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J Endod. Author manuscript; available in PMC 2016 April 01.
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Published in final edited form as:

J Endod. 2015 April ; 41(4): 457–463. doi:10.1016/j.joen.2014.12.012.

Differential Diagnoses for Persistent Pain Following Root Canal

Treatment: A Study in the National Dental PBRN
Donald R. Nixdorf1,2,3,*, Alan S. Law4,5, Mike T. John1,6, Radwa M. Sobieh7, Richie Kohli8,
Ruby H.N. Nguyen6, and National Dental PBRN Collaborative Group9
1Division of TMD and Orofacial Pain, School of Dentistry, University of Minnesota, Minneapolis,
MN
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2Department of Neurology, Medical School, University of Minnesota, Minneapolis, MN

3HealthPartners Institute for Education and Research, Bloomington, MN
4Private Practice, The Dental Specialists, Lake Elmo, MN
5Division of Endodontics, School of Dentistry, University of Minnesota, Minneapolis, MN
6Division
of Epidemiology & Community Health, School of Public Health, University of Minnesota,
Minneapolis, MN
7Private Practice, Norfolk, VA
8Dental Public Health, Portland, OR
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Abstract
Introduction—Pain present 6 months following root canal treatment (RCT) may be either of
odontogenic or nonodontogenic origin. This is importance because treatments and prognoses are
different; therefore the aim of this study was to provide specific diagnoses of patients reporting
pain 6 months after receiving initial orthograde RCT.

Methods—We enrolled patients from the Midwest region of an existing prospective

observational study of pain after RCT. Pain at 6 months was defined as ≥1 day of pain and average
pain intensity of at least 1/10 over the preceding month. An Endodontist and an Orofacial Pain
practitioner independently performed clinical evaluations, which included periapical and cone-
beam CT radiographs, to determine diagnoses.

Results—Thirty-eight out of the 354 eligible patients in the geographic area (11%) met the pain
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criteria, with 19 (50%) consenting to be clinically evaluated. As the sole reason for pain, 7 patients

© 2014 American Association of Endodontics. All rights reserved.

*
Corresponding author: Donald R. Nixdorf, DDS, MS, 6-320 Moos Tower, University of Minnesota, 515 Delaware Street S.E.,
Minneapolis, MN 55455, Phone: 612-626-5407, Fax: 612-626-0138, nixdorf@umn.edu.
9The National Dental PBRN Collaborative Group includes practitioner, faculty and staff investigators who contributed to this activity.
A complete list is at http://nationaldentalpbrn.org/
The authors deny any conflicts of interest
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 Nixdorf et al. Page 2

(37%) were given odontogenic diagnoses (4 involving the RCT tooth, 3 involving an adjacent
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tooth). Eight patients (42%) were given nonodontogenic pain diagnoses (7 from referred
temporomandibular disorder (TMD) pain, 1 from persistent dentoalveolar pain disorder (PDAP)).
Two patients (11%) had both odontogenic and nonodontogenic diagnoses, while 2 (11%) no
longer fit the pain criteria at the time of the clinical evaluation.

Conclusion—Patients reporting “tooth” pain 6 months following RCT had a nonodontogenic

pain diagnosis accounting for some of this pain, with TMD being the most frequent
nonodonotgenic diagnosis. Dentists should have the necessary knowledge to differentiate between
these diagnoses to adequately manage their patients.

Keywords
Root Canal Therapy; Tooth; Pain; Chronic; Temporomandibular Disorders; Diagnosis
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Introduction
Approximately 20 million Americans receive root canal therapy (RCT) each year (1).
Persistent pain after RCT is known to occur and is not an uncommon event, being estimated
by meta-analysis to be 5.4% (2) and by prospective observation to be 10.0% at 6 months
following RCT (3). Taxonomy of diagnoses underlying persistent pain after RCT can be
broadly classified as either odontogenic (4) or nonodonogentic (5) in etiology. A previous
meta-analysis found that 56% of all patients with pain present 6 months or more following
RCT had a nonodontogenic etiology for this pain (6). This suggests that with the 10%
occurrence rate of persistent pain, with half from nonodonotogenic etiology, that
approximately 1 million Americans experience “tooth” pain and would not benefit from
dental interventions, such as endodontic retreatment or tooth extraction.
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While odontogenic sources for such pain are well described, information about
nonodontogenic sources primarily resides in cross-sectional case-reports (7) and case-series
(8, 9). While these reports provide information about the clinical features necessary to
diagnose patients, they do not further our understanding of the prevalence of these
conditions in dental clinic populations. Some studies have reported on the frequency of pain
consistent with the diagnosis of Persistent Dentoalveolar Pain disorder (PDAP) following
RCT (10, 11), as well as assessing the different diagnoses (12), no study has followed a
cohort of patients of RCT patients with persistent pain to determine the various diagnoses
underlying this pain. Furthermore, the retrospective nature of the systematic review that
estimated about 50% of patients had nonodontogenic pain (6) allows only for a dichotomous
outcome but does not provide information about the types of nonodontogenic diagnoses.
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Therefore, to inform and improved clinical decision-making, it is necessary to recognize the

differing diagnoses accounting for the symptom of pain in RCT patients. This study aimed
to provide specific diagnoses of patients reporting pain 6 months after receiving initial
orthograde RCT. Also, as a secondary aim, we reported the patient charateristics, as well as
their clinical signs, symptoms, and imaging findings to describe how such patients may
present to their dentist for evaluation.

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Methods
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Existing Parent Observational Cohort of RCT Patients

This study originated from a large-scale prospective longitudinal cohort study following
patients that received RCT from dentists enrolled in the National Dental Practice-Based
Research Network (13, 14). Sixty-two practitioner investigators in 5 geographic regions:
Alabama/Mississippi, Florida/Georgia, Minnesota, Permanente Dental Associates in
Oregon/Washington, and Scandinavia (Denmark and Sweden) were trained regarding the
standardized study protocol. Enrollment and baseline data collection occurred over 6 months
with follow up at 6 month after RCT. Patients and dentists completed questionnaires before
and immediately after treatment visits. Patients also completed questionnaires at 1 week, 3
months, and 6 months after RCT. For more details of this parent study, see the publication of
the Study Methods (15). Ethics approval was garnered from each institution involved in the
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parent study, as well as the nested study (University of Minnesota).

Selection criteria of the parent study

Inclusion criteria included: patients aged 19 to 70 years and patients with a permanent tooth
requiring initial orthograde RCT. Exclusion criteria included; iatrogenic pulpal exposure
(cases with carious exposure are included), previously enrolled in the parent study (each
patient could only contribute 1 tooth to the study), previous endodontic treatment (previous
treatment would make it unclear whether pain was associated with the prior treatment or
attempt at treatment), obvious cognitive impairments (e.g., previous stroke with
communication deficits, dementia or mental disability), the inability to read, understand, or
complete the baseline patient questionnaire, and the anticipated inability to provide 6-month
follow-up information.
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Primary outcome measure of parent study

In the parent study, all enrolled patients were asked to complete a follow-up patient survey
at 6 months following the obturation of the RCT treated tooth. The primary outcome
measure of persistent pain at 6 months was defined by 2 questions: “How many days in the
past month have you had pain in the area that was treated with a root canal?” and “In the
past month, on the average, how intense was your tooth pain rated on a 0 to 10 scale where
0 is ‘no pain’ and 10 is ‘pain as bad as could be’?”. A positive response (≥1) to both
questions was the criteria for persistent pain in this parent study. Patients that did not meet
these criteria were defined as non-cases, which included patients providing discordant
responses (e.g., patients that reported ≥1 having pain for more than one day in the past
month but did not report ≥1 pain level).
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Eligibility criteria and enrollment for nested study

Patients meeting the criteria for persistent pain in the parent study were eligible to enter this
study. For feasibility reasons, namely local proximity, only patients within the Midwest
region (Minnesota) of the network were considered for inclusion in this study so that
patients could travel for evaluations to be held in one central location. Therefore, eligible
patients were treated by one of the region's 33 dentists (7 endodontists, 26 general dentists)

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who had practices mostly in the Twin Cities area, but also in out state Minnesota and
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western Wisconsin.

Study setting and data collection protocol

This study was conducted in the Oral Health Clinical Research Center at the University of
Minnesota School of Dentistry, Minneapolis, Minnesota. Patients were independently
evaluated by a board certified Endodontist (ASL) and a board certified Orofacial Pain
practitioner (DRN). Each practitioner performed a complete history and clinical examination
independently, following accepted practices in each discipline, and reviewed the periapical
and cone-beam CT (cbCT) radiographs that were obtained on all patients. Odontogenic
diagnoses followed diagnostic criteria and terminology established for periapical/
periradicular disease (16-18), while those for nonodontogenic diagnoses followed the
orofacial pain criteria outlined in a current textbook (5). More specifically, the orofacial pain
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diagnoses were derived following the criteria for temporomandibular disorders (TMD) (19),
neurovascular disorders (20), neuralgias (20), and PDAP (21). The final diagnoses were
derived by consensus discussion between the two evaluators using all available data
collected.

Data management and statistical analyses

The data were recorded on paper forms and entered in the database (Excel version 14.3.2 for
Mac, Microsoft, Seattle, WA) with single entry and verification by another individual.
Statistical analyses were performed using the same software (means and t-tests to describe
continuous variables, proportions and chi-square tests for categorical variables) with
associated 95% confidence intervals.
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Results
The parent research study enrolled 390 patients in the Midwest region at baseline, and 354
(91%) returned data at 6 months, which comprised the study sample for this nested study. Of
those 354 patients, 38 (11%, 95% CI: 8-14%) met criteria for pain at 6 months following
RCT and were considered eligible cases, which was slightly higher than 10.0% observed
over the entire (“parent”) study population (3). Only subjects that had consented to be
contacted were invited to participate in this study. Nineteen of the 38 patients meeting
persistent pain criteria (50%) agreed to participate in the nested study and were evaluated at
the University of Minnesota. The average time from completion of the 6-month
questionnaire to when the clinical evaluations were performed was 65 days (SD=41). The 19
patients not evaluated were found to be similar to those who were evaluated (Table 1).
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Patient and tooth characteristics

The mean age of patients with pain was 49 (SD±13) years old (Table 1). Most patients were
White (89%), non-Hispanic or Latino (100%), female (84%), with dental insurance (89%).
Maxillary teeth compromised 53% of treated teeth and 89% were posterior teeth. Soft tissue
assessment of all teeth was within normal limits. Of the 19 root canal treated teeth, none
responded to pulp testing, had mobility, or cracks detected. Sixteen (84%) teeth were
restored with permanent crowns, with the remaining teeth were posterior teeth and restored

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with amalgam (n=2) and composite (n=1) materials. Most of the teeth (79%) showed no
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signs of periodontal disease with probing pocket depths ≤3mm. Only one tooth had
significant periodontal bone loss at a probing depth of 6mm.

Experts' consensus diagnoses for persistent pain

Clinical evaluation of the 19 patients revealed that 7 (37%, 95% CI: 15-59%) had
exclusively odontogenic reasons for their pain symptom, 8 (42%, 95% CI: 20-64%) had
exclusively nonodontogenic reasons, 2 (11%, 95% CI: 0-24%) had mixed odontogenic/
nondontogenic reasons, and 2 (11%, 95% CI: 0-24%) were pain free and considered normal
at the time of evaluation (Figure 1).

1. Exclusively odontogenic pain group—The odontogenic pain group comprised 7

patients and all 7 had an apical diagnosis of symptomatic apical periodontitis (SAP). The
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pulpal diagnoses were previously treated for the 4 study teeth and 1 adjacent tooth, while the
pulpal diagnoses were irreversible pulpitis for the 2 other patients who had pain associated
with an adjacent tooth. In those 4 patients with RCT study teeth associated pain, the
etiologies were though to be related either to a missed mesiobuccal canal (2 teeth), C-shaped
distal canal (1 tooth), and delayed healing associated with systemic lupus (1 tooth).

2. Exclusively nonodontogenic pain group—The nonodontogenic pain group

comprised 8 patients, 7 diagnosed with TMD and 1 diagnosed with PDAP. None of the
patients were diagnosed as having trigeminal neuralgia, a neurovascular disorder (e.g.,
migraine headache,) or distant pathosis referring to the dentoalveolar region and presenting
as “tooth” pain.

3. Mixed odontogenic/nonodontogenic pain group—This group comprised 2

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patients, 1 diagnosed with TMD and irreversible pulpitis of an adjacent tooth and the other
diagnosed with PDAP and SAP secondary to necrotic pulp in an adjacent tooth.

4. No pain group—This group comprised 2 patients that presented without pain at the
time of evaluation and neither an odontogenic nor a nonodontogenic pain diagnosis could be
made.

Pain-related characteristics
Table 3 details the pain characteristics in relation to the different diagnoses. The majority of
patients with an odontogenic reason for their persistent pain (N=4/7, 57%) reported a pain
intensity of “0” at the time of their clinical evaluation for this research, with the average of
this pain intensity being 0.6/10. For the most part, these patients described their pain as
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“well localized” with either “dull/achy” or “sharp” in quality. Also, almost half
characterized their pain as “intermittent” and almost half as “constant”, with 1 patient not
responding. The majority of patients with a nonodontogenic reason for their persistent pain
(N=6/8, 75%) had a pain of mild-to moderate intensity with the average intensity being
1.5/10 at the time of the evaluation. “Dull” and “achy”, as well as “throbbing”, were the
most used descriptions by these patients. There was a difference noted in the report of pain
localization by classification, with 83% (N=5/6) of patients with an odontogenic diagnosis

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describing their pain as “well localized” versus only 25% (N=2/8) of patients with a
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nonodontogenic diagnosis using the same description.

The majority of the persistent pain patients (63%) reported a history of chronic pain
elsewhere in the body, including neck, shoulder, knee, ankle and pelvic pain, and one case
of multiple sclerosis. Surprisingly, 75% of patients with nonodontogenic reasons for their
pain, which was mainly TMD, reported no previous history of TMD diagnoses.

Physical findings related to pain

Clinical findings supporting an odontogenic diagnosis of persistent pain included responding
positively to tenderness to percussion on the study tooth and/or the adjacent tooth (6/7, 86%)
(Table 3). Palpation of the area buccal to the tooth apex produced tenderness in 1 patient and
this patient also experienced tenderness to percussion. No maxillary-mandibular arch
referral of pain was noted in our sample of patients.
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Clinical findings supporting a nonodontogenic diagnosis included tenderness to palpation on

the masseter, temporalis, and lateral pterygoid muscles, as well as the temporalis tendons,
reproducing a component of the patient's complaints of persistent pain. These patients fit the
TMD diagnosis of myofascial pain with referral. A positive response to sensory testing, such
as pain to touch (i.e., allodynia), suggested the presence of nerve dysfunction and supported
the diagnosis of PDAP in 2 patients. One of these patients diagnosed with PDAP reported a
history of pain with exposure to cold air that started after a midface injury that occurred
years prior to RCT. On the other hand, the other patient diagnosed with PDAP had no such
report and therefore was believed to represent a new onset of sensory nerve dysfunction
associated with dental disease and treatment.
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Radiographic findings
The majority of patients with an odontogenic reason for their persistent pain demonstrated
significant findings on their periapical films and cbCT scans (Table 4). In 57% of the
patients the findings were evident on their periapical films, while 100% of patients had
findings evident on their cbCT scans. Examples of the findings were missed canals, C-
shaped canal, and overfilled/underfilled canals of either the study tooth or an adjacent tooth.
On the other hand, patients with nonodontogenic reasons for their pain had fewer findings
on their periapical films and cbCT scans. The radiographs of most patients (75%) with a
nonodontogenic diagnosis revealed no potential etiology for persistent pain, while only 25%
had periapical radiolucencies. Pre-operative radiographs were not available to determine
whether there was radiographic evidence of “healing” in these patients.
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Discussion
This nested case series determined that a little over a third of patients reporting pain 6
months following RCT had solely an odontogentic reason for this pain and almost half had a
nonodontogenic reason. The remaining patients had either both odontogenic and
nonodontogenic reasons or no pain diagnoses (Figure 1).

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Of all patients who were diagnosed with odontogenic reasons for “tooth” pain, only 3
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patients (16%) were determined to have persistent pathosis associated with the RCT tooth,
likely related to failure to remove all the diseased or necrotic pulpal tissue in the case of
missed canals (i.e., missed mesiobuccal canal and C-shaped canal), or possibly extruded root
canal filling/debris (22). In two-thirds of the patients with an odontogenic diagnosis, the pain
was related to pathosis in an adjacent tooth. This presentation of dental-related disease in
adjacent tissues should not be unexpected because factors related to the presentation of oral
disease are known to have local effects, both to the site of disease and to the person
experiencing the disease, such as secondary caries (23).

The most common nonodontogenic reason for “tooth” pain was TMD, which was identified
in 42% of all patients with pain 6 months following RCT. The subtype of TMD related to
the RCT tooth was myofascial pain with referral and involved the masseter, temporalis, and
lateral pterygoid muscles, as well as the temporalis tendon. Patients' perception of their
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TMD symptoms as “tooth” pain can be explained as the concept of referred pain (19), with
the most common referred pain source to the teeth being the masseter and the lateral
pterygoid muscles (8).

Due to the lack of diagnostic information prior to RCT, this study cannot address the
questions of whether the initial symptoms of pain may have been misdiagnosed as
odontogenic in origin (12, 24), whether the odontogenic pathosis sensitized the
somatosensory system and contributed to the initiation of TMD that was maintained while
the pathosis was adequately treated (25-27), or whether the onset of TMD was more related
to the provision of RCT, such as the patient's mouth being open wide for a protracted period
of time (28). This is a question of considerable importance to clinicians and future research
should investigate how TMD and odontogenic pain are related, especially the possible
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bidirectional interactions.

PDAP, which many feel has underlying dysfunction of the somatosensory system (29-32),
was diagnosed in 11% of those presenting with pain 6 months following RCT. One of the 2
patients diagnosed with PDAP had long-standing symptoms consistent with neuropathic
pain and is likely secondary to a prior midfacial fracture; thereby being considered a pre-
existing condition. The other patient appeared to have had a new onset of this pain disorder,
thus fitting the definition of an incident case of PDAP.

The presence of a mixed odontogenic/nonodontogenic pain group is important because it

requires the clinician to diagnose both etiologies for the report of pain, which can be
challenging.
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Two patients in this study reported no pain and no objective pain-related findings, leading to
the opinion that their symptoms of pain at 6 months following RCT may have resolved by
the time they presented for their clinical evaluation. We speculated that these patients were
experiencing odontogenic pain that was associated with a delay in healing.

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Findings related to pain characteristics

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Due to the small sample size it was difficult to draw conclusions regarding certain pain
characteristics that can help differentiate those with odontogenic reasons versus
nonodontogenic reasons. However, it is worth mentioning that patients within the
nonodontogenic group that were diagnosed with TMD had no prior TMD diagnosis. This
highlights the importance of performing a thorough TMD evaluation at baseline, to rule out
the possibility of TMD representing the complaint of “tooth” pain and again at follow up 6
month after RCT to determine an etiology of the persistent pain complaint.

Findings related to radiographs

The fact that cbCT scans revealed more findings which were significant in rendering a
diagnosis compared to the PA films demonstrates its value and is consistent with previous
research (33). While this study is not longitudinal in nature, it nonetheless suggests that
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there is importance for using cbCT, in selected instances, to assess the integrity of RCT
when pain persists 6 months after treatment. Even though cbCT imaging was helpful in
confirming the absence of odontogenic findings in some patients, specifically the patients
with referred TMD pain, it is important to always use clinical judgment to limit patient
exposure to ionizing radiation used for diagnostic purposes (34). Furthermore, our imaging
findings are in line with findings from a study investigating the value of adding cbCT
imaging to periapical films for patients diagnosed with PDAP (35).

Strengths of the study

Minimized bias—The nested case series design of this study provides an added benefit
because it allowed for prospective assessment of pain at 6 months, which limited previous
studies that used retrospective assessment. This design minimizes bias in case selection
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since eligibility criteria for being a case was pre-determined and study investigators were not
involved in the enrollment process. Additionally, the consensus expert driven diagnoses
were reached after independent evaluations by two boarded clinicians in the two fields of
interest (i.e., Enododontics, Orofacial Pain), thus rendering reliable results and minimizing
bias.

Generalizability of the results to the typical endodontic patient—Original

recruitment of patients in the parent study through the National Dental PBRN offered the
advantage of recruiting large numbers of patients from various geographic areas and
multiple practices including both general dentists and endodontists. Most endodontic studies
report data from patients treated by endodontists (36) although the majority of patients
receiving RCT are treated by general dentists (1).
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Limitations of the study

Even with large numbers, 11% prevalence of pain at 6 months resulted in a small sample of
patients in the Midwest region from which to draw our study sample. Therefore the
prevalence estimates have wide confidence intervals. This can be improved upon by
increasing the original samples size, such as enrolling more patients in the parent study or
having other sites in the parent network conducting the nested study protocol.

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The low recruitment rate, 19/38 (50%) of those who reported pain at 6 months, was likely
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related to not having this nested study included within the initial consenting process of the
parent study; however, those enrolled in this study were similar at baseline to those who did
not participate (Table 1). It is recognized that sample sizes for many of the individual
diagnoses are small, leading to wide confidence intervals that make it difficult to draw
definitive and precise conclusions. However even with these limitations, this study has
reduced other potential biases and addresses an important gap in knowledge. Taken together,
this small project was designed to be an incremental step towards understanding persistent
pain following RCT.

Finally, the lack of pre-operative diagnostic information, specifically the indication for
initiation of RCT, limits the ability to assess healing following RCT. Furthermore, having
pre-operative radiographs could have allowed for assessment of longitudinal changes, such
as increased or decreased size of a periapical radiolucency and changes in the lamina dura.
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Conclusion
We found that most patients reporting “tooth” pain 6 months following RCT had a
nonodontogenic pain diagnosis accounting for some of this pain with TMD being the most
frequent nonodonotgenic diagnosis. The reported pain was related to the RCT tooth in about
one fifth of the patients. This suggests that patients experiencing a persistent pain following
RCT should be evaluated for TMD. It also suggests that further research should investigate
the relationship between odontogenic and nonodonotogenic pains.

Acknowledgments
Supported by National Institutes of Health (K12-RR023247, U01-DE016746, U01-DE016747, U19-DE022516),
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the American Academy of Orofacial Pain, and the American Association of Endodontists Foundation. The authors
declare that there are no conflicts of interest. Opinions and assertions contained herein are those of the authors and
are not to be construed as necessarily representing the views of the respective organizations or the National
Institutes of Health.

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Figure 1. Experts' consensus diagnoses for the patients' pain

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Table 1
Baseline characteristics of patients meeting pain criteria at 6 months
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Characteristics Number of Cases Evaluated (19) Number of Cases not Evaluated (19) p-value
N (%) or Mean (SD) N (%) or Mean (SD) (chi-square or t-test)

Gender
Female 16 (84) 15 (79) 0.676

Age
In years 49 (13) 41 (14) 0.098

Ethnicity
Non Hispanic or Latino 19 (100) 18 (95) 0.311

Race
White 17 (89) 15 (79) 0.374
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Dental Insurance
Yes 17 (89) 15 (79) 0.374

Education
College degree 13 (68) 12 (63) 0.732

Income
>$50,000/year household 13 (68) 8 (42) 0.103

Arch
Maxillary 10 (53) 12 (63) 0.511

Tooth type
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Posterior 17 (89) 16 (84) 0.631

Pain intensity, “now”

0-10/10 2.3 (2.5) 3.7 (3.4) 0.148

Days in pain over last week

0-7/7 4.9 (2.7) 5.2 (2.6) 0.807
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Table 2
Patients' pain related characteristics in relation to diagnoses
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Odontogenic (study Nonodontogenic (TMD Mixed Odontogenic/Nonodontogenic Normal

& adjacent teeth) & PDAP) Number (%) Number (%)
Number (%) Number (%)

Pain intensity
0 4/7 (57) 2/8 (25) 0 2/2 (100)
1-2 2/7 (29) 5/8 (62) 1/2 (50) 0
3-4 1/7 (14) 1/8 (13) 1/2 (50) 0

Pain quality
No pain 1/7 (17) 1/8 (13) 0 2/2 (100)
Dull achy 4/7 (50) 4/8 (50) 1/2 (50) 0
Sharp 2/7 (33) 1/8 (13) 0 0
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Throbbing 0 2/8 (25) 1/2 (50) 0

*Pain localization

No pain 1/7 (17) 3/8 (38) 0 2/2 (100)

Well localized 6/7 (83) 2/8 (25) 0 0
Diffuse 0 2/8 (25) 2/2 (100) 0

*Temporality of pain

No pain 1/7 (17) 2/8 (25) 0 0

Intermittent 3/7 (50) 2/8 (25) 0 0
Constant 3/7 (33) 2/8 (25) 1/2 (50) 1/2 (33)
Variable 0 1/8 (13) 1/2 (50) 2/2 (67)
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History of Orofacial pain

- TMD
- HA 3/7 (43) 2/8 (25) 1/2 (50) 0
- Sinusitis 4/7 (57) 3/8 (38) 1/2 (50) 0
1/7 (14) 2/8 (25) 0 0

**History of other chronic

pain
Yes 5/7 (71) 6/8 (75) 2/2 (100) 1/2 (50)

*
1 patient with missing data for nonodontogenic group
**
Other overall chronic pain included: neck, shoulder, knee, ankle and pelvic pain, and one case of multiple sclerosis.
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Table 3
Physical findings related to persistent pain
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Clinical signs Exclusively

Odontogenic Exclusively
(study & adjacent Nonodontogenic
teeth) (TMD & PDAP) Mixed (Odontogenic/Nonodontogenic) Normal
Number (%) Number (%) Number (%) Number (%)

Percussion testing, vertical

Tender 6/7 (86) 5/8 (62) 2/2 (100) 0
Nontender 1/7 (14) 3/8 (38) 0 2/2 (100)

Palpation testing (apical tissue,

buccal to tooth)
Tender 1/7 (14) 3/8 (38) 0 0
Nontender 6/7 (86) 5/8 (62) 2/2 (100) 2/2 (100)
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Table 4
Radiographic findings in relation to diagnoses
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PA films CBCT scans

Normal Radiolucency Normal *Significant

Number (%) Number (%) Number (%) Number (%)
Odontogenic 3/7 (43) 4/7 (57) 0/7 (0) 7/7 (100)
(RCT tooth, adjacent tooth)

Nonodontogenic 6/8 (75) 2/8 (25) 7/8 (89) 1/8 (11)

(TMD &PDAP)

Mixed odontogenic/Nonodontogenic 1/2 (50) 1/2 (50) 1/2 (50) 1/2 (50)
Normal 1/2 (50) 1/2 (50) 1/2 (50) 1/2 (50)

*
Significant findings included missed canals, C-shaped canals, overfilled and/or underfilled canals.
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