Received: 9 September 2021

| Accepted: 15 November 2021

DOI: 10.1111/iej.13664

ORIGINAL ARTICLE

Patients with persistent idiopathic dentoalveolar pain in

dental practice

Frank Sanner1 | David Sonntag2 | Norbert Hambrock3 | Matthias Zehnder4

1
Dental Office, Frankfurt, Germany Abstract
2
Carolinum, Clinic of Conservative Aim: To assess whether persistent idiopathic dentoalveolar pain (PIDAP), a diagno-
and Preventive Dentistry, Frankfurt am
Main, Germany
sis of exclusion, exhibits common features that can facilitate its diagnosis. PIDAP is
3
Dental Office, Drachten, The defined by the International Classification of Orofacial Pain (ICOP 6.3.) as ‘Persistent
Netherlands unilateral intraoral dentoalveolar pain, rarely occurring in multiple sites, with vari-
4
Clinic of Conservative and Preventive able features but recurring daily for more than 2 h per day for more than 3 months,
Dentistry, Center of Dental Medicine,
in the absence of any preceding causative event’.
University of Zurich, Zurich,
Switzerland Methodology: In this observational study, participants fulfilling the new ICOP di-
agnostic criteria of PIDAP were included, covering 16 years of consecutive data. A
Correspondence
Frank Sanner, Dental Office, Niedenau
systematic, retrospective assessment of patients utilizing the new PIDAP criteria on
50, Frankfurt 60325, Germany. complaints of chronic tooth pain in a referral-­based endodontic practice was under-
Email: [email protected] taken. Non-­idiopathic cases were excluded on the basis of clinical and radiologic
findings. A modified neuropathic pain questionnaire was used to describe the pain-
ful sensations. Furthermore, allodynia in the periodontal space and sensory changes
in the oral mucosa were assessed using a periodontal probe.
Results: Amongst the 160 patients assessed, 78 (63 women) fulfilled the strict
PIDAP criteria. Pain history of PIDAP included no nocturnal awakening (85%) and
a ‘pulling/dragging’ pain quality (59%). In 69% of the patients with PIDAP, pain was
associated with a root filled tooth at the same site. In 14% of the cases, no endodontic
treatment was performed in the affected quadrant. Mechanical allodynia in the gin-
gival sulcus was observed in 91% of patients with painful teeth or implants.
Conclusions: In this observational study, PIDAP mainly affected females and was
associated with undisturbed sleep and periodontal allodynia.

KEYWORDS
endodontic diagnostics, International Classification of Orofacial Pain, persistent idiopathic
dentoalveolar pain

I N T RO DU CT ION The main reason for this pain is usually endodontic in-
fection (Zehnder & Belibasakis, 2015). However, whilst
Dental pain is a relatively common condition with a sig- toothaches from endodontically involved, i.e. infected
nificant socioeconomic impact (Constante et al., 2012). teeth can be excruciatingly intense, they do not normally

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided
the original work is properly cited.
© 2021 The Authors. International Endodontic Journal published by John Wiley & Sons Ltd on behalf of British Endodontic Society.

Int Endod J. 2022;55:231–239.  wileyonlinelibrary.com/journal/iej   | 231

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232    PIDAP DENTAL SIGNS AND SYMPTOMS

last long before the patient seeks dental care (Rechenberg this observational study was on pain history, dental signs
et al., 2016). This form of ‘typical’ tooth pain usually re- and symptoms.
solves after endodontic intervention (Law et al., 2015). The data collected in this study made it possible to
On the other hand, patients with persistent toothache apply the new ICOP criteria for PIDAP and rule out
require dentists to differentiate between odontogenic, other possible causes for chronic or persistent pain to
non-­odontogenic and mixed pain. In contrast to ‘typical’ the maximum extent by characterizing this group of
tooth pain, pain with a neuropathic or idiopathic charac- patients.
ter presents a greater clinical challenge. The pathophysiol-
ogy (Vickers & Cousins, 2000), classification (ICOP, 2020),
risk factors (Aggarwal et al., 2010), diagnosis, prognosis MATERIALS AND METHODS
and therapy for persistent dentoalveolar pain have been
discussed extensively (Malacarne et al., 2018). However, Patient evaluations
despite newer classifications being published, many open
questions remain. Prospective data collection in all patients with chronic tooth
The new International Classification of Orofacial Pain pain was performed by the principal investigator (F.S.), a
(ICOP) classification emphasizes the difference between trained endodontist and a physician with a focussed inter-
neuropathic and idiopathic pain that can result in per- est in pain, between January 2003 and June 2019. The use
sistent dentoalveolar pain. The latter was the subject of of this censored data for publication was approved by the
this observational study. In this context, ‘Idiopathic’ is de- local ethics commission (LZK Hessen, 01/2020). The ma-
fined as ‘arising spontaneously or from an obscure or un- jority of patients were referred from other endodontists
known cause’ (Merriam-­Webster 2021 https://www.merri​ within Germany because of ongoing pain after treatment
am-­webst​er.com/dicti​onary/​idiop​athic). (Figure 1). Patients aged >18 years who had experienced
Patients experiencing persistent dentoalveolar pain pain persisting for more than three months at the time of
experience significant psychological strain that adversely the examination were eligible for inclusion. All 160 patients
affects their quality of life (Shueb et al., 2015). Persistent reported pain related to a tooth or extraction site.
idiopathic dentoalveolar pain (PIDAP), which has been Good-­quality periapical radiographs of the painful re-
redefined most recently (ICOP, 2020), is mainly a diagno- gions were available and examined in all patients. Any
sis of exclusion. For the clinician, however, the typical fea- signs of caries, fractures, bleeding on probing, patho-
tures of PIDAP can help to better distinguish this type of logical pocket depths (>3.5 mm), mucogingival lesions,
pain from odontogenic and other possible pain conditions internal or external resorption or possible lesions of end-
at an early stage. odontic origin resulted in the exclusion of the patient from
Thus, the goal of this observational study was to de- the study group (Table 1). Patients suspected to have pain
scribe patients with PIDAP from the dentist's perspective of a dental inflammatory or traumatic nature or due to
and to identify possible common features within this co- other sources of pain related to teeth were excluded from
hort. From a series of consecutive patients complaining of this analysis, as were patients with suspected pain referred
chronic tooth pain in a referral-­based endodontic practice, from adjacent anatomic structures, such as acute sinusitis,
patients who fulfilled the ICOP diagnosis of PIDAP (ICOP, sialadenitis, myofascial pain, arthrogenic pain and signs of
2020) were included over a period of 16 years. The focus of trigeminal neuralgia (Figure 1). Patients with a history of

Other endodontist Pain clinic Own practice

Patient source

n=132 n=16 n=12

Apical periodontitis (n=21)

Facial autonomic signs (n=15)
Gingivitis (n=7)
Signs of trigeminal neuralgia (n=7)
non-iodiopathic

Mucogingival lesion (n=4)

Exclusion

Maxillary sinusitis (n=4)

pain

Myogenic pain (n=2)

History of multiple sclerosis (n=2)
Pulpitis (n=1)
Nasopharyngeal carcinoma (n=1)
Likely or possible PTTNP (n=18)
n=82 F I G U R E 1 Patient flow classifying
Inclusion

patients with persistent idiopathic

ICOP 6.3
dentoalveolar pain (PIDAP) according
Idiopathic dentoalveolar pain to the International Classification of
n = 78
Orofacial Pain (ICOP)
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SANNER et al.    233

TABLE 1 Exclusion criteria based on pain type

Relevant clinical findings and case history Diagnosis

Vertical knocking pain, apical tenderness, evidence of deep caries, mobile restorations, internal Odontogenic pain:
or external resorption, crown or root fractures of the affected teeth or their neighbours or Symptomatic pulpitis,
antagonists, pain to heat or cold when applied to the teeth. Symptomatic apical periodontitis.
Bleeding on probing, pathological pocket depths, mucogingival lesions. Periodontal and mucogingival pain.
Myogenic trigger points or active or passive movements that reproduce the typical pain, Referred orofacial pain, head
radiographic signs of maxillary sinusitis, pain in the tuber region or paranasal pressure and neck tumours, sickle-­cell
pain, swollen and sensitive salivary glands, medical history or clinical examination findings anaemia.
relevant to head and neck tumours or sickle-­cell anaemia.
Symptoms of the autonomic orofacial nervous system (e.g. running tears, running nose) Various incarnations of facial
associated with the intensity of the pain. Occurrence of other typical constellations of findings headache pain.
listed in the ICOP 5.1–­5.3 definition (International Classification of Orofacial Pain, ICOP,
2020) or pain relief by triptans.
Intense shock-­like pain within the affected trigeminal distribution and occurrence of typical Trigeminal neuralgia.
general medical and specific pain-­related history as listed in ICOP 4.1.1 (ICOP, 2020).
A neurological disorder known to be capable of causing and explaining, the trigeminal Trigeminal neuropathic pain
neuropathic pain has been diagnosed and occurrence of diagnostic criteria as listed in ICOP attributed to other disorders.
4.1.2.4 (ICOP, 2020).
Pain in a neuroanatomically plausible area within the distribution(s) of one or both trigeminal Possible or likely post-­traumatic
nerve(s) and a history of trauma to the peripheral trigeminal nerve(s) and other criteria listed trigeminal neuropathic pain
in ICOP 4.1.2.3 and 4.1.2.3.1 (ICOP, 2020). (PTTNP).
Criterion C: History of external trauma and iatrogenic injuries from dental treatments such as
local anaesthetic injections, root canal therapies, extractions, oral surgery, dental implants,
orthognathic surgery and other invasive procedures within 6 months before the onset of pain
Criterion D: Associated with somatosensory symptoms and/or signs in the same
neuroanatomically plausible distribution.
Note: Only the most relevant criteria are described in this table (see text).

external trauma and iatrogenic injuries from dental treat- Pain questionnaire and interview
ments such as local anaesthetic injections, extractions,
root canal treatment, oral surgery, dental implants, or- All patients completed a pain questionnaire for atypical
thognathic surgery and other invasive procedures in the or persistent tooth pain. This questionnaire (Appendix
painful area within 6 months before the onset of pain were S2) consisted of 46 standard questions, first assessing the
also excluded because of possible or likely post-­traumatic main location of the pain and then addressing the onset,
trigeminal neuropathic pain (PTTNP) according to ICOP intensity, quality, medications, sleep patterns and other
4.1.2.3 (ICOP, 2020) when sensory changes in a neuroana- possible contributing factors. A history of surgery or
tomically plausible area were observed. trauma to the head and neck, history of root canal treat-
All pain interviews and clinical examinations were ments and diseases of the nervous system were investi-
conducted by the principal investigator. After their dental gated. In patients who underwent root canal treatment
examinations reported here, the patients diagnosed with in teeth associated with the painful site, the sequence
PIDAP were referred to headache and facial pain clinics of events was noted. This questionnaire was based on
or specialized pain therapists. a standard neuropathic pain questionnaire (Krause &
Backonia, 2003) and recommendations made by Goulet
(2001). Additionally, pain-­related symptoms of the oro-
Medical history facial autonomic system and symptoms related to other
orofacial structures were addressed. The patients then
The medical history was obtained using a health question- reviewed their questionnaires with their examiners, who
naire that included questions pertaining to current health obtained clarification for ambiguous answers. The 11-­
status (Appendix S1) and the use of prescribed drugs point numeric pain rating scale (NRS-­11) was used to
taken on a regular regimen, based on the answers given rate pain intensity (Warren Grant Magnusson Clinical
by the patients. Center, 2003).
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234    PIDAP DENTAL SIGNS AND SYMPTOMS

Clinical examination descriptive statistical analysis. Normally distributed data

sets (Shapiro–­Wilk test) are presented as means and
The area or tooth producing the most pain, as indicated standard deviations, whilst non-­parametric data are pre-
by the patients, was recorded. All patients underwent the sented as medians and ranges.
same intra-­ and extraoral examinations. Basic clinical
examinations were performed as described in standard
endodontic texts (Berman & Hartwell, 2006). Teeth were RESULTS
examined for root fractures and caries with ×4.3 dental
loupes (Zeiss). When a root fracture was suspected, the Patients considered for inclusion
coronal restorations were removed for better visualization.
Accessible masticatory muscles and accessible parts In total, 160 patients with persistent dental pain were
of both TMJs were palpated, and active and passive jaw assessed. Sixty-­four of these were excluded since odon-
movements were performed. The patient was asked togenic pain, facial headache variants, referred pain and
whether their typical pain could be reproduced during the other non-­idiopathic pain sources could not be ruled out
examination, and if so, they were excluded from the study. or signs of gingivitis were present (Figure 1). Eighteen pa-
The periodontium was tested for bleeding on probing tients with persistent pain were excluded because of the
or pathological pocket depths (>3.5 mm) circumferen- criteria for PTTNP. Two of them had injection injuries to
tially. Patients presenting with one or more of these symp- the inferior alveolar nerve, 10 had undergone root canal
toms in the painful region were excluded from this study treatments within 6 months and sensory changes were
(Figure 1). All teeth were tested for mechanical allodynia noted in a neuroanatomically plausible area. Six patients
of the gingival sulcus (‘pain induced by stimuli that are not with a history of root canal treatment within 6 months
normally painful’; International Association for the Study and no apparent sensory changes were excluded from this
of Pain https://www.iasp-­pain.org/resou​rces/termi​nolog​ study because not all possible sensory changes could be
y/#allod​ynia) using a periodontal probe (Periodontometer ruled out (see Appendix S3)
PCP 12; Hu-­Friedy) and applying light pressure. Patients None of the patients were pregnant or had a history of
were not asked before probing whether they had experi- herpes zoster infection in the head and neck area.
enced any pain. Patients who had a reaction indicating
that they might have felt pain were asked to state explic-
itly whether or not the touch was painful. The reaction PIDAP patients
was then compared with the corresponding reaction to
the same procedure on the contralateral side. The original Seventy-­eight patients (63 women, 15 men) met the in-
painful procedure was then repeated, and the patient was clusion criteria for this study and were diagnosed with
asked to comment on any differences compared with the PIDAP. The site of pain was the teeth of 75 patients,
non-­painful contralateral side. Probing of the gingival sul- implants in one patient or edentulous post-­extraction
cus was performed in all quadrants. sites in two patients (Table 2). The painful jaw was the
The attached gingiva and mucosa in the painful quad- mandible in 33 patients and the maxilla in 45 patients.
rant were tested by touching them lightly with a periodon- The region of the first molars was the most frequently
tal probe and asking the patient for comparison to the reported painful site (32%). In 54 of the 78 patients, the
contralateral side. The patient's reactions were also noted. painful site had been endodontically treated prior to ex-
No sensation, less sensation, painful sensations, or an amination. In all cases with painful implant-­ or tooth-
unpleasant sensation in the painful quadrant compared less post-­extraction sites, the preceding extraction was
with the contralateral side were classified as numbness, associated with a formerly root canal-­treated tooth. In
hypoesthesia or allodynia according to the IASP terminol- 24 cases, the painful tooth had no clinical or radiological
ogy (https://www.iasp-­pain.org/resou​rces/termi​nolog​y/) signs of pulp necrosis and exhibited a normal reaction
or as an unpleasant sensation (dysesthesia). If at least one when applying the cold test. Of these 24 patients, 13 had
of these symptoms was present, it was noted as a sensory undergone root canal treatment in the same quadrant
change in the gingiva in the painful quadrant. as the painful tooth. In only 14% of the cases, root canal
treatment was performed neither in the painful tooth
nor in the quadrant.
Statistical analysis In 25 cases in the PIDAP group, the persistent pain was
preceded for more than 6 months by root canal treatments
The RStudio software tools (https://rstud​io.com/ or other dental procedures that are listed to be relevant
produ​cts/rstud​io/downl​oad/) were used to perform a to a diagnosis of PTTNP in the ICOP classification, such
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SANNER et al.    235

T A B L E 2 PIDAP patient
Sex (female/male) 63/15
characteristics, pain duration, intensity
Age in years (mean ± SD) 49 ± 14
and location
Pain duration in years (median/IQR) 1.5/(1.4)
Mean NRS-­11 pain intensity during the last 2 weeks (median/IQR) 3/(2.5)
Maximum NRS-­11 pain intensity during the last 2 weeks (median/IQR) 8/(5.9)
Affected jaw (maxilla/mandible) 45/33
Tooth region (molar/premolar/front) 38/25/15
Dentition at the painful site (tooth/edentulous/implant) 75/2/1
History of root canal treatment at the painful site (yes/no) 54/24
Abbreviations: IQR, inter-­quartile range (0.25 Quartile, 0.75 Quartile); NRS, Numerical Rating Scale for
pain intensity; SD, standard deviation.

as extractions, oral surgery, dental implants, orthognathic mean: 7.2). The mean average pain score in the same pe-
surgery and other invasive procedures. In 12 cases, per- riod was 3.8 (median: 3), and the mean NRS-­11 scores for
sistent pain preceded the root canal treatment, and in 24 female and male patients were 3.8 and 4.1, respectively.
cases, no root canal treatment or other invasive dental Sixty-­six of the 78 (85%) patients stated that the pain
procedures were performed on the tooth. In 12 cases, the did not wake them at night. Furthermore, 64 (82%) pa-
root canal treatment preceded the beginning of persistent tients experienced pain-­free intervals on waking in the
pain for less than 6 months, but since sensory changes morning before the pain set in. Pain was present during
were found in other quadrants as well, these cases met the daytime for more than 2 h in all patients.
the criteria for PIDAP, not PTTNP (Appendix S3). Cases Patients generally used more than one term to describe
in which the timing of dental procedures was not known the nature of their pain. The most frequently used adjec-
were not included in the study. tives were as follows: ‘pulling/dragging’, reported by 46 of
78 patients (59%); ‘pressing’ by 41 (52%); ‘burning’ by 33
(42%); ‘tingling’ by seven (9%); ‘electric’ by three (4%); and
Medical history and medication usage ‘stabbing’ by 14 (18%). Forty-­three (55%) patients reported
experiencing pulsating or throbbing pain at the affected
Other chronic pain conditions reported by patients with site from time to time. When describing the quality of
PIDAP included chronic back pain (8 individuals), irrita- their pain in more words, patients frequently used non-­
ble bowel syndrome (3), migraine (4), fibromyalgia (2) and standard, figurative expressions that differed from more
tension headache (1). A history of depression was reported common ways of describing toothaches, such as ‘like
in nine cases and psychosis in one. The most frequently being stabbed with a knife’, ‘like a wound’, ‘like dead tis-
reported medical conditions were thyroid disorders (21), sue that is nevertheless painful’, ‘as if the tooth were to
including 12 cases of Hashimoto's thyroiditis. Eleven pa- explode’ and ‘as if the bones were moving’.
tients had cardiovascular and respiratory disorders. Other
disorders or diseases were present in very small numbers
of patients. Twenty-­one patients reported no other health Clinical findings
problems besides the existing persistent intraoral pain.
Drugs taken on a regular basis included l-­thyroxin (18), Pressure to the periapical bone exerted by digital palpa-
contraceptive medication (4), drugs used for chronic pain tion was never painful, nor could pain be elicited by ver-
treatment (8), psychotropic drugs (3) and cardiovascular tical tapping on a tooth with an instrument in any case.
drugs (10). Discomfort was elicited by horizontal tapping in six pa-
tients. Mechanical allodynia of the gingival sulcus was
found in 68 of 75 teeth and in one implant. Thus, allo-
Pain characteristics dynia in the periodontium/peri-­implant mucosa was ob-
served in 69 of 76 patients with painful teeth or implants
The pain had been present for an average period of (91%). In two of the cases in which the pain affected the
2.7 years before the examination (median: 1.5; range: edentulous region, this sign could not be tested. The pain-
4 months to 13 years). A group of 17 women had pain ful section invariably consisted of only part of the gingival
persisting for more than or equal to five years. The maxi- sulcus and never included its entire circumference. The
mum pain intensity during the 2 weeks prior to assess- same symptoms could frequently be elicited in the sulcus
ment ranged from 2 to 10 on the NRS-­11 scale (median: 8; of the adjacent teeth or in the antagonistic or contralateral
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236    PIDAP DENTAL SIGNS AND SYMPTOMS

quadrants. An allodynic area in the gingival sulcus of the pain was present from the beginning and a root canal
neighbouring teeth was present in 53 cases. More than treatment was performed with the intent to help the pa-
one quadrant was affected in 39 cases: two quadrants in 22 tient. This point should be addressed in future studies. Sex
cases, three quadrants in 11 cases and all four quadrants dependence of chronic pain has been frequently described
in six cases. (Mogil, 2020). A previous study reported a predominance
The gingiva and mucosa of all patients were checked of female patients (List et al., 2007), which was also con-
for sensitivity changes to touch by using the tip of a peri- firmed in this study.
odontal probe to slightly touch the gingiva and mucosa in
the painful quadrant, first on the non-­painful contralat-
eral side and then on the affected painful side. In 9 cases, Medical history
patients reported numbness near the site of the pain
after repeated comparisons with the non-­painful contra- Thyroid disorders (27%), chronic pain conditions (23%),
lateral side. None of the patients had been aware of this and depression (10%) were reported by the patients.
numbness before the examination. Twenty-­eight patients Because this information was questionnaire-­based, its
showed sensitivity changes other than numbness in the completeness and accuracy were not assured. It was only
painful quadrant beyond the gingival sulcus; mechani- included to describe the group of patients under investi-
cal allodynia was present in five patients. Seven patients gation in more general terms. Nevertheless, the relatively
reported reduced sensitivity to touch (hypoesthesia) and high frequency of thyroid disorders in this cohort warrants
15 reported discomfort when touched with a periodontal further research. An examination of a large sample of self-­
probe compared to the non-­painful side. In seven patients, reported chronic pain (McWilliams et al., 2003) found that
more than one sensitivity change in the fixed gingiva was the incidence of apparent thyroid disease amongst indi-
present concurrently. viduals affected by chronic pain was 5.5%.
The painful sensation sometimes increased as a result
of the examination, especially on contact with the gingival
sulcus. A total of 32 patients reported an increase in pain Pain characteristics
levels after completion of the examination.
The maximum pain intensity of the PIDAP pa-
tients under investigation that was reported for the
DI S C US S I O N two weeks prior to clinical assessment was similar
to that of a cohort of endodontic emergency patients
In this observational study, strict PIDAP criteria were ap- with infection-­related pain (median of 8 on the NRS-­
plied to illuminate the condition from the dentist's per- 11 scale) (Rechenberg et al., 2016). However, and more
spective. This allowed the identification of PIDAP features importantly, the finding that the pain did not wake
that have not been described previously, including the ab- patients at night in these individuals with PIDAP sets
sence of nocturnal pain and the presence of allodynia in their condition apart from infection-­related tooth pain.
otherwise healthy periodontal sites. In the study by Rechenberg et al. (2016), 80% of emer-
gency patients experiencing acute pulpitis and 83% of
those with acute apical periodontitis stated that their
PIDAP patients pain woke them at night. An increase in intensity when
lying down or resting is typical of inflammation-­related
Until recently, the nomenclature for the conditions under pain. Atypical odontalgia that affects patients mostly at
investigation was not standardized (Nixdorf et al., 2012). and throughout the day, on the other hand, has been
A new ICOP was introduced in 2020 (ICOP, 2020), which reported previously (Rees & Harris, 1979) but has never
was followed here. Studies on atypical odontalgia in endo- been specifically assessed.
dontic patients have reported an occurrence rate of <5% Similar pain descriptors as in this study have been
(Campbell et al., 1990). An association between persistent reported previously in the literature (List et al., 2007). A
toothaches and endodontically treated teeth has also been striking typical pain characteristic in the population stud-
reported (Nixdorf et al., 2010). ied here is the burning pain quality, which affected 42% of
The association between root canal-­treated teeth and the patients. Burning pain is also generally described as a
non-­odontogenic tooth pain could be explained by either characteristic of neuropathic pain (Collaca et al., 2017).
pathophysiological changes under special circumstances Undisturbed sleep and a pain-­free interval after waking
following root canal treatment that led to pain chronifica- are typical characteristics of neuropathic pain (Odrcich
tion or, more likely, indicating that non-­odontogenic tooth et al., 2006).
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SANNER et al.    237

A delayed onset of pain following irritation (41%) has Although extraoral QST has been standardized (Matos
also been described in neuropathic pain. In this regard, et al., 2011), and intraoral QST has been described (Baad-­
mechanisms similar to those of ‘wind-­up’, a progressive, Hansen et al., 2015), more practical means for dental prac-
frequency-­dependent increase in excitability, may play a titioners are needed and developed in the form of QualST
role (Coste et al., 2008). (Baad-­Hansen et al., 2013).
Probing of the gingival sulcus is usually not painful. In
the present study, a high percentage of patients (91%) had
Clinical findings this sensory abnormality, often not only in the painful tooth
but also in other teeth and quadrants. Neurophysiological
Persistent idiopathic dentoalveolar pain was the most research on this topic has shown that trauma to one den-
frequent diagnosis amongst patients with chronic den- tal nerve may alter the processing of pain in neighbouring
toalveolar pain. In addition to nociceptive and inflam- teeth and other quadrants (Kondo et al., 1992; Sabino et al.,
matory pain, as is the case with odontogenic pain, from 2002). Sabino et al. (2002) reported a correlation between
a pathophysiological point of view, there are two other the invasiveness of dental procedures and neuroplastic
pain types frequently implicated in chronic pain, namely changes in the brainstem. The invasiveness of the pro-
neuropathic pain (Finnerup et al., 2016) and neuroplastic cedures was correlated with the extent of changes on the
pain (Kosek et al., 2016). same and contralateral sides. In the present study, allody-
The ICOP classification describes the type of pain nia in the gingival sulcus, which could be a result of neu-
under investigation as idiopathic. roplastic changes, was also found in 68% of neighbouring
The diagnosis of non-­odontogenic toothaches is usu- teeth and in 50% of other quadrants. More insights can be
ally a differential diagnosis based on the absence of any gained into this topic by obtaining better knowledge of the
explanatory tooth-­related pathology. Although the sign innervation of the junctional and oral epithelium within
of non-­response to local anaesthesia was not examined in the sulcus and the periodontal ligament, the sensory
this study, such non-­response at the site of the pain (List changes within the periodontal space, and the changes in
et al., 2006) can be helpful in the diagnostic process. the nerve following separation of the pulp from its nerves,
as they occur during endodontic treatment.
The inclusion of mechanical allodynia within the gin-
Sensory changes gival sulcus into the already described PIDAP diagnostic
features may provide additional important diagnostic
Simple methods available to any general dentist can be ap- utility.
plied to detect gross sensory changes in the gingiva and
mucosa. Somatosensory tests such as the ‘Quantitative
Sensory Test’ (QST) (Maier et al., 2010) and the ‘Qualitative Strengths, limitations and outlook
Sensory Test’ (QualST) (Baad-­Hansen et al., 2013) have
been described for sensory testing. The present data col- The strengths of this study include the fact that an at-
lection started earlier than the description of the sensory tempt was made to systematically exclude nociceptive
tests described above. Nevertheless, a different aspect of odontogenic pain, referred pain, facial headaches and
sensory testing has been emphasized. A simpler approach post-­traumatic neuropathic pain to the maximum ex-
using a periodontal probe was followed. The area con- tent possible. The inclusion and exclusion criteria were
nected most closely to the dental nerve and pulp is the chosen to avoid creating a mixture of different charac-
periodontium and hence the gingival sulcus. Pulpal and teristics within the group with otherwise unexplained
periodontal innervation develop concurrently with the non-­odontogenic pain (headache variants, referred pain,
development and eruption of the dentition. Innervation odontogenic pain) and to identify characteristics of spe-
occurs during tooth eruption (Fristad et al., 1994). The cific groups that may be due to changes in the pain pro-
periodontal space is characterized by unique innervation. cessing system typical of PIDAP.
Sensory changes in this region related to PIDAP have not Nevertheless, this observational study was limited by
yet been studied, nor do the intraoral variants of QST the fact that it was not a cross-­sectional study, and the
and QualST cover this aspect. Quantitative sensory test- pain and treatment history depended on the patient's
ing is mentioned as a means for further specifying PIDAP memory. As a result, no conclusions can be drawn re-
into 6.3.1 with and 6.3.2 without somatosensory changes. garding the prevalence of the conditions under investi-
Further discrimination of PIDAP depending on sensory gation. Furthermore, there was a selection bias because
findings must be taken into consideration, since this clas- patients were mostly seen in endodontic clinics (Figure
sification is very dependent on the methods involved. 1), which represents a specific cohort and may not be
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13652591, 2022, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/iej.13664 by Nat Prov Indonesia, Wiley Online Library on [20/05/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
238    PIDAP DENTAL SIGNS AND SYMPTOMS

representative. However, because PIDAP is experienced AUTHOR CONTRIBUTIONS

in teeth, patients frequently seek help from endodontists, Frank Sanner: clinical assessments, data collection, data
or cases are referred because general practitioners have curation, analysis, and writing. David Sonntag: conceptu-
already initiated root canal treatment. Another limita- alisation and writing. Norbert Hombrock: data collection
tion of this study is that no comparisons were made per- and review of manuscript. Matthias Zehnder: conceptuali-
taining to thesigns and symptoms that were identified in sation, data curation, analysis, and writing.
the current cohort in comparison to patients experienc-
ing infection-­related tooth pain. Nevertheless, the cur- ETHICS STATEMENT
rent results can be compared with reported data in the The use of data pertaining to this observational study was
literature on both atypical odontalgia and in contrast to approved by the local ethics committee (LZK Hessen,
‘typical’ infection-­related tooth pain (Rechenberg et al., 01/2020).
2016). Since there is a regional and cultural element to
pain (Peacock & Patel, 2008), it has to be taken into con- CONFLICT OF INTEREST
sideration, that the study was performed on a German The authors have stated explicitly that there are no con-
patient population. flicts of interest in connection with this article.
The focus of the current work was on how PIDAP pa-
tients presented in endodontic practice, and which were ORCID
the key features of their condition from a dental perspec- Frank Sanner https://orcid.org/0000-0003-0781-0279
tive. In a future study, an attempt will be made to follow Matthias Zehnder https://orcid.org/0000-0001-9545-7828
the PIDAP patients identified here to assess how their
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