Acute orofacial pain

1. Acute orofacial pain Mohammad Shooriabi. Assistant Professor, Department of Oral Medicine, Faculty of Dentistry, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran

2. Introduction • Acute orofacial pain is primarily associated with the teeth and their supporting structures (the periodontium). • Rated as moderate to severe in intensity • Pain is conceived of as deep and unpleasant • In about 60%of cases pain is not localized but spreads into remote areas of the head and face. • Prevalence in community dwelling adults ranges from 12 to 40%, depending on the description of dental pain used

3. Mechanisms of Dental Pain

4. Continue drying by application of absorbent paper or a stream of air, mechanical stimulation (e.g. cutting, scratching, probing) and changes in osmotic pressure, pH or temperature.

5. Continue • Well established algesic substances, such as potassium chloride, acetylcholine, 5-hydroxytryptamine (5-HT), bradykinin and histamine, to exposed dentine does not evoke pain

6. Hydrodynamic Mechanism • Brannstrom’s • The pressure-sensitive neurons are A fibres and are much more sensitive to outward than inward flow through the dentinal tubules

7. Type Of Acute Orofacial Pain • Dental Pain • Dentinal Pain • Cracked Tooth Syndrome • Pulpal Pain • Periodontal Pain • Acute Periapical Periodontitis • Lateral Periodontal Abscess • Gingival Pain • Food impaction • Pericoronitis • Acute Necrotizing Ulcerative Gingivitis • Mucosal Pain • Pain from Salivary Glands

8. Dentinal Pain • A sharp, deep sensation usually evoked by an external stimulus and subsides within a few seconds. • Pain is poorly localized, often only to an approximate area within two or three teeth adjacent to the affected tooth • Patient is unable to distinguish whether the pain originates from the lower or the upper jaw

9. Continue • The most common processes associated with dentine pain are early dental caries, defective restorations and areas of exposed dentine, e.g. abrasion or erosion of the enamel, and exposed roots due to gingival recession or periodontal therapy • dental probe • cold or hot stimuli • bite-wing dental radiograph

10. Cracked Tooth Syndrome • Symptoms typical for dentinal pain • Complain of a sharp pain, elicited by biting, that resolves immediately after pressure on the teeth ceases

11. Continue • Possible additional diagnoses, with signs and symptoms resembling the cracked tooth syndrome, • occlusal abrasion • a cracked filling • vertical root fracture

12. Treatment of Dentinal Pain • Dentinal pain due to caries is best treated by removal of the carious lesion and restoring the tooth. • Treatment of the cracked tooth depends on the state of the tooth • Tubule-blocking agents include resins, glass ionomer cements and bonding agents • Good oral hygiene is essential

13. Pulpal Pain • Spontaneous , strong, often throbbing and exacerbated by changes in temperature, sweet foods and pressure on the carious lesion. • Pain is evoked it outlasts the stimulus • Localization is poor and seems to be even poorer when pain becomes more intense • No definitive pain radiation patterns • Does not usually cross the midline

14. CONTINUE • Patients may describe pain in different ways and a continuous dull ache can be periodically exacerbated (by stimulation or spontaneously) for short (minutes) or long (hours) periods • many instances wakes the patient from sleep • Pain originating from the pulp is frequently not continuous and abates spontaneously; the precise explanation for such abatement is unclear

15. Continue • Although pain is the most common symptom of a diseased pulp, no correlation exists between specific pain characteristics and the histopathological status of the pulp. • Approximately 40% of 2202 teeth treated endodontically had no history of spontaneous pain or of prolonged pain to thermal stimulation

16. Continue • The application of a cold stimulus is commonly used to diagnose pulpal conditions. • In irreversible pulpitis application of ethyl chloride results in excruciating pain that outlasts the stimulus for well beyond 10 seconds. • Percussion aids in localizing the affected tooth as about 80% of teeth with painful pulpitis are tender to percussion. • Electrical pulp testers

17. Continue • The state of the pulp cannot be judged from one single symptom and should be based on the combination of several signs and symptoms

19. Periodontal Pain • The periodontal tissues include the alveolar bone, the periodontal ligament and the gingivae • A major feature of periodontal disease is that it is usually painless. This is due to the fact that periodontal inflammation is chronic in nature, a fact also true for asymptomatic periapical rarifying osteitis lesions often detected on routine dental radiographs.

20. Continue • periodontal pain is usually experienced in response to localized acute inflammation • gingivae, the periodontal ligament and alveolar bone due to bacterial or viral infection • Pain originating in the structures surrounding the teeth is easily localized; • the affected teeth are very tender on chewing and are readily localized by percussion.

21. Acute Periapical Periodontitis • Moderate to severe in intensity and long-lasting (hours). • Pain is exacerbated by biting on the affected tooth • Patient reports symptoms of pulpal pain that preceded pain from the periapical area • Is usually better tolerated • Localization of pain originating from the periapical area is usually precise • Approximately half the cases the pain is diffuse

22. Continue • Physical and radiographic signs • gentle tooth percussionand the periapical vestibular area may be tender to palpation. • The pulp of the affected tooth is non-vital • In more severe, purulent cases, swelling of the face associated with cellulitis is sometimes present and can be associated with fever and malaise • The affected tooth may be extruded and mobile, both vertically and horizontally • When facial swelling appears, pain diminishes in intensity(dentoalveolar abscess.)

23. Continue • No periapical radiographic changes are detected in the early stages. • re-acutization of chronic periapical periodontitis

24. Treatment • While the pain originates from the periodontal periapical tissues, the source of insult and infection usually lies within the pulp chamber and the root canal. • No demonstrable benefit from penicillin supplementation • if cellulitis, fever and malaise are present, systemic administration of antibiotics is recommended

25. Continue • Antibiotics should also be prescribed in addition to abscess drainage and tooth debridement in immunocompromised patients • 2–3 days of antibiotics was sufficient with standard doses • Grinding the tooth to prevent contact with the opposing teeth helps to relieve pain.

27. Lateral Periodontal Abscess • Pain characteristics of a lateral periodontal abscess are very similar to those of acute periapical periodontitis • The pain is continuous, moderate to severe in intensity and well localized and is exacerbated by biting on the affected tooth • During examination swelling and redness of the gingiva may be noticed, usually located more coronally than in acute periapical lesions.

29. Continue • The swelling is tender to palpation and the affected tooth is sensitive to percussion and may be mobile and slightly extruded • A deep periodontal pocket is usually located around the tooth once probed, pus exudation may occur with occasional pain relief • In more severe cases, cellulitis, fever and malaise may occur. • The tooth pulp is usually vital; i.e. it reacts normally to temperature changes and electrical stimulation • Pulp may occasionally be slightly hyperalgesic

30. Continue • Abscess formation usually results from a blockage of drainage from a deep periodontal pocket, and is frequently associated with a deep infrabony pocket and teeth with root furcation involvement

31. Treatment • Gentle irrigation and curettage of the pocket should be performed. • A vertical incision for drainage is recommended when the abscess is fluctuant but cannot be adequately approached through the pocket. • Acute lateral periodontal abscess causes rapid alveolar bone destruction hence the need for early and prompt intervention.

32. Vertical Root Fracture • A fracture of the tooth that involves most of the root will induce pain on biting. • Root fractures are more common in endodonticallytreated teeth that have been restored with a post and core. • An isolated periodontal pocket in the area of the fracture is often found • If left untreated infection and abscess formation may occur. • only treatment option for vertical root fractures is extraction.

33. Gingival Pain • Gingival pain may occur as a result of • mechanical irritation such as food impaction • acute inflammation associated with a partially erupted tooth (pericoronitis) • an acute bacterial or viral infection

34. Food Impaction • localized pain that develops between two teeth after meals, • Feeling of pressure and discomfort that is annoying and sometimes severe • Pain gradually diminishes until evoked again at the next meal, • Faulty contact between two adjacent teeth is noticed so that food is usually trapped between these teeth • the gingival papilla is tender to touch and bleeds easily. • The two adjacent teeth are usually sensitive to percussion

36. Continue • Food impaction should be treated promptly as it may cause cervical caries and interdental alveolar bone resorption • Cause of the faulty contact between the teeth is often a carious lesion, • In some cases though the contacts are tight food impaction may occur, and creating anatomical escape grooves adjacent to the marginal ridge may eliminate food impaction

38. Pericoronitis • In teeth that are incompletely erupted and are partially covered by a flap or operculum of gingival tissue. • Pain, which may be severe, is usually located at the distal end of the arch of teeth in the lower jaw. • Pain is spontaneous and may be exacerbated by closing the mouth. • In more severe cases, pain is aggravated by swallowing and results in limited mouth opening.

40. CONTINUE • Upon examination, the operculum is acutely inflamed (red, oedematous) and frequently an indentation of the opposing tooth can be seen on the swollen gingival flap. Occasionally there is fever, malaise and restricted mouth opening.

41. Treatment • Irrigation of debris between the operculum and the affected tooth with saline or antibacterial agent(e.g. chlorhexidine 0.5%) should be performed. • Trauma can be eliminated by grinding or extracting the opposing tooth. • Systemic antibiotic administration is recommended when Limited mouth opening occurs or the patient is febrile. • first-line treatment suggested is amoxicillin with clavulanic acid

42. Acute Necrotizing Ulcerative Gingivitis

43. An ulcerative gingival disease characterized by pain, bleeding and papillary necrosis • Pain is intensified by eating and tooth brushing; these activities are usually accompanied by gingival bleeding • A metallic taste is sometimes experienced and usually there is a foetidodor from the mouth.

44. Continue • Pain is fairly well localized to the affected areas, but in cases with widespread lesions pain is experienced throughout the mouth. • Fever and malaise are sometimes present. • An adherent greyish slough represents the so-called pseudo- embranepresent in the acute stage • It appears more frequently in undernourished children and young adults as well as in patients with immunodeficiency.

45. Treatment • Treatment includes swabbing and gentle irrigation of the ulcerative lesions, preferably with chlorhexidine or an oxidizing agent (hydrogen peroxide), and scaling and cleaning the teeth. • Systemic antibiotics are recommended especially when fever and malaise are present

46. Mucosal Pain • Pain originating from the oral mucosa can be • localized • diffuse natre. • Localized pain is usually associated with a detectable erosive or ulcerative lesion whilst diffuse pain may be associated with a widespread infection, a systemic disease or other unknown factor

47. Localized Mucosal Pain • Recurrent aphthousulcers • Acute Herpetic Gingivostomatitis

48. Diffuse Mucosal Pain • usually has a burning nature and may be accompanied by a dysgeusia, predominantly of a bitter metallic quality. • Candidiasis • chronic iron-deficiency anaemia,

49. Pain from Salivary Glands • Pain from salivary glands is localized to the affected gland, and is of moderate to severe intensity. • The salivary gland is swollen and very tender to palpation. • Pain is intensified by increased saliva production,