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Endodontic diagnosis. Mystery or mastery?

UNLABELLED: Review of 6 clinical distinctions: (1) Symptom: "anything under the sun." DIAGNOSIS: pulp exposure. Duplicate: clinical or radiographic pulp exposure evidence. TREATMENT: endodontics or pulp cap under strict protocol conditions. (2) Symptom: "cold." DIAGNOSIS: hyperemia. Duplicate: ice. TREATMENT: pulp protection or endodontics. (3) Symptom: "heat." DIAGNOSIS: pulpitis. Duplicate: heat. TREATMENT: pulpotomy for multirooted teeth or pulpectomy for single-rooted teeth. Schedule endodontic completion. (4) Symptom: "I recently had a toothache and now it is gone." DIAGNOSIS: necrosis. Duplicate: Electric Pulp Test and ice are negative. TREATMENT: endodontics. (5) Symptom: "I had a toothache awhile back and now it is gone." DIAGNOSIS: LEO. Duplicate: Electric Pulp Test, ice, and test cavity are negative. TREATMENT: endodontics. (6) Symptom: "It really hurts to touch my tooth." DIAGNOSIS: percussion. Duplicate: may or may not have a LEO and may or may not have cellulitis. TREATMENT: reduce occlusion, access cavity, water chew, and schedule to finish endodontics. If these tests are carefully performed, then they are objective and the doctor does not have to be in a subjective situation. A newfound sense of endodontic diagnostic mastery is experienced. Perhaps the best way to summarize the simplicity of this clinical diagnostic scheme is to quote Sherlock Holmes: "Nothing is more deceptive than the obvious."

Dental Pulp Diseases↗

[Vertical root fracture--case report and clinical evaluation].

It is observed at the Dental OPD that some of the patients suffer from toothache are due to tooth fracture. Of the various types of tooth fracture, it is noted that vertical root fracture of molars which have never undergone endodontic treatment has rarely been reported. It is suggested that x-ray examination is the best diagnostic tool as it would show a certain section of the abnormally large root canal. This will indicate a fracture in the root. As the fractured root is mostly very poor in prognosis, the tooth in question should be extracted or it can be treated with root amputation or hemisection to eradicate the fractured root. Three cases of vertical root fracture are reported. The intent of this paper is to probe such cases, the means of diagnosis, and their treatments in clinical practices. Dental colleagues are thus advised to take into consideration the possibility of vertical root fracture whenever patients complain about toothache without any apparent cause.

Adult↗

Sensation and experience of pain in children.

The study explored children's self-assessment of the pain experience and to understood the relative factors that influence the words used to represent children's pain. Using an outline of a human figure and a section of the open questionnaire to study, 106 nine- to sixteen-year-old children marked their pain location using colors to represent pain. They rated the intensity and duration of their pain, and described their experience of pain (sensation, causes, and ways to manage pain). The results showed that children clearly described pain, that there were appreciable differences between feelings of headache, leg pain, backache, and shoulder pain with pain intensity and duration of pain; that explained the difference of occurrence of abdominal pain in cross effect between age and sex; that explained the difference of the occurrence of toothache in cross effect among triangle of hospitalized experience, age, and sex; that there was significant relationship between abdominal pain and family structure. For severe abdominal pain or toothache the children could ask doctors for pain relief. For the others, they could take medication or rest for their middle or mild abdominal pain. The ways to manage leg pain were injection and massage. Change of position was applied to relieve backache. From the children's self-reports, we understand that causes of children's pain were derived from bad sleep, food, decayed teeth, exercising, and hitting. Pain avoidance is best achieved by accident prevention, cultivation of good health habits, and integration of daily living skills.

Adolescent↗

Malignant neoplasms of the maxillary antrum in Nigerians.

OBJECTIVE: To highlight the presentation of antral cancers in Nigerians. PATIENTS AND METHODS: Hospital records of all patients with a histologically diagnosed antral cancer who presented at the Lagos University Teaching Hospital (a tertiary referral centre) over a 16 year period were analysed. RESULTS: 28.7% of orofacial cancers and 12.6% of head and neck cancers were located in the antrum. 54.1% were squamous cell carcinoma, 27.4% were minor mucus gland carcinoma and 14.8% were mesenchymal cancers. Males were more frequently affected (ratio 1.7 to 1) and were relatively younger (peak age = 4th decade) than females (peak age = 6th decade). Males who had squamous cell carcinoma (x = 47.5 +/- 18.8 years) were relatively younger than their female counterparts (x = 57.2 +/- 13.8 years). But females with minor mucus gland carcinoma were relatively younger (x = 34.2 +/- 19.5 years) than males (x = 49.1 +/- 17.9 years). All patients had facial swelling at presentation and the most frequent initial symptom was toothache (36.2%). Fifty-two percent had prior treatment and the most common was an extraction of a molar tooth (50%). Two-thirds of the patients were of low socio-economic status. CONCLUSION: Antral cancer constituted sizeable proportion of orofacial and head and neck cancers in Nigerians. Clinicians need to maintain a high index of suspicion in cases of maxillary molar toothache or mobility of obscure aetiology. Predisposing aetiologic factors of this disease peculiar to our environment need to be further investigated.

Adolescent↗

Present state of dental health knowledge, attitudes/behaviour and perceived oral health of Japanese employees.

The aim of this survey was to assess the present state of dental health knowledge, attitudes/behaviour and perceived oral health of Japanese employees. A 60-item questionnaire was used in a dental health project in the work place. The subjects comprised 77,845 employees, 76 per cent of whom reported delaying a dental visit until they had toothache, with about 60 per cent delaying even when they discovered a decayed tooth. The majority did not regard decayed teeth as a disease and only a minority reported regular dental visits. About three quarters reported bleeding gums on brushing, although more than half had never been taught professionally how to clean their teeth and less than 5 per cent flossed daily. More than half believed that false teeth were inevitable in old age, and that their teeth were getting worse despite daily brushing. About 70 per cent of the employees thought that it was impossible to prevent gum disease with toothbrushing alone, and nearly half believed a toothpaste with fluoride was effective in preventing periodontal disease. Reorientation of oral health care in Japan, therefore, is urgently needed and dental services have to be provided for the implementation of systematic oral health promotion for employees in the workplace.

Adolescent↗

Needs and demands for dental care in patients attending the University Dental Hospital in Sri Lanka.

AIMS: To determine the needs and demands for dental care in patients visiting a university dental hospital. DESIGN: A cross-sectional study of first visit patients. SETTING: The University Dental Hospital in Peradeniya, Sri Lanka. PARTICIPANTS: A total of 849 first visit patients. METHODS: The main complaint of each patient was recorded and was considered as a measure of demand for dental care. Tooth based and orthodontic treatment needs were assessed using the WHO basic methods. Periodontal treatment need was assessed by the periodontal treatment needs system. Need for prosthetic care was also assessed. RESULTS: Thirty per cent and 23% of patients demanded treatment for decayed teeth and toothache respectively. Nearly 34%, 27% and 17% of patients needed surgical, restorative and periodontal care respectively for the main complaint. Of those seeking care, 94% needed treatment other than what was required for the main complaint. The predominant normative treatment need was for periodontal care (77%) whilst 47% needed restorations or extractions. CONCLUSION: Normative needs of patients demanding treatment were high and many had demanded treatment before acute symptoms had developed. However, delays in seeking care were evident. Further studies are needed to identify factors for delay in obtaining care.

Adolescent↗

Predictive factors for child behaviour in the dental environment.

AIM: This was to evaluate the potential factors that influence behaviour in the paediatric dentistry environment of children aged 48 to 68 months who have never before been to a dentist. STUDY DESIGN: Cross sectional. METHODS: Child behaviour was evaluated using the Frankl scale during both clinical examination procedures and prophylaxis. All mothers of the 118 children investigated underwent a test to assess their anxiety (Manifest Anxiety Scale-MAS) and responded to a questionnaire on the medical history of the child as well as socioeconomic factors. The children were given a test to assess their anxiety (Venham Picture Test-VPT). STATISTICS: The statistical tests adopted were the Chi-squared test and both simple and multiple unconditional logistic regression. RESULTS: Children with high anxiety, those had previously experienced toothache and those had behaved uncooperatively during prior medical experiences, had a greater probability of behaving uncooperatively during their first dental consultation. CONCLUSIONS: Dental professionals can identify the presence of predictive factors for child behaviour prior to the first clinical examination by including relevant questions in the dental and medical history, thereby facilitating a more positive initial contact between paediatric dentists and their patients.

Behavior Control↗

Focal renal cortical necrosis associated with zomepirac.

Anaphylactoid shock, disseminated intravascular coagulation, and anuric renal failure requiring dialysis occurred in a patient receiving zomepirac sodium for toothache. Although renal function showed gradual improvement after seven days of anuria, the recovery was slow and incomplete. Renal biopsy three weeks after the onset of renal failure revealed evidence of focal renal cortical necrosis. Association of zomepirac administration with renal cortical necrosis is not known to have been previously demonstrated. This observation adds another dimension to the previously reported renal complications of nonsteroidal anti-inflammatory agents, especially zomepirac. The proportions of lymphocyte subsets, as defined with monoclonal antibodies, and the proliferative response to mitogens were normal. The patient's lymphocytes showed no proliferative response to zomepirac. Serum complement components and immunoglobulin levels were within normal limits, and radioallergosorbent testing gave negative results. The mechanism of anaphylactoid reaction to zomepirac in this case, therefore, remains unclear.

Analgesics↗

Case series of four different headache types presenting as tooth pain.

Case reports in the literature discuss various headache disorders that present as pain in the face. The current understanding of neuroanatomy and headache mechanisms suggests that headache pain originates within intracranial structures and is then referred to the face, jaws, and teeth. This case series describes four patients, one each with migraine headache, cluster headache, paroxysmal hemicrania, and hemicrania continua, all of which who presented to dentists with the chief complaint of tooth pain. This is the first report of hemicrania continua presenting as tooth pain. It is important that dentists be cognizant of headache disorders so that they may be able to identify headache pains masquerading as toothache.

Adult↗

Trigeminal pain under vagus nerve stimulation.

Three epilepsy patients treated by cyclic continuous vagus nerve stimulation (VNS) experienced trigeminal pain during the periods of stimulation, which was reported as toothache in the left lower jaw, ipsilateral to the side of stimulation. The symptom occurred with a latency of days to weeks following an increase in stimulation current intensity (SCI). Trigeminal pain was reversible with decrease in SCI, or subsided due to habituation. These findings show that clinically relevant effects of VNS on nociception may occur. Because of the late onset and variable form of this side effect, trigeminal pain may not be regarded as VNS-related which may result in unnecessary diagnostic and therapeutic procedures.

Aged↗

Liaison psychiatry and psychology in dentistry.

Dentists are trained to provide treatment for patients with straightforward problems that respond to routine therapy and do not recur. However, patients may present to dentists and complain solely of physical symptoms such as toothache, headache, and facial pain: only after much inappropriate treatment these symptoms are revealed to be due to emotional disturbance. The dentist may spend hours investigating such patients, in some of whom dental pathology may be present, but the symptoms and ensuing disability cannot be satisfactorily explained as a result. There are other patients who are preoccupied by physical symptoms or by their appearance. In others, anxiety may manifest itself as a phobia, or a dysmorphic concern about certain aspects of their appearance. This article reviews the role of liaison psychiatry and psychology in dentistry.

Dental Anxiety↗

Incidence and possible causes of dental pain during simulated high altitude flights.

Of 11,617 personnel participating in simulated high altitude flights up to 43,000 feet, only 30 (0.26%) complained of toothache (barodontalgia). The cause of the barodontalgia in 28 episodes of pain in 25 of these subjects was investigated. Chronic pulpitis was suspected as the cause in 22 cases and maxillary sinusitis in 2. No pathosis was detected in the other four. In 10 cases in which the pulpitis was treated by root filling or replacing a deep filling, subsequent exposure to low pressure caused no pain.

Adult↗

Race/ethnic differences in health care use for orofacial pain among older adults.

The purpose of this study was to describe race/ethnic differences in the use of formal health care services for painful oral symptoms by older adults. We also considered the sex of the respondent rather than assuming that males and females within a specific racial group would use health care services similarly. To our knowledge, these specific utilization patterns have never been reported before in the pain literature.Telephone interviews were conducted on a stratified random sample of 1,636 community dwelling older (65+) north Floridians. A total of 5,860 households were contacted and screened, with 75.3% participating to the point where their eligibility for the study could be determined. Overall race/ethnic differences in patterns of health care use for orofacial pain were not found. However, when we stratified race/ethnicity by sex, Black females (37.6%) were the least likely to have visited a health care provider, followed by non-Hispanic White females (47.2%), non-Hispanic White males (49.3%), and Black males (62.7%). Point estimates of odds ratio, adjusting for financial differences, indicate that more non-Hispanic White males (OR=1.79) and Black males (OR=2.74) visited a health care provider than Black females. Our results also suggest that for older Black adults, financial constraints have a more significant impact on decisions about health care for orofacial pain than they do for non-Hispanic Whites. For non-Hispanic White respondents, characteristics of the pain symptoms were significant determinates of health care use for their painful oral symptoms. Pain at its worst was a positive predictor for four of the five analyses (jaw joint pain, painful oral sores, temperature sensitivity, and toothache pain). The duration variable (years with pain) was a negative predictor of health care use. This is consistent with the conclusion that individuals seek care early in the course of the symptom, i.e. an active care seeking phase, make emotional or physical adjustments, and then resign themselves to the symptoms.

Black or African American↗

Orofacial pain symptom prevalence: selective sex differences in the elderly?

This study investigated sex differences in orofacial pain symptoms in a sample of elderly adults. Furthermore, differences across sex were tested on symptom continuity, overall duration, pain severity, activity reduction, and health care utilization, related to each specific symptom. Telephone interviews were conducted with a stratified random sample of community dwelling older (65+) north Floridians. A total of 5860 households were contacted and screened, with 75.3% participating to the point where their eligibility for the study could be determined. Of the remaining households, 1636 completed the interview. Of the total sample, 17.4% reported experiencing at least one of the four target orofacial pain symptoms (jaw joint pain, face pain, oral sores, burning mouth) during the past year, suggesting that orofacial pain symptoms are common in older adults. Our findings for prevalence of each specific symptom (jaw joint pain, 7.7%; face pain, 6.9%; oral sores, 6.4%; toothache, 12.0%; burning mouth, 1.7%) are similar to those estimated by the 1989 National Health Interview Survey, for the US adult population. Consistent with other epidemiological and clinical studies, we found that females were more likely to report jaw joint pain and face pain than males. In contrast to clinical studies, no differences were found on subjective ratings of pain severity, for any symptom. Differences across sex were most likely to be reported for jaw joint pain related variables, suggesting undetermined sex-uniqueness for these symptoms. In contrast to previous studies, older females tended to report lower levels of health care utilization than older males. This is the first study to our knowledge that reports orofacial symptom-specific sex differences among the elderly.

Adult↗

Clinical manifestations and diagnostic approach to metastatic cancer of the mandible.

In a 12-month period, metastatic cancer was diagnosed in eight patients. Six of them presented with pain mimicking toothache, temporomandibular joint disorders or trigeminal neuralgia, while two showed osteopenic bone lesions in the panoramic radiography, and perimandibular swelling. Anesthesia of the lower lip was the only common clinical feature. In seven of the eight patients, a whole body bone scintigraphy and single photon emission computed tomography (SPECT) of the skull in combination with a whole body and SPECT anti-granulocyte (Tc-99m MAK 250/183) bone marrow scintigraphy was performed. One patient did not have combined scintigraphy performed secondary to severe systemic illness. In six of the seven, the results were conclusive for a metastatic bone lesion. Biopsies confirmed three patients to have a previously unrecognized primary cancer, one patient to have previously unrecognized recurrent cancer, and three patients to exhibit new metastatic spread of an already diagnosed cancer. Histology revealed breast, lung, renal cancer and a malignancy of inconclusive origin. In the remaining patient, combined scintigraphy suggested osteomyelitis, yet biopsy revealed a prostate cancer metastasis with acute inflammatory cell infiltration. Thus, the scintigraphy pattern of a hot spot in the bone scan and a cold lesion in the bone marrow scintigraphy is highly suggestive of a mandibular metastasis, if accompanied by anesthesia of the lower lip.

Aged↗

Relationship of dental status, sociodemographic status, and oral symptoms to perceived need for dental care.

OBJECTIVE: Previous studies have noted a discrepancy between clinically determined oral health status (normative need), patients' perceptions, and perceived significance of dental signs and symptoms. Our objective was to quantify the relationships between normative need and self-reports to improve our understanding of the factors that contribute to perceived need for care. METHODS: Clinical examination and questionnaire data were derived from the Florida Dental Care Study, a study of oral health and dental care, in a representative sample of community-dwelling adults aged > or = 45 years. The questionnaire provided information about presence of signs and symptoms, self-ratings of oral health, perceived need for dental care, and sociodemographic status (SDS). Perceived need was measured on a 4-point nominal scale. RESULTS: Self-reported broken filling, broken denture, cavities, loose tooth, teeth that look bad, and toothache were strongly associated with self-reported perceived need for dental care. Satisfaction with dental health was also associated with perceived need, but self-rated oral health was not. Most measures of SDS were associated with perceived need. However, in a single multiple regression, with self-reported signs and symptoms accounted for, race, age group, sex, and educational attainment were not significantly associated with a currently perceived dental problem. CONCLUSIONS: Certain dental signs and symptoms were significantly associated with perceived need for dental care, as were certain aspects of SDS; even once differences in dental signs and symptoms had been taken into account. Disaggregating measurement of perceived need from a single dichotomous ('yes/no') scale to a 4-point nominal scale was elucidative.

Aged↗

Two-year incidence of oral disadvantage, a measure of oral health-related quality of life.

UNLABELLED: Dental research has progressed from describing the burden of oral disease using traditional epidemiologic measures of incidence and prevalence, to measuring how oral disease, oral signs, and oral symptoms affect the daily activities and the overall quality of life of the individual. However, longitudinal evaluation of these associations remains rare. OBJECTIVES: To (i). describe the 2-year incidence and patterns of oral disadvantage; (ii). identify dimensions of oral health measures that are significant antecedents of oral disadvantage; and (iii). determine which oral health dimensions are the most strongly predictive of oral disadvantage. METHODS: The Florida Dental Care Study was a longitudinal study of oral health in diverse groups of persons who at baseline had at least one tooth and were 45 years or older. Incidence rates, odds ratios, and 95% confidence intervals were used to describe oral disadvantage and its relation to other measures of oral health. RESULTS: Nearly one-half of the participants experienced oral disadvantage at least once during 24 months of follow-up. The strongest antecedents associated with oral disadvantage were toothache pain and chewing difficulty. CONCLUSIONS: The incidence of oral disadvantage is substantial and consistent with the notion that oral health has a substantial impact on quality of life. Measures of oral pain and oral functional limitation were more strongly predictive of oral disadvantage than disease and tissue damage antecedents.

Aged↗

Queen Elizabeth I and her teeth.

Throughout her life, Elizabeth I encountered problems with her teeth or lack of them. The anecdote involving Bishop Aylmer in 1578, Strype's account of which being rarely, if ever, quoted in full, and Hentzner's description of her two decades later are well-known, but are by no means the only references to her personal dental history. In a number of biographical studies, the saga of her toothache has been treated as no more than an amusing anecdote, but secondary sources show frequent errors, through either patchwork, imaginativeness or omission. This paper seeks to present a more comprehensive picture of Elizabeth's dental history, so primary sources, quoted as fully as possible, have been allowed to speak for themselves. No assessment has been attempted of the effects of the clinical circumstances upon political decisions or indecision.

England↗