Toothache 2

Question 1

Where may pain come from in a tooth if the pulp is necrosed?

Answer 1

Periodontal tissues since they are richly innervated connective tissues
Injury might be apical or marginal (marginal is of periodontal origin)

Question 2

What conditions can cause pain arising from the periodontium?

Answer 2

Apical periodontitis - symptomatic or non symptomatic
Apical abscess - acute or chronic

Question 3

What is apical periodontitis?

Answer 3

Inflammation of the PDL (this will always cause pain!)

Question 4

What are the causes of apical periodontitis?

Answer 4

Bacterial - toxins passing into apical tissues, eg from caries perio or iatrogenically introduced via RCT
Physical - trauma; occlusion/overinstrumentation during RCT (mechanically irritating apical tissues)
Chemical - tissue breakdown from pulpal degeneration or medicaments used in RCT

Question 5

What are the clinical features of periapical periodontitis?

Answer 5

Pain often well localised by patients

Question 6

What are the types of apical periodontitis?

Answer 6

Symptomatic apical periodontitis
Non-symptomatic AP

Question 7

What are the symptoms of symptomatic AP?

Answer 7

Well located dull ache not affected by thermal changes or body position
At first pain is on biting only, later pain is constant and made worse by biting
Pt will often have lost sleep and be using pain relief (can be extremely painful!)

Question 8

What does sympatomatic AP look like clinically?

Answer 8

Tooth often slightly extruded
Vitality of tooth compromised - suspect (if a tooth is necrotic and filled with pus, you can get thermal conduction of cold or hot tests through the tooth to the periodontium which can give false positive results)

Question 9

What special tests might aid symptomatic AP diagnosis?

Answer 9

Radiographs - often nothing significant, may just see PDL widening
Tooth will be ttp or apical pressure
Tooth may be traumatised

Question 10

Does all AP show up on rads?

Answer 10

May take a few weeks for periapical changes to show up in a radiograph.

Question 11

What is sequelae to AP?

Answer 11

May progress to destruction of apical bone and death of WBVs forming pus (ie apical abscess)
Frustrated healing at apex may lead to chronic apical periodontitis

Question 12

What is non-sympatomatic AP the result on?

Answer 12

An organism/host imbalance leading to frustrated healing

Question 13

What are the symptoms of non-sympatomatic AP?

Answer 13

Tooth may feel ‘different’, usually not painful
May be asymptomatic
May arise de novo or be a sequel of untreated SAP

Question 14

How does non-symptomatic AP present clinically?

Answer 14

Commonly associated with a non-viral tooth which may be ‘dull’ to percussion
May be an associated sinus

Question 15

How does non-symptomatic AP present radiographically?

Answer 15

Apical lucency
(Be careful though because this is a snapshot and does not show if it has progressed, worsened or stayed the same)

Question 16

How do you treat AP?

Answer 16

Eliminate the cause of the irritation
Definitive Tx - extraction or RCT to remove the bugs inside canal system
Non-symptomatic AP may not need emergency Tx but symptomatic AP does
Emergency Tx will be an extraction or to extirpate and dress the tooth

Question 17

What is acute apical abscess?

Answer 17

Collection of pus at the apex of an affected tooth

Question 18

What are symptoms of an acute apical abscess?

Answer 18

Well located, severe throbbing pain
Very tender
Worse when lying down

Question 19

Why are acute apical abscesses worse when lying down?

Answer 19

As you lie horizontally you get a rush of blood to the head, so around the apices of tooth will swell very slightly putting pressure on the abscess

Question 20

What do you see clinically for acute apical abscess?

Answer 20

Associated with a loose and extruded non vital tooth
Mucosa overlying apex is erythematous, tender, may be swollen
Facial swelling, halitosis, malaise

Question 21

What special test results will occur for an acute apical abscess?

Answer 21

Tooth VERY tender to apical pressure or percussion
Radiographically - PDL widening or radiolucency at apex

Question 22

What is the sequelae to acute apical abscess?

Answer 22

If left untreated - spreading infection may occur
May become a chronic apical abscess

Question 23

What is the treatment for acute apical abscess?

Answer 23

Emergency Tx required!
Check pt is not clinically unwell due to spreading infection, eg Pyrexia, swellings etc
Drain the infection if possible (to relived pressure and decrease bacterial load) by extraction, buccal or palatal incision, RCT
Do not leave pus!

Question 24

Should you prescribe antibIotics for acute apical abscess?

Answer 24

Only if it is not possible to achieve drainage and if the infection is spreading (never first course of action)

Question 25

What are symptoms of chronic apical abscess?

Answer 25

May have history of pain from area which has not settled to some extent - as infection is draining the pain is less severe Often painless or just ‘feels different’ Pt may complain of bad taste

Question 26

How does chronic apical abscess present clinically?

Answer 26

Tooth may have a draining sinus - spot on gum Tooth may be extruded or slightly lose May be tender to pressure or percussion

Question 27

What might special tests show for a chronic apical abscess?

Answer 27

May be tender to percussion or pressure Radiographically an apical radiolucency will often be present

Question 28

What is the sequelae to chronic apical abscess?

Answer 28

If untreated - acute exacerbation Chronic apical periodontitis if healing is partial

Question 29

What is treatment for chronic apical periodontitis?

Answer 29

RCT or extraction of the affected tooth

Question 30

How does chronic apical periodontitis affect the success rate of RCT?

Answer 30

The more long-standing the infection, the lower the success rate of RCT

Question 31

What is lateral periodontal abscess?

Answer 31

Collection of pus at a marginal location within the periodontium Usually tooth is tender to lateral rather than apical pressure Associated tooth is usually vital as infection arises from a perio pocket rather than necrotic dental pulp

Question 32

What are some causes of dental pain not related to AP or pulpal origin?

Answer 32

Any structure supported by sensory branches of trigeminal nerve Trigeminal neuralgia Sinuses - sinusitis affecting maxillary teeth (inflammation in sinus lining could inflame periodontal tissues) TMJD Muscles - myofacial pain dysfunction syndrome Bone - post-extraction - acute alveolar osteitis Nerve - trigeminal neuralgia, Herpes zoster (shingles) Salivary glands - sialedenitis Vessels - cluster headaches, temporal arteritis, atypical migraine. Medical emergency presenting as jaw pain = MI

Question 33

What are trigger words for trigeminal neuralgia?

Answer 33

Electric shock pain or sand/grit thrown at face pain etc Sudden radiations of pain Eliminate dental origins first!

Question 34

Diagnosis of dental pain relies on pain history. What are all the q’s for a pain history? (Read)

Answer 34

Type? - sharp, dull, throbbing, stabbing, burning, electric shock like, deep, superficial Site? - specific tooth, other teeth, gums, cheeks, lips ear, scalp, neck, chest,arms History? - onset, duration, constant or episodic, frequency, consistency, intensity, severity Precipitating or alleviating factors? - hot/cold/sweet, touch or pressure, movement (opening/closing could be TMD), biting may indicate periapical disease, leaning forward might indicate sinusitis, lying down or postural change might indicate abscess) Analgesia - does it help/how many have they taken/gauge pain tolerance eg how much do they usually take for a headache