Atypical Odontalgia

Atypical odontalgia, also known as atypical facial pain, phantom tooth pain, or neuropathic orofacial pain, is characterized by chronic pain in a tooth or teeth, or in a site where teeth have been extracted or following endodontic treatment, without an identifiable cause. Over time, the pain may spread to involve wider areas of the face or jaws.

The pain is called “atypical” because it is a different type of pain than that of a typical toothache. Typical toothache comes and goes and is aggravated by exposure of the tooth to hot or cold food or drink, and/or by chewing or biting on the affected tooth. There is an identifiable cause, such as decay, periodontal disease, or injury to the tooth and the pain is predictably relieved by treatment of the affected tooth. 

With atypical odontalgia, the pain is described as a constant throbbing or aching in a tooth, teeth, or extraction site that is persistent and unremitting, and which is not significantly affected by exposure to hot or cold food or drink, or by chewing or biting. The pain may or may not be relieved by the injection of local anesthetic.  The intensity of the pain can vary from very mild to very severe. There is typically no identifiable cause to explain the pain and it often follows or is associated with a history of some type of dental procedure such as having a root canal or tooth extraction. On occasion, the pain can occur without any reason. The pain is felt in a tooth or teeth and persists in spite of treatment aimed to relieve the pain such as a filling, a root canal, or even an extraction. This often presents a frustrating and confusing situation for both the patient and the dentist, and can lead to more and more dental treatment, none of which is effective at relieving the pain.

The diagnosis of atypical odontalgia is made after a thorough history, clinical examination, and radiographic assessment fail to identify a cause for the pain. Once the diagnosis is made, medications can be used in an effort to reduce the level of pain.


Q: What causes atypical odontalgia?
A: The cause of atypical odontalgia is not known, and therefore, some clinicians refer to the pain as “idiopathic”. In all likelihood, it is probably due to a variety of factors which may include genetic predisposition, age, and sex. It is more common in women than in men, and is found most often in the middle-aged to older age group. Some studies have found an association between atypical odontalgia and depression and anxiety, however, the significance of this association is unclear. The actual pathologic mechanism seems to be dysfunction or “short-circuiting” of the nerves that carry pain sensations from the teeth and jaws that is triggered by some type of dental or oral manipulation. Areas of the brain that process pain signals appear to undergo molecular and biochemical changes that result in a persistent sensation of pain in the absence of an identificable cause of the pain.

Q: Why doesn’t dental treatment cure the pain?
A: In most cases, dental treatment doesn’t help. In some cases it may temporarily lesson or change the severity of the pain, but it will inevitably return. This is because the pain is not caused by any pathology in the teeth or gums, but rather it is due to dysfunction of the nerves or a portion of the brain that processes pain sensation. It is important to recognize this in order to prevent unnecessary and ineffective dental treatment.

Q: How is atypical odontalgia treated?
A: Atypical odontalgia is a chronic pain condition that is treated by using a variety of medications. Many different medications have been used to treat this condition; however, the tricyclic antidepressants are used most frequently. Although these are antidepressant medications, they are primarily used for their pain relieving properties and not for their antidepressant effects. Amitriptyline is one of the more commonly prescribed tricyclic medications used for atypical dontalgia. In addition to the tricyclics, other drugs used to treat chronic pain conditions, such as gabapentin, baclofen, and duloxetine may be prescribed. Generally, treatment is successful in reducing the pain but not eliminating it completely.

Q: Is this a permanent condition?
A: Since the exact cause of this problem is not known, it is difficult to say whether this is a permanent condition. There are cases in which the pain goes away spontaneously as well as cases in which the pain gradually subsides and disappears after prolonged treatment with medications. There are many cases however, that persist and require the continued use of medications.

Q: Why doesn’t my dentist know about this problem?
A: While atypical odontalgia is not rare, it is uncommon enough that many dentists have not seen the problem and are not familiar with it. Therefore, diagnosis and treatment is best done by a dentist with advanced training and familiarity with the problem, such as a specialist in oral medicine or orofacial pain. The information contained in this monograph is for educational purposes only. 

Prepared by D Falace and the AAOM Web Writing Group
Prepared 22 January 2015
