Diagnostic re-evaluation of non-odontogenic orofacial pain after treatment failure: a retrospective case series

Background: Orofacial pain often arises from overlapping odontogenic and non-odontogenic causes, which can lead to misdiagnosis and unnecessary irreversible procedures. Practical guidance on diagnostic re-evaluation in treatment-refractory cases with negative dental findings remain limited. Methods: This retrospective case series describes six illustrative patients (one man and five women; median age, 74.5 years) selected from referrals for suspected non-odontogenic orofacial pain, based on diagnostic difficulty, treatment refractoriness, and objective negative dental findings. Two oral and maxillofacial surgeons independently re-evaluated each case using the International Classification of Orofacial Pain, the 3rd edition of the International Classification of Headache Disorders, and the Diagnostic Criteria for Temporomandibular Disorders. Results: The final or most strongly suspected diagnoses included persistent idiopathic dentoalveolar pain, lingual nerve injury, trigeminal neuralgia, trigeminal autonomic cephalalgia, and myofascial pain. The median diagnostic delay was 17 months (interquartile range, 7–96). Initial empiric dental management (e.g., antibiotics and/or nonsteroidal anti-inflammatory drugs (NSAIDs)) was insufficient in all cases. Pain intensity improved from a median numerical rating scale score of 8 at baseline to 0–2 at final observation. Across cases, common diagnostic pitfalls included premature attribution to a single cause, overreliance on imaging or prior medication history, and insufficient musculoskeletal or neurological examination. One or more clinical features prompting diagnostic re-evaluation were observed in each case, including persistent pain with objective negative dental findings, autonomic signs, or incongruent treatment response. Conclusions: In cases of treatment-refractory orofacial pain with objective negative dental findings, suspending further irreversible interventions and conducting systematic diagnostic re-evaluation may help reduce diagnostic delays and avoid unnecessary procedures.

Orofacial pain; Persistent dentoalveolar pain disorder; Trigeminal neuralgia; Differential diagnosis; Non-odontogenic pain

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