Irreversible Pulpitis. Occlusal Trauma. Differential Diagnosis. Differential Diagnosis. Pulp tests. Treatments. Chief complaints:

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1 Differential Diagnosis Differential Diagnosis Bruxism Fibromyalgia Migraine, Cluster headache Tension-type headache Arthritides Myositis Lyme disease Tumors (primary or metastatic) Systemic diseases Toxic/traumatic neuropathies Temporomandibular disorders Pain of dental or periodontal origin Ear infections Eagle's syndrome Chronic sinusitis Atypical facial pain Atypical odontalgia Burning mouth syndrome Nasopharyngeal malignancies Glossopharyngeal neuralgia Trigeminal neuralgia Pain of psychogenic origin Occlusal Trauma Irreversible Pulpitis Pain when chewing Pain when teeth are in contact Tooth sensitive to percussion Pain when chewing Pain when teeth are in contact Tooth sensitive to percussion Chief complaints: headaches on left side only intense pain left side of head, neck, shoulder pain spreads to left arm, chest, with difficulty to breathe Cold test: lingering pain Pulp tests Treatments Percussion: + Cold test: pain Imitrex NSAIDS Physiotherapy Chiropractic from 3.7 to 3.1 Diagnosis: pulpitis

2 Salivary glands Female 41 y.o. Pain in lower left teeth, at start of meals Worse with citrus fruits Decreased or absent salivary flow Submandibular/parotid gland infection or blockage (swelling) Maxillary Sinusitis Female, 39 y.o. Pain in several maxillary teeth Right side only Pain exacerbated by sudden head movements History of nasal congestion and cold Cold test: exaggerated response Teeth sensitive to percussion Sinus opacity A.H Coronal section. A.H Glossopharyngeal Neuralgia Female 37 y.o. Spontaneous, brief stabbing pain in left posterior teeth and back of tongue Provoked by swallowing or talking Pain radiates to ear, jaw and neck Trigger zones: tonsil region, pharynx, back of tongue Glossopharyngeal Neuralgia Female 37 y.o. Spontaneous, brief stabbing pain in left posterior teeth and back of tongue Provoked by swallowing or talking Pain radiates to ear, jaw and neck Trigger zones: tonsil region, pharynx, back of tongue

3 Eagle's Syndrome Tooth and jaw pain associated with swallowing, chewing, rotation of the head Complaint of persistent sore throat Calcified stylohyoid May be confused with glossopharyngeal neuralgia 45 years old male Chief complaint: pain and swelling in the left jaw joint Occasional pain in the left jaw muscles Frequent unprovoked nose bleeding Palpation: pain in left TMJ and muscles Movements all within normal limits L. S. D years old male Osteophytes Chief complaint: pain and swelling in the left jaw joint Occasional pain in the left jaw muscles Frequent unprovoked nose bleeding Palpation: pain in left TMJ and muscles Movements all within normal limits L. S. D L. S. D Arthritis sagittal view L.S. D Arthritis sagittal view L.S. D

4 Arthritis coronal view L.S. D Turbinate Chondra pneumatisation bullosa Deviation nasal septum L. S. D years old male Chief complaint: intense pain on left side of face (worst pain rated 10/10) Severe swelling of left face Pain fluctuates with weather Pain aggravated by movements 48 years old male Chief complaint: intense pain on left side of face (worst pain rated 10/10) Severe swelling of left face Pain fluctuates with weather Pain aggravated by movements F.A F.A F.A Arthritis of left TMJ. Coronal view. F.A. 2007

5 Arthritis of left TMJ. Sagittal view. F.A Trigeminal Neuralgia 42 y.o. female Brief electric shock-like pain provoked by touching inside of upper lip, speaking, sneezing, faire la moue Tooth 11 had RCT, apical surgery Scar and color change at gingiva of 11 Trigger zone: gingiva, upper lip Pulp tests negative Trigeminal Neuralgia Brief electric shock-like pain provoked by non-noxious stimulation of trigger zones Trigger zones: extra- or intraoral Affects mostly the anterior face (2nd & 3rd divisions of CN V) Mostly unilateral Trigeminal Neuralgia Age at onset: 6th or 7th decade If occurs between y.o., rule out possibility of multiple sclerosis Compression Secondary Demyelination to trauma, of of CN Vtumor, root as herpes it exits the zoster pons Multiple Sclerosis Female, 27 y.o. Severe short-lasting shooting pain in anterior maxillary teeth and upper lip Pain provoked by kissing, chewing Pain and numbness migrating Periodical weakness in legs and arms Multiple Sclerosis Female, 27 y.o. Severe short-lasting shooting pain in anterior maxillary teeth and upper lip Pain provoked by kissing, chewing Pain and numbness migrating Periodical weakness in legs and arms

6 University of Pennsylvania Acute Herpes-zoster Pain in all lower right teeth and skin Clusters of cutaneous vesicles in the distribution of 3 rd division of CN V Signs and symptoms unilateral Reactivation of Varicella-Zoster virus in sensory ganglia of spinal cord and brainstem Axonal damage from virus-evoked neurolysis and inflammation Pulp test inconclusive Neuropathic Pain Diabetes Nerve compression Endodontic treatment Injection of anaesthetics Amputation (tooth extraction) Viral infection (Herpes Zoster) Demyelinization (multiple sclerosis) 43 years old female Nov Chief complaint: intense pain in upper front teeth ( ) for several years Spontaneous, lasting pain rated 9 to 10/10 Burning, thick, itchy, alternating between left and right tooth Diagnosed with trigeminal neuralgia in 1996 Severe side effects with amitriptyline Suicidal thoughts; quitted work and can not be left alone at home??? Neuropathic pain. A.H Neuropathic pain. A.H. 2006

7 Neuropathic pain. A.H Report from Neurology Jan 3: Gabapentin 300 mg qid + Percocet bid Jan 17: Gabapentin 600 mg tid + 10 mg Oxycodone at breakfast: Pain = 6/10 Jan 31: Gabapentin as above + Oxycodone 20 mg tid: Pain = 3/10 Stable in April, May, June September 12: + Nortriptyline 10 mg qhs: Pain = 2/10. Patient returned to work Anemias Weakness Malaise CNS hypoxia, headache, faintness Pernicious anemia: myelin degeneration in the dorsal and lateral tracts Systemic Lupus Erythematosus American College of Rheumatology Criteria Diagnosis based on at least 4 or more criteria out of the 11 Malar and discoid rash Photosensitivity Oral ulcers Arthritis Serositis Renal disorder Neurologic disorder Hematologic disorder Immunologic disorder Antinuclear antibody Systemic Lupus Erythematosus American College of Rheumatology Criteria Malar and discoid rash Photosensitivity Oral ulcers Arthritis Serositis Renal disorder Neurologic disorder Hematologic disorder Immunologic disorder Antinuclear antibody

8 Systemic Lupus Erythematosus Prevalence Arthritis 90% Myalgia 33% Peripheral neuropathy 14% Parotid gland enlargement 8% Klasser et al, JOP 2007 Sjögren s syndrome Orofacial Manifestations Autoimmune disease Chronic inflammation of exocrine glands (lacrimal, salivary): xerostomia Enlargement + swelling of parotid glands (30 to 40%) Pain upon eating: muscle pain? Glossodynia, altered taste Neuropathies, peripheral and general (sensory and motor) Headaches in 75% of patients Up to 90% of patients with SLE Rheumatoid Arthritis Criteria Morning stiffness Arthritis of 3 or more joint areas Arthritis of hand joints Symmetric arthritis Rheumatoid nodules Serum rheumatoid factor Radiographic changes Presence of at least 4 out of 7 criteria Rheumatoid Arthritis Orofacial Manifestations Inflammatory disease, unknown origin 50% of patients have TMJ involvement 50 to 80% have radiographic changes, e.g. erosion, flattening, osteophytes, Bilateral pain, swelling preauricular area Masticatory muscle pain Anterior open bite Secondary Sjögren s syndrome Klasser et al, JOP years old male Flattening + erosion? Elongated coronoid process Flattening + erosion? Chief complaint: gradual decrease in mouth opening Intermittent pain Past treatment: NTI Medical history non-contributory Family history: rheumatoid arthritis A.C Dense bone island A.C. 2007

9 Rheumatoid arthritis Sagittal view A.C Rheumatoid arthritis coronal view A.C years old male Chief complaint: gradual decrease in mouth opening Intermittent pain Past treatment: NTI Medical history non-contributory Family history: rheumatoid arthritis A.C Diabetes Mellitus Pain in teeth, migrating Wounds often infected Constantly hungry and thirsty Unexplained weakness & weight loss Symmetric peripheral neuropathy affecting both motor and sensory nerves Angina Pectoris 53 y.o male with pain only in lower jaw and teeth Pain sometime bilateral Pain exacerbated by physical activity Retrosternal pain Medical history: several cardiovascular risk factors Cluster Headache Male, 47 y.o. Severe pain starts in tooth 46, then ocular, frontal, and temporal areas Ipsilateral signs: temporal headaches, blocked nose, tearing, eyelid oedema, rhinorrhea photophobia Lasts 1/2 hr then spontaneous remission Attacks mainly in Spring and Autumn

10 Cluster Headache Male, 47 y.o. Severe pain starts in tooth 46, then ocular, frontal, and temporal areas Ipsilateral signs: temporal headaches, blocked nose, tearing, eyelid oedema, rhinorrhea photophobia Lasts 1/2 hr then spontaneous remission Attacks mainly in Spring and Autumn Periodic Migrainous Neuralgia: a Cause of Dental Pain Brooke R.I., OOO, patients 57% had toothache 43% had jaw pain 46% Final had diagnosis: extractions migraine or endodontic treatment in one or more teeth in an attempt to alleviate the pain Tension-Type Headache At least 2 of the following characteristics: quality: tightening, nonpulsating quantity: continuous, mild or moderate location: bilateral No aggravation by walking stairs or similar routine physical activities Migraine During headache, at least 1 of the following: nausea and/or vomiting photophobia and phonophobia No organic or metabolic disorders International Headache Society Migraine with Aura Female, 22 y.o. Blurring of vision lasting 20 minutes to 2 days Numbness or paralysis in ipsilateral hand and face Followed by severe toothache and ipsilateral headaches Often triggered by changes in weather Migraine with Aura Premonitory phase lasting 1-2 days Prodrome (aura): blurring of vision for about 20 minutes Sensory disturbances in the hand and ipsilateral face Mild paralysis in limb, followed by dysarthria and aphasia

11 Temporal Arteritis Patients > 50 y.o. Affects principally the cranial vessels, in particular the temporal arteries May also affect vertebral & ophtalmic arteries Genetic predisposition Osteochondroma Right TMJ. Courtesy Dr. G. Petrikowsky Differential Diagnosis Bruxism Fibromyalgia Migraine, Cluster headache Tension-type headache Arthritides Myositis Lyme disease Tumors (primary or metastatic) Systemic diseases Toxic/traumatic neuropathies Nasopharyngeal malignancies Pain of psychogenic origin Differential Diagnosis Pain of dental or periodontal origin Ear infections Eagle's syndrome Chronic sinusitis Atypical facial pain Atypical odontalgia Burning mouth syndrome Glossopharyngeal neuralgia Trigeminal neuralgia Neuropathic pain Temporomandibular disorders Temporomandibular Disorders Group I: Group II: GroupIII: Muscle disorders I.a. Myofascial pain I.b. Myofascial pain with limited opening Disc displacements II.a. Disc displacement with reduction II.b. Disc displacement without reduction, with limited opening II.c. Disc displacement without reduction, without limited opening Arthralgia, Arthritis, Arthrosis III.a. Arthralgia III.b. Arthritis of the TMJ III.c. Arthrosis of the TMJ

12 Myofascial Pain Research Diagnostic Criteria Report of pain or ache in the jaw, temples, face, preauricular area, or inside the ear Pain in 3 or more of the 20 muscle sites on digital palpation, with at least one of the sites being on the same site as the complaint of pain Dworkin & LeResche, 1992 Diagnostic Criteria Myofascial pain Report of pain or ache in the jaw, temples, face, preauricular area, or inside the ear Pain in 3 or more of the 20 muscle sites on digital palpation Fibromyalgia History of widespread pain Pain in 11 of the 18 tender points, in response to digital palpation American College of Rheumatology, 1990 Muscle Disorders Most muscle-related pain conditions are identified on the basis of clinical attributes. There are no biomarkers of exposure or effect that would permit both valid and case ascertainment. Myofascial pain Fibromyalgia Stohler, 1999 Prevalence of Pain at Various Body Sites Dao et al, 1996 MFP Face 100 % Neck 68.4 Shoulders 57.9 Arms 31.6 Chest 26.3 Abdomen 15.8 Upper back 42.1 Lower back 57.9 Hips 31.6 Legs 31.6 FM 69.0 % Prevalence of positive reports of MFP Headache 73.7% Sleep disturbance 52.6 Fatigue 47.4 Muscle weakness 10.5 Loss of memory 21.1 Loss of coordination 5.3 Pins and needles sensations 42.1 Indigestion 21.1 Diarrhea 5.3 Abdominal bloating 26.3 Constipation 15.8 Urinary urgency 0.0 Dao et al, 1996 FM 89.6%

13 Muscle Disorders Muscle-related TMD are not a single entity, but include several overlapping conditions. Significant overlap between TMD and fibromyalgia (Plesh et al; Dao et al, 1996) High association between TMD and the two most common types of headaches, tensiontype and migraine (Agerberg & Carlsson, 1973) The most important, almost universal feature of TMD is chronic pain. Persistent orofacial pain and psychosocial dysfunction are the overwhelming reasons people seek TMD treatment. The muscle-related conditions are the most prevalent presentations, with at least 50% of the cases falling into this category.