DENTAL PAIN

BY MIREMBE JEMIMAH SYSON

OBJECTIVES

• definition of dental pain

• Mechanism of dental pain
• Causes of dental pain.
DEFINITION

• Dental pain also called tooth ache is an aching sensation in or around

the tooth

• It may be due to dental origin or non dental origin.

• When severe it may impact sleep, eating and other daily activities
MECHANISM OF DENTAL PAIN

• Dental pain typically stems from irritation of the tooth’s nerve.

External stimulation is an important factor in causing dental pain.

• As carries progress through the enamel and then to the dentine,

bacterial byproducts diffuse towards the pulp through dentinal tubules
resulting in inflammation of the coronal pulp.
• There is subsequent increased vascularity and the activation and
sensitization of A-fibre nociceptors causing sharp pain on stimulation
CONTINUATION

• As caries progress to include the full width of dentine, bacteria invade

the pulp and severe inflammation ensues with areas of necrosis, as
inflammation reaches the center of the pulp, more c-fibers are affected
and the spontaneous intense.
• Severe pulpitis is more likely to produce c-fiber-mediated pain
because these fibers are more tolerant to tissue hypoxia found in the
severely inflamed pulp than A-fibers
CONTINUATION

• C- fibers therefore remain active longer in the degrading tissue.

Because of the limited proprioceptive capacity of the pulp and the fact
that single afferent nerve fibres may branch to serve multiple teeth,
pain associated with pulpitis is typically poorly localized.

• A-fibers mediate fast pain, which is initial pain response while C-

fibers mediate slow pain (dull aching, which occurs later and lasts
longer.
CAUSES OF DENTAL PAIN

• Toothache is caused when the nerve to a tooth is irritated.

• Tooth infection, decay, injury or loss of a tooth are the most common causes
of dental pain

The pain may be arising from variety of different structures and may be
classified as
 pulpal pain
Periapical/periradicular pain
Non dental pain
PULPAL PAIN

• Most common cause of dental pain is ( pulpitis)

• May be subject to a wide variety of insults e.g. bacterial, thermal,
chemical, traumatic and the effects of which are cumulative and can
ultimately lead to inflammation in the pulp

• Dental pulp does not contain any proprioceptive nerve endings and
therefore the patient is unable to localize the affected tooth
REVERSIBLE PULPITIS

• The pain is usually sharp and may be difficult to locate

• The pain quickly subsides after removal of the stimulus.it is of short
duration
• Symptoms; fleeting sensitivity/ pain to hot, cold or sweet, sour or touch
with intermediate onset.

• Management- remove any caries present and restore or place a sedative

dressing or permanent restoration with suitable pulp protection
IRREVERSIBLE PULPITIS

• Symptoms; spontaneous dull, throbbing pain which may last several

minutes or hours, be worse at night and is often pulsatile in nature.
• Pain is exacerbated by hot and cold but in later stages cold may ease
symptoms
• Characteristic feature is that pain remains after the removal of the
stimulus and localization of pain may be difficult.
DENTINE HYPERSENSIVITY

• It is pain arising from exposed dentine in response to a thermal, tactile

or osmotic stimulus
• It is thought to be due to dentinal fluid movement stimulating pulpal
pain receptors. Warm, cold, sweet and mechanical stimuli cause an
increased flow of fluid through the open dentinal tubules in exposed
dentine.
• The fluid flow generates action potentials in A-fibers within the
peripheral pulp and inner dentine by opening ion channels in these
neurons which result in sharp, transient pain
Continuation

• The patient will complain of sensitivity to hot, cold and sweet food or
drink.
• Sensitivity rather than pain is poorly localized and it may indeed be
generalized in several areas of the mouth

• Pulp tests applied to the enamel surface will produce a normal

response but if the exposed dentine surface is stimulated thermally or
electrically or scratched with a probe
CRACKED TOOTH SYNDROME

• Symptoms-sharp pain on biting using the affected tooth but short

duration.
• Signs; tooth often has a large restoration. Crack may not be apparent at
first but transillumination and possibly removal of the restoration may
aid visualization.

• Pain can normally be elicited by getting a patient to bite then release

with affected tooth on a cotton wool roll
• May be associated with bruxing habit.
PERIAPICAL/ PERIRADICULAR PAIN

• Progression of irreversible pulpitis ultimately leads to death of the

pulp which is called pulp necrosis. At this stage patient may
experience relief from pain and thus may not seek attention.

• If neglected however, the bacteria and pulpal breakdown products

leave the root canal system via the apical foramen or lateral canals and
lead to inflammatory changes and possibly pain.
Continuation

• The patient can precisely identify the affected tooth as the periodontal
ligament which is well supplied with proprioceptive nerve endings is
inflamed.
Pupal necrosis with periapical periodontitis

Symptoms variable but patients generally describe a dull ache exacerbated by

biting on the tooth
periodontal pain is caused by a lesion involving the periodontium, the
periodontal ligament and the adjacent alveolar bone tissue.
As pulp inflammation progresses in the presence of apically advancing bacterial
occlusion, the inflammatory process finds its way into the periapical tissues
through apical and lateral foramina.

Pain observed is constant and aching in character, with exacerbation of pain on

biting due to compression of the periapical tissues
Acute periapical abscess

• Symptoms; severe pain which will disturb sleep. Tooth is exquisitely

tender to touch
• Signs; affected tooth is usually extruded, mobile. May be associated
with intro-oral and facial swelling or with a more localized intra-oral
swelling.

• Sensibility testing may be misleading as pus, may conduct stimulus to

apical tissues
Lateral periodontal abscess

Symptoms –similar to periapical abscess with acute pain and tenderness

and often an associated bad taste.

Signs – tooth is mobile with associated localized or diffuse swelling of

the adjacent periodontium. A deep periodontal pocket is usually
associated which will exude pus on probing.
NON-DENTAL PAIN

• When no signs of dental or periradicular pathology can be detected

then non-dental causes must be considered.

• Other causes that present as toothache include,

1. Temporomandibular pain.
2. 2. Sinus and paranasal pain.
3. Psychological disorders
4. Tumors (benign tumors of the mouth.
SINUS AND PARANASAL PAIN

• Sinusitis is a common cause of dull constant pain.

• The location of this pain can vary from the maxilla and maxillary teeth
in maxillary sinusitis to the upper orbit and frontal process in frontal
sinusitis
• Pain from sinus may be referred into the oral cavity, the teeth in
particular.
EAR PAIN

• Pain within the ear can be caused by a disease within the ear and
related structures.

• Pain may also be referred from the ear to other structures of the head
and neck including teeth, tonsils, tongue, trachea, temporomandibular
joint.
SALIVARY GLAND DISORDERS

• The salivary glands can be affected by many diseases, including

obstruction, infection, degeneration and tumor growth.

• In sjogren syndrome, parotits is also accompanied by diminished by

diminished salivation and some other connective tissue disorder such
as lupus erythematous; pain from these conditions will refer to the
teeth.
TEMPOROMANDIBULAR PAIN

• Trauma and stress appear to pre-dispose through increasing tension

affecting the masticatory muscles.
• Acute trauma can occasionally precede TMJ dysfunction, other facts
like prolonged and excessive mandibular opening, habits such as
chewing a pen, abnormal habits like night time tooth
grinding(bruxism)can also lead to it.