Seminar on

ODONTOGENIC
PAIN

ADITI CHANDRA
DEPARTMENT OF
CONSERVATIVE DENTISTRY
AND ENDODONTICS
MDS-12

CONTENTS
Introduction
Definition
History
Changing concepts
Dual nature of pain
Structures involved in pain
Mechanism of pain pathway
Physiology of pain perception
Levels of pain perception
Theories of pain
Pain assessment tools
Classification of pain
Odontogenic pain
Pulpal diseases
Reversible pulpitis
Irreversible pulpitis
Necrotic pulp
Hot tooth
Cracked tooth
Dentinal hypersensitivity

 Barodontalgia
Periapical diseases
Acute apical periodontitis
Chronic apical periodontitis
Acute apical abscess
Phoenix abscess
Post endodontic surgery pain
Pericoronitis
Maxillary sinusitis mimicking tooth pain
Phantom pain
Referred pain
Management
Conclusion

PAIN
Greek word - Poin- meaning penalty
Latin word - Poena- meaning punishment from God
The International Association for the Study of : Pain is "an unpleasant sensory
and emotional experience associated with actual or potential tissue damage, or
described in terms of such damage"
Monheim : An unpleasant emotional experience usually initiated by noxious
stimulus and transmitted over a specialized neural network to the CNS where it is
interpreted as such.

HISTORY :
Homer thought pain was due to arrows shot by God.
Aristotle, who probably was the first to distinguish five physical senses considered
pain to the passion of the soul that somehow resulted from the intensification of
other sensory experience.
Plato, contented pain and pleasure arose from within the body, an idea that
perhaps gave birth to the concept that pain is an emotional experience more than a
localized body disturbance.
The Bible makes reference to pain not only in relationship to injury and illness but
also an anguish of the soul.

CHANGING CONCEPTS
Increased knowledge of anatomy and physiology, it became possible to
differentiate pain resulting from physical and emotional cause. During the 19th
century, the developing knowledge of neurology fostered the concept that pain was
mediated by specific pain pathways and was not simply a result of excessive
stimulation of special senses.

REVISED CONCEPT OF PAIN

Proposed by Subcommittee of Taxonomy of the International Association for the
Study of Pain. It represent pain as subjective psychological state.

DUAL NATURE OF PAIN

Pain perception:
Physioanatomical process, Similar to all healthy individuals, Nociceptive input
reaches brain.
Pain reaction:
Psychophysiological process, Varies markedly among individual.

STRUCTURES INVOLVED IN PAIN TRANSMISSION

Somatic
structure

Neural
structure

Deep

Visceral :
Pulp, Blood
vessels,
Glands,
Visceral
Musculoskelet
mucosa
al :
Joints, PDL,
Muscles,
Bones

Superficial

Skin, Mucosa,
Gingiva

Somatic

NEURAL STRUCTURES :

Central Nervous System

Processing of pain information
Brain & spinal chord.
Autonomic Nervous System
Innervation of all tissue other than skeletal.
It can be divided into sympathetic &
parasympathetic.

Peripheral Nervous System

- Primary Afferent Neuron
- A Beta , A Delta , C fibers
- Transduction and Transmission.

DENTAL PULP
A-delta fibers
: Myelinated fibers.
: Conduction speed high .

: Impulses interpreted as sharp and pricking pain.

: Associated with dentinal pain.
: Located at the periphery of the nerve trunk.

C fibers
: Unmyelinated fibers.
: Conduction speed low.
: Impulses interpreted as throbbing and aching pain.
: Present in the centre of nerve trunk.

LEVELS OF PAIN PROCESSING :

Nocicepti
on

Pain

Suffering

Pain
behavior

THEORIES OF PAIN
SPECIFICITY THEORY: (VON FREY, 1894)
Pain is stimulation of specific nociceptors and perceived by specific nociceptors in
the brain. Poorly accepted, because it is known that free nerve endings transmit
pain, touch and pressure.
Pattern theory (Goldscheider in 1894)

Proposes that pain perception is based on STIMULUS INTENSITY CENTRAL

SUMMATION . Pain signal can be generated by stimulation of any
sensory receptor, provided the stimulation is intense enough. The
pattern of stimulation, not the receptor type, determines whether
nociception occurs.
Gate Control Theory (Melzack and Wall in 1965)
It proposes a dorsal spinal gating mechanism in the substantia gelatinosa that
modulates sensory input by the balance of activity of small diameter (C) and large
diameter(A-beta) fibers. Activity of large fibers closes the gate and prevents
synaptic transmission to centrally projecting T-cells, while small diameter fibers
open the gate and facilitate T-cells activity once a critical level is reached.

PAIN ASSESSMENT TOOLS

Subjective reports
Visual Analogue Scale
Faces Pain Scale
McGill Pain questionnaire
Subjective Reports
o Pain is a subjective experience that is communicated to us only through
words.
o
o

Measuring pain intensity is extremely difficult.

Specific words the patient uses to describe pain may provide valuable clues
in determining the pain category (eg. Dull, throbbing, sharp, shooting etc.)

Face Pain Rating Scale(Bieri et al 1990;Wong and Baker 2001)

MACGILL PAIN QUESTIONARE

Developed by Melzack (1975)
The questionnaire is designed to evaluate sensory(groups 1-10), affective(groups
11-15) and evaluative (group 16-20) dimensions of pain.

CLASSIFICATION OF TOOTHACHES OF ODONTOGENIC

ORIGIN

OROFACIA
L
PAIN

ODONTOGENIC

NONODONTOGENIC

Periapical disease
Pulpal disease
~Reversible pulpitis
~Irreversible pulpitis
~Necrotic pulp

PULPAL PAIN :

~Acute apical
periodontitis
~Acute apical abscess
~Chronic apical
periodontitis

Heterotopic pain
~Projected pain
~Referred pain

 Dentinal hypersensitivity
Barodontalgia
Traumatic occlusion
Incomplete fracture

PULPAL DISEASES
1. Reversible Pulpitis:
Symptoms of Reversible Pulpitis:
Thermal:
Hypersensitivity with mild pain of <30 seconds
Sweets:
Sensitive (if caries, crack, or exposed dentin) with mild pain of <30
seconds
Biting Pressure:
None (unless tooth is cracked)
Reversible Pulpitis
Radiograph
Normal Periapex

2.Irreversible Pulpitis:
Symptoms of Irreversible Pulpitis:
Pain : severe, spontaneous, sharp, piercing, shooting, intermittent or
continuous.
Exacerbated by change of position and may be referred to other locations.
Thermal:
Hypersensitive with moderate to severe prolonged pain
Sweets:
Moderately to severely sensitive
Biting Pressure:
Usually sensitive in later stages.
Radiograph
Normal or thickened periodontal ligament

3. Necrotic Pulp :
Symptomatic (severe pain, lasting
few minutes to hours, followed by
complete, sudden cessation) or
Asymptomatic.

No response:
Thermal test
Electrical test- minimum response
in case of moisture in root canal or
few apical nerve fibers survive

Radiograph:
Normal or thickened periodontal
ligament, or radiolucent lesions

4. Chronic hyerplastic pulpitis (pulp polyp) :

Cause

Slow,
progressive
carious exposure
of young pulp

Symptoms
Symptomless,
except during
mastication,
pressure of the
food bolus cause
discomfort

Diagnosis
Fleshy, reddish
pulpal mass fills
most of the pulp
chamber

5. Hot Tooth :
The term HOT tooth generally refers to a pulp that has been diagnosed with
irreversible pulpitis, with spontaneous, moderate-to-severe pain.
Classic example : Patient is sitting in the waiting room, sipping on a large glass of
ice water to help control the pain.
A challenge for dentist:
Local acidic inflammatory by products lower the pH, so most anaesthetic
molecules remain in inactive cationic form.
Local prostaglandins and bradykinin can antagonize local anaesthetics.
Sodium channel expression on C fibres shifts from TTX sensitive to TTX resistant.
TTX resistant channels are five times more resistant to anaesthetic (lidocaine).
Management
Bupivacaine found to be more potent.
Alternate and supplementary injection sites: intraosseous, intraligamentry.
Cohen and others found that a supplemental periodontal ligamental injection with
2% lidocaine was 74% successful in achieving pain control in patients with
irreversible pulpitis.
6.Cracked Tooth syndrome :
1. Craze Lines- No symptoms
2. Fractured Cusp Mild pain and generally symptomatic to biting and cold
Cracked tooth- Acute pain on biting and occasional sharp pain to cold.
Split tooth - Marked pain on chewing.
Vertical root fracture - Vague pain and
Mimics periodontal disease.

Diagnosis - History, visual & tactile examination, radiographs, dye, bite test,
transillumination, magnifying mirrors, loupes, microscope etc.
Cracked Tooth syndrome- CASE REPORT
A 42-year-old man came with the chief complaint Sometimes it hurts on the
upper left side when I chew.
Clinical examination revealed normal findings with no restorations in his posterior
maxillary or mandibular quadrants, no pain on percussion or palpation, no
periodontal pockets, EPT revealed presence of vital pulp.
Radiographic examination revealed no pathology.
Transillumination of the patients teeth revealed a distinct crack on distolingual
cusp of left mandibular second molar. The patient experienced a sharp, intense pain
response when the disto lingual cusp of tooth was bite tested.
Hence, it was diagnosed that the CRACK IN TOOTH was referring pain to the
maxillary arch.
7. Dentinal hypersensitivity:
Dentin hypersensitivity is characterized by short, sharp pain arising from exposed
dentin in response to stimuli typically thermal, evaporative, tactile, osmotic or
chemical and which cannot be described to any other form of dental defect or
pathology.
Causes: Exposure of dentine by attrition, caries etc.
Clinical Features : Pain response to chemical, thermal, tactile, or osmotic stimuli.
8.BARODONTALGIA :
Oral pain caused by the changes in the pressure due to altitude changes either
on deep sea diving or inflight conditions. In the diving environment, this pain
is commonly called tooth squeeze and the previous name aerodontalgia
was used regarding its feature inflight.

PERIAPICAL DISEASE :
1. Acute Apical Periodontitis:
Diagnosis
Palpation and Percussion: Sensitive
Mobility: Slight to no mobility
Thermal: Response: consider traumatic occlussion ,irreversible pulpitis.
No response : consider necrotic pulp
EPT: Response : Pulp is vital (reversible or irreversible)
No response : Pulp is necrotic
Radiographic: Thickening of the periodontal ligament
2.Acute Apical Abscess
DIAGNOSIS :

Percussion:
Extremely
sensitive

Mobility:
Horizontal /
vertical; often in
hyperocclusion

Palpation:
Sensitive;
vestibular or
facial swelling
likely

Thermal:
No response

EPT:
No response
(false-positive
from fluid in
canal)

Selective
Anesthesia:
Not necessary,
offending tooth
easily located

Transilluminati
on:
Not used unless
fractured is
suspected

Test cavity:
Not necessary
unless vitality is
suspected

3.Chronic Apical Periodontitis:

Caused by death
of pulp followed
continuous, mild
infection of the
periapical tissues .

Lesion contains
granulation tissue
consisting of
fibroblasts and
collagen (with
macrophages and
lymphocytes).

4. Phoenix abscess:
Acute exacerbation of a chronic lesion, Diseases mimicking toothache
5.Post- endodontic surgery pain :
Severe aching pain following endodontic treatment (root canal therapy or
apicoectomy) Majority of patients improve over time ,few develop a chronic
neuropathic pain state. Starts as a sharp stabbing pain, becomes progressively
dull and throbbing. May radiate and be referred to other areas of the mouth.
Pain exacerbated by lying down. May be intermittent with no regular pattern
Heat makes the pain worse whereas cold may alleviate it.
6.PERICORONITIS:
7.ATYPICAL ODONTALGIA/ PHANTOM PAIN
Most commonly confused with dentinal pain of pulpal origin leading to
unnecessary dental treatment. Atypical odontalgia is thought to arise due to
deafferentation of nerves caused by traumatic injury.
8.Maxillary sinusitis mimicking toothache :
A patient of maxillary sinusitis might report with dental pain. Clinical
examination of the teeth would often be irrelevant. However on taking
medical history, the following signs and symptoms may be seen:
Tenderness over the sinuses
Nasal congestion
Headache
Foul odor
Nasal discharge
Fever
Dental pain

9.REFFERED PAIN :

MANAGEMENT OF ODONTOGENIC PAIN

Most patients can attain satisfactory relief of odontogenic pain through an
approach that incorporates primary dental care in conjunction with local
anesthetics and the administration of analgesics.
PAIN PERCEPTION CONTROL
Vertical root fracture- case report
39-year-old female patient reported with the chief complaint of pain in lower left
back tooth since 2 months.
Patient gave history of root canal therapy about 2 years back in relation to 36.
Both mobility and percussion tests were negative and periodontal probing revealed
isolated 7-mm pocket in the distal root region of 36.
Radiographic examination, revealed radiolucency at the furcation and widening of
the periodontal ligament space in relation to the mesial and distal root of 36.
A fine radiolucent line was noted running from middle third to apical third of the
distal root of 36 which was suggestive of VRF .

Case reports
Maxillary sinusitis mimicking toothache- case report
56-year-old patient with no reported medical background of general importance,
visits a dentist with pain in the posterior left maxillary area which irradiates toward
the area of the same side of the cheek and feeling pressure in the area, along with
recurrent headaches.
Clinical examination revealed no pain on palpation and percussion.

Radiographic examination revealed thickening of the distal periodontal space along

with endodontically treated maxillary 2nd molar.
According to the clinical features and history of the patient an existence of LEFT
MAXILLARY CHRONIC SINUSITIS was diagnosed.
PHANTOM PAIN- CASE REPORT
70yr old patient with chief complaint of pain in the extraction site of lower left
posterior tooth since 1 year.
Patients pain characterization was complex, inconsistent and confusing with pain
being absent during sleep.
History revealed pain had persisted after extraction of decayed mandibular left
second molar 1 year back.
Clinical examination revealed healthy alveolar ridge in the area of missing left
mandibular second molar. Adjacent teeth and adjacent mucosa was healthy with
shallow pockets.
Palpation of edentulous ridge in the 2nd molar region and percussion of 1st and 3rd
molars gave equivocal response.
Taking all the above features into consideration a case of ATYPICAL
ODONTALGIA was diagnosed.
ROLE OF ANALGESICS AND ANTIBIOTICS
In 1990 the World Health Organization (WHO) recommended a three-step pain
management ladder based on the intensity of pain.
Antibiotics
Some clues on diagnosing pain
1) PAIN TO SWEETNESS indicate three things:
- Patient has a dental problem
- Tooth is vital

- Dentin is exposed
2) PAIN TO COLD indicates that the problem is almost without exception
dental and the pulp is vital.
3) A) SHARP PAIN, RELIEVED ON REMOVAL OF STIMULUSindicates dentin type of pain
B) STAYS ON REMOVAL OF STIMULUS- indicates commencement of
pulpitis.
4) DELAYED RESPONSE TO HEAT Irreversible pulpitis.
5) UNEXPLAINED SENSITIVITY TO COLD ON POSTERIOR TOOTH:
Recent restoration, occlusal trauma, exposed dentin,
caries, loose restoration or crack in teeth.
6) ROOT FILLED ENDODONTICALLY TREATED TOOTH
SENSITIVITY TO COLD - Uninstrumented canal.
However majority of cases describes thermal sensitivity
in an adjacent teeth.
7) PAIN ON BITING IN VITAL POSTERIOR TEETH
Crack teeth, maxillary sinusitis, occulsal trauma, Bruxism and trigeminal
neuralagia.
8) PAIN ON BITING ON VITAL ANTERIOR TOOTH- majority of cases unlikely
to be of dental origin .
Most of it times it is neuropathic pain facial pain e.g. atypical odontologia and
phatom tooth pain.
9) PAIN ON WALKING IN THE MORNING - Pulpitis , cluster headache,
clenching, sinusitis, muscle pain and neuralgias.

9) PAIN ON WHEN PATIENT GOES OUT INTO THE COLD- If he suffers when
the mouth is open then it is of dental origin .
10) WHEN MOUTH IS CLOSED- most common cause is masseter spasm and
other facial spasm.
11) PAIN RELIVE BY CLENCHING INDICATES1) Sinusitis
2) Early stages of Periapical inflammation.
12) PATIENT ON TRAVELLING ON AIRCRAFT
INDICATESAerodontolagia and sinusitis.
13) PAIN ON RELIEF BY PLACEMENT OF HAND
SIDE OF FACE INDICATES- Facial muscle pain and sinusitis.
Orofacial pains, especially dental pain, are among the most commonly reported
complaints. Thus, the dentist assumes a great responsibility for the proper
management of pains in and around the mouth, face and neck.
He/she must differentiate between that arise from dental, oral and masticatory
sources and those that arise from elsewhere.
Proper diagnosis and therapy can only be rendered by a sound knowledge of the
pathways and processes of pain.

REFERENCES
Bells Orofacial pains Jeffrey P.Okeson (6th edition)
Pathways of pulp Cohen. (9th edition)
Endodontics Ingle,Bakland (6th edition)
Oral medicine,Diagnosis and treatment Burkets

 Textbook of endodontics- Amit Garg and Nisha Garg

Grossmans endodontic practice (12th edition)
Monheim: Textbook of Local Anesthesia
Dental (Odontogenic) Pain, Tara Renton Reviews in Pain 2011 5: 2
Odontogenic pain, G. Prpi-Mehii, N. Gali: Medical Sciences,
34(2010):43-54
Recognition and management of odontogenic referred pain, General
Dentistry July/August 2009
The Cracked Tooth Syndrome; J Can Dent Assoc 2002; 68(8):470-5
Diagnostic Challenges of Neuropathic Tooth Pain ;J Can Dent Assoc 2004;
70(8):5426
Maxillary sinusitis of dental origin. A case report and literature review; Int.
J. Odontostomat., 3(1):5-9, 2009