1 Pain of Dental Origin New

7/21/2019 1 Pain of Dental Origin New

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Pain



pain

Subjective

Usually signifies tissue damage

Severity of pain is not directly proportional tothe extent of damage

Arises peripherally by stim of receptors

Modified centrally

Complicated by: cultural, cognitive andemotional factors and modified by previouspainful experiences



Diagnosis of pain

May have nothing to assess visually

History taing more value



Ask the ff q’s:

!" Ho# #ould you describe the pain$

%" &here is the pain most severe$

'" &here does the pain spread to$

(" Ho# severe is the pain$

)" *oes the pain prevent you from getting to sleep ordoes it #ae you up at night$

+" &hen did the pain start$

" -s the pain continuous or does it come and go$.or ho# long""

/" *oes anything cause the pain to start$

0" *oes anything mae the pain better$

!1" Are there any other problems$



CHARACTER OF PAIN

Sharp2stabbing

*ull2throbbing2boring

3urning



Sharp/staing

4xposed dentin

4arly pulpitis

5rigeminal neuralgia6lossopharyngeal neuralgia



D!""/throing/oring

7ate pulpitis

Apical and lateralperiodontitis

8eriodontal9endodontic lesion

8ericoronitis

Acute necrotiing

ulcerative gingivitis*ry socet

Herpes oster

8eriodic migrainous

neuralgia

6iant cell arteritis

5umors

Sinusitis

5M; disorders

Atypical odontalgia

atypical facial pain



#!rning pain

3urning mouth syndrome

8ost herpetic neuralgia

<amsay9Hunt syndrome



SE$ERIT% OF PAIN

Scale of 19!1

Mild Moderate Severe

Atypical pain and trigeminal neuralgia, do not

affect sleep8ain at the same time each night = periodicmigrainous neuralgia

Acute pulpitis2periodontitis prevent sleep2

#aes up at night4xtreme pain >unbearable? 5rig neuralgia, glossph" @", periodic migrainous n",post

herpetic n"



SITE OF PAIN

-f from pathology unilateral

3ilateral:Sinusitis

C@S dse

8sychosomatic painneuralgias



D&RATION OF PAIN

Sharp2stabbing fe# secs or mins

*ull2throbbing fe# hrs, days,

#ees

Continuous psychosomatic origin



TI'IN(/E)ACER#ATIN(

FACTORSMerest contact of trigger one

8ain on s#allo#ing

8ain on biting or touchingn hot or cold stim

*entin exposure Caries

*efective resto Unlined recent resto .ractured th pulpitis



&ith s#eet food *entin exposure Caries

n biting, particularly on release of pressurepmn

Alcohol

<elated to meals Salivary gland obst 5M; disorder 69p neuralgia

5 n" 6iant cell arteritis *ental or oral mucosal dse



RE*IE$IN( FACTORS

Sharp responds poorly to analgesics

*ull responds usually to analgesics

Constant dull of long duration >years?,

unaffected by pain relievers atypical

odontalgia or burning mouth syndrome



OTHER S%'PTO'S

S#elling, discharge, bad taste, bad

breath, raised temperature, malaise,

cervical lymphadenopathy may be infective in origin



IDENTIF%

!" 5he nerve, division, branch

%" 7iely site of cause of pain

!" 8eripheral

%" 8roximal

'" -ntracranial



Denta" pain

Unilateral >usually?

@ever referred across to the other side

of the face >exceptBBBBBBBBBBBBB?8eriodontal pain is BBBBBBBBB localied

8ulpal pain is BBBBBBBBB localied

common things occur commonly,eliminate them firstDE

*iagnostic local inj

well

poorly

incisor region



+, P!"pa" pain

*entin sensitivitySharp2stabbing, al#ays related to hot, cold

or s#eet stimulus, never spontaneousccurs immediately after stim

<elief immediate after removal of stim



Signs

6ingival recessionCaries, fx, lea

3ubbles of saliva #hen moving a bridge

retainer lea

5ooth surface loss

*iagnostic testsCold air, ethyl chloride, hot gutta percha

5x



Cra-ke. tooth

4namel

4namel and dentin

4namel dentin and pulp<oot cro#n and root

@otes6ood periodontal status

May have large resto

S



Sx Faries ccasional pain from biting -ntermittent, may be #orse upon release of pressure G

rebound pain &ell localied Short duration, never spontaneous Some sensitivity to heat and cold

Signs pposing tooth usually present #ith excellent perio

status

5ests

7ight: m mirror, fiber optics, magnification 3ite on resilient object: cotton roll, rubber dam, etc radio

5x



.x involving pulpSpointaneous pain

8asses thru hyperemia irreversible suppurative stages >severe persistent

throbbing

acute periodontitis tender to percussion5ests

Fitality tests

<adio

5x



P!"pitis

*H <ecent dental scalings, recent depp resto, deep

caries, trauma hx

Sx Sharp stabbing

-ntermittent , immediate onset: coldIII, hotII,

s#eet

Stim needed, short duration J!) secs *ifficult to localie



Signs

7arge resto or large caries5ests8ercussion: no tenderness or dullness to

percussionFitality tests: exaggerated responses

Color: normal

<adio: #ith caries or restoK normal

radio appearance



5x<emove the cause

<epeat vitality tests

Serial radio

4ndo2 exo



A-!te p!"pitis

-rreversible, leading to suppurative pulpitis

MH nil

*H large resto2caries, trauma hx,

Sx Unilateral, initially sharp2stabbing, becoming dull

throbbing #ith time

-nitial: exaggerated responses to stimK is of long

duration, L !) secs to hrs after removal of stim

May radiate

3ecome spontaneous



May prevent sleep

Cold may reduce pressure and may

provide temporary relief 8ersist for days to #ees, then subsides as

pulp necroses

8oorly localied until bec tender to bite on



Signs 7arge caries2 resto, fx, discolored th

5ests *iagnostic local anesth

Fitality tests: exagg responses to heat initially,

until no responsesK cold may relieve painK Confusing in multirooted teeth

7ater stages: I percussion

<adio: deep caries2 resto

5x <emove cause



Chroni- p!"pitis

MH nil

*H large resto,etc

Sx -ntermittent mild pain over months or years8oorly localied, II to heat

<are pain concernsSigns7arge resto"2caries



5ests

Fitality: gradual rxn III heat common,J responses to cold

8ercussion: minor tenderness

<adio: loss of lamina dura apically,sclerosis in he pulp chamber and alveolar

bone

5x4xo2endo



Chroni- hperp"asti-

p!"pitisMH nil

*H neglect in young patient

S Usually none, lump sensation

Signs

Fisible pulp polyp, extensive caries5ests: radio, large apical foramina

5x: exo



(a"0anis1

MH nil

*H recent metallic restoNs adj, opposing

Sx-ntermittent pain, #ell localied, no referral

5x: reassurance: problem #ill diminish in a

=fe# days, as corrosion products accumulate



Aero.onta"gia

ccuring at reduced atmospheric pressureMH possible sinusitis

*H <ecent resto

Sx: acute pulpitic pain

Sgns: recently restored teeth

5ests: radio: possible antral opacityK deepresto

5x: monitor >pulpitis?K refer for for tx ofsinusitis



2, Perio.onta" pain

A8 of pulpal origin

5raumatic periodontitis

CA8 >apical granuloma?

Acute periodontitis of gingival origin

>lateral periodontitis?

8erio9endo lesions



A-!te Perio.ontitis of

p!"pa" origin

MH nil

*H trauma, resto, caries, pins, endo,hx of priortoothache

Sx: unilateral, severe, continuous, dull2throbbing pain, very

rapid onset 4xOuisitely tender, may feel loose

8reventing eating and sleeping Fery #ell localied Soft tissue s#elling soft and pufffy 8ain stops as pointing appears



Signs7arge resto, caries, rctSurrounding gingival tissue may be

inflamed8usI may come out of pocet

<egional lymph nodes may be enlargedMay be pyrexic and malaised*iscolorationMay be extruded and mobiler 8alpation: softG local edemaK firm and

erythematous 99 cellulitis



5ests

8ercussion: III apical, dull noteFitality: >9? or unreliable bec"BBBBBBBBBBB

<adio: #idening of pl space, loss of lamina

dura inc radiolucency

5x:pen and drain >overnight only?

- and * Antibiotics

4ndo2exo



Tra!1ati- perio.ontitis

@oninfectve butinflammatory

High resto, excessive

loading,Sx: &ell localied pain on biting .eels high to the bite Slightly loose

Signs <ecent resto or prostho, or

ortho May be slightly mobile

5ests: vitality: normal

responses 8ercussion : I, dull note

-dentify occlusal contacts#ith articulating paper

5x cclusal adjustment

Adjust ortho appliance ordenture or if necessary

refer bac to specialist

Ch i i "



Chroni- api-a"

perio.ontitis

Sx: pain unusual, if occurs: dull throbbing and not #ell localied ccasional discharge if a sinus is present

Signs 7arge resto etcK sinus may be present

5ests 8ercussion: possible minor tenderness, very slightly dull

percussion note

Fitality: usually >9?K heat may occasionally cause aresponse <adio: apical radiolucency, usually #ell defined

5x:



A-!te perio.ontitis of

gingi0a" originMH Common in *M pxs orimmunocompromised pxs

*H hx of gingival dse, abscess, tooth loss,tooth drifting2looseness, dentla neglect



Sx &ell localied,

continuous, dull and

throbbing

7oose teeth

May have an

associated s#elling

<are extraoral

s#elling

PHigh biteN

Signs

Mobile, deep pocets 8oor oral hygiene,

plaOue and calculus

Sinus liely

8us liely Supra9occluded



5estsFitality >I?

8ercussion: >I? lateralII, dull note<adio: generalied bone loss,

horiontal2vertical pattern

5x



Perio.onta"3en.o.onti-

"esionsMostly molars

May be primarily 8eriodontial in orgigin

r primarily endodontic in origin

S2sx: As for apical or lateral periodontitis

5ests Fitality: 8ercusiion: >I? to a dull note <adio: gutta perch point probe in pocet reaches apex

5x



4, (ingi0a" pain

5raumatic gingivitis

A@U6

Acute pericoronitis

5eething

*esOuamative gingivitis



Tra!1ati- gingi0itis

Cause8hysical

Chemical4lectrical

5reatment

Hot salt #ater rinses, chlorhexidine



AN&(

Ulceration of interdental papillaeK Anaerobic

6>9? involvedK pportunistic

8redilection: malesK young to middle agedadult s

MH smoer, heavy driner, stress, upper

respiratory tractinfection, immunosuppression

*H irregular attender, neglect, poor plaOue

removal



Sx Mod to severe gingival tenderness, pain #hen

eating and brushing

*ull2 boring pain, bad breath, unpleasant metallic

taste

Spontaneous gum bleeding

Signs Halitosis, obvious dental neglect,

Ulcerations

6rey pseudomembrane lies over the gingival

tissues, profuse bleeding if removed 7imited to gingival dse

8yrexia, malaise systemic sx



5ests6>9? orgs in smears

3lood tests indicated if severe, recurrent oraccompanied by systemic upset, toexclude leuemia etc

5x*ebridement, irrigationMetronidaole %11 mg tid )daysHydrogen peroxide mouth rinsing %1 vols

diluted !:( or chlorhexidineH-, scaling and polishingStop smoing



A-!te peri-oronitis

MH : Stress, U<5-,

*H: partially erupted lo#er 'rds, max agearound %1 yrs

Sx *ull throbbing pain, #ell localied S#elling possible beneath the angle of the mandible 5rismus liely

8x feels un#ell @ec and ja# pain if cervical or submandi nodes

affected



Signs 5rismus, difficult to examine i9o

-ntraoral s#elling can be seen extraorally 7ymphadenopahty S#ollen operculum, pus may be evident Upper tooth occludes onto operculum 8yrexia

5ests 'rd molar palpable >unerupted th do not cause pain? 7ymph node examination <adiographs: partially erupted /Ns, enlarged follicle

surrounding cro#n may sometimes be seen

5x 8alliative, then extract



Teething

A pericoronitis around erupting primary

teeth

MH possible incidence of viral infxn

Self limiting, does not usually reOuire

treatment, if severe, an analgesic gel



5Desq!a1ati0e’

gingi0itis5erm is descriptive only and does not

constitute a diagnosis

Used #here gingiva appear red or ra#

Causes: lichen planus, mucous

membrane pemphigoid

3iopsy



6, #one pain

*ry socet

steomyelitis

-nfected dental cyst

5rauma



Dr so-ket

MH: possible radiotherapyK pagetNs dse

*H: recent exo, %9( days previouslyK

mostly lo#er thSx *ull, throbbing, continuous, severe, deep seated

PboneQ pain, accompanied by bad breath

8ain arising after a fe# days after expo

Site painful to touch and #hen eating



SignsHalitosis

<eveals destroyed clot or contains debris<ed and inflamed gingiva around the

socet&hitish dead bone may be visible lining the

socet

5x<emove debris, irrigate #ith nss

*ress #ith alvogyl&arn px, pain for ! #analgesics



#one pain

steomyelitis

-nfected dental cyst

5rauma, fracture



Pain of NonDenta" Origin

7ess common than pain of dental origin

Most common causes of pain of non9

dental origin :5emporomandibular joint disorders



Differentia" .iagnosis

!" @eurologic

%" Fascular

'" Maxillary antrum 2nasopharynx

(" Salivary glands

)" ral mucosa

+" ;a#s2masticatory muscles

" 4ars/" 4yes

0" 8sychogenic



@eurologic



Trige1ina" ne!ra"gia

Sudden very severe, brief >secs?, recurrent

Stabbing Along distribution of trigeminal nerve

&ith trigger zone

@ever crosses the midlineclustersE 9

with periods of daily pain, then periods ofremission



4tiologies:*emyelination

Fascular compression5rauma or infection -diopathic

Signs5ic doloureux



Petrige1ina" ne!ra"gia

As mild toothache type pain in the

absence of any other dental signs

6oes on to deteriorate into trigeminalneuralgia



("ossopharngea"

ne!ra"giaSymptoms -dentical to trigeminal neuralgia but affecting the

glossopharyngeal nerve % distributions

tic 8haryngeal

5rigger one G at oropharynxK or initiated by

s#allo#ingSigns Fagal features >nausea, bradycardia?



Herpes 7oster

5he only non9dental pain that may truly mimicpulpal pain

Symptoms Severe, unilateral, deep seated, burning pain G

prodromal phase >fe# days before rashes? <ashes:

sin: #eeping and crusting Mouth: shallo# ulcers

Un#ell

Signs Unilateral, anatomical distributions



Post3herpeti- ne!ra"gia

8revious hx of herpes oster

Sx

8ersistent >not paroxysmal?, unilateral, verysevere, dull2boring pain

Signs

<ed overlying sin, scratching Psuicidal depressionN



#e""’s pa"s

Unilateral pain around the ear

.ollo#ed closely by unilateral facial palsy >paralysis?

*ifferential dx Stroe

5umor 5rauma Multiple sclerosis H-F *M <amsay9Hunt 6uillain93arre 3otulism etc



'!"tip"e s-"erosis

Multiple neurologic lesions8aresthesia, motor defect, incontinence,

visual disturbanceMuscular #eaness, vertigo

*isseminated in time and location

.reOuent remissions, but progressivedeterioration



Intra-rania" t!1ors

Symptoms<ecurrent headaches, aggravated or

precipitiated by straining or coughingFomiting8rogressive defects of function

Signs8apilloedema >bulging of optic disc?Fisual impairness, eye disturbances



Ca!sa"gia

Arise after injury to a peripheral sensorynerve

8ain due abherrant nerve repair

Sx Constant, burning or boring pain

Signs

Scarring from previous surgery or trauma*iagnostic test *x local anesthetic



2, $as-!"ar origin



'igraine

5hrobbing day9time headache lasting severalhours

8rodromal >pre9headache?K #ith PauraN

8hotophobia

@ausea and vomiting

SeOuence

8rodromal >pre9headache aura tingling? Severe, throbbing, temporal, frontal, and orbital

pain



C"!ster hea.a-he

Mainly males

Fery severe pain, paroxysmal,

dull2boring2burning pain4pisodic >periodic?

Similar time, often at night >Palarm cloc

a#aeningN?ccur in bouts >cluster?

Autonomic symptoms



Paro8s1a" he1i-rania

Similar to cluster headache but #ithout

autonomic problems



(iant -e"" arteritis

*ue to ishemia resulting to arteritis

Severe, unilateral, restricted to temporal andfrontal areas

*ull2boring

4lderly, females

Masseteric claudication

8ain brought on by eating due to ishemia ofmasticatory muscles

Systemic upset



Car.ia- ishe1ia

8reexisting heart or circulatory dse,

hypertension, *M

Sx<eferred pain to left arm and left ja#, may

be related to exercise, eating

.e# minutes only, relieved by rest Attacs often in cold #eather



Sin!sitis

1a8i""ar antr!19 nasopharn8Unilateral pain under the eye

@umerous maxillary teeth on one side

may be painfulStuffy nose

.luid level3y transillumination of the antra or an

occipitomental radiograph



'a"ignan-

s2sxccur late in the disease process

*epend upon the direction of spread >seeabove?

May mimic those of other dental and other

non9dental diseases



Te1poro1an.i!"ar

oint .isor.ers5M;9 8*S >pain9dysfunction syndrome? Symptoms

Unilateral2bilateral dull pain #2in 5M; -f bilateral, one side is usually more affected 5M; may loc open or closed Clicing, crunching, grating often described Headaches, facial pain, and nec aches 8ain on temporal region, often on #aing

Signs ;oint clics 4licited on palpation of 5M; 7imited mandibular movement 8arafunctional habits >)1R? 3ruxism G scalloping borders of the tongue, ridged buccal m,

tooth #ear, resto #ear, dentin exposure and sensitivity



8sychological consideration Chronic pain may affect pxs psychologically

Contributory: anxiety, depression, others

*epression in 8*S )x L*x tests:

Clinical and radio exam reveals no 5M; pathology

-solated headaches and painless joint sounds are

@5 8*S



ther 5M; disorderssteoarthritis

<heumatoid arthritis5rauma*evelopmental defects Anylosis -nfection@eoplasia

EARS



EARS

Otitis 1e.ia8ain at 5M; region

May involve the facial nerve facial

paralysisMay lead to cerebral abscess

E



Ees

("a!-o1a*ue to rapid inc in - pressure

Sx

8ersistent, severe, unilateral orbital pain,centered above the eye but may radiateacross one side of the eye

Signs4ye is stony hard*ull pupil, sea green, oval, dilated



Ps-hogeni-

Atypical facial pain

Significant number of patients suffer

from it@o organic lesion

MH: possibel hx of depression

*H: may have gone to many dentistsand doctorsK serial extractionexperience in atempt to BBBBBBBB



Sx Fague, constant, dull ache, present all day every day" Continuous

>years?" 8oorly localied, maxilla is often involved"

Start unilaterally

may spread to other side Unbearable pain, sleep is @5 affected *escription of pain is often biarre: Plie ants cra#ling over my faceN 8atients may present #ith detailed #ritten llists of problems and

dates

Signs

@o causative factor detectable Cranial nerves are intact -nconsistent responses to vitality tests



# i th



#!rning 1o!th

sn.ro1e4tio: psycho factors s2as anxiety,

cancerophobia, hypochondria, depression

Sx Severe, constant, burning pain, often bilateral,

present for many months or years

5ongue is involved often, any mucous membranes

Sleep is not affectedSigns @o mucous m abnormalities



*ifferential dx of burning mouth 8sychogenic

3urning mouth syndrome *eficiency states

Fitamin 3

-ron

.olic acid -nfections

Candidiasis

*enture discomfort

*ry mouth Allergy

*M



The end.

1 Pain of Dental Origin New

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