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Diagnosis of Dental Pain II

Aceil Al-Khatib DDS, MS, Diplomat ABOM

Chronic Pulpitis; Symptoms

Intermittent, mild pain over a long period (months or years) Pain is poorly localized Pain may be limited to occasional hypersensitivity to heat Is rarely the patients chief complaint

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Chronic Pulpitis; Signs

Large restoration Carious lesion Fractured or discoloured tooth The tooth may be tender to percussion (in later stages)

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Chronic Pulpitis; Diagnostic Tests

Vitality Gradual reaction leading to an exaggerated reaction to heat, reduced response to cold and EPT Percussion There may be minor and dullness TTP Radiograph May reveal sclerosis of the pulp ic chamber and root canal , some loss of PA lamina dura and there may be sclerosis of PA bone

Chronic Hyperplastic Pulpitis

Symptoms Signs Diagnostic tests A lump in the mouth A pulp polyp within a carious tooth Destruction of coronal tooth tissue Radiographs: Large apical foramina

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Galvanism; Cause & Symptoms

Caused by production of an electrical current (dissimilar metals + saliva) Intermittent pain Pain occurs only after placement of a new metal restoration Pain is well localized and does not refer Usually pain diminishes over a few days

Aerodontalgia
Cause Symptoms Reduced atmospheric pressure ,possible sinusitis and recent restoration Sharp acute pulpitis like pain only during flying at high altitude Recent restoration, aerosinusitis if maxillary teeth are involved No apical pathology

Signs Diagnostic tests

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Periodontal Pain
Acute apical periodontitis of pulpal origin Traumatic periodontitis Chronic apical periodotitis (apical granuloma) Acute periodontitis of gingival origin (lateral periodontal abscess) Periodontal-endodontic lesion

Acute Apical Periodontitis Of Pulpal Origin

Causes Trauma Large restoration or carious cavity Pins involving the pulp Defective endodontics Unilateral, localized severe, continuous dull/throbbing pain of rapid onset ( may awaken at night) Soft and puffy soft tissue swelling Patient does not look well Iimited mouth opening ( if posterior teeth are involved) Facial swelling and eye closure (if anterior upper teeth are involved

Symptoms

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Acute Apical Periodontitis Of Pulpal Origin; Signs

Large restoration, caries.. Discharge of pus Inflamed surrounding gingival tissue Tender and enlarged regional lymph nodes Fever and malaise Soft tissue swelling at the apex, there may be a sinus Extruded and mobile tooth Palpation of swelling may reveal : Soft (local edema) or firm and erythematous (cellulitis)

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Acute Apical Periodontitis Of Pulpal Origin; Diagnostic Tests

Percussion TT apical percussion, with dull tone Negative; sometimes unreliable: pus may Vitality conduct the stimulus In multi rooted teeth May respond to heat as a result of expansion of gases in the pulp Cold may relieve pain Radiograph Widening of periodontal ligament with loss of lamina dura y Periapical radiolucency * Signs may be delayed

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Traumatic Periodontitis
This condition is reversible Caused by trauma : Recent high restoration: Excessive loading during ortho tx Excessive loading after the fitting of a partial denture

Traumatic Periodontitis; Diagnostic Tests

Symptoms Well localized pain on biting or on pressure Tooth feel high and may feel loose Normal response to heat, cold and EPT Minor TTP and dull percussion note

Vitality

Percussion

Articulating paper Occlusal contacts can be identified

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Chronic Apical Periodotitis (Apical Granuloma)

Causes Trauma Large restoration or carious cavity Pins involving the pulp Defective endodontics Pain is unusual Patient may report occasional discharge A sinus may be present

Symptoms

Chronic Apical Periodotitis (Apical Granuloma); Diagnostic Tests

Percussion Mild TTP and mild dull percussion note

Vitality tests
Radiography

Negative, heat may cause a response

Apical well defined radiolucency, defective root canal filling

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Tracking of Pus
Post max teeth Palatal root of upper 6 Upper centrals Upper laterals Most lower teeth Lower 7&8 Lower anterior teeth Lower 6 & upper 3 & upper 6 Pus points into the buccal sulcus Into the palate. Rarely to the floor of the sinus or the nose Into the labial sulcus, rarely into the nose Into the anterior palate Into the buccal sulcus Pus may track lingually, or into the neck Into the buccal sulcus or chin Pus may point onto the face

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Can be traced to their root of origin by inserting a GP point into the opening to its origin and taking an X-ray

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Approximately 80% of cutaneous sinus of dental origin are associated with mandibular teeth and 20% with maxillary teeth.

Extraoral cutaneous sinus tract of mandibular left canine

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