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.2–4 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 Malaise |
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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