History of Endodontics aae/abe



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Non-odontogenic pain (Subramanian; Nixdorf – 3.4%)


  1. Myofascial Pain Disorder


    1. Pain of muscular origin, Triggered by contraction of masticatory muscle

    2. Trigger point – small foci of hyperexcitable muscle

    3. Pain – Dull, aching, diffuse, constant

    4. Muscles of mastication (TMLA)

      1. Temporalis – Max Teeth

      2. Masseter – Max/Mand Posterior Teeth, TMJ

      3. Lateral Pterygoid – TMJ

      4. Anterior Digastric – Mandibular Incisors

    5. Testing – Group of teeth typically positive to percussion/palpation; Palpation of involved muscle group reproduces “toothache” like symptoms

    6. LA injection – directly into affected muscle for relief, local tooth block will not relieve pain

Non-odontogenic pain


  1. Neurovascular Pain – aka Headache Disorders


    1. Pain – Severe, Throbbing, Pulsatile; Episodic w/ complete remission between episodes

    2. Location – Temples, Ocular, Sinuses, Jaws, Teeth

Migraine

  1. 4-72 hours, Unilateral, Pulsatile

  2. Nausea, vomiting, photo/phonophobia

  3. Tx: Sumatriptan (Imitrex), Amitryptiline - TCA

Tension type

  1. Most common, short lasting

TACs (Trigeminal Autonomic Cephalgias)

  1. Cluster headaches, Paroxysmal hemicranias, short lasting neuralgiform headache, more common males

  2. Severe Unilateral headaches with ipsilateral autonomic symptoms

  3. 15 mins – 2 hours, 5-8 x/day, clustered active periods

  4. 10 mins 100% O2 pain relief = Cluster headache

Non-odontogenic pain


  1. Neuropathic Pain Disorders – Trigeminal Neuralgia


    1. Pain – Intense, intermittent, sharp, stabbing/shooting/electrical

    2. Location – Unilateral along any of 3 branches of Trigeminal nerve

    3. Trigger point – external (i.e.: touch, cold, shaving) or internal (i.e.: lips or teeth); Response to stimulus is NOT proportional to intensity of stimulus

    4. LA of trigger zone may result in relief of symptoms, which may confuse the diagnosis if trigger is internal

    5. Episodicup to 50 times per day, lasting 60 seconds to minutes

    6. Initial symptoms mimic odontogenic pain

    7. Under 40 yrs, MS is a common etiology for Trigeminal neuralgia (Brain MRI)

    8. Refer to Oral Pain – Carbamazepine (Tegretol), Pregabalin (Lyrica)

    9. Etiology: Abnormality of neural structures (gasserian ganglion pressure from carotid artery branches)

Non-odontogenic pain


  1. Neurogenic Pain Disorders – Neuromas, Neuritis


Neuromas

    1. Traumatic neuroma – proliferative mass of disorganized neural tissue at the site of a traumatically or surgically transected nerve

    2. Symptoms develop 10 days post trauma

      1. Sharp electric pain when touching area of injury

      2. Zone of anesthesia peripheral to area of neuroma

    3. Location – mental foramen, lip, tongue, ext site or post RCT (deafferentation – Holland; Hu/Sessle)

Neuritis

  1. Inflammation of nerve secondary to injury or infection of viral or bacterial etiology (i.e.: pain associated w/ herpes zoster)

  2. May lead to post-infection neuropathy of infected nerve

  3. Localized trauma – chemical, mechanical (i.e.: endo sealers, irrigating solutions, intracanal medicaments, overextended gp, implant placement)

  4. Pain - constant, burning; parethesia/dysesthesia/anesthesia; allodynia

Non-odontogenic pain


  1. Neuropathic Pain Disorders – Atypical Facial Pain


    1. Localized, sustained, non-episodic pain secondary to an injury or change in neural structure

    2. Pain is chronic, present daily, and most part of the day

    3. Pain – “Deep”, Sharp, throbbing, aching; Hyperalgesia/Allodynia

    4. Central sensitization due to injury/peripheral barrage induces central neuroplastic changes

    5. Surgical approaches are not effective – do not desensitize the nerve

    6. Pain may migrate to different quadrants or ipsilateral side

    7. LA will NOT relieve pain

    8. No Trigger points, One tooth or cluster of teeth may be involved

    9. Symptoms are preceeded by traumatic event, i.e.: RCT, Ext

    10. Management: Referral to pain specialist/ENT, Rxs: TCAs, Neurontin (gabapentin), SSRIs, topical desensitizers, Pain management therapy, Physical therapy

Non-odontogenic pain


Psychogenic

  1. Somatoform disorder – mental disorder

  2. Undiagnosed pain with no apparent etiology and poorly characterized symptoms (i.e.: burning mouth syndrome)

Cardiac (Kreiner)

  1. Cardiac pain (ischemia-angina, MI) refers to left arm, shoulder, neck, face

  2. Anginal pain may solely refer to the Lower Left jaw

  3. Endo testing will be normal, LA will not relieve pain

  4. Stimulation of C fibers

Sinus (Kretzschmar 2003) - Rhinosinusitis

  1. Sinus pain can exhibit fullness or pressure below the eyes

  2. Multiple maxillary teeth with sensitivity to percussion, palpation

  3. Sensitivity to palpation of structures overlying sinues; throbbing or increased pain when head is placed lower than heart

  4. Systemic signs of sinus infection; Rx Amoxicillin, ZPac
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