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ODONTOGENIC
PAIN
ADITI CHANDRA
DEPARTMENT OF
CONSERVATIVE DENTISTRY
AND ENDODONTICS
MDS-12
CONTENTS
Introduction
Definition
History
Changing concepts
Dual nature of pain
Structures involved in pain
Mechanism of pain pathway
Physiology of pain perception
Levels of pain perception
Theories of pain
Pain assessment tools
Classification of pain
Odontogenic pain
Pulpal diseases
Reversible pulpitis
Irreversible pulpitis
Necrotic pulp
Hot tooth
Cracked tooth
Dentinal hypersensitivity
Barodontalgia
Periapical diseases
Acute apical periodontitis
Chronic apical periodontitis
Acute apical abscess
Phoenix abscess
Post endodontic surgery pain
Pericoronitis
Maxillary sinusitis mimicking tooth pain
Phantom pain
Referred pain
Management
Conclusion
PAIN
Greek word - Poin- meaning penalty
Latin word - Poena- meaning punishment from God
The International Association for the Study of : Pain is "an unpleasant sensory
and emotional experience associated with actual or potential tissue damage, or
described in terms of such damage"
Monheim : An unpleasant emotional experience usually initiated by noxious
stimulus and transmitted over a specialized neural network to the CNS where it is
interpreted as such.
HISTORY :
Homer thought pain was due to arrows shot by God.
Aristotle, who probably was the first to distinguish five physical senses considered
pain to the passion of the soul that somehow resulted from the intensification of
other sensory experience.
Plato, contented pain and pleasure arose from within the body, an idea that
perhaps gave birth to the concept that pain is an emotional experience more than a
localized body disturbance.
The Bible makes reference to pain not only in relationship to injury and illness but
also an anguish of the soul.
CHANGING CONCEPTS
Increased knowledge of anatomy and physiology, it became possible to
differentiate pain resulting from physical and emotional cause. During the 19th
century, the developing knowledge of neurology fostered the concept that pain was
mediated by specific pain pathways and was not simply a result of excessive
stimulation of special senses.
Somatic
structure
Neural
structure
Deep
Visceral :
Pulp, Blood
vessels,
Glands,
Visceral
Musculoskelet
mucosa
al :
Joints, PDL,
Muscles,
Bones
Superficial
Skin, Mucosa,
Gingiva
Somatic
NEURAL STRUCTURES :
DENTAL PULP
A-delta fibers
: Myelinated fibers.
: Conduction speed high .
C fibers
: Unmyelinated fibers.
: Conduction speed low.
: Impulses interpreted as throbbing and aching pain.
: Present in the centre of nerve trunk.
Nocicepti
on
Pain
Suffering
Pain
behavior
THEORIES OF PAIN
SPECIFICITY THEORY: (VON FREY, 1894)
Pain is stimulation of specific nociceptors and perceived by specific nociceptors in
the brain. Poorly accepted, because it is known that free nerve endings transmit
pain, touch and pressure.
Pattern theory (Goldscheider in 1894)
OROFACIA
L
PAIN
ODONTOGENIC
NONODONTOGENIC
Periapical disease
Pulpal disease
~Reversible pulpitis
~Irreversible pulpitis
~Necrotic pulp
PULPAL PAIN :
~Acute apical
periodontitis
~Acute apical abscess
~Chronic apical
periodontitis
Heterotopic pain
~Projected pain
~Referred pain
Dentinal hypersensitivity
Barodontalgia
Traumatic occlusion
Incomplete fracture
PULPAL DISEASES
1. Reversible Pulpitis:
Symptoms of Reversible Pulpitis:
Thermal:
Hypersensitivity with mild pain of <30 seconds
Sweets:
Sensitive (if caries, crack, or exposed dentin) with mild pain of <30
seconds
Biting Pressure:
None (unless tooth is cracked)
Reversible Pulpitis
Radiograph
Normal Periapex
2.Irreversible Pulpitis:
Symptoms of Irreversible Pulpitis:
Pain : severe, spontaneous, sharp, piercing, shooting, intermittent or
continuous.
Exacerbated by change of position and may be referred to other locations.
Thermal:
Hypersensitive with moderate to severe prolonged pain
Sweets:
Moderately to severely sensitive
Biting Pressure:
Usually sensitive in later stages.
Radiograph
Normal or thickened periodontal ligament
3. Necrotic Pulp :
Symptomatic (severe pain, lasting
few minutes to hours, followed by
complete, sudden cessation) or
Asymptomatic.
No response:
Thermal test
Electrical test- minimum response
in case of moisture in root canal or
few apical nerve fibers survive
Radiograph:
Normal or thickened periodontal
ligament, or radiolucent lesions
Cause
Slow,
progressive
carious exposure
of young pulp
Symptoms
Symptomless,
except during
mastication,
pressure of the
food bolus cause
discomfort
Diagnosis
Fleshy, reddish
pulpal mass fills
most of the pulp
chamber
5. Hot Tooth :
The term HOT tooth generally refers to a pulp that has been diagnosed with
irreversible pulpitis, with spontaneous, moderate-to-severe pain.
Classic example : Patient is sitting in the waiting room, sipping on a large glass of
ice water to help control the pain.
A challenge for dentist:
Local acidic inflammatory by products lower the pH, so most anaesthetic
molecules remain in inactive cationic form.
Local prostaglandins and bradykinin can antagonize local anaesthetics.
Sodium channel expression on C fibres shifts from TTX sensitive to TTX resistant.
TTX resistant channels are five times more resistant to anaesthetic (lidocaine).
Management
Bupivacaine found to be more potent.
Alternate and supplementary injection sites: intraosseous, intraligamentry.
Cohen and others found that a supplemental periodontal ligamental injection with
2% lidocaine was 74% successful in achieving pain control in patients with
irreversible pulpitis.
6.Cracked Tooth syndrome :
1. Craze Lines- No symptoms
2. Fractured Cusp Mild pain and generally symptomatic to biting and cold
Cracked tooth- Acute pain on biting and occasional sharp pain to cold.
Split tooth - Marked pain on chewing.
Vertical root fracture - Vague pain and
Mimics periodontal disease.
Diagnosis - History, visual & tactile examination, radiographs, dye, bite test,
transillumination, magnifying mirrors, loupes, microscope etc.
Cracked Tooth syndrome- CASE REPORT
A 42-year-old man came with the chief complaint Sometimes it hurts on the
upper left side when I chew.
Clinical examination revealed normal findings with no restorations in his posterior
maxillary or mandibular quadrants, no pain on percussion or palpation, no
periodontal pockets, EPT revealed presence of vital pulp.
Radiographic examination revealed no pathology.
Transillumination of the patients teeth revealed a distinct crack on distolingual
cusp of left mandibular second molar. The patient experienced a sharp, intense pain
response when the disto lingual cusp of tooth was bite tested.
Hence, it was diagnosed that the CRACK IN TOOTH was referring pain to the
maxillary arch.
7. Dentinal hypersensitivity:
Dentin hypersensitivity is characterized by short, sharp pain arising from exposed
dentin in response to stimuli typically thermal, evaporative, tactile, osmotic or
chemical and which cannot be described to any other form of dental defect or
pathology.
Causes: Exposure of dentine by attrition, caries etc.
Clinical Features : Pain response to chemical, thermal, tactile, or osmotic stimuli.
8.BARODONTALGIA :
Oral pain caused by the changes in the pressure due to altitude changes either
on deep sea diving or inflight conditions. In the diving environment, this pain
is commonly called tooth squeeze and the previous name aerodontalgia
was used regarding its feature inflight.
PERIAPICAL DISEASE :
1. Acute Apical Periodontitis:
Diagnosis
Palpation and Percussion: Sensitive
Mobility: Slight to no mobility
Thermal: Response: consider traumatic occlussion ,irreversible pulpitis.
No response : consider necrotic pulp
EPT: Response : Pulp is vital (reversible or irreversible)
No response : Pulp is necrotic
Radiographic: Thickening of the periodontal ligament
2.Acute Apical Abscess
DIAGNOSIS :
Percussion:
Extremely
sensitive
Mobility:
Horizontal /
vertical; often in
hyperocclusion
Palpation:
Sensitive;
vestibular or
facial swelling
likely
Thermal:
No response
EPT:
No response
(false-positive
from fluid in
canal)
Selective
Anesthesia:
Not necessary,
offending tooth
easily located
Transilluminati
on:
Not used unless
fractured is
suspected
Test cavity:
Not necessary
unless vitality is
suspected
Caused by death
of pulp followed
continuous, mild
infection of the
periapical tissues .
Lesion contains
granulation tissue
consisting of
fibroblasts and
collagen (with
macrophages and
lymphocytes).
4. Phoenix abscess:
Acute exacerbation of a chronic lesion, Diseases mimicking toothache
5.Post- endodontic surgery pain :
Severe aching pain following endodontic treatment (root canal therapy or
apicoectomy) Majority of patients improve over time ,few develop a chronic
neuropathic pain state. Starts as a sharp stabbing pain, becomes progressively
dull and throbbing. May radiate and be referred to other areas of the mouth.
Pain exacerbated by lying down. May be intermittent with no regular pattern
Heat makes the pain worse whereas cold may alleviate it.
6.PERICORONITIS:
7.ATYPICAL ODONTALGIA/ PHANTOM PAIN
Most commonly confused with dentinal pain of pulpal origin leading to
unnecessary dental treatment. Atypical odontalgia is thought to arise due to
deafferentation of nerves caused by traumatic injury.
8.Maxillary sinusitis mimicking toothache :
A patient of maxillary sinusitis might report with dental pain. Clinical
examination of the teeth would often be irrelevant. However on taking
medical history, the following signs and symptoms may be seen:
Tenderness over the sinuses
Nasal congestion
Headache
Foul odor
Nasal discharge
Fever
Dental pain
9.REFFERED PAIN :
Case reports
Maxillary sinusitis mimicking toothache- case report
56-year-old patient with no reported medical background of general importance,
visits a dentist with pain in the posterior left maxillary area which irradiates toward
the area of the same side of the cheek and feeling pressure in the area, along with
recurrent headaches.
Clinical examination revealed no pain on palpation and percussion.
- Dentin is exposed
2) PAIN TO COLD indicates that the problem is almost without exception
dental and the pulp is vital.
3) A) SHARP PAIN, RELIEVED ON REMOVAL OF STIMULUSindicates dentin type of pain
B) STAYS ON REMOVAL OF STIMULUS- indicates commencement of
pulpitis.
4) DELAYED RESPONSE TO HEAT Irreversible pulpitis.
5) UNEXPLAINED SENSITIVITY TO COLD ON POSTERIOR TOOTH:
Recent restoration, occlusal trauma, exposed dentin,
caries, loose restoration or crack in teeth.
6) ROOT FILLED ENDODONTICALLY TREATED TOOTH
SENSITIVITY TO COLD - Uninstrumented canal.
However majority of cases describes thermal sensitivity
in an adjacent teeth.
7) PAIN ON BITING IN VITAL POSTERIOR TEETH
Crack teeth, maxillary sinusitis, occulsal trauma, Bruxism and trigeminal
neuralagia.
8) PAIN ON BITING ON VITAL ANTERIOR TOOTH- majority of cases unlikely
to be of dental origin .
Most of it times it is neuropathic pain facial pain e.g. atypical odontologia and
phatom tooth pain.
9) PAIN ON WALKING IN THE MORNING - Pulpitis , cluster headache,
clenching, sinusitis, muscle pain and neuralgias.
9) PAIN ON WHEN PATIENT GOES OUT INTO THE COLD- If he suffers when
the mouth is open then it is of dental origin .
10) WHEN MOUTH IS CLOSED- most common cause is masseter spasm and
other facial spasm.
11) PAIN RELIVE BY CLENCHING INDICATES1) Sinusitis
2) Early stages of Periapical inflammation.
12) PATIENT ON TRAVELLING ON AIRCRAFT
INDICATESAerodontolagia and sinusitis.
13) PAIN ON RELIEF BY PLACEMENT OF HAND
SIDE OF FACE INDICATES- Facial muscle pain and sinusitis.
Orofacial pains, especially dental pain, are among the most commonly reported
complaints. Thus, the dentist assumes a great responsibility for the proper
management of pains in and around the mouth, face and neck.
He/she must differentiate between that arise from dental, oral and masticatory
sources and those that arise from elsewhere.
Proper diagnosis and therapy can only be rendered by a sound knowledge of the
pathways and processes of pain.
REFERENCES
Bells Orofacial pains Jeffrey P.Okeson (6th edition)
Pathways of pulp Cohen. (9th edition)
Endodontics Ingle,Bakland (6th edition)
Oral medicine,Diagnosis and treatment Burkets