1/14/2015

Hakam Rabi
BSc., DDS, MSc.

Department Of Radiology & Diagnosis

Pain Pain
 When a patient complains of toothache it may be
arising from a variety of different structures and may
be classified as follows:
 Pulpal pain
 Periapical/Periradicular pain
 Non-dental pain

Pain Special Tests

 Dental pain can be very difficult to diagnose and the  These tests are used to try to get to the source of pain
clinician must gather as much information as possible or reach the nature of the problem
from the history, clinical and radiographic  The tests include:
examinations, and other special tests 1) Vitality Tests
2) Percussion
3) Mobility
4) Palpation
5) Crack check
6) Radiographs
7) Local Anesthesia

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Vitality Tests a) Cold Test

 There are 4 types of vitality tests that are used to  It is most practically carried out using ethyl chloride
determine if the pulp is vital or necrotic on a piece of cotton wool
a) Cold test  If the person responds to the application of cold then
b) Heat test the tooth is vital
c) Electric pulp test  If he doesn’t we move to a different test
d) Mechanical test

b) Heat Test c) Electric Pulp Test

 A piece of Gutta Percha is melted over it carefully so as
not to harm neighboring soft tissue
 Vaseline is applied to the tooth before the test to
prevent gutta percha from sticking
 If there was no response this suggests that the tooth is
non-vital
 If there is an increased or exaggerated response then
the tooth is hyperemic (contains excessive blood in the
pulp)
 Is done with a machine that forms an electric current
through the tooth
 The tooth should be dried first then prophylactic paste
is applied to it to act as a conductive medium
 An electrode is applied to the tooth
 The results appear on the machine and are interpreted
according to patient’s reaction
 The results could vary depending on the position of
the electrode on the tooth or the battery strength in
the machine

c) Electric Pulp Test c) Electric Pulp Test

 Misleading results can occur: False Negative
False Positive  Nerve supply damaged, blood supply intact
 Multi rooted tooth with vital and non-vital pulp  Thick secondary dentin
 Canal full of puss  Large insulating restorations
 Anxious patient

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d) Mechanical Test
 Also called “Cavity Test”
 Is usually used as a last resort to determine if a tooth is
vital
 Drilling starts in the tooth without local anesthesia
 It can be helpful in situations of crowded teeth
Mobility
 Mobility of teeth increases by the decrease in bone
support (e.g due to periodontal disease or an epical
abscess)
Crack check
 Biting on a gauze or rubber can be used to try and
elicit pain due to a cracked tooth
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Percussion
 Is carried out by gently tapping the suspected tooth
and adjacent teeth with the end of a mirror handle
 A positive response indicates the presence of an
exudate in the periapical or lateral periodontal tissues
Palpation
 Palpation of the buccal sulcus next to a painful tooth
can help to determine if there is an associated apical
abscess
Radiographs
OrthoPanTomograph (OPT)
 Used to get a general scan of teeth and jaws
 Check for presence of retained roots, or unerupted
teeth
 Sinuses (also occipito-mental radiograph)
 Temporomandibular joint (TMJ)
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Radiographs Periapical Radiograph

Periapical Radiographs
 Localization of unerupted teeth
 Examination of roots and periapical area

Radiographs Bitewings
Bitewings
 Examine crowns of teeth
 Interdental bone
 Caries
 Restorations

Local Anesthesia Pulpal Pain

 Can be used to eliminate confusion and try to localize
a painful area
 The pulp may be subject to a wide variety of insults
 e.g. bacterial, thermal, chemical, traumatic
 The effect of these are cumulative and can ultimately
lead to inflammation of the pulp
 Inflammation of the pulp = Pulpitis

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Pulpal Pain Pulpal Pain

 The pulp does not contain any proprioceptive nerve  It is impossible to reliably achieve an accurate
endings diagnosis of the state of the pulp based on clinical
 Thus a characteristic of pulpal pain is that the patient grounds alone
cannot localize the affected tooth  The only 100% accurate method is histological section
 The ability of the pulp to recover from injury depends
upon its blood supply, not the nerve supply, which
must be kept in mind when performing vitality testing

Pulpal Pain Pulpal Pain

 Although numerous classifications of pulpal disease  Pulpal pain can be further classified into 4 categories:
exist, only a limited number of clinical diagnostic 1) Reversible Pulpitis
situations require identification before effective 2) Irreversible Pulpitis
treatment can be given
3) Dentin Hypersensitivity
4) Cracked Tooth Syndrome

Reversible Pulpitis Reversible Pulpitis

Symptoms Signs
 Transitory sensitivity/pain to hot, cold or sweet, with  Exaggerated response to pulp testing
immediate onset  Carious cavity, or
 Pain is usually sharp and may be difficult to locate  Leaking restoration
 Quickly subsides after removal of the stimulus

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Reversible Pulpitis Irreversible pulpitis

Treatment Symptoms
 Remove any caries present and place a sedative  Spontaneous pain which may last several hours
dressing (e.g Zinc oxide Eugenol) or permanent  Is worse at night
restoration with suitable lining  Often pulsatile in nature
 At first pain is elicited by hot and cold but later on
heat is more significant and cold may actually ease the
symptoms

Irreversible pulpitis Irreversible pulpitis

 A characteristic feature is that the pain remains after Signs
removal of the stimulus  Application of heat elicits pain
 Localization of pain may be difficult initially, but as  Affected tooth may give no or a reduced response to
the inflammation spreads to the periapical tissues the electric pulp tester
tooth will become more sensitive to pressure

Irreversible pulpitis Dentin Hypersensitivity

Treatment
 Extirpation of the pulp and root canal treatment
 Pain arising from exposed dentin in response to a
thermal, tactile or osmotic stimuli
 It is thought to be due to dentinal fluid movement
stimulating pulpal pain receptors
 Prevelance is approximately 1 in 7 adults
 Diagnosis is by elimination of other possible causes
and by evoking symptoms

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Dentin Hypersensitivity Cracked Tooth Syndrome

Treatment
 Involves decrease in etiologic factors and by
decreasing permeability of dentinal tubules (e.g. by
toothpaste containing strontium, formalin and
fluoride, placement of varnishes or restorations)
Symptoms
 Sharp pain on biting, short duration
Signs
 Relatively few signs
 Diagnosis is difficult
 Tooth often has a large restoration
 Crack might not be apparent at first but
transillumination and possibly removal of the
restoration may aid visualization

Cracked Tooth Syndrome Cracked Tooth Syndrome

Cracked Tooth Syndrome Cracked Tooth Syndrome

 Testing is done by having the patient bite on a cotton
roll on the suspected tooth
 It may be associated with bruxism
Treatment
 An adhesive composite restoration may be appropriate
in teeth which are minimally restored but some cases
will require a cast restoration with full occlusal
coverage
 Occasionally RCT may be required

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Periapical/Periradicular Pain Periapical/Periradicular pain

 Progression of irreversible pulpitis ultimately leads to  The patient can precisely identify the affected tooth as
death of the pulp (pulpal necrosis) the periodontal ligaments, which are well supplied
 At this stage the patient may feel relief from pain and with proprioceptive nerve endings, are inflammed
thus may not seel attention
 If neglected, the bacteria and pulpal breakdown
products leave the root canal system via the apical
foramen or lateral canals and lead to inflammatory
changes and possibly pain

Pulpal Necrosis with Periapical

Periodontitis Acute Periapical Abscess
 Symptoms Symptoms
 Variable, but patients gnerally describe a dull ache that  Severe pain which will disturb sleep
increases with biting on the tooth
 Tooth is extremely tender to touch
 Signs Signs
 No response to vitality testing  Mobile tooth
 Radiographically the PDL is widened and there may be a  May be associated with swelling
periapical radiolucency (Granuloma or cyst)
 Vitality testing is misleading
 Treatment  Radiographic changes may range from widening of
 RCT or extraction apiccal periodontal space to obvious radiolucency

Acute Periapical Abscess Acute Periapical Abscess

Treatment
 Drain pus (usually through the root canal for less than
24 hours)
 Relieve occlusion
 Place temporary dressing in the root canal
 When the symptoms have completely subsided, then
RCT must be performed
 If not then extraction

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Chronic Periapical Abscess Chronic Periapical Abscess

 Often symptomless
 Possibly associated with persistant sinus tract

Treatment
 Drainage, dressing, then RCT
 If not successful then extraction

Lateral Periodontal Abscess

Symptoms Lateral Periodontal Abscess
 Similar to periapical abscess with acute pain and
tenderness and often an associated bad taste
Signs
 Tooth is usually mobile
 An associated local or diffuse periodontal swelling
 Deep periodontal pocket which will exude pus on
probing
 Radiographs will show vertical or horizontal bone
loss
 Vitality tests are usually positive unless there is an
associated endodontic problem (perio-endo lesion)

Lateral Periodontal Abscess Pericoronitis

Treatment
 Debride the pocket and achieve drainage of pus
 Irrigate with chlorhexidine solution
 If it is a recurrent problem prescribe antibiotics
(metranidazole or amoxycillin)
 The common complaint of the patient with
pericoronitis is severe radiating pain in the posterior
mouth and the inability to comfortably open or close
the mandible.
 Not only is it painful to close against the inflamed
operculum distal to the erupting mandibular molar,
but the pain of muscle trismus limits translation of the
mandible as well.
 The tissue distal to the erupting molar is most painful
to touch, especially during eating.

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 Pericoronitis is caused by injury and infection of the
pericoronal tissue associated with erupting molars,
usually mandibular third molars.
 The tissue may be injured during eating by trauma
from food such as peanuts or bread crust.
 Or food and plaque can get accumulated under the
operculum
 The infection begins under the operculum and extends
with attendant swelling around the entire unerupted
crown
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 The pain radiates through the region, down into the
neck, and up into the ear and can easily be confused
with pulp pain.
 Occasionally, an erupting third molar elicits the same
deep, spreading pain well before the tooth breaks
through the oral epithelium
Referred Pain
 Referred Pulp Pain
 The term referred or reflected pain, denotes the pain
felt in the body part which is remote from the place
of stimulation or tissue damage.
 A reflected pain originates in one place (e.g. the
lower first molar), and is felt in the other (e.g. ear)
 The 2 types of sensory nerve fibers in the pulp are
myelinated A fibers (A-delta and A-beta fibers)
and unmyelinated C fibers
 The C fibers are located in the core of the pulp, or
the pulp proper, and extend into the cell-free zone
underneath the odontoblastic layer
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 The A-delta fibers have a small diameter and
therefore a slower conduction velocity than other
types of A fibers, but are faster than C fibers.
 The A fibers transmit pain directly to the
thalamus, generating a fast, sharp pain that is
easily localized.
 The C fibers are influenced by many modulating
interneurons before reaching the thalamus,
resulting in a slow pain, which is characterized as
dull and aching
 Aferrent fibers which also converge here belong to
cranial nerves V, VII, IX and X, and the upper cervical
nerves C2 and C3 respectively
 It is the very proximity of these converging nerves,
coming from different parts of head and neck, which
causes complex synaptic communication in the
subnucleus caudalis
 When the system for pain transfer gets activated, and
nerve impulses travel to the brain centers, the higher
centers are not able to identify the cause of the painful
stimuli
Mandibular incisors, canine, and first premolar may refer
pain into the mental area.
The mandibular second premolar may refer pain into
the mental and midramus area
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 The key location of the phenomenon of the reflected
pain is the spinal core of the trigeminal nerve
 The mechanism of the referred pain is explained by
the theory of convergence.
 Aferrent nociceptive nerve fibers which conduct the
stimuli from different parts of the head and neck
converge in the area of the second neuron of the
sensory pathway of pain in subnucleus caudalis of the
spinal core of the trigeminal nerve
The maxillary canine may refer to the maxillary
first or second premolars and/or the first or second
molars, as well as to the mandibular first or second
premolars
Maxillary premolars may refer pain to the mandibular
premolars. The reverse is also true
Mandibular first or second premolars may
also refer pain into maxillary molars.
Mandibular molars may refer pain forward
to the mandibular premolars.
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Maxillary incisors may refer pain to frontal
area.
Maxillary canine and first premolar may
refer pain into the nasolabial area and orbit
Mandibular first and second molars may commonly refer
pain to the ear and to the angle of the mandible.
The mandibular third molar may refer pain to the ear
and occasionally to the superior laryngeal area
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The maxillary second premolar and first
molar may refer pain to the maxilla and back to the
temporal region.
Maxillary second and third molars may refer pain
to mandibular molar area and occasionally into the ear
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