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Locating refered pulpal pains
LOCATING
REFERRED
PULPAL
PAINS
1UWERREJ.I
I’.\IN
CfWtrnl or direct pain is spontanrons pain in a definite area, with or wit Iioul a demonstrable lesion. Elimination of the pause usually eliminates tlic paili. Referred pain seems l-0 owiw in an arra otliw than its point of origin. and severe pain may arise witliaut~ an associated cxiisal-ivr lcsiori. This irivolws radiation or transmission of paiJl to an ad,jaccnt or distant awa supplied by the same or a related nerve. The exact mechanism r(\mains 11~poth~ti(*;tl, l)l~t ill1 ll(‘I’V(! aWcpted t,lieory of referred I'ilCiill pain is as follows : TllC ~‘0111111011 scllsory to the face is the trigeminal J~PIYC, and afYrwnt I sc~nsory ) implllsrs along the ophthalmic. maxillary, and Ina~ltlil)ulirla l)~'il,~~~ll~'S I);tSS tlllY)Ug:h t IIC t riq~ui i?lill iltl i7litiill pin iri ;I I imitctl tract in the brain stem. .\ stimulus wuld ('ilU%' portion of die nci’vc, tlwi in otl1w portions oi’ 1 hc ~IP~TYL scgnictit. ;1nc1 finall; in ad.jacent segments or far-disiilnt sites. A1 cwll inuous pain, (9771 :It i\ linlinill lWd, inn>weritually Ci1llN' all ovcrirl’itation Of t Ilcl II('l'V(L ilTl(I I IIPJI OVC~YflO\\frola one division of triyeniinal iriwrration to illlOtllt~l~, \vliic*li rcwllts iI) wferwd ptrix. IIutchins and Reynolds” demonstrated that Ijaill t~slwricwcetl in the nas;~l mucosa cwuld be correlated with pathologic conditions in thcl twtll. Thnsc~ twill, alt,hough not painfnl in thernsclvcs, wow ir1*itwl(~(l sufficit~ntl\- to F;lciIitat(~ pail1 ~%lltchitlS ;lJltl I
,
wl-hcrcas ltain did not. o(*cur Ott l,he side liantllcd gently and treated under analgosica l~loclr. (h ihf: side \VIIWC~ referred pain was espcric9rc~t1, pain p)atlernS rCtttiiittod rtticbattgetl for tttottths. JlOYeOVCr, il h1Ock ;ttt(*sllt(>sia Of the r~ugltl~ Itantll~~tl 1cc.tII, i~ltltotiglt it wow ofi in a few ho~ti~s. p~~tmaitcwtl~ aholishcd tltc
r(~t’tlw~tl paitt. 1ttflattttttittot~y processw, particulavlg i~l~~ss~~s, ol’ 1Iic i’acc or detmatottcs itd,ja(s(ltlt to Ihc l)~i~tlclt(~s of the fifth IICI’VC ma\- cause ttcuritis by esteasiott. inay oe~ur antl, II is cottc*cival)le that pulpal irritation lcadin, 0’ to inflatntt~at-ion il’ ]~rolOng~~tl, lcad tu 111~:necrosis of the pulp with sttltscqucnt periapiral SWlU(‘lilV. This irritation ~a11 result from a carious h~sion, mechanical and/or calttmical ittjnyv, ttxuttta, or :I retrograde pulpitis front a dccy pcriotlontal poc’ket, mlterc~ ( )l’l)ilU’ tY’[Wl’tS Utlatt2LVllt1tl JIUlft ittflatttniatiott irl\-iltl(!S tllc: p\lll) at. tllc: ;IpCs. Sl.OtlC’S ilS it SO11L’C(’ Of pUl~)ill pitill. 1 lli\Ve >llSO Ol-XX~rVCCl SC?VCI’I: PefeITWl ptitt ftY)tlt pulp stones its has \l’olfsolllL’ ,ZrchCr” reports otttt of it ninnl)cr Of SitIlilitr C’ilSf’S The pulpitis which drvclolts OU t I’ifilPiit I tic~imrlgia RS it WSUlt Of pulp StOlIW. ftVltt ;illy SOltL’CC0I’ irritat5on gives rise to ~l(~ll~itl$$i, whicalt may Sp~C:Xl i310llg the nct’ve ~~ranclic~ supl)lyin, 0’ the alveolns of thcl tooth and also estend to neighboring branches and into the sensory fihcrs oc the ittvolvcld division of the t rigerninii I n(‘rv(‘. Through this pathway, [tnlpal irtitirtiOtt citn give rise 10 reft>rrcd paitt without scvcrc pain in the affectc4 tool lt : this, in t.urtt, CIUS~S difficulty in locating lli(t sent, Of the pain. puitl It is possible to ascc~rtain wltct,li(~r a given 100th is tltt, (~attsc Of a i~~f’crrecl I)g injecting a local anesthetic into the tissues surrounding the tooth in question. If the pain is h~llli~tiCd1~ reduced or (~litllinatcd by the local anesthetic, tltctl t hc suspcctctl tooth, cv(‘n though apparently nonpat,hologic, is the Ca~ts(~ of tltc ref’errccl pain.’ Tltc l)cst, thcrnpeutie measure for the cdossation Of pain is t,lt(l l)locdking or nullification ot’ the stimalns causing the I)ain. Xnothc~r &‘cctivc~ ilid in localizing rct’crred pilill is palpation oi’ the! aw;i ati~l percussion of t ltcb 1Pf411. Lack of’ tctntlcrttcss in the arca in which tlrc patient ctomplains 01 I)ililt ttiigltt well inclic*:ttc~ that the pain is fillSCl?localisctl and is referrt31 I’rotn it cliff~reltt site. .\n ext cnsion of sinusitis may product inAa.mmation and/or compression of tltct first and ~ec~~td divisions of the fift,h nerve which, in turn, may produce signs and symptoms Of neuritis, including &erred pain. There is an intimatc~ rclationsttil) hetwcc>n il numhrr of maxillary dental nerves and the nruco~tcrosteal lilting of the sinus. All of tlic snperior alvcWlar ncrvc’s run For a distattc~(~ itI thin honey walls Of the tnaxillary sinus, and in yonrig;c~t* persons they ilrt’ sepit t~tl~tl 11~7at1 cutrctncly deli,,t,e layer of 110ne. Siclier’ stat,es Ihat, Ihis intitnatc> rclat ionship ltetwcen the dental nerves and the lining of thr: sinus mill (‘itlts(1 at1 ini-olvc~ttrcnt of the ~IPI+VPSif there is an ittl-l;trtttnat,iotl Of tltc> sintts itscllf. ;titcl iltc qttality oi’ pain sonic+rti(~s closely rc5t~11iltlcs that 01’ pulpitis. III c~stitltliSltitt~ il diff~~l?tlliill diagnosis for pain in this arca, one must. bfxr itt triintl tlt;tl ii !/)‘ol(j) 0I’ ltlrtlt ;It’v 1lSllilll~ itt7.olvcd itt sittttsitis. \\.ll(‘L’CilS Only ou(’ loolh is ittvol\-otl iti l)ttll)ilis. \Volfi’.’ in il sctt*icJs ot’ c~spc~t~itttc’ttls itt Ivliiclt clM rical stitnttlation was al)plied to a d(lt’cetivc tooth. dc~lll0ilstriltcd t It;lt TVllCtl il Inasillary toot11 WElS
Fig.
14.
Fig.
16.
while he was suffering au attack o 1’ coronary artery occlusion his mandibular and maxillary teeth ached and his sinus felt as if it would explode. Inglej has noted several instances in which 111~Iiltcral incisors refer pain to the premolars and molars in the same arch. Tt is well to realize the possibility of these much ICSS common referrals, but the most, 1~0nimon 0cc111’~~cnCcs are tliosc shown in the illustrations.
The total efYects of pain arc dependent upon t,hc intimate interrelationship between perception and reaction to pain, and both facets must be taken into account when the problem is evaluated clinicall~~. Pain can initial.e or perpetuate a biologically destructive vicious c+ycle. It ShOLllcl be COKlhtd without, undue delay, since continued pain has an injurious affect upon the nervous activity or function of the affected area. IXseases of the t.eeth usually produce
REFERRED
PULPAL
PAINS
1UWERREJ.I
I’.\IN
CfWtrnl or direct pain is spontanrons pain in a definite area, with or wit Iioul a demonstrable lesion. Elimination of the pause usually eliminates tlic paili. Referred pain seems l-0 owiw in an arra otliw than its point of origin. and severe pain may arise witliaut~ an associated cxiisal-ivr lcsiori. This irivolws radiation or transmission of paiJl to an ad,jaccnt or distant awa supplied by the same or a related nerve. The exact mechanism r(\mains 11~poth~ti(*;tl, l)l~t ill1 ll(‘I’V(! aWcpted t,lieory of referred I'ilCiill pain is as follows : TllC ~‘0111111011 scllsory to the face is the trigeminal J~PIYC, and afYrwnt I sc~nsory ) implllsrs along the ophthalmic. maxillary, and Ina~ltlil)ulirla l)~'il,~~~ll~'S I);tSS tlllY)Ug:h t IIC t riq~ui i?lill iltl i7litiill pin iri ;I I imitctl tract in the brain stem. .\ stimulus wuld ('ilU%' portion of die nci’vc, tlwi in otl1w portions oi’ 1 hc ~IP~TYL scgnictit. ;1nc1 finall; in ad.jacent segments or far-disiilnt sites. A1 cwll inuous pain, (9771 :It i\ linlinill lWd, inn>weritually Ci1llN' all ovcrirl’itation Of t Ilcl II('l'V(L ilTl(I I IIPJI OVC~YflO\\frola one division of triyeniinal iriwrration to illlOtllt~l~, \vliic*li rcwllts iI) wferwd ptrix. IIutchins and Reynolds” demonstrated that Ijaill t~slwricwcetl in the nas;~l mucosa cwuld be correlated with pathologic conditions in thcl twtll. Thnsc~ twill, alt,hough not painfnl in thernsclvcs, wow ir1*itwl(~(l sufficit~ntl\- to F;lciIitat(~ pail1 ~%lltchitlS ;lJltl I
,
wl-hcrcas ltain did not. o(*cur Ott l,he side liantllcd gently and treated under analgosica l~loclr. (h ihf: side \VIIWC~ referred pain was espcric9rc~t1, pain p)atlernS rCtttiiittod rtticbattgetl for tttottths. JlOYeOVCr, il h1Ock ;ttt(*sllt(>sia Of the r~ugltl~ Itantll~~tl 1cc.tII, i~ltltotiglt it wow ofi in a few ho~ti~s. p~~tmaitcwtl~ aholishcd tltc
r(~t’tlw~tl paitt. 1ttflattttttittot~y processw, particulavlg i~l~~ss~~s, ol’ 1Iic i’acc or detmatottcs itd,ja(s(ltlt to Ihc l)~i~tlclt(~s of the fifth IICI’VC ma\- cause ttcuritis by esteasiott. inay oe~ur antl, II is cottc*cival)le that pulpal irritation lcadin, 0’ to inflatntt~at-ion il’ ]~rolOng~~tl, lcad tu 111~:necrosis of the pulp with sttltscqucnt periapiral SWlU(‘lilV. This irritation ~a11 result from a carious h~sion, mechanical and/or calttmical ittjnyv, ttxuttta, or :I retrograde pulpitis front a dccy pcriotlontal poc’ket, mlterc~ ( )l’l)ilU’ tY’[Wl’tS Utlatt2LVllt1tl JIUlft ittflatttniatiott irl\-iltl(!S tllc: p\lll) at. tllc: ;IpCs. Sl.OtlC’S ilS it SO11L’C(’ Of pUl~)ill pitill. 1 lli\Ve >llSO Ol-XX~rVCCl SC?VCI’I: PefeITWl ptitt ftY)tlt pulp stones its has \l’olfsolllL’ ,ZrchCr” reports otttt of it ninnl)cr Of SitIlilitr C’ilSf’S The pulpitis which drvclolts OU t I’ifilPiit I tic~imrlgia RS it WSUlt Of pulp StOlIW. ftVltt ;illy SOltL’CC0I’ irritat5on gives rise to ~l(~ll~itl$$i, whicalt may Sp~C:Xl i310llg the nct’ve ~~ranclic~ supl)lyin, 0’ the alveolns of thcl tooth and also estend to neighboring branches and into the sensory fihcrs oc the ittvolvcld division of the t rigerninii I n(‘rv(‘. Through this pathway, [tnlpal irtitirtiOtt citn give rise 10 reft>rrcd paitt without scvcrc pain in the affectc4 tool lt : this, in t.urtt, CIUS~S difficulty in locating lli(t sent, Of the pain. puitl It is possible to ascc~rtain wltct,li(~r a given 100th is tltt, (~attsc Of a i~~f’crrecl I)g injecting a local anesthetic into the tissues surrounding the tooth in question. If the pain is h~llli~tiCd1~ reduced or (~litllinatcd by the local anesthetic, tltctl t hc suspcctctl tooth, cv(‘n though apparently nonpat,hologic, is the Ca~ts(~ of tltc ref’errccl pain.’ Tltc l)cst, thcrnpeutie measure for the cdossation Of pain is t,lt(l l)locdking or nullification ot’ the stimalns causing the I)ain. Xnothc~r &‘cctivc~ ilid in localizing rct’crred pilill is palpation oi’ the! aw;i ati~l percussion of t ltcb 1Pf411. Lack of’ tctntlcrttcss in the arca in which tlrc patient ctomplains 01 I)ililt ttiigltt well inclic*:ttc~ that the pain is fillSCl?localisctl and is referrt31 I’rotn it cliff~reltt site. .\n ext cnsion of sinusitis may product inAa.mmation and/or compression of tltct first and ~ec~~td divisions of the fift,h nerve which, in turn, may produce signs and symptoms Of neuritis, including &erred pain. There is an intimatc~ rclationsttil) hetwcc>n il numhrr of maxillary dental nerves and the nruco~tcrosteal lilting of the sinus. All of tlic snperior alvcWlar ncrvc’s run For a distattc~(~ itI thin honey walls Of the tnaxillary sinus, and in yonrig;c~t* persons they ilrt’ sepit t~tl~tl 11~7at1 cutrctncly deli,,t,e layer of 110ne. Siclier’ stat,es Ihat, Ihis intitnatc> rclat ionship ltetwcen the dental nerves and the lining of thr: sinus mill (‘itlts(1 at1 ini-olvc~ttrcnt of the ~IPI+VPSif there is an ittl-l;trtttnat,iotl Of tltc> sintts itscllf. ;titcl iltc qttality oi’ pain sonic+rti(~s closely rc5t~11iltlcs that 01’ pulpitis. III c~stitltliSltitt~ il diff~~l?tlliill diagnosis for pain in this arca, one must. bfxr itt triintl tlt;tl ii !/)‘ol(j) 0I’ ltlrtlt ;It’v 1lSllilll~ itt7.olvcd itt sittttsitis. \\.ll(‘L’CilS Only ou(’ loolh is ittvol\-otl iti l)ttll)ilis. \Volfi’.’ in il sctt*icJs ot’ c~spc~t~itttc’ttls itt Ivliiclt clM rical stitnttlation was al)plied to a d(lt’cetivc tooth. dc~lll0ilstriltcd t It;lt TVllCtl il Inasillary toot11 WElS
Fig.
14.
Fig.
16.
while he was suffering au attack o 1’ coronary artery occlusion his mandibular and maxillary teeth ached and his sinus felt as if it would explode. Inglej has noted several instances in which 111~Iiltcral incisors refer pain to the premolars and molars in the same arch. Tt is well to realize the possibility of these much ICSS common referrals, but the most, 1~0nimon 0cc111’~~cnCcs are tliosc shown in the illustrations.
The total efYects of pain arc dependent upon t,hc intimate interrelationship between perception and reaction to pain, and both facets must be taken into account when the problem is evaluated clinicall~~. Pain can initial.e or perpetuate a biologically destructive vicious c+ycle. It ShOLllcl be COKlhtd without, undue delay, since continued pain has an injurious affect upon the nervous activity or function of the affected area. IXseases of the t.eeth usually produce