Endodontic pain can be odontogenic or non-odontogenic in origin. Odontogenic pain includes pulpal pain from reversible or irreversible pulpitis, as well as pain from periapical/periodontal conditions like acute apical periodontitis. Pulpal pain ranges from mild hypersensitive pulpalgia to severe advanced acute pulpalgia. Non-odontogenic pain includes musculoskeletal, neuropathic, neurovascular, inflammatory and systemic conditions. A thorough history and clinical/radiographic examination is needed to diagnose the source and type of endodontic pain present. Appropriate testing and treatment options are then selected.

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

12. Subjective history:
 Gives rise to provisional diagnosis
 Determines urgency of treatment
 Confirmed by examination and special tests

13. Objective Testing

Visual Examination

Periodontal probing

Radiographs

Selective anesthesia

Percussion

Test cavity

Palpation

Occlusion

Mobility

Vitality pulp testing

14. 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

15. 4. Hyperplastic pulpitis
5. Necrotic pulp
6. Internal resorption
7. Traumatic occlusion
8. Incomplete fracture

16. 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

18. Dentinal tubules
Tubular fluid
Odontoblastic
process
Nerve fibre
Odontoblast

19. Hyperemia :
Hyperemia →
increased blood flow → increased pulpal pressure
Application of heat → increased pulpal pressure
stimulate the nerve endings → Pain

20. 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

21. 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 ]

22. 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

23. Chemical/mechanical obstruction:
Desensitizing agents
potassium oxalate
strontium chloride [sensodyne]
sodium and stannous fluoride
Potassium nitrate
Dentin bonding agents

24. 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

25. 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

26. Treatment :
Excavation of caries and placing a sedative dressing
Follow up.

27. 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

28. 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

29. Cold test may give an immediate , severe and long
lasting response.
EPT may be inconclusive
Treatment:
Pulpectomy

30. 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]

31. 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]

32. 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.

34. 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

35. 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

36. 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

37. Hyperplastic pulpitis:
Chronically inflammed pulp tissue which extends outside
the carious lesion

39. Eliciting factors:
None
Examination:
Differentiate from Gingival polyp [using an excavator]
Treatment :
Pulpectomy
Extraction

40. 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

41. 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

42. Clinical examination :
Pink colored discoloration
Radiographic
Radiolucency involving the canal
outline
Treatment :
Pulpectomy

43. 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

44. Treatment ;
Relieving the occlusal trauma by selective grinding using an
articulating paper.

45. 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

46. TOOTH SLOOTH
Making the patient bite on any hard substance may elicit
sharp pain.

47. 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