Diagnosis of pulpal pain |
Dentistry Club
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TYPES AND FEATURES OF PULPAL AND RELATED PAIN Reversible pulpitis Pain of short duration on response to hot, cold or sweet things. Relieved by analgesics. Poor pain localisation. Irreversible pulpitis Pain of long duration, often worse with hot stimuli, may be throbbing and dull in nature, better pain localisation than reversible pulpitis, not always relieved by analgesics. Periapical periodontitis Dull, throbbing, often constant pain; frequently kept awake, patient can usually localise pain to a particular tooth, tender to chew on tooth, poor relief by analgesics. HISTORY Pain history is important in the diagnosis of pulpal pain. Important features are: PAIN QUALITY Sharpness Sharp pain can indicate, e.g. exposed dentinal tubules, fractured cusp. Dullness May indicate pulpal hyperaemia. Throbbing Throbbing pain, particularly if constant, may indicate an irreversible pulpitis. DURATION Short (i.e. a few seconds) can indicate a reversible pulpitis but may indicate pain of non-dental origin, e.g. trigeminal neuralgia Constant Often indicates irreversible pulpitis or one of its sequelae. STIMULI Reaction to heat Often irreversible pulpitis if reacts to heat but not cold. Reaction to cold Often reversible pulpitis, exposed dentine or cracked cusp. These conditions also often react to heat. Reaction to pressure May indicate periapical or periodontal abscess. Reaction to release of pressure may indicate a cracked cusp. Reaction to sweet stimuli Frequent occurrence in reversible pulpitis. SITE AND RADIATION History should indicate the primary site of pain and where it radiates. Pain in teeth adjacent to the tooth the patient suspects as the cause of pain or opposing arch is common. Referred pain from non-dental causes (e.g. sinusitis) should be borne in mind. Pain localisation is particularly difficult in low-grade reversible pulpitis and in children. TIMING Pain pattern day and night is important. Pulpal pain is often worse at night. A pain history gives the dentist a guide as to the source of pulpal pain. It does not produce a diagnosis on its own. CLINICAL EXAMINATION In dealing with pulpal pain, the examination should be conducted as follows: VISUAL Look for: • obvious cavities • cracked cusps • fractured restorations • swelling • sinus tracts. PROBING To aid visual examination. PERCUSSION When coupled with pain history, tenderness on percussion is an important feature of irreversible pulpitis, periapical periodontitis and periapical abscess. Percussion should be in an apical and lateral direction and several ‘control’ teeth should be percussed to check responses. Special tests are extremely useful in confirming suspicions from a pain history and examination. SENSIBILITY (VITALITY) TESTING Use heat, cold, electric stimuli. Important to use ‘control’ teeth. May indicate normal, exaggerated or no response to stimulus. LASER DOPPLER Measures pulpal blood flow and gives an indication of pulpal vitality. Money Making Opportunities |
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