Common causes of dental pain in

children (Differential diagnosis)

INTRO:
PRIMARY TEETH LESS SENSITIVE TO PAIN
(DENSITY OF INNERVATIONS LESS, TERMINATE AS
FREE NERVE ENDINGS IN ODONTOBLASTIC AREAS)
VS TERMINATION AT PREDENTIN AND
ODONTOBLASTIC AREAS
 Cause Explaination
Caries (dentinal Pain after stimulation (heat, cold, sweet food or drink, brushing)
sensitivity) Pain is isolated to a single tooth and usually stops when stimulus is
removed
Usually a visible carious lesion or a root surface exposed by gum
recession
Incomplete Sharp pain on release from a chewing stroke
fracture of the Marked sensitivity to cold
crown of a vital
tooth
Irreversible Pain without stimulation, lingering pain after stimulation, or both
pulpitis Usually difficulty identifying the involved tooth

Reversible pulpitis Similar to caries but with difficulty identifying the involved
tooth
Vertical root Tooth is mobile, exquisitely sensitive to touch
fracture
Apical Pain when chewing/ biting, can indicate the precise tooth involved
periodontitis Tooth tender to percussion
Apical abscess Similar to apical periodontitis but more severe
Sometimes visible fluctuant swelling of mucosa over affected
root, painful swelling of adjacent cheek or lip, or both
What primary tooth has erupted in a
4 year old child?
Diagnostic tools to diagnose pain in her tooth and
their effectiveness
Eidelman et al “no single diagnostic means can be relied for determining diagnosis of
pulp conditions”
 History of pain (Pain from mastication-caries etc)
 Pain measurement tools include physiological (heart rate), behavioral, and self-
report (pain face scale) measures

 Visual and tactile examination of carious dentin and associated periodontium

 Pain from percussion (Apical periodontitis)
 Degree of mobility (Vertical root fracture)
 Palpation of surrounding soft tissues (Apical abscess)
 Size, appearance and amount of hemorrhage associated with pulp exposure
 Radiographic examination of: Periradicular and furcation areas, Pulp canals,
Periodontal space, Developing succedenous teeth
What are the vital pulp therapy techniques?

Intro
Capitalizes on: Healing potential of the non-inflamed
remaining pulp
Pulp healing depends on:
Endogenous factors: coronal cellularity , apical
vascularity (increased)
Exogenous factors: bacterial
invasion/chemical/thermal insult (need of bacterial
microleakage control)
In primary teeth, reparative dentin beneath carious
lesion more extensive but localization of infection
and inflammation is poorer
 VITAL PULP THERAPY

Includes:
IndirectPulp Therapy
Direct Pulp Cap

Pulpotomy

Apexification
 Normal Pulp or Reversible Pulpitis

Protective Base
 Material placed on the pulpal surface of a cavity preparation,
covering exposed dentin tubules, to act as a protective barrier
between the restorative material or cement and the tooth's pulp. Placement
of a protective base such as calcium hydroxide or glass ionomer cement.
 Indications: In a tooth with a normal pulp, when dentin is exposed and
all caries is removed during the preparation for a restoration, a
protective radiopaque base may be placed between the permanent
restoration and the dentin to minimize injury to the pulp, promote
pulp tissue healing, or minimize postoperative sensitivity.
 Objectives: A protective base is utilized to preserve the tooth's vitality,
promote pulp tissue healing and tertiary dentin formation, and
minimize microleakage. Adverse post-treatment clinical signs or
symptoms such as sensitivity, pain, or swelling should not occur.
 Indirect pulp capping
Based on:
Decalcification of dentin precedes bacterial invasion (2mm of softened dentin not infected)/
reversibly denatured, capable of remineralization layer differentiated with irreversibly denatured,
infected dentin layer with basic fuchsin

 Deep excavation (no exposure of pulp)

 Application of a medicament (ZOE, CAOH) over a thin layer of remaining carious dentin
 Temporary restoration (GIC)

Purpose:
 Stimulate pulp to generate reparative dentin
 Arrest of caries progression
 Preservation of vitality of non-exposed pulp

After 8 weeks
 Temporary restoration and remaining softened caries removed
 Final restoration placed (amalgam, composite resin)
- Thinner dentin remaining after cavity preparation + longer treatment= faster dentin formed

Indirect pulp cap should be used whenever possible to avoid pulp exposure. In immature teeth (open
apices) every attempt must be made to maintain pulp vitality until root development is complete.
Loss of vitality before complete root development leaves a short, thin, weak root more prone to
fracture, poorer crown:root ratio.
 Indications:

Teeth free from irreversible signs and symptoms

History : absence of spontaneous pain, mild
discomfort from chemical and thermal stimuli
Clinical examination: large carious lesion,
absence of lymphadenopathy, normal appearance
of adjacent gingival, normal colour of teeth,
Responds to thermal and electric pulp tests
Radiographc examination: large carious lesion in
close proximity to pulp,normal lamina dura,
periodontal ligament space, no interradicular or
periapical radiolucency
 Contraindications

History: sharp, penetrating pain that persists

after withdrawing stimulus, prolonged spontaneous
pain esp at night
Clinical examination: excessive tooth mobility,
parulis in gingival approximating roots of tooth,
tooth discolouration , non-responsiveness to
pulp testing techniques
Radiographic examination: large carious lesion with
apparent pulp exposure, interrupted or broken
lamina dura, widened periodontal ligament space,
radiolucency at root apices or furcation areas
 INDIRECT PULP THERAPY

SUCCESS RATE
 99% success for avoiding pulp exposure
 Failed indirect pulp therapy means irreversible pulpal
disease
Depends on maintainence of a patent seal
against microleakage by the temporary and
final restorations, minimum of 6-8 weeks for
remineralization of cavity floor
 DIRECT PULP CAPPING

 DEFINITION:
 Placement of biocompatible agent on
healthy pulp tissue that has been EXPOSED
 Objective is to seal the pulp against bacterial
leakage, encourage pulp to wall off
exposure site by initiating a dentin bridge
and maintain the vitality of the underlying
pulp tissue regions, No post-treatment signs or
symptoms such as sensitivity, pain, or swelling
should be evident, no radiographic signs of
pathologic external or internal root resorption or
furcation/apical radiolucency, no harm to the
succedaneous tooth.
 DIRECT PULP CAP

 MECHANISM OF ACTION:
CaOH- antibacterial (pH 12.5) cause necrosis 1.5mm of pulp tissue
Toxicity of CaOH neutralized in deeper areas
->coagulative necrosis at junction of necrotic and vital pulp
-> mild irritation : inflammation response
-> Dentin bridge formation occurs at junction of necrotic and
inflamed vital tissue.
 INDICATIONS:

 This procedure is indicated in a primary tooth with a

normal pulp following a small mechanical or
traumatic exposure when conditions for a
favorable response are optimal.
 Minimal pulpal inflammation
 No clinical signs of pulpal degeneration
 No radiographic signs of p/a inflammation
 Young pulp better prognosis
 No pulp calcifications better
 Little or no bleeding at exposure site
 Mechanical better than carious
 Direct pulp capping of a carious pulp exposure in a
primary tooth is not recommended.
 Contraindications

 History of spontaneous and nocturnal toothaches,

Excessive tooth mobility
 Thickening of periodontal ligament,
Radiographic evidence of furcal or periradicular
degeneration
Uncontrollable hemorrhage at the time of exposure
 Purulent or serious exudates from exposure
 DIRECT PULP CAP

SUCCESS RATE:
 Success depends on coronal and radicular pulp healthy
and free from bacterial invasion, Exposure diameters of
less than 1mm, good blood supply for best healing
potential, quality of restoration to exclude microleakage
 PULPOTOMY

 DEFINITION:
Surgical removal of the entire coronal pulp, leaving
intact the vital radicular pulp within the canals.
 Remaining vital radicular pulp tissue surface should be treated with:
* Formocresol: (1) fixative; (2) chronic inflammation; (3) possibly mutagenic or
carcinogenic; (4) 83.8% success rate.
• Glutaraldehyde: (1) superior fixation by cross-linkage; (2) diffusibility is
limited; (3) excellent antimicrobial agent; (4) causes less necrosis of pulpal
tissue; (5) causes less dystrophic calcification in pulp canals; (6) does not
stimulate a significant immune response; (7) minimal systemic distribution.
• Ferric sulfate: (1) astringent; (2) forms a ferric ion-protein complex that
mechanically occludes capillaries; (3) less inflammation than FC; (4) 92.7%
success rate.
• Electrosurgery and laser: less successful than ferric sulfate or dilute
formocresol
 The coronal pulp chamber is filled with a suitable base, and the tooth is restored
with a restoration that seals the tooth from microleakage.
 PURPOSE:
 To protect and preserve the remaining radicular pulp’s
vitality and function
 PULPOTOMY

INDICATIONS:
 Cariously exposed primary teeth, when their retention is more
advantageous than extraction.
 Inflammation is confined to the coronal portion of the pulp.

CONTRAINDICATIONS:

• the tooth crown is nonrestorable,

• marked tenderness to percussion,
• mobility,
• radiolucency exists in the furcal or periradicular areas,
• spontaneous pain, especially at night,
• dystrophic calcification (pulp stones).
Nonvital Pulp Treatment with Irreversible
Pulpitis or Necrotic Pulp
 Pulpectomy is a root canal procedure for pulp
tissue that is irreversibly infected or necrotic
due to caries or trauma. The root canals are
debrided, enlarged, disinfected, and filled
with a resorbable material such as
nonreinforced zinc oxide-eugenol. The tooth
then is restored with a restoration that seals
the tooth from microleakage.

PURPOSE
 Maintain the tooth free of infection
• Hold the space for the erupting permanent
tooth.
 Pulpectomy

Indications
 Cooperative patient,
• Teeth with poor chance of vital pulp treatment,
• Strategic importance for space maintenance,
• Absence of severe root resorption,
• Absence of surrounding bone loss from infection,
• Expectation of restorability,

Contraindications
 Teeth with nonrestorable crowns,
• Periradicular involvement extending to the permanent tooth bud,
• Pathologic resorption of at least one-third of the root with a fistulous sinus tract,
• Excessive internal resorption,
• Extensive pulp floor opening into the bifurcation,
• Systemic illness such: as congenital or rheumatic heart disease, hepatitis,
leukemia, and children on long-term corticosteroid therapy, or those who are
immunocompromised,
• Primary teeth with underlying dentigerous or follicular cysts.
 Pulpectomy

Objectives: resolve in 6 months, as evidenced by

bone deposition in the pretreatment radiolucent
areas, and pretreatment clinical signs and
symptoms should resolve within 2 weeks. The
treatment should permit resorption of primary
tooth root structures and filling materials at the
appropriate time to permit normal eruption of the
succedaneous tooth. There should be no
pathologic root resorption or
furcation/apical radiolucency.