Differential Diagnosis in Endodontics is a challenging topic and most important to understand to arrive at an accurate diagnosis

1. Differential Diagnosis in Endodontics
Guided by:
Dr. Chetan Patil
Presented by:
Dr. Sahana Umesh

2. CONTENTS
 Introduction
 History, Examination and Diagnosis
 Pulpal Pain
 Post operative pain
 Peri-radicular pain
 Periodontal lesion pain
 Referred pain
 Extra-oral pain
 Conclusion
 References

3. INTRODUCTION
 Correct treatment begins with a correct diagnosis.
 Arriving at a correct diagnosis requires
 Knowledge
 Skill
 Art
 Diagnostic procedures should follow a consistent, logical
order to arrive at accurate final diagnosis.

4. HISTORY, EXAMINATION & DIAGNOSIS
 Listen to your patient… The patient will give you
diagnosis.
 A case history is defined as a planned professional
conversation that enables the patient to communicate
his/her symptoms, feelings and fears to the clinician so
as to obtain an insight into the nature of patient’s illness
& his/her attitude towards them.
- Sir William Osler

5.  Differential diagnosis is the most crucial step at arriving
to final diagnosis.
 Diagnosis is defined as the correct determination,
discriminative estimation, and logical appraisal of
conditions found during examination as evidenced by
distinctive signs, marks, and symptoms.
- Grossman’s Endodontic Practice 13th ed

6. PAIN & IT’S EXAMINATION
 Dorland’s medical dictionary defines pain as “A
more or less localized sensation of discomfort, distress
or agony resulting from the stimulation of nerve
endings”
 History of Pain – Location of pain, causative &
aggravating factors and description of pain since its
origin.
 Chief complaint –
1. Location
2. Onset
3. Chronology – Mode, periodicity, frequency,
duration

7. 4. Quality – Dull, gnawing or aching
Throbbing, pounding or pulsating
Sharp, recurrent or stabbing pain
Squeezing or crushing pain
5. Intensity – mild/moderate/severe
6. Aggravating factors – local/ conditional factors
7. Precipitating factors
8. Past medical and dental history
9. Psychologic analysis
Faces pain rating scale

9. PULPAL PAIN/ PULPALGIA
Acc. to degree of severity & pathologic process:
1. Hyperactive pulpalgia –
• Dentin Hypersensitivity
• Hyperemia
2. Acute pulpalgia – Incipient/Moderate/Advanced
3. Chronic pulpalgia
4. Barodontalgia
5. Hyperplastic pulpitis
6. Necrotic pulp
7. Internal resorption
8. Traumatic occlusion
9. Incomplete fracture

10. Hyperreactive Pulpalgia
 Mildest pulp discomfort, experienced when no
inflammation is present is hyperreactive pulpalgia.
 Short, sharp, shock
 Never spontaneous
 Brännström theory

11.  Beveridge measured a fall in intrapulp pressure when
cold was applied to a tooth.
 Beveridge also demonstrated a true increase in
intrapulp pressure when heat was applied to the tooth.

12. Hyperreactive pulpalgia commonly seen:
New restoration
Root planing/
curettage
Teeth
involving
sinus
Incompletely fractured tooth
Carious lesions
Bruxism

13. Dentinal Hypersensitivity
 Exciting factors –
• Cold / Hot / Sour food and drinks
• contact of two dissimilar metals that will yield a
galvanic shock
• stimulation of the exposed dentin on the root
surface by cold
o Sicher postulated that the oral cavity is positively
charged and the pulp is negatively charged.
o Anderson believes that pain can
be evoked from dentin by
applying to it solutions which
exert high osmotic pressure.

14. Hyperemia
 Hyperemia - an increased blood flow in the pulp.
 This difference in the character of the painful response
between cold and hot - explained by the difference in
the nerve fibers supplying the pulp.
 Cold – A fibers
 Heat – C fibers
o Pain from pressure - Pulp
pain causes first a fall and
then, when removed, a
rise in intrapulp tissue
pressure.

15. Examination
 Isolation of suspected tooth followed by spraying
stream of ice water.
 Other methods - Ice, carbon dioxide ice, fluori-
methane or ethyl chloride sprayed on cotton pellet.
 Hyperreactive teeth – More sensitive to pulp tester.
 Electrical stimulation does not cause movement of the
fluid within the dentinal tubules.
 At low levels – A beta fibers are stimulated with
conduction velocities well beyond A delta fibers
stimulated by tubule fluid movement.
 At higher levels – Both A & C fibers are stimulated
causing a painful response.

16. Treatment
 Physiologic methods
• Remineralization of the dentinal tubulii from the
“calcium phosphate-carbohydrate-protein complex”
in the saliva
• Formation of irritation dentin from the pulp.
 Chemical/Mechanical obstruction – Tubule sealing
agents
• Potassium oxalate – PROTECT
• Strontium chloride – SENSODYNE &
THERMADENT
• Fluorides – Sodium & Stannous fluorides

17. • Fluoride Iontophoresis – Gangerosa –
ElectroApplicator
• Desensitron was also effective.
• Potassium Nitrate – Hodash – Sold
as PROMISE , SENSODYNE
FRESH & DENQUEL
• Composite resins & bonding
adhesives

18. Acute Pulpalgia
o The mild discomfort experienced as the anesthetic
wears off following cavity preparation is a good
example of incipient pulpalgia.
o Excitation - stimulated by an irritant such as cavity
preparation, cold, sugar, or traumatic occlusion.
o Examination – due to caries – tooth is obvious.
o Initial caries – Explorer & Radiographs
o Treatment – Removal of carious lesion, Sedative
dressing. Relieving tooth from TFO
1. Incipient Acute Pulpalgia

19. 2. Moderate Acute Pulpalgia
 Moderate acute pulpalgia is a true toothache (Tolerable)
 Frequently described as a “nagging” or a “boring” pain
 Localized in the beginning, later becomes diffuse
 Excitation – Start spontaneously usually when lying down.
Classically patient complains of toothache at night.
 Examination – Radiographs, Electrical Pulp Tester,
Thermal test (cold), Segmental nerve blocks,
interligamentary injections
 Treatment – Pulpectomy, endodontic therapy & extraction

20. o Hodosh and colleagues - Potassium nitrate as a desensitizing
agent, also used the as chemical mixed with carboxylate
cement as a pulp-capping medium in teeth with pulpitis.
o Glick used Formocresol to treat pulps that continue to ache
after root canal therapy has been completed. His supposition
is that vital, inflamed tissue still exists in a canal that is
impossible to locate.
o Total pulpectomy and root canal filling completely
eliminates the postoperative pain.

21. 3. Advanced Acute Pulpalgia
 Patient is in exquisite agony and sometimes becomes
hysterical from the pain.
 Temporary relief – cold water, preferably iced.
 Examination – Closed pulp chamber, as revealed by
the radiograph.
 Teeth - less sensitive to the pulp tester.
 Thermal test is conclusive.
 Treatment – Pulpectomy and endodontic therapy for
the salvageable tooth and extraction for the hopeless
ones.

22. Chronic Pulpalgia
 “Grumble” pain – patient usually withstands this kind
of pain for weeks, months or years by taking
analgesics.
 Pain – diffuse, may lead to mild referred pain.
 Excitation – Not affected by cold.
 Tooth might be tender on percussion.
 Commonly, tooth is sore on biting.
 Food lodged into the cavity causes pain and relieved
when irritant is removed from cavity.

23. Barodontalgia or Aerodontalgia
 It is pain experienced in a recently
restored tooth during low atmospheric
pressure.
 Pains are caused by the extraoral
decompression of the ambient
pressure which allows for a
compensating increase of pressure
within the pulp chamber and root
canal.

24.  Class I – In acute pulpitis - pain on ascent - sharp
momentary pain
 Class II – In chronic pulpitis, dull throbbing pain on
ascent & relief on descent
 Class III – Necrotic pulp, a dull throbbing pain on
descent & asymptomatic on ascent
 Class IV – Periradicular abscess or cyst, severe
persistent pain - occurs with both on ascent and descent
Rauch classified barodontalgia according to the chief complaint

25.  Usually, large carious lesion / amalgam restoration is
fractured at the isthmus / recurrent caries under a
restoration.
 Pulp tester and the radiograph are the best tools for
locating the tooth involved.
 Radiograph - Reveals interproximal or root caries, or
recurrent caries under a restoration. “Thickened”
periodontal membrane.
 Condensing osteitis of the cancellous bone at the
apices. Osteosclerosis disappears after successful
endodontic therapy
Examination

26. Treatment
 The treatment for chronic pulpalgia is quite basic:
 Pulp extirpation and endodontic therapy if the tooth is
to be saved and extraction otherwise.

27. Hyperplastic Pulpitis
 The exposed tissue of a hyperplastic pulp is practically
free of symptoms unless stimulated directly.
 Excitation – Tissue “erupts” out of its open bed of caries.
o Differential diagnosis is concerned
with only one problem – whether the
polyp is pulp or gingival in origin
because both are covered by
epithelium.
o Pulp polyp may be lifted away from
the walls with a spoon excavator and
the pedicle of its origin thus revealed.

28. Differences between pulp & gingival polyp
Pulp Polyp
Soft &
edematous
More reddish
Friable
On probing –
Origin is tooth
Gingival Polyp
Comparatively firm
Color similar to
adjacent gingiva
Non Friable
On probing –
Origin is around
tooth

29. Treatment
 Frequently, the teeth involved in hyperplastic pulpitis
are so badly decayed that restoration is virtually
impossible.
 Hence, extraction is usually indicated.
 If the tooth can be restored, pulpectomy and
endodontic therapy are recommended.

30. Necrotic Pulp
 No true symptoms in complete necrosis - the pulp with
its sensory nerves is totally destroyed.
 In partial necrosis – mild discomfort maybe a
symptom.
 Pulp in one or two canals in multirooted teeth may be
necrotic, and the pulp in a second or third canal may be
vital and quite probably involved in acute or chronic
pulpitis.
 Each level of pulp vitality is represented by a confused
response.

31.  Examination – Routine radiographic examination or
coronal discoloration – first indication.
 Demonstrated by transillumination with a fiber optic.
 Radiographically, the tooth with the necrotic pulp may
exhibit only slight periradicular change.

32.  Electric pulp tester - instrument of choice for
determining pulp necrosis.
 Complete necrosis – No response at any level.
 Partial necrosis – Vague response at the top of the
scale.
 Treatment – Endodontic therapy

33. Internal Resorption
 Insidious process - afflicted pulp is completely free of
symptoms.
 May mimic moderate acute pulpalgia in pain intensity.
 When confined to the crown, enough tooth structure
may be destroyed for the pulp to show through the
enamel— “pink tooth”

34.  Excitation - Pulp undergoes dystrophy localized to a single
area - Not likely to be excited by the drinking of hot or
cold fluids.
 The pulp that erodes through the root surface may give
vague symptoms, primarily with mastication.
 Examination - Two methods of examination reveal the
case of internal resorption:
1. Visual method – when crown is involved.
2. Radiographic method – when crown & root is involved

35. Treatment
 Pulpectomy is the only treatment for internal
resorption.
 As long as the pulp remains, it is most likely to
continue its destructive process.
 If the tooth can be saved by endodontic restoration, the
defect can best be obturated by thermoplasticized and
compacted gutta-percha.

36. Traumatic Occlusion
 A tooth traumatized by bruxism or traumatized
because a restoration is in hyperocclusion often
responds much like the tooth with mild pulpalgia.
 The pulp is usually hypersensitive- Reacts primarily to
cold.
 The pain may be vague, reminiscent of chronic
pulpalgia.

37.  Examination - History of “toothache” on awakening is an
unusual symptom and should direct diagnosis toward
bruxism at night.
 Thermal and pulp tester response is often like that of a
normal or hyperreactive pulp.
 When pain from trauma is suspected, one should look for
facets of wear on the tooth.

38. Examination should be done in:
Median occlusion
position (centric)
Lateral excursion of
function (working bite)

39.  Involved tooth or teeth are frequently not sensitive to
percussion but are sensitive to mastication.
 Biting or chewing on a narrow cotton roll or Burlew
disk will sometimes elicit discomfort.
 The radiograph may show no periradicular changes or
may exhibit a widened periodontal space and apical
external root resorption

40. Treatment
 Relieving the point of occlusal trauma by judicious
grinding to reshape the involved tooth and its
opponent.
 Tooth should be completely disoccluded to give the
inflamed tissue a chance to recover.

41. Incomplete Fracture or Split Tooth
 Symptoms range from those of a constant unexplained
hypersensitive pulp to constant unexplained toothache.
 Tooth may be uncomfortable during mastication, and at
that time the pain may be quick, unbearable stab.
 This is when the crack in the dentin suddenly spreads as
the cusp separates from the remainder of the tooth.

42.  Many of the cases involve noncarious, unrestored
teeth; hence it is hard to believe that anything could be
wrong with the tooth.
 If the split has extended through the pulp, bacterial
invasion occurs, and true pulpitis results
 Excitation - discomfort of the split tooth is elicited by
biting on the tooth or contacting cold fluids.
 If the pulp is involved in fracture, any exciting agent
for pulpalgia will bring on discomfort.

43. Examination
 Dried and under good light, to find the crack in the enamel.
 Pulp tester customarily gives a normal reading unless the
pulp is involved.
 Biting on an applicator stick or cotton roll - elicits pain.
 Crown may also be painted with tincture of iodine, which is
washed off after 2 minutes. The crack often appears as a
dark line.

44.  Tooth Slooth a triangular plastic tip on a handle.
 With this device, it can be determined quite accurately
which cusp is splitting away.
o Radiograph records an obvious split only if it is in
correct alignment to the central rays

45. Treatment
 Incomplete fracture without involving pulp – Tooth
must be prepared for full crown.
 Incomplete fracture involving pulp – Root canal
therapy indicated followed by full crown.
 Fracture extending completely through pulp & PDL –
Extraction is indicated.

46. POSTOPERATIVE PAIN
 Apical overextension of necrotic debris, instruments,
paper points, medicaments, and filling materials lead to
postoperative pain.
 Best way to prevent it is to not extend instrumentation
beyond working length.
 Complete pulpectomy - Prevents postoperative pain in
patients presenting with preoperative toothache in teeth
with vital pulpitis.
 Chronic postoperative pain following endodontic
surgery is quite unusual, even though immediate
postsurgical acute pain is expected

47. Conclusions:
1. The chance on postoperative pain is relatively high in the case of
a non-vital pulp in conjunction with preoperative pain on the day
of treatment. The probability is reduced in the case of a vital pulp,
irrespective of the presence of preoperative pain, and least in the
case of a non-vital pulp in the absence of preoperative pain;
2. The chance on postoperative pain is also relatively high when a
radiolucency larger than 5 mm in diameter is present;
3. The chance of postoperative pain increases with the number of
root canals in a tooth.

48. Preoperative Therapy
 A Navy group found that the preoperative administration of
flurbiprofen significantly reduced postoperative pain
compared to placebos.
 Morse and his group at Temple University found that the
intracanal use of a corticosteroid solution following
pulpectomy was efficacious.
 A group at Iowa University found that there was no
statistically significant difference between routine occlusal
relief and placebo relief.
 But, they did not imply that occlusal relief should be
abandoned in cases of acute apical abscess or acute apical
periodontitis.

49. PERIRADICULAR PAIN
 Periradicular pain may be almost as excruciating as
pulp pain and may often continue for a longer period of
time.
 Periradicular lesions that may produce discomfort are:
1. Symptomatic Apical Periodontitis
2. Acute apical abscess
3. Chronic apical abscess
4. Apical cyst.

50. Symptomatic Apical Periodontitis
 Symptoms - excruciating pain - constant, gnawing,
throbbing, and pounding.
 Painful to touch
 Tooth elevated slightly in its socket.
 Etiology – Usually iatrogenic.
 Mandibular premolars and molars are the teeth most
frequently involved.
 If bacteria are present in the canal and are extruded
apically, an acute abscess develops as complication.

51.  Examination – patient is in severe pain, and the
involved tooth is exquisitely painful to touch.
 The tooth is in supraocclusion, and the mandible
cannot be closed without initial impact on the involved
tooth.
 Treatment – Prevent over instrumentation.
 When the length of the tooth is re-established, a reamer
with an instrument stop should be set for this exact
length and then employed to just barely perforate
(trephine) through the apical foramen. Sometimes this
brings forth a flow of blood and fluid, which reduces
the periradicular pressure.

52. Acute Apical Abscess
 Necrosis of the acute abscess usually destroys enough
tissue to permit fluid dispersement.
 Unbearable throbbing pain and tender on palpation.
 Etiology - Due to bacterial invasion of the periradicular
region from a necrotic, infected pulp canal.
 Examination - patient has pain and, invariably swelling.
 Degree of swelling varies from the initial, undetected
swelling to gross cellulitis and massive asymmetry

53.  Radiographically, the picture may vary from a widened
periodontal space to a large alveolar radiolucency
 Electric pulp testing - best to differentiate an AAA from
an acute periodontal abscess.
 Pulp is necrotic in AAA while its usually not necrotic in
acute periodontal abscess.
 AAA is tender to vertical percussion while acute
periodontal abscess is tender on lateral percussion.

54. Treatment
 Drainage is established through the root canal if the
abscess is in its initial stage, or by incision if the abscess is
fluctuant.
 Trephination may also be performed to establish drainage
and relieve pressure.
 A regimen of systemic antibiotics and either hot rinses or
cold applications is prescribed for the patient depending
on the stage of development of the abscess.
 Endodontic therapy or extraction, whichever is indicated,
is completed after the acute symptoms have subsided and
while the patient is still receiving antibiotics.

56.  Beta-lactam- based antibiotics (primarily amoxicillin 500 mg
three times per day for three to seven days) remain the first line
of effective antibiotics for patients in whom antibiotics are
indicated.
 These regimens can be complimented with metronidazole 500
mg three times per day in resistant infections.
 For the patient who is allergic to penicillin, the patient needs to
be asked about the type of reaction that they received. True
allergy is identified only for patients with history of
anaphylaxis, angioedema or hives.
 If the patient did not have these reactions, oral cephalexin (500
mg, four times per day, three to seven days) would be
indicated.

57.  For patient with true allergy to penicillin, the primary
alternative antibiotic recommendation has changed. It is
now azithromycin with a loading dose of 500 mg, and then
250 mg for four additional days.
 Clindamycin now has a U.S. Food and Drug
Administration black box warning for Clostridioides
difficile infection, which can be fatal. Therefore, it is only
indicated if the patient cannot take azithromycin.
 For all patients on antibiotics, the antibiotic treatment is
discontinued as soon as definitive treatment and
improvement of the condition occurs (as short as three
days), rather than to the full course of the prescription.

58. Chronic apical abscess
 Also called suppurative apical periodontitis.
 History of a lesion with a draining fistula and mild
swelling and discomfort.
o Etiology - Chronic apical abscess is
the inflammatory response to an
infection by bacteria of low
virulence from the root canal.
o Chronic lesion may develop an acute
exacerbation, the phoenix abscess,
exhibiting all symptoms of AAA.

59.  Examination - Patient may remember pain in the involved
area or perhaps a traumatic incident in which the pulp was
devitalized by a blow.
 Lesion of CAA, easiest to detect, has an associated draining
fistula, usually intraoral.
 This sinus tract, lined with inflammatory tissue, drains the
abscess through a stoma into the oral cavity.
 Usually GP cone of #25 or #30 is used to trace the draining
sinus

60. Treatment
 If the tooth can be saved, it may be retained by
endodontic therapy.
 Periradicular surgery is sometimes indicated for these
pathologic lesions.
 The chronic lesion that becomes acutely infected must
be treated as an AAA until the symptoms have
subsided.
 The tooth may then be handled as an endodontic case
or extracted, as conditions indicate.

61. Apical Cyst
 Painless unless it becomes infected. Case should be
handled as an AAA when symptomatic.
 Examination – Usually found on routine examination.
 Treatment - Treated endodontically & the apical cyst
may be enucleated during periradicular surgery

62. PERIODONTAL LESION PAIN
 Few periodontal lesions are severely painful.
 The causes of these lesions are divided into diseases
that attack just the gingiva and those that involve the
deeper periodontal complex
 Two painful conditions that involve the pericemental
structures and must be differentiated are the acute
gingival or periodontal abscess and pericoronitis.

63. Acute gingival or periodontal abscess
 Patient with an acute periodontal abscess seeks
treatment for a tooth that is painful to move or to bite
on.
 The pain, however, is not as deep-seated or throbbing
as that of an AAA.
 Some localized swelling is present, not as extensive as
with the AAA.

64. Etiology
 Due to virulent infection of an existing periodontal
pocket or as an apical extension of infection from a
gingival pocket.
 Most gingival abscesses are associated with traumatic
injury to the gingiva or periodontium by a mechanical
force.
 Both types of abscess are frequently seen in patients
who have compulsive clenching or bruxism.

65. Examination
 Periodontal abscess points opposite the coronal third of
the root, whereas apical abscess generally points
opposite the apex.
 Use of the periodontal probe often reveals a tract from
the gingival sulcus to the abscess.
Treatment
 Drainage of abscess.
 Pocket elimination procedures.
 If abscess extends to apex and involves the root canal
causing endo – perio lesion, endodontic therapy
indicated after periodontal therapy.

66. Pericoronitis
 Severe radiating pain in the posterior mouth and the
inability to comfortably open or close the mandible.
 Inflamed operculum distal to the erupting mandibular
molar.
 Etiology - caused by injury and infection of the
pericoronal tissue associated with erupting molars.
 Area is frequently a source of primary infection with
Borrelia vincentii and Fusiformis dentium.

67. Examination
 The history of trismus and discomfort on opening or
closing the mandible is indicative of pericoronitis.
 When the operculum is palpated or probed, it is found
to be swollen and exquisitely painful.
Treatment
 Removal of operculum and oral hygiene instructions to
be followed.
 If the tooth is maligned or doesn’t have adequate space
to erupt, usually advised extraction.

68. REFERRED PAIN
 One of the most frequently encountered and most
baffling phenomena with which the dental diagnostician
must deal is the problem of referred pulp pain.
 Glick has well illustrated referred pain from pulpalgia—
from tooth to tooth and from tooth to nearby cutaneous
and deep structures.

69. Referred pain pathways from teeth involved with
pulpalgia to other teeth as well as to the immediate area

71. Pain referred from pulpalgia to structures remote from the
involved tooth

73. Robertson et al. produced toothache by placing stimulating
electrodes into defects in the enamel of their own teeth

74. Broad area of referred pain developed from maxillary third
molar pulpalgia. Injecting procaine into the referred area
alleviated pain only at the site of injections. All primary and
referred pain was totally eliminated by injecting at the site of
primary noxious stimuli (third molar)

75. EXTRAORAL PAIN
Atypical Toothache
 Rees and Harris described a disorder that they called
atypical odontalgia.
 Patients present themselves with all of the typical
features of an acute toothache—severe, throbbing,
continuous pain starting in one quadrant but spreading
even across the midline.
 Also referred to as “dental migraine” or “phantom
tooth pain,” this condition is often associated with
patients suffering from unipolar, or common,
depression.

76. Salivary Gland Disorders
 CLASSIFICATION:
1. Ductal Obstruction
2. Infection
3. Inflammation
4. Cystic degeneration
5. Tumour growth
 The most common causes of salivary
gland pain are mumps and acute parotitis
in children.
 In adults, blockage of salivary flow by a
mucus plug or a sialolith can result in
pain.

77.  Sjogren’s syndrome, a disease
of unknown etiology typically
seen in older women.
 Characterized by dry eyes, dry
oropharyngeal mucosa, and
enlargement of the parotid
glands.
 This disorder may also cause
salivary gland pain if the
glands become inflamed.

78. Symptoms
o Salivary gland pain is typically located to the gland
itself
o Mouth opening may aggravate the pain because of
pressure on the gland from the posterior border of the
mandible during this movement
o Also increased pain with chewing may lead the
clinician to mistake the pain as being from the
masticatory system.

79. Examination
 The pain can be fairly localized well by palpation.
 Precipitating and aggravating factors to the pain are
salivary production prior to meals, eating, and
swallowing.
 Mouth opening may aggravate the pain because of
pressure on the gland from the posterior border of the
mandible during this movement
 The clear signs of inflammation make the diagnosis
straight forward and easy to treat

80. Diagnosis
o Radiographs of the gland and ducts may reveal a
calcific mass in the region of the gland.
o Sialography may also show obstruction or abnormal
ductal patterns.
o Salivary flow testing is useful to verify salivary gland
hypo function.
Treatment
 The mucus plug or sialolith should be removed in the
case of obstruction.
 Antibiotics may be needed if infection accompanies
the pain.

81. Ear pain
o Most patients who have a primary complaint of ear
pain will seek help of their primary care physician.
o When a medical workup is negative, patients may be
referred to the dentist for evaluation.
o Patients with inflammation of the external auditory
canal may present themselves to the dentist because
this pain is aggravated by swallowing.

82. Etiology
 The ear is innervated by cranial nerves V, VII, IX, X
and also branches of the upper cervical roots that
supply the immediate adjacent scalp and muscles
 Pain can be referred to the ear from inflammatory or
neoplastic disease of the structures supplied by these
branches

83. Examination :
o The dentist must carefully examine the dentition for
PULPAL DISEASE and the OROPHARYNGEAL
MUCOSA for inflammation to rule out referred ear pain
from oral or dental sources.
o Otitis externa may be misdiagnosed as arthralgia of the
TMJ if the condyle is palpated through the external
auditory canal without first evaluating the ear.
o Myofascial trigger points in the lateral and medial
pterygoid muscles frequently refer pain to the ear as well
o Deep masseter and SCM trigger points may cause
tinnitus.

84. Treatment
o Primary ear pain is managed by an ENT specialist.
o Dental sources of ear pain are treated by treating the
oral pathosis.

85. Sinus and paranasal pain
 The most common extra oral
source of dental pain arises from
the maxillary sinus and associated
pain-sensitive nasal mucosa.
 Many teeth have been mistakenly
extracted because of an incorrect
diagnosis of this syndrome

86. Etiology
o Swelling of turbinates in turn blocking the ostia of
maxillary sinuses
o Vicinity of superior alveolar nerve to the thin wall of
sinus
o Opening of the canaliculi of teeth towards the sinus

87. Symptoms
 Chronic sinusitis may cause symptoms of fullness or pressure
 Maxilla, at the junction of the hard and soft palate
 Upper orbit and behind the eyes
 Frontal process
 Temple and ear (rare)
 Mild pain in a number of posterior maxillary teeth on one
side.
 The teeth feel elongated, as if they ‘‘touch first’’.
 The teeth are tender, and are hypersensitive to cold fluids.
 Stuffy nose, blood- or pus-tinged mucus, fever, and malaise.

88. Diagnosis
 Palpation - the cheek on the involved side, (canine fossa to
the base of the zygomatic process), will be tender.
 Spraying 4% lidocaine anesthetic from a spray bottle into
the nostril on the affected side – relieve pain.
INTRAORAL EXAMINATION :
 The teeth are painful and sound ‘‘mushy’’ when percussed.
 The teeth may be hypersensitive to cold or electric testing.
 Illuminating the sinuses with a fiber optic in a darkened
room may reveal changes in the affected sinus.

89. Treatment
 Complete diagnosis and treatment of maxillary
sinusitis are left to the ENT specialist.
 Treatment usually consists of the use of decongestants
and analgesics.
 If there is persistent purulent discharge, cultures should
be taken and appropriate antibiotics should be
prescribed.

90. Referred pain from remote pathological sites
1) Angina Pectoris
2) Myocardial Infarction
3) Thyroid
4) Carotid Artery
5) Cervical Spine

91. Angina Pectoris
o Heaviness, tightness or aching pain in the
mid or upper sternum
o These symptoms may radiate upward
from the epigastrium to the mandible- the
left more frequently than right
o Precipitating factors include exertion and
emotional excitement or ingestion of food.
o Angina attacks are usually short-lasting,
rarely longer than 15 minutes.

92. Etiology Of Referred Pain
o Thoracic dermatomes innervating the chest and arms,
overlap with the cervical dermatomes that innervate the
arm, shoulder and as well as part of the lower face.
o The second cervical dermatome in turn slightly
overlaps the trigeminal nerve

93. Symptoms
 Anginal pain referred to the teeth may be experienced with or
without concomitant chest pain. So patient presents dental
complaints as the chief complaint.
 A lack of dental cause for dental pain should always be an
alerting sign.
 Anesthetizing the lower jaw or providing dental treatment
does not decrease the tooth pain.
 Pain is of sudden in onset, gradually increasing in intensity.
 Tooth pain is increased with physical activities.
 It is decreased by taking rest or sublingual nitroglycerin.
 Patient should be immediately referred to cardiac unit in
hospital

94. Myocardial Infarction
o Sudden gradually increasing precordial pain with a
feeling of suffocation.
o The squeezing pain radiates in a pattern similar to that
described for angina pectoris.
o In advanced stages patient becomes unconscious and
cyanotic.
o If conscious, patient complains of severe pain and rubs
the chest, jaws and arms.

95. Examination
o A careful history is important in diagnosing the
referred oral pain of cardiac origin.
o The patient has a rather unusual story to tell, with a
fairly severe pain that began rather suddenly in left jaw
and grew in intensity.
o The dentist must rule out dental pathosis quickly and
efficiently.

96. Diagnosis
o Radiographs and Pulp Testing in the site of pain.
o Analgesic block of the involved tooth or teeth will fail
to relieve the pain.
o After localized dental or TMJ origins have been ruled
out, referred pain from the chest must be considered.

97. Treatment
o If previously undiagnosed cardiac pain is suspected the
patient must be referred to an emergency room
immediately.
o If patient losses consciousness, basic cardiopulmonary
resuscitation should be performed until help arrives.
o Every dental office should be equipped with a
defibrillator.

98. Thyroid
Subacute Thyroiditis
o Sore throat with pain over at least one lobe of thyroid
gland OR
o Pain radiating up the sides of the neck and into the lower
jaws, ears or occiput.
o This is usually associated with a feeling of pressure or
fullness in the throat
Etiology
Occurs 2-3 weeks after an upper respiratory infection
and is viral in origin

99. Examination
o Thyroid gland is visibly enlarged and will be
exquisitely tender to palpation with nodularity.
o If thyroiditis or other thyroid disease is suspected,
referral to the patients physician should be made.
Diagnosis
o A complete blood count may show an elevated
leukocyte count
o The erythrocyte sedimentation rate will be substantially
elevated
o Thyroid function tests in the realm of the physician

100. Treatment
 It resolves spontaneously
 Large doses of aspirin and steroids to control the pain
and inflammation
 Thyroid supplements are sometimes indicated

101. Carotid artery
CAROTIDYNIA :
It is a symptom of unilateral vascular neck pain.
Stimulation of the artery in the region of the bifurcation
causes pain in the ipsilateral jaw, maxilla, teeth, gums,
scalp, eyes or nose.

102. Symptoms
o Constant or intermittent dull aching pain may involve
the temple and TMJ region and radiate forward into the
masseter muscle with occasional concomitant
tenderness and fullness.
o Aggravating factors include chewing, swallowing,
bending over or straining.
o A history of migraine maybe present

103. Examination
o Tenderness and swelling over the ipsilateral carotid artery
along with pronounced throbbing of the carotid pulse.
o Palpation aggravates the pain.
o It has an extensive differential diagnosis like pharyngitis,
otitis ,bruxism , TMJ syndrome, Neuralgia, myalgia and
temporal arteritis and these should be ruled out with
appropriate history and examination
Treatment
 Medications used in the treatment and prevention of
migraine headaches have been shown to be effective in
controlling the symptoms of carotidynia

104. Cervical Spine
Cervical Joint Dysfunction
 IN THE CRANIOCERVICAL
region , cervical joint dysfunction
may occurs as a result of
1) Trauma (whiplash injury)
2) Degenerative osteoarthritis
3) Chronic poor postural habit
As the cervical spine loses mobility
and adapts to abnormal positions
Nerve compression and nerve
irritation takes place

105. Symptoms
o Stiffness of the neck, pain and limited range of motion
of the head and neck
o Throat tightness and difficulty in swallowing
o Dermatomal pain – neuritic quality, follows the
distribution of the cervical nerve root
o Referred pain –deep aching, unilateral headache, as in
a syndrome known as CERVICOGENIC HEDACHE

106. Examination
o Postural evaluation,
especially anterior head
position.
o Examination of cervical
spine should include
range of motion in:

107. Treatment
o Local treatment of referred symptoms does not provide
long lasting relief
o Craniofacial pain resolves once the cervical problem is
corrected
o Physical therapy including joint immobilization along
with home exercise program and postural retraining.

108. CONCLUSION
o Vast majority of patients who present themselves in pain are
suffering acute pain.
o The dentist who is experienced in pain diagnosis will
systematically examine and test to narrow down the
suspected source of the pain.
o The inexperienced often push ahead and blunder into a
serious error in misdiagnosis and treatment.

109.  To aid correct diagnosis, precise understanding of
clinical characteristics of odontogenic and non-
odontogenic toothache, careful history, clinical and
radiologic examination, and thorough evaluation of the
nature of the pain are recommended, that can lead to
deliver appropriate therapy and avoid unnecessary
procedures and aggravating the condition.

110. REFERENCES
 Ingle endodontics – 5th & 6th edition
 Cohen pathways of dental pulp – 8th edition
 Grossman’s endodontic practice – 13th edition
 Textbook of endodontics – Nisha Garg – 3rd edition
 Genet JM, et al. Preoperative and operative factors
associated with pain after the first endodontic visit. Int
Endodont J 1987;20:53
 Fouad AF. Communiqué Topics. American Association
of Endodontists, Dec 2019