Endodontics Lecture 1

Diagnosis: is a personal and cognitive experience & a group of steps & procedures that will lead to know what the patient is suffering from.
therefore, many of the qualities of a good diagnostician are of an interpersonal nature and based on knowledge, experience, and diagnostic tools. Diagnosing orofacial disease is similar to medical diagnosis. The pulp test, radiographs, percussion, palpation, and other tests and procedures can facilitate the diagnosing of facial disease, just as the electrocardiograph, electroencephalograph, liver and kidney function tests, echocardiograph, computed axial tomographic scanners, and a host of other radiographs can facilitate medical diagnosis.


REQUIREMENTS OF A DIAGNOSTICIAN:-
A dentist can develop a number of assets to become a successful diagnostician. Again, the most important of these are knowledge, interest, intuition, curiosity, and patience. The successful diagnostician must also have acute senses and the necessary tools for diagnosis.

HISTORY “recollection” or “calling to memory,” is the first step in developing a diagnosis. The chief complaint, enlarging on this complaint with questions about the present dental illness, relating the history of past dental illness to the chief complaint, and combining this with information about the patient’s general health (medical history) and the examination results.

Chief Complaint:-
The chief complaint, usually in the patient’s own words, is a description of the dental problem for which the patient seeks care. The verbal complaint may be accompanied by the patient pointing to the general area of the problem.

Present Dental Illness:-
Pain is frequently the main component of the patient’s complaint. A history of pain that persists The initial questions should help establish two basic components of pain: time (chronicity) and severity (or intensity). Start by asking such questions as “How long have you had this problem?”
“How painful is it?”
“How often does it hurt?”
“When does it hurt?”
“When does it go away?”
“What makes it hurt?”
“What makes it hurt worse?” and
“What makes it hurt less or go away?”
“What kind of treatment have you had?”
This might elicit a history of pulp capping, deep fillings with sedative bases, or indirect pulp caps. These teeth, as well as those that have received impact trauma, may exhibit calcific metamorphosis or dystrophic calcifications and may be a difficult endodontic treatment.
“How recently has this tooth or area been treated?” “How many times has this tooth or have these teeth been treated?”
Medical History:-
Heart Failure, Heart Disease, Attack Angina Pectoris, High Blood Pressure, Heart Murmur, Rheumatic Fever, or Congenital Heart Lesions, all of these with no. of systemic diseases the dentist should ask about in reviewing the medical history, particular emphasis must be placed on illnesses, history of bleeding, and medications. illness often means hospitalization. medication means to many people only those items obtained by written prescription.
CLINICAL EXAMINATION:-
In general, the clinical examination should follow a logical sequence from the general to the specific, from the more obvious to the less obvious, from the external to the internal. The patient must be examined for asymmetries, localized swelling, changes in color or bruises, abrasions, cuts or scars, and similar signs of disease, trauma, or previous treatment. Positive findings combined with the chief complaint and information about past injuries or previous treatments to teeth or jaws will begin to clarify the extent of the patient’s problem.
The extraoral examination includes the face, lips, and neck, which may need to be palpated if the patient reports soreness or if there are apparent areas of inflammation. Painful and/or enlarged lymph nodes are of particular importance. They denote the spread of inflammation as well as possible malignant disease. The extent and manner of jaw opening can provide information about possible myofascial pain and dysfunction.
The temporomandibular joint should be examined during function for sensitivity to palpation, joint noise, and irregular movement.
Intraoral Examination:-
The intraoral examination is begun with a general evaluation of the oral structures. The lips and cheeks are retracted while the teeth are in occlusal contact and the oral vestibules and buccal mucosa are examined for localized swelling and sinus tract or color changes.
Coronal Evaluation :-
Using a mouth mirror and an explorer, and possibly a fiber-optic light source, the dentist carefully and thoroughly examines the suspected tooth or teeth for caries, defective restorations, discoloration, enamel loss, or defects that allow direct passage of stimuli to the pulp. Sometimes sealing off such leakage with temporary cements or periodontal dressings can be diagnostic, Transillumination with a fiber-optic light, directed through the crowns of teeth, can add further information. a pulpless tooth that is not noticeably discolored may show a gross difference in translucency when the shadow produced on a mirror is compared to that of adjacent teeth. Transillumination may also locate teeth with vertical cracks or fractures.
Pulpal Evaluation:-
The clinical condition of the pulp can be evaluated by thermal stimuli, percussion, palpation, and vitality tests. generally, pain of endodontic origin results from pulp inflammation that spreads from the coronal pulp apically to the periodontal ligament, which then spreads to the periosteum overlying the apical bone and beyond. Pulpal and periradicular symptoms, therefore, sometimes combine, making pulpal assessment difficult. After determining the diagnosis, there are specific treatment options for each pulpal condition. Irreversible pulpitis and pulp necrosis require removal of the pulp (pulp extirpation and root canal treatment, or extraction of the tooth), whereas a tooth with a normal pulp or with reversible pulpitis may be treated by preserving the pulp (vital pulp therapy).

Clinical Endodontic Tests
Thermal Tests:-
Two types of thermal tests are available, cold and hot stimuli.Neither is totally reliable in all cases, but both can provide very useful information in many cases of pulpal involvement. The cold test may be used in differentiating between reversible and irreversible pulpitis and in identifying teeth with necrotic pulps. It can also alleviate pain brought on by hot or warm stimuli, a finding that patients sometimes discover can provide them with much relief. Cold testing can be made with an air blast, a cold drink, an ice stick, ethyl chloride or Fluori-Methane
(CO2) dry “ice” stick.
Hot testing can be made with a stick of heated gutta-percha or hot water. Both have advantages, but hot water may be preferable because it allows simulation of the clinical situation and also may be more effective in penetrating porcelain-fused-to-metal crowns.
Percussion:-
Apical periodontitis is usually an extension of pulpal inflammation, but it may also result from impact trauma, traumatic occlusion, or sinusitis affecting maxillary teeth, since apical periodontitis is so frequently associated with pulpal inflammation, percussion tests are included when evaluating pulpal conditions even though the percussion produces a response in the periodontium rather than the pulp.
Palpation:-
Sensitivity to finger pressure (palpation) on the mucosa over the apex of a tooth, buccal or lingual, signals the further spread of inflammation from the periodontal ligament to the periosteum overlying the bone. Besides the pain response to this test, information can also be obtained about asymmetry and fluctuation in the areas examined.
Electric Pulp Test:-
To achieve consistent results with an electric pulp tester, one must follow a standard procedure. Dry the teeth to be tested and isolate them with cotton rolls. Cover the tip of the electrode with toothpaste or a similar electrical conductor. To stimulate the pulp nerve fibers, the electric current must complete a circuit from the electrode through the tooth, through the patient, and back to the electrode.
Liquid Crystal Testing:-
Cholesteric liquid crystals have been used by investigators to show the difference in tooth temperature between teeth with vital (hotter) pulps and necrotic (cooler) pulps. The laser Doppler flowmeter has also been shown to measure pulpal blood flow and thus the degree of vitality
Occlusal Pressure Test:-
A frequent patient complaint is pain on biting or chewing. The causes for such symptoms include apical periodontitis, apical abscess, and incomplete tooth fractures (infractions).
Tooth Slooth, and Burlew disks allow pinpoint testing of individual cusp areas, whereas the wet cotton roll has the advantage of adapting to the occlusal surface, allowing for pressure over the entire occlusal table.

Anesthetic Test:-
The anesthetic test can help identify the quadrant from whence the focus of pain originates. The suspected tooth should be anesthetized, and, if the diagnosis is correct, the referred pain should disappear, even when it is referred to the opposite arch.

Test Cavity:-
This test is often a last resort in testing for pulp vitality. It is important to explain the procedure to the patient because it must be done without anesthesia.
Make a preparation through the enamel or the existing
restoration until the dentin is reached. If the pulp is vital, the heat from the bur will probably generate a response from the patient.

RADIOGRAPHIC EXAMINATION
The importance of an adequate radiograph. a number of important details may be learned from radiographic film:
(1) size and character of periradicular lesion.
(2) curvature of root end.
(3) relationship of root to adjacent roots.
(4) mesial or distal inclination of root.
(5) approximate length of tooth.
(6) relationship of exploring instrument to root curve.
(7) size of canal.
(8) divergence of coronal cavity
(9) Periodontal lesions and root fractures .
(10)Conditions Inside the Tooth .
(11)Pulp Stones.
(12) Internal & External resorption.
(13) Periradicular Lesions

***- Pulpal changes such as inflammation and necrosis cannot be detected radiographically within the canal.
PULP PAIN
(pulpalgia)
Pulp pain, or pulpalgia, is by far the most commonly experienced pain in and near the oral cavity and may be classified according to the degree of severity and the pathologic process present:
1. Hyperreactive pulpalgia
a. Dentinal hypersensitivity
b. Hyperemia
2. Acute pulpalgia
a. Incipient
b. Moderate
c. Advanced
3. Chronic pulpalgia
a. Barodontalgia
4. Hyperplastic pulpitis
5. Necrotic pulp
6. Internal resorption
7. Traumatic occlusion
8. Incomplete fracture
***The mildest pulp discomfort, experienced when no inflammation is present, is hyperreactive pulpalgia.

Hyperreactive Pulpalgia:-
Hyperreactive pulpalgia is characterized by a short, sharp, shock—that is, “pain” best described as a sensation of sudden shock. The sensation is as sharp as it is sudden and must be elicited by some exciting factor. It is never spontaneous. The pain is of short duration, lasting only slightly longer than the time during which the irritating element is in contact with the tooth. Like the pain generated by blowing air over exposed dentin. The same phenomenon is produced by the dental drill, Scraping or chiseling the dentin.
Hyperreactive pulpalgia is common following the placement of a new restoration. Patients also complain after root planing and curettage or following periodontal surgery, Hyperreactive pulpalgia also may be present in the tooth with a carious lesion. Teeth traumatized by bruxism or incompletely fractured teeth are generally more hyperreactive.

Dentinal Hypersensitivity:-
The exciting factors of a hypersensitive pulp are usually cold food or drink or cold air, contact of two dissimilar metals that will yield a galvanic shock, or stimulation of the exposed dentin on the root surface by cold, sweet or sour substances, vegetable or fruit acid, salt, or glycerine, or often just touching the surface with a fingernail, a toothbrush, an interdental stimulator, or an explorer.

Hyperemia:-
All minor pulp sensations were once thought to be
associated with hyperemia, an increased blood flow in
the pulp.
Treatment:-
Application of the new resin adhesives or placement of an insulating base under metallic restorations will materially reduce most hypersensitivity. Moreover, this sensation usually diminishes gradually as irritation dentin builds to protect the dental pulp.
Acute Pulpalgia:-
True pulpalgia begins with the development of pulp inflammation or pulpitis. an increased intrapulp tissue pressure is possible. It may be postulated that this pressure might well be the stimulus that is applied to the sensory nerves of the pulp and leads to severe toothache.
a-Incipient Acute Pulpalgia:-
The mild discomfort experienced as the anesthetic wears off following cavity preparation.
The patient may be vaguely aware that the tooth feels different, “as though it has been worked on,” but the sensation disappears by the next morning.
Excitation. Incipient acute pulpalgia must be stimulated by an irritant such as cavity preparation, cold, sugar, or traumatic occlusion.
Examination. If the pulpalgia follows cavity preparation, the involved tooth is obvious. If dental caries is the noxious stimulus, the cavity is found by an explorer and radiographs. The lesion may be quite small, just into the dentin. The patient can usually tell which quadrant is involved and may even point out the involved tooth. Cold is the best stimulus to initiate incipient acute pulpalgia. The pulp tester is of questionable value in these cases.
Treatment. Removal of the carious lesion followed by calcium hydroxide application and a sedative cement for a few days may be all that is required to arrest incipient acute pulpalgia.
b-Moderate Acute Pulpalgia:-
The pain is a true toothache, but one the patient can usually tolerate. Many patients report for dental attention after hours, or sometimes days, of discomfort from the developing pulpitis. The pain is frequently described as a “nagging” or a “boring” pain, which may at first be localized but finally becomes diffuse or referred to another area. The pain differs from that of a hyperreactive pulp in that it is not just a short, uncomfortable sensation but an extended pain. Moreover, the pain does not necessarily resolve when the irritant is removed, but the tooth may go on aching for minutes or hours, or days for that matter.
Excitation. Moderate pulpalgia may start spontaneously from such a simple act as lying down. This alone accounts for the seeming prevalence of toothache at night. Some patients report that the pulp aches each evening, when they are tired. Others say that leaning over to tie a shoe or going up or down stairs—any act that raises the cephalic blood pressure
Examination: The patient may report after days of discomfort, and by this time the pain, though still present, may be widespread and vague. If the pain is only vague when the patient is first seen, the dentist should attempt, by careful questioning, to obtain a general idea of the area of the pain. Usually, the patient can tell which side is involved and frequently whether pain is in the maxilla or the mandible. the pain may be referred from one arch to the other. The patient may remember where the pain started initially, hours or days before. Examination of the suspected area may immediately reveal the involved tooth, made obvious by a large carious lesion or huge restoration. Then again, nothing unusual may be present. Radiographs may give an immediate clue in the form of a huge interproximal cavity or a restoration impinging on the pulp chamber. If nothing is learned from radiographic examination, the electric pulp test is then employed, but generally without great success.
Treatment. The treatment for moderate pulpalgia is quite simple: pulpectomy and endodontic therapy if the tooth can and should be saved or extraction if the tooth should be sacrificed.
c-Advanced Acute Pulpalgia:-
There is never any question about the patient suffering the pain of advanced acute pulpalgia.He is experiencing one of the most excruciating acute pains known to humanity, comparable to otic abscess, renal colic, and childbirth. If every dentist personally experienced the pain of advanced acute pulpalgia, he would be a more sympathetic practitioner for the experience. The relief for this pain is embarrassingly simple: cold water, preferably iced. Cold water rinsed over the tooth is all that is usually needed to arrest the pain temporarily.
Examination. The examination for advanced acute pulpalgia, in comparison to that for moderate pulpalgia, is relatively simple, even if the tooth is not aching when the patient presents himself. The involved tooth always has a closed pulp chamber, as revealed by the radiograph. Otherwise, the tremendous intrapulp pressure could not develop. In addition, the radiograph may reveal a thickened periodontal membrane space at the apex as the inflammation
spreads out of the pulp. Because the inflamed pulp reacts so violently to heat, the most decisive test is the heat test, although one must have a cold water syringe in the other hand, ready to give immediate relief
Treatment. The treatment for advanced pulpalgia is the same as for moderate pulpalgia: pulpectomy and endodontic therapy for the salvageable tooth and extraction for the hopeless one.
Chronic Pulpalgia:-
The discomfort from chronic pulpalgia is best described as a “grumble,” a term commonly used by patients who withstand the mild pain for weeks, months, or years. Often the pain can easily be kept under control with one or two analgesic tablets, two or three times daily. Frequently, the patient seeks relief only when the pulp begins to ache every night. The pain from chronic pulpalgia is quite diffuse, and the patient may have difficulty locating the source of annoyance. Patients frequently say that they have a “vague pain in my lower jaw.” Chronic pulpalgia is likely to cause referred pain, which is also mild. Other patients may appear with beginning acute apical abscess and confess to knowing that something was “wrong” with the tooth for months.
Excitation: The pulp involved in chronic pulpalgia is not affected by cold but may ache slightly on contact with hot liquids. If meat or a bread crust, for example, is crushed into the cavity, the pain lasts until the irritant is dislodged.
Examination. Determining which tooth is involved with chronic pulpalgia is often ridiculously simple and, on other occasions, most difficult. Frequently, a large carious lesion is present, or an amalgam restoration is fractured at the isthmus. Another common offender is recurrent caries under a restoration, usually an inlay. The radiograph often reveals interproximal or root caries, or recurrent caries under a restoration. In chronic pulpalgia, the so-called “thickened” periodontal membrane also may be present, even a slow response appear from chronically inflamed pulp to E.P.T. The apices of the involved roots also show external resorption, although this condition is more prevalent following pulp necrosis and complete periradicular involvement,there may be referring its vague pains throughout the region. The patient may insist that a mandibular molar is aching, whereas examination reveals that a maxillary molar is the offender. Often anesthetizing the involved tooth is the only convincing proof to the patient that he is wrong.
Treatment. Pulp extirpation and endodontic therapy if
the tooth is to be saved and extraction otherwise. anesthesia is no problem.
Hyperplastic pulp:-
It is quite simple. It “erupts” out of its open bed of caries for all to see. Differential diagnosis is concerned with only one problem, namely that of discerning whether the polyp is pulp or gingival in origin because both are covered by epithelium.
Necrotic Pulp:-
There are no true symptoms of complete pulp necrosis for the simple reason that the pulp, with its sensory nerves, is totally destroyed. Often, however, only partial necrosis has occurred, and the patient has the same vague, comparatively mild discomfort described for chronic pulpalgia.
Examination. A routine radiographic survey or coronal discoloration may present the first indication that something is amiss in the case of the tooth with a necrotic pulp. On questioning, the patient may recall an accident of years ago or a bout of pulpalgia long since forgotten. The radiograph may be helpful if a periradicular lesion exists because its presence usually indicates associated pulp death. Radiographically, the tooth with the necrotic pulp may exhibit only slight periradicular change.
**The electric pulp tester, therefore, is the instrument of choice for determining pulp necrosis.With complete necrosis, no response will be given at any level on the tester. With partial necrosis, a vague response that can easily be tolerated may be elicited at the top of the scale. The tooth with a necrotic pulp may also be slightly painful to percussion.

Treatment. If the tooth can be saved, endodontic therapy is indicated.
Internal Resorption:-
Afflicted pulp is completely free of symptoms. On the other hand, this condition has been known to mimic moderate acute pulpalgia in pain intensity. The usual case, however, closely resembles the chronic pulpalgia syndrome, that is, mild pain at the tolerable level.
Examination. Two methods of examination reveal the case of internal resorption: visual examination if the crown is involved and radiographic examination for the crown and root.
Treatment. Pulpectomy is the only treatment for internal resorption. As long as the pulp remains, it is most likely to continue its destructive process. If the tooth can be saved by endodontic restoration, the defect can best be obturated by thermoplasticized and compacted gutta-percha.
Incomplete Fracture or Split Tooth:-
The tooth may be uncomfortable only occasionally during mastication, and at that time the pain may be one quick, unbearable stab.

Excitation. The discomfort of the split tooth is elicited by biting on the tooth or contacting cold fluids. If the pulp is involved in fracture, any exciting agent for pulpalgia will bring on discomfort.
Examination. First, one thinks of carefully examining the tooth, dried and under good light, to find the crack in the enamel, Percussion alone, surprisingly enough, is usually not helpful, yet biting on an applicator stick or cotton roll may give the spreading action needed to elicit pain.
**The pulp tester customarily gives a normal reading unless the pulp is involved.
Treatment. If an incomplete fracture is suspected but the pulp is not involved, the crown should be prepared for a full crown, which should then be cemented temporarily with zinc oxide–eugenol cement. The full crown binds the remaining tooth structure, if the incomplete fracture has entered the pulp and a true pulpalgia indicates that pulpitis is present, then root canal therapy should be completed first.

POSTOPERATIVE PAIN: INCIDENCE,
PREVENTION AND TREATMENT
Apical overextension of necrotic debris (infected or otherwise), instruments, paper points, medicaments, and filling materials lead to postoperative pain. Apical perforation is a common occurrence that can mainly be avoided by careful attention to establishing and maintaining correct working length. Preoperative administration of flurbiprofen(a nonsteroidal anti-inflammatory drug NSAID) significantly reduced postoperative pain the use of an NSAID, the shorter-acting ibuprofen, as a preoperative prophylactic against the possibility of postoperative pain.
PERIRADICULAR PAIN
Periradicular pain may be almost as excruciating as pulp pain and may often continue for a longer period of time. Periradicular lesions that may produce discomfort are:-
(1) Symptomatic Apical Periodontitis
(2) Symptomatic Apical Abscess
(3) Asymptomatic apical abscess
(4) Apical cyst. The adjective “acute,” as used here, refers to the severity and the rapidity of the course of the lesion. Acute apical periodontitis is by far the most distressing periradicular lesion.

Symptomatic Apical Periodontitis:-
Symptoms. This acute form of periradicular pain can be most excruciating and sometimes lasts for days. The tooth is exquisitely painful to touch, and even contacting the tooth in closure may bring a flood of tears. The pain is most persistent, lasting 24 hours a day. The pain has been described as constant, gnawing, throbbing, and pounding. Eventually, the patient may gain blessed relief, only to bite on the tooth while eating or during sleep, which starts the pain cycle once more.
Examination. the patient is in severe pain, and the involved tooth isexquisitely painful to touch. The tooth is in supraocclusion, and the mandible cannot be closed without initial impact on the involved tooth.
Treatment.
? To relieve the pain, an immediate injection of a long-lasting local anesthetic.
? The occlusion should be adjusted to free the tooth completely from contact in closure.
? A rubber dam should then be placed and the temporary filling removed very carefully.
? The tooth must be supported with the fingers to prevent further trauma.
? Determination of accurate tooth length is most important.
? Cleaning the root canal & use of intracanal medicaments.
? The corticosteroids as anti-inflammatory agents has improved the treatment anti-inflammatory antibacterial medicament.
Acute Apical Abscess:-
The pain of AAA is similar to that described for AAS but somewhat lower in intensity. After all, necrosis is an extension of the inflammatory cycle, which begins with acute apical periodontitis and continues to the abscess state if not checked. a full systolic throbbing pain, particularly on palpation. The involved tooth is also painful to movement or mastication.
Examination. Diagnosis of AAA is a relatively simple matter. The patient has pain and, invariably, swelling. Although the swelling may not always be observable to the examiner, the patient feels the tenseness of the swollen area. The degree of swelling varies from the initial, undetected swelling to gross cellulites and massive asymmetry.
Tooth also is extremely painful to percussion or palpation.
Radiographically:- The picture may vary from a widened periodontal space to a large alveolar radiolucency. Actually, the radiograph is not the best means of diagnosis because it frequently reveals nothing of true diagnostic value.
Electric pulp testing is the best method of diagnosis because the pulp of the tooth involved in AAA is invariably necrotic. The vitality test, moreover, is the best criterion to differentiate an AAA from an acute periodontal abscess. Thermal tests have little value. Extremes of heat may increase gas expansion in the area and thereby increase the pain momentarily. Cold may give slight relief but usually does nothing at all. Palpation of the area reveals the swelling, and the pressure increases the discomfort.
Treatment. Suffice it to say here that drainage is established through the root canal if the abscess is in its initial stage, or by incision if the abscess is fluctuant. Trephination may also be performed to establish drainage and relieve pressure. The occlusion is relieved and a regimen of systemic antibiotics and either hot rinses or cold applications is prescribed for the patient depending on the stage of development of the abscess.
Chronic Apical Abscess:- Also called:-
(Suppurative apical periodontitis):-
CAA is generally free of symptoms. There may be stages in the long history of such a lesion when a draining fistula closes, and mild swelling and discomfort ensue. The patient reports that the abscess drains daily or that opening the abscess with a needle relieves the discomfort.
Examination. It is frequently associated with long-standing dental restorations such as full gold or jacket crowns, large composites or amalgams, and extensive bridgework. Occasionally, a routine radiograph reveals a CAA, associated with a discolored anterior tooth. This may appear as an area of diffuse radiolucency around the apex of the tooth in question and may vary from a minor lesion to a massive loss of bone. External resorption of the root end is also a common finding.
Treatment. If the tooth involved with CAA can be saved, it may be retained by endodontic therapy. Periradicular surgery is sometimes indicated for these pathologic lesions. The chronic lesion that becomes acutely infected must be treated as an AAA until the symptoms have subsided. The tooth may then be handled as an endodontic case or extracted, as conditions indicate. Apical Cyst. The apical cyst is painless unless it becomes infected. In that event, the case should be handled as an AAA.
PERIODONTAL LESION PAIN
Two uncomfortable lesions that involve the gingiva and mucosa are acute necrotizing ulcerative gingivitis and herpes simplex. These diseases offer no severe problems in the differential diagnosis of pain because both lesions are diagnosed from their appearance and/or odor.
Two painful conditions that involve the pericemental structures and must be differentiated are the acute gingival or periodontal abscess and pericoronitis.
Acute Gingival or Periodontal Abscess:-
The patient with an acute periodontal abscess seeks treatment for a tooth that is painful to move or to bite on. The pain, however, is not as deep-seated or throbbing as that of an AAA. Although some localized swelling is present, it is not as extensive as with the AAA. different; the periodontal abscess “points” opposite the coronal third of the root, whereas the apical abscess generally “points” opposite the apex.
Treatment. Referre to a periodontist.
Pericoronitis:-
The common complaint of the patient with pericoronitis is severe radiating pain in the posterior mouth and the inability to comfortably open or close the mandible.
Occasionally, an erupting third molar elicits the same deep, spreading pain well before the tooth breaks through the oral epithelium.
Examination. The history of trismus and discomfort on opening or closing the mandible is indicative of pericoronitis When the operculum is palpated or probed, it is found to be swollen and painful. The patient usually assumes that it is the tooth that is painful.
Treatment. Referre to an oral surgerion.
REFERRED PAIN
Symptoms. Pain from pulpalgia from a tooth is felt in an other tooth and/or oral structures & vise versa.for example:-
Pain is referred to teeth when the patient has mumps or Inflammation of the temporomandibular joint & pain is felt in mandible , temporal area , or the eye when toothache in the same side occur .
EXTRAORAL PAIN
As explained above, pain from sources outside the oral cavity may refer into the oral cavity. The reverse is also true.
Atypical Toothache or Atypical odontalgia
Patients present themselves with all of the typical features of an acute toothache severe, throbbing, Continuous pain starting in one quadrant but spreading even across the midline. Also referred to as “dental migraine”or “phantom tooth pain,” this condition is often associated with patients suffering from unipolar, or common, depression
Salivary Gland Disorders
The salivary glands can be affected by many diseases, including obstruction, infection, degeneration, and tumor growth. Pain and tenderness, however, are usually found in association with inflammation of the gland itself. In Sj?gren’s syndrome, parotitis is also accompanied by diminished salivation and lacrimation and some other connective tissue disorder, such as lupus erythematosus or rheumatoid arthritis. Pain from any of these conditions will refer to the teeth.
Sinus and Paranasal Pain
Sinusitis is a common cause of dull, constant pain.The location of this pain can vary from the maxilla and maxillary teeth in maxillary sinusitis to the upper orbit and frontal process in frontal sinusitis, between and behind the eyes in ethmoid sinusitis, and at the junction of the hard and soft palate, occiput, and mastoid process in sphenoid sinusitis. Pain from the sinuses may be referred into the oral cavity, the teeth in particular. The reverse is also true; that is, pain from the teeth or from periradicular lesions may be discerned as sinus pain or may be the source of maxillary sinus disease.