Odontogenic and non

odontogenic pain

PRESENTED BY
DR JEEVAN
pain

• an unpleasant sensory and

emotional experience
Definition associated with actual or
potential tissue damage
 ODONTOGENIC

PAIN
NON
ODONTOGENIC
 ODONTOGENIC PAIN

PERAPICAL
PULPAL PAIN 1. Periodontal pain HETEROTOPIC PAIN
Reversible pulpitis acute apical Projected pain referred
irreversible pulpitis periodontitis acute pain
apical abscess
 Non odontogenic pain

1.MUSCULO NEUROPATHIC SYSTEMIC

SKELETAL NEUROVASCULAR DISORDERS
INFLAMMATORY PSYCHOGENIC
TRIGEMINAL
MYOFASCIAL NEURALGIA MIGRAINE CLUSTER CARDIAC PAIN
ALLERGIC SINUSITIS MUNCHAUSENS
PAIN [MPDS] TMD GLOSSOPHARYNG HEADACHES HERPES ZOSTER
BACTERIAL SINUSITIS SYNDROME
[ BRUXISM] EAL NEURALGIA NEOPLASTIC
DISEASE
 HETEROTOPIC PAIN
 Pain felt in an area other than its true site of origin
1. Projected pain: perceived in the anatomic distribution of the same nerve that
mediates the primary pain (painful adjacent teeth).
2. 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).
Pulpal pain / Pulpalgia

One of the most commonly encountered Oro-facial pains

Unfavorable Result
Anatomic Feature Limits pulp swelling
Limits blood supply
Unyielding Walls Subject to
Constricted Blood "strangulation" by
Source Tooth pulp swelling
Surrounded by Bone
Bone infection
invariably results
Etiologic agent source
 Microbial infection  Dental caries
 Cracked teeth

 irritation  Chemicals[used in cavity preparation]

 Trauma[blow to face]
 Heat[dry tooth preparation]
 Electrical stimulus[EPT]
Pain History

 Location
 Character of pain
 Severity
 Duration of pain
 Exacerbating factors
 Relieving factors
 Spontaneity
 Other symptoms
 Subjective history:
 Gives rise to provisional diagnosis
 Determines urgency of treatment
 Confirmed by examination and special tests
Objective Testing
 Visual Examination
 Periodontal probing
 Radiographs
 Selective anesthesia
 Percussion
 Test cavity
 Palpation
 Occlusion
 Mobility
 Vitality pulp testing
PULPAL PAIN / PULPALGIA
 Classified according to the degree of severity and the pathologic process present
 Hyperreactive pulpalgia
1. Dentinal hypersensitivity
2. Hyperemia

 Acute pulpalgia
1. Incipient
2. Moderate
3. Advanced

 Chronic pulpalgia
1. Barodontalgia
 Hyperplastic pulpitis
 Necrotic pulp
 Internal resorption
 Traumatic occlusion
 Incomplete fracture
HYPERREACTIVE PULPALGIA
 Dentin hypersensitivity
 PAIN : Sharp. Short [described as sudden shock]

 Eliciting factor: Any stimulating factor like Heat , cold , sweet, sour , drying of dentin etc.


Mechanism
 Noxious stimuli Odontoblastic process pulpal nerves
 Hydrodynamic theory : The displacement of tubule contents, if the movement occurs rapidly
enough, may produce deformation of nerve fibers in the pulp or predentin or damage to the
cells;
 both of these effects may be capable of producing pain
 Dentinal tubules Tubular fluid Odontoblastic process Nerve fibre
Odontoblast
 Hyperemia

Application of
Hyperemia → heat →
increased increased
blood flow → pulpal pressure
increased stimulate the
pulpal pressure nerve endings
→ Pain
PULPAL A FIBRES
[ A δ FIBRES]
 Fast conduction
 Low response threshold
 Transmits : Sharp, localized
 pain response Responds to cold
stimulation
NERVES C FIBRES
 Slow conduction
 Higher activation threshold
 Transmits : Dull, poorly localized
response
 Responds to Heat stimulation
Diagnosis :
 May not respond abnormally with cold test.
 The tooth should be isolated and continuous stream of water is put on the
tooth → pain
 Scratching the cervical dentin also elicits pain
 EPT may elicit an earlier response
Electric stimulation does not cause fluid movement
EPT stimulates the faster A fibres [ A β fibres] initially and then the C fibres .
[A + C fibres produce painful response on higher level of electrical stimulation ]
 MANAGEMENT:
 Prevention is the best treatment
 Bases under the restorations to prevent irritation of the dentinal tubules

Physiologic methods:
 Remineralization of the dentinal tubules by the calcium phosphate-
carbohydrate-protein complex from saliva
 Formation of the tertiary dentine from the pulpal side
 Both are time consuming
Chemical/mechanical obstruction:
 Desensitizing agents
 potassium oxalate
 strontium chloride [Sensodyne]
 sodium and stannous fluoride
 Potassium nitrate
 Dentin bonding agents
ACUTE PULPALGIA

INCIPIENT PULPALGIA /[REVERSIBLE PULPITIS]

 Mild pain or ache in response to cold beverages/foods, sweets
 Also seen after cavity preparation and restorations especially after the
anesthesia wears off.
 Eliciting factor : caries , cavity preparation, cold sugar, traumatic occlusion
 If not treated my turn into moderate/acute pulpalgia
 Examination :
 Recently restored teeth
 Carious lesions
1. clinical
2. Radiographic
 Cold test causes pain which lasts for less than 10 secs after removal of the
stimulus
 EPT may not be very confirmative
 Treatment :
 Excavation of caries and placing a sedative dressing
 Follow up.
MODERATE PULPALGIA

 Pain is nagging or boring pain which is initially localized but later becomes
diffuse or referred to another area.
 Pain is continuous and may extend for hours or even days
Eliciting factor:
 Cold and Hot food/ beverages
 Spontaneous at times and increases when the patient lies down or even bends
his head due to an increase in the cephalic blood pressure
 Pain increases after mastication especially when food gets lodged into the
carious cavity
 Rinsing with cold water aggravates the pain

Examination:
 The patient usually cannot localize the tooth due to diffuse pain
 Carious tooth / tooth with a large restoration
1. Clinical
2. Radiographic
Cold test
 may give an immediate , severe and long lasting response.
 EPT may be inconclusive

Treatment:
 Pulpectomy
ADVANCED ACUTE PULPALGIA

 Most severe type of pulpalgia

 Pain is excruciating
 Patient may be hysterical

Eliciting factors:
 Spontaneous
 May be relieved with rinsing cold water [unlike moderate pulpalgia]
Examination :
Patient points to the involved tooth
Tender to percussion
Radiograph may reveal large restoration or caries involving pulp
Periapical changes may/may not be present

Heat test produces profound pain [cold water should be sprayed over the
tooth if the patient is in severe pain after the heat test]
 Local anesthesia will provide an immediate relief.
Treatment :
Pulpectomy

In some cases Local anaesthesia may be ineffective hence would require

Intra canal injection and supplemental periodontal injections.
CHRONIC PULPALGIA

 Pain is diffuse and the patient cannot locate the tooth

 Most likely to cause referred pain
 Eliciting factors: Hot drinks/foods
 Food lodged into a carious tooth

 Barodontalgia: Earlier called as AERODONTALGIA Due to

increased/decreased air pressues
Barodontalgia

 Class I - Sharp momentary pain on ascent – acute pulpitis

 Class II - Dull throbbing pain on ascent – chronic pulpitis
 Class III- Dull throbbing pain on descent - necrotic tooth [Asymptomatic on
ascent]
 Class IV – Severe persistant pain on ascent/descent – periapical
abscess/cyst
Examination:
 Large carious lesion
 Large restoration
 Recurrent caries with restorations
 Radiograph often shows Periapical radiolucency

Both electric pulp testing and cold tests are non confirmatory May show pain with heat test

Treatment :
Pulpectomy
Hyperplastic pulpitis

 Chronically inflammed pulp tissue which extends outside the carious lesion
 Eliciting factors: None Examination
 Differentiate from Gingival polyp [using an excavator]

Treatment
1. Pulpectomy
2. Extraction
 NECROTIC PULP
 Usually asymptomatic
 In most of the cases the patient reports with a discolored tooth
 Clinical examination
1. discolored teeth
2. may at times be tender to percussion
 EPT may or may not give any response May give a false positive in multi rooted
teeth
Treatment :
Pulpectomy
INTERNAL RESORPTION

 Mostly asymptomatic , but the patient may complain of vague, dull pain
 Clinically seen as the pink tooth
 Pain on percussion may be present in some cases
Clinical examination :
 Pink colored discoloration
Radiographic
 Radiolucency involving the canal outline
Treatment
 Pulpectomy
TRAUMATIC OCCLUSION

 Traumatic occlusion due to

1. bruxism
2. High restoration
Eliciting factors
 Patient usually complains of pain on biting after a recent restoration
 Pain in all the teeth after waking up in the morning
Clinical examination:
 Shiny spots on the amalgam restorations
 Wear facets on the occlusal surface of the teeth
Treatment
 Relieving the occlusal trauma by selective grinding using an articulating
paper.
Incomplete tooth fracture

 Tooth that is split or cracked but not yet fractured

 symptoms range from those of a constant, unexplained hypersensitive
pulp to constant, unexplained toothache
 Tooth uncomfortable during biting
Eliciting factors
 Biting will induce pain
Examination
 Clean and dry the tooth and examine under light for any cracks
 TOOTH SLOOTH
 Making the patient bite on any hard substance may elicit sharp pain.
Pulp tests
may not show any abnormal response unless the pulp is involved.
Treatment
 If the pulp is not involved, a crown is given
 If pulp is involved, Pulpectomy followed by crown
Selected features of non-odontogenic dental pain
 No apparent etiologic factors for odontogenic pain (no caries, leaky
restorations, trauma, fracture, etc.)
 Pain not consistently relieved by local anaesthetic injection
 Bilateral pain or multiple teeth are painful
 Pain can be chronic and not responsive to dental treatment
 Diagnosis-specific: pain concurrent with a headache
 Diagnosis-specific: palpation of trigger points or muscles can increase pain
 Diagnosis-specific: pain increased by emotional stress, physical exercise, head
position, etc