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