**NON-ODONTOGENIC TOOTHACHE** Ramesh Balasubramaniam OAM DENT5310 Orofacial Pain and Dental Sleep Medicine Module 24th April 2026 Ramesh Balasubramaniam OAM DENT5310 Orofacial Pain and Dental Sleep Medicine Module 24th April 2026 **DISCLOSURES** **Ramesh Balasubramaniam OAM** Associate Professor Discipline Lead in Oral Medicine UWA Dental School The University of Western Australia **Neither I nor my immediate family have any financial interests that would create a conflict of interest or restrict my independent judgment with regard to the content of this presentation.** #### Academic and Professional Affiliations - Ramesh Balasubramaniam OAM - Associate Professor - Discipline Lead in Oral Medicine - UWA Dental School - The University of Western Australia #### Conflict of Interest Statement Neither I nor my immediate family have any financial interests that would create a conflict of interest or restrict my independent judgment with regard to the content of this presentation. # **OUTLINE** * **ODONTOGENIC PAINS** * **SITE VS SOURCE OF OROFACIAL PAIN** * **NON-ODONTOGENIC PAINS** * **TAKE HOME MESSAGE** #### Presentation Topics - Odontogenic Pains - Site vs Source of Orofacial Pain - Non-Odontogenic Pains - Take Home Message **ODONTOGENIC PAINS** The multiple 'faces' of toothache | Odontogenic pain originates from the teeth, dental pulp, periodontal ligaments, or surrounding structures like the alveolar bone. **"There was never yet philosopher that could endure the toothache patiently"** William Shakespeare - **"Much Ado About Nothing"** | Healthy tooth | **Insult to tooth** ↓ **Trauma** | **Insult to tooth** ↓ **Caries** | **Pulpal** **ischaemia** | **Pulpal** **necrosis** | | :--- | :--- | :--- | :--- | :--- | | | **Cracked tooth syndrome** | | | | | | | **Hyperaemia of the pulp** | | | | In health allodynia is felt to cold, electrical and mechanical stimuli | Intermittent neuralgic pain on biting with no other symptoms | Pulpal Inflammation causes sensitivity of A delta fibers allodynic pain with cold and sugary stimuli | Pulpal ischaemia causes sensitivity of C fibers and allodynia to heat and **spontaneous episodic throbbing pain** | Pulpal death causes periapical tissue inflammation. Episodic **spontaneous throbbing pain** and allodynia on biting | | *Renton T. Tooth-Related Pain or Not?.* **Headache.** 2020;60(1):_235-246. | | | | |  Odontogenic pain originates from the teeth, dental pulp, periodontal ligaments, or surrounding structures like the alveolar bone. This type of pain presents with multiple clinical "faces" depending on the nature of the insult. #### Clinical Progression of Odontogenic Pain - **Healthy Tooth** - In health, allodynia is felt to cold, electrical, and mechanical stimuli. - **Cracked Tooth Syndrome (Trauma)** - Characterized by intermittent neuralgic pain on biting with no other symptoms. - **Hyperaemia of the Pulp (Caries)** - Pulpal inflammation causes sensitivity of A-delta fibers. - Results in allodynic pain triggered by cold and sugary stimuli. - **Pulpal Ischaemia** - Causes sensitivity of C-fibers. - Results in allodynia to heat and spontaneous episodic throbbing pain. - **Pulpal Necrosis** - Pulpal death causes periapical tissue inflammation. - Results in episodic spontaneous throbbing pain and allodynia on biting. Labeled anatomical diagram illustrating 'The multiple faces of toothache' through five stages. The visual sequence depicts a Healthy tooth, followed by Cracked tooth syndrome (showing a fracture line), Hyperaemia of the pulp (showing red pulp), Pulpal ischaemia (showing darkened/red pulp), and Pulpal necrosis (showing a blue vessel). Below each illustration, text describes specific symptoms such as 'Intermittent neuralgic pain on biting' for trauma and 'Episodic spontaneous throbbing pain' for necrosis. No unique content provided for Page 6. **OUTLINE** **ODONTOGENIC PAINS** **SITE VS SOURCE OF OROFACIAL PAIN** **NON-ODONTOGENIC PAINS** **TAKE HOME MESSAGE** #### Presentation Outline - ODONTOGENIC PAINS - SITE VS SOURCE OF OROFACIAL PAIN - NON-ODONTOGENIC PAINS - TAKE HOME MESSAGE <RB> **SITE VS SOURCE OF PAIN** **Site of Pain** * The location where the patient feels the pain **Source of Pain** * That tissue from which the pain actually originates Balasubramaniam R et al. OJS 2011;1:92-102. Thomas DC et al. Dent Clin North Am. In press. </RB> #### Definitions - **Site of Pain** - The location where the patient feels the pain. - **Source of Pain** - The specific tissue from which the pain actually originates. **SITE VS SOURCE OF PAIN** Primary Pain • Site (where it hurts) = Source (where it originates) Heterotopic Pain • Site $\neq$ Source • Projected Pain or Referred Pain Treatment Success is achieved by treating the Source of Pain, **NOT** the Site of Pain **Structure Analysis below image:** Price of $\alpha$- *honey*ng (3) 0. 1. Price of no.:... #### Classification of Pain Location - **Primary Pain** - The Site (where it hurts) is equal to the Source (where it originates). - **Heterotopic Pain** - The Site is not equal to the Source. - Includes Projected Pain or Referred Pain. #### Clinical Application Treatment success is achieved by treating the **Source of Pain**, NOT the Site of Pain. No unique content provided for Page 10. # OUTLINE * ODONTOGENIC PAINS * SITE VS SOURCE OF OROFACIAL PAIN * NON-ODONTOGENIC PAINS * TAKE HOME MESSAGE #### Outline - ODONTOGENIC PAINS - SITE VS SOURCE OF OROFACIAL PAIN - NON-ODONTOGENIC PAINS - TAKE HOME MESSAGE # NON-ODONTOGENIC PAINS | | | | :--- | :--- | | **Myofascial Origin** | **Neuropathic Origin** | | **Neurovascular Origin** | **Sinus Origin** | | **Cardiac Origin** | **Psychogenic Origin** |       Non-odontogenic pains can be classified by their systems of origin: - Myofascial Origin - Neurovascular Origin - Cardiac Origin - Neuropathic Origin - Sinus Origin - Psychogenic Origin An anatomical diagram of a human skull in profile view showing the musculature of the face and jaw. Specific muscles are highlighted in red, illustrating the 'Myofascial Origin' of pain. A clinical photograph of a woman holding her forehead with one hand, eyes closed, demonstrating symptoms associated with headache or migraine pain. A medical illustration of a human heart floating against a dark background with an ECG waveform overlay, representing the 'Cardiac Origin' of pain. A labeled anatomical diagram of a human head in profile (side view) displaying the sensory innervation zones of the head and neck. Different regions are color-coded to show nerve pathways relevant to diagnosis. A clinical photograph of a young woman pressing her fingers against the bridge of her nose and rubbing her eye area, depicting facial discomfort or sinus pressure. A photograph of a middle-aged woman with grey hair standing with arms crossed and looking directly at the camera with a worried expression, used to represent the psychological aspect of pain. | | MYOFASCIAL ORIGIN | | |:---|:---|:---| | **Non-Odontogenic Pain** | | | **Non-Odontogenic Pain of Myofascial Origin** refers to pain originating from muscles and fascia that present as tooth | **TRIGGER POINT** | pain | | **Active trigger point**: localized hyperexcitable nodule (neuromuscular dysfunction at the motor endplate) | Taut band of skeletal muscle | Convergence Theory: | | | A firm nodule that is tender to palpation will refer pain to a distant site 80% of the time | trigeminal sensory complex | | Hong et al. Arch Phys Med Rehabil 1997;78:957-60. | Wright JDAA 2000;131:1307-15. | Sessle et al. Pain 1986;27:219-35. | | Travell and Simons' Myofascial Pain and Dysfunction: the trigger point manual 1999 | | |  Non-odontogenic pain of myofascial origin refers to pain originating from muscles and fascia that presents as tooth pain. #### Active Trigger Points - **Definition**: A localized hyperexcitable nodule representing neuromuscular dysfunction at the motor endplate. - **Physical Characteristics**: Located within a taut band of skeletal muscle. - **Clinical Presentation**: A firm nodule that is tender to palpation; it will refer pain to a distant site 80% of the time. #### Mechanism of Referred Pain - **Convergence Theory**: Pain referral is mediated through the trigeminal sensory complex. A conceptual diagram illustrating the 'Convergence Theory' of myofascial pain. It features a large, curved arrow representing the pathway of referred pain originating from a 'Taut band of skeletal muscle' (labeled as an active trigger point) and converging towards the 'trigeminal sensory complex'. The visual includes labels for specific stages: 'Active trigger point: localised hyperexcitable nodule', 'A firm nodule that is tender to palpation will refer pain to a distant site 80% of the time', and 'Convergence Theory: trigeminal sensory complex'. A teal box labeled 'TRIGGER POINT' highlights the source. <cstring>RB</cstring> MYOFASCIAL ORIGIN: TRIGGER POINT A TrP1 B TrP2 A B.D.C B B.D.C C TrP3 D TrP4 C B.D.C D B.D.C Travell JG, Simons DG. Myofascial pain and dysfunction: the trigger point manual. Vol. 1. Upper half of body. 2nd ed. Baltimore: Williams & Wilkins; 1999.  #### Trigger Point Mapping Trigger point locations and their associated referral patterns (B.D.C.): - **TrP1**: Associated with referral pattern A - **TrP2**: Associated with referral pattern B - **TrP3**: Associated with referral pattern C - **TrP4**: Associated with referral pattern D Anatomical diagram titled 'MYOFASCIAL ORIGIN: TRIGGER POINT' illustrating trigger points (TrP) and referred pain patterns in the upper half of the human body. The figure is divided into two columns: the left column shows muscle activation sites (marked with black crosses) and associated red dotted referral zones for four muscles labeled A through D; the right column shows the corresponding B.D.C. (band of distribution and contraction) areas shaded in dark tones. Specific labels include TrP1, TrP2, TrP3, and TrP4 indicating distinct trigger points within the facial and jaw musculature. # MYOFASCIAL ORIGIN: MANAGEMENT * **RB** * Education & Reassurance * Pain-Free Jaw Function * Habit Awareness & Reversal * Spray & Stretch * Jaw Strengthening & Stretching Exercises * Physical Therapy * Trigger Point Injections * Oral Appliance Therapy * Pharmacotherapy * Botulinum Toxin Injections * Psychological Therapy            #### Conservative and Behavioral Interventions - Education & Reassurance - Pain-Free Jaw Function - Habit Awareness & Reversal - Spray & Stretch - Jaw Strengthening & Stretching Exercises - Physical Therapy #### Clinical and Therapeutic Interventions - Trigger Point Injections - Oral Appliance Therapy - Pharmacotherapy - Botulinum Toxin Injections - Psychological Therapy Clinical photo of a healthcare provider (doctor) in blue scrubs talking to a patient seated in a dental chair. Caption: 'Education & Reassurance'. Photo of an elderly woman making a pained facial expression while holding food and a cup. Caption: 'Pain-Free Jaw Function'. Close-up photo of a person's hands near their mouth, demonstrating a specific jaw or lip movement/habit. Caption: 'Habit Awareness & Reversal'. Photo showing a gloved hand administering a spray or applying a topical treatment to the side of a patient's head/neck. Caption: 'Spray & Stretch'. Photo of a young woman holding her jaw with both hands, appearing to be in pain or performing an exercise. Caption: 'Jaw Strengthening & Stretching Exercises'. Photo showing close-up of hands performing manual physical therapy on a patient's neck/shoulder area. Caption: 'Physical Therapy'. Photo of a gloved medical professional performing an injection into a patient's face/jaw area. Caption: 'Trigger Point Injections'. Photo of a clear plastic oral appliance (likely a night guard or splint) resting on a blue textured surface. Caption: 'Oral Appliance Therapy'. Photo displaying various pills and blister packs of medication scattered on a white surface. Caption: 'Pharmacotherapy'. Photo of a syringe filled with clear liquid, representing Botulinum Toxin. Caption: 'Botulinum Toxin Injections'. Photo of two people sitting in chairs facing each other in a clinical setting, suggesting a therapy session. Caption: 'Psychological Therapy'. <h1>RB PAIN OF NEUROVASCULAR ORIGIN</h1> **“Headache”** may present as variant in the orofacial region mimicking toothache. <table> <tr> <th>Migraine</th> </tr> <tr> <th>Trigeminal<br>Autonomic<br>Cephalalgias</th> </tr> </table> NEUROVASCULAR OROFACIAL PAIN Klasser & Balasubramaniam 2007; Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 104:640-646. Balasubramaniam & Klassser 2007; Oral Surg Oral Med Oral Pathol Oral Radiol Endod 104:345-358. Klasser & Balasubramaniam 2007; Oral Surg Oral Med Oral Pathol Oral Radiol Endod 104:763-171. Balasubramaniam et al. 2008; JADA 139(12): 1616-1624.    "Headache" may present as a variant in the orofacial region, frequently mimicking toothache. #### Primary Classifications of Neurovascular Orofacial Pain - Migraine - Trigeminal Autonomic Cephalalgias Text-based visual element highlighting that 'Headache' may present as a variant in the orofacial region mimicking toothache. Diagram showing two opposing arrows. The left arrow is labeled 'Migraine' and points to the left; the right arrow is labeled 'Trigeminal Autonomic Cephalalgias' and points to the right. Text-based visual element highlighting the term 'NEUROVASCULAR OROFACIAL PAIN'. RŤB PAIN OF NEUROVASCULAR ORIGIN Alonso AA, Nixdorf DR. J Endod. 2006 Nov;32(11):1110-3.  Pain of neurovascular origin. Labelled anatomical diagram illustrating pain of neurovascular origin in a lateral view of the head. It shows a sagittal section with the brain and skull partially removed to reveal underlying structures. The trigeminal nerve (CN V) is highlighted: its ophthalmic division (V1, yellow) courses from the midbrain through the cavernous sinus to branches over the eye, nose, upper lip, and maxillary teeth; its mandibular division (V3, red) descends from the foramen ovale to innervate the lower jaw, chin, and mandibular teeth. A segment of the pons/medulla junction is colored red where CN V emerges. The caption 'PAIN OF NEUROVASCULAR ORIGIN' appears at the top, and the source citation 'Alonso AA, Nixdorf DR. J Endod. 2006 Nov;32(11):1110-3.' is at the bottom. <PAIN OF NEUROVASCULAR ORIGIN: CLINICAL PRESENTATION> Haviv Y. et al. J Oral Facial Pain Headache 2020;34(2):121–8. F:M = 3.2:1 • Age of onset: 40 years 70% Unilateral • 62% alveolar process • 32% mucosal sites Moderate – Severe Pulsating Pain • 35% woke patient Duration: < 1 week • 1/3 chronic pain Autonomic Features: tearing nasal congestion rhinorrhoea fullness nausea photophobia phonophobia • DENTAL HYPERSENSITIVITY   #### Demographics and Onset - **Gender Ratio (F:M):** 3.2:1 - **Average Age of Onset:** 40 years #### Pain Characteristics and Location - **Laterality:** 70% Unilateral - **Distribution:** - 62% Alveolar process - 32% Mucosal sites - **Intensity and Quality:** - Moderate to Severe - Pulsating pain - 35% of cases woke the patient from sleep - **Duration:** - Typically < 1 week - 1/3 of cases involve chronic pain #### Associated Symptoms and Autonomic Features - Tearing - Nasal congestion - Rhinorrhoea - Fullness - Nausea - Photophobia - Phonophobia - Dental hypersensitivity Clinical photo of an elderly woman with blonde hair and glasses holding her cheek in pain, illustrating the subject of neurovascular facial pain. Schematic diagram showing a large orange arrow pointing rightwards. The arrow contains three brown circular nodes along its path, representing stages or data points. Text labels are distributed around the arrow: 'Duration: < 1 week', '70% Unilateral', 'F:M = 3.2:1', 'Moderate – Severe Pulsating Pain', and 'Autonomic Features' listing symptoms like tearing and nasal congestion. # PAIN OF SINUS ORIGIN ## MANAGEMENT **Consider antibiotic therapy in addition to intranasal corticosteroids for patients who have any of the following indicators of bacterial infection:** * Symptoms of rhinosinusitis lasting longer than 7 days, with purulent nasal discharge, sinus tenderness (particularly unilateral) or maxillary toothache * Severe symptoms and high fever (39°C or higher) at the onset of illness and lasting longer than 3 days * Worsening symptoms after initial improvement ('double sickening') Chow AW et al. Clin Infect Dis 2012;54(8):e72-e112. | Drug/Regimen | Dosage & Dose | Diet Instructions | Duration | | :--- | :--- | :--- | :--- | | amoxycillin | amoxycillin 500 mg (child: 15 mg/kg up to 500 mg) orally, 8-hourly | Normal Diet | 5 days | | amoxycillin + clavulanate | amoxycillin + clavulanate 500+125 mg (child: 22.5+3.2 mg/kg up to 500+125 mg) orally, 8-hourly | Normal Diet | 7 to 14 days | | **For Patients hypersensitive to Penicillins:** | | | | | cefuroxime | cefuroxime 500 mg (child 3 months to 2 years: 10 mg/kg up to 125 mg; 2 years or older: 15 mg/kg up to 500 mg) orally, 12-hourly | Normal Diet | 5 days | | doxycycline | doxycycline 100 mg (child 8 years or older: 2 mg/kg up to 100 mg) orally, 12-hourly | Normal Diet | 5 days |  A structured table titled 'PAIN OF SINUS ORIGIN MANAGEMENT' summarizing antibiotic regimens. It is divided into two main sections: standard treatment and a section for 'For Patients hypersensitive to Penicillins'. The table lists specific drugs (amoxycillin, amoxycillin + clavulanate, cefuroxime, doxycycline) with detailed dosage instructions including pediatric dosing in mg/kg, frequency of administration (e.g., 8-hourly, 12-hourly), duration of therapy, and diet instructions. * **Myocardial ischemia:** insufficient blood flow and oxygen supply to the myocardium, usually due to narrowing or blockage of the coronary arteries from atherosclerosis. * Imbalance between oxygen supply and myocardial demand leads to reversible cellular dysfunction and chest pain. **Substernal Pain** * **Dull, aching, pressure-like, or crushing sensation** * **Radiates to left neck, shoulders, arms, epigastrium** **Provoked by** physical exertion, emotional stress, cold exposure, heavy meals * **Dyspnoea, diaphoresis, nausea, light-headedness, fatigue, sense of impending doom or anxiety** **Women > Men** **2:1**  Diagram illustrating 'Substernal Pain' with a central cluster of overlapping translucent circles. The diagram is surrounded by descriptive labels: 'Provoked by physical exertion, emotional stress, cold exposure, heavy meals'; 'Dull, aching, pressure-like, or crushing sensation'; 'Radiates to left neck, shoulders, arms, epigastrium'; 'Women > Men 2:1'; and 'Dyspnoea, diaphoresis, nausea, light-headedness, fatigue, sense of impending doom or anxiety'. PAIN OF CARDIAC ORIGIN **CLINICAL PRESENTATION** Kreiner et al. J Oral Facial Pain Headache. 2014 Fall;28(4):317-21. 32% with coronary symptoms have pain in other areas 38% have orofacial pain Tooth (4%); mandible (45%); ear/TMJ (18%) 6% solely in orofacial region Diagnostic local anaesthetic site of the painful tooth will not eliminate the pain      Clinical photo of an elderly person clutching their chest, illustrating the presentation of pain of cardiac origin. The image serves as a visual anchor for the slide's topic. Data point within a flowchart diagram. Label reads: '38% have orofacial pain' with breakdown: 'Tooth (4%); mandible (45%); ear/TMJ (18%)'. This is part of a sequence showing clinical presentation statistics. Data point within a flowchart diagram. Label reads: '32% with coronary symptoms have pain in other areas'. This statistic appears at the start of the visual flow. Data point within a flowchart diagram. Label reads: '6% solely in orofacial region'. This represents a subset of patients presenting only with facial symptoms. Text block within the flowchart diagram acting as a diagnostic note. Reads: 'Diagnostic local anaesthetic site of the painful tooth will not eliminate the pain'. ### PAIN OF CARDIAC ORIGIN MANAGEMENT - **Immediate** - **Emergency** - **Medical Services Activation** - **Aspirin 300 mg chewed immediately** - **Sublingual nitro-glycerine 0.4 mg every 5 minutes (up to 3 doses)** - **Supplemental oxygen only if hypoxic (oxygen saturation < 90%) or if patient is dyspnoeic or has signs of heart failure.** - **Routine oxygen therapy in normoxemic patients is NOT recommended and may cause harm.**  Clinical photo of an ambulance in motion with green and white livery. The vehicle serves as the background context for a medical management slide titled 'PAIN OF CARDIAC ORIGIN MANAGEMENT'. | | A | Recurrent paroxysms of the unilateral facial pain in the distribution(s) of one or more divisions of the trigeminal nerve, with no radiation beyond, and fulfilling criteria B and C | | :--- | :--- | :--- | | | B | Pain has all of the following characteristics:<br>1. Lasting from a fraction of a second to 2 minutes<br>2. Severe intensity<br>3. Electric shock-like, shooting, stabbing or sharp in quality | | | C | 1. Precipitated by innocuous stimuli within the affected trigeminal distribution | | | D | Not better accounted by another ICHD-3 diagnosis |  A structured table titled 'Diagnostic Criteria for Trigeminal Neuralgia' summarizing the International Classification of Orofacial Pain (ICOP) criteria. The table is divided into four distinct rows labeled A, B, C, and D. Row A defines recurrent unilateral facial pain in trigeminal nerve distributions. Row B lists pain characteristics including duration (fraction of a second to 2 minutes), severe intensity, and electric shock-like quality. Row C notes that pain is precipitated by innocuous stimuli. Row D specifies that the diagnosis is not better accounted for by another ICHD-3 diagnosis. **TRIGEMINAL NEURALGIA** CLINICAL PRESENTATION TRIGEMINAL NEURALGIA CLINICAL PRESENTATION **Targeting the neurovascular contact:** panel (a) is view of the right trigeminal root through the operating microscope. An arterial loop of the superior cerebellar artery has been lifted off the root. There is a band-like grayish discoloration of the root where it had been compressed close to its entrance to the brainstem. In panel (b), the picture is represented in diagrammatic form with the anatomical landmarks identified. (With permission from: Rappaport 2015) **A** Superior cerebellar artery **B** Trigeminal root **C** Zone of discoloration at site of compression on nerve root **D** Brainstem entry zone **E** Brain retractor   Clinical photo (panel a) showing the view of the right trigeminal root through an operating microscope. Visible features include a band-like grayish discoloration on the nerve root where it was compressed near the brainstem entry, and a loop of the superior cerebellar artery lifted off the root. Anatomical diagram (panel b) representing the neurovascular contact with labeled landmarks: A is Superior cerebellar artery, B is Trigeminal root, C indicates the zone of discoloration at the site of compression on the nerve root, D marks the brainstem entry zone, and E points to the brain retractor. Secondary trigeminal neuralgia related to a schwannoma: heavily T2-weighted high-resolution axial (a) and T2-weighted fat-saturated coronal (b) MR images show a well-circumscribed ovoid nodule (arrow) in the left side of the prepontine cistern, inseparable from the cisternal segment of the left trigeminal nerve. Post-gadolinium T1 fat-saturated axial (c) image shows strong homogeneous enhancement of the mass (arrow). (Images courtesy of Dr Rudolf Boeddinghaus, Perth Radiological Clinic, Perth WA, Australia) TRIGEMINAL NEURALGIA CLINICAL PRESENTATION Farah CS, Balasubramaniam R, McCullough MJ, eds. Contemporary Oral Medicine: A Comprehensive Approach to Clinical Practice. Springer; 2019.  Composite medical figure displaying three MRI panels labeled a, b, and c. Panel (a) is a heavily T2-weighted high-resolution axial image showing a well-circumscribed ovoid nodule (indicated by an arrow) in the left prepontine cistern. Panel (b) is a T2-weighted fat-saturated coronal view also highlighting the nodule with an arrow. Panel (c) is a post-gadolinium T1 fat-saturated axial image demonstrating strong homogeneous enhancement of the mass (arrow). The caption identifies the finding as secondary trigeminal neuralgia related to a schwannoma. # PAIN OF NEUROPATHIC ORIGIN “Neuropathic pain is pain that arises as a direct consequence of a lesion or diseases affecting the somatosensory system” <img/>       Flowchart node labeled 'Neuropathic Pain' in a dark teal box, serving as the root of a classification hierarchy. Flowchart node labeled 'Episodic' in a light blue box, representing one branch of neuropathic pain classification. Flowchart node labeled 'Continuous' in a light blue box, representing the other main branch of neuropathic pain classification. Flowchart node labeled 'Trigeminal Neuralgia' in a grey box, positioned under the 'Episodic' category. Flowchart node labeled 'Post-Traumatic Trigeminal Neuropathic Pain' in a green box, positioned under the 'Continuous' category. Anatomical illustration showing a human head profile with highlighted yellow trigeminal nerve pathways branching across the face and into the brain structure. # NON-ODONTOGENIC PAINS - Myofascial Origin - Cardiac Origin - Neurovascular Origin - Neuropathic Origin - Sinus Origin - Psychogenic Origin SOMATIC SYMPTOM DISORDER CLINICAL PRESENTATION - Pain descriptors often diffuse, vague and difficult to localise - Multiple teeth often involved, with frequent change in character and location - Inconsistent with physiological pain and present without any identifiable pathological cause - Chronic pain behaviour - Lack of response to reasonable dental treatment - Unusual or unexpected response to therapy Balasubramaniam R et al. OJS 2011;1:92-102. Thomas DC et al. Dent Clin North Am. In press. # SOMATIC SYMPTOM DISORDER ## MANAGEMENT **Regular Consultations** * Schedule short-interval follow-up to stop overuse of medical care * stress coping rather than cure **Empathy** * Spend most of the time listening to the patient and acknowledge that what he or she is feeling is real **Mind-Body Interface** * Emphasize the mind-body connection; avoid comments such as “there is nothing medically wrong with you” **REFER TO PSYCHIATRIST** * 90% have persistent symptoms at 5 years follow-up Kurlansik SL, Maffei MS. Am Fam Physician. 2016 Jan 1;93(1):49-54. **SOMATIC SYMPTOM DISORDER** **MANAGEMENT** **REFER TO A PSYCHIATRIST** (Kurlansik SL, Maffei MS. Am Fam Physician. 2016 Jan 1;93(1):49-54.) | Modality | Evidence | Findings | | :--- | :--- | :--- | | Cognitive Behavioural Therapy | Multicenter randomised controlled trial,<br>reviews of controlled clinical trials | Effective for treatment of somatic symptom disorder and medically unexplained symptoms<br>“Health anxious” patients had sustained symptomatic benefit over two years,<br>with no significant effect on total costs.<br>Reduced physical symptoms, psychological distress, and disability. | | Mindfulness-Based Therapy | Meta-analysis of randomised controlled trials | May be effective in treating some aspects of somatic symptom disorder.<br>Significant and sustained improvements in clinical outcomes (overall symptom severity, depression, and anxiety) compared with control groups. | | Pharmacotherapy | Systematic reviews of controlled trials | **Amitriptyline** shows benefit for one or more of the following outcomes: fatigue, functional symptoms, global improvement, morning stiffness, pain, sleep, and tender points.<br>**Fluoxetine** shows benefit for functional status, global well-being, morning stiffness, pain, sleep, and tender points.<br>monoamine oxidase inhibitors, bupropion, antiepileptics, and antipsychotics showed no benefit and should not be used. | | St. John’s Wort | Randomised, double-blind, placebo-controlled trials (lower-quality studies) | More effective than placebo for improvement in self-reported somatic symptoms; well-tolerated and safe |  A structured table titled 'REFER TO A PSYCHIATRIST' summarizing management strategies for Somatic Symptom Disorder. The table contains three columns: 'Modality', 'Evidence', and 'Findings'. Rows detail four treatment modalities: Cognitive Behavioural Therapy (effective for medically unexplained symptoms), Mindfulness-Based Therapy (significant improvements in clinical outcomes), Pharmacotherapy (specifically highlighting Amitriptyline and Fluoxetine benefits while noting lack of benefit for others like bupropion), and St. John's Wort (more effective than placebo). Key drug names are highlighted in red text within the findings column. **OUTLINE** **ODONTOGENIC PAINS** **SITE VS SOURCE OF OROFACIAL PAIN** **NON-ODONTOGENIC PAINS** **TAKE HOME MESSAGE**  Flowchart diagram showing the outline of a presentation on orofacial pain. The diagram consists of four connected nodes (circles) linked by lines in a vertical sequence. The first three nodes are dark gray circles containing white text: 'ODONTOGENIC PAINS', 'SITE VS SOURCE OF OROFACIAL PAIN', and 'NON-ODONTOGENIC PAINS'. The final node is an orange circle labeled 'TAKE HOME MESSAGE'. A logo 'RB' appears in the top left corner. # THANK YOU ## Ramesh Balasubramaniam OAM | # | Organization Name | | :--- | :--- | | 1 | The University of Western Australia | | 2 | Perth Oral Medicine & Dental Sleep Centre | | 3 | Perth Children's Hospital | | 4 | PERIOGOLD® (Helps Improve Oral Health) | | 5 | OMAAA (Oral Medicine Academy of Australasia) | | 6 | DSSWA | | 7 | ADA (Australian Dental Association) | | 8 | Aus-Med-Sleep (Australian Sleep Association) | **** [^1]: Original PDF page 1: [[L32 Non-Odontogenic Toothache.pdf#page=1|L32 Non-Odontogenic Toothache, p.1]] [^2]: Original PDF page 2: [[L32 Non-Odontogenic Toothache.pdf#page=2|L32 Non-Odontogenic Toothache, p.2]] [^3]: Original PDF page 3: [[L32 Non-Odontogenic Toothache.pdf#page=3|L32 Non-Odontogenic Toothache, p.3]] [^4]: Original PDF page 4: [[L32 Non-Odontogenic Toothache.pdf#page=4|L32 Non-Odontogenic Toothache, p.4]] [^5]: Original PDF page 5: [[L32 Non-Odontogenic Toothache.pdf#page=5|L32 Non-Odontogenic Toothache, p.5]] [^6]: Original PDF page 6: [[L32 Non-Odontogenic Toothache.pdf#page=6|L32 Non-Odontogenic Toothache, p.6]] [^7]: Original PDF page 7: [[L32 Non-Odontogenic Toothache.pdf#page=7|L32 Non-Odontogenic Toothache, p.7]] [^8]: Original PDF page 8: [[L32 Non-Odontogenic Toothache.pdf#page=8|L32 Non-Odontogenic Toothache, p.8]] [^9]: Original PDF page 9: [[L32 Non-Odontogenic Toothache.pdf#page=9|L32 Non-Odontogenic Toothache, p.9]] [^10]: Original PDF page 10: [[L32 Non-Odontogenic Toothache.pdf#page=10|L32 Non-Odontogenic Toothache, p.10]] [^11]: Original PDF page 11: [[L32 Non-Odontogenic Toothache.pdf#page=11|L32 Non-Odontogenic Toothache, p.11]] [^12]: Original PDF page 12: [[L32 Non-Odontogenic Toothache.pdf#page=12|L32 Non-Odontogenic Toothache, p.12]] [^13]: Original PDF page 13: [[L32 Non-Odontogenic Toothache.pdf#page=13|L32 Non-Odontogenic Toothache, p.13]] [^14]: Original PDF page 14: [[L32 Non-Odontogenic Toothache.pdf#page=14|L32 Non-Odontogenic Toothache, p.14]] [^15]: Original PDF page 15: [[L32 Non-Odontogenic Toothache.pdf#page=15|L32 Non-Odontogenic Toothache, p.15]] [^16]: Original PDF page 16: [[L32 Non-Odontogenic Toothache.pdf#page=16|L32 Non-Odontogenic Toothache, p.16]] [^17]: Original PDF page 17: [[L32 Non-Odontogenic Toothache.pdf#page=17|L32 Non-Odontogenic Toothache, p.17]] [^18]: Original PDF page 18: [[L32 Non-Odontogenic Toothache.pdf#page=18|L32 Non-Odontogenic Toothache, p.18]] [^19]: Original PDF page 19: [[L32 Non-Odontogenic Toothache.pdf#page=19|L32 Non-Odontogenic Toothache, p.19]] [^20]: Original PDF page 20: [[L32 Non-Odontogenic Toothache.pdf#page=20|L32 Non-Odontogenic Toothache, p.20]] [^21]: Original PDF page 21: [[L32 Non-Odontogenic Toothache.pdf#page=21|L32 Non-Odontogenic Toothache, p.21]] [^22]: Original PDF page 22: [[L32 Non-Odontogenic Toothache.pdf#page=22|L32 Non-Odontogenic Toothache, p.22]] [^23]: Original PDF page 23: [[L32 Non-Odontogenic Toothache.pdf#page=23|L32 Non-Odontogenic Toothache, p.23]] [^24]: Original PDF page 24: [[L32 Non-Odontogenic Toothache.pdf#page=24|L32 Non-Odontogenic Toothache, p.24]] [^25]: Original PDF page 25: [[L32 Non-Odontogenic Toothache.pdf#page=25|L32 Non-Odontogenic Toothache, p.25]] [^26]: Original PDF page 26: [[L32 Non-Odontogenic Toothache.pdf#page=26|L32 Non-Odontogenic Toothache, p.26]] [^27]: Original PDF page 27: [[L32 Non-Odontogenic Toothache.pdf#page=27|L32 Non-Odontogenic Toothache, p.27]] [^28]: Original PDF page 28: [[L32 Non-Odontogenic Toothache.pdf#page=28|L32 Non-Odontogenic Toothache, p.28]] [^29]: Original PDF page 29: [[L32 Non-Odontogenic Toothache.pdf#page=29|L32 Non-Odontogenic Toothache, p.29]] [^30]: Original PDF page 30: [[L32 Non-Odontogenic Toothache.pdf#page=30|L32 Non-Odontogenic Toothache, p.30]]