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Diagnosing

Diagnosing. Orofacial & Dental Pain Material used by permission from B.C. Decker Publishing Co. PAIN. An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. Acute v Chronic. Acute Pain.

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Diagnosing

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  1. Diagnosing Orofacial & Dental Pain Material used by permission from B.C. Decker Publishing Co.

  2. PAIN • An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.

  3. AcutevChronic

  4. Acute Pain • Associated with tissue damage or injury. • Recent onset. • Limited duration. • Stimulation of peripheral and central nociceptors by algogenic substances (bradykinin, prostoglandin, leukotrienes, histamines, substance P, excitatory AAs).

  5. Chronic Pain • Prolonged persistence of pain beyond the healing of tissue. • Frequently experienced in the absence of peripheral stimulation or lesions. • Result from changes in the dorsal horn and brain.

  6. Teeth Periodontium Mucosa Muscle Bone Blood vessels Lymph nodes Paranasal sinuses Salivary glands TMJ’s Urgent dental problems most often involve acuteorofacial pain and may originate from:

  7. Toothache is one of the most common acute pain complaints in the orofacial region. Toothache behavior can be so varied that it is wise to consider all pains in the orofacial region to be of odontogenic origin until proven otherwise.

  8. The first step is to classify the type of pain based on the history and clinical characteristics. Various tissues (e.g., muscles, glands, blood vessels, mucosa) possess unique characteristics that help to identify the tissue of origin.

  9. Pain Classification • Somatic Pain - results from stimulation of normal neural tissue. • Superficial – apthous ulcer • Bright, stimulating, easily localized • Deep – internal structures (pain referral) • Dull, depressing, difficult to localize

  10. Deep Somatic Pain • Musculoskeletal Pain • Gradient, biomechanical • Pain is proportional to degree of movement • Source can be localized • Visceral Pain • Not perceived until a threshold is reached • Not stimulated by biomechanical function • Diffuse, difficult to localize

  11. Pain Classification • Neuropathic Pain – arises from abnormal neural tissue that has been altered. • Non-painful stimuli are now painful • Can be episodic or continuous • Example: trigeminal neuralgia (light touch)

  12. Acute Orofacial Pain SOMATIC NEUROPATHIC SUPERFICIAL DEEP VISCERAL MUSCULOSKELETAL Pulp Blood Vessel Glands Visceral Mucosa Ears Periodontal Ligaments Joints Muscles Bone

  13. TOOTHACHE PAIN Toothache of odontogentic origin can be visceral (pupal) or musculoskeletal (periapical or periodontal). • When the pulp is exposed to a noxious stimulus, there is a reactive inflammatory response. • The resulting edema is unable to expand because of the surrounding inflexible cementum → ↑ tissue pressure and ↓ blood flow that causes damaging effects to the pulp.

  14. Considerations: • Healthy pulp (cellular) v Aged pulp (fibrous) • As an increasing amount of pulp tissue is involved, the inflammatory process progresses apically, until it 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. Pulpal Status Vital Nonvital Normal Inflamed Necrotic Reversibly Inflamed Irreversibly Inflamed

  16. Periapical Status Normal Inflamed Chronic Apical Periodontitis Acute Apical Periodontitis Acute Apical Abscess

  17. Diagnostic Process: systemic approach using history and clinical examination. History(more important) • CC • HPI • PMH • PSH • Meds • SH Location Onset Timing (frequency, duration) Quality(sharp, dull, throbbing, aching, burning, etc.) Intensity (0-10) Relieves / Aggravates Associated symptoms

  18. Clinical Examination:confirms the history and identifies the true source of pain. • Visual Inspection – pain source is usually evident. Gutta percha / fistulous tract. • Palpation – sensitivity over apex of tooth suggests periapical inflammation. Firm or fluctuant swelling consistent with abscess. • Percussion – pain/sensitivity consistent with periapical inflammation. Percussion of each cusp helps locate incomplete fracture.

  19. Mobility – check horizontal and vertical. • Periodontal Probing – evaluate periodontal status as contributor to pain. Aids in decision regarding retaining or extracting. • Thermal Sensitivity – tests pulpal status. Cold (ethyl chloride) is test of choice. • Normal / reversible pulpitis: not prolonged • Irreversible pulpitis: prolonged response • Necrotic pulp: no response • Heat test not usually done, difficult • Air / water syringe to detect fractures

  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 anesthesia.

  21. Primary Odontogenic Pain Odontogenic toothache arises from pulpal tissue or periapical tissue with general characteristics that indicate the tissue of origin.

  22. Characteristics of Pulpal & Periapical Pain

  23. Classification of Toothaches of Odontogenic Origin • Pulpal disease • Reversible pulpitis (brief, stimulated pain) • Irreversible pulpitis (prolonged, stimulated or spontaneous pain) • Necrotic pulp (prolonged or spontaneous pain, no response to pulp testing, sensitive to percussion) • Periapical disease • Acute apical periodontitis (sensitivity to percussion) • Acute apical abscess (sensitivity to percussion, swelling, pus) • Chronic apical periodontitis (often asymptomatic, periapical radiolucency) • Heterotopic pain • Projected pain (pain in adjacent teeth) • Referred pain (pain in teeth in opposing arch)

  24. Heterotopic Pain • Pain felt in an area other than its true site of origin (associated with deep, somatic pain). • Projected pain: perceived in the anatomic distribution of the samenerve that mediates the primary pain (painful adjacent teeth). • Referred pain: felt in an area innervated by a differentnerve from the one that mediates the primary pain (teeth in opposing arch, face, head, neck). • Does not cross the midline. • Convergence of afferent neurons.

  25. Nonodontogenic Toothaches Most toothaches will be of odontogenic origin. However, if there is no identifiable cause or source (e.g. caries) for the pain, or the history and clinical findings are inconsistent with odontogenic pain, then a nonodontogenic source should be considered.

  26. Toothache of Maxillary Sinus/Nasal Mucosa Origin

  27. Toothache of Myofascial Origin

  28. Toothache of Neuropathic Origin (Trigeminal Neuralgia)

  29. Toothache of Neuropathic Origin [Atypical Odontalgia (Phantom Pain)]

  30. Toothache of Neurovascular Origin (Tooth migraine)

  31. Toothache of Cardiac Origin

  32. Toothache of Psychogenic Origin

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