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
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).

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.

Urgent dental problems most often involve acute orofacial pain and may originate from:
Teeth Periodontium Mucosa Muscle Bone Lymph

nodes Paranasal sinuses Salivary glands TMJs

Blood

vessels

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.

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.

Pain Classification
Somatic

normal neural tissue.

Bright,

Pain - results from stimulation of

Superficial apthous ulcer

stimulating, easily localized

Deep internal structures (pain referral)

Dull,

depressing, difficult to localize

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

Pain Classification
Neuropathic

abnormal neural tissue that has been altered.

Non-painful stimuli are now painful Can be episodic or continuous Example: trigeminal neuralgia (light touch)

Pain arises from

Acute Orofacial Pain

SOMATIC SUPERFICIAL NEUROPATHIC

DEEP MUSCULOSKELETAL
Periodontal Ligaments Joints Muscles Bone

VISCERAL
Pulp Blood Vessel Glands Visceral Mucosa Ears

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.

Considerations:
Healthy As

pulp (cellular) v Aged pulp (fibrous)

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. inflammation from non-pulpal causes can exhibit similar symptoms:
Hyperocclusion Bruxism

Periapical

Pulpal Status
Vital Normal Inflamed Nonvital

Necrotic

Reversibly
Inflamed

Irreversibly
Inflamed

Periapical Status
Normal
Inflamed

Acute Apical Periodontitis

Acute Apical Abscess

Chronic Apical Periodontitis

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

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.

 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

 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 Waters maxillary sinuses

Selective

Anesthesia infiltration, blocks, TPIs Test Cavity prep suspected tooth with no anesthesia.

Primary Odontogenic Pain

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

Characteristics of Pulpal & Periapical Pain

Pupal Pain
(Deep, Somatic, Visceral)

Periapical Pain
(Deep, somatic, Musculoskeletal)

Masticatory function
(Biomechanical stimulation)

Not stimulated by biting, chewing, or percussion Frequently difficult to localize specifically

Stimulated by biting, chewing, or percussion

Localization

Usually can localize precisely Usually follows pulpal pain (unless periodontitis,
hyperocclusion, bruxism)

Sequence

Usually precedes periapical pain

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)

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 same nerve that mediates the primary pain (painful adjacent teeth). Referred pain: felt in an area innervated by a different nerve from the one that mediates the primary pain (teeth in opposing arch, face, head, neck).
Does

not cross the midline. Convergence of afferent neurons.

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.

Toothache of Maxillary Sinus/Nasal Mucosa Origin

Origin
Infection of the maxillary sinus or inflammation of nasal mucosa.

Constant dull ache or pressure; sensitivity to cold, Clinical percussion, chewing; pain in multiple teeth; pain Characteristics increased by bending body forward; sinus tender to palpation; Waters may show air-fluid level.

Local Anesthesia Treatment

Topical anesthesia of nasal mucosa relieves pain in anterior teeth; infiltration anesthesia of posterior teeth relieves pain.

Antibiotics, antihistamine with a decongestant, analgesic.

Toothache of Myofascial Origin

Origin
Referral of pain from myofascial trigger points in muscles of mastication primarily masseter, temporalis, anterior digastric.

Nonpulsatile; constant, aching; variable and cyclic; Clinical pain increases with stress and use of offending Characteristics muscles.

Local Anesthetics Treatment

Anesthetic block of tooth does not alter pain; anesthetic injection of trigger point relieves pain.

Treatment and elimination of trigger points by spray and stretch, injection, or physical therapy.

Toothache of Neuropathic Origin (Trigeminal Neuralgia)

Origin
Abnormal function of nerves that innervate teeth (mandibular and maxillary branch of the trigeminal nerves).

Unilateral, severe, paroxysmal bursts of electric-like Clinical shocks stimulated by minor superficial provocation; Characteristics may be felt in teeth; asymptomatic between episodes.

Local Anesthetics
Treatment

Topical anesthetic of mucosal or skin trigger blocks pain; anesthetic block of nerve root blocks pain. Referral to neurologist or neurosurgeon.

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

Origin
Not definitely known; most probably a deafferentation pain after trauma.

Constant pain with no obvious pathology; burning, Clinical aching pain in molar/premolar area longer than 4 Characteristics months; local provocation not reliably effect pain.

Local Anesthetics
Treatment

Equivocal response

Tricyclic antidepressants, gabapentin

Toothache of Neurovascular Origin (Tooth migraine)

Origin
Neurogenic inflamation in the trigeminovascular system

Maxillay canines/premolars; no dental cause; Clinical throbbing, episodic, persistent, recurrent pain; dental Characteristics treatment may provide temporary relief; may become widespread.

Local Anesthetics
Treatment

Effects are unpredictable.

Same as for migraine headache; triptans, NSAIDs, beta blockers, ergotamines.

Toothache of Cardiac Origin

Origin
Myocardial ischemia with regional referral of pain.

Periodic dull pressure of aching in the mandible or Clinical teeth; may accompany pain in chest or arm; history of Characteristics angina; pain precipitated by exercise, stress, or physical activity.

Local Anesthetics
Treatment

Anesthesia of teeth not effective.

Refer to medical physician

Toothache of Psychogenic Origin

Origin
Psychogenic origin.

Bizarre behavior; history of psychiatric treatment; Clinical migratory pain in multiple teeth, frequently bilateral; Characteristics unexpected or inappropriate response to treatment.

Local Anesthetics
Treatment

Equivocal effects.

Refer to psychiatrist.