Figure 4.32 Periapical radiographs: (a) maxillary anterior; (b) mandibular anterior.
I. Diagnosis/Diagnoses
Other
- Traumatic occlusion tooth 11.
J. Case Assessment
- The working diagnosis in this case is traumatic occlusion, and the source of the patient’s pain is inflammation of the pulp and periapical tissues due to chronic occlusal trauma. The differential diagnosis for the pulp and periapical tissues includes reversible pulpitis, symptomatic irreversible pulpitis, and symptomatic apical periodontitis.
- The absence of any caries, restoration, crack, or known history of trauma to the tooth renders pathosis of endodontic origin an unlikely cause of the patient’s pain.
- In the absence of tooth pathology, the plan is to address the occlusion and monitor for resolution of symptoms, rather than perform root canal therapy.
- The diagnosis in this case was made based on the patient’s reported history of pain, the clinical and radiographic exam, and the diagnostic test results. The clinical exam and examination of the occlusion were critical in making the diagnosis.
K. Evidence-based Treatment Plan including Aims
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Treatment options for tooth 11 include (1) occlusal adjustment and monitor for resolution of symptoms, (2) root canal therapy, (3) extraction, and (4) do nothing.
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The treatment plan is to perform an occlusal adjustment on tooth 41, which occludes end to end with tooth 11. The aim is to remove the source of the pulpal and periapical inflammation, thereby eliminating the patient’s pain. The patient will be monitored for resolution of symptoms after the occlusal adjustment. If symptoms do not resolve, the patient will be reevaluated for the need for endodontic therapy or other treatment.
L. Prognosis and Discussion
- The prognosis is favorable. However, if the occlusal adjustment does not relieve the symptoms, then root canal therapy or other treatment may be indicated.
- In the case presented, occlusal adjustment was performed on tooth 41, which occluded end to end with tooth 11. The next day, the patient reported his symptoms had resolved. The tooth was not endodontically treated. Had root canal therapy been performed instead of the occlusal adjustment, it is likely that the treatment would have alleviated the patient’s sensitivity to cold, but not all of his symptoms, as the tooth would still have been in traumatic occlusion.
Background Information
- The American Academy of Periodontology (AAP, 2012) defines occlusal trauma as injury resulting in tissue changes within the attachment apparatus due to physiologic or parafunctional forces which may exceed its adaptive capacity. Primary occlusal trauma is injury resulting in tissue changes from excessive occlusal forces applied to a tooth or teeth with normal support. Secondary occlusal trauma is injury resulting in tissue changes from normal or excessive occlusal forces applied to a tooth or teeth with reduced support. Traumatic occlusion is occlusion that produces such trauma.
- The relationship between traumatic occlusion and dental pain symptoms is recognized by clinicians, but there is little available literature to describe this clinical phenomenon. The majority of what is known about pain due to traumatic occlusion is based on clinical observations and small case reports. There is no known published data on the incidence or prevalence of pain due to traumatic occlusion, and no known published controlled clinical studies on treatment. Thus, there is a great need for clinical research on pain due to traumatic occlusion.
- Painful symptoms associated with traumatic occlusion have been described as including temperature sensitivity, pressure sensitivity, and spontaneous pain. These symptoms reflect pulpal and periapical inflammation, and therefore may mimic pain of endodontic origin. However, endodontic therapy is not indicated in these cases, if the traumatic occlusion is addressed and symptoms resolve. Treatment of traumatic occlusion may include an occlusal splint and/or occlusal adjustment, in addition to other therapies. Root canal therapy is only indicated in cases where the dental pulp has become irreversibly inflamed or necrotic.
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