DiagnosingDiagnosing
Orofacial &Orofacial &
Dental PainDental Pain
Material used by permission from B.C. Decker Publishing...
PAINPAIN
►An unpleasant sensory and emotionalAn unpleasant sensory and emotional
experience associated with actual orexper...
AcuteAcute
vv
ChronicChronic
Acute PainAcute Pain
►Associated with tissue damage or injury.Associated with tissue damage or injury.
►Recent onset.Recen...
Chronic PainChronic Pain
►Prolonged persistence of pain beyond theProlonged persistence of pain beyond the
healing of tiss...
Urgent dental problems most often involveUrgent dental problems most often involve
acuteacute orofacial pain and may origi...
Toothache is one of the most common acuteToothache is one of the most common acute
pain complaints in the orofacial region...
The first step is to classify the type of painThe first step is to classify the type of pain
based on thebased on the hist...
Pain ClassificationPain Classification
►Somatic PainSomatic Pain - results from stimulation of- results from stimulation o...
Deep Somatic PainDeep Somatic Pain
►Musculoskeletal PainMusculoskeletal Pain
 Gradient, biomechanicalGradient, biomechani...
Pain ClassificationPain Classification
►Neuropathic PainNeuropathic Pain –– arises fromarises from
abnormalabnormal neural...
Acute Orofacial PainAcute Orofacial Pain
SOMATIC NEUROPATHIC
SUPERFICIAL
DEEP
VISCERAL MUSCULOSKELETAL
Pulp
Blood Vessel
G...
TOOTHACHE PAINTOOTHACHE PAIN
Toothache of odontogentic origin can beToothache of odontogentic origin can be
visceralviscer...
Considerations:Considerations:
► Healthy pulp (cellular) v Aged pulp (fibrous)Healthy pulp (cellular) v Aged pulp (fibrous...
Pulpal StatusPulpal Status
Vital Nonvital
Normal Inflamed
Reversibly
Inflamed
Irreversibly
Inflamed
Necrotic
Periapical StatusPeriapical Status
Normal
Inflamed
Acute
Apical
Periodontitis
Acute
Apical
Abscess
Chronic
Apical
Periodon...
Diagnostic ProcessDiagnostic Process:: systemicsystemic
approach using history and clinicalapproach using history and clin...
Clinical Examination:Clinical Examination: confirms theconfirms the
history and identifies the true source of pain.history...
►MobilityMobility – check horizontal and vertical.– check horizontal and vertical.
►Periodontal ProbingPeriodontal Probing...
►EPT – pulp is responsive (vital) or it is not
(nonvital). False (+) and false (-).
►Translumination – helps detect enamel...
Primary Odontogenic PainPrimary Odontogenic Pain
Odontogenic toothache arises fromOdontogenic toothache arises from
pulpal...
Characteristics of Pulpal & PeriapicalCharacteristics of Pulpal & Periapical
PainPain
Pupal PainPupal Pain
(Deep, Somatic,...
Classification of Toothaches of Odontogenic OriginClassification of Toothaches of Odontogenic Origin
► Pulpal diseasePulpa...
Heterotopic PainHeterotopic Pain
►Pain felt in an area other than its true site ofPain felt in an area other than its true...
Nonodontogenic ToothachesNonodontogenic Toothaches
Most toothaches will be of odontogenic origin.Most toothaches will be o...
Toothache of Maxillary Sinus/NasalToothache of Maxillary Sinus/Nasal
Mucosa OriginMucosa Origin
OriginOrigin
Infection of ...
Toothache of Myofascial OriginToothache of Myofascial Origin
OriginOrigin
Referral of pain from myofascial trigger points ...
Toothache of Neuropathic OriginToothache of Neuropathic Origin
(Trigeminal Neuralgia)(Trigeminal Neuralgia)
OriginOrigin
A...
Toothache of Neuropathic OriginToothache of Neuropathic Origin
[Atypical Odontalgia[Atypical Odontalgia (Phantom Pain)(Pha...
Toothache of Neurovascular OriginToothache of Neurovascular Origin
(Tooth migraine)(Tooth migraine)
OriginOrigin Neurogeni...
Toothache of Cardiac OriginToothache of Cardiac Origin
OriginOrigin Myocardial ischemia with regional referral of pain.Myo...
Toothache of Psychogenic OriginToothache of Psychogenic Origin
OriginOrigin Psychogenic origin.Psychogenic origin.
Clinica...
DOWNLOAD THIS FILE
DOWNLOAD THIS FILE
DOWNLOAD THIS FILE
Upcoming SlideShare
Loading in...5
×

DOWNLOAD THIS FILE

850

Published on

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
850
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
67
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

DOWNLOAD THIS FILE

  1. 1. DiagnosingDiagnosing Orofacial &Orofacial & Dental PainDental Pain Material used by permission from B.C. Decker Publishing Co.Material used by permission from B.C. Decker Publishing Co.
  2. 2. PAINPAIN ►An unpleasant sensory and emotionalAn unpleasant sensory and emotional experience associated with actual orexperience associated with actual or potential tissue damage or described inpotential tissue damage or described in terms of such damage.terms of such damage.
  3. 3. AcuteAcute vv ChronicChronic
  4. 4. 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 centralStimulation of peripheral and central nociceptors by algogenic substancesnociceptors by algogenic substances (bradykinin, prostoglandin, leukotrienes,(bradykinin, prostoglandin, leukotrienes, histamines, substance P, excitatory AAs).histamines, substance P, excitatory AAs).
  5. 5. Chronic PainChronic Pain ►Prolonged persistence of pain beyond theProlonged persistence of pain beyond the healing of tissue.healing of tissue. ►Frequently experienced in the absence ofFrequently experienced in the absence of peripheral stimulation or lesions.peripheral stimulation or lesions. ►Result from changes in the dorsal horn andResult from changes in the dorsal horn and brain.brain.
  6. 6. Urgent dental problems most often involveUrgent dental problems most often involve acuteacute orofacial pain and may originate from:orofacial pain and may originate from: ► TeethTeeth ► PeriodontiumPeriodontium ► MucosaMucosa ► MuscleMuscle ► BoneBone ► Blood vesselsBlood vessels ► Lymph nodesLymph nodes ► Paranasal sinusesParanasal sinuses ► Salivary glandsSalivary glands ► TMJ’sTMJ’s
  7. 7. Toothache is one of the most common acuteToothache is one of the most common acute pain complaints in the orofacial region.pain complaints in the orofacial region. Toothache behavior can be so varied that it isToothache behavior can be so varied that it is wise to consider all pains in the orofacialwise to consider all pains in the orofacial region to be of odontogenic origin untilregion to be of odontogenic origin until proven otherwise.proven otherwise.
  8. 8. The first step is to classify the type of painThe first step is to classify the type of pain based on thebased on the historyhistory andand clinicalclinical characteristicscharacteristics .. Various tissues (e.g., muscles, glands, bloodVarious tissues (e.g., muscles, glands, blood vessels, mucosa) possess uniquevessels, mucosa) possess unique characteristics that help to identify the tissuecharacteristics that help to identify the tissue of origin.of origin.
  9. 9. Pain ClassificationPain Classification ►Somatic PainSomatic Pain - results from stimulation of- results from 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
  10. 10. 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
  11. 11. Pain ClassificationPain Classification ►Neuropathic PainNeuropathic Pain –– arises fromarises from abnormalabnormal neural tissue that has beenneural 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 touch)Example: trigeminal neuralgia (light touch)
  12. 12. Acute Orofacial PainAcute Orofacial Pain SOMATIC NEUROPATHIC SUPERFICIAL DEEP VISCERAL MUSCULOSKELETAL Pulp Blood Vessel Glands Visceral Mucosa Ears Periodontal Ligaments Joints Muscles Bone
  13. 13. TOOTHACHE PAINTOOTHACHE PAIN Toothache of odontogentic origin can beToothache of odontogentic origin can be visceralvisceral (pupal) or(pupal) or musculoskeletalmusculoskeletal (periapical or periodontal).(periapical or periodontal).  When the pulp is exposed to a noxiousWhen the pulp is exposed to a noxious stimulus, there is a reactive inflammatorystimulus, there is a reactive inflammatory response.response.  The resulting edema is unable to expandThe resulting edema is unable to expand because of the surrounding inflexible cementumbecause of the surrounding inflexible cementum → ↑ tissue pressure and ↓ blood flow that↑ tissue pressure and ↓ blood flow that causes damaging effects to the pulp.causes damaging effects to the pulp.
  14. 14. Considerations:Considerations: ► Healthy pulp (cellular) v Aged pulp (fibrous)Healthy pulp (cellular) v Aged pulp (fibrous) ► As an increasing amount of pulp tissue is involved,As an increasing amount of pulp tissue is involved, the inflammatory process progresses apically, untilthe inflammatory process progresses apically, until it extends out into the periapical tissueit extends out into the periapical tissue → apex becomes sensitive to palpation and percussion. ► Periapical inflammation from non-pulpal causes can exhibit similar symptoms:  Hyperocclusion  Bruxism
  15. 15. Pulpal StatusPulpal Status Vital Nonvital Normal Inflamed Reversibly Inflamed Irreversibly Inflamed Necrotic
  16. 16. Periapical StatusPeriapical Status Normal Inflamed Acute Apical Periodontitis Acute Apical Abscess Chronic Apical Periodontitis
  17. 17. Diagnostic ProcessDiagnostic Process:: systemicsystemic approach using history and clinicalapproach using history and clinical examination.examination. HistoryHistory (more important)(more important)  CCCC  HPIHPI  PMHPMH  PSHPSH  MedsMeds  SHSH Location Onset Timing (frequency, duration) Quality (sharp, dull, throbbing, aching, burning, etc.) Intensity (0-10) Relieves / Aggravates Associated symptoms
  18. 18. Clinical Examination:Clinical Examination: confirms theconfirms the history and identifies the true source of pain.history and identifies the true source of 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 orsuggests 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 eachperiapical inflammation. Percussion of each cusp helps locate incomplete fracture.cusp helps locate incomplete fracture.
  19. 19. ►MobilityMobility – check horizontal and vertical.– check horizontal and vertical. ►Periodontal ProbingPeriodontal Probing – evaluate periodontal– evaluate periodontal status as contributor to pain. Aids instatus as contributor to pain. Aids in decision regarding retaining or extracting.decision regarding retaining or 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
  20. 20. ►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
  21. 21. Primary Odontogenic PainPrimary Odontogenic Pain Odontogenic toothache arises fromOdontogenic toothache arises from pulpalpulpal tissuetissue oror periapicalperiapical tissuetissue with general characteristics that indicate thewith general characteristics that indicate the tissue of origin.tissue of origin.
  22. 22. Characteristics of Pulpal & PeriapicalCharacteristics of Pulpal & Periapical PainPain Pupal PainPupal Pain (Deep, Somatic, Visceral) Periapical PainPeriapical Pain (Deep, somatic, Musculoskeletal) Masticatory functionMasticatory function (Biomechanical(Biomechanical stimulation)stimulation) NotNot stimulated bystimulated by biting, chewing, orbiting, chewing, or percussionpercussion Stimulated by biting,Stimulated by biting, chewing, or percussionchewing, or percussion LocalizationLocalization Frequently difficult toFrequently difficult to localize specificallylocalize specifically Usually can localizeUsually can localize preciselyprecisely SequenceSequence Usually precedesUsually precedes periapical painperiapical pain Usually follows pulpalUsually follows pulpal painpain (unless periodontitis,(unless periodontitis, hyperocclusion, bruxism)hyperocclusion, bruxism)
  23. 23. Classification of Toothaches of Odontogenic OriginClassification of Toothaches of Odontogenic Origin ► Pulpal diseasePulpal disease  Reversible pulpitis (brief, stimulated pain)Reversible pulpitis (brief, stimulated pain)  Irreversible pulpitis (prolonged, stimulated or spontaneous pain)Irreversible pulpitis (prolonged, stimulated or spontaneous pain)  Necrotic pulp (prolonged or spontaneous pain, no response to pulpNecrotic pulp (prolonged or spontaneous pain, no response 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, pus)Acute apical abscess (sensitivity to percussion, swelling, pus)  Chronic apical periodontitis (often asymptomatic, periapicalChronic 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)
  24. 24. Heterotopic PainHeterotopic Pain ►Pain felt in an area other than its true site ofPain felt in an area other than its true site of origin (associated with deep, somatic pain).origin (associated with deep, somatic pain).  Projected pain:Projected pain: perceived in the anatomicperceived in the anatomic distribution of thedistribution of the samesame nerve that mediates thenerve that mediates the primary pain (painful adjacent teeth).primary pain (painful adjacent teeth).  Referred pain:Referred pain: felt in an area innervated by afelt in an area innervated by a differentdifferent nerve from the one that mediates thenerve from the one that mediates the primary pain (teeth in opposing arch, face,primary pain (teeth in opposing arch, face, head, neck).head, neck). ►Does not cross the midline.Does not cross the midline. ►Convergence of afferent neurons.Convergence of afferent neurons.
  25. 25. Nonodontogenic ToothachesNonodontogenic Toothaches Most toothaches will be of odontogenic origin.Most toothaches will be of odontogenic origin. However, if there isHowever, if there is no identifiable causeno identifiable cause or sourceor source (e.g. caries) for the pain,(e.g. caries) for the pain, oror thethe history and clinical findings are inconsistenthistory and clinical findings are inconsistent withwith odontogenic pain,odontogenic pain, thenthen a nonodontogenic source should be considered.a nonodontogenic source should be considered.
  26. 26. Toothache of Maxillary Sinus/NasalToothache of Maxillary Sinus/Nasal Mucosa OriginMucosa Origin OriginOrigin Infection of the maxillary sinus or inflammation of nasalInfection of the maxillary sinus or inflammation of nasal mucosa.mucosa. ClinicalClinical CharacteristicCharacteristic ss Constant dull ache or pressure; sensitivity to cold,Constant dull ache or pressure; sensitivity to cold, percussion, chewing; pain in multiple teeth; painpercussion, chewing; pain in multiple teeth; pain increased by bending body forward; sinus tender toincreased by bending body forward; sinus tender to palpation; Water’s may show air-fluid level.palpation; Water’s may show air-fluid level. LocalLocal AnesthesiaAnesthesia Topical anesthesia of nasal mucosa relieves pain inTopical anesthesia of nasal mucosa relieves pain in anterior teeth; infiltration anesthesia of posterior teethanterior teeth; infiltration anesthesia of posterior teeth relieves pain.relieves pain. TreatmentTreatment Antibiotics, antihistamine with a decongestant,Antibiotics, antihistamine with a decongestant, analgesic.analgesic.
  27. 27. Toothache of Myofascial OriginToothache of Myofascial Origin OriginOrigin Referral of pain from myofascial trigger points inReferral of pain from myofascial trigger points in muscles of mastication – primarily masseter,muscles of mastication – primarily masseter, temporalis, anterior digastric.temporalis, anterior digastric. ClinicalClinical CharacteristicCharacteristic ss Nonpulsatile; constant, aching; variable and cyclic;Nonpulsatile; constant, aching; variable and cyclic; pain increases with stress and use of offendingpain increases with stress and use of offending muscles.muscles. LocalLocal AnestheticsAnesthetics Anesthetic block of tooth does not alter pain;Anesthetic block of tooth does not alter pain; anesthetic injection of trigger point relieves pain.anesthetic injection of trigger point relieves pain. TreatmentTreatment Treatment and elimination of trigger points by sprayTreatment and elimination of trigger points by spray and stretch, injection, or physical therapy.and stretch, injection, or physical therapy.
  28. 28. Toothache of Neuropathic OriginToothache of Neuropathic Origin (Trigeminal Neuralgia)(Trigeminal Neuralgia) OriginOrigin Abnormal function of nerves that innervate teethAbnormal function of nerves that innervate teeth (mandibular and maxillary branch of the trigeminal(mandibular and maxillary branch of the trigeminal nerves).nerves). ClinicalClinical CharacteristicCharacteristic ss Unilateral, severe, paroxysmal bursts of electric-likeUnilateral, severe, paroxysmal bursts of electric-like shocks stimulated by minor superficial provocation;shocks stimulated by minor superficial provocation; may be felt in teeth; asymptomatic between episodes.may be felt in teeth; asymptomatic between episodes. LocalLocal AnestheticsAnesthetics Topical anesthetic of mucosal or skin “trigger” blocksTopical anesthetic of mucosal or skin “trigger” blocks pain; anesthetic block of nerve root blocks pain.pain; anesthetic block of nerve root blocks pain. TreatmentTreatment Referral to neurologist or neurosurgeon.Referral to neurologist or neurosurgeon.
  29. 29. Toothache of Neuropathic OriginToothache of Neuropathic Origin [Atypical Odontalgia[Atypical Odontalgia (Phantom Pain)(Phantom Pain)]] OriginOrigin Not definitely known; most probably a deafferentationNot definitely known; most probably a deafferentation pain after trauma.pain after trauma. ClinicalClinical CharacteristicCharacteristic ss Constant pain with no obvious pathology; burning,Constant pain with no obvious pathology; burning, aching pain in molar/premolar area longer than 4aching pain in molar/premolar area longer than 4 months; local provocation not reliably effect pain.months; local provocation not reliably effect pain. LocalLocal AnestheticsAnesthetics Equivocal responseEquivocal response TreatmentTreatment Tricyclic antidepressants, gabapentinTricyclic antidepressants, gabapentin
  30. 30. Toothache of Neurovascular OriginToothache of Neurovascular Origin (Tooth migraine)(Tooth migraine) OriginOrigin Neurogenic inflamation in the trigeminovascularNeurogenic inflamation in the trigeminovascular systemsystem ClinicalClinical CharacteristicCharacteristic ss Maxillay canines/premolars; no dental cause;Maxillay canines/premolars; no dental cause; throbbing, episodic, persistent, recurrent pain; dentalthrobbing, episodic, persistent, recurrent pain; dental treatment may provide temporary relief; may becometreatment may provide temporary relief; may become widespread.widespread. LocalLocal AnestheticsAnesthetics Effects are unpredictable.Effects are unpredictable. TreatmentTreatment Same as for migraine headache; triptans, NSAIDs,Same as for migraine headache; triptans, NSAIDs, beta blockers, ergotamines.beta blockers, ergotamines.
  31. 31. Toothache of Cardiac OriginToothache of Cardiac Origin OriginOrigin Myocardial ischemia with regional referral of pain.Myocardial ischemia with regional referral of pain. ClinicalClinical CharacteristicCharacteristic ss Periodic dull pressure of aching in the mandible orPeriodic dull pressure of aching in the mandible or teeth; may accompany pain in chest or arm; history ofteeth; may accompany pain in chest or arm; history of angina; pain precipitated by exercise, stress, orangina; pain precipitated by exercise, stress, or physical activity.physical activity. LocalLocal AnestheticsAnesthetics Anesthesia of teeth not effective.Anesthesia of teeth not effective. TreatmentTreatment Refer to medical physicianRefer to medical physician
  32. 32. Toothache of Psychogenic OriginToothache of Psychogenic Origin OriginOrigin Psychogenic origin.Psychogenic origin. ClinicalClinical CharacteristicCharacteristic ss Bizarre behavior; history of psychiatric treatment;Bizarre behavior; history of psychiatric treatment; migratory pain in multiple teeth, frequently bilateral;migratory pain in multiple teeth, frequently bilateral; unexpected or inappropriate response to treatment.unexpected or inappropriate response to treatment. LocalLocal AnestheticsAnesthetics Equivocal effects.Equivocal effects. TreatmentTreatment Refer to psychiatrist.Refer to psychiatrist.
  1. A particular slide catching your eye?

    Clipping is a handy way to collect important slides you want to go back to later.

×