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The findings in twenty-two cases of a condition that causes pain in the teeth and gingivae are presented. Two cases are described in detail. The importance of recognizing the problem and avoiding unnecessary dental treatment is stressed. The most effective treatment appears to be reassurance and the use of antidepressant drugs.
In summary, we must be aware of the limitations of our instruments for determining success. A diagnosis is achieved by developing a composite picture through a keen gathering of all factors leading to the disease. Pain must surely be considered in patient management and patient-dentist rapport, but to allow our judgment to be swayed by pain alone is no more rational than to hinge our diagnosis upon a single other test. It is of paramount importance that we realize that, pulpally, periodontally, and periapically, there is no correlation between amount of destruction and reported presence or absence of pain. Pain is a poor parameter of evaluation.
The aid of endodontists was sought in an attempt to determine the incidence PTP in an endodontically treated population. A total of 732 questionnaires were mailed to past patients of one endodontist; 463 (63 percent) usable responses were returned. Of 256 female subject, eight (3 percent) manifested persistent chronic pain not explained by physical or radiographic examination but consistent with the signs and symptoms of PTP. Other patients met three of the four criteria of PTP. The incidence of PTP in the population studied is between 3 and 6 percent.
In fifty consecutive clinical patients with endodontically involved teeth that responded with vital pulp test readings, a corticosteroid solution and a saline placebo were alternately used as an intracanal anodyne. The patients subjectively rated their pain on a scale of 0 to 100 as "none," "mild," "moderate," and "severe" (0 = none, 1 to 33 = mild, 34 to 66 = moderate, 67 and above = severe). The ratings were done before the first treatment and then at 24, 48, and 72 hours after treatment. Corticosteroid-treated and placebo-treated cases were not significantly different in terms of type of teeth treated, clinical pulpal diagnosis, and preoperative patient evaluation of pain. The results showed a decreased subjective report of pain for the corticosteroid cases as compared to the controls through the three posttreatment time periods (p less than 0.10). A statistically significant decreased incidence of pain was reported for the corticosteroid cases as compared to the control at the 24-hour time period (p less than 0.05). No clinical indication of infection was noted in either the corticosteroid or saline control cases.
This study was designed to measure the degree of association between dental pain and its frequency during sickle cell crisis. Randomized study and control groups, each consisting of outpatient clinic patients, were selected. Each subject was interviewed via a questionnaire designed to record information describing immediate and past experiences of dental pain and its characteristics. The results were analyzed statistically. This investigation showed that there is an increase of dental pain, in the apparent absence of specific pathosis, in sickle cell patients during crisis. It was found that 36% of these patients had experienced some significant transitory pain in the oral-maxillofacial complex either alone or as part of the crisis syndrome.
The diplomates of the American Association of Endodontists were surveyed regarding difficulties in regionally anesthetizing acutely painful mandibular molar teeth. Frequently patients developed evidence of adequate regional block anesthesia but experienced pain when the dentist attempted access. A pilot projection was undertaken to determine if a scientific basis existed for this problem. With the animal under general anesthesia, the mandibular nerve of a cat was isolated and then regionally blocked. A stimulating electrode was implanted in a cuspid tooth and a receiving electrode in the cortex of the brain. When a state of inflammation was created in the tooth in the presence of a regional block, there was an increasing cortical response to this stimulation. It was concluded that the pilot project offered a realistic technique for the study of this clinical entity.
Seventy-four patients with acute pulpitis, apical periodontitis, marginal periodontitis, or pulpoperiodontitis were examined. A series of symptoms and signs was registered. Diagnostic specificities and sensitivities were calculated, and thirteen variables were subjected to discriminant analysis and log-linear multiway contingency table analysis. Pulpoperiodonitis was found inseparable from pulpitis on the basis of the registered symptoms and signs. Several symptoms and signs previously believed to have differential diagnostic power were found insignificant. The following combination of symptoms and signs yielded a correct diagnosis in 82.1% of the cases: constant pain, tenderness to temperature changes, "the tooth feels extruded," impaired mouth opening, tenderness to palpation in apical area, and mobility.
Although rare, barodontalgia can be a problem for those who fly. Two cases are presented, one which occurred during simulated high-altitude flight in the altitude chamber and the other during actual flight. The case that occurred during actual flight was resolved by treatment of the most suspect tooth after diagnostic tests failed to identify the problem. The other case was eventually treated successfully when symptoms became localized. The difficulties encountered in making a diagnosis are described.
Two hundred patients with pain in the head and neck area completed the McGill-Melzack Pain Questionnaire before a diagnosis was made or treatment was recommended for their complaints. The class and subclass of the chosen pain descriptors were compiled for each of three broad categories of pain: pain of periodontal origin, pain of pulpal origin, and pain associated with temporomandibular syndrome (TMS). Chi-square analysis showed that TMS pain-word patterns were significantly different from those associated with pain of periodontal or pulpal origin (p less than or equal to 0.05). Word patterns for pulpal and periodontal pain did not differ significantly (p greater than or equal to 0.05). A larger sample and further study are indicated to determine whether unique word patterns may be developed for individual oral pain syndromes. Ease of administration and the capability of detecting consistent patterns of pain descriptors make the McGill-Melzack Pain Questionnaire a potentially useful tool for the diagnosis and management of pain syndromes in dentistry.
By means of questionnaires, 303 endodontists were asked about their experiences in the diagnosis and treatment of incompletely fractured teeth. The present article discloses the results relative to which teeth are most likely to fracture, which predisposing factors involve higher or lower risk, how endodontists prefer to treat root-fractured teeth, and the success rate they have had with them. The endodontists also reported the frequency of endodontic treatment failures attributable to root fractures. These results are discussed with respect to the potential implications for clinical dental practice.
Two renal dialysis patients with oral manifestations of oxalosis had undecalcified sections of iliac and alveolar bone and teeth examined histologically in an attempt to explain the development of tooth mobility and tooth loss. Osteomalacia was detected in all bone specimens and attributed to aluminum toxicity after the histochemical localization of aluminum at the calcification front between osteoid and calcified matrix. Aluminum was also detected histochemically in the cementum of teeth. Calcium oxalate crystals were present in bone marrow, teeth, and gingiva. It is proposed that tooth mobility and tooth loss in oxalosis result from the combined effects of osteomalacia and oxalate crystal deposition within the periodontium. To prevent avoidable tooth loss it is suggested that patients with oxalosis who develop tooth mobility should have aluminum toxicity and osteomalacia excluded as causal factors.
A case report is presented that deals with mental nerve paresthesia resulting from the "flare-up" of a mandibular second premolar with three root canals. A review of the literature and discussion follow, which suggest possible mechanisms that may be responsible for paresthesia as well as treatment regimens that may be used to minimize the incidence of this unexpected but occasional post-treatment endodontic sequela.
Traitement SPAD is a new root canal filling material that is advertised as an efficient universal paste recommended for the treatment of all kinds of teeth in one visit. Pushing the paste beyond the apex is highly recommended by the manufacturer for the treatment of periapical lesions and to aid in rapid regeneration of the tissues. A clinical study was conducted to determine the response to this material and to compare it with the response to laterally condensed gutta-percha. SPAD was intentionally forced beyond the apex in some of the patients to evaluate its effect on periapical lesions and on the surrounding tissues. In the majority of patients, the periapical tissues were unable to absorb the excess material, which caused persistent pain and swelling and had to be removed surgically. After removal of the extruded material, which had set into a hard mass with rough surface texture, healing followed a normal course. The use of SPAD and the laterally condensed gutta-percha for filling root canals to their apical constriction provided equally high percentages of success.
Case histories of 15 patients with dental pain who were examined at the Royal Adelaide Hospital Pain Clinic were reviewed. These were the only patients with dental pain seen at the clinic over a 10-year period and represent less than 1% of the total patients fully examined at the clinic. Only one patient had an underlying organic problem; the remainder had a diagnosis of atypical facial pain. Common characteristics that pointed to the diagnosis of intractability were the duration of the pain, extensive and multiple ineffective treatments, a history of pain elsewhere in the body, and a history of psychologic disturbance. Ten of the 12 patients who were offered and accepted psychotherapeutic treatment had appreciable symptomatic relief. No dental or surgical treatments resulted in any pain relief.
Symptoms in the lower first molar developed in a 15-year-old girl. The problems started with tenderness during occlusion. The first radiographic examination revealed a radiopacity at the distal root, which was considered in the radiographic report to be a cementoma. Therapy commenced with occlusal adjustment, but this was followed 20 months later by endodontic therapy, which was undertaken because of the suspicion of partial pulpal necrosis with condensing osteitis. A painful condition developed and led first to apicoectomy and then to extraction 2 1/2 years after the start of the endodontic therapy. Light microscopic examination of adjacent hard tissue revealed signs of chronic inflammation on both occasions, and a diagnosis of diffuse sclerosing osteomyelitis was made. The pain was not relieved but remained at a tolerable level for 18 months. Then a reexamination of the first radiographs led to a strong suspicion of a benign cementoblastoma. A thorough third operation revealed a small piece of hard tissue in a lacuna of the lingual part of the mandible covered buccally by granulation tissue and inflammatory affected bone. The final histopathologic diagnosis was benign cementoblastoma combined with chronic inflammation.
Retrospective study was done on 118 patients who underwent nonsurgical endodontics and then surgical endodontics. Seventy-nine patients had pain before nonsurgical endodontics, and an additional 39 were pain free. After the open surgical procedure, six patients (5%) had continual pain and were considered failures. Three patients (2.5%) were thought to have had posttraumatic dysesthesia, and the other three (2.5%) were considered to have phantom tooth pain. Possible mechanisms for each chronic pain type are discussed.
One hundred fifty cases of endodontic treatment failures were studied clinically, radiographically, and histologically. Fifty-seven percent of the teeth were asymptomatic. Pain alone and/or associated with swelling was present in 21% of the teeth. There was no correlation between the size of periradicular rarefaction and the occurrence or severity of clinical signs and/or symptoms. Stainable bacteria were demonstrated in 69% of the teeth and were present mostly in the canal. The severity of periradicular inflammation was related to presence of stainable bacteria in the canal. Swelling and pain or a draining sinus tract was often associated with stainable bacteria inside the canal. The development of a radicular cyst associated with an endodontically treated tooth that has failed is not necessarily the cause of endodontic treatment failure.
Referred pain is common in the orofacial region and can cause considerable difficulties in diagnosis. Referred pain is defined as pain that is referred to a part of the body other than the site of origin, and as a result, severe pain may arise without an associated causative lesion. A muscular trigger point that resembled a tooth with endodontic involvement is discussed.