Differential diagnosis of the Differential diagnosis of the pain in orofacial system.pain in orofacial system.

Pain of dental origin and Pain of dental origin and nondental origine pain. nondental origine pain.

Orofacial painOrofacial pain

Orofacial pain is the pain in the area of Orofacial pain is the pain in the area of face and its adjacent structures.face and its adjacent structures.

The pain is expressing itself in various The pain is expressing itself in various clinical syndroms which are arising by the clinical syndroms which are arising by the influence of various mechanisms and they influence of various mechanisms and they involve multidiscilpinary approach to involve multidiscilpinary approach to diagnostics and the treatment itselfdiagnostics and the treatment itself..

Dental painDental pain may be classified as follows: may be classified as follows:Pulpal painPulpal painPeriapical/periradicular painPeriapical/periradicular pain

Non-dental painNon-dental painDental pain can be very difficult to diagnose.

Pulpal painThe pulp may be subject to a wide variety ofinsult, (bacterial, thermal, chemical, traumatic) the effects of which are cumulative and can ultimately lead to inflamation in the pulp (pulpitis) and pain.

A characteristicA characteristic of pulpal pain as that the patient of pulpal pain as that the patient is unable to localize the affected tooth.is unable to localize the affected tooth.

The ability of the pulp to recover from injury The ability of the pulp to recover from injury depends upon its blood supply, not the nerve depends upon its blood supply, not the nerve supply, which must be borne in brain when supply, which must be borne in brain when vitality (sensibility) testingvitality (sensibility) testing is carried out is carried out

Although numerous classifications of pulpal Although numerous classifications of pulpal disease exist, only limited number of clinical disease exist, only limited number of clinical diagnostic situations require identification before diagnostic situations require identification before affective treatment can be given.affective treatment can be given.

1. Dental pain1. Dental painExpressive painExpressive pain Non-expressive Non-expressive

pain pain

Dentine hypersensitivityDentine hypersensitivity Chronic PulpitisChronic Pulpitis

PulpitisPulpitis Neuritis from inclusion Neuritis from inclusion teethteeth

PeriodontitisPeriodontitis Dental ripDental rip

Chronic apical Chronic apical PeriodontitisPeriodontitis

Dentitio difficilisDentitio difficilis

Retentio dentisRetentio dentis

SynalgiaSynalgia

Sekundárne neuralgieSekundárne neuralgie

2. Non-dental pain, located near the 2. Non-dental pain, located near the teethteeth

Expressive painExpressive pain Non-expressive Non-expressive painpain

Affection near the Affection near the tooth and its tooth and its neighboursneighbours

PregnancyPregnancy

Affection of a distant Affection of a distant bodiesbodies

aerodontalgiaaerodontalgia

Primary neuralgiaPrimary neuralgia

Systemic diseasesSystemic diseases

PULPAL DISEASEPULPAL DISEASE

Classified as:Classified as:

– Reversible pulpitisReversible pulpitis

– Irreversible pulpitisIrreversible pulpitis

– Necrotic pulpNecrotic pulp

Reversible PulpitisReversible Pulpitis

Condition should return to normal with Condition should return to normal with removal of the cause.removal of the cause.

Common causes:Common causes:– Caries, recent restorative procedures, faulty Caries, recent restorative procedures, faulty

restorations, trauma, exposed dentinal restorations, trauma, exposed dentinal tubules, periodontal scaling.tubules, periodontal scaling.

Pulpal recovery will occur if reparative Pulpal recovery will occur if reparative cells in the pulp are adequate.cells in the pulp are adequate.

Symptoms of Reversible PulpitisSymptoms of Reversible Pulpitis

Thermal:Thermal:– Hypersensitive with mild Hypersensitive with mild painpain less thanless than <30 seconds, <30 seconds,

but similar to control toothbut similar to control tooth

Sweets:Sweets:– Sensitive (if caries, crack, or exposed dentin) with Sensitive (if caries, crack, or exposed dentin) with

mild mild painpain less thanless than<30 seconds (similar to control <30 seconds (similar to control tooth)tooth)

Biting Pressure:Biting Pressure:– None (unless tooth is cracked)None (unless tooth is cracked)

DiagnosisDiagnosisReversible PulpitisReversible Pulpitis

If there is a discrepancy between the If there is a discrepancy between the patient’s patient’s main main complaint, symptoms, and complaint, symptoms, and clinical examination – obtain more clinical examination – obtain more information or data interpretation.information or data interpretation.

Remember: both a preoperative pulpal Remember: both a preoperative pulpal and periapical diagnosis are made before and periapical diagnosis are made before treatment is initiated treatment is initiated ((if reversible pulpitis is only if reversible pulpitis is only condition, the periapical area should be normalcondition, the periapical area should be normal).).

If the tooth is percussion sensitive – If the tooth is percussion sensitive – consider bruxism or hyperocclusion.consider bruxism or hyperocclusion.

Treatment of Reversible PulpitisTreatment of Reversible Pulpitis

Remove irritant if present Remove irritant if present (caries; fracture; (caries; fracture; exposed dentinal tubules).exposed dentinal tubules).

– If no pulp exposure: CaOH, restore, monitorIf no pulp exposure: CaOH, restore, monitor– If pulp exposure:If pulp exposure:

Carious: initiate RCTCarious: initiate RCT

Mechanical: >1 mm: initiate RCTMechanical: >1 mm: initiate RCT

<1 mm crown planned: initiate RCT<1 mm crown planned: initiate RCT

<1 mm: direct cap or RCT<1 mm: direct cap or RCT

If recent operative or trauma – postpone If recent operative or trauma – postpone additional treatment and monitor.additional treatment and monitor.

Irreversible PulpitisIrreversible Pulpitis

Pulpal inflamation and degeneration Pulpal inflamation and degeneration not not expected to improve.expected to improve.

A physiologically older pulp has less ability to A physiologically older pulp has less ability to recover due to decrease in vascularity and recover due to decrease in vascularity and reparative cells.reparative cells.

As inflammation spreads apically, cellular As inflammation spreads apically, cellular organization begins to break down.organization begins to break down.

Localized pressure slows venous return, Localized pressure slows venous return, resulting in buildup of toxins and lower pH that resulting in buildup of toxins and lower pH that causes widespread cellular destruction.causes widespread cellular destruction.

Symptoms of Irreversible PulpitisSymptoms of Irreversible PulpitisThermalThermal::– Hypersensitive with moderate to severe Hypersensitive with moderate to severe

prolongedprolonged painpain (>30 seconds) as compared (>30 seconds) as compared to the controlto the control

SweetsSweets::– Moderately to severely sensitive (if caries, Moderately to severely sensitive (if caries,

crack, or exposed dentin)crack, or exposed dentin)

Biting PressureBiting Pressure::– Usually sensitive in later stages Usually sensitive in later stages ((periapical periapical

symptomsymptom))

Moderate to severe Moderate to severe spontaneousspontaneous painpain

DiagnosisDiagnosisIrreversible PulpitisIrreversible Pulpitis

Hypersensitive to hot or cold that is Hypersensitive to hot or cold that is prolonged.prolonged.

A history of spontaneous pain.A history of spontaneous pain.

Vital or partially vital pulp.Vital or partially vital pulp.

Treatment of Irreversible PulpitisTreatment of Irreversible Pulpitis

MinimumMinimum immediate treatment (if not immediate treatment (if not extractionextraction))

PulpPulpototomyomy::– Remove all decay (essential)Remove all decay (essential)– Large canals: passively broach 75% of tooth lengthLarge canals: passively broach 75% of tooth length– Small canals: spoon excavate orifice while removing Small canals: spoon excavate orifice while removing

pulpal tissue from chamber.pulpal tissue from chamber.– Copious irrigation with sodium hypochlorite (1%).Copious irrigation with sodium hypochlorite (1%).– Dry chamber with cotton pledgetDry chamber with cotton pledget– Place Ca(OH)Place Ca(OH)² ² intointo large and large and overover small canals small canals– Place dry cotton pellet in chamber, cover with cavit, Place dry cotton pellet in chamber, cover with cavit,

temporarily restore with Ketac-fill; temporarily restore with Ketac-fill; completelycompletely relieve relieve occlusion if have acute apical peridontitisocclusion if have acute apical peridontitis

Treatment of Irreversible PulpitisTreatment of Irreversible Pulpitis

IdealIdeal immediate treatment immediate treatment

PulpectomyPulpectomy (complete removal of pulpal tissue)(complete removal of pulpal tissue)

– Determine the ideal working length (WL)Determine the ideal working length (WL)– Fully instrument canals with master apical fileFully instrument canals with master apical file

At least # 25 file for small canals (and anterior teeth)At least # 25 file for small canals (and anterior teeth)

# 35 - 40 file for larger canals# 35 - 40 file for larger canals

Alternate working files with #8 or 10 patency fileAlternate working files with #8 or 10 patency file

– Copious irrigation with sodium hypochlorite (1%)Copious irrigation with sodium hypochlorite (1%)– Dry chamber with cotton pledgetDry chamber with cotton pledget– Place dry cotton pellet over canals, cover with cavit, Place dry cotton pellet over canals, cover with cavit,

temporarily restore with Ketac-fill; temporarily restore with Ketac-fill; completelycompletely relieve relieve occlusion if have acute periapical peridontitis.occlusion if have acute periapical peridontitis.

Irreversible PulpitisIrreversible Pulpitis(more treatment considerations(more treatment considerations))

Any residual decay can result in an inadequate Any residual decay can result in an inadequate seal, contamination of canal space, and inter-seal, contamination of canal space, and inter-appointment flare-ups.appointment flare-ups.

Inflammation can be judged by the amount of Inflammation can be judged by the amount of hemorrhage from the remaining pulp stump. If hemorrhage from the remaining pulp stump. If bleeding continues, re-broach or file for residual bleeding continues, re-broach or file for residual pulpal tags with copious irrigation.pulpal tags with copious irrigation.

To decrease risk of instrument separation within To decrease risk of instrument separation within the canal space, do the canal space, do notnot engage the canal walls engage the canal walls with broach.with broach.

Irreversible PulpitisIrreversible Pulpitis(additional considerations(additional considerations))

Do not leave teeth open between appointments – Do not leave teeth open between appointments – causes contamination of the canals and difficulty causes contamination of the canals and difficulty closing them later.closing them later.

Incomplete tooth fractures involving the pulp will Incomplete tooth fractures involving the pulp will show symptoms of irreversible pulpitis. show symptoms of irreversible pulpitis. Periodontal probing of associated pocket will Periodontal probing of associated pocket will indicate depth of fracture. If depth of pocket indicate depth of fracture. If depth of pocket (fracture) extends below the attachment level, the (fracture) extends below the attachment level, the prognosis is guarded to poor.prognosis is guarded to poor.

Necrotic PulpNecrotic Pulp

Results from continued degeneration of an Results from continued degeneration of an acutely inflamed pulp.acutely inflamed pulp.

Involves a progressed breakdown of cellular Involves a progressed breakdown of cellular organization and no reparative potential.organization and no reparative potential.

Commonly have apical radiolucent lesion. Commonly have apical radiolucent lesion. ((alwaysalways conduct proper pulp testing to rule out a conduct proper pulp testing to rule out a non-pulpal origin).non-pulpal origin).

With multi-rooted teeth, one root may contain With multi-rooted teeth, one root may contain partially vital pulp, whereas other roots may be partially vital pulp, whereas other roots may be nonvital (necrotic).nonvital (necrotic).

Maxillary first molar with large amalgam restoration and Maxillary first molar with large amalgam restoration and periapical radiolucencies around all three roots. The tooth periapical radiolucencies around all three roots. The tooth was unresponsive to electrical and thermal testing.was unresponsive to electrical and thermal testing.

Symptoms of Necrotic PulpSymptoms of Necrotic Pulp

Thermal:Thermal:– No responseNo response

Sweets:Sweets:– No responseNo response

Biting Pressure:Biting Pressure:– Usually moderate to severe Usually moderate to severe painpain (not symptom of (not symptom of

necrotic pulp, but rather periapical inflammation)necrotic pulp, but rather periapical inflammation)

Moderate to severe Moderate to severe spontaneousspontaneous painpain (usually dull and throbbing; associated with (usually dull and throbbing; associated with periapical areaperiapical area))

Diagnosis of Necrotic PulpDiagnosis of Necrotic Pulp

Distinguishing features:Distinguishing features:– No response to cold.No response to cold.– No response to No response to pulpal testpulpal test..

CaveatsCaveats– Decreased sensitivity to cold/ept may be from Decreased sensitivity to cold/ept may be from

of insulating effects of additional dentin.of insulating effects of additional dentin.– Fluid in canal space conducting electrical Fluid in canal space conducting electrical

current can give false-positive.current can give false-positive.– Periapical radiolucency is strong but not Periapical radiolucency is strong but not

conclusive evidence that pulp is necrotic.conclusive evidence that pulp is necrotic.

Treatment of Necrotic PulpTreatment of Necrotic Pulp

MinimumMinimum immediate treatment (if not immediate treatment (if not extractionextraction))Partial instrumentationPartial instrumentation of canals: of canals:– Remove all decay, evaluate restorabilityRemove all decay, evaluate restorability– Determine working length of all canalsDetermine working length of all canals– Large canals: up to #40 file, 4mm short of WLLarge canals: up to #40 file, 4mm short of WL– Small canals: up to #25 file, 4mm short of WLSmall canals: up to #25 file, 4mm short of WL– Alternate working file with #8 or 10 patency fileAlternate working file with #8 or 10 patency file– Copious irrigation with sodium hypochlorite (1%)Copious irrigation with sodium hypochlorite (1%)– Dry chamber with cotton pledgetDry chamber with cotton pledget– Place Ca(OH)Place Ca(OH)² into all canals² into all canals– Place dry cotton pellet in chamber, cover with cavit, Place dry cotton pellet in chamber, cover with cavit,

temporarily restore with Ketac-fill; temporarily restore with Ketac-fill; completelycompletely relieve relieve occlusion if have acute apical periodontitis.occlusion if have acute apical periodontitis.

Treatment of Necrotic PulpTreatment of Necrotic Pulp

Ideal Ideal immediate treatmentimmediate treatment

Complete instrumentationComplete instrumentation of canals: of canals:– Determine the ideal working lengthDetermine the ideal working length– Fully instrument canals with master apical fileFully instrument canals with master apical file

At least # 25 file for small canals (and anterior teeth)At least # 25 file for small canals (and anterior teeth)

# 35 - 40 file for larger canals# 35 - 40 file for larger canals

Alternate with #8 or 10 patency fileAlternate with #8 or 10 patency file

– Copious irrigation with sodium hypochlorite (1%)Copious irrigation with sodium hypochlorite (1%)– Place dry cotton pellet over canals, cover with cavit, Place dry cotton pellet over canals, cover with cavit,

temporarily restore with Ketac-fill; temporarily restore with Ketac-fill; completelycompletely relieve relieve occlusion if have acute apical periodontitis.occlusion if have acute apical periodontitis.

Necrotic PulpNecrotic Pulp(additional considerations(additional considerations))

Antibiotic coverageAntibiotic coverage– Usually not required unless patient has progressive Usually not required unless patient has progressive

swelling or fever.swelling or fever.

Pain ManagementPain Management– Always determine allergy, contraindication, and Always determine allergy, contraindication, and

interaction with present medicationsinteraction with present medications– Clock regulate NSAID (ibuprofen) for 3 daysClock regulate NSAID (ibuprofen) for 3 days– Narcotic for approximately 3 days, if neededNarcotic for approximately 3 days, if needed

Occlusal ReductionOcclusal Reduction– Reduction in all cases with acute apical periodontitis Reduction in all cases with acute apical periodontitis

(remember that length measurements may change)(remember that length measurements may change)

PERIAPICAL DISEASEPERIAPICAL DISEASE

Classified as:Classified as:

– Acute Apical PeriodonitisAcute Apical Periodonitis

– Acute Apical AbscessAcute Apical Abscess

– Chronic Apical PeriodontitisChronic Apical Periodontitis(Suppurative Apical Periodontitis with sinus (Suppurative Apical Periodontitis with sinus

tract)tract)

– Condensing OsteitisCondensing Osteitis

Treatment of Periapical DiseaseTreatment of Periapical Disease

Pulpal statusPulpal status

always dictates treatmentalways dictates treatment

of periapical diseaseof periapical disease

Acute Apical PeriodontitisAcute Apical Periodontitis

Mild to severe inflammation that surrounds Mild to severe inflammation that surrounds or is closely associated with the apex of a or is closely associated with the apex of a tooth.tooth.

Results from:Results from:– Irreversible inflammation or necrotic pulp.Irreversible inflammation or necrotic pulp.– Trauma or bruxism of normal or reversibly Trauma or bruxism of normal or reversibly

inflamed pulpitic conditions.inflamed pulpitic conditions.

Consider vertical fractures, periodontal Consider vertical fractures, periodontal abscess, and abscess, and non-odontogenic pain.non-odontogenic pain.

Clinical Findings inClinical Findings inAcute Apical PeriodontitisAcute Apical Periodontitis

VisualVisual– Check for decay, fracture lines, swelling, sinus tracts, orientation Check for decay, fracture lines, swelling, sinus tracts, orientation

of tooth, and hyperocclusionof tooth, and hyperocclusion

PalpationPalpation– Sensitive (usually on buccal surface)Sensitive (usually on buccal surface)

PercussionPercussion– Moderate to severe (initially use index finger to reduce patient Moderate to severe (initially use index finger to reduce patient

discomfort)discomfort)

MobilityMobility– Slight to no mobility (if moderate mobility exists, check for Slight to no mobility (if moderate mobility exists, check for

possible periodontal condition before continuing)possible periodontal condition before continuing)

Acute Apical PeriodontitisAcute Apical Periodontitis, con’t., con’t.

Perio ProbingPerio Probing– WNLWNL (unless concomitant periodontal disease or vertical (unless concomitant periodontal disease or vertical

fracturefracture exists)exists)

Thermal Thermal (pulpal symptom)(pulpal symptom)– Response (not prolonged) – consider traumatic occlussionResponse (not prolonged) – consider traumatic occlussion– If response prolonged – consider irreversible pulpitisIf response prolonged – consider irreversible pulpitis– No response – consider necrotic pulpNo response – consider necrotic pulp

EPT EPT (pulpal test)(pulpal test)– Response – pulp is vital (reversible or irreversible)Response – pulp is vital (reversible or irreversible)– No response – pulp is necroticNo response – pulp is necrotic

Acute Apical PeriodontitisAcute Apical Periodontitis, con’t., con’t.

TransluminationTranslumination– Not used unless fractured is suspectedNot used unless fractured is suspected

Selective AnesthesiaSelective Anesthesia– Not necessary, offending tooth easily locatedNot necessary, offending tooth easily located

Test cavityTest cavity– Not necessaryNot necessary

RadiographicRadiographic– Periapical image does not showPeriapical image does not show a radiolucent lesion; some a radiolucent lesion; some

thickening of the periodontal ligament is commonthickening of the periodontal ligament is common

Immediate Treatment ofImmediate Treatment ofAcute Periapical PeriodontitisAcute Periapical Periodontitis

If from irreversible pulpitis:If from irreversible pulpitis:Pulpotomy or extraction.Pulpotomy or extraction.

If from necrotic pulp:If from necrotic pulp:Root canal therapy initiated or extraction.Root canal therapy initiated or extraction.

If from hyperocclusion:If from hyperocclusion:When the pulp is normal or reversibly inflamed, adjusting the occlusion When the pulp is normal or reversibly inflamed, adjusting the occlusion provides immediate relief. Always consider cracked tooth, irreversible provides immediate relief. Always consider cracked tooth, irreversible pulpitis, or necrotic pulp if discomfort persists.pulpitis, or necrotic pulp if discomfort persists.

If from bruxism:If from bruxism:A biteguard may be indicated.A biteguard may be indicated.

Acute Apical AbscessAcute Apical Abscess

Acute inflammation of the periapical tissue Acute inflammation of the periapical tissue characterized by localized accumulation of characterized by localized accumulation of pus at the apex of a tooth.pus at the apex of a tooth.

A A painfulpainful condition that results from an condition that results from an advanced necrotic pulp.advanced necrotic pulp.

Patients usually relate previous painful Patients usually relate previous painful episode from irreversible or necrotic pulp.episode from irreversible or necrotic pulp.

Swelling, tooth mobility, and fever are Swelling, tooth mobility, and fever are seen in advanced cases.seen in advanced cases.

Symptoms ofSymptoms of Acute Apical AbscessAcute Apical Abscess

Spontaneous dull, throbbing, persistent Spontaneous dull, throbbing, persistent pain; exacerbated by lying down.pain; exacerbated by lying down.Percussion:Percussion:– Extremely sensitiveExtremely sensitive

Mobility:Mobility:– Horizontal / vertical; often in hyperocclusionHorizontal / vertical; often in hyperocclusion

Palpation:Palpation:– Sensitive; vestibular or facial swelling likelySensitive; vestibular or facial swelling likely

Thermal:Thermal:– No responseNo response

Clinical Findings ofClinical Findings ofAcute Apical AbscessAcute Apical Abscess

Visual:Visual:– Check for decay, fracture lines, swelling, sinus tracts, orientation Check for decay, fracture lines, swelling, sinus tracts, orientation

of tooth, hyperocclusionof tooth, hyperocclusion

Palpation:Palpation:– sensitive; intraoral or extraoral swelling presentsensitive; intraoral or extraoral swelling present

Percussion:Percussion:– Moderate to severe (initially use index finger)Moderate to severe (initially use index finger)

Mobility:Mobility:– Slight to none; may be compressibleSlight to none; may be compressible

Perio probing:Perio probing:– WNL (unless have perio disease or vertical fracture)WNL (unless have perio disease or vertical fracture)

Acute Apical AbscessAcute Apical Abscess, con’t., con’t.

Thermal:Thermal:– No response (pulp is necrotic)No response (pulp is necrotic)

EPT:EPT:– No response (false-positive from fluid in canal)No response (false-positive from fluid in canal)

Translumination:Translumination:– Not used unless fractured is suspectedNot used unless fractured is suspected

Selective Anesthesia:Selective Anesthesia:– Not necessary, offending tooth easily locatedNot necessary, offending tooth easily located

Test cavity:Test cavity:– Not necessary unless vitality is suspectedNot necessary unless vitality is suspected

Acute Apical AbscessAcute Apical Abscess, con’t., con’t.

Radiographic:Radiographic:Thickening of the periodontal ligament is common; may not show a Thickening of the periodontal ligament is common; may not show a frank lesionfrank lesion

If tests indicate If tests indicate pulp vitalitypulp vitality: (: (red flag!red flag!))Review diagnostic information (repeat diagnostic tests)Review diagnostic information (repeat diagnostic tests)

Rule out lateral periodontal abscessRule out lateral periodontal abscess

Review medical history for previous malignant lesions or Review medical history for previous malignant lesions or other conditions (hyperparathyroidism) that may explain other conditions (hyperparathyroidism) that may explain contradictory informationcontradictory information

Do not begin treatment until this discrepancy has been Do not begin treatment until this discrepancy has been resolvedresolved

Treatment ofTreatment of Acute Apical AbscessAcute Apical Abscess (necrotic pulp)(necrotic pulp)

MinimumMinimum immediate treatment (if not immediate treatment (if not extractionextraction))

Partial instrumentationPartial instrumentation of canals: of canals:– Remove all decay, evaluate restorabilityRemove all decay, evaluate restorability– Determine working length of all canalsDetermine working length of all canals– Achieve apical patency all canals with #10 file, look for Achieve apical patency all canals with #10 file, look for

drainage and allow to continue until it stopsdrainage and allow to continue until it stops– Large canals: up to #40 file, 4mm short of WLLarge canals: up to #40 file, 4mm short of WL– Smaller canals: up to #25 file, 4mm short of WLSmaller canals: up to #25 file, 4mm short of WL– Alternate with #8 or 10 patency fileAlternate with #8 or 10 patency file– Copious irrigation with sodium hypochlorite (1%)Copious irrigation with sodium hypochlorite (1%)– Dry chamber with cotton pledgetDry chamber with cotton pledget

continued on next continued on next slideslide

Treatment ofTreatment of Acute Apical AbscessAcute Apical Abscess, , con’t.con’t.

– Place Ca(OH)Place Ca(OH)² into all canals² into all canals– Place dry cotton pellet in chamber, cover with cavit, Place dry cotton pellet in chamber, cover with cavit,

temporarily restore with Ketac-fill, and temporarily restore with Ketac-fill, and completelycompletely relieve tooth from occlusion.relieve tooth from occlusion.

– Incision and drainage may be requiredIncision and drainage may be required– Prescribe antibiotics and analgesicsPrescribe antibiotics and analgesics

Continued painContinued pain and swelling are common and swelling are common postoperative problems – so prepare the postoperative problems – so prepare the patient for several days of discomfort. patient for several days of discomfort.

Chronic Apical PeriodontitisChronic Apical Periodontitis

Results from prolonged inflammation that has Results from prolonged inflammation that has eroded the cortical plate making a periapical eroded the cortical plate making a periapical lesion visible on the radiograph.lesion visible on the radiograph.

Caused by a necrotic pulp, the lesion contains Caused by a necrotic pulp, the lesion contains granulation tissue consisting of fibroblasts and granulation tissue consisting of fibroblasts and collagen (with macrophages and lymphocytes).collagen (with macrophages and lymphocytes).

Must rule out central giant cell granuloma, Must rule out central giant cell granuloma, traumatic bone cyst, and cemental dysplasia.traumatic bone cyst, and cemental dysplasia.

Usually asymptomatic, but in acute phase may Usually asymptomatic, but in acute phase may cause a dull, throbbing cause a dull, throbbing pain.pain.

Chronic apical periodontitis. Extensive tissue destruction in Chronic apical periodontitis. Extensive tissue destruction in the periapical region of a mandibular first molar occurred as the periapical region of a mandibular first molar occurred as a result of pulpal necrosis. Lack of symptoms together with a result of pulpal necrosis. Lack of symptoms together with presence of a radiographic lesion is diagnostic.presence of a radiographic lesion is diagnostic.

Chronic Apical PeriodontitisChronic Apical Periodontitis, con’t., con’t.

Most common pitfall is assuming that the presence Most common pitfall is assuming that the presence of a periapical lesion automatically indicates a of a periapical lesion automatically indicates a necrotic pulp.necrotic pulp.

If tests indicate If tests indicate pulp vitalitypulp vitality: (: (red flag!red flag!))

Review diagnostic information (repeat diagnostic tests)Review diagnostic information (repeat diagnostic tests)

Rule out lateral periodontal abscess, central giant cell Rule out lateral periodontal abscess, central giant cell granuloma, traumatic bone cyst, and cemental dysplasia.granuloma, traumatic bone cyst, and cemental dysplasia.

Review medical history for previous malignant lesions or Review medical history for previous malignant lesions or other conditions (hyperparathyroidism) that may explain other conditions (hyperparathyroidism) that may explain contradictory informationcontradictory information

Do not begin treatment until this discrepancy has been Do not begin treatment until this discrepancy has been resolvedresolved

Treatment ofTreatment of Chronic Apical Chronic Apical PeriodontitisPeriodontitis (necrotic pulp)(necrotic pulp)

If asymptomatic, no immediate treatment needed; If asymptomatic, no immediate treatment needed; schedule for root canal therapyschedule for root canal therapyIf in acute suppurative phase, immediate If in acute suppurative phase, immediate treatment same as with acute apical abscess, i.e.,treatment same as with acute apical abscess, i.e.,Partial instrumentationPartial instrumentation of canals: of canals:– Remove all decay, evaluate restorabilityRemove all decay, evaluate restorability– Determine working lengths of all canalsDetermine working lengths of all canals– Achieve apical patency all canals with #10 file, look for Achieve apical patency all canals with #10 file, look for

drainage and allow to continue until it stopsdrainage and allow to continue until it stops– Large canals: up to #35 file, 4mm short of WLLarge canals: up to #35 file, 4mm short of WL– Smaller canals: up to #25 file, 4mm short of WLSmaller canals: up to #25 file, 4mm short of WL– Alternate with #8 or 10 patency fileAlternate with #8 or 10 patency file

Treatment ofTreatment of Chronic Apical Chronic Apical PeriodontitisPeriodontitis, con’t., con’t.

– Copious irrigation with sodium hypochlorite (1%)Copious irrigation with sodium hypochlorite (1%)– Dry chamber with cotton pledgetDry chamber with cotton pledget– Place Ca(OH)Place Ca(OH)² into all canals² into all canals– Place dry cotton pellet in chamber, cover with cavit, Place dry cotton pellet in chamber, cover with cavit,

temporarily restore with Ketac-fill, and temporarily restore with Ketac-fill, and completelycompletely relieve tooth from occlusion.relieve tooth from occlusion.

– Incision and drainage may be requiredIncision and drainage may be required– Prescribe antibiotics and analgesicsPrescribe antibiotics and analgesics

Continued painContinued pain and swelling are common and swelling are common postoperative problems – so prepare the postoperative problems – so prepare the patient for several days of discomfort.patient for several days of discomfort.

Condensing OsteitisCondensing Osteitis

Increased trabecular bone in response to Increased trabecular bone in response to persistent irritant diffusing from the root persistent irritant diffusing from the root canal into the periradicular tissue.canal into the periradicular tissue.May be either May be either asymptomaticasymptomatic (pulpal necrosis)(pulpal necrosis) or associated with or associated with painpain (pulpitis).(pulpitis).

Therefore, may or may not respond to Therefore, may or may not respond to diagnostic tests, i.e., thermal, electric, diagnostic tests, i.e., thermal, electric, palpation, percussion.palpation, percussion.Root canal treatment, when indicated, may Root canal treatment, when indicated, may result in complete resolution.result in complete resolution.

Inflammation followed by necrosis in the pulp of the first Inflammation followed by necrosis in the pulp of the first molar has resulted in the diffuse radiopacity of the molar has resulted in the diffuse radiopacity of the periradicular tissue.periradicular tissue.

Reversible pulpitisReversible pulpitis Symptoms: Fleeting sensitivity/pain to hot, cold or Symptoms: Fleeting sensitivity/pain to hot, cold or sweet with inmmediate onset.Pain is usually sweet with inmmediate onset.Pain is usually sharp and may be difficult to locate. Quickly sharp and may be difficult to locate. Quickly subsides after removal of the stimulus. subsides after removal of the stimulus.

Signs: Exaggerated response to pulp testing.Signs: Exaggerated response to pulp testing.

Carious cavity/leaking restorationCarious cavity/leaking restoration

Ireversible pulpitisIreversible pulpitisSymptoms: Spontaneous pain which may last several Symptoms: Spontaneous pain which may last several

hours, be worse at night, and is often hours, be worse at night, and is often

pulsatile in nature. Pain is elicited by hot pulsatile in nature. Pain is elicited by hot

and cold at first, but in later stages heat is and cold at first, but in later stages heat is

more significant and cold may actually more significant and cold may actually

ease symptoms. ease symptoms.

A characteristic feature is that the pain remains after the A characteristic feature is that the pain remains after the removal of the stimulus. Localization of pain may be removal of the stimulus. Localization of pain may be difficult intially, but as the inflammation spreads to the difficult intially, but as the inflammation spreads to the periapical tissues the tooth will become more sensitive periapical tissues the tooth will become more sensitive to pressure.to pressure.

Signs: Signs: Application of heat elicits pain.Application of heat elicits pain.

Dentine hypersensitivityDentine hypersensitivity This is pain arising from exposed dentine in response to This is pain arising from exposed dentine in response to

a thermal, tactile, or osmotic stimulus. It is thought to a thermal, tactile, or osmotic stimulus. It is thought to be due to dentinal fluid movement stimulating pulpal be due to dentinal fluid movement stimulating pulpal pain receptors.pain receptors.

Cracked tooth syndrome Cracked tooth syndrome

Symptoms: Symptoms: Sharp pain on biting-short duration.Sharp pain on biting-short duration.

Signs: Signs: Tooth often has a large restoration.Tooth often has a large restoration. CrackCrack

may not be apparent at first but may not be apparent at first but transillumination and possibly removal of the transillumination and possibly removal of the restoration may aid visualization. Positive response to restoration may aid visualization. Positive response to vitality (sensibility) testing and pain can normally be vitality (sensibility) testing and pain can normally be alicited by getting the patient to bite with the affected alicited by getting the patient to bite with the affected tooth on a cotton-wol roll or tooth sleuth. May be tooth on a cotton-wol roll or tooth sleuth. May be associated with bruxing habit. associated with bruxing habit.

Periapical/periradicular pain Periapical/periradicular pain Progression of irreversible pulpitis ultimately leads to Progression of irreversible pulpitis ultimately leads to

death of the pulp (pulpal necrosis). At this stage the death of the pulp (pulpal necrosis). At this stage the

patient may experience relief from pain and thus may not patient may experience relief from pain and thus may not

seek attention. seek attention.

Characteristically the patient can precisely identify the Characteristically the patient can precisely identify the

affected tooth, as the periodontal ligament, which is well affected tooth, as the periodontal ligament, which is well

supplied with proprioreceptive nerve endings, is inflamed.supplied with proprioreceptive nerve endings, is inflamed.

Pulpal necrosis with periapical periodontitisPulpal necrosis with periapical periodontitis

SymptomsSymptoms:Variable, but patients generally describe a dull :Variable, but patients generally describe a dull

ache exacerbated by biting on the tooth.ache exacerbated by biting on the tooth.

Signs:Signs: usually no response to vitality testing, unless one usually no response to vitality testing, unless one canal of a multirooted tooth is still vital. canal of a multirooted tooth is still vital. Rtg: Periapical lession- granuloma, cystRtg: Periapical lession- granuloma, cyst

Acute periapical abscessAcute periapical abscessSymptoms:Symptoms: Severe pain which will disturb sleep. Tooth is Severe pain which will disturb sleep. Tooth is exquisitely tender to touch. exquisitely tender to touch. Sings:Sings: Affected tooth is usually extruded, mobile. May be Affected tooth is usually extruded, mobile. May be associated with a localized or diffuse swelling. Vitality associated with a localized or diffuse swelling. Vitality testing may be misleading as pus may conduct stimulus to testing may be misleading as pus may conduct stimulus to apical tissues.apical tissues.

Chronic periapical abscessChronic periapical abscessOften symptomless. Possibly associated with persistent Often symptomless. Possibly associated with persistent sinus. Presentation may be: coincidental or acute sinus. Presentation may be: coincidental or acute exacerbation. exacerbation.

Lateral periodontal abscessLateral periodontal abscessSymptoms: Symptoms: similar to periapical abscess with acute painsimilar to periapical abscess with acute pain and tenderness, and often an associated bad taste.and tenderness, and often an associated bad taste.Sings:Sings: Tooth is usually mobile, with associated localized Tooth is usually mobile, with associated localized or diffuse swelling of the adjacent periodontium. or diffuse swelling of the adjacent periodontium. A deep periodontal pocket is usually associated,A deep periodontal pocket is usually associated, which will exude pus on probing.which will exude pus on probing.RTG: RTG: vertical or horizontal bone loss,(vitality testing ) is vertical or horizontal bone loss,(vitality testing ) is usually positive, unless there is an associated perio-usually positive, unless there is an associated perio- endo lesion. endo lesion.

Non-dental painNon-dental pain When no signs of dental or periradicular pathology can When no signs of dental or periradicular pathology can

be detected then non-dental causes must be considered. be detected then non-dental causes must be considered. Other causes of pain that can present as toothache Other causes of pain that can present as toothache include: include:

temporomandibular pain-dysfunction/facial temporomandibular pain-dysfunction/facial arthromyalgia arthromyalgia

sinusitissinusitis

psychological disorders (atypicalodontalgia)psychological disorders (atypicalodontalgia)

tumours tumours

Temporomandibular pain – Temporomandibular pain – dysfunction/facial arthromyalgiadysfunction/facial arthromyalgia

The prblem being addressed is pain in the The prblem being addressed is pain in the preauricular area and muscles of mastication with preauricular area and muscles of mastication with trismus, with or without evidence of internal trismus, with or without evidence of internal derangement of the meniscus. derangement of the meniscus.

Clinical features:Clinical features: pain, clicking, locking, crepitus pain, clicking, locking, crepitus and trismus are the clasical signs and symptoms. and trismus are the clasical signs and symptoms. Some patients may be clinically depressed but most Some patients may be clinically depressed but most are not. Pain is elicited by palpation over the muscles are not. Pain is elicited by palpation over the muscles of mastication or the preauricular region.of mastication or the preauricular region.

SinusitisSinusitis

Antral pathology: Antral pathology: often mimics symptoms attributable often mimics symptoms attributable to maxillary teeth. Diagnosis is by exclusion of to maxillary teeth. Diagnosis is by exclusion of dental pathology, nasal discharge or stiffiness, dental pathology, nasal discharge or stiffiness, tenderness over the cheeks, and pain worse on tenderness over the cheeks, and pain worse on moving the head. moving the head.

X-raysX-rays may reveal antral opacity, fluid level or may reveal antral opacity, fluid level or fractures. Other X-rays: DPT (dental panoramic fractures. Other X-rays: DPT (dental panoramic tomogram) for cysts, and roots and CT scans for tomogram) for cysts, and roots and CT scans for tumours, pansinusitis, and blowout fractures.tumours, pansinusitis, and blowout fractures.

Facial pain – Facial pain – pain not directly related to the pain not directly related to the teeth and jaws.teeth and jaws.

Trigeminal Trigeminal neuralgia-neuralgia-it is present as a shooking it is present as a shooking electric shock type of pain of rapid onset and short electric shock type of pain of rapid onset and short duration, which is often stimulated by touching a duration, which is often stimulated by touching a trigger point in the distribution of the trigeminal trigger point in the distribution of the trigeminal nerve. In the early stages of the disease there may be nerve. In the early stages of the disease there may be a period of prodromal pain not conforming to the a period of prodromal pain not conforming to the classical description and it may be difficult to arrive classical description and it may be difficult to arrive at a diagnosis. Patients often have multiple at a diagnosis. Patients often have multiple extractions in a attempt to relieve the symptoms. extractions in a attempt to relieve the symptoms.

Atypical facial painAtypical facial pain

This constitutes a large proportion of patients This constitutes a large proportion of patients presenting with facial pain.presenting with facial pain.

Classicaly, their symptoms are unrelated to anatomical Classicaly, their symptoms are unrelated to anatomical

distribution of nerves or any known pathological distribution of nerves or any known pathological

process, and these patients have often been throughprocess, and these patients have often been through

a number of specialist disciplines in an attempt toa number of specialist disciplines in an attempt to

establish a diagnosis and gain relief. This diagnosis establish a diagnosis and gain relief. This diagnosis

tends to be used as a catch-all for a large group of tends to be used as a catch-all for a large group of

patients, with the connecting underlying supposition patients, with the connecting underlying supposition

that the pain is of psychogenic origin.that the pain is of psychogenic origin.

Pointers to a psychogenic etiology include imprecise Pointers to a psychogenic etiology include imprecise localization, often bilateral pain or all over the place. localization, often bilateral pain or all over the place. Pain is described as being continuous for long periods Pain is described as being continuous for long periods with no change, and none of the usual relieving or with no change, and none of the usual relieving or exacerbating factors apply.exacerbating factors apply.

Most analgesics are said to be unhelpful. Most analgesics are said to be unhelpful.

Oral dysaesthesia Oral dysaesthesia or burning mouth syndrome is an or burning mouth syndrome is an unpleasant abnormal sensation affecting the oral unpleasant abnormal sensation affecting the oral mucosa in the absence of clinically evident disease. mucosa in the absence of clinically evident disease. Five times more common in women aged 40-50 years Five times more common in women aged 40-50 years than other groups. Related to atypical facial pain.than other groups. Related to atypical facial pain.