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.
►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.
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).
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
Urgent dental problems most often involveUrgent dental problems most often involve
acuteacute orofacial pain and may originate from:orofacial pain and may originate from:
► Blood vesselsBlood vessels
► Lymph nodesLymph nodes
► Paranasal sinusesParanasal sinuses
► Salivary glandsSalivary glands
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.
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
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.
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
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
Pain ClassificationPain Classification
►Neuropathic PainNeuropathic Pain –– arises fromarises from
abnormalabnormal neural tissue that has beenneural tissue that has been
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)
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
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.
► 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:
Pulpal StatusPulpal Status
Periapical StatusPeriapical Status
Diagnostic ProcessDiagnostic Process:: systemicsystemic
approach using history and clinicalapproach using history and clinical
HistoryHistory (more important)(more important)
Timing (frequency, duration)
Quality (sharp, dull, throbbing, aching,
Relieves / Aggravates
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.
►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
►EPT – pulp is responsive (vital) or it is not
(nonvital). False (+) and false (-).
►Translumination – helps detect enamel and
pulpal floor fractures.
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,
►Test Cavity – prep suspected tooth with no
Primary Odontogenic PainPrimary Odontogenic Pain
Odontogenic toothache arises fromOdontogenic toothache arises from
with general characteristics that indicate thewith general characteristics that indicate the
tissue of origin.tissue of origin.
Characteristics of Pulpal & PeriapicalCharacteristics of Pulpal & Periapical
Pupal PainPupal Pain
Periapical PainPeriapical Pain
Masticatory functionMasticatory function
NotNot stimulated bystimulated by
biting, chewing, orbiting, chewing, or
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
SequenceSequence Usually precedesUsually precedes
periapical painperiapical pain
Usually follows pulpalUsually follows pulpal
painpain (unless periodontitis,(unless periodontitis,
hyperocclusion, bruxism)hyperocclusion, bruxism)
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
► 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)
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.
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,
thethe history and clinical findings are inconsistenthistory and clinical findings are inconsistent withwith
odontogenic pain,odontogenic pain,
a nonodontogenic source should be considered.a nonodontogenic source should be considered.
Toothache of Maxillary Sinus/NasalToothache of Maxillary Sinus/Nasal
Mucosa OriginMucosa Origin
Infection of the maxillary sinus or inflammation of nasalInfection of the maxillary sinus or inflammation of nasal
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.
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.
Antibiotics, antihistamine with a decongestant,Antibiotics, antihistamine with a decongestant,
Toothache of Myofascial OriginToothache of Myofascial Origin
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.
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
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.
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.
Toothache of Neuropathic OriginToothache of Neuropathic Origin
(Trigeminal Neuralgia)(Trigeminal Neuralgia)
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
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.
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.
Toothache of Neuropathic OriginToothache of Neuropathic Origin
[Atypical Odontalgia[Atypical Odontalgia (Phantom Pain)(Phantom Pain)]]
Not definitely known; most probably a deafferentationNot definitely known; most probably a deafferentation
pain after trauma.pain after trauma.
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.
Equivocal responseEquivocal response
TreatmentTreatment Tricyclic antidepressants, gabapentinTricyclic antidepressants, gabapentin
Toothache of Neurovascular OriginToothache of Neurovascular Origin
(Tooth migraine)(Tooth migraine)
OriginOrigin Neurogenic inflamation in the trigeminovascularNeurogenic inflamation in the trigeminovascular
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
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.
Toothache of Cardiac OriginToothache of Cardiac Origin
OriginOrigin Myocardial ischemia with regional referral of pain.Myocardial ischemia with regional referral of pain.
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.
Anesthesia of teeth not effective.Anesthesia of teeth not effective.
TreatmentTreatment Refer to medical physicianRefer to medical physician
Toothache of Psychogenic OriginToothache of Psychogenic Origin
OriginOrigin Psychogenic origin.Psychogenic origin.
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.
Equivocal effects.Equivocal effects.
TreatmentTreatment Refer to psychiatrist.Refer to psychiatrist.