by; dr. Mostafa kareem B.D.S

1. By :
Dr. Mustafa Kareem
B.D.S

2. Unpleasant sensory &
emotional experience
associated with actual
or potential tissue
damage or described
in terms of such
damage.”

3. • Specialized receptors = free nerve endings
• Stimulation
– Mechanical damage
– Extreme temperature
– Chemical irritation
• Two types of neurons
– A-delta: first pain, sharp
– C: second pain, dull

4. Four distinct processes
 Transduction
 Transmission
 Modulation
 Perception

5. Origin of pain
1) Nociceptive pain
 Result of mechanical, thermal or
chemical
 Subdivided into
• Somatic
• Visceral
2) Neuropathic pain
– PNS
– CNS
Duration of pain
1. Chronic
2. Acute
Other types of pain
1. Projected pain
2. Referred pain
3. Phantom pain

6. • Phantom pain:
– Pain coming from a body part that's no longer
exist
– Used to be considered a psychological problem,
but now is recognized as real sensations
originate in the spinal cord & brain
• Projected Pain:
– Pain felt at peripheral ends of nerve, while
stimulus occurred along the course of that
nerve.
– Example: pain in TMJ sensed as pain in ear
• Referred pain:
– Pain felt in an area distant from that in which
the causative pathology is located
– Example: angina pectoris sensed as pain over
the left side of the mandible / pain in lower
teeth felt in upper teeth

7. ‡Pain and anxiety are two sides of the same
coin.
Pain can cause a person to be anxious, and an anxious
patient is likely to experience more pain than a patient
who is not anxious.
Therefore interventions that modulate anxiety reduce
pain. Defining anxious patient and do the necessary to
reduce its anxiety is a mean part of pain management

8. ‡Even the most experienced clinician is
often unsure how to interpret a
patient’s response to dental treatment. Is it
really pain, or is the patient just
jumpy? Is it painful or merely unpleasant?
Why is this particular patient so
upset?

9. The dentist may ask certain questions as part of the
routine preoperative patient history or during the
patient interview
Patient interview questions
If you had to go the dentist tomorrow, how would you
feel about it?
When you are waiting in the dentist’s office for your turn
in the chair, how do you feel?
When you are in the dentist’s chair waiting he or she get’s
the drill ready to begin working on your teeth, how do you
feel?

10. When investigating acute dental pain,
the history should focus on the
pain's:
•Location
•‡type
•frequency and duration
•Onset
•exacerbation and remission (for
example the response to heat or cold)
•Severity
•area of radiation.
•Current Medications
•History of Allergies
•Associated pathology and
•referred pain should also be
considered.

11. ‡Information regarding a patient’s
medications not only provides insight
regarding medical status but also may alert
the dentist to possible drug interactions.
Careful attention should be paid to any
prescribed medications the patient is taking
currently or has taken within
the past month.

12. ‡Patients may label any adverse drug
experience as an allergic reaction.
‡Any report of allergy should be further
questioned to clarify that signs and
symptoms were consistent with
hypersensitivity reactions (i.e., rash,
pruritus, urticaria, airway compromise).

13. ‡Tongue
Buccal mucosa
‡Floor of the mouth
‡Hard palate
Teeth and periodontal tissues
Tonsils
‡Temporomandibular joints
‡Airway
‡Ears
‡Salivary glands
‡Lymph nodes.
The following structures need to be
examined carefully in order to be sure that
the pain is of dental origin:

14. There are several simple tests that may assist
in diagnosis of dental pain.
Dry ice, or an ordinary ice
stick (made in a plastic or
glass tube), is placed on the
cervical third (neck region) of
the tooth crown. A response
to the stimulus indicates that
the pulpal tissue is capable
of transmitting nerve
impulses. No response may
indicate pulp necrosis.
Pulp sensitivity test

15. Using an instrument handle, the tooth is
tapped in the longitudinal axis. A painful
response suggests possible periapical
inflammation
Placing a fine, blunt probe
gently into the gingival
sulcus surrounding the
tooth enables the health
of the gingival tissues to
be assessed. Bleeding
and/or sulcus depths
greater than 3-4 mm
indicate gum disease
Percussion test
Probing

16. Holding a tooth firmly on the buccal and
lingual sides between the two instrument
handles enables mobility to be assessed. All
teeth have a small amount of mobility (<0.5
mm), but visible movement suggests loss of
bone support around the root of the tooth.
Careful palpation around the area of concern
may reveal tenderness and the type and
extent of swelling
Mobility test
Palpation

17. If it is possible to obtain a screening radiograph, such as an
orthopantomograph (OPG), this may assist in the diagnosis and
localisation of the cause of the pain. The radiograph should
show clearly the apical and periapical structures of teeth and
associated tissues. The relationship of the maxillary molars and
premolars to the floor of the maxillary sinus can be examined,
and radiographs may reveal recurrent caries or periapical
radiolucencies associated with an established infection.
Radiographic examination

18. Teeth and supporting Tissue Disease
Disease of the Jaw
Oral mucosal diseases
Pain in the edentulous patient
Pain triggered by mastication
Referred pain
Neurological diseases

19. The pulp is capable of a full recovery if the irritating factors
subsided or removed
Signs and symptoms:-
 The pain is moderate to sharp.
The pain is of short duration.
The pain does not occur without stimulation.
No mobility or sensitivity to percussion.
Change in the body position do not affect the
nature or duration of the pain.
The pain is easily to be localized.

20. The pulp will not recover. The pulp tissue will exhibit a wide
spectrum of acute and chronic inflammatory changes.
Signs and symptoms:-
Sharp sever pain on thermal stimulation.
The pain is continuous after the stimuli is
removed .
The pain may be spontaneous or continous.
The pain may be exacerbated when the
patient lies down.
The pain increases in intensity as a throbbing
pressure that can keep the patient awake at
night .
The pain is difficult to be localized.
No mobility or sensitivity to percussion.

21. Pain from acute periapical periodontitis should be
readily identifiable as there is precisely localised
tenderness of the tooth in its socket. Radiographs are of
little value in the early stages but useful after sufficient
destruction shows itself as loss of definition of the
periapical lamina dura.
Acute maxillary sinusitis can rarely cause similar
tenderness of a group of teeth, particularly upper
molars

22. The tooth is tender
in its socket,
It is vital and there
is deep localised
pocketing.
Acute ulcerative gingivitis usually causes soreness, but
when it extends deeply and rapidly, destroying the
underlying bone, there may be severe aching pain. In
such cases the diagnosis is usually obvious clinically.
HIV-associated periodontitis presents a somewhat
similar picture and is acutely painful.

23. Ulcer generally cause soreness rather
than pain , but deep ulceration may cause
sever pain.
Carcinoma in particular causes sever
pain once nerve fibers become involved.
Herpes zoster causes sever pain ,
sometime indistinguishable from toothache
, (because of involvement of cervical ganglia.

24. The important feature of these conditions is that, as
well as the history and clinical presentation, the
provisional diagnosis depends on the radiographic
findings.
Fractures and osteomylitis should be
recognizable by radiograph.
The differentiation of infected cyst from a malignant
tumor is difficult and the diagnosis depends on biopsy
and histological examination.
Painful jaw diseases :
 Fractures
 Osteomyelitis
 Infected cysts
 Malignant neoplasm

25. These conditions differ from most others
because dental causes can be excluded. The
chief difficulty is to decide whether the pain
is due to the dentures themselves, or to
some condition of the mucosa or jaws on
which a denture is pressing.

29. The common dental cause for pain on mastication is
apical Periodontitis.
Diseases of teeth and supporting tissues
Pain dysfunction syndrome
Diseases of the temporomandibular joint
Temporal arteritis
Trigeminal neuralgia (rarely)
Salivary calculi
The least common cause of pain during eating is
organic disease of the temporomandibular joint.

30. Diseases of the maxillary antrum
Acute sinusitis
Carcinoma, particularly when it involves the
antral floor
Diseases of salivary glands
Acute parotitis
Salivary calculi
Sjogren's syndrome
Malignant neoplasms
Diseases of the ears
Otitis media
Neoplasms in this region
Myocardial infarction

31. Clinical Presentation
• Affects elderly (5th-7th decade)
• Almost always unilateral
• Usually one branch is involved
• Paroxysmal pain – seconds to < 2 min
• Distributed along 5th cranial nerve
• Pain provoked by touching, smiling, eating
or cold air and teeth brushing.
• Asymptomatic between attacks
• Trigger points

32. Investigations:
• Always exclude dental origin (cracked
tooth)
• Full cranial nerve assessment
• Refer to neurologist if:
– patient <50y
– Bilateral presentation
– Associated neurological signs or cranial
nerve defect
Suspect multiple sclerosis
Cause:
• Demyelination & hyper-excitability of
the nerve induced by vascular pressure
• 2% of cases associated with posterior
fossa tumor

34. Surgical
• for refractory cases
• Simple peripheral cryotherapy or open
intracranial procedure
• If these fail , micro vascular decompression
of the trigeminal ganglion may be required.
Medical
• Anticonvulsant
– Carbamazepine (100mgX2) up to 1000 mg/day
– Gabapentin
• Start with small initial dose
• Side effects includes drowsiness , dryness of
the mouth , diarrhea and nausea.

35. • Similar to Trigeminal Neuralgia
• Less common & less severe
• The pain felt in the base of the tongue and
fauces on one side. It may also radiate
deeply into the ear.
• Unilateral pain precipitated by swallowing ,
chewing , and coughing.
– Pharynx
– Soft palate
– Base of tongue
– Ear
– Mastoid
• Treatment as for TN

37.  Treatment
Unfortunately, postherpetic neuralgia is remarkably
resistant to treatment. Nerve or root section are
ineffective and the response to drugs of any type.
Application of transcutaneous electrical stimulation to
the affected area by the patient himself is sometimes
effective.
– Anticonvulsants (Gabapentin)
– TCAs
– Antiviral in combination with TCA
 All patients with HZ infection should be vigorously
treated with acyclovir to reduce risk of PHN
The pain is more variable in character and severity than
trigeminal neuralgia. It is typically persistent rather than
paroxysmal.
Affect elderly & immunocompromised patients
The diagnosis is straightforward if there is a history of facial
zoster or if scars from the rash are present.

38. A minority of patients with multiple sclerosis have pain
indistinguishable from trigeminal neuralgia.
younger persons (under 50) are typically affected.
In about 30%, pain, unlike trigeminal neuralgia, may be
persistent and lack trigger zones, or may spread beyond the
trigeminal area
Disturbances of sensation are distributed according to the
sites of lesions in the brain.
The lip may be affected and symptoms may range from
paraesthesia to extreme hypersensitivity, whereby the patient
will literally jump or scream with pain if the lip is touched.
The diagnosis usually depends on the presence of multiple
deficits, particularly defects of vision, weakness of the limbs,
and sensory losses.
Carbamazepine is sometimes effective for trigeminal
neuralgia-like pain, otherwise surgical treatment as for
trigeminal neuralgia may be required.

39. Migrainous neuralgia is caused by vascular changes at the
base of the skull and may occasionally be mistaken for
trigeminal neuralgia. It is rarely seen in dental practice.
Migrainous neuralgia has many features in common with
classical migraine (hemicrania) and is due to oedema and
dilatation of the wall of the internal carotid and probably also
the external carotid arteries.
Cluster headache mainly affects men, usually young adults
but up to the age of 50.
Attacks may be precipitated by alcohol or vasodilators, or
come on spontaneously one to three times a day.
Attacks sometimes recur at precisely the same time each
day or may disturb sleep.
Pain is localized to the region of the orbit, or maxilla. The
duration is 0.5-2 hours.

40. Cluster headache may respond to simple analgesics or to
ergotamine.
Ergotamine should be given an hour before the expected
attack and is most effective by subcutaneous. Alternatively,
ergotamine powder can be inhaled from a spinhaler.
Treatment should preferably be stopped for one day each
week to see whether there has been spontaneous remission.
The eye may become suffused and water, the nostrils may be
blocked, the skin over the cheek may become red and there
may be sweating on that side.

41. Paraesthesia of the lip can cause by Osteomyelitis or
Fracture of the jaw
Prolonged anaesthesia or paraesthesia of the lip can
occasionally follow inferior dental blocks.
The inferior dental nerve may be compressed by a neoplasm
or a tumour may infiltrate the nerve sheath.
The mental foramen can become exposed by excessive
resorption of mandibular bone in an edentulous patient
Tetany is the result of hypocalcaemic states and causes
heightened neuromuscular excitability together disorders of
sensation