1 pain of dental origin new
DESCRIPTION
PAINTRANSCRIPT
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Pain
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pain
Subjective
Usually signifies tissue damage
Severity of pain is not directly proportional tothe extent of damage
Arises peripherally by stim of receptors
Modified centrally
Complicated by: cultural, cognitive andemotional factors and modified by previouspainful experiences
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Diagnosis of pain
May have nothing to assess visually
History taing more value
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Ask the ff q’s:
!" Ho# #ould you describe the pain$
%" &here is the pain most severe$
'" &here does the pain spread to$
(" Ho# severe is the pain$
)" *oes the pain prevent you from getting to sleep ordoes it #ae you up at night$
+" &hen did the pain start$
" -s the pain continuous or does it come and go$.or ho# long""
/" *oes anything cause the pain to start$
0" *oes anything mae the pain better$
!1" Are there any other problems$
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CHARACTER OF PAIN
Sharp2stabbing
*ull2throbbing2boring
3urning
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Sharp/staing
4xposed dentin
4arly pulpitis
5rigeminal neuralgia6lossopharyngeal neuralgia
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D!""/throing/oring
7ate pulpitis
Apical and lateralperiodontitis
8eriodontal9endodontic lesion
8ericoronitis
Acute necrotiing
ulcerative gingivitis*ry socet
Herpes oster
8eriodic migrainous
neuralgia
6iant cell arteritis
5umors
Sinusitis
5M; disorders
Atypical odontalgia
atypical facial pain
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#!rning pain
3urning mouth syndrome
8ost herpetic neuralgia
<amsay9Hunt syndrome
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SE$ERIT% OF PAIN
Scale of 19!1
Mild Moderate Severe
Atypical pain and trigeminal neuralgia, do not
affect sleep8ain at the same time each night = periodicmigrainous neuralgia
Acute pulpitis2periodontitis prevent sleep2
#aes up at night4xtreme pain >unbearable? 5rig neuralgia, glossph" @", periodic migrainous n",post
herpetic n"
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SITE OF PAIN
-f from pathology unilateral
3ilateral:Sinusitis
C@S dse
8sychosomatic painneuralgias
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D&RATION OF PAIN
Sharp2stabbing fe# secs or mins
*ull2throbbing fe# hrs, days,
#ees
Continuous psychosomatic origin
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TI'IN(/E)ACER#ATIN(
FACTORSMerest contact of trigger one
8ain on s#allo#ing
8ain on biting or touchingn hot or cold stim
*entin exposure Caries
*efective resto Unlined recent resto .ractured th pulpitis
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&ith s#eet food *entin exposure Caries
n biting, particularly on release of pressurepmn
Alcohol
<elated to meals Salivary gland obst 5M; disorder 69p neuralgia
5 n" 6iant cell arteritis *ental or oral mucosal dse
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RE*IE$IN( FACTORS
Sharp responds poorly to analgesics
*ull responds usually to analgesics
Constant dull of long duration >years?,
unaffected by pain relievers atypical
odontalgia or burning mouth syndrome
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OTHER S%'PTO'S
S#elling, discharge, bad taste, bad
breath, raised temperature, malaise,
cervical lymphadenopathy may be infective in origin
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IDENTIF%
!" 5he nerve, division, branch
%" 7iely site of cause of pain
!" 8eripheral
%" 8roximal
'" -ntracranial
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Denta" pain
Unilateral >usually?
@ever referred across to the other side
of the face >exceptBBBBBBBBBBBBB?8eriodontal pain is BBBBBBBBB localied
8ulpal pain is BBBBBBBBB localied
common things occur commonly,eliminate them firstDE
*iagnostic local inj
well
poorly
incisor region
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+, P!"pa" pain
*entin sensitivitySharp2stabbing, al#ays related to hot, cold
or s#eet stimulus, never spontaneousccurs immediately after stim
<elief immediate after removal of stim
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Signs
6ingival recessionCaries, fx, lea
3ubbles of saliva #hen moving a bridge
retainer lea
5ooth surface loss
*iagnostic testsCold air, ethyl chloride, hot gutta percha
5x
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Cra-ke. tooth
4namel
4namel and dentin
4namel dentin and pulp<oot cro#n and root
@otes6ood periodontal status
May have large resto
S
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Sx Faries ccasional pain from biting -ntermittent, may be #orse upon release of pressure G
rebound pain &ell localied Short duration, never spontaneous Some sensitivity to heat and cold
Signs pposing tooth usually present #ith excellent perio
status
5ests
7ight: m mirror, fiber optics, magnification 3ite on resilient object: cotton roll, rubber dam, etc radio
5x
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.x involving pulpSpointaneous pain
8asses thru hyperemia irreversible suppurative stages >severe persistent
throbbing
acute periodontitis tender to percussion5ests
Fitality tests
<adio
5x
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P!"pitis
*H <ecent dental scalings, recent depp resto, deep
caries, trauma hx
Sx Sharp stabbing
-ntermittent , immediate onset: coldIII, hotII,
s#eet
Stim needed, short duration J!) secs *ifficult to localie
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Signs
7arge resto or large caries5ests8ercussion: no tenderness or dullness to
percussionFitality tests: exaggerated responses
Color: normal
<adio: #ith caries or restoK normal
radio appearance
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5x<emove the cause
<epeat vitality tests
Serial radio
4ndo2 exo
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A-!te p!"pitis
-rreversible, leading to suppurative pulpitis
MH nil
*H large resto2caries, trauma hx,
Sx Unilateral, initially sharp2stabbing, becoming dull
throbbing #ith time
-nitial: exaggerated responses to stimK is of long
duration, L !) secs to hrs after removal of stim
May radiate
3ecome spontaneous
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May prevent sleep
Cold may reduce pressure and may
provide temporary relief 8ersist for days to #ees, then subsides as
pulp necroses
8oorly localied until bec tender to bite on
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Signs 7arge caries2 resto, fx, discolored th
5ests *iagnostic local anesth
Fitality tests: exagg responses to heat initially,
until no responsesK cold may relieve painK Confusing in multirooted teeth
7ater stages: I percussion
<adio: deep caries2 resto
5x <emove cause
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Chroni- p!"pitis
MH nil
*H large resto,etc
Sx -ntermittent mild pain over months or years8oorly localied, II to heat
<are pain concernsSigns7arge resto"2caries
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5ests
Fitality: gradual rxn III heat common,J responses to cold
8ercussion: minor tenderness
<adio: loss of lamina dura apically,sclerosis in he pulp chamber and alveolar
bone
5x4xo2endo
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Chroni- hperp"asti-
p!"pitisMH nil
*H neglect in young patient
S Usually none, lump sensation
Signs
Fisible pulp polyp, extensive caries5ests: radio, large apical foramina
5x: exo
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(a"0anis1
MH nil
*H recent metallic restoNs adj, opposing
Sx-ntermittent pain, #ell localied, no referral
5x: reassurance: problem #ill diminish in a
=fe# days, as corrosion products accumulate
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Aero.onta"gia
ccuring at reduced atmospheric pressureMH possible sinusitis
*H <ecent resto
Sx: acute pulpitic pain
Sgns: recently restored teeth
5ests: radio: possible antral opacityK deepresto
5x: monitor >pulpitis?K refer for for tx ofsinusitis
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2, Perio.onta" pain
A8 of pulpal origin
5raumatic periodontitis
CA8 >apical granuloma?
Acute periodontitis of gingival origin
>lateral periodontitis?
8erio9endo lesions
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A-!te Perio.ontitis of
p!"pa" origin
MH nil
*H trauma, resto, caries, pins, endo,hx of priortoothache
Sx: unilateral, severe, continuous, dull2throbbing pain, very
rapid onset 4xOuisitely tender, may feel loose
8reventing eating and sleeping Fery #ell localied Soft tissue s#elling soft and pufffy 8ain stops as pointing appears
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Signs7arge resto, caries, rctSurrounding gingival tissue may be
inflamed8usI may come out of pocet
<egional lymph nodes may be enlargedMay be pyrexic and malaised*iscolorationMay be extruded and mobiler 8alpation: softG local edemaK firm and
erythematous 99 cellulitis
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5ests
8ercussion: III apical, dull noteFitality: >9? or unreliable bec"BBBBBBBBBBB
<adio: #idening of pl space, loss of lamina
dura inc radiolucency
5x:pen and drain >overnight only?
- and * Antibiotics
4ndo2exo
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Tra!1ati- perio.ontitis
@oninfectve butinflammatory
High resto, excessive
loading,Sx: &ell localied pain on biting .eels high to the bite Slightly loose
Signs <ecent resto or prostho, or
ortho May be slightly mobile
5ests: vitality: normal
responses 8ercussion : I, dull note
-dentify occlusal contacts#ith articulating paper
5x cclusal adjustment
Adjust ortho appliance ordenture or if necessary
refer bac to specialist
Ch i i "
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Chroni- api-a"
perio.ontitis
Sx: pain unusual, if occurs: dull throbbing and not #ell localied ccasional discharge if a sinus is present
Signs 7arge resto etcK sinus may be present
5ests 8ercussion: possible minor tenderness, very slightly dull
percussion note
Fitality: usually >9?K heat may occasionally cause aresponse <adio: apical radiolucency, usually #ell defined
5x:
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A-!te perio.ontitis of
gingi0a" originMH Common in *M pxs orimmunocompromised pxs
*H hx of gingival dse, abscess, tooth loss,tooth drifting2looseness, dentla neglect
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Sx &ell localied,
continuous, dull and
throbbing
7oose teeth
May have an
associated s#elling
<are extraoral
s#elling
PHigh biteN
Signs
Mobile, deep pocets 8oor oral hygiene,
plaOue and calculus
Sinus liely
8us liely Supra9occluded
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5estsFitality >I?
8ercussion: >I? lateralII, dull note<adio: generalied bone loss,
horiontal2vertical pattern
5x
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Perio.onta"3en.o.onti-
"esionsMostly molars
May be primarily 8eriodontial in orgigin
r primarily endodontic in origin
S2sx: As for apical or lateral periodontitis
5ests Fitality: 8ercusiion: >I? to a dull note <adio: gutta perch point probe in pocet reaches apex
5x
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4, (ingi0a" pain
5raumatic gingivitis
A@U6
Acute pericoronitis
5eething
*esOuamative gingivitis
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Tra!1ati- gingi0itis
Cause8hysical
Chemical4lectrical
5reatment
Hot salt #ater rinses, chlorhexidine
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AN&(
Ulceration of interdental papillaeK Anaerobic
6>9? involvedK pportunistic
8redilection: malesK young to middle agedadult s
MH smoer, heavy driner, stress, upper
respiratory tractinfection, immunosuppression
*H irregular attender, neglect, poor plaOue
removal
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Sx Mod to severe gingival tenderness, pain #hen
eating and brushing
*ull2 boring pain, bad breath, unpleasant metallic
taste
Spontaneous gum bleeding
Signs Halitosis, obvious dental neglect,
Ulcerations
6rey pseudomembrane lies over the gingival
tissues, profuse bleeding if removed 7imited to gingival dse
8yrexia, malaise systemic sx
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5ests6>9? orgs in smears
3lood tests indicated if severe, recurrent oraccompanied by systemic upset, toexclude leuemia etc
5x*ebridement, irrigationMetronidaole %11 mg tid )daysHydrogen peroxide mouth rinsing %1 vols
diluted !:( or chlorhexidineH-, scaling and polishingStop smoing
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A-!te peri-oronitis
MH : Stress, U<5-,
*H: partially erupted lo#er 'rds, max agearound %1 yrs
Sx *ull throbbing pain, #ell localied S#elling possible beneath the angle of the mandible 5rismus liely
8x feels un#ell @ec and ja# pain if cervical or submandi nodes
affected
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Signs 5rismus, difficult to examine i9o
-ntraoral s#elling can be seen extraorally 7ymphadenopahty S#ollen operculum, pus may be evident Upper tooth occludes onto operculum 8yrexia
5ests 'rd molar palpable >unerupted th do not cause pain? 7ymph node examination <adiographs: partially erupted /Ns, enlarged follicle
surrounding cro#n may sometimes be seen
5x 8alliative, then extract
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Teething
A pericoronitis around erupting primary
teeth
MH possible incidence of viral infxn
Self limiting, does not usually reOuire
treatment, if severe, an analgesic gel
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5Desq!a1ati0e’
gingi0itis5erm is descriptive only and does not
constitute a diagnosis
Used #here gingiva appear red or ra#
Causes: lichen planus, mucous
membrane pemphigoid
3iopsy
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6, #one pain
*ry socet
steomyelitis
-nfected dental cyst
5rauma
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Dr so-ket
MH: possible radiotherapyK pagetNs dse
*H: recent exo, %9( days previouslyK
mostly lo#er thSx *ull, throbbing, continuous, severe, deep seated
PboneQ pain, accompanied by bad breath
8ain arising after a fe# days after expo
Site painful to touch and #hen eating
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SignsHalitosis
<eveals destroyed clot or contains debris<ed and inflamed gingiva around the
socet&hitish dead bone may be visible lining the
socet
5x<emove debris, irrigate #ith nss
*ress #ith alvogyl&arn px, pain for ! #analgesics
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#one pain
steomyelitis
-nfected dental cyst
5rauma, fracture
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Pain of NonDenta" Origin
7ess common than pain of dental origin
Most common causes of pain of non9
dental origin :5emporomandibular joint disorders
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Differentia" .iagnosis
!" @eurologic
%" Fascular
'" Maxillary antrum 2nasopharynx
(" Salivary glands
)" ral mucosa
+" ;a#s2masticatory muscles
" 4ars/" 4yes
0" 8sychogenic
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@eurologic
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Trige1ina" ne!ra"gia
Sudden very severe, brief >secs?, recurrent
Stabbing Along distribution of trigeminal nerve
&ith trigger zone
@ever crosses the midlineclustersE 9
with periods of daily pain, then periods ofremission
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4tiologies:*emyelination
Fascular compression5rauma or infection -diopathic
Signs5ic doloureux
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Petrige1ina" ne!ra"gia
As mild toothache type pain in the
absence of any other dental signs
6oes on to deteriorate into trigeminalneuralgia
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("ossopharngea"
ne!ra"giaSymptoms -dentical to trigeminal neuralgia but affecting the
glossopharyngeal nerve % distributions
tic 8haryngeal
5rigger one G at oropharynxK or initiated by
s#allo#ingSigns Fagal features >nausea, bradycardia?
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Herpes 7oster
5he only non9dental pain that may truly mimicpulpal pain
Symptoms Severe, unilateral, deep seated, burning pain G
prodromal phase >fe# days before rashes? <ashes:
sin: #eeping and crusting Mouth: shallo# ulcers
Un#ell
Signs Unilateral, anatomical distributions
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Post3herpeti- ne!ra"gia
8revious hx of herpes oster
Sx
8ersistent >not paroxysmal?, unilateral, verysevere, dull2boring pain
Signs
<ed overlying sin, scratching Psuicidal depressionN
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#e""’s pa"s
Unilateral pain around the ear
.ollo#ed closely by unilateral facial palsy >paralysis?
*ifferential dx Stroe
5umor 5rauma Multiple sclerosis H-F *M <amsay9Hunt 6uillain93arre 3otulism etc
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'!"tip"e s-"erosis
Multiple neurologic lesions8aresthesia, motor defect, incontinence,
visual disturbanceMuscular #eaness, vertigo
*isseminated in time and location
.reOuent remissions, but progressivedeterioration
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Intra-rania" t!1ors
Symptoms<ecurrent headaches, aggravated or
precipitiated by straining or coughingFomiting8rogressive defects of function
Signs8apilloedema >bulging of optic disc?Fisual impairness, eye disturbances
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Ca!sa"gia
Arise after injury to a peripheral sensorynerve
8ain due abherrant nerve repair
Sx Constant, burning or boring pain
Signs
Scarring from previous surgery or trauma*iagnostic test *x local anesthetic
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2, $as-!"ar origin
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'igraine
5hrobbing day9time headache lasting severalhours
8rodromal >pre9headache?K #ith PauraN
8hotophobia
@ausea and vomiting
SeOuence
8rodromal >pre9headache aura tingling? Severe, throbbing, temporal, frontal, and orbital
pain
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C"!ster hea.a-he
Mainly males
Fery severe pain, paroxysmal,
dull2boring2burning pain4pisodic >periodic?
Similar time, often at night >Palarm cloc
a#aeningN?ccur in bouts >cluster?
Autonomic symptoms
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Paro8s1a" he1i-rania
Similar to cluster headache but #ithout
autonomic problems
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(iant -e"" arteritis
*ue to ishemia resulting to arteritis
Severe, unilateral, restricted to temporal andfrontal areas
*ull2boring
4lderly, females
Masseteric claudication
8ain brought on by eating due to ishemia ofmasticatory muscles
Systemic upset
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Car.ia- ishe1ia
8reexisting heart or circulatory dse,
hypertension, *M
Sx<eferred pain to left arm and left ja#, may
be related to exercise, eating
.e# minutes only, relieved by rest Attacs often in cold #eather
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Sin!sitis
1a8i""ar antr!19 nasopharn8Unilateral pain under the eye
@umerous maxillary teeth on one side
may be painfulStuffy nose
.luid level3y transillumination of the antra or an
occipitomental radiograph
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'a"ignan-
s2sxccur late in the disease process
*epend upon the direction of spread >seeabove?
May mimic those of other dental and other
non9dental diseases
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Te1poro1an.i!"ar
oint .isor.ers5M;9 8*S >pain9dysfunction syndrome? Symptoms
Unilateral2bilateral dull pain #2in 5M; -f bilateral, one side is usually more affected 5M; may loc open or closed Clicing, crunching, grating often described Headaches, facial pain, and nec aches 8ain on temporal region, often on #aing
Signs ;oint clics 4licited on palpation of 5M; 7imited mandibular movement 8arafunctional habits >)1R? 3ruxism G scalloping borders of the tongue, ridged buccal m,
tooth #ear, resto #ear, dentin exposure and sensitivity
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8sychological consideration Chronic pain may affect pxs psychologically
Contributory: anxiety, depression, others
*epression in 8*S )x L*x tests:
Clinical and radio exam reveals no 5M; pathology
-solated headaches and painless joint sounds are
@5 8*S
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ther 5M; disorderssteoarthritis
<heumatoid arthritis5rauma*evelopmental defects Anylosis -nfection@eoplasia
EARS
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EARS
Otitis 1e.ia8ain at 5M; region
May involve the facial nerve facial
paralysisMay lead to cerebral abscess
E
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Ees
("a!-o1a*ue to rapid inc in - pressure
Sx
8ersistent, severe, unilateral orbital pain,centered above the eye but may radiateacross one side of the eye
Signs4ye is stony hard*ull pupil, sea green, oval, dilated
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Ps-hogeni-
Atypical facial pain
Significant number of patients suffer
from it@o organic lesion
MH: possibel hx of depression
*H: may have gone to many dentistsand doctorsK serial extractionexperience in atempt to BBBBBBBB
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Sx Fague, constant, dull ache, present all day every day" Continuous
>years?" 8oorly localied, maxilla is often involved"
Start unilaterally
may spread to other side Unbearable pain, sleep is @5 affected *escription of pain is often biarre: Plie ants cra#ling over my faceN 8atients may present #ith detailed #ritten llists of problems and
dates
Signs
@o causative factor detectable Cranial nerves are intact -nconsistent responses to vitality tests
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# i th
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#!rning 1o!th
sn.ro1e4tio: psycho factors s2as anxiety,
cancerophobia, hypochondria, depression
Sx Severe, constant, burning pain, often bilateral,
present for many months or years
5ongue is involved often, any mucous membranes
Sleep is not affectedSigns @o mucous m abnormalities
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*ifferential dx of burning mouth 8sychogenic
3urning mouth syndrome *eficiency states
Fitamin 3
-ron
.olic acid -nfections
Candidiasis
*enture discomfort
*ry mouth Allergy
*M
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The end.