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Key Takeaways:
- What is referred pain? It’s a phenomenon where pain experienced in one area of the body is actually caused by pain or injury in another area, and it can make diagnosing and treating dental pain much more difficult for your dentist.
- That’s because the complex network of nerves in the face and neck can lead to pain that feels like it’s coming from a different tooth, or even from the sinuses, ears, or jaw. This can lead to misdiagnoses, improper treatment plans, and even unnecessary dental procedures.
- Fortunately, there are things you as a patient can do to help your dentist accurately diagnose and treat you when you’re experiencing pain, including keeping a pain diary, communicating clearly during endodontic evaluation and diagnosis, and following your treatment plan.
Have you ever experienced pain in one part of the body, only to find out that the source of your pain was actually somewhere entirely different? This phenomenon is what’s called referred pain, and it’s probably the biggest cause of misdiagnosis in dentistry.
While referred pain is something you can experience with a variety of health issues—I think the most common example is pain in the jaw, neck, shoulders, back, or arms during a heart attack—it’s extremely common in relation to teeth and other oral health problems. For example, an issue with one of your upper teeth can lead to pain that’s felt in the cheeks, eyes, or even the forehead due to shared nerve pathways, and this can make it challenging for your dentist to properly diagnose and treat you.
Fortunately, however, understanding what referred pain is, why it happens, and what you can do to help your dentist locate the source of the problem can help you avoid prolonged suffering, unnecessary dental procedures, and exorbitant healthcare fees and get you feeling better as quickly as possible!
What is Referred Pain?
Referred pain is a phenomenon where pain experienced in one area of the body is actually caused by pain or injury in another area. This can be due to the way sensory nerves are wired in the human body, leading to confusion in the brain about where the pain is actually coming from.
Like our heart attack example, there are many instances where someone might feel referred pain throughout the body, including gallstones, kidney stones, appendicitis, cervical spine issues, and endometriosis.
In endodontic evaluation and diagnosis, referred pain can be particularly challenging to deal with, because the complex network of nerves in the face and neck can lead to pain that feels like it’s coming from a different tooth, or even from the sinuses, ears, or jaw. As you can imagine, this can lead to a lot of trouble with diagnosing and treating your pain—and in the worst cases, it can even lead to unnecessary dental procedures being performed!
The good news is that there are ways for your dentist to pinpoint the source of your pain, even when it’s not immediately clear to you where it’s coming from. To show you what I mean, let’s take a look at a tooth story involving one of my own patients and how I was able to make a proper diagnosis despite some sneaky referred pain!
A Case of Sneaky Referred Tooth Pain
Our tooth story demonstrating what referred pain is and how it can complicate endodontic evaluation and diagnosis begins with a patient who came to my office because of some intense tooth pain. In fact, he was in so much pain that he could barely think, and he hadn’t slept for two nights straight.
When he arrived at my practice, he presented me with this referral slip:
According to this slip, which was filled out by the patient’s referring dentist, I should perform a root canal on tooth #30, which is one of the lower-right molars. The patient himself even pointed to tooth #30 when I asked him to identify where his pain was coming from, and when I took a radiograph of the lower right quadrant, this is what I saw:
From what I could see, it was definitely possible that tooth #30 could be cracked and therefore need a root canal! There was certainly enough occlusal wear for that to be the case. It may be hard to see in the x-ray, but as an endodontist, it’s clear from the image that this patient grinds or clenches his teeth, which can lead to cracking.
Seems pretty straightforward, right?
Well… not quite.
Because once I started doing my routine endodontic evaluation and diagnostic testing to see if the teeth in that quadrant were sensitive to cold or percussion, I couldn’t reproduce the patient’s pain! That meant that despite what the patient was feeling, his pain was NOT coming from tooth #30 and we were dealing with a case of what is called referred pain.
You see, it all comes down to the theory of convergence. So many of the nerves in the head and neck converge onto the same ganglion in the brain (the nucleus caudalis) that the brain gets confused as to which nerve fiber is firing.
With this in mind, I decided to do more digging.
The next thing I did was take a bitewing radiograph so I could get a good look at both the top and bottom teeth in that side of his mouth:
Do you see that white area on the tooth above tooth #30? That’s a filling, and it’s a pretty deep one. Given that, I decided to repeat my cold and percussion tests in the upper right quadrant this time—a quadrant he was NOT referred for—and I’m so glad I did.
As it turns out, the tooth with the filling—tooth #3—was really tender to percussion and had no response to cold. That meant the tooth’s nerve had died, which is why the patient was experiencing pain. Typically, a finding that we see in my world is that when a nerve dies, it’s very common to have referred pain. That’s why it’s so important to find and treat the correct tooth through another consultation!
And that’s exactly what happened here. After a little investigation, we had finally found the culprit!
A Happy Ending for Tooth #3—and Tooth #30!
With a proper diagnosis in hand, I numbed the patient up really well on the top tooth, which made his pain go away. (Had it been a bottom tooth, the pain wouldn’t have gone away upon anesthesia!) I then proceeded to do a root canal on tooth #3 that very day, since he was in so much agony. He was so happy to have the anesthesia that he actually fell asleep during the procedure!
Here was the post-treatment radiograph:
When I called the patient the next day to see how he was doing, he had no more pain! In fact, he said he had slept so well during the night that he hadn’t woken up with his alarm.
Do you see how important it is for both your dentist and endodontist to do a thorough evaluation? Thanks to my insistence on taking my own radiographs and doing my own diagnostic tests, I was not only able to properly diagnose and treat the patient—curing him of his pain—but I was also able to prevent an unnecessary root canal procedure on the WRONG tooth!
I think it’s safe to say I saved not one, but TWO teeth that day.
How Patients Like You Can Help
While it’s ultimately your dentist’s responsibility to accurately diagnose and treat you when you’re experiencing pain, that doesn’t mean there aren’t ways that you can help them arrive at the right conclusion. In fact, simply understanding what referred pain is can go a long way in giving your dentist a leg up, as diagnosis can be very tricky sometimes. Of course when your dentist sees you in pain, they want to help you as quickly as possible—but they also don’t want to pick the wrong tooth!
With that in mind, here are six things you can do the next time you go to the dentist because of tooth pain to ensure you get the treatment you need:
- Keep a Pain Diary: There are things you can do as a patient to help your dentist even before going in for your appointment! For example, if your pain is ongoing, keeping a diary of when the pain occurs, its intensity, and its exact location can be very helpful for your dentist.
- Notice Patterns: In the days or weeks leading up to your appointment, pay attention to any patterns in your pain, such as if it occurs at certain times of the day, after eating, or when you perform specific actions (like biting down or drinking something hot or cold). Note these in your diary.
- Provide a Detailed History: When you first arrive at the dentist, provide them with a comprehensive history of your pain, including when it started, what seems to trigger it, and any previous dental or medical issues that might be related. Your pain diary can be a huge help with this.
- Describe the Pain as Specifically as Possible: As you describe your symptoms, try to be as specific as possible about the type and location of the pain. Note if the pain is sharp, throbbing, constant, intermittent, or if it changes location. Your words matter here!
- Follow Recommendations: Make sure you follow any diagnostic recommendations your dentist gives you, such as X-rays, tests, or a referral to a specialist. While they may feel tedious or uncomfortable—especially if you have to do them more than once—they’re crucial to helping your dentist pinpoint the exact source of your pain. My tooth story is a perfect example!
- Communicate Effectively: Keep an open line of communication with your dentist, even after your appointment. If treatments aren’t relieving the pain, let your dentist know so adjustments can be made to your treatment plan.
Improve Your Outcomes Through Patient Education
When you have a better understanding of your teeth, what to expect when you go to the dentist, and how to advocate for your own health, you can greatly improve your outcomes and even save your teeth from being extracted!
Through my online course, Tooth Wisdom: The Patient’s Guide to Endodontic Empowerment, you can learn to take control of your dental health and feel confident in getting the care you need through accessible and empowering patient-focused education.
– Sonia
