• Pulpal inflammation is often not painful
• at times, an inflamed pulp may be exquisitely painful, causing spontaneous, throbbing,and intense pain that is worsened by hotand cold stimuli.' When pain is not spontaneou
Patients describe pain from pulpitis in a variety of ways:
• It may increase and throb when they are lying down.
• It may present as a continuous dull ache that is increased by a stimulus.
• The pain is intermittent and may abate suddenly for no apparent cause
• or, conversely, awaken the patient.
• Pulpal pain tends to be diffuse and to be referred.
• As the pain increases in intensity it may spread to the ear, temple, cheek, or other teeth, although never across the midline
• Pulpal pains never across the midline.
• If the inflammation extends into the periradicular tissues, localization is usually easier, presumably because of proprioceptors.
Obscure causes of pulpal pain:
There are several fairly common causes of pulpal pain that are clinically difficult to recognize
Perhaps the most common of these is the mesiodistally split tooth, the margins of wich are obscured by adjacent teeth and the presence of wich is not radiographically visible.
Another common cause is an occlusal filling that is slightly dislodged in apulpal direction.
Recurrent caries obscured both clinically and radiographically.
Mechanical abrasion of the root of atooth due to the presence of an adjacent impacted tooth.
• Direct extension from a periodontal pocket via an aberrant lateral root canal.
• Hematogenous infection of the dental pulp has been reported.
Identification of pulpal pain:
• The examiner should suspect pain as being of pulpal origin when it is difficult for the patient to precisely localize it to a certain tooth.
• Obvious possible sources of the pulpal pain should be investigated first, when a suspicious tooth is located, an attempt to induce r increase the pain b noxious stimulation of that toth should be made.
• If the pain can be influnced by local irritation, the tooth should be anesthetized locally to see whether anesthesia promptly and completely arrests the pain.
• If such is the case, the offending tooth has been satisfactorily identified.
• When there is no clues about which tooth is the source of pain(if indeed it is atooth at all), the examiner is obliged to be suspicious of every tooth on the side on which there is pain, both maxillary and mandibular .
• largely painless
• It may occasionally manifest with acute pain such as that associated with a lateral periodontal abscess.
• When the periodontal pain involves several teeth ,especially opposing teeth, the matter of occlusal overloading should be considered.
• With multirooted teeth ,one root may be periapically or periodontally involved , while another shows symptoms of pulpal pain.These circumstances can certainly confuse the clinician.
• Phenomena Complicating the Diagnosis of Dental Pain
By definition, referred pain comprises input from a site of tissue damage
combined with input from another site where
there is no tissue damage; therefore the pain is referred and is perceived to originate from the site of
• Referred pain mechanism
Afferent nerves from a variety of
tissues converge on the cell body of the second-order neuron (the transmission T cell) in the brainstem, which stimulates the action system. Once the T cell is activated, it may be difficult
for higher centers to determine the exact location of the i nitiating pain, which may be wrongly assigned
• Odontogenic pain is more likely to be referred
when it is more intense.
• but duration and quality do not seem to be related to referral.
• Pain is never referred across the midline but readily from arch to arch.
When the offending tooth is not obvious and cannot be stimulated to reproduce the patient's symptoms, examination should be extended
to include these other possibilities. For example, muscles of mastication, the ear, sinuses, the heart, and other teeth may be the source of the referred pain.
v The sources of reffered pain
v Muscles of Mastication
v Ear Nasal and Sinus Mucosa
v Cardiac Origin
v Other Teeth
Muscles of Mastication
v The clinical characteristics of a muscular toothache are as follows:
1-The pain is relatively constant ,dull,aching and nonpulsatile.
2-The pain is not responsive to local provocation of the tooth.
3-Examination reveals the presence of localized firm ,hypersensitive bands within the muscle tissues(trigger opints)
4-The toothache is increased with function of the involved muscle (trigger points).
5-Local anesthesia of the tooth does not affect the toothache.
Ear Nasal and Sinus Mucosa
• Pain arising from the nasal mucosa as the result of viral or allergic rhinitis is prone to be expressed as referred pain throughout the maxilla and maxillary teeth in the form of a toothache.
The clinical characteristics of sinus or nasal mucosal toothche are as follows:
1-The patient reports afeeling of pressure below the eyes.
2-The pain is increased by application of pressure over the involved sinus.
3- The tooth is sensitive to percussion.
4-The toothache is increased by lowering the head.
5-The toothache is increased by stepping hard on to the heel of the foot (walking down steps).
6-Local anesthesia of the tooth does not eliminate the pain.
7-Diagnosis is confirmed by appropriate imaging of the sinus.
Headaches are the most common painful entities of the head and neck .33 The pain is often referred to teeth and may be confused with toothache.
• Functional headaches are caused by vascular (migraine, cluster, toxic vascular, and hypertensive),musculoskeletal, and emotional disturbances.
Types of Headache:
• The following characteristics are common to neurovascular toothache:
1-The pain may be spontaneous,variable,pulsatile and very intense.
2-The toothache is characterized by periods of total remission between episodes(like migraine pain).
3-The episodes of pain may pose a temporal behavior ,appearing at similar times during the day,week or month.
4-The pain is felt in a maxillary canine or premolar.
5-The patient reveals a history of other neurovascular disorders.
6-A trial of an abortive migraine medication (eg, sumatriptan) reduces the tooth ache.
1-These are severe.
2-The patient experiences several (sometimes daily) within a 2- or 3-month period, each lasting up to an
3-The pain is usually limited to the distribution of the first and second divisions of the trigeminal nerve
4-may be manifest in the maxillary
and occasionally the mandibular teeth.
• This is the most common form of headache.
• may be referred over a wide area, including the forehead, temples, and back of the neck.
• These headaches are caused by mass lesions (tumors,
hematomas, and so on), infection, arteritis, phlebitis, vascular occlusion, cranial neuralgias,and diseases of the eye, ear, nose, throat, and teeth.
• the headache is most often a deep, aching, steady, dull pain.