Differential diagnosis of the pain in orofacial system. Pain of dental origin and nondental origine pain. - PowerPoint PPT Presentation

Loading...

PPT – Differential diagnosis of the pain in orofacial system. Pain of dental origin and nondental origine pain. PowerPoint presentation | free to download - id: 74a3d6-MzFlN



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Differential diagnosis of the pain in orofacial system. Pain of dental origin and nondental origine pain.

Description:

Differential diagnosis of the pain in orofacial system. Pain of dental origin and nondental origine pain. Symptoms of Acute Apical Abscess Spontaneous dull, throbbing ... – PowerPoint PPT presentation

Number of Views:63
Avg rating:3.0/5.0
Slides: 59
Provided by: toprec1
Learn more at: http://www.toprecommendedwebsites.com
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Differential diagnosis of the pain in orofacial system. Pain of dental origin and nondental origine pain.


1
Differential diagnosis of the pain in orofacial
system.Pain of dental origin and nondental
origine pain.
2
Orofacial pain
  • Orofacial pain is the pain in the area of face
    and its adjacent structures.
  • The pain is expressing itself in various clinical
    syndroms which are arising by the influence of
    various mechanisms and they involve
    multidiscilpinary approach to diagnostics and the
    treatment itself.

3
  • Dental pain may be classified as follows
  • Pulpal pain
  • Periapical/periradicular pain
  • Non-dental pain
  • Dental pain can be very difficult to diagnose.
  • Pulpal pain
  • The pulp may be subject to a wide variety of
  • insult, (bacterial, thermal, chemical, traumatic)
  • the effects of which are cumulative and can
  • ultimately lead to inflamation in the pulp
    (pulpitis)
  • and pain.

4
  • A characteristic of pulpal pain as that the
    patient is unable to localize the affected tooth.
  • The ability of the pulp to recover from injury
    depends upon its blood supply, not the nerve
    supply, which must be borne in brain when
    vitality (sensibility) testing is carried out
  • Although numerous classifications of pulpal
    disease exist, only limited number of clinical
    diagnostic situations require identification
    before affective treatment can be given.

5
1. Dental pain
Expressive pain Non-expressive pain
Dentine hypersensitivity Chronic Pulpitis
Pulpitis Neuritis from inclusion teeth
Periodontitis Dental rip
Chronic apical Periodontitis
Dentitio difficilis
Retentio dentis
Synalgia
Sekundárne neuralgie
6
2. Non-dental pain, located near the teeth
Expressive pain Non-expressive pain
Affection near the tooth and its neighbours Pregnancy
Affection of a distant bodies aerodontalgia
Primary neuralgia
Systemic diseases
7
PULPAL DISEASE
  • Classified as
  • Reversible pulpitis
  • Irreversible pulpitis
  • Necrotic pulp

8
Reversible Pulpitis
  • Condition should return to normal with removal of
    the cause.
  • Common causes
  • Caries, recent restorative procedures, faulty
    restorations, trauma, exposed dentinal tubules,
    periodontal scaling.
  • Pulpal recovery will occur if reparative cells in
    the pulp are adequate.

9
Symptoms of Reversible Pulpitis
  • Thermal
  • Hypersensitive with mild pain less than lt30
    seconds, but similar to control tooth
  • Sweets
  • Sensitive (if caries, crack, or exposed dentin)
    with mild pain less thanlt30 seconds (similar to
    control tooth)
  • Biting Pressure
  • None (unless tooth is cracked)

10
DiagnosisReversible Pulpitis
  • If there is a discrepancy between the patients
    main complaint, symptoms, and clinical
    examination obtain more information or data
    interpretation.
  • Remember both a preoperative pulpal and
    periapical diagnosis are made before treatment is
    initiated (if reversible pulpitis is only
    condition, the periapical area should be normal).
  • If the tooth is percussion sensitive consider
    bruxism or hyperocclusion.

11
Treatment of Reversible Pulpitis
  • Remove irritant if present (caries fracture
    exposed dentinal tubules).
  • If no pulp exposure CaOH, restore, monitor
  • If pulp exposure
  • Carious initiate RCT
  • Mechanical gt1 mm initiate RCT
  • lt1 mm crown planned
    initiate RCT
  • lt1 mm direct cap or RCT
  • If recent operative or trauma postpone
    additional treatment and monitor.

12
Irreversible Pulpitis
  • Pulpal inflamation and degeneration not expected
    to improve.
  • A physiologically older pulp has less ability to
    recover due to decrease in vascularity and
    reparative cells.
  • As inflammation spreads apically, cellular
    organization begins to break down.
  • Localized pressure slows venous return, resulting
    in buildup of toxins and lower pH that causes
    widespread cellular destruction.

13
Symptoms of Irreversible Pulpitis
  • Thermal
  • Hypersensitive with moderate to severe prolonged
    pain (gt30 seconds) as compared to the control
  • Sweets
  • Moderately to severely sensitive (if caries,
    crack, or exposed dentin)
  • Biting Pressure
  • Usually sensitive in later stages (periapical
    symptom)
  • Moderate to severe spontaneous pain

14
DiagnosisIrreversible Pulpitis
  • Hypersensitive to hot or cold that is prolonged.
  • A history of spontaneous pain.
  • Vital or partially vital pulp.

15
Treatment of Irreversible Pulpitis
  • Minimum immediate treatment (if not extraction)
  • Pulpotomy
  • Remove all decay (essential)
  • Large canals passively broach 75 of tooth
    length
  • Small canals spoon excavate orifice while
    removing pulpal tissue from chamber.
  • Copious irrigation with sodium hypochlorite (1).
  • Dry chamber with cotton pledget
  • Place Ca(OH)² into large and over small canals
  • Place dry cotton pellet in chamber, cover with
    cavit, temporarily restore with Ketac-fill
    completely relieve occlusion if have acute apical
    peridontitis

16
Treatment of Irreversible Pulpitis
  • Ideal immediate treatment
  • Pulpectomy (complete removal of pulpal tissue)
  • Determine the ideal working length (WL)
  • Fully instrument canals with master apical file
  • At least 25 file for small canals (and anterior
    teeth)
  • 35 - 40 file for larger canals
  • Alternate working files with 8 or 10 patency
    file
  • Copious irrigation with sodium hypochlorite (1)
  • Dry chamber with cotton pledget
  • Place dry cotton pellet over canals, cover with
    cavit, temporarily restore with Ketac-fill
    completely relieve occlusion if have acute
    periapical peridontitis.

17
Irreversible Pulpitis(more treatment
considerations)
  • Any residual decay can result in an inadequate
    seal, contamination of canal space, and
    inter-appointment flare-ups.
  • Inflammation can be judged by the amount of
    hemorrhage from the remaining pulp stump. If
    bleeding continues, re-broach or file for
    residual pulpal tags with copious irrigation.
  • To decrease risk of instrument separation within
    the canal space, do not engage the canal walls
    with broach.

18
Irreversible Pulpitis(additional considerations)
  • Do not leave teeth open between appointments
    causes contamination of the canals and difficulty
    closing them later.
  • Incomplete tooth fractures involving the pulp
    will show symptoms of irreversible pulpitis.
    Periodontal probing of associated pocket will
    indicate depth of fracture. If depth of pocket
    (fracture) extends below the attachment level,
    the prognosis is guarded to poor.

19
Necrotic Pulp
  • Results from continued degeneration of an acutely
    inflamed pulp.
  • Involves a progressed breakdown of cellular
    organization and no reparative potential.
  • Commonly have apical radiolucent lesion. (always
    conduct proper pulp testing to rule out a
    non-pulpal origin).
  • With multi-rooted teeth, one root may contain
    partially vital pulp, whereas other roots may be
    nonvital (necrotic).

20
Maxillary first molar with large amalgam
restoration and periapical radiolucencies around
all three roots. The tooth was unresponsive to
electrical and thermal testing.
21
Symptoms of Necrotic Pulp
  • Thermal
  • No response
  • Sweets
  • No response
  • Biting Pressure
  • Usually moderate to severe pain (not symptom of
    necrotic pulp, but rather periapical
    inflammation)
  • Moderate to severe spontaneous pain (usually dull
    and throbbing associated with periapical area)

22
Diagnosis of Necrotic Pulp
  • Distinguishing features
  • No response to cold.
  • No response to pulpal test.
  • Caveats
  • Decreased sensitivity to cold/ept may be from of
    insulating effects of additional dentin.
  • Fluid in canal space conducting electrical
    current can give false-positive.
  • Periapical radiolucency is strong but not
    conclusive evidence that pulp is necrotic.

23
Treatment of Necrotic Pulp
  • Minimum immediate treatment (if not extraction)
  • Partial instrumentation of canals
  • Remove all decay, evaluate restorability
  • Determine working length of all canals
  • Large canals up to 40 file, 4mm short of WL
  • Small canals up to 25 file, 4mm short of WL
  • Alternate working file with 8 or 10 patency file
  • Copious irrigation with sodium hypochlorite (1)
  • Dry chamber with cotton pledget
  • Place Ca(OH)² into all canals
  • Place dry cotton pellet in chamber, cover with
    cavit, temporarily restore with Ketac-fill
    completely relieve occlusion if have acute apical
    periodontitis.

24
Treatment of Necrotic Pulp
  • Ideal immediate treatment
  • Complete instrumentation of canals
  • Determine the ideal working length
  • Fully instrument canals with master apical file
  • At least 25 file for small canals (and anterior
    teeth)
  • 35 - 40 file for larger canals
  • Alternate with 8 or 10 patency file
  • Copious irrigation with sodium hypochlorite (1)
  • Place dry cotton pellet over canals, cover with
    cavit, temporarily restore with Ketac-fill
    completely relieve occlusion if have acute apical
    periodontitis.

25
Necrotic Pulp(additional considerations)
  • Antibiotic coverage
  • Usually not required unless patient has
    progressive swelling or fever.
  • Pain Management
  • Always determine allergy, contraindication, and
    interaction with present medications
  • Clock regulate NSAID (ibuprofen) for 3 days
  • Narcotic for approximately 3 days, if needed
  • Occlusal Reduction
  • Reduction in all cases with acute apical
    periodontitis (remember that length measurements
    may change)

26
PERIAPICAL DISEASE
  • Classified as
  • Acute Apical Periodonitis
  • Acute Apical Abscess
  • Chronic Apical Periodontitis
  • (Suppurative Apical Periodontitis with sinus
    tract)
  • Condensing Osteitis

27
Treatment of Periapical Disease
  • Pulpal status
  • always dictates treatment
  • of periapical disease

28
Acute Apical Periodontitis
  • Mild to severe inflammation that surrounds or is
    closely associated with the apex of a tooth.
  • Results from
  • Irreversible inflammation or necrotic pulp.
  • Trauma or bruxism of normal or reversibly
    inflamed pulpitic conditions.
  • Consider vertical fractures, periodontal abscess,
    and non-odontogenic pain.

29
Clinical Findings inAcute Apical Periodontitis
  • Visual
  • Check for decay, fracture lines, swelling, sinus
    tracts, orientation of tooth, and hyperocclusion
  • Palpation
  • Sensitive (usually on buccal surface)
  • Percussion
  • Moderate to severe (initially use index finger to
    reduce patient discomfort)
  • Mobility
  • Slight to no mobility (if moderate mobility
    exists, check for possible periodontal condition
    before continuing)

30
Acute Apical Periodontitis, cont.
  • Perio Probing
  • WNL (unless concomitant periodontal disease or
    vertical fracture exists)
  • Thermal (pulpal symptom)
  • Response (not prolonged) consider traumatic
    occlussion
  • If response prolonged consider irreversible
    pulpitis
  • No response consider necrotic pulp
  • EPT (pulpal test)
  • Response pulp is vital (reversible or
    irreversible)
  • No response pulp is necrotic

31
Acute Apical Periodontitis, cont.
  • Translumination
  • Not used unless fractured is suspected
  • Selective Anesthesia
  • Not necessary, offending tooth easily located
  • Test cavity
  • Not necessary
  • Radiographic
  • Periapical image does not show a radiolucent
    lesion some thickening of the periodontal
    ligament is common

32
Immediate Treatment ofAcute Periapical
Periodontitis
  • If from irreversible pulpitis
  • Pulpotomy or extraction.
  • If from necrotic pulp
  • Root canal therapy initiated or extraction.
  • If from hyperocclusion
  • When the pulp is normal or reversibly inflamed,
    adjusting the occlusion provides immediate
    relief. Always consider cracked tooth,
    irreversible pulpitis, or necrotic pulp if
    discomfort persists.
  • If from bruxism
  • A biteguard may be indicated.

33
Acute Apical Abscess
  • Acute inflammation of the periapical tissue
    characterized by localized accumulation of pus at
    the apex of a tooth.
  • A painful condition that results from an advanced
    necrotic pulp.
  • Patients usually relate previous painful episode
    from irreversible or necrotic pulp.
  • Swelling, tooth mobility, and fever are seen in
    advanced cases.

34
Symptoms of Acute Apical Abscess
  • Spontaneous dull, throbbing, persistent pain
    exacerbated by lying down.
  • Percussion
  • Extremely sensitive
  • Mobility
  • Horizontal / vertical often in hyperocclusion
  • Palpation
  • Sensitive vestibular or facial swelling likely
  • Thermal
  • No response

35
Clinical Findings ofAcute Apical Abscess
  • Visual
  • Check for decay, fracture lines, swelling, sinus
    tracts, orientation of tooth, hyperocclusion
  • Palpation
  • sensitive intraoral or extraoral swelling
    present
  • Percussion
  • Moderate to severe (initially use index finger)
  • Mobility
  • Slight to none may be compressible
  • Perio probing
  • WNL (unless have perio disease or vertical
    fracture)

36
Acute Apical Abscess, cont.
  • Thermal
  • No response (pulp is necrotic)
  • EPT
  • No response (false-positive from fluid in canal)
  • Translumination
  • Not used unless fractured is suspected
  • Selective Anesthesia
  • Not necessary, offending tooth easily located
  • Test cavity
  • Not necessary unless vitality is suspected

37
Acute Apical Abscess, cont.
  • Radiographic
  • Thickening of the periodontal ligament is common
    may not show a frank lesion
  • If tests indicate pulp vitality (red flag!)
  • Review diagnostic information (repeat diagnostic
    tests)
  • Rule out lateral periodontal abscess
  • Review medical history for previous malignant
    lesions or other conditions (hyperparathyroidism)
    that may explain contradictory information
  • Do not begin treatment until this discrepancy has
    been resolved

38
Treatment of Acute Apical Abscess (necrotic pulp)
  • Minimum immediate treatment (if not extraction)
  • Partial instrumentation of canals
  • Remove all decay, evaluate restorability
  • Determine working length of all canals
  • Achieve apical patency all canals with 10 file,
    look for drainage and allow to continue until it
    stops
  • Large canals up to 40 file, 4mm short of WL
  • Smaller canals up to 25 file, 4mm short of WL
  • Alternate with 8 or 10 patency file
  • Copious irrigation with sodium hypochlorite (1)
  • Dry chamber with cotton pledget
  • continued on next slide

39
Treatment of Acute Apical Abscess, cont.
  • Place Ca(OH)² into all canals
  • Place dry cotton pellet in chamber, cover with
    cavit, temporarily restore with Ketac-fill, and
    completely relieve tooth from occlusion.
  • Incision and drainage may be required
  • Prescribe antibiotics and analgesics
  • Continued pain and swelling are common
    postoperative problems so prepare the patient
    for several days of discomfort.

40
Chronic Apical Periodontitis
  • Results from prolonged inflammation that has
    eroded the cortical plate making a periapical
    lesion visible on the radiograph.
  • Caused by a necrotic pulp, the lesion contains
    granulation tissue consisting of fibroblasts and
    collagen (with macrophages and lymphocytes).
  • Must rule out central giant cell granuloma,
    traumatic bone cyst, and cemental dysplasia.
  • Usually asymptomatic, but in acute phase may
    cause a dull, throbbing pain.

41
Chronic apical periodontitis. Extensive tissue
destruction in the periapical region of a
mandibular first molar occurred as a result of
pulpal necrosis. Lack of symptoms together with
presence of a radiographic lesion is diagnostic.
42
Chronic Apical Periodontitis, cont.
  • Most common pitfall is assuming that the presence
    of a periapical lesion automatically indicates a
    necrotic pulp.
  • If tests indicate pulp vitality (red flag!)
  • Review diagnostic information (repeat diagnostic
    tests)
  • Rule out lateral periodontal abscess, central
    giant cell granuloma, traumatic bone cyst, and
    cemental dysplasia.
  • Review medical history for previous malignant
    lesions or other conditions (hyperparathyroidism)
    that may explain contradictory information
  • Do not begin treatment until this discrepancy has
    been resolved

43
Treatment of Chronic Apical Periodontitis
(necrotic pulp)
  • If asymptomatic, no immediate treatment needed
    schedule for root canal therapy
  • If in acute suppurative phase, immediate
    treatment same as with acute apical abscess,
    i.e.,
  • Partial instrumentation of canals
  • Remove all decay, evaluate restorability
  • Determine working lengths of all canals
  • Achieve apical patency all canals with 10 file,
    look for drainage and allow to continue until it
    stops
  • Large canals up to 35 file, 4mm short of WL
  • Smaller canals up to 25 file, 4mm short of WL
  • Alternate with 8 or 10 patency file

44
Treatment of Chronic Apical Periodontitis, cont.
  • Copious irrigation with sodium hypochlorite (1)
  • Dry chamber with cotton pledget
  • Place Ca(OH)² into all canals
  • Place dry cotton pellet in chamber, cover with
    cavit, temporarily restore with Ketac-fill, and
    completely relieve tooth from occlusion.
  • Incision and drainage may be required
  • Prescribe antibiotics and analgesics
  • Continued pain and swelling are common
    postoperative problems so prepare the patient
    for several days of discomfort.

45
Condensing Osteitis
  • Increased trabecular bone in response to
    persistent irritant diffusing from the root canal
    into the periradicular tissue.
  • May be either asymptomatic (pulpal necrosis) or
    associated with pain (pulpitis).
  • Therefore, may or may not respond to diagnostic
    tests, i.e., thermal, electric, palpation,
    percussion.
  • Root canal treatment, when indicated, may result
    in complete resolution.

46
Inflammation followed by necrosis in the pulp of
the first molar has resulted in the diffuse
radiopacity of the periradicular tissue.
47
Reversible pulpitis Symptoms Fleeting
sensitivity/pain to hot, cold or
sweet with inmmediate onset.Pain is usually
sharp and may
be difficult to locate. Quickly
subsides after removal of the stimulus.
Signs Exaggerated response to pulp
testing. Carious cavity/leaking
restoration Ireversible pulpitis Symptoms
Spontaneous pain which may last several
hours, be worse at night, and is often
pulsatile in nature. Pain is
elicited by hot and cold at
first, but in later stages heat is
more significant and cold may
actually ease symptoms.
48
  • A characteristic feature is that the pain remains
    after the removal of the stimulus. Localization
    of pain may be difficult intially, but as the
    inflammation spreads to the periapical tissues
    the tooth will become more sensitive to pressure.
  • Signs Application of heat elicits pain.
  • Dentine hypersensitivity
  • This 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.

49
  • Cracked tooth syndrome
  • Symptoms Sharp pain on biting-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.
    Positive response to vitality (sensibility)
    testing and pain can normally be alicited by
    getting the patient to bite with the affected
    tooth on a cotton-wol roll or tooth sleuth. May
    be associated with bruxing habit.

50
  • Periapical/periradicular pain
  • Progression of irreversible pulpitis ultimately
    leads to
  • death of the pulp (pulpal necrosis). At this
    stage the
  • patient may experience relief from pain and thus
    may not
  • seek attention.
  • Characteristically the patient can precisely
    identify the
  • affected tooth, as the periodontal ligament,
    which is well
  • supplied with proprioreceptive nerve endings, is
    inflamed.
  • Pulpal necrosis with periapical periodontitis
  • SymptomsVariable, but patients generally
    describe a dull
  • ache exacerbated by biting on the tooth.

51
  • Signs usually no response to vitality testing,
    unless one
  • canal of a multirooted tooth is still
    vital.
  • Rtg Periapical lession- granuloma, cyst
  • Acute periapical abscess
  • Symptoms Severe pain which will disturb sleep.
    Tooth is
  • exquisitely tender to touch.
  • Sings Affected tooth is usually extruded,
    mobile. May be
  • associated with a localized or diffuse swelling.
    Vitality
  • testing may be misleading as pus may conduct
    stimulus to
  • apical tissues.

52
  • Chronic periapical abscess
  • Often symptomless. Possibly associated with
    persistent
  • sinus. Presentation may be coincidental or acute
  • exacerbation.
  • Lateral periodontal abscess
  • Symptoms similar to periapical abscess with
    acute pain
  • and tenderness, and often an
    associated bad taste.
  • Sings Tooth is usually mobile, with associated
    localized
  • or diffuse swelling of the adjacent
    periodontium.
  • A deep periodontal pocket is usually
    associated,
  • which will exude pus on probing.
  • RTG vertical or horizontal bone loss,(vitality
    testing ) is
  • usually positive, unless there is an
    associated perio-
  • endo lesion.

53
  • Non-dental pain
  • When no signs of dental or periradicular
    pathology can be detected then non-dental causes
    must be considered. Other causes of pain that can
    present as toothache include
  • temporomandibular
    pain-dysfunction/facial arthromyalgia
  • sinusitis
  • psychological disorders
    (atypicalodontalgia)
  • tumours

54
  • Temporomandibular pain dysfunction/facial
    arthromyalgia
  • The prblem being addressed is pain in the
    preauricular area and muscles of mastication with
    trismus, with or without evidence of internal
    derangement of the meniscus.
  • Clinical features pain, clicking, locking,
    crepitus and trismus are the clasical signs and
    symptoms. Some patients may be clinically
    depressed but most are not. Pain is elicited by
    palpation over the muscles of mastication or the
    preauricular region.

55
Sinusitis
  • Antral pathology often mimics symptoms
    attributable to maxillary teeth. Diagnosis is by
    exclusion of dental pathology, nasal discharge or
    stiffiness, tenderness over the cheeks, and pain
    worse on moving the head.
  • X-rays may reveal antral opacity, fluid level or
    fractures. Other X-rays DPT (dental panoramic
    tomogram) for cysts, and roots and CT scans for
    tumours, pansinusitis, and blowout fractures.

56
  • Facial pain pain not directly related to the
    teeth and jaws.
  • Trigeminal neuralgia-it is present as a shooking
    electric shock type of pain of rapid onset and
    short duration, which is often stimulated by
    touching a trigger point in the distribution of
    the trigeminal nerve. In the early stages of the
    disease there may be a period of prodromal pain
    not conforming to the classical description and
    it may be difficult to arrive at a diagnosis.
    Patients often have multiple extractions in a
    attempt to relieve the symptoms.

57
  • Atypical facial pain
  • This constitutes a large proportion of patients
    presenting with facial pain.
  • Classicaly, their symptoms are unrelated to
    anatomical
  • distribution of nerves or any known pathological
  • process, and these patients have often been
    through
  • a number of specialist disciplines in an attempt
    to
  • establish a diagnosis and gain relief. This
    diagnosis
  • tends to be used as a catch-all for a large group
    of
  • patients, with the connecting underlying
    supposition
  • that the pain is of psychogenic origin.

58
  • Pointers to a psychogenic etiology include
    imprecise localization, often bilateral pain or
    all over the place. Pain is described as being
    continuous for long periods with no change, and
    none of the usual relieving or exacerbating
    factors apply.
  • Most analgesics are said to be unhelpful.
  • Oral dysaesthesia or burning mouth syndrome is an
    unpleasant abnormal sensation affecting the oral
    mucosa in the absence of clinically evident
    disease. Five times more common in women aged
    40-50 years than other groups. Related to
    atypical facial pain.
About PowerShow.com