20. Management of Dental Pain


Management of Dental Pain

G. Rex Holland

Some of the most common pain conditions are associated with the teeth. This chapter outlines the signs and symptoms of conditions expressing pain in the teeth as well as outlines principles and approaches to be used in their diagnosis and management.

Diagnostic Considerations

The successful treatment of dental pain begins with a sound diagnosis. The most common cause of pain from the mouth is inflammatory disease of the dental pulp or periodontal tissues. Diagnosis, however, may pose a challenge to the practitioner since pain may have an obscure cause or originate by referral from a distant location. Referred pain results from the convergence of input from a site of tissue damage and from another site (where there is no tissue damage) on the same central neurons in which central sensitization may be present (see chapter 5). Pain may be referred to one tooth from another or from a nondental or even extraoral site. The true origin is always on the same side as the site of referral.1 Other sites from which pain may be referred to the teeth include the muscles of mastication, the ear, the sinuses, and the heart.24 Thirty-seven percent of patients with myofascial pain of the jaw muscles include pain from teeth as one of their symptoms. The management of referred pain lies in its recognition and in identification of the true cause of pain. Treating the target to which pain is referred will be ineffective.

While most pain of dental origin results from inflammatory changes, inflammation of the dental pulp and the periapical tissues is not always painful. The physiologic basis of this is unknown, although the presence of morphine receptors on pulpal nerves and the presence of opioids in the pulp, especially during inflammation, suggest that there may be local antinociceptive mechanisms5 (see chapters 6 and 8). Many inflammatory periapical lesions following necrosis of the pulp are detected by chance on radiographs with no prior history of pain.

Relieving toothache with predictable success involves removal of the cause rather than merely addressing the symptoms. When the pain is of dental origin, the tooth (or teeth) involved must be accurately identified. Problems with localization due to referral can lead to a healthy tooth being extracted or root filled.

Table 20-1 outlines signs and symptoms that assist in the differential diagnosis of the several clinical conditions considered in this chapter.

Table 20-1 Dental pain diagnosis and management
Symptoms Signs Radiography Pulp tests
Short discomfort to therma stimulus Exposed dentin Normal Normal
Stronger, longer pain to thermal stimulus Caries
Deficient restoration
Caries or poor margins Normal
Strong and lingering pain to cold stimulus, perhaps spontaneous Caries
Deficient restoration
Caries Lingering pain to thermal tests
Hot tooth syndrome; spontaneously very painful, tender tooth Anesthesia difficulty Caries Lingering pain to thermal tests
Pain on biting loose tooth Mesiodistal vertical fracture Radiolucency, often J-shaped Normal
Pain on biting No obvious fracture
Buccolingual crack detected by transillumination
Normal Normal
Pain on biting ”High” restoration (recent endodontic treatment) Normal Normal
Tender buccal swelling Tense, tender buccal swelling Periapical radiolucency Negative
Mildly tender buccal swelling Bad taste Pus discharged on pressing
No periodontal pocketing
Periapical radiolucency Negative
Mildly tender buccal swelling Periodontal pocketing
Pus discharge from pocket
Periapical radiolucency Often vital
Face/neck swollen Tender lymph nodes
Elevated body temperature
Periapical radiolucency Negative
Soreness/swelling around erupting tooth Partially erupted tooth Partially erupted tooth Normal
Pain and localized swelling in molar region Recent extraction Extraction socket No tooth
Table 20-1 (cont)
Periapical test (percussion) Diagnosis Emergency treatment Definitive treatment

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Jan 8, 2015 | Posted by in Occlusion | Comments Off on 20. Management of Dental Pain
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