Non Pulpal Diseases Mimicking Pulpal Diseases PDF

Non Pulpal Diseases Mimicking Pulpal Diseases Endodontics Asgeir Sigurdsson, cand. odont. MS Chairman of the Quartararo Department of Endodontics [email protected] PAIN Pain has an element of blank; It cannot recollect When it began, or if there were A day when it was not. Emily Dickinson What i...

Non Pulpal Diseases Mimicking Pulpal Diseases Endodontics Asgeir Sigurdsson, cand. odont. MS Chairman of the Quartararo Department of Endodontics [email protected] PAIN Pain has an element of blank; It cannot recollect When it began, or if there were A day when it was not. Emily Dickinson What is PAIN? Pain is an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage. International Association for Study of Pain, 2020 What is PAIN? Notes: Pain is always a personal experience that is influenced to varying degrees by: • biological, • psychological, and • social factors. International Association for Study of Pain, 2020 How do we find the source of the pain? Examination: "Dental diagnosis are mainly established by what we see not what we hear" "Pain diagnosis are mainly established by what we hear not what we see." (Okeson) PAIN How does one measure pain? ???????? Reaction Noxious Stimulation Pain Sensation Sensory Discriminative Affective How does one measure pain? Historically simple pain scales have been used in clinical settings: 1 , 2, 3 0, 1 , 2, 3, 4, 5 0, 1 , 2, 3, 4, 5, 6, 7, 8, 9,10 What does 0 mean? What does 10 (or highest number mean? ü No sensation at all? ü Painful sensation ü No pain sensation? ü A lot of pain? ü Tolerable pain? ü As much pain as imaginable? Does this scale capture both intensity as well as the type of the pain? AND does the patient understand numbers at all?? How does one measure pain? Historically simple pain scales have been used in clinical settings: Does this scale capture both sensory as well as emotion or is it just emotions? How does one measure pain? Historically simple pain scales have been used in research settings: ü Visual Analogue Scale (VAS) where the pain is rated by marking on a line with a predetermined length usually 100 mm. None Severe Sensory Fibers in the Pulp Fiber A-b (beta) A-d (delta) C Size mm Sensation Conduction rate m/sec Light touch 15 - 30 6-7 Heavy Sharp pricking 5 - 30 1- 5 "Thin" Long lasting Burning 2-5 1-3 None Myelin Neurofibers in the Pulp Normal healthy vs inflamed human pulp: Those subjects who experienced pulsating, dull, lingering pain (clinically diagnosed as pulpitis) showed a poor correlation between magnitude estimates of their mixed pain percepts and the total flux of A-delta nerve activity. (Ahlquist and Franzen 1994) Examples of Pain Intensity Rating Scales Gracely verbal descriptors: Affective Very Intolerable Intolerable Very Distressing Slightly Intolerable Very Annoying Distressing Very Unpleasant Slightly Distressing Annoying Unpleasant Slightly Annoying Slightly Unpleasant Neutral Sensory 44.8 32.3 18.3 13.6 12.1 11.4 10.7 6.2 5.7 5.6 3.5 2.8 0.0 Extremely intense 59.5 Very Intense 43.2 Intense 34.6 Strong 22.9 Slightly Intense 21.3 Barely Strong 12.6 Moderate 12.4 Mild 5.5 Very Mild 3.9 Weak 2.8 Very Weak 2.3 Faint 1.1 Nothing 0.0 Gracely et al. 1979 Non Pulpal Diseases A retrospective survey of a sample of patients referred for endodontic treatment: 88% correctly diagnosed with solely endodontic problems. 9% had endodontic plus other orofacial pain problems. 3% had no endodontic problems but other orofacial pain problems. (J Linn et al. 2007) Non Pulpal Diseases A prospective study of complex non-dental orofacial pain cases: 44 of 100 non-dental orofacial pain patients had previously received either extractions or endodontics. (J Linn et al. 2007) Non Pulpal Diseases Diagnostic delay and suboptimal management in persistent idiopathic facial pain and persistent dentoalveolar pain; a cross-sectional study n=34 The average time between the onset of symptoms to correct diagnosis was 19.3 + 11.1 months. Diagnostic delay was significantly longer in patient with pain localized to intraoral sites (22.6 + 7.4) compared with patients with extraoral pain (16.1 +9.3). (Hassona Y et al. 2019) Non Pulpal Diseases Examination: It is important to remember that the primary source of the pain does not have to be the chief complaint of the patient! ? Referred Pain from Teeth (Head 1922, Glick 1962) Referred Pain from Teeth (Head 1922, Glick 1962) Referred Pain from Teeth Dr. Glick, 1962 in OOO ü The referred pain did not cross midline. ü The referred pain was not only felt in the deep but also to the superficial or cutaneous tissues. ü Lower teeth were more likely to refer to upper teeth than upper to lower Referred to Teeth and/or Face from other sources (Travell 1960) Non Pulpal Diseases Prior to any invasive procedure: - An 'educated' diagnosis has to be made. - Any possible differential diagnosis has to be ruled out. ? How do we find the source of the pain? Prior to any invasive procedure: Examination: üChief complaint – History of the pain Changes in the pain Current status of the pain When, Where, How …… ? Non Pulpal Diseases Prior to any invasive procedure: Examination: If in doubt about the diagnosis: üGet a second opinion. üIf not life threatening "wait and see". ? Pulpal Diseases Pulpitis: Chief Complaint: pain and/or discomfort; - Initially primarily A-delta fibers, later C - Frequently difficult for the pt. to locate. Tooth or teeth in the area; - that have deep restorations or decay. Vitality testing (e.g. ice) confirms vital but possibly hyper-sensitive pulp. Problem Solving Endo During Cleaning and Shaping: Most commonly missed canals: – Second M-F canal in upper molars: 94.2% of all upper first molars have 2 mes. Canals. (Pineda 1973) – Second canal in lower anteriors: 30% centrals and 45% laterals have 2 canals. (Fahid and Taintor 1983) – Second canal in lower first premolars: 27% first premolars have 2 canals. (Zillich and Dowson 1973) – Second canal in distal root of lower molars: 29% first molars have 2 canals in the distal root. (Green 1973) Non Pulpal Diseases Other tooth/teeth with pulpitis: Carefully listen to the patient and then try to reproduce the symptoms. Vitality testing should confirm vitality in the wrong tooth. Pulpal Diseases Necrotic pulp: Chief Complaint: dull pain and/or discomfort; - No pain from pulpal fibers after first few days; A-delta fibers survive only for a very short time in the anoxic area, C-fibers possibly for few days. - Frequently difficult for the pt. to locate due to neuroplastic changes in the CNS. Tooth or teeth in the area; - that do not respond to vitality testing. Non Pulpal Diseases Angina Pectoris Chief Complaint: pain in lower left jaw; - pain episodes usually associated with exercise. Up to 18% of all angina pt. do only get symptoms in the jaw/teeth that can be bilateral. (Natkin 1974) Non Pulpal Diseases Angina Pectoris Prospective, consecutive patients with a verified cardiac ischemic episode (n = 186) Craniofacial pain was the only complaint during the ischemic episode in 6%, - 1/4 had acute myocardial infarction (AMI) at the time of complaint. Another 32% reported craniofacial pain concomitant with pain in other regions. (Kreiner M et al. JADA 2007) Non Pulpal Diseases Angina Pectoris Prospective, consecutive patients with a verified cardiac ischemic episode (n = 186) The most common craniofacial pain locations were: - throat, - left mandible, - right mandible, - left temporomandibular joint/ear region - teeth. Craniofacial pain was preponderantly manifested in female subjects and was the dominating symptom in both sexes in the absence of chest pain. (Kreiner M et al. JADA 2007) Non Pulpal Diseases Angina Pectoris Prospective, consecutive patients with a verified cardiac ischemic episode (n = 186) In the absence of chest pain, craniofacial pain is far more common than pain in any other area. “Since patients who have myocardial infarction without chest pain run a higher risk of experiencing a missed diagnosis and death, the dentist’s awareness of this symptomatology can be crucial for early diagnosis and timely treatment.” (Kreiner M et al. JADA 2007) Orofacial Pain and Toothache as the Sole Symptom of an Acute Myocardial Infarction Entails a Major Risk of Misdiagnosis and Death During myocardial ischemia, orofacial pain is reported by 4 in 10 patients and described as oppressive and/or burning. Up to 4% of myocardial infarction patients experience pain solely in the orofacial structures, women more often than men. (Kreiner M et al 2020) Orofacial Pain and Toothache as the Sole Symptom of an Acute Myocardial Infarction Entails a Major Risk of Misdiagnosis and Death (Kreiner M et al 2020) Non Pulpal Diseases Angina Pectoris Chief Complaint: pain in lower left jaw; - pain episodes usually associated with exercise. Careful medical/symptoms history usually reveals several risk factors and indications. Vitality testing confirms vital pulps. Non Pulpal Diseases Malignant lesions of the jaws: Chief Complaint: usually minor or no discomfort. Few case reports where malignancies have caused pain in jaw/teeth, usually getting worse over long period of time. Vitality testing may be conflicting. Non Pulpal Diseases Malignant lesions of the jaws: Non-Hodgkin’s lymphoma: Can cause swelling, non-vital pulp and periapical lesions without obvious causes. (Bavitz et al 1992) Tissue biopsy will confirm malignancy. Vitality testing may be conflicting. Non pulpal So what else is out there? Non Pulpal Diseases Salivary Glands: Chief Complaint: moderate to severe pain - pain usually associated with eating. Could have swelling - submandubular/parotid gland infection or blockage. Decreased or absent salivary flow. Vitality testing confirms vital pulps. Non Pulpal Diseases Maxillary sinusitis: Chief Complaint: pain in the maxillary teeth; - pain usually very diffused, not in a single tooth. - can be uni- or bilateral. - pain gets worse with sudden movements. - often history of congestion or cold. Vitality testing confirms vital pulp; - teeth can be hypersensitive to cold. - teeth are often sensitive to percussion. Non Pulpal Diseases Trigeminal neuralgia Chief Complaint: pain that comes in bursts; -pain episodes usually short (milli second to few seconds) and no pain in between. -pain does usually not affect the sleep of the pt. Careful palpation of the affected area should reveal a 'Trigger Point' that if touched will cause the pain. Females (post menopause) >>Males Vitality testing confirms a vital pulp. Non Pulpal Diseases Trigeminal neuralgia Etiology not clear one theory calls for anatomical lesions in various structures like: skin, pulp, blood supply to the face and trigeminal nerve, peripheral branches of the nerve, gasserian ganglion, posterior root and brain stem nuclei of the trigeminal nerve. Roberts A M, Person P 1979. Ratner E J, et al. 1979 Non Pulpal Diseases Trigeminal neuralgia Another theory calls for compression of the trigeminal root adjacent to the pons, usually by an artery, occasionally a vein and rarely a small neoplasm. Jannetta P J, 1967 Non Pulpal Diseases Persistent Idiopathic Facial Pain (Atypical Odontalgia): Chief Complaint: moderate to severe pain - can be sharp shooting over to dull radiating Does not always have a trigger-point equivocal results with local anesthetic Often perfectionist / obsessive personality Vitality testing might be conflicting. Non Pulpal Diseases Persistent Idiopathic Facial Pain (Atypical Odontalgia): Etiology unknown: Marbach (1989) “phantom tooth pain” or “deafferentation pain” secondary to trauma like: ØExtraction of a tooth ØPulpectomy ØAlveolar fracture Atypical Odontalgia (Malacarne A, et al 2018) Non Pulpal Diseases Persistent Idiopathic Facial Pain (Atypical Odontalgia): Patients frequently seek out multiple providers from various specialties in search of a more satisfying diagnosis. Subsequently, they may receive invasive and unnecessary procedures with little to no relief from their pain. (Weiss AL et al 2017) Non Pulpal Diseases Persistent Idiopathic Facial Pain (Atypical Odontalgia): “Although far from proven, a deafferentation associated with peripheral nerve injury may be responsible for some types of atypical facial pain.” Yair Sharav, Textbook of Pain, 1996 Central sensitization may account for the persistent facial pain Melek LN et al. 2018 Non Pulpal Diseases Herpes Zoster: Chief Complaint: acute pain - pain only in the involved neural-segment. Skin lesions usually apparent after few days. Careful medical history usually reveals some risk factors like emotional stress, age, imunocompromising diseases. Vitality testing confirms initially vital pulps, pulp(s) in the involved area can become necrotic! Non Pulpal Diseases Cluster headache: Chief Complaint: severe unilateral headache in orbit / periorbit / temporal. Male:female 6:1 Could have certain triggers, including dental pain or discomfort or be confused with referred pain from tooth or teeth. Vitality testing confirms vital pulps; 100% O2 for 15 min will significantly reduce the pain. Non Pulpal Diseases “Cluster headache”: Cocaine snorting has been reported triggering pain in the maxillary premolar area similar to cluster headache or odontalgia. - Onset 1 to 2 hours after use. - Lasting 30 to 120 min. - Another cocaine hit will counteract the pain in 5 to 10 min. (Penarrocha et al. 2000) Non Pulpal Diseases 'Drug seekers': Chief Complaint: pain everywhere or in a specific site; - pain report often follows 'text book' symptoms. No medical reason can be found for the pain; - often refuse treatment. - often ask for specific drugs. - often have very good pharmacology knowledge. Vitality testing always unreliable; - sometimes these pt. do have a burnt down tooth. Non Pulpal Diseases 'Drug seekers': Remember 'prescription' drug abusers are often elderly housewives that no one would suspect of anything but good things. se: Dorr LA; Prescription drug abuse: it could happen to somebody's mother. (1992) Non Pulpal Diseases 'Munchausen syndrome’ or ‘Munchausen by-proxy’: Chief Complaint: pain everywhere or in specific site - pain report often follows 'text book' symptoms. No medical reason can be found for the pain; - 'patient' wants a treatment without any apparent drug or financial gain from the treatment. Careful medical history often reveals many complex medical treatments. Vitality testing usually unreliable. (Scully C. et al. 1995, Stirling J. 2007) Non Pulpal Diseases 'Munchausen syndrome’ or ‘Munchausen by-proxy’: Beyond Munchausen Syndrome by Proxy: Identification and Treatment of Child Abuse in a Medical Setting John Stirling, Jr and and the Committee on Child Abuse and Neglect Pediatrics2007;119;1026-1030 Non Pulpal Diseases Examination: It is important to remember that the primary source of the pain does not have to be the chief complaint of the patient! Non Pulpal Diseases Prior to any invasive procedure: Examination: Document ALL findings Non Pulpal Diseases " We made too many wrong mistakes" Yogi Berra