The nature of such pain may be spontaneous or may be induced in various ways. It can be intermittent or continuous but with lancinating exacerbations that radiate throughout the face and head. Dental pain is usually described as an aching sensation; sometimes throbbing, and when severe, may have a burning quality.
Pulpal pain
Pulpal pain may be classified as acute, chronic, and recurrent or mixed with periodontal element. Pulpal pain may resolve, become chronic or proceed to involve the periodontal structures by direct extension through the apex of the tooth root.
Acute pain
It is, most of the times, not completely localized by the patient.
Objective evidence such as deep caries, erosion, fracture or splitting may immediately identify the offending tooth.
The cause of acute pulpal pain is noxious stimulation of the pulpal receptors.
If the tooth structure is breached by splitting, a normal pulp may immediately become painful on contact with saliva or air. This occurs especially when masticatory stresses tend to open the split.
These conditions may be reversible unless congestion occurs causing pulpal gangrene.
The pain threshold of all deep receptors and nerve fibers that mediate pain is lowered by sustained hyperemia or inflammation. Thus, dental pulp that is hyperemic or inflamed is hypersensitive to all stimuli including electric stimulation, thermal shock, probing and percussion. And as the inflammatory process progresses spontaneous toothache may occur without any outside provocation.
Acute pulpal pain may range from occasional hypersensitivity caused by sweet and other minor stimulants to spontaneous violent throbbing toothache of intolerable intensity. It may be induced by any type of irritant or be wholly spontaneous.
• It may be increased by both heat and cold or increased by heat and relieved by cold.
Pain may start without any apparent external irritation and frequently occurs at night when the patient lies down or when the patient leans down, most probably because of an increase in blood pressure.
The difference between a hyperemic pain caused by thermal reaction and acute pulpitis is that in acute pulpitis the pain does not necessarily resolve when the irritant is removed but continues to ache for few minutes and possibly for hours.
The usual relief for advanced acute pulpitis is cold water. Heat is the exciting factor in advanced acute pulpitis.
Chronic pain
Injured pulpal tissue may progress from an acute to chronic inflammatory phase.
It results from a continued low grade infection.
When chronic pulpitis occurs, pain response changes from extremely variable character of acute pulpal pain to milder and less variable vague discomfort that may not be described as pain at all. Tooth may become symptomless.
Toothache from dental cause
Pain referred to teeth from inflamed nasal mucosa, nonspastic myofacial pain especially involving temporalis and masseter muscle, myofacial pain- dysfunction syndrome, pain of the heart muscles as a symptom of cardiac disease.
• Neuritic pain such as those involving the maxillary teeth from inflammatory involvement of the superior dental plexus by the disease of the antrum and from neuritic conditions of the inferior alveolar nerve.
Neuralgic pain
Psychogenic pain
Periodontal pain
The receptors of the periodontal ligament are capable of rather precise localization of the stimulus, therefore periodontal pain of all types present no difficulty in diagnosis.
The offending tooth is identified by applying the pressure to it laterally or axially.
It may occur as a primary periodontal inflammatory condition due to local causes such as trauma, occlusal stress, and contact with an adjacent embedded tooth, dental treatment like dental prophylaxis, occlusal interference, over contoured or under contoured, proximal contact area.
It may result from spread of pulpal infection or by direct extension from a nearby inflammatory condition involving an adjacent tooth, the maxillary antrum, or a spreading osseous infection.
When periodontal pain involves several teeth, especially opposing teeth, then occlusal overstressing either by clenching or bruxism should be considered. Overstressing of posterior teeth may occur as a result of decreased vertical height of the mandibular ramus due to osseous fracture or degenerative changes in the TMJ.
Musculoskeletal Pain
Pain arising from musculoskeletal structures present clinical characteristics by which they may be differentiated from other causes of deep pain;
The pain relates reasonably and logically to use, movement and the demand of function.
The pain can be provoked or aggravated by manipulation of the structure involved.
The pain is usually but not always accompanied by some dysfunction.
Muscle pain
Muscle pain frequently occurs in otherwise normal area, as a result of reflex protective mechanism and myofacial triggers.
Muscle pain is usually felt as a non-pulsatile variable aching sensation, sometimes having a boring quality. The pain may become more lancinating and may occur spontaneously and in response to stretching, contraction, manipulation or manual palpation.
Sometimes, pain is not more than a feeling of pressure whereas sometimes its intensity is increased. It may be transitory, persistent, constant, intermittent or recurrent.
Dysfunction may be expressed as tightness and weakness or impairment of muscle function such as stiffness, rigidity, swelling and tenderness on palpation. The fact that movement and functioning modify the pain and stiffness are clinical indications of the presence of muscle pain.
Local muscle soreness
• It is a local condition with a local cause.
It is a primary hyperalgesia with lowered pain threshold due to local factors such as strain, injury, abusive use, infection and inflammation.
• It is accompanied by symptoms, accurately localized by the patient and obvious dysfunction.
• When the dysfunction involves elevator masti- catory muscle, trismus may result, restricting the normal mouth opening.
When the muscle becomes inflamed as a result of injury or infection, the pain may relate to irritation and pressure of inflammatory exudates.
The source of muscle pain may be Related to accumulation of metabolites after excessive use.
• Distortion of blood vessels within the muscle, ischemia and hyperemia.
Forceful and sustained contraction causing vasoconstriction of the relevant nutrient arteries. Soreness of masticatory muscle may develop due to
Unusual yawning, biting, chewing and strained sleeping position
From minor blows, playing a musical instrument, period of sustained emotional tension.
Bruxism, excessive or prolonged opening for dental treatment and use of local anesthetics.
Muscle splinting pain
It is defined as rigidity of the muscle occurring as a means of avoiding pain caused by movement of the part. It is a reflex protective mechanism whereby skeletal muscle becomes hypertonic and painful when contracted.
Il differs from muscle spasm in which contraction is sustained even when the muscle is at rest.
There is pain and restriction of movement during active contraction of the involved muscle with little or no evidence of pain and restriction when purely passive movement is executed.
Splinting of masticatory muscle may occur as a protective mechanism in conditions such as toothache, occlusal interference, sensitive over- stressed teeth, and effect of local anesthetics, surgery, and trauma.
Sustained splinting may develop into muscle spasm.
Nonspastic myofacial pains
There is no muscle spasm and pain is the only complaint and this is generally referred to structures outside the muscle proper.
Certain muscles tend to develop trigger areas within the muscles or tendons.
When these sites are stimulated by ordinary function (contraction and stretching) pain impulses are generated and pain may or may not be sensed in the muscle.
There is secondary referred pain which is felt in structures located some distance from the trigger site and thus the pain may be felt in adjacent normal structures.
It may be caused by atrophied muscles due to inactivity, sustained emotional tension, illness, nutritional deficiency.
Once the myofacial triggers develop within the muscle, they tend to persist as a source of intermittent and recurrent pain when the triggers are stimulated.
Zones of pain reference from myofacial triggers
The masseter muscle refers to the ear, TMJ and mandibular teeth
• The temporalis to the temple, orbit and maxillary teeth
The medial pterygoid to the infra-auricular and postmandibular area
The lateral pterygoid to the TMJ
The sternomastoid to the ear, pre-auricular area and widely throughout the face.
• The splenius capitis to the parietal region.
• Trapezius to the neck, temple and frontal region. Among the neck conditions that the dentist should
be familiar with, are
Chronic cervical muscle spasm
Acute cervical strain
Osteoarthritis of the cervical spine
Scalenus anticus syndrome