OROFACIAL PAIN
Myofascial pain with referral from the anterior digastric
muscle mimicking a toothache in the mandibular anterior
teeth: a case report
Mythili Kalladka, BDS, MSD/Muralidhar Thondebhavi, MD, CCT, MBA/Sowmya Ananthan, BDS, DMD, MSD/
Gautam Kalladka, BDS, MDS/Junad Khan, BDS, MPH, MSD, PhD
Background: Non-odontogenic toothaches often present as a
diagnostic dilemma to clinicians. Myofascial pain with referral
from the trigger points in the masticatory muscles are one of the
common causes of non-odontogenic toothaches. However, there
are limited reports of myofascial pain from the anterior digastric
muscle referring pain to the mandibular anterior teeth and mim-
icking odontogenic pain. Case presentation: A case of non-
odontogenic toothache in the mandibular anterior teeth due
to myofascial pain with referral from trigger points in the anterior
digastric muscle is presented. The patient had significant relief
with a trigger point injection of the anterior digastric muscle.
Key words: anterior digastric muscle, myofascial pain, pain, temporomandibular disorder, trigger point
Non-odontogenic toothaches often present as a diagnostic
challenge to clinicians. The clinical picture is confusing and the
diagnosis is often elusive. Multiple dental procedures are often
attempted, presuming the pain to be odontogenic in nature.
Myogenous temporomandibular disorders (TMD) com-
prise a significant proportion of the cases of non-odontogenic
toothache, 1 although the exact epidemiologic data are not
available. The diagnostic criteria for TMD (DC/TMD) for clinical
and research applications broadly classifies myogenous TMD
into local myalgia, myofascial pain, and myofascial pain with
referral.2 The DC/TMD criteria describes myofascial pain with
referral as “pain of muscle origin that is affected by jaw move-
ment, function or parafunction and replication of this pain oc-
curs with provocation testing of the masticatory muscles and
with referral of pain beyond boundary of the muscle being
56 QUINTESSENCE INTERNATIONAL | volume 51 • number 1 • January 2020
Amitriptyline 10 mg once daily was prescribed for 1 month. In
addition, she was advised home care instructions to control
predisposing, perpetuating, and precipitating factors, and given
home care exercises, a hard joint stabilization splint, physiother-
apy, and postural re-education. Conclusion: Non-odontogenic
toothaches may be multifactorial. The case presented empha-
sizes the importance of a comprehensive evaluation to differen-
tiate odontogenic pain from non-odontogenic pain. Irreversible
dental procedures should be instituted after an accurate diagno-
sis and multidisciplinary management may be required in com-
plex cases. (Quintessence Int 2020;51:56–62; doi: 10.3290/j.qi.a43615)
palpated when using the myofascial examination protocol.
Spreading pain may also be present.”2 Referred pain from a
myofascial trigger point is defined as “pain arising from a
trigger point, but felt at a distance often remote from the
source.”3 The trigger points in different muscles have docu-
mented reproducible patterns of referral; primarily related
to their site of origin.3 The pattern of referred pain from trig-
ger points is often distant from the site of the trigger point
and may not entirely coincide with the peripheral nerve dis-
tribution or dermatomal segment.3 A trigger point is defined
as a “hyperirritable spot in a skeletal muscle that is associated
with a hypersensitive palpable nodule in a taut band.”2-4 The
patient’s complaints of pain are replicated when the muscle is
examined using the examination protocol by DC/TMD cri-
teria with pain referral beyond the muscle being tested.

Myofascial pain with referral is confirmed by the presence of
trigger points, pain referral to distant sites characteristic for
each muscle, twitch response at the site, and reproduction of
the patient’s pain complaint. It may also be accompanied
by motor dysfunction and autonomic symptoms.2-5 In many
instances the pain may be referred to the maxillary and/or
mandibular teeth. The characteristic referral patterns of the var-
ious masticatory and accessory muscles have been described in
detail by Simons et al.3
Presented is a case of non-odontogenic toothache in the
mandibular anterior teeth due to myofascial pain with referrals
from trigger point in the anterior digastric muscle, and the
management is described.
Case presentation
A 43-year-old woman presented to the Orofacial Pain Center
with the chief complaint of pain in the mandible and mandibu-
lar teeth.
Six months previously, following an episode of intense
yawning, the patient reported that she felt a “stretching sen-
sation” in her jaw and developed pain and sensitivity in the
mandibular anterior teeth. She consulted a general dental
practitioner and was prescribed multiple brands of desensi-
tizing toothpastes and medicaments, assuming her com-
plaints were related to dentinal hypersensitivity. At the time
of onset of symptoms, the patient described the pain in the
alveolar process of the mandibular anterior teeth as being
continuous, dull aching (20 mm on a visual analog scale
[VAS]) and the pain in the mandibular anterior teeth as similar
to a tooth being sensitive.
Subsequently, she was referred to an endodontist who per-
formed root canal treatments (RCTs) of the mandibular right
and left central and lateral incisors, presuming the complaints
had an endodontic origin. She was prescribed multiple broad
and narrow spectrum antibiotics, assuming an odontogenic
infection. The medications and RCTs failed to provide relief and
the pain persisted. Hence, the RCTs were repeated and finally
the patient was advised to undergo extraction of the mandib-
ular right and left central and lateral incisors and both mandib-
ular canines 4 months after the pain complaints started. This
resulted in an aggravation and change in the quality of pain
(from mild, continuous, dull aching pain to severe, continuous,
sharp pain [VAS 70 mm]).
The patient was then prescribed a trial of carbamazepine
300 mg once daily, pregabalin 75 mg once daily, and vitamin
B12, presuming the condition to be trigeminal neuralgia. The
QUINTESSENCE INTERNATIONAL | volume 51 • number 1 • January 2020
Kalladka et al
medications were administered for a period of 3 weeks. The
patient did not report any side effects at the dose administered.
The medications did not have any effect on the pain.
The patient was advised to have a removable partial den-
ture in the area of the missing mandibular anterior teeth.
During the course of the dental treatment, the patient devel-
oped tenderness in her jaw and was referred to an oral surgeon.
A soft night guard was fabricated. She had a mild reduction in
pain with the soft night guard. She was then referred to a pain
physician who in turn referred her to the Orofacial Pain Center.
Investigations ordered by previous dental practitioners and
physicians included an panoramic radiograph, full-mouth
radiographs, temporomandibular joint (TMJ) tomograms, com-
puted tomography (CT) of the brain and face, magnetic reso-
nance imaging (MRI) of the brain, complete blood count (CBC),
thyroid profile, and peripheral smear, all of which were within
normal limits. The CT scan showed a deviated nasal septum to
the left with bilateral inferior turbinate hypertrophy. The pan-
oramic radiograph and full-mouth radiographs were negative
for dental pathology.
At the time of her presentation, the pain was severe (VAS
80 mm). In the region of the mandibular anterior teeth, the
pain was sharp and continuous, with no known aggravating or
relieving factors. The patient did not notice the pain during
sleep. However, the patient reported disturbed sleep with diffi-
culty initiating and maintaining sleep. The patient had gastritis
and a history of right sided Bell palsy a few months prior to the
onset of the symptoms of facial pain. She was prescribed pred-
nisolone and physiotherapy for the Bell palsy. Her medical and
family history was otherwise noncontributory. The patient’s job
was active and involved regular bending. The patient also
reported mouth breathing. Extraoral examination revealed a
moderately built and nourished, conscious, cooperative patient
who was well-oriented with the surroundings. She had mild
deficits on the right side of the face (weakness of the facial
muscles) due to Bell palsy.
TMJ and musculoskeletal evaluation revealed a range of
movement that was within normal limits. She had mild tender-
ness on the lateral and posterior pole of the right TMJ. Muscle
palpation revealed severe tenderness and trigger points in the
right superficial masseter, sternocleidomastoid muscle (SCM),
and anterior digastric muscle. Palpation of the trigger points in
the right anterior digastric reproduced the patient’s com-
plaints. Intraoral examination revealed an edentulous area in
the region of the mandibular right and left central incisors, lat-
eral incisors, and canines. A bony spicule was present in the
region of the extraction site of the mandibular right canines.
57
 OROFACIAL PAIN
GE
Subcutaneous tissue
Digastric Anterior Belly
Digastric Anterior Belly 1
1 3 cm
Fig 1 The digastric muscle on ultrasound.
On palpation of the bony spicule, the patient reported mild
tenderness, but it did not reproduce the patient’s chief com-
plaint. A full-mouth radiograph taken 1 month previously was
negative for dental pathology. Topical local anesthetic spray
was used and an infiltration of 1 mL of 2% lignocaine without
epinephrine local anesthetic injection bilaterally in the region
of the mandibular anterior teeth did not resolve the pain. The
clinical examination, radiographs, and local anesthesia tests
ruled out odontogenic sources of pain. A vapocoolant spray
and stretch of the anterior digastric using ethyl chloride spray
was performed and this relieved the pain of the chief complaint
completely. Spray and stretch of the anterior digastric muscle
using ethyl chloride spray reduced the pain significantly (VAS
80 mm prior to the procedure, VAS 30 mm subsequently). The
source of pain was confirmed by palpation of the anterior
digastric muscle and was relieved by vapocoolant spray and
stretch. With the odontogenic causes ruled out, a diagnosis of
myofascial pain due to referral from trigger point in the anterior
digastric was made. The patient was advised to undergo a trig-
ger point injection.
The patient was then referred to a pain management phy-
sician. The procedure was explained to the patient and
informed consent was obtained. The area was isolated and ster-
ilized with alcohol and povidone-iodine (Betadine). The digas-
tric muscle was determined using ultrasound (Fig 1). Following
needle placement confirmation using the ultrasound, a 1-inch
long, 22-gauge needle was advanced into the anterior belly of
the digastric muscle. Following negative aspiration, the 1.8 mL
of 2% lignocaine without epinephrine local anesthetic injec-
58 QUINTESSENCE INTERNATIONAL | volume 51 • number 1 • January 2020
2
Fig 2 Digastric trigger point injection.
tion using a Luer-Lok syringe was slowly deposited in the anter-
ior belly of the digastric muscle with a gentle needling motion
to break up the trigger point (Fig 2). The patient had complete
relief of pain for 1 day (VAS 0 mm) and partial relief for 1 week
(VAS reduced from 80 mm to 30 mm). She was followed up
with home care instructions on controlling predisposing, per-
petuating, and precipitating factors, home care exercises, hard
joint stabilization splint, amitriptyline 10 mg once daily for
1 month, physiotherapy, and postural re-education. She
reported substantial relief of pain (VAS 10 mm).The patient was
also referred for psychological counseling and was diagnosed
with comorbid depression, secondary to the facial pain. She
was treated with duloxetine 20 mg once a day. The pain relief
was sustained at a follow-up 16 months following treatment.
Discussion
Dental practitioners receive extensive training to diagnose and
treat dental pathologies. Non-odontogenic toothache may
occur due to referral of pain from structures in the head and
neck such as ear, nose, and throat (ENT) pathology, sinusitis,
TMD, neurovascular pain, and neuropathic pain.6 It often pres-
ents as a diagnostic enigma. Myofascial pain with referral from
trigger points in the masticatory muscles can frequently refer
to intraoral structures7 and other distant structures.8 The pain in
these instances can mimic odontogenic pain. Previously, cases
of non-odontogenic toothache due to referral from trigger
points in the masseter and other masticatory muscles have
been described.9-14

Pain and sensitivity in the
mandibular anterior teeth
Negative findings Clinical exam:
• Percussion
• Radiography
• Periodontal exam
Diagnostic testing:
• Local anesthesia (topical or injection)
No change in pain levels
• Non-odontogenic cause
Positive:
Muscle palpation:
• Myofascial pain
• Muscles of mastication
• Cervical muscles Negative:
• Digastric • Neuropathic pain
• Neurovascular pain
Fig 3 Flowchart for the diagnosis of non-odontogenic dental pain.
In the present case, the pain in the mandibular anterior
teeth and mandible was misdiagnosed as pain of odontogenic
origin and irreversible procedures were performed. The institu-
tion of irreversible procedures resulted in progression of the
condition. The case highlights the importance of carefully col-
lecting a patient history combined with a comprehensive clin-
ical examination. This facilitates the arrival at an accurate diag-
nosis of the source of pain, before initiation of an irreversible
procedure.10 Odontogenic pain may also co-exist with other
orofacial pain conditions or headache disorders.15,16 In such
instances, a local anesthetic injection block may be a useful
adjunct tool to differentiate odontogenic pain from non-odon-
togenic pain. The complete cessation of pain with local anes-
thetic injection block generally indicates odontogenic origin. A
paradigm for the diagnosis of non-odontogenic toothache due
to myofascial trigger points is presented in Fig 3.
Non-odontogenic pain may be referred from different mas-
ticatory muscles and accessory muscles and masquerade as a
toothache. The patterns of referral and method of palpation of
trigger points have been detailed in the Trigger Point Manual
by Simons et al.3 Trigger points in the anterior, middle, and pos-
terior temporalis may refer pain to the maxillary anterior region,
premolars, and molars, respectively. Similarly, the trigger points
QUINTESSENCE INTERNATIONAL | volume 51 • number 1 • January 2020
Kalladka et al
3
• Percussion positive Dental cause
• Caries
• Bleeding on probing
• Widened periodontal
ligament
• Periapical pathology
Pain reduction:
• Dental cause
• Trigeminal neuralgia
• Burning mouth syndrome
• Pain reduced but not eliminated in
some continuous neuropathic pain
conditions such as post-traumatic
trigeminal neuropathy
in the masseter can refer to the mandibular molars, and anter-
ior digastric trigger points can refer pain to the mandibular
anterior region.
The function of the anterior digastric muscle is to depress
and retrude the mandible. The action of the digastric muscle is
especially important at maximum opening and quick or forced
jaw opening. The digastric muscle has a predominance of Type
II muscle fibers, which enables quick opening; however, it has a
very few muscle spindles and Type I muscle fibers. Thus it is
unable to maintain prolonged tension.3 Trigger points in the
digastric often develop in patients with parafunctional habits
like bruxism, mouth breathing (it may be secondary to nasal
obstructions such as a nasal polyp, or structural abnormalities
in the nose such as a deviated nasal septum),3 and episodes of
intense yawning. Trigger points in the masseter and other ele-
vator muscles of the jaw may also result in trigger points in the
digastric muscle.3 Additionally, it has been suggested that key
trigger points in the SCM may also induce satellite trigger points
in the anterior digastric muscle.3 As mentioned previously, the
patient was a mouth breather, which could have predisposed
her to developing trigger points in the digastric muscle.
A comprehensive evaluation of the masticatory muscles is
essential. Reproduction of the patient’s pain complaint during
59
 OROFACIAL PAIN
Table 1 Differential diagnosis of odontogenic vs non-odontogenic pain from myofascial trigger points
Odontogenic pain
Dental pathology such as caries, apical periodontitis Positive
Percussion of tooth Positive
Palpation of trigger point No change
Response to spray and stretch No change
Response to local anesthetic injection into trigger point No change
Response to local anesthetic injection at tooth site Pain reduction
the clinical examination can help diagnose the source of pain.
Table 1 describes the differentiating features between odonto-
genic and non-odontogenic pain by myofascial trigger points.
In the present case, the diagnosis was confirmed by reproduc-
tion of the patient’s pain complaint by palpation of the anterior
digastric muscle, failure of local anesthetic injection blocks to
relieve pain in the mandibular anterior teeth, negative findings
with intraoral radiographs and intraoral examination, and relief
of pain through vapocoolant spray and stretch followed by trig-
ger point injections. The trigger point injections were accom-
plished using lignocaine without epinephrine. Epinephrine is
generally avoided in trigger point injections as it may be myo-
toxic and constrict blood flow to the muscles. The treatment
was multidisciplinary. The case also reflects the importance of
cross-referrals between physicians and dental practitioners to
aid in successful diagnosis and management of complex cases.
Predisposing, perpetuating, and precipitating events were
identified, and addressed to prevent further recurrences.
Treatment of myofascial pain includes trigger point spray
and stretch, trigger point pressure release, trigger point injec-
tions, home care instructions, corrective actions, pharmaco-
therapy, appliance therapy, psychological counseling, and
addressing comorbidities such as depression, physiotherapy,
and postural re-education.5,17 The management paradigm for
digastric trigger points is detailed in Fig 4. Trigger point spray
and stretch, and trigger point pressure release is the first step.
This aids in confirming the diagnosis and may be therapeutic in
mild cases. If it provides relief or the relief is temporary, it may
be followed with a trigger point injection. Identification and
treatment of predisposing, perpetuating, and precipitating
events is crucial for successful treatment and prevention of
recurrences. Patients are counselled on home care instructions,
corrective actions, and exercises to prevent recurrences. Phar-
macotherapy of myofascial pain includes muscle relaxants such
60 QUINTESSENCE INTERNATIONAL | volume 51 • number 1 • January 2020
Non-odontogenic pain from
myofascial trigger points
Negative
No change
Increase pain to referral site
Pain reduction
Pain reduction
No change
as cyclobenzaprine, carisoprodol, and amitriptyline.5,17 Amitrip-
tyline and nortriptyline may be beneficial in chronic myofascial
pain18 or patients with myofascial pain and concomitant sleep
disturbances. Amitriptyline is a tricyclic antidepressant that is
well validated in low doses for chronic pain. It is a serotonin-nor-
epinephrine reuptake inhibitor,17 and is especially beneficial in
chronic pain patients with sleep disturbances such as the pres-
ent patient. Although the mechanism of action is still unclear,
appliances such as a TMJ stabilization appliance have been
found to be beneficial in patients with TMD and are recom-
mended in cases of painful TMD or TMD cases that present with
functional limitations. Patients with orofacial pain conditions
may have comorbidities such as depression, and in such
instances psychological counseling and psychiatric evaluation
may be essential. Many cases of TMD may persist or recur, and
in such cases physiotherapy may be recommended. Postural
re-education is also performed in patients with forward head
posture or poor work ergonomics. In the present patient, phar-
macotherapy and appliance therapy were done in the early
stages of treatment following trigger point spray and stretch
and trigger point injection.
General dental practitioners may encounter patients with
complaints of pain in the teeth or alveolar process in the
absence of dental pathologies on clinical and radiographic
examination. In these instances, an accurate history and com-
prehensive clinical examination may help in locating the source
of pain. The site of pain is often different from the source of
pain in myofascial pain with referral. In patients with myofascial
pain with referral from trigger points in the anterior digastric
muscle, the site of pain may be the alveolar process of the man-
dible and the mandibular anterior teeth, whereas the source of
pain is the anterior digastric muscle. Hence, emphasis should
be on diagnosing and treating the source of pain rather than
the site of pain.
 Kalladka et al

The key to successful treatment of toothache of non-dental

origin lies in an accurate diagnosis. An accurate diagnosis Trigger point in the anterior digastric muscle
stems from a logical process combining history, comprehen-
sive clinical evaluation, use of appropriate diagnostic aids, and
Trigger point spray and stretch and
in certain instances, a trial of therapeutic agents. trigger point pressure release

Conclusion/recommendation Trigger point injection

A case of myofascial pain with referral of the anterior digastric

presenting as a non-odontogenic toothache in the mandibular Home care instructions, corrective actions
anterior teeth was described. The management of the case with
trigger point injections, pharmacotherapy, and physiotherapy
was detailed. Trigger point injections to the anterior digastric Pharmacotherapy, appliance therapy

muscle may be complicated to accomplish in a general dental

clinic; however, the history and examination (including palpa- Psychological counseling and addressing comorbidities
tion) are not. It is mandatory for general dental practitioners to such as depression
institute appropriate referrals for further evaluation and man-
agement when necessary, such as in cases where odontogenic
Physiotherapy, postural re-education
causes of toothache or facial pain may be a factor or when a
4
diagnosis is not apparent. Thoroughness in patient care is cru-
cial and, as this case study illustrates, can result in avoidance of Fig 4 Flow chart depicting the management paradigm for digastric
unnecessary, harmful, and/or irreversible procedures. trigger points.

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QUINTESSENCE INTERNATIONAL | volume 51 • number 1 • January 2020 61

 OROFACIAL PAIN

Mythili Kalladka Muralidhar Thondebhavi Consultant Pain physician, Apollo

Specialty Hospital, Bangalore, India

Sowmya Ananthan Assistant Professor, Rutgers School of Den-

tal Medicine, Department of Diagnostic Sciences, Newark, NJ, USA

Gautam Kalladka Assistant Professor, Department of Orthodon-

tics and Dentofacial Orthopedics, Bangalore Institute of Dental
Sciences, Bangalore, India

Mythili Kalladka Adjunct Assistant Professor, Orofacial Pain and Junad Khan Program Director, Orofacial Pain and Temporoman-
Temporomandibular Disorders, Eastman Institute for Oral Health, dibular Disorders, Eastman Institute for Oral Health, University of
Rochester, NY, USA Rochester, NY, USA

Correspondence: Dr Mythili Kalladka, Adjunct Assistant Professor, Orofacial Pain and Temporomandibular Disorders, Eastman Institute
for Oral Health, 625 Elmwood Ave, Rochester, NY-14620, USA. Email: dr.mythili@gmail.com

62 QUINTESSENCE INTERNATIONAL | volume 51 • number 1 • January 2020