Dental Pain-zaid Ahmed

Diagnosis of dental pain

Prepared By Zaid Ahmed Ridha Supervised By Dr.Abid Aljabaar

DENTAL PAIN When a patient attends the surgery and complains of toothache, pain may be arising from a variety of different structures and may be classified as follows: • Pulpal pain • Periapical/periradicular pain. • Non-dental pain. Dental pain can be very difficult to diagnose, and the clinician must first gather as much information as possible from the history, clinical and radiographic examinations, and other special tests.

Pulpal pain The pulp may be subject to a wide variety of insults, e.g. bacterial, thermal, chemical, traumatic,The effects of which are cumulative and can ultimately lead to inflammation in the pulp (pulpitis) and pain. The dental pulp does not contain any proprioceptive nerve endings, therefore a characteristic of pulpal pain is that the patient is unable to localize the affected tooth. The ability of the pulp to recover from injury depends upon its blood supply, not the nerve supply, which must be borne in mind when vitality (sensibility) testing is carried out . It is impossible to reliably achieve an accurate diagnosis of the state of the pulp on clinical grounds alone; the only 100% accurate method is histological section.

Although numerous classifications of pulpal disease exist, only a limited number of clinical diagnostic situations require identification before effective treatment can be given.

Reversible pulpitis Symptoms Fleeting sensitivity/pain to hot, cold or sweet with immediate onset. Pain is usually sharp and may be difficult to locate. Quickly subsides after removal of the stimulus. Signs Exaggerated response to pulp testing. Carious cavity/leaking restoration. Rx Remove any caries present and place a sedative dressing (e.g. ZOE) or permanent restoration with suitable pulp protection.

Irreversible pulpitis Symptoms Spontaneous pain which may last several hours, be worse at night, and is often pulsatile in nature. Pain is elicited by hot and cold at first, but in later stages heat is more significant and cold may actually ease symptoms. A characteristic feature is that the pain remains after the removal of the stimulus. Localization of pain may be difficult initially, but as the infiammation spreads to the periapical tissues the tooth will become more sensitive to pressure.

Signs Application of heat (e.g. warm GP) elicits pain. Affected tooth may give no or a reduced response to electric pulp tester. In later stages may become TTP. Rx Extirpation of the pulp and RCT is the treatment of choice (assuming the tooth is to be saved). If time is short or if anaesthesia proves elusive then removal of the coronal pulp and a Ledermix dressing can often control the symptoms until the remaining pulp can be extirpated under LA at the next appointment.

Dentine hypersensitivity This is pain arising from exposed dentine in response to a thermal, tactile, or osmotic stimulus (but not all exposed dentine gives rise to symptoms). It is thought to be due to dentinal fiuid movement stimulating pulpal pain receptors. Prevalence is ~ 1:7 adults with a peak in young adults, then reduce with age. diagnosis is by elimination of other possible causes and by evoking symptoms. Rx Involves reducing aetiological factors (i.e. OHI, possibly including toothbrushing technique and intrinsic and extrinsic dental erosion) and by reducing permeability of dentinal tubules (e.g. by toothpaste containing strontium, formalin, and/or fluoride; placement of varnishes, dentine

desensitizers,dentine adhesive systems, or, if indicated, a restoration).

Cracked tooth syndrome Symptoms Sharp pain on biting--short duration. Signs Often relatively few, therefore diagnosis difficult. Tooth often has a large restoration. Crack may not be apparent at first but transillumination and possibly removal of the restoration may aid visualization. Positive response to vitality (sensibility) testing and pain can normally be elicited by getting the patient to bite with the affected tooth on a cotton-wool roll or a tooth sleuth. May be associated with bruxing habit. Rx An adhesive resin composite restoration may be appropriate in teeth which are minimally restored, but some cases a cast restoration with full occlusal coverage will be needed. Occasionally RCT may be required. .Pulpnecrosis describes the death of pulpal tissue partially or totally as a result of loss of adequate blood supply. The necrotic 'tissue may not yet be infected, particularly if the condition was brought on by trauma that led to the severance of apical blood vessels.No radiographic changes are associated with the process of necrosis.The tooth will not normally respond to electrical and thermal tests.

The necrotic tissue will eventually result in the development of periradicular periodontitis the tooth should either be root treated or extracted.

Pulp calcijication results in the obliteration of part or all of the pulp space due to an irritant stimulating the laying down of tertiary dentine. It is usually painless, unless it is accompanied by necrosis and bacterial infection. The crown of the tooth may be a darker yellow colour compared to the neighbouring teeth (due to tertiary dentine being deposited in the pulp chamber). Radiographically, there is partial or complete obliteration of the pulp space . A periradicular radiolucency may be noted if the canals have become infected. Vitality testing is not always likely to produce a response. Electrical tests are more likely to elicit a reaction than thermal tests. Interventive treatment is indicated only if symptoms indicate irreversible pulpitis . or there are radiographic changes indicating periradicular breakdown

Internal resorption results in destruction of the internal aspect of the root canal by osteoclasts. It is usually an asymptomatic condition; thermal and electrical

tests are unreliable. The radiographic appearance is one of a circumscribed round or oval radiolucency which is continuous with the root canal . Immediate root canal treatment is the treatment of choice.

Periapical/periradicular pain Progression of irreversible pulpitis ultimately leads to death of the pulp (pulpal necrosis). At this stage the patient may experience relief from pain and thus may not seek attention. If neglected, however, the bacteria and pulpal breakdown products leave the root canal system via the apical foramen or lateral canals and lead to inflammatory changes and possibly pain. Characteristically the patient can precisely identify the affected tooth, as the periodontal ligament, which is well supplied with proprioceptive nerve endings, is inflamed. Pulpal necrosis with periapical periodontitis Symptoms Variable, but patients generally describe a dull ache exacerbated by biting on the tooth. Signs Usually no response to vitality testing, unless one canal of a multirooted tooth is still vital. The tooth will be TTP. Radiographically the apical PDL may be widened or there may be a periapical radiolucency (granuloma or cyst). Rx RCT or extraction.

Acute periapical abscess Symptoms Severe pain which will disturb sleep. Tooth is exquisitely tender to touch. Signs Affected tooth is usually extruded, mobile, and TTP. May be associated with a localized or diffuse swelling. Vitality (sensibility) testing may be misleading as pus may conduct stimulus to apical tissues. Radiographic changes can range from a widening of the apical PDL space to an obvious radiolucency. It is important to differentiate this condition from a periodontal abscess. Rx Drain pus and relieve occlusion, if indicated. Drainage of pus can often be achieved by entering the pulp chamber with a high-speed diamond bur. The tooth should be steadied with a finger to prevent excessive vibration. After drainage has been achieved it is preferable to prepare the canal and place a temporary dressing. Leaving the tooth on 'open drainage' should be avoided if possible, but if absolutely necessary for <24 h, as after this time further contamination of the root canal by anaerobic bacteria makes subsequent RCT very difficult. If a fluctuant swelling is present in the soft tissues, this should be incised to achieve drainage. Antibiotics should be prescribed if there is systemic involvement (pyrexia, lymphadenopathy) or if the infection is spreading significantly along tissue planes. When the acute

symptoms have subsided, RCT must be performed or the tooth extracted.

Chronic periapical abscess Often symptomless. Possibly associated with persistent sinus. Presentation may be: coincidental or acute exacerbation.

Lateral periodontal abscess Symptoms Similar to periapical abscess with acute pain and tenderness, and often an associated bad taste. Signs Tooth is usually mobile and TTP, with associated localized or diffuse swelling of the adjacent periodontium. A deep periodontal pocket is usually associated, which will exude pus on probing. Radiographs normally show vertical or horizontal bone loss, and vitality (sensibility) testing is usually positive, unless there is an associated endodontic problem (perio-endo lesion). Rx Debride the pocket and achieve drainage of pus. Irrigate with a chlorhexidine solution. If there is systemic involvement or it is a recurrent problem, prescribe antibiotics (metronidazole or amoxicillin).

Non-dental pain When no signs of dental or periradicular pathology can be detected then non-dental causes must be considered. Other causes of pain that can present as toothache include: • TMPDS • sinusitis • psychological disorders (atypical odontalgia)

References OXFORD HANDBOOK OF CLINICAl DENTISTRY - 4th Ed. ( ((2005