DiagnosingDiagnosingOrofacial &Orofacial &

Dental PainDental Pain

Material used by permission from B.C. Decker Publishing Co.Material used by permission from B.C. Decker Publishing Co.

PAINPAIN

►An unpleasant sensory and emotional An unpleasant sensory and emotional experience associated with actual or experience associated with actual or potential tissue damage or described potential tissue damage or described in terms of such damage.in terms of such damage.

AcuteAcutevv

ChronicChronic

Acute PainAcute Pain

►Associated with tissue damage or injury.Associated with tissue damage or injury.►Recent onset. Recent onset. ►Limited duration.Limited duration.►Stimulation of peripheral and central Stimulation of peripheral and central

nociceptors by algogenic substances nociceptors by algogenic substances (bradykinin, prostoglandin, leukotrienes, (bradykinin, prostoglandin, leukotrienes, histamines, substance P, excitatory histamines, substance P, excitatory AAs).AAs).

Chronic PainChronic Pain

►Prolonged persistence of pain beyond Prolonged persistence of pain beyond the healing of tissue.the healing of tissue.

►Frequently experienced in the absence Frequently experienced in the absence of peripheral stimulation or lesions.of peripheral stimulation or lesions.

►Result from changes in the dorsal horn Result from changes in the dorsal horn and brain.and brain.

Urgent dental problems most often Urgent dental problems most often involve involve acuteacute orofacial pain and may orofacial pain and may originate from:originate from:

► TeethTeeth► PeriodontiumPeriodontium► MucosaMucosa► MuscleMuscle► BoneBone► Blood vesselsBlood vessels

► Lymph nodesLymph nodes► Paranasal sinusesParanasal sinuses► Salivary glandsSalivary glands► TMJ’sTMJ’s

Toothache is one of the most common Toothache is one of the most common acute pain complaints in the orofacial acute pain complaints in the orofacial region.region.

Toothache behavior can be so varied Toothache behavior can be so varied that it is wise to consider all pains in that it is wise to consider all pains in the orofacial region to be of the orofacial region to be of odontogenic origin until proven odontogenic origin until proven otherwise.otherwise.

The first step is to classify the type of The first step is to classify the type of pain based on the pain based on the historyhistory and and clinical characteristicsclinical characteristics..

Various tissues (e.g., muscles, glands, Various tissues (e.g., muscles, glands, blood vessels, mucosa) possess unique blood vessels, mucosa) possess unique characteristics that help to identify the characteristics that help to identify the tissue of origin.tissue of origin.

Pain ClassificationPain Classification

►Somatic PainSomatic Pain - results from - results from stimulation of stimulation of normalnormal neural tissue. neural tissue.

Superficial – apthous ulcerSuperficial – apthous ulcer►Bright, stimulating, easily localizedBright, stimulating, easily localized

Deep – internal structures (pain referral)Deep – internal structures (pain referral)►Dull, depressing, difficult to localizeDull, depressing, difficult to localize

Deep Somatic PainDeep Somatic Pain

►Musculoskeletal PainMusculoskeletal Pain Gradient, biomechanicalGradient, biomechanical Pain is proportional to degree of movementPain is proportional to degree of movement Source can be localizedSource can be localized

►Visceral PainVisceral Pain Not perceived until a threshold is reachedNot perceived until a threshold is reached Not stimulated by biomechanical functionNot stimulated by biomechanical function Diffuse, difficult to localizeDiffuse, difficult to localize

Pain ClassificationPain Classification

►Neuropathic PainNeuropathic Pain – – arises from arises from abnormalabnormal neural tissue that has been neural tissue that has been altered.altered.

Non-painful stimuli are now painfulNon-painful stimuli are now painful Can be episodic or continuousCan be episodic or continuous Example: trigeminal neuralgia (light Example: trigeminal neuralgia (light

touch)touch)

Acute Orofacial PainAcute Orofacial Pain

SOMATIC NEUROPATHIC

SUPERFICIALDEEP

VISCERAL MUSCULOSKELETAL

PulpBlood Vessel

GlandsVisceral Mucosa

Ears

Periodontal LigamentsJoints

MusclesBone

TOOTHACHE PAINTOOTHACHE PAIN

Toothache of odontogentic origin can be Toothache of odontogentic origin can be visceralvisceral (pupal) or (pupal) or musculoskeletalmusculoskeletal (periapical or periodontal).(periapical or periodontal).

When the pulp is exposed to a noxious When the pulp is exposed to a noxious stimulus, there is a reactive inflammatory stimulus, there is a reactive inflammatory response.response.

The resulting edema is unable to expand The resulting edema is unable to expand because of the surrounding inflexible because of the surrounding inflexible cementum cementum → ↑ tissue pressure and ↓ blood ↑ tissue pressure and ↓ blood flow that causes damaging effects to the pulp.flow that causes damaging effects to the pulp.

Considerations:Considerations:

► Healthy pulp (cellular) v Aged pulp (fibrous)Healthy pulp (cellular) v Aged pulp (fibrous)

► As an increasing amount of pulp tissue is As an increasing amount of pulp tissue is involved, the inflammatory process involved, the inflammatory process progresses apically, until it extends out into progresses apically, until it extends out into the periapical tissue the periapical tissue → apex becomes sensitive to palpation and percussion.

► Periapical inflammation from non-pulpal causes can exhibit similar symptoms: Hyperocclusion Bruxism

Pulpal StatusPulpal Status

Vital Nonvital

Normal Inflamed

ReversiblyInflamed

IrreversiblyInflamed

Necrotic

Periapical StatusPeriapical Status

NormalInflamed

AcuteApical

Periodontitis

AcuteApical

Abscess

ChronicApical

Periodontitis

Diagnostic ProcessDiagnostic Process: : systemic systemic approach using history and clinical approach using history and clinical examination.examination.HistoryHistory (more important)(more important)

CCCC HPI HPI PMHPMH PSHPSH MedsMeds SHSH

LocationOnset Timing (frequency, duration)Quality (sharp, dull, throbbing, aching,

burning, etc.)Intensity (0-10)Relieves / AggravatesAssociated symptoms

Clinical Examination:Clinical Examination: confirms the confirms the history and identifies the true source of history and identifies the true source of

pain.pain.►Visual InspectionVisual Inspection – pain source is usually – pain source is usually

evident. Gutta percha / fistulous tract.evident. Gutta percha / fistulous tract.►PalpationPalpation – sensitivity over apex of tooth – sensitivity over apex of tooth

suggests periapical inflammation. Firm or suggests periapical inflammation. Firm or fluctuant swelling consistent with abscess.fluctuant swelling consistent with abscess.

►PercussionPercussion – pain/sensitivity consistent with – pain/sensitivity consistent with periapical inflammation. Percussion of periapical inflammation. Percussion of each cusp helps locate incomplete fracture.each cusp helps locate incomplete fracture.

►MobilityMobility – check horizontal and vertical. – check horizontal and vertical.►Periodontal ProbingPeriodontal Probing – evaluate – evaluate

periodontal status as contributor to pain. periodontal status as contributor to pain. Aids in decision regarding retaining or Aids in decision regarding retaining or extracting.extracting.

►Thermal SensitivityThermal Sensitivity – tests pulpal status. – tests pulpal status. Cold (ethyl chloride) is test of choice. Cold (ethyl chloride) is test of choice. Normal / reversible pulpitis: not prolongedNormal / reversible pulpitis: not prolonged Irreversible pulpitis: prolonged responseIrreversible pulpitis: prolonged response Necrotic pulp: no responseNecrotic pulp: no response Heat test not usually done, difficultHeat test not usually done, difficult Air / water syringe to detect fracturesAir / water syringe to detect fractures

►EPT – pulp is responsive (vital) or it is not (nonvital). False (+) and false (-).

►Translumination – helps detect enamel and pulpal floor fractures.

►Radiographs: Panorex – overall survey PAs – provide definition of PA areas, caries, fxs BWs – bone level and interproximal caries Occlusal – buccal / lingual and floor of mouth Water’s – maxillary sinuses

►Selective Anesthesia – infiltration, blocks, TPIs

►Test Cavity – prep suspected tooth with no anesthesia.

Primary Odontogenic PainPrimary Odontogenic Pain

Odontogenic toothache arises fromOdontogenic toothache arises from

pulpalpulpal tissue tissue

oror

periapicalperiapical tissue tissue

with general characteristics that with general characteristics that indicate the tissue of origin.indicate the tissue of origin.

Characteristics of Pulpal & Characteristics of Pulpal & Periapical PainPeriapical Pain

Pupal PainPupal Pain(Deep, Somatic,

Visceral)

Periapical PainPeriapical Pain(Deep, somatic, Musculoskeletal)

Masticatory functionMasticatory function(Biomechanical (Biomechanical stimulation)stimulation)

NotNot stimulated by stimulated by biting, chewing, or biting, chewing, or percussionpercussion

Stimulated by biting, Stimulated by biting, chewing, or chewing, or percussionpercussion

LocalizationLocalization Frequently difficult Frequently difficult to localize to localize specifically specifically

Usually can localize Usually can localize preciselyprecisely

SequenceSequence Usually precedes Usually precedes periapical painperiapical pain

Usually follows Usually follows pulpal pain pulpal pain (unless (unless periodontitis, periodontitis, hyperocclusion, hyperocclusion, bruxism)bruxism)

Classification of Toothaches of Odontogenic Classification of Toothaches of Odontogenic OriginOrigin

► Pulpal diseasePulpal disease Reversible pulpitis (brief, stimulated pain)Reversible pulpitis (brief, stimulated pain) Irreversible pulpitis (prolonged, stimulated or spontaneous Irreversible pulpitis (prolonged, stimulated or spontaneous

pain)pain) Necrotic pulp (prolonged or spontaneous pain, no response Necrotic pulp (prolonged or spontaneous pain, no response

to pulp to pulp testing, sensitive to percussion)testing, sensitive to percussion)

► Periapical diseasePeriapical disease Acute apical periodontitis (sensitivity to percussion)Acute apical periodontitis (sensitivity to percussion) Acute apical abscess (sensitivity to percussion, swelling, Acute apical abscess (sensitivity to percussion, swelling,

pus)pus) Chronic apical periodontitis (often asymptomatic, periapical Chronic apical periodontitis (often asymptomatic, periapical

radiolucency)radiolucency)

► Heterotopic painHeterotopic pain Projected pain (pain in adjacent teeth)Projected pain (pain in adjacent teeth) Referred pain (pain in teeth in opposing arch)Referred pain (pain in teeth in opposing arch)

Heterotopic PainHeterotopic Pain

►Pain felt in an area other than its true Pain felt in an area other than its true site of origin (associated with deep, site of origin (associated with deep, somatic pain).somatic pain). Projected pain:Projected pain: perceived in the anatomic perceived in the anatomic

distribution of the distribution of the samesame nerve that mediates nerve that mediates the primary pain (painful adjacent teeth).the primary pain (painful adjacent teeth).

Referred pain:Referred pain: felt in an area innervated by felt in an area innervated by a a differentdifferent nerve from the one that nerve from the one that mediates the primary pain (teeth in mediates the primary pain (teeth in opposing arch, face, head, neck).opposing arch, face, head, neck).

►Does not cross the midline.Does not cross the midline.►Convergence of afferent neurons.Convergence of afferent neurons.

Nonodontogenic ToothachesNonodontogenic Toothaches

Most toothaches will be of odontogenic origin.Most toothaches will be of odontogenic origin.

However, if there is However, if there is no identifiable causeno identifiable cause or or source (e.g. caries) for the pain,source (e.g. caries) for the pain,

oror

the the history and clinical findings are inconsistenthistory and clinical findings are inconsistent with odontogenic pain,with odontogenic pain,

thenthen

a nonodontogenic source should be considered.a nonodontogenic source should be considered.

Toothache of Maxillary Toothache of Maxillary Sinus/Nasal Mucosa OriginSinus/Nasal Mucosa Origin

OriginOrigin Infection of the maxillary sinus or inflammation Infection of the maxillary sinus or inflammation of nasal mucosa.of nasal mucosa.

Clinical Clinical CharacteristiCharacteristicscs

Constant dull ache or pressure; sensitivity to Constant dull ache or pressure; sensitivity to cold, percussion, chewing; pain in multiple cold, percussion, chewing; pain in multiple teeth; pain increased by bending body forward; teeth; pain increased by bending body forward; sinus tender to palpation; Water’s may show air-sinus tender to palpation; Water’s may show air-fluid level.fluid level.

Local Local AnesthesiaAnesthesia

Topical anesthesia of nasal mucosa relieves Topical anesthesia of nasal mucosa relieves pain in anterior teeth; infiltration anesthesia of pain in anterior teeth; infiltration anesthesia of posterior teeth relieves pain.posterior teeth relieves pain.

TreatmentTreatment Antibiotics, antihistamine with a decongestant, Antibiotics, antihistamine with a decongestant, analgesic.analgesic.

Toothache of Myofascial OriginToothache of Myofascial Origin

OriginOriginReferral of pain from myofascial trigger points in Referral of pain from myofascial trigger points in muscles of mastication – primarily masseter, muscles of mastication – primarily masseter, temporalis, anterior digastric.temporalis, anterior digastric.

Clinical Clinical CharacteristiCharacteristicscs

Nonpulsatile; constant, aching; variable and Nonpulsatile; constant, aching; variable and cyclic; pain increases with stress and use of cyclic; pain increases with stress and use of offending muscles.offending muscles.

Local Local AnestheticsAnesthetics

Anesthetic block of tooth does not alter pain; Anesthetic block of tooth does not alter pain; anesthetic injection of trigger point relieves anesthetic injection of trigger point relieves pain.pain.

TreatmentTreatment Treatment and elimination of trigger points by Treatment and elimination of trigger points by spray and stretch, injection, or physical therapy.spray and stretch, injection, or physical therapy.

Toothache of Neuropathic Origin Toothache of Neuropathic Origin (Trigeminal Neuralgia)(Trigeminal Neuralgia)

OriginOriginAbnormal function of nerves that innervate Abnormal function of nerves that innervate teeth (mandibular and maxillary branch of the teeth (mandibular and maxillary branch of the trigeminal nerves).trigeminal nerves).

Clinical Clinical CharacteristiCharacteristicscs

Unilateral, severe, paroxysmal bursts of electric-Unilateral, severe, paroxysmal bursts of electric-like shocks stimulated by minor superficial like shocks stimulated by minor superficial provocation; may be felt in teeth; asymptomatic provocation; may be felt in teeth; asymptomatic between episodes.between episodes.

Local Local AnestheticsAnesthetics

Topical anesthetic of mucosal or skin “trigger” Topical anesthetic of mucosal or skin “trigger” blocks pain; anesthetic block of nerve root blocks pain; anesthetic block of nerve root blocks pain.blocks pain.

TreatmentTreatment Referral to neurologist or neurosurgeon.Referral to neurologist or neurosurgeon.

Toothache of Neuropathic Origin Toothache of Neuropathic Origin [Atypical Odontalgia [Atypical Odontalgia (Phantom Pain)(Phantom Pain)]]

OriginOrigin Not definitely known; most probably a Not definitely known; most probably a deafferentation pain after trauma.deafferentation pain after trauma.

Clinical Clinical CharacteristiCharacteristicscs

Constant pain with no obvious pathology; Constant pain with no obvious pathology; burning, aching pain in molar/premolar area burning, aching pain in molar/premolar area longer than 4 months; local provocation not longer than 4 months; local provocation not reliably effect pain.reliably effect pain.

Local Local AnestheticsAnesthetics

Equivocal responseEquivocal response

TreatmentTreatment Tricyclic antidepressants, gabapentinTricyclic antidepressants, gabapentin

Toothache of Neurovascular Toothache of Neurovascular Origin (Tooth migraine)Origin (Tooth migraine)

OriginOrigin Neurogenic inflamation in the trigeminovascular Neurogenic inflamation in the trigeminovascular systemsystem

Clinical Clinical CharacteristiCharacteristicscs

Maxillay canines/premolars; no dental cause; Maxillay canines/premolars; no dental cause; throbbing, episodic, persistent, recurrent pain; throbbing, episodic, persistent, recurrent pain; dental treatment may provide temporary relief; dental treatment may provide temporary relief; may become widespread.may become widespread.

Local Local AnestheticsAnesthetics

Effects are unpredictable.Effects are unpredictable.

TreatmentTreatment Same as for migraine headache; triptans, Same as for migraine headache; triptans, NSAIDs, beta blockers, ergotamines.NSAIDs, beta blockers, ergotamines.

Toothache of Cardiac OriginToothache of Cardiac Origin

OriginOrigin Myocardial ischemia with regional referral of Myocardial ischemia with regional referral of pain.pain.

Clinical Clinical CharacteristiCharacteristicscs

Periodic dull pressure of aching in the mandible Periodic dull pressure of aching in the mandible or teeth; may accompany pain in chest or arm; or teeth; may accompany pain in chest or arm; history of angina; pain precipitated by exercise, history of angina; pain precipitated by exercise, stress, or physical activity.stress, or physical activity.

Local Local AnestheticsAnesthetics

Anesthesia of teeth not effective.Anesthesia of teeth not effective.

TreatmentTreatment Refer to medical physicianRefer to medical physician

Toothache of Psychogenic OriginToothache of Psychogenic Origin

OriginOrigin Psychogenic origin.Psychogenic origin.

Clinical Clinical CharacteristiCharacteristicscs

Bizarre behavior; history of psychiatric Bizarre behavior; history of psychiatric treatment; migratory pain in multiple teeth, treatment; migratory pain in multiple teeth, frequently bilateral; unexpected or frequently bilateral; unexpected or inappropriate response to treatment.inappropriate response to treatment.

Local Local AnestheticsAnesthetics

Equivocal effects.Equivocal effects.

TreatmentTreatment Refer to psychiatrist.Refer to psychiatrist.