Toothache pain typically occurs due to problems associated with pupal pathology, periapical pathology or both. In most cases (94% of the time) root canal treatment resolves the pain. But a small percentage of patients continue to experience pain that is not responsive to medications and /or surgical procedures. When this occurs a number of factors could be responsible including a tooth fracture that is undetected, untreated canals in the tooth that had not been visualized, or a persistent bacterial infection.
It does happen, however, that the lingering pain in the tooth or tooth site is due to referred pain from muscles of the jaw and neck, or referred pain from medical diseases outside the immediate tooth site region. In addition, causes of the pain may be due to nerve-related disorders, headache disorders and/or psychogenic disorders. When investigation suggests that the pain is not related to a lingering tooth or tooth site problem, the term Persistent Dentoalveolar Pain has been proposed.
When no regional medical disorder (pathology in the sinuses, pharynx, salivary glands, or thyroid glands) or distant disorder (cardiac-related) has been implicated, the pain that lingers is thought to be due to a neuropathic phenomenon. This is when an Orofacial pain expert should direct care.
The Risk Factors that Lead to Neuropathic Toothaches
Previous chronic pain problems experienced by the patient (particularly if female)
The duration of time the pain had been present before treatment was obtained
Pre-treatment pain in the tooth while chewing or when percussed
Pain in the tooth in between treatment sessions
Elevated psychological stress
In my practice I have identified these risk factors leading to neuropathic toothaches. I have developed courses of treatment that lead to an easing of the pain and give the patient a chance to live life without the persistent discomfort of lingering toothaches.
If a patient is experiencing persistent tooth pain and the above factors exist, I recommend pain management be started immediately with anticonvulsant or antidepressant medications (or both) and complemented by psychological approaches including meditation and cognitive behavioral therapies. Even acupuncture has proven to be useful at times.