Tooth Loss in the Chronic Pain Population
"Suffering” is a term notably absent from most medical dictionaries and is different from “pain.” Suffering is the negative emotional or psychological state that occurs in response to or in anticipation of nociception, whereas pain is the perceived nociception.1
Chronic pain is persistent pain that becomes part of the patient’s daily routine and is often resistant to medical treatment because of neuroplastic changes throughout the central nervous system (CNS).2 Chronic pain may present with psychopathologic symptoms, such as depression, and an increased possibility of comorbid conditions with links between stressor effects on the CNS and digestive, respiratory, musculoskeletal, cardiovascular, endocrine, and immune systems.3
With many chronic pain conditions, we also see concomitant social, behavioral, and psychological disturbances that may precede or follow the development of pain. Patients report feelings of frustration, anxiety, depression, hypochondriasis, and anger during chronic pain. Maladaptive behaviors, such as poor sleep and dietary habits, lack of exercise, bruxism, poor posture, and medication dependence also can be seen in patients with chronic pain. Each of these may complicate the clinical picture by perpetuating the pain, preventing compliance, and causing the development of self-perpetuating chronic pain cycles.4
Recently, an increasing number of chronic pain patients and their treating practitioners are recognizing the loss of teeth as a source of aggravation, suffering, and even increased pain. Participating in the active practice of dentistry since 1967, I have seen many patients lose teeth as a result of decay and periodontal disease due to poor oral hygiene and a lack of proper professional dental care. However, in the past 20 years, I have seen an increase in the number of teeth lost due to the effects of chronic pain from non-oral issues. This article will explore some of the causes of tooth loss in chronic pain patients.
Common Causes of Tooth Loss
What are the common causes of tooth loss in the adult population? People lose teeth because of trauma—excess forces to the oral cavity that have the ability to fracture a tooth or cause avulsion of the tooth or teeth. This is not related to tooth loss due to chronic pain. However, when a tooth or teeth are lost because of pain, we are always faced with certain questions:
- Is the pain the result of an underlying pathology unrelated to the “toothache” or did the toothache result from lack of proper oral hygiene or poor nutrition, leading to tooth decay and/or periodontal disease that ultimately resulted in pain and loss of teeth?
- Did a “chronic pain” situation result in the change in lifestyle (poor oral hygiene) that led to the tooth loss?
- Did the side effects of the common medications used to treat chronic pain lead to the change in lifestyle, poor oral hygiene, poor nutrition, and loss of saliva that resulted in decay, periodontal disease, and ultimately tooth loss?
Central Pain Manifests As Tooth Pain
Because dental pain is a common cause of chronic orofacial pain, the clinician can be easily drawn to this diagnosis, especially when the patient convincingly reports that the pain is emanating from a particular tooth. It is a frustrating experience for both the patient and the clinician when a “toothache” continues long after sound dental treatment has been completed. It is not uncommon to hear patients report a history of multiple endodontic procedures (root canal treatments) followed by extraction of the tooth or teeth with no reduction in pain.5-7
There are many structures in the head and neck that can produce heterotopic pain in a tooth. These heterotopic pains occur as secondary effects from central sensitization or excitation of the second-order neurons produced by a constant barrage of nociceptive input from deep structures.5,6 In these cases, the healthcare provider must investigate the underlying cause of pain, and address those issues in order to prevent further tooth loss.
Chronic Pain Can Lead to Poor Dental Hygiene
Chronic pain has an emotional, psychological, and physical impact on the way a person conducts his or her day-to-day life. This includes but is not limited to lack of proper diet, poor sleeping habits, and poor personal and oral hygiene. The chronic pain situation becomes a “catch-22” for the individual, with each circumstance presenting a dilemma because of mutually conflicting or dependent conditions. The question is whether a chronic pain condition or state resulted in this lifestyle change that led to tooth loss or decay.
Consistent with the learned helplessness theory, once pain becomes chronic, continuous unsuccessful coping efforts may cause depressogenic cognitions of helplessness and may further amplify both functional disability and depression.8,9 When, in time, the pain proves uncontrollable and consequences of this now chronic condition in daily functioning are inescapable, helplessness may even surpass the fear of pain.10,11
Depression is one of the most serious and common consequences of chronic illness.12 It has been associated with increased morbidity (and mortality) and affects people of all ages. Among patients with chronic pain, estimated at 19% of the population, 21% suffer from depression.13 With depression being one of the most prevalent comorbid conditions, many patients with chronic pain stop the regular care and treatment of their dental needs. This can and will ultimately lead to dental disease—resulting in even more pain and, finally, to the extraction of the offending tooth or teeth.
For the person experiencing chronic pain, the quest for relief often remains elusive. People who experience chronic pain must confront not only the stress created by the pain, but also a cascade of ongoing stressors that may compromise all aspects of their lives. Living with chronic pain requires considerable emotional resilience; chronic pain tends to deplete emotional reserve and taxes not only the person experiencing the pain, but also the capacity of significant others to provide support.14
Medications Can Contribute to Tooth Loss
One common side effect of many medications used by pain patients is xerostomia (dry mouth). The lack of saliva can lead to an increase in cavities. It is recommended, therefore, that patients keep hydrated by sipping water regularly, chew sugarless gum or suck on sugarless hard candy, breathe through their nose, brush teeth twice a day and have regular dental check-ups, and consider using a moisturizing mouth spray. Unfortunately, patients with “dry mouth” often consume sugared drinks, sugared chewing gum, and hard candies, which often lead to increased dental caries (decay).
Common medications with side effects that can cause tooth decay include: