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Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
Endodontic Pain
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Endodontic Pain

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Clinical Endodontics …

Clinical Endodontics
Fifth Year

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  • 1. ENDODONTIC PAIN
  • 2. PAIN Definition: an unpleasant sensory and emotional experience associated with actual or potential tissue damage
  • 3. PAIN ODONTOGENIC NON ODONTOGENIC
  • 4. NON ODONTOGENIC PAIN MUSCULO SKELETAL MYOFASCIAL PAIN [MPDS] TMD [ BRUXISM] NEUROPATHIC TRIGEMINAL NEURALGIA GLOSSOPHARYNGEAL NEURALGIA NEUROVASCULAR MIGRAINE CLUSTER HEADACHES INFLAMMATORY ALLERGIC SINUSITIS BACTERIAL SINUSITIS SYSTEMIC DISORDERS CARDIAC PAIN HERPES ZOSTER NEOPLASTIC DISEASE PSYCHOGENIC MUNCHAUSENS SYNDROME
  • 5. Selected features of non-odontogenic dental pain  No apparent etiologic factors for odontogenic pain (no caries, leaky restorations, trauma, fracture, etc.)  Pain not consistently relieved by local anaesthetic injection  Bilateral pain or multiple teeth are painful  Pain can be chronic and not responsive to dental treatment  Diagnosis-specific: pain concurrent with a headache  Diagnosis-specific: palpation of trigger points or muscles can increase pain  Diagnosis-specific: pain increased by emotional stress, physical exercise, head position, etc
  • 6. ODONTOGENIC PAIN PULPAL PAIN REVERSIBLE PULPITIS IRREVERISBLE PULPITIS PERAPICAL/ PERIODONTAL PAIN ACUTE APICAL PERIODONTITIS ACUTE APICAL ABSCESS HETEROTOPIC PAIN PROJECTED PAIN REFERRED PAIN
  • 7. HETEROTOPIC PAIN Pain felt in an area other than its true site of origin 1. Projected pain: perceived in the anatomic distribution of the same nerve that mediates the primary pain (painful adjacent teeth). 2. Referred pain: felt in an area innervated by a different nerve from the one that mediates the primary pain (teeth in opposing arch, face, head, neck).  Does not cross midline
  • 8. Pulpal pain / Pulpalgia One of the most commonly encountered Oro-facial pains Anatomic Feature Unyielding Walls Constricted Blood Source Tooth Surrounded by Bone Unfavorable Result • Limits pulp swelling • Limits blood supply • Subject to "strangulation" by pulp swelling • Bone infection invariably results
  • 9. Etiologic Agent Source Microbial Infection Dental caries Cracked teeth Irritation Chemicals (e.g., used in cavity preparation Trauma (e.g., blows to face) Heat (e.g., dry tooth cutting) Electrical stimulation (e.g., pulp testing)
  • 10. Pain History  Location  Character of pain  Severity  Duration of pain  Exacerbating factors  Relieving factors  Spontaneity  Other symptoms
  • 11. Subjective history:  Gives rise to provisional diagnosis  Determines urgency of treatment  Confirmed by examination and special tests
  • 12. Objective Testing  Visual Examination  Periodontal probing  Radiographs  Selective anesthesia  Percussion  Test cavity  Palpation  Occlusion  Mobility  Vitality pulp testing
  • 13. PULPAL PAIN / PULPALGIA Classified according to the degree of severity and the pathologic process present 1. Hyperreactive pulpalgia a. Dentinal hypersensitivity b. Hyperemia 2. Acute pulpalgia a. Incipient b. Moderate c. Advanced 3. Chronic pulpalgia a. Barodontalgia
  • 14. 4. Hyperplastic pulpitis 5. Necrotic pulp 6. Internal resorption 7. Traumatic occlusion 8. Incomplete fracture
  • 15. HYPERREACTIVE PULPALGIA Dentin hypersensitivity PAIN : Sharp. Short [described as sudden shock] Eliciting factor: Any stimulating factor like Heat , cold , sweet, sour , drying of dentin etc Mechanism: Noxious stimuli Odontoblastic process pulpal nerves Hydrodynamic theory : The displacement of tubule contents, if the movement occurs rapidly enough, may produce deformation of nerve fibers in the pulp or predentin or damage to the cells; both of these effects may be capable of producing pain
  • 16. Dentinal tubules Tubular fluid Odontoblastic process Nerve fibre Odontoblast
  • 17. Hyperemia : Hyperemia → increased blood flow → increased pulpal pressure Application of heat → increased pulpal pressure stimulate the nerve endings → Pain
  • 18. PULPAL A FIBRES [ A δ FIBRES] Fast conduction NERVES C FIBRES Slow conduction Low response threshold Higher activation threshold Transmits : Sharp, localized Transmits : Dull, poorly pain response Responds to cold stimulation localized response Responds to Heat stimulation
  • 19. Diagnosis :  May not respond abnormally with cold test.  The tooth should be isolated and continuous stream of water is put on the tooth → pain  Scratching the cervical dentin also elicits pain  EPT may elicit an earlier response Electric stimulation does not cause fluid movement EPT stimulates the faster A fibres [ A β fibres] initially and then the C fibres . [A + C fibres produce painful response on higher level of electrical stimulation ]
  • 20. MANAGEMENT:  Prevention is the best treatment  Bases under the restorations to prevent irritation of the dentinal tubules Physiologic methods: • Remineralization of the dentinal tubules by the calcium phosphate-carbohydrate-protein complex from saliva • Formation of the tertiary dentine from the pulpal side Both are time consuming
  • 21. Chemical/mechanical obstruction: Desensitizing agents potassium oxalate strontium chloride [sensodyne] sodium and stannous fluoride Potassium nitrate Dentin bonding agents
  • 22. ACUTE PULPALGIA INCIPIENT PULPALGIA / [REVERSIBLE PULPITIS] Mild pain or ache in response to cold beverages/foods, sweets Also seen after cavity preparation and restorations especially after the anesthesia wears off. Eliciting factor : caries , cavity preparation, cold sugar, traumatic occlusion If not treated my turn into moderate/acute pulpalgia
  • 23. Examination : -Recently restored teeth -Carious lesions • clinical • radiographic Cold test causes pain which lasts for less than 10 secs after removal of the stimulus EPT may not be very confirmative
  • 24. Treatment : Excavation of caries and placing a sedative dressing Follow up.
  • 25. MODERATE PULPALGIA: Pain is nagging or boring pain which is initially localized but later becomes diffuse or referred to another area. Pain is continuous and may extend for hours or even days Eliciting factor:  Cold and Hot food/ beverages  Spontaneous at times and increases when the patient lies down or even bends his head due to an increase in the cephalic blood pressure
  • 26. Pain increases after mastication especially when food gets lodged into the carious cavity Rinsing with cold water aggravates the pain Examination: The patient usually cannot localize the tooth due to diffuse pain Carious tooth / tooth with a large restoration Clinical Radiographic
  • 27. Cold test may give an immediate , severe and long lasting response. EPT may be inconclusive Treatment: Pulpectomy
  • 28. ADVANCED ACUTE PULPALGIA Most severe type of pulpalgia Pain is excruciating Patient may be hysterical Eliciting factors: Spontaneous May be relieved with rinsing cold water [unlike moderate pulpalgia]
  • 29. Examination : Patient points to the involved tooth Tender to percussion Radiograph may reveal large restoration or caries involving pulp Periapical changes may/may not be present Heat test produces profound pain [cold water should be sprayed over the tooth if the patient is in severe pain after the heat test]
  • 30. Local anesthesia will provide an immediate relief. Treatment : Pulpectomy In some cases Local anaesthesia may be ineffective hence would require Intra canal injection and supplemental periodontal injections.
  • 31. CHRONIC PULPALGIA Pain is diffuse and the patient cannot locate the tooth Most likely to cause referred pain Eliciting factors: Hot drinks/foods Food lodged into a carious tooth Barodontalgia: Earlier called as AERODONTALGIA Due to increased/decreased air pressues
  • 32. Barodontalgia ; Class I - Sharp momentary pain on ascent – acute pulpitis Class II - Dull throbbing pain on ascent – chronic pulpitis Class III- Dull throbbing pain on descent - necrotic tooth [Asymptomatic on ascent] Class IV – Severe persistant pain on ascent/descent – periapical abscess/cyst
  • 33. Examination:  Large carious lesion  Large restoration  Recurrent caries with restorations  Radiograph often shows Periapical radiolucency Both electric pulp testing and cold tests are non confirmatory May show pain with heat test Treatment : Pulpectomy
  • 34. Hyperplastic pulpitis: Chronically inflammed pulp tissue which extends outside the carious lesion
  • 35. Eliciting factors: None Examination: Differentiate from Gingival polyp [using an excavator] Treatment : Pulpectomy Extraction
  • 36. NECROTIC PULP  Usually asymptomatic  In most of the cases the patient reports with a disclored toothmost of the cases  Clinical examination discolored teeth may at times be tender to percussion EPT may or may not give any reponse May give a false positive in multi rooted teeth Treatment : Pulpectomy
  • 37. INTERNAL RESORPTION: Mostly asymptomatic , but the patient may complain of vague, dull pain Clinically seen as the pink tooth Pain on percussion may be present in some cases
  • 38. Clinical examination : Pink colored discoloration Radiographic Radiolucency involving the canal outline Treatment : Pulpectomy
  • 39. TRAUMATIC OCCLUSION: Traumatic occlusion due to bruxism High restoration Eliciting factors: Patient usually complains of pain on biting after a recent restoration Pain in all the teeth after waking up in the morning Clinical examination: Shiny spots on the amalgam restorations Wear facets on the occlusal surface of the teeth
  • 40. Treatment ; Relieving the occlusal trauma by selective grinding using an articulating paper.
  • 41. Incomplete tooth fracture: •Tooth that is split or cracked but not yet fractured •symptoms range from those of a constant, unexplained hypersensitive pulp to constant, unexplained toothache •Tooth uncomfortable during biting Eliciting factors: Biting will induce pain Examination : Clean and dry the tooth and examine under light for any cracks
  • 42. TOOTH SLOOTH Making the patient bite on any hard substance may elicit sharp pain.
  • 43. Pulp tests : may not show any abnormal response unless the pulp is involved. Treatment: If the pulp is not involved, a crown is given If pulp is involved, Pulpectomy followed by crown

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