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dentistry Dominic Thorncroft

How Can A Dentist Recognise And Treat Dental Erosion

Treating Dental Erosion

Dental erosion is defined as the loss of surface tooth structure due to acid other than from bacterial plaque.

The two most common diseases in the mouth are dental caries and periodontal disease. They are both caused by bacteria in plaque. Dental caries result of tooth erosion but hard tooth structure is also lost by three other methods. Tooth surface loss encompasses abrasion, attrition and erosion.

Abrasion and attrition are caused by mechanical tooth wear but erosion is caused by chemical wear. The critical pH for enamel erosion to take effect is when it dips below 5.5. This is because saliva has an inherent buffering capacity.

In dental erosion the source of acid is extrinsic or extrinsic.

Intrinsic acid is due to recurrent vomiting from psychological diseases such as anorexia and bulimia. Intrinsic acid may also be due to acid reflux in gastric disorders. The acid travels from the stomach, up into the oesophagus and into the oral cavity. It is worse at night when the person is lying flat.

Extrinsic acid is usually due to acidic foods and acidic drinks. In the past, exposure to acid in the atmosphere due to industrial processes used to occur  but not anymore.

When acid is introduced into the mouth, the saliva is extremely important due to its rinsing and due to its buffering effect.

The rinsing effect of saliva is due to the constant salivary flow rate and helps to wash the acid away quickly after swallowing. In addition, the buffering effect of the saliva helps to neutralize the acids before a low pH can cause demineralization hence it cannot cause damage to the enamel and dentine.

Common foods which are acidic are all citric foods such as apples, oranges and especially lemons. In addition berries and pickles.

Common acidic drinks are soft drinks, energy drinks, sports drinks, vinegar and pure fruit drinks.

Research shows that the critical frequency for fruits is “3 exposures or more.” This means that you are allowed to have 2 meals or snacks in a day containing acids and this is safe but above this amount, you will suffer acid erosion.

The critical exposure with drinks is only more than once daily. This also depends on how long the drink is in the mouth because it is known that children and young people often swish the drink around their mouth and they may even use fizzy sweets to produce a crackling effect. If the food or drink also contains sugar, this also additionally contributes to dental caries. And if the plaque control is inadequate, periodontal diseases will also take hold.

Many of these acidic drinks described above have a pH of less than 4.

The acid inside these drinks is in the form of citric acid, phosphoric acid, malic acid, and carbonic acid.

The effects of acid erosion on teeth causes sensitivity, affects the appearance and finally the loss of enamel reduces resistance to dental caries.

The effects of chewing gum has been extensively researched and it is known that chewing gum immediately after eating removes 90% of food debris within a few minutes.

The chewing of gum also increases the salivary flow rate. This causes an increase in bicarbonate and calcium ions which help to remineralize the tooth enamel and also to neutralise plaque or dietary acids.

It is important to note that unlike dental caries, dental erosion does not undergo a process of remineralisation because the actual process is different. During dental erosion, the surface of the enamel becomes soft and then it is lost permanently.

This is why it is also important to advise patients not to brush my teeth immediately after they have consumed acidic foods or drinks because they will literally be spitting their teeth down the sink. They should wait at least 20 minutes so that the effects of saliva can protect properly.

In many patients, the effects of acid erosion, abrasion, attrition, dental caries and periodontal disease often occur in combination.  Often as a dentist, you are trying to to battle the ravages of acid erosion abrasion attrition, dental caries and periodontal disease simultaneously.

Always, you must take a good  dental history,  a thorough medical history and the examination then leads on to a correct diagnosis. Once the diagnosis has been established, you can then formulate a treatment plan for the patient. The treatment plan will consist of distinct stages which include prevention, immediate temporization, medium-term restorative treatment and long-term monitoring.

Consent must also always be gained and the consent must be valid. The patient must be able to understand what you have communicated to them and be able to make a decision that they feel best suits them. Consent therefore is an ongoing process as the treatment plan progresses from one stage to the next stage.

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dentistry Dominic Thorncroft

Dental Morphology Of Permanent Premolars

The term premolar is used to denote any tooth in the permanent dentition of mammals that replaces a primary molar.

There are 8 premolars – 4 in the maxillary arch and 4 in the mandibular arch. They can be identified by the International Numbering System using the formula of Viohla as teeth 14, 15, 24, 25 for maxillary premolars and 34, 35, 44, 45 for mandibular premolars.

Functions: The premolars function with the molars in the mastication of food and in maintaining the vertical dimension of the face. They assist the canines in shearing and cutting food morsels. All premolars support the corners of the mouth and cheeks from sagging, which is more visible in older people.

Fillings in premolars should be aesthetic, especially on mesio-occlusal surfaces of upper first premolars in patients with a wide smile and a high lip line.

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dentistry Dominic Thorncroft

Complications Of Sinus Lifting

Sinus Lifting

The name for this procedure is a “maxillary sinus floor augmentation” but you may also hear the terms “sinus augmentation” “sinus lifting” and “sinus graft” used. One of the major problems when trying to place implants in the upper jaw is that the maxillary sinus limits the amount of available bone height for the implant.

The way to encounter this is to lift the floor of the maxillary sinus and use bone to fill in the space created. It is a time-consuming and invasive procedure which has many complications. The complications can arise during the surgery itself but also afterwards.

In addition, complications can arise from the bone graft that has been placed. The bone-graft can be from your own body such as the lower mandible or another bone altogether such as in the hip or the leg. These are known as auto grafts and are not very popular now.

The bone can come from a different human being altogether and these are known as allografts.

Bone can also be used from cow bone or pig bone known as a xenograft.

Finally, there are a number of synthetic bone materials currently in use. These tend to be the preferred option nowadays.

It is interesting to note that maxillary sinus floor elevation without a bone graft results in new bone formation and a high implant survival rate instead of maxillary sinus floor augmentation with bone grafting.

The most common complications of a maxillary sinus augmentation procedure are the perforations of the schneiderian membrane which lines the floor of the sinus. A small tear or hole is not very problematic however a larger one means that the procedure has to be abandoned until healing has occurred in order to re-operate.

As with any surgical procedure, infection can occur and this is no exception with a maxillary sinus lift procedure. Pre-antibiotics and post-operative antibiotics are usually given but when an infection does occur and cannot be controlled, the procedure will be deemed to be failing and the infection needs to be controlled before an implant can be placed again.

Complications with bleeding do arise because there are a number of major blood vessels in the anatomical area. The infraorbital artery is a frequent one that is torn and this results in severe bleeding.

It is not uncommon for an implant to be pushed up past the floor of the maxillary sinus and the implant has gone astray. Another procedure has to be carried out in order to retrieve the lost implant.

Benign paroxysmal positional vertigo is one complication that can occur after a maxillary sinus augmentation and is particularly unpleasant for the patient. It can be temporary and is controlled by appropriate medication however it can become a permanent problem which is troublesome for the patient.

Complications seem to be more prevalent if the patient has an underlying health condition or is a smoker. For instance in smokers, perforation of the membrane is more common and that is because the schneiderian membrane is thinner in smokers. Another common underlying health condition is diabetes and these patients heal much less quickly and more poorly than normal healthy patients.

Chronic sinusitis is also fairly common and patients experience a different array of symptoms such as headaches, blocked nose, facial pain, changes in sensation when the head position suddenly changes, difficulty breathing through the nose, nasal obstruction and tenderness around the area. In acute sinus infection, facial pain, swelling is increased with purulent nasal discharge.

Due to all the possible complications of maxillary sinus lift operations, it is important to discuss with your dentist if there are any other viable options such as using shorter implants, using internal sinus lift technique which is less invasive and placing implants in a different region.

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dentistry Dominic Thorncroft

Disadvantages Of Mini Dental Implants

Mini dental implant usage continues to increase at a rapid rate in comparison to traditional or more conventional implants.

They are less complex, less surgery is required and the costs are significantly less. Overall, fewer complications arise from mini dental implants than conventional implants however there are certain things to be aware about beforehand. These are also the implants that many general dentists use rather than specialists.

Although there are many advantages in comparison to traditional and conventional implants, it is important to realise that they can have certain disadvantages but overall, their advantages easily outweigh their drawbacks which in any case can be predicted beforehand. The main disadvantages relate to the following three situations that can occur.

Disadvantage 1

A disadvantage of mini implants can be difficult to replicate and to look like a proper permanent tooth in the anterior region. This arises if there is a high smile line or if there has been extensive bone resorption. By definition, a mini dental implant has a diameter of between 1.5 mm to about 2.5 mm.

As a consequence, the abutment or head of the implant will be smaller than a more conventional implant. This can make it more difficult to restore the tooth so that it is aesthetically imperceptible from the adjacent natural teeth. The difficulty lies in achieving a good emergence profile.

The laboratory who will ultimately make the permanent crown, sometimes will try to navigate the difficulty with the emergence profile by over-contouring the permanent crown. If the patient is not capable of cleaning underneath the crown, peri-implantitis may occur as a result although these conditions seem to occur far less frequently than with conventional implants.

However, if the crown margin is not in the smile- line all or it is further back in the mouth, then this is not an issue at all.

Disadvantage 2

A mini dental implant is a one piece implant in that the abutment and the thread of the implant is all in one piece. This is one of the reasons why they are so much easier to place.

Due to these implants being a one-piece system, it is sometimes necessary clinically to use a 2 piece system where the crown and the implant have a different and significant angulation. Small differences in angulation can be accomplished by adjusting the implant abutment when prepping that tooth.

Where a more significant angulation is required which cannot be achieved by prepping the abutment, in these situations, a mini implant may not be suitable. However, if this is envisaged beforehand and the patient is willing to compromise the appearance, then these implants can still be used successfully.

Disadvantage 3

Mini dental implants have by definition smaller surface areas and therefore they cannot be used in areas of high loading. They can still be used for dental bridgework but the loading has to be commensurate with the situation.

You also have to be careful as with traditional implants when treating patients who have bruxism and clenching. As long as you are sensible and adhered to the manufacturers guidelines, you are in safe territory.

Once you know the limits of many dental implants, they are extremely advantageous and have important and significant features for long-term use.

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dentistry Dominic Thorncroft

Communication Skills For Dentistry

Communication Skills

A successful dentist will have good communication skills to build rapport and trust.

A good dentist will be able to really get along with his/her patients and this relationship is crucial for the management of their anxiety.

There are various communication strategies, general and specific, both of which are very important. This communication should always be two way but the dentist should first take the lead and a good place to begin is to introduce themselves and their nurse personally with the patient in the treatment room.

Initially, ask them something non-dental and just listen carefully in a calm, composed way. A general question asking them about their dental concerns is information to be acquired from the patient but also to listen about their fears which forms part of the iatrosedative technique.

Further down the line, patients should be encouraged to ask questions about their treatment and should be kept fully informed about what they think can be done before starting any treatment and also during their treatment/care.

Treatment

During any treatment, you and your nurse need to keep inquiring if the patients are having any discomfort, want to have a break and to give continuous moral support plus to always reassure during the procedure. The patient should feel genuinely that their words are taken seriously and with caring concern.

Following GDC guidelines/principles, dentists should give all the necessary complete information regarding description of the treatment, alternative treatment options, costs, advantages, disadvantages, lifespan and preventive advice. Consent should be informed and valid.

This initial visit is the hub to build good rapport and increase the patient’s confidence in the dentist. Patients appreciate clear, honest, and straightforward answers in a language that makes sense to them avoiding medical terminology/jargon; one must also avoid unrealistic outcomes or reassurances, as these can break trust.

Normalizing feelings of being nervous does help and avoiding negative phrasing can be beneficial so always put phrases into the positive.

Nonverbal communication with patients is an essential acquired skill. Dentists and their staff should go on NLP courses to learn anchoring, circle of excellence, reading eye cues and mirroring. Touch can be used to comfort and guide nervous and phobic patients.

The dentist with their dental nurse on the 1st visit should face the patient, make eye contact, nod gently and observe them. Talk less and listen more! Avoid hurrying them, mirror movements, empathize with the patients, and make them feel welcome, and use non-jargonistic words when talking about the treatment.

Usually, a friendly, sensitive, and sympathetic approach is all that the patient wants and will be well appreciated. Patients then go home and will brag about how good you all are.

The Distraction Technique

Distraction is a very useful technique of moving the patient’s attention from what they perceive as an unpleasant procedure/process. This enables decreased anxiety levels and avoids negative or avoidant behaviours.

Giving the patient a short break during all procedures can be an effective use of distraction such as asking them to have a quick rinse out even though they may not need one. Always use a simpler procedure prior to considering more advanced procedures such as carrying out a fissure sealant before a composite filling.

Several technological options are available for both visual and auditory distraction such as bringing your own music device, background music of their choice, television sets on the ceilings , computer games to play, and also 2-D/ 3-D video glasses for watching movies.

Suitable music has been shown to influence in a good way human brain wave activity leading to deep relaxation and therefore alleviating pain and anxiety.

Music distraction is a non-invasive technique which is low cost and easy in which the patient listens to pleasant music during a procedure such as a normal crown prep which involves sounds to be drowned out. The best use of this is to ask the patient to bring their own music in.

Enhancing Control

Loss of control over being at the dentist is a significant cause for anxiety, and hence providing control is very essential. Telling the patient what to expect and how everything will be fine will help make the treatment and them as comfortable as possible.

“The Tell-Show & Do Method”

Control can be provided with this “The Tell-Show and Do Method.”

The Tell-show-do is a behaviour shaping technique that reduces uncertainty and increases predictability for the patient in the clinical setting and non-clinical aspects of going to the dentist.

This “Tell-Show and Do Method”/technique can be used for both children and adult patients.

It involves a verbal explanation of procedures in phrases appropriate to the developmental level of the patient (This is called: tell); Then we have a demonstration for the patient of the sensory modality visual, auditory, olfactory, and tactile aspects of the procedure in a carefully defined manner which your nurse can also do: (show); and then the completion of the procedure: (do).

“Tell-Show and Do Method” is also used with communication skills (verbal and nonverbal) and positive reinforcement. However TSD can’t be used for injections.

Modelling As a Technique

It is shown that Individuals learn much about their environment from observing other people’s behaviour. Modelling is a technique used to alleviate anxiety/phobias. This can be achieved through observation of a dental procedure either by viewing a videotaped model who is demonstrating appropriate cooperative behaviours in the dental setting or through observation of an actual live successful dental procedure.

This could reduce anxiety due to removing “fear of the unknown” and demonstrates to the anxious patient what is considered appropriate behaviour in the dental practice environment setting and also as to what can be expected in the upcoming treatment plan. 

When setting up the Modeling technique/program, the following details should be taken care of: the model should be close to the age of the patient, the model should be shown also as entering and leaving the surgery to prove treatment has no adverse effect and the dentist/nurse/receptionist should be shown to be a caring person who praises the patient.

Signalising Controls

Signaling control involves giving the patient a chance to feel that they are in control of the treatment procedure and involves signalling to the dentist to stop the procedure.

And this increases the patients’ sense of control and trust in the dentist. A signal can be as simple as a raised hand to notify the dental practitioner that the patient would like to stop the procedure. The actual specific signals can be decided before the treatment commences.

The dentist should always stop the procedure as agreed earlier because failure to do so will breach the trust/relationship. Patients can also be given mirrors to watch the procedure, so as to feel they are in control but it depends what the procedure is and most don’t want to look.

Systematic Desensitization Technique / Exposure Therapy

Wolpe’s technique known as “systematic desensitization”, is based on relaxation and played a very prominent role in behavior therapy during the 1960s and 1970s. The treatment procedure is carried out in multiple sessions and the use of systematic desensitization involves three sets of activities.

Firstly, to encourage the patients to discuss their status of fear and anxiety, in order to construct a hierarchy of feared dental situations, from the least to the most anxiety-provoking.

Then the second step is to teach the patient certain relaxation techniques. The most commonly used techniques are progressive breathing and muscle relaxation. The final step is to gradually expose the patient to these situations from the least to the most anxiety-promoting.

When it is difficult to expose the patient directly to the dental setting, it may be appropriate to instruct the patients to practice imaginary systematic desensitization wherein the patients are encouraged to imagine that they are entering the dental clinic, able to sit in the dental chair, and eventually able to receive dental treatment. Flooding or implosion therapy is an intensive form of in vivo exposure therapy for treating phobias.

The patient is confronted with the feared stimuli for repeated and prolonged duration until they experience a reduction in their anxiety level using Systematic desensitization technique/ exposure therapy.

Positive Reinforcement

Positive reinforcement is an effective technique to reward desired behaviours and thus strengthens the recurrence/repeating of those behaviours.

Reinforcers include positive voice modulation, positive facial expression such as smiling or nodding, obvious verbal praise and appropriate physical demonstrations such as tapping their arm. These when individualized, frequently provided, and varied over time produce anchors.

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dentistry Dominic Thorncroft

Denture Cleaner

Denture cleaners at home consist of manual cleaning, chemical cleaning and both.

All dentures must be cleaned in a similar fashion as cleaning natural teeth because oral bacteria will still build up on surfaces of all dentures. If the denture is not cleaned regularly, it will soon build up bacteria which can harm your gums and any remaining teeth if you still have any.

In addition, an infection called denture stomatitis can arise which is quite difficult to treat once it has taken hold in your mouth.

A denture cleaner can be one that a dentist uses or one that you can use at home.

For a small fee, you can ask your dentist to clean any stubborn marks or calculus on your dentures. Many patients don’t know that calculus or tartar which used to build on your teeth can also build upon the surface of the denture.

This cannot be brushed off manually and needs to be cleaned mechanically using an ultrasonic scaler which the dentist or the dentist’s laboratory have access to.

Denture cleaners at home consist of manual cleaning, chemical cleaning and both.

Manual cleaning consists of using a denture brush with a cleaning agent in the form of a paste. It is perfectly acceptable to use a normal manual toothbrush with a normal toothpaste. However, denture brushes seem to have harder bristles so they can be seen to be more effective.

Chemical cleaning usually consists of tablets which are dissolved in running water and then the denture is soaked in them.

You can also buy mechanical ultrasonic cleaners under the counter.

 A cleaner must have several characteristics in that it must be able to remove bacteria that builds on the denture, must have a pleasant taste, must not alter the colour of dentures and must not weaken the physical nature of your dentures.

Which is the best denture cleaner to use? Without a doubt, manual cleaning using a toothbrush and paste is the best but some patients may have difficulty using this so additional denture cleaners as mentioned above can be used either on their own or as an adjunct.

When you are at the dentists, always ask if they have samples of denture cleaners which they get for free and which you can try out yourself.

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dentistry Dominic Thorncroft

Gum Pain After An Extraction

Gum pain can occur after you have had a tooth extracted. If you have had several teeth taken out then this gum pain will be more likely and more common than just having a simple extraction of one tooth carried out.

Gum pain after an extraction may be simply due to where you had the injection placed prior to the extraction. The injection site has just caused a bruising. This usually clears up after 24 hours after the extraction.

Gum pain after an extraction is often due to the physical trauma of having a tooth or teeth removed. After all, an extraction is a surgical procedure and all surgical procedures cause an initial trauma to the body which the body responds to.

The pain from a trauma after extraction will be dealt with by the body’s natural healing process which may take seven days.

However, if the extraction was particularly difficult and you think that you may have an infection, you should go and see a dentist who may need to prescribe you antibiotics and further painkillers to prevent the infection for occuring or going further.

Gum pain can also be caused by a condition called dry socket. A dry socket is simply a socket which has become infected. The gum will appear red, swollen and will be extremely painful to touch. Dry socket is more likely if the extraction was a difficult one or you are a smoker.

In all cases, you should go back and see your dentist who will advise you further.

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dentistry Dominic Thorncroft

Dentures Or Implants

This is a common question amongst patients and it can sometimes depend on who you go to. If you go to an implant dentist, he or she will tell you that implants are the best solution. However if you go to a dentist who specialises in dentures, he will tell you that dentures are better.

In reality, the answer lies between the two.

Implants are not suitable for all situations and likewise, dentures are not suitable for all patients either.

To make an informed choice, various bits of information need to be made available to you. This includes costs. But within this, you need to know the initial costs but also ongoing costs and long-term costs of treatments and possible complications that can occur with any treatment.

How long will the treatment take is a good question to ask. You may not want to or be able to undergo a lengthy complex treatment involving long sessions and many visits.

The chances of success also need to be weighed up appropriately. Although implants may seem a good solution for you, complications may arise and you should be aware of these and how these could be dealt with.

Your expectations with a certain treatment are important. You may need to be aware that if you are having dental implants and dentures made, they may move about and you may not become used to them very easily. On the other hand, having an implant may not have the exact aesthetic results that you expect and you could be disappointed.

Finally, when exploring the decision between implants or dentures, you need to also explore subcategories of each. For instance, dentures have evolved and different types are available as with implants as well.

Always take your time in making the correct decision and be prepared to get second and even third opinions.

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dentistry Dominic Thorncroft

Case Study – Defective Filling

Case Study

Consent is a complex subject and although there are universally agreed principles there are also certain “grey areas” when the dental team needs to make their own balanced judgements. For consent to be valid, the patient must have received enough information to make the decision.

This is what we mean by ‘informed consent’. Giving and getting consent is a process, not a one-off event. It should be part of an ongoing discussion between the dentist and the patient. The Montgomery ruling with regards to consent has replaced the previous ruling with Bollam. The dentist must therefore share all material risks as well as those that he thinks that the individual patient would want to know.

The guidance states that the dentist needs to find out what your patients want to know, as well as telling them what you think they need to know. So examples of information which patients may want to know include:

  • Why you think the proposed treatment is necessary.
  • The risks and benefits of the proposed treatment.
  • What might happen if the treatment is not carried out?
  • And other forms of treatment, their risks and benefits.
  • And whether or not you consider the treatment is appropriate.

This case was discussed whereby a patient came in and the examination revealed a defective filling in LL5. The notes revealed that this restoration had only been done in the last 6 months at another dentist.

Furthermore, the reason had been to remove a previous overhang. The patient was informed and it was proposed to correct the filling material and the options were given to the patient including demonstrating on the patient’s own radiographs. In the end, the patient decided not to have further treatment as this was now going to be the third lot of treatment for this tooth.

In addition, the patient made it clear that should she experience any symptoms, then she would have an extraction. It was therefore decided to keep the tooth under observation.

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dentistry Dominic Thorncroft

What Is Atypical Facial Pain?

Atypical Facial Pain

‘Atypical’ pain is a diagnosis of exclusion after other similar conditions have been investigated and eliminated, hence the reason why it is diagnosed late in the day at frustration for many patients.

But it is idiopathic and is characterized by chronic, constant pain without any apparent cause in the face or brain.

Cause

Atypical odontalgia or phantom tooth pain is a variation of atypical facial pain where intense discomfort is associated with a particular tooth or group of teeth with no obvious dental cause on examination, special tests or on a radiograph.

Atypical facial pain syndrome is more common in women than in men with most patients aged between 30 and 50 years. The most commonly affected area is the maxillary region although any area of the face can be involved.

Clinical presentation of Atypical Facial Pain is very variable in its presentation but mostly described by a continuous, daily pain of variable intensity with no cause. Typically, the pain is deep ( unlike trigeminal neuralgia) and poorly localized and is described as dull and aching. It does not awaken the patient from sleep.

Characteristics

At initial onset the pain may be confined to a limited area on one side of the face, while later in the day, it may spread to involve a larger area.

Atypical odontalgia is characterized also by a continuous, dull, aching pain of moderate intensity in apparently normal teeth or endodontically treated teeth and occasionally after an extraction or post-extraction sites. 

Atypical odontalgia is a variation localised to a tooth. It is not usually affected by testing the tooth with cold, heat or electric stimuli. Moreover, the toothache frequently remains unchanged for months or years hence the differentiation of atypical odontalgia from pulpal/periodontal origin dental pain.

Treatment

Many a dentist will end up extracting the tooth but the pain remains in the underlying alveolar ridge. Occasionally, the pain may spread to adjacent teeth, especially after extraction of the painful tooth or after an unnecessary extraction.

The lack of a demonstrable organic/physical cause will cause a high level of anxiety and depression among these patients. Often, they will see multiple dentists and become increasingly disillusioned by the advice received.

Genetic factors could be important in some patients with chronic facial pain as their nerves are susceptible to damage from minor insults that would not normally produce chronic pain and this can be seen in patients where this type of pain follows a successful minor/easy procedure such as a tooth extraction.

There are no specific tests that can confirm the diagnosis of idiopathic/atypical facial pain and is based on not finding any other cause.

Treatment of Atypical or Idiopathic facial pain is managed by a variety of ways including medication, psychological treatments and physical treatments such as acupuncture or TENS nerve stimulation.

But many of these patients have a poor response to all treatment options and will do the rounds having had consultations with a lot of specialists, multiple ineffective alternative therapy treatments, and even surgical explorations at considerable costs and considerable stress to their partners/family. 

As mainstream treatments can be ineffective a different approach is to accept the pain but try to improve patients quality of life as well as trying to ease some of the pain often with an increase in mood, activity and social contact. Analgesics will not work for atypical facial pain.

Pain relief is mainly through the use of tricyclic antidepressant and anti-epileptic drugs intended normally for use in the treatment of depression or epilepsy but have proved very helpful in these patients. 

The tricyclic antidepressants such as amitriptyline and nortriptyline are often generally helpful in both reducing pain experience and improving mood and coping with the associated depression including some placebo effect that something is being done.

Interestingly, newer antidepressant drugs such as fluoxetine and paroxetine seem less effective. 

However, the newer antiepileptic medications such as gabapentin and valproate are very successful also in treating neuropathic pain.

 Education, physical therapy, psychological/CBT/NLP counselling, and alternative pain management strategies, such as acupuncture and TENS/biofeedback, may also be useful in holistic patient care. Surgical procedures are rarely effective and can aggravate the condition and may lead to a painful permanent disabling facial numbness.

Atypical odontalgia patients may undergo many unsuccessful unnecessary dental procedures before the correct diagnosis is made. Once the diagnosis is made, dental treatment aimed to relieve the pain is not advised since it can result in further deterioration of the patient’s dentition without any beneficial effect on the pain.

Gabapentin combined with tricyclic antidepressants can make the extremes of the pain less severe but must be used continuously and not only during an acutely painful episode.