Ray D’Alonzo, Ph.D., is a visiting professor in the Chemistry Department of the University of Massachusetts Amherst and a retired R&D Manager of Procter & Gamble where he worked for over 31 years.  He has led research programs in bone metabolism, infectious disease, respiratory disease, arthritis, and nutrition and has published scientific papers on a wide variety of topics from the chemical composition of fats and oils to the pharmacoeconomics of osteoporosis.  Dr. D’Alonzo is the recipient of the Chancellor’s Medal from the University of Massachusetts, Amherst, in part, for his contributions to the development of new pharmaceutical agents.  As both a patient and scientist, he has made a personal effort to increase the awareness of Chiari in the health care sector and to assist others afflicted with the syndrome.  He has published the story of his personal struggle with Chiari in a book, Contents Under Pressure, with 100% of royalties going towards Chiari education, awareness, and research programs.

January 31^st, 2009 --     

Many Chiari patients have symptoms that are unusual or strange and do not fall into any of the major symptom categories of Chiari such as headache, weakness, balance problems, or swallowing problems.  Nevertheless, the symptoms of Chiari can be extremely diverse and individualized making it difficult to dismiss unusual symptoms as possibly not related to Chiari. 

In this newsletter article, I will address one unusual symptom, unexplained or phantom tooth pain also known as atypical odontalgia or AO.  Why?  To be honest, my interest stems from the fact that I personally experienced it and over the years I have encountered a handful of other Chiari patients who have mentioned it.  In fact, my tooth pain led to crowning a tooth with no clinical signs or symptoms other than pain and without radiographic evidence of tooth fracture.  I think it is also reasonable to consider odontalgia as a possible Chiari symptom because it is well documented that lower cranial nerve compression due to Chiari can cause facial and throat pain.  

To look into this situation, I decided to begin by performing a literature search.  The first terms that I searched for were Chiari and tooth pain which expectedly resulted in no hits.  I then searched trigeminal neuralgia and tooth pain.  Trigeminal neuralgia is a term used to describe pain in the face stemming from the trigeminal or 5^th cranial nerve.  The literature documents the fact that Chiari can sometimes compress the 5^th cranial nerve resulting in trigeminal neuralgia.  This search produced several hits however I quickly noticed that I should have been using the medical term for phantom tooth pain, atypical odontalgia (AO), so I repeated the search simply using that term.  While a search using the term odontalgia resulted in over 2,200 hits, a more relevant search using the term atypical odontalgia produced 85 hits.  Refining the search to show only entries involving humans for which abstracts were available in English produced 59 hits.  Of the 59 abstracts, I found 14 to contain relevant information.  These 14 papers were published between 1982 and 2009. 

Some of the very first facts I noticed of interest were that patients with AO are predominately women^1-3 and that prior to the early 1990’s were often dismissed as having a psychological defect.  I also could not help but notice that OA is often successfully treated with tricyclic antidepressants^4-7.   With regard to these aspects, Chiari is a very similar picture.  In the early 1990’s however a couple of good papers were published refuting the idea that AO has psychogenic origins^8,9 after which time the literature becomes focused on the real pathophysiological causes of OA.  Three papers^1,10,11 also provided data on the prevalence of OA indicating estimates ranging from 2 to 6%. 

When looking for pathophysiological explanations of AO, four papers were of particular interest^6,12-14.  While several causes of AO were identified including pulpitis (inflammation of the dental pulp), cranial nerve tumors, temporomandibular disorders, fibromyalgia, and tension headaches all four papers mentioned neuropathic alteration of the trigeminal nerve as a possible cause.  Since we know that Chiari can falsely present as trigeminal neuralgia, it is reasonable to assume that Chiari is responsible for a small number of AO cases.  If you have tooth pain in the absence of clinical or positive radiographic findings and you have Chiari it may be wise to avoid getting a crown or dental surgery in the hopes it will alleviate the pain.  Rather, discuss with your dentist or doctor the option of managing your neuropathic tooth pain with an appropriate medication such a tricyclic antidepressant, clonazepam, or pregabalin.   

¹J Am Dent Assoc. 2009 Feb;140(2):223-8.

²Arg Neuropsiquiatr. 2004 Dec;62(4):988-96.

³Headache. 2003 Nov-Dec;43(10):1060-74.

⁴Northwest Dent. 2008 Jan-Feb:87(1):37-8.

⁵J Contemp Dent Pract. 2007 Mar 1;8(3):81-9.

⁶J Calif Dent Assoc. 2006 Aug;34(8):599-609.

⁷Oral Surg Oral Med Pathol. 1992 Apr;73(4):445-8.

⁸ Oral Surg Oral Med Pathol. 1993 Feb:75(2):225-32.

⁹ Oral Surg Oral Med Pathol. 1993 May;75(5):579-82.

¹⁰Aust Endod J. 2000 Apr;26(1):19-26

¹¹Oral Surg Oral Med Oral Pathol. 1982 Feb;53(2):190-3.

¹²J Oral Rehabil. 2008 Jan;35(1):1-11.

¹³J Can Dent Assoc. 2004 Sep;70(8):542-6.

¹⁴Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1998 Jan;85(1):24-32

-- Ray D'Alonzo

 ** If you would like to share your comments, thoughts, or ideas with Ray,  please send them to dalonzo.rp@gmail.com.  Due to the volume and nature of email received, individual responses are not possible. **

[Ed. Note:  The opinions expressed above are solely those of the author.  They do not represent the opinions of the editor, publisher, or this publication.  Mr. D'Alonzo is not a medical doctor and does not give medical advice.  Anyone with a medical problem is strongly encouraged to seek professional medical care.]    

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