This document discusses various methods for assessing pulpal blood flow, including laser Doppler flowmetry, pulse oximetry, and dual wavelength spectrophotometry. It also discusses challenges in accurately examining pulp blood circulation. Different types of odontogenic and nonodontogenic pain are outlined, including pulpal pain, periodontal pain, referred pain, myofascial pain, neurovascular pain, sinus pain, and neuropathic pain. Diagnostic features and treatments are provided for various conditions like reversible and irreversible pulpitis, necrotic pulp, apical periodontitis, apical abscess, periodontal abscess, and pericoronitis.

1. 10. Pulp vascularity test
•Laser Doppler Flowmetry
Attempts are being made to adapt this technology to assess pulpal
blood flow. LDF utilizes red light beam which is scattered by moving
red blood cells and produces a signal that can be used as a measure
to pulpal blood flow.

2.  Pulse Oximetry
It is non invasive device to detect the pulp vitality. This
process measures oxygen saturation in the
examined tissue utilizes red and infrared light
that passes through the tissue and received by a photo
detector.
 Dual Wavelength Spectrophotometry(DWLS)
This method measures oxygenation changes in the
capillary bed rather than the supply vessels and
hence does not depend on a pulsating blood flow.

3.  Sometimes it is difficult to examine
accurately the pulp blood circulation
because:
 1) The circulatory system of the pulp is encased in a
rigid structure and therefore is difficult to study
without the removal of hard tissue.
 2) The interference of extrapulpal circulatory
systems (signal contamination from the periodontal
blood flow).

4. 11. Transillumination & Fiber optic ligh
A powerful light can be used for trans-illuminating
teeth to show interproximal caries, fracture or
discoloration..

5. OROFACIAL PAIN
Although the dental pain is considered the most
common causes of orofacial pain, many structures in
the head and neck region which can simulate the
dental pain causing what is called referred
pain(heterotrophic pain). To prevent this confusion
in diagnosis,Orofacial pain can be basically divided
according to its origin into:
1.Odontogenic pain (Dental pain).
2.Nonodontogenic pain (Non dental pain).

6. 1. Odontogenic pain (Dental pain). :
Pulpal pain (pulpagia)
A. Dentinal sensitivity.
B. Reversible pulpitis (pulpal hyperemia).
C. Irreversible pulpitis (acute pulpitis) (acute pulpagia).
D. Necrotic pulp (chronic pulpitis) (chronic pulpagia).
Periodontal pain
1. Symptomatic apical periodontitis( Acute apical periodontitis)
2. A Symptomatic apical periodontitis (Chronic apical periodontitis)
3. Symptomatic apical Abscess (Acute apical abscess)
4. A Symptomatic apical Abscess (Chronic apical Abscess)
5. Periodontal abscess
6. Pericoronitis.

7. Pulpal pain
A. Dentinal hypersensitivity
It is not pathologic, but is rather, fluid flow in the dentinal
tubules which stretches or compresses the nerve endings of
the pulp tissue.
Diagnosis
• Short, sharp pain at thermal stimuli mainly coldness, also pain
to tactile stimulation.
• All diagnostic tests such as electric pulp test, percussion and
radiographs give normal response.
Treatment
Various agents can be use to occlude the dentinal tubules like
varnishes, fluoride compounds like sodium fluoride, stannous
fluoride and dentin bonding agents.

8. B.Reversible Pulpitis (pulpal hyperemia)
Diagnosis
- Pain on stimulus (usually cold or sweets) & the pain ceases
within few seconds.
-The pulp returns to normal after removal of causative factor.
The common causes of reversible pulpitis are caries, faulty
restorations, trauma or any recent restorative procedures.
Treatment
• Removal of the cause (caries, fractured restoration, exposed
dentinal tubules).

9. C. Irreversible Pulpitis (acute pulpagia)
Diagnosis
• Patient usually gives a history of sharp, diffused, spontaneous pain especially at night
& cannot be relieved by analgesia.
• Tooth is hypersensitive to hot that is prolonged in duration, in certain cases the
patient may arrive at the dental clinic with a glass of ice/cold water. Why??
Cooling of the dentin will contract the fluid of the dentinal tubules& so this will relieve
the pressure on pulpal nerve fibers caused by edema and inflammation of the pulp.
Treatment
Complete removal of pulpal tissue should be done, i.e. endodontic therapy.

10. D. Necrotic pulp (chronic pulpitis)
Diagnosis
• Tooth is usually asymptomatic; may give moderate to
severe pain on biting pressure (It is not symptom of
necrotic pulp but it indicates P.D.L inflammation).
Treatment
Complete removal of pulpal tissue that is root canal
treatment.

11. Chronic Hyperplastic Pulpitis (pulp
polyp)
Overgrowth of pulp tissue outside the boundary of
pulp chamber, it is a granulation tissue covered at
times with epithelium. it commonly occurs in
primary &immature permanent teeth(perm.
mand.molars) with rich blood supply leading to
proliferation response. it occurs due to low grade
chronic irritation ;i.e. slow progressive carious
exposure. it is a form of chronic pulpal
inflammation.

12. Periodontal pain
1.Acute Apical Periodontitis (Symptomatic Apical
Periodontitis)
it is a localized inflammation of the periodontal ligament in the apical
region occurs due to diffusion of irritant from inflamed or necrotic pulp to periapical
area.
Diagnosis
• The tooth is very painful to touch, and even contacting the tooth in closure may bring
a flood of tears. The pain is most persistent, lasting 24 hours a day.
• There is no overt swelling involved, just a grossly painful tooth elevated slightly in its
socket.
• Pulp tests??.
it cannot be performed because the tooth is very tender to percussion with possibility
of false readings from P.D.L.
• Radiographs may show no change or widening of periodontal ligament space in some
cases.
Treatment
• Complete removal of pulp (endodontic treatment).
• Occlusal adjustment.

13. 2. Asymptomatic apical periodontitis
(Chronic Apical Periodontitis)
-Asymptomatic apical periodontitis (AAP) may be
preceded by SAP or by an apical abscess. However, the
lesion frequently develops and enlarges without any
subjective signs and symptoms.
-Radiographically visible periradicular bone resorption
( Radiographic findings are the diagnostic key).
-Asymptomatic apical periodontitis has traditionally
been classified histologically as either a periradicular
granuloma or a periradicular cyst

14. Periradicular granuloma:
consists predominantly of
granulation inflammatory tissue
with numerous connective tissue
fibers and usually a connective
tissue capsule. the white arrow
pointed for the capsule.
Note: Inadequate root canal
treatment may also cause the
development of these lesions
Periradicular Cyst. it is a
central cavity lined by stratified
squamous epithelium. The
lumen of the periradicular cyst
contains a pale eosinophilic fluid
and occasionally some cellular
debris.

15. 3.Acute Apical Abscess(AAA) symptomatic
apical abscess
An abscess is a localized collection of pus
in a cavity formed by the disintegration
of tissues.
note:-The exacerbation of a
previously asymptomatic chronic
apical periodontitis has been
termed a phoenix abscess.
Diagnosis
-Rapid onset pain , tenderness to
percussion and fever .
-Commonly, the swelling remains
localized, but it also may become diffuse
and spread widely (cellulitis) and
massive asymmetry.

16. Radiographically, the picture may vary
from a widened periodontal space to
a large alveolar radiolucency.
• Pulp tests show negative results.
Treatment
• Drainage (either through the root
canal or by incision).
• Complete extirpation of pulp.
• Appropriate analgesics and
antibiotics if necessary

17. 4.Chronic apical abscess (suppurative apical
periodontitis)
. Chronic periradicular abscess is
similar to chronic apical periodontitis
except that it is characterized by the
presence of a draining sinus
tract.
The lesion is asymptomatic with an
intermittent discharge of pus through
the sinus tract. This lesion is also
referred to as chronic suppurative
apical periodontitis.
Root canal treatment or extraction is
required.


18. 5.Periodontal Abscess
Diagnosis
• Tooth is tender to lateral percussion.
• When sinus tract is traced using gutta-percha, it points
towards the lateral aspect of the tooth.
Treatment
Root planning and curettage.
6.Pericoronitis
It is inflammation of the periodontal tissues surrounding
the erupting third molar.
Diagnosis
• Deep pain which radiates to ear and neck.
• May be associated with trismus.
Treatment
Operculectomy and surgical removal of tooth if required.

19. Condensing osteitis( chronic focal sclerosing
osteomyelitis): it is a radiographic variation of
AAP and is characterized as a localized
overproduction of apical bone in response to chronic
pulpitis.


20. 2.Nonodontogenic pain (Non dental).
Nondental pain can be in form of myofacial toothache,
vascular headache, cluster headache, sinusitis, trigeminal
neuralgia.
A differential diagnosis to the source of orofacial pain must
be carefully detected to exclude the possibility of referred
pain.
REFERRED PAIN
Referred pain is a heterotrophic pain, i.e. felt in an area
innervated by a different nerve, from the one that
mediates the primary pain.

21. Dental (Odontogenic) Referred Pain
pain originates from pulpally
involved tooth and is referred
to adjacent teeth/tooth or
proximating deep and
superficial structures. For
example, pain from pulpal
involvement of mandibular
second or third molar is
referred to ear. This pain is
diagnosed by selective
anesthesia technique.

24. Nondental (non odontogenic) Referred
Pain
In this pain originates from deep tissues, muscles, joints,
ligaments, and referred as toothache causing confusing
with pulpitis.
Nondental reasons that causes toothache as referred pain
can be classified into:
Myofascial pain.
Neurovascular pain, otherwise known as headache
disorders.
3.Sinus or paranasal pain
Neuropathic pains.
cardiac pain.


25. 1.Myofascial pain: Muscles which are commonly
affected are masseter, temporalis but in some cases
medial, and lateral pterygoid and digastric muscles
are also affected.
Characteristic Findings of Muscular Toothache
• Nonpulsatile, diffuse, dull and constant pain.
• Pain increases with function of masticatory muscles.
For example, pain is increased when chewing is
done because of effect on masseter muscle

26. • Palpation of the involved
muscles at specific points
(trigger points)* may induce
pain.
*Trigger points are
hyperexcitable muscle tissues
which may feel like taut
bands or knots.
Tooth pain is relieved by
injecting local anesthesia to
affected muscle &not relieve
by selective anesthesia
(block).

27. 2.Neurovascular pain
The most common neurovascular pain in the mouth
and face is migraine &tension headache, cluster
headache.
Features of Neurovascular Toothache
• The pain is deep, throbbing, spontaneous in
onset which simulate pulpal pain.
• The pain is predominantly unilateral shows
periods of remission &Recurrence.

28. 3.Sinus or paranasal
pain
Severe ache, throbbing,
nonepisodic lasting for
hours or days involve
multiple maxillary
posterior teeth
exaggerated by tooth
percussion& Lowering
of head. Local
anesthesia of referred
tooth/teeth does not
eliminated pain.

30. Neuropathic Pain
Absence of dental etiology along the max. Molars &
premolars with symptoms of paroxysmal, sharp,
shooting pain always unilateral alert the dentist to
include neuralgia in the differential diagnosis

31. Cardiac Toothache
Cardiac pain is clinically
characterized by heaviness,
tightness or throbbing pain in
the substernal region which
commonly radiates to left
shoulder, arm, neck and
mandible.