sure it is this next tooth, please extract it.”

CONCLUSIONS
Although we recommend a wide tolerance for the attempts of clinical dentists to help their patients
with DAP via traditional dental procedures, there is no question that the line into malpractice can
be crossed under various conditions. Although these patients are experiencing chronic non-
odontogenic pain, their dentists still have the responsibility of managing such problems appropri-
ately. On the basis of current dental literature, it is clear that neurologic and psychological
evaluations of patients with chronic OFP have become the standard of modern dental practice.24,25
Therefore, all dental professionals must be aware of their ethical duty to “first, do no harm” and refer
patients properly to an expert colleague while avoiding unnecessary diagnostic delays and treatment
mistakes.26,27 It is hoped that the information we present here will help dentists avoid getting into
such unfortunate situations, regardless of whether they ultimately lead to medicolegal actions. n

Dr. Greene is a clinical professor emeritus, Department of Orthodontics, Dr. Manfredini is a professor, Department of Biomedical Science, School
University of Illinois at Chicago, Chicago, IL. Address correspondence to Dr. of Dentistry, University of Siena, Siena, Italy.
Greene, 1041 Ridge Rd, Apt. 304, Wilmette, IL 60091, e-mail cgreene@uic. Disclosures. The authors reported no disclosures.
edu.

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