Transcript Diagnosing - University of Kentucky

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:
► Lymph
► Teeth
► Periodontium
► Mucosa
► Muscle
► Bone
► Blood
vessels
nodes
► Paranasal sinuses
► Salivary glands
► TMJ’s
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
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
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
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)
Acute Orofacial Pain
SOMATIC
SUPERFICIAL
NEUROPATHIC
DEEP
VISCERAL
MUSCULOSKELETAL
Pulp
Blood Vessel
Glands
Visceral Mucosa
Ears
Periodontal Ligaments
Joints
Muscles
Bone
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
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
Pulpal Status
Vital
Normal
Inflamed
Reversibly
Inflamed
Nonvital
Irreversibly
Inflamed
Necrotic
Periapical Status
Normal
Acute
Apical
Periodontitis
Inflamed
Acute
Apical
Abscess
Chronic
Apical
Periodontitis
Diagnostic Process: systemic approach
using history and clinical examination.
History (more important)
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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.
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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:
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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.
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
Masticatory function
Pupal Pain
Periapical Pain
(Deep, Somatic,
Visceral)
(Deep, somatic,
Musculoskeletal)
(Biomechanical
stimulation)
Not stimulated by
biting, chewing, or
percussion
Stimulated by biting,
chewing, or percussion
Localization
Frequently difficult to
localize specifically
Usually can localize
precisely
Sequence
Usually precedes
periapical pain
Usually follows pulpal
pain (unless periodontitis,
hyperocclusion, bruxism)
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; Water’s may show air-fluid level.
Local
Anesthesia
Topical anesthesia of nasal mucosa relieves pain in
anterior teeth; infiltration anesthesia of posterior teeth
relieves pain.
Treatment
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
Anesthetic block of tooth does not alter pain;
anesthetic injection of trigger point relieves pain.
Treatment
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
Topical anesthetic of mucosal or skin “trigger” blocks
pain; anesthetic block of nerve root blocks pain.
Treatment
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
Equivocal response
Treatment
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
Effects are unpredictable.
Treatment
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
Anesthesia of teeth not effective.
Treatment
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
Equivocal effects.
Treatment
Refer to psychiatrist.