Lec.

4 5th Level

•“Pain in Endodontcs”

Mohammed Aldawla
Department of Conservative Dentistry,
Faculty of Dentistry
 Terminology
Pain is unpleasant sensory and emotional experience
with actual or potential tissue damage.
Pain is always subjective…..
Pain threshold is “the least stimulus that can cause pain
to an individual”.
Generally pain threshold is affected by:
1. Age and sex.
2. Psychological status and experience of the individual.
3. Physical status of individual.
 Orofacial pain

Causes

Odontogenic
Odontogenic
salivary glands
bone lesions
Pulpitis
musculoskeletal origin
Primary vascular disorder Periapical pathosis
Neuralgias
cracked tooth
lesions of nose and ear
Psychogenic periodontal
generalized pain syndroms
others
FIG. 3-2 A graphic depiction of the trigeminal nerve entering the brainstem. The primary afferent
neuron synapses with a second-order neuron in the trigeminal nucleus. The second-order neuron
carries pain information to the thalamus from which it is sent to the cerebral cortex for
interpretation.
FIG. 3-3 Illustration of pain that is referred from an area innervated by one nerve (C2) to an area
innervated by a different nerve (V2). Note that this phenomenon occurs secondary to the
convergence of different neurons onto the same second-order neuron in the trigeminal nucleus.
The sensory cortex perceives two locations of pain. One area is the trapezius region that
represents the source of pain. The second area of perceived pain is felt in the temporomandibular
joint area, which is only a site of pain, not a source of pain. This pain is heterotopic (referred).
FIG. 3-4 Illustration of the laminated pattern of innervation from orofacial structures into the
trigeminal nucleus. These laminated patterns commonly reflect the patterns of referred pains felt
in the orofacial structures.
 Pain Type

 Sensory nerves supplying

the dental pulp contain
both myelinated and
unmyelinated axons

 The stimulation of myelinated pain fibers Fast, sharp

pain.
 Activation of the non-myelinated pain fibers A duller,
slower pain.
 Dental pain
Myelinated A nerve fibers non-myelinated C nerve fibers other neurofibers

Record pain sensations. Are considered to be able

to record pain impulses
and not sensations like
sweetness, salt, touch or
pressure.
 Pulpal pain
 Very poorly localized
Intermittent
Throbbing
Intensified by heat, cold and
sometimes chewing
May be relieved by cold
Usually severe
 Periradicular/ Periodontal pain

 May be well localized

 Deep pain
 Intensified by chewing
 Moderate to severe in
intensity
Phenomena Complicating the Diagnosis of
Dental Pain
Referred Pain
• Comprises input from a site of tissue damage combined
with input from another site where there is no damage;
therefore the pain is referred and is perceived to originate
from the site of no damage.
Tooth A
Tooth B
Muscle T cell Action system
Ear
Nasal/sinus mucosa
 Phenomena Complicating the Diagnosis of
Dental Pain
Referred Pain
 Muscles of Mastication
 Ear, Nasal, and Sinus Muscosa

 Cardiac Origin

 Other Tooth
Phenomena Complicating the Diagnosis of Dental Pain
Referred Pain (Maxillary sinusitis)
 The close proximity of the maxillary sinuses to the maxillary teeth can make the diagnosis of
pain in these segments difficult.
 The distinction between pain of dental origin and sinusitis may be helped by the presence of
obvious dental disease, or a typical acute or recurrent sinusitis with nasal discharge.
 Acute sinusitis rarely occurs without preceding symptoms of „a cold‟, and tenderness to
pressure of a whole quadrant of teeth is characteristic.
 Periapical infection of premolar or molar teeth may lead to purulent discharge into the sinus
with associated pain.
 A further consideration is the risk of penetration of the sinus wall or even the sinus lining by
endodontic instruments, or during apical surgery. This may result in acute sinusitis from
bacterial contamination.
 Phenomena Complicating the Diagnosis of
Dental Pain
Spreading Pain
Inflammation progress & Chemical mediators lead to
spread to adjacent tissues accompanied by spread of pain
to wider area.
The Pain may not be localized because the origin is
somewhere within the area.
Masticatory dysfunction may occur spasm of
muscle of mastication pain (2ry spreading pain)
 Phenomena Complicating the Diagnosis of
Dental Pain
Psychogenic Pain
 Pain may originate in higher centers in the brain without
input from peripheral nerves, whoever the patient indicates
a painful site.
 Patterns
– No identifiable origin
– Multiple (may be bilateral) pain sites
– No predictable response to therapy (especially analgesics)
– Unusual, inconsistent, nonanatomically logical pain patterns
– No demonstrable etiology for the pain
– Patient focus on social and emotional problems when giving their
history
 Phenomena Complicating the Diagnosis of
Dental Pain
Headaches
 Are the most common painful entities of the head and neck
 Pain may referred to teeth

 Classification
– Functional
 Migraine headaches
 Cluster headaches

 Tension headaches

– Organic
 Phenomena Complicating the Diagnosis of
Dental Pain
Functional Headaches
 Causes: vascular, musculoskeletal, and emotional disturbances

 Migraine Headaches
– Classic migraine is readily daignosd by unilateral throbbing
pain associated with photophobia and nausea
– History of recurrent episodes
– May refer to teeth (maxillary canines and premolars)
– Atypical variations may confuse diagnosis
 Phenomena Complicating the Diagnosis of
Dental Pain
Functional Headaches
 Cluster Headaches (sever pain)
– The pain is usually limited to the distribution of the 1st and
2nd divisions of the trigeminal nerve and may manifest in the
maxillary and occasionally the mandibular teeth.

– Patient may suffer from daily one hour episodes for 2-3
month period.
 Phenomena Complicating the Diagnosis of
Dental Pain
Functional Headaches
 Tension Headache

– Is the most common form

– Muscle spasm may induce the pain which

referred over wider area of forehead, temples,
and back of the neck.
 Phenomena Complicating the Diagnosis of
Dental Pain
Organic Headaches
 Caused by mass lesion (tumors, hematomas, etc.),
infection, arteritis, vascular occlusion, cranial
neuralgias, and diseases of eye, ear, nose, throat and
teeth.

 Headache often deep, aching, steady, and dull pain.

 Neuralgias associated with sever pain.

 Phenomena Complicating the Diagnosis of
Dental Pain
Neuritis
 Pain due to inflammation of the nerves

 It may arise from trauma or spread of disease

(inflammatory or neoplastic) from adjacent structures

 Anesthesia or parathesia, and occasionally muscle

weakness and paralysis may be present

 History of trauma may be present

 Phenomena Complicating the Diagnosis of
Dental Pain
Trigeminal Neuralgia
 Is initiated by innocuous stimuli from a trigger zone and
causes sever pain.
 Common in old patients.
 It has neuroanatomic pattern, usually limited to one
division of trigeminal nerve.
 Trigger zones mostly present extraorally, but it may be
intraoral and therefore confused with tooth pain.
 The cause is controversial.
 Phenomena Complicating the Diagnosis of
Dental Pain
Atypical Oral and Facial Pain
 Group of poorly defined conditions, such as; atypical facial
neuralgia, atypical odontalgia, phantom tooth pain and
burning mouth.
 Common in females.
 Symptoms include chronic pain of a steady intensity
(burning or throbbing) that is poorly localized.
 Pain changes location and may cross the midline.
 Multiple dental treatments may present seeking for relief.
 The etiology is unknown but a psychiatric basis is strongly
suspected.
 Antidepressants may be successful for treatment.
 Diagnostic Procedures
Signs of a Difficult Diagnosis
 Patient can‟t localize the pain, or it appears in
different locations at different times.
 The pain is spontaneous and intermittent and is not
necessarily associated with precipitating factors.
 Stimulation of the suspected tooth or teeth does not
reproduce the symptoms.
 The indicated tooth lacks any defect.
 More than one tooth appears to be involved, or the
symptoms are bilateral.
Suspicious that Pain is not of Tooth Origin
 Unidentified local dental cause for pain.
 Stimulating, burning, non-pulsatile toothaches.
 Constant, unremitting, non-variable toothaches.
 Spontaneous multiple toothaches.
 Non-elimination of pain from the suspected tooth after a
local anesthetic block.
 Failure to respond to reasonable dental therapy of the
tooth.
 Characteristics of Oral Pain

History
Ability to
Source of pain Character of pain Pain intensified by
localize
Evoked doesn't outlast
Dentinal Poor Hot, cold, sweet, sour
stimulus; brief

Explosive, intermittent, Hot, cold, sometimes

Pulpal Very poor
throbbing, boring chewing

For hours at same level,

Periradicular Good Chewing
deep, boring
For hours at the same level,
Periodontal Good Chewing
boring

Gingival Good Pressing, annoying Food impaction, brushing

Usually
Mucosal Burning, sharp Sour, sharp, and hot food
good
 Characteristics of Oral Pain
History
Source of pain Pain intensity Associated signs Pain duplicated by

Caries, defective restoration,

Dentinal Mild to moderate Hot or cold, scratching
exposed dentin

Usually sever (acute),

Deep caries, extensive Hot or cold, some times
Pulpal may be mild to
restoration percussion
moderate (chronic)

Periradicular swelling and Percussion, palpation of

Periradicular Moderate to sever
redness, tooth mobility periradicular area

Periodontal swelling, deep

Periodontal Mild to sever pockets with pus, tooth Percussion, palpation
mobility

Gingival Mild to sever Acute gingival inflammation Touch, percussion

Erosive or ulcerative
Mucosal Mild to moderate Palpation of lesion
lesions, redness
Summery
 Summery

Demo: PainControl2009.pdf