Orofacial pain

النسخ

1 OROFACIAL PAIN األنى انف ان ر

2 Orofacial pain is the field of dentistry related to diagnosis and management of chronic, complex facial pain and orofacial disorders. أل ا ل ٴ ١ ا ع ٢ غب ك ٢ ت أل ب ٣ ؼي ا ٠ ر ق ٤ ٴ رلث ٤ و أل ا ع ٢ ا ؼول ا ٴي ال واث بد ا لٴ ٣ خ ا ع ٤ خ.

3 Orofacial pain, like pain elsewhere in the body, is usually the result of tissue damage and the activation of nociceptors, which transmit a noxious stimulus to the brain. Orofacial disorders are complex and difficult to diagnose due to rich innervations in head, face and oral structures. األ ا ع ٢ ا ل ٴ ١ ٴب األ ك ٢ أ ١ ب آفو ز ٤ غخ أم ٣ خ ٤ غ ٤ خ رلؼ ٤ زوجالد األم ا ز ٢ زو ا بهح ثن ي ا ٠ ا ل بؽ. ال واثبد ا ل ٣ خ ا ع ٤ خ ؼولح ؼجخ ا ز ق ٤ ٴ ث جت ا زؼ ٤ ت ا ض ٤ ق ك ٢ ا ؼ ن ا ع ا ج ٠ ا ل ٣ خ.

4 Ninety percent of orofacial pain arises from teeth and adjoining structures. As a dentist, one must be trained to diagnose and treat acute dental pain problems. األ ا لٴ ١ ا ع ٢ ٣ ؤ أل ب ا ج ٠ ا ورج خ ث ب. %90 ج ٤ ت أ ب ٣ غت أ ٣ زلهة ػ ٠ ر ق ٤ ٴ ؼب غخ ا ٴ ب األ ٴ ٤ خ ا ؾب كح ا ٤ خ.

5 PAIN Dorland s Medical Dictionary defines pain as A more or less localized sensation of discomfort, distress or agony resulting from the stimulation of nerve endings. It indicates that pain is a protective mechanism against injury. ٴب ٣ غؼ هب Dorland s ا ج ٢ ٣ ؼو ف أل بؽ ب غ )أ ضو أ أ ه ( ثؼ ل ا واؽخ ا و ة أ أل ا ٴجوػ برظ ػ رؾو ٣ ا ب ٣ ب د ا ؼ ج ٤ خ. أل آ ٤ كخكبػ ٤ خ ل األم.

6 International Association for the Study of Pain (IASP) has defined pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.l رؼو ف ا غ ؼ ٤ خ ا ل ٤ خ لها خ األ (IASP) األ ث ؤ ) ؽ ٢ ػب ل ٢ ٣ ز اوكنثؤم ٣ خ ٤ غ ٤ خ اهؼخ أ ب خ. ؼ ه يػظ )ؿ ٤ و و ٣ ؼ

7 DIAGNOSIS The most important component of managing pain is in understanding the problem and establishing the proper diagnosis. For establishing the correct diagnosis, the dentist must record all relevant information regarding signs, symptoms, history of present complaint, past medical and dental history. ٴ ٴ ق ٤ ٴ: ا ز األ ب ٢ ك ٢ رلث ٤ و األ ا ا ا ال بد ا ٴاوكوخ ٴب ا ٤ وح ا ؾ ٤ ؼك ب ج ٤ ت األ ب ٣ غت أ ٣ غ األػو ا ز ق ٤ ا ٢ ا بثن. ا ج ٢ ا ؾب ٤ خا زبه ٣ ٤ خ ا ٴو ف ف ىان شكهح ػغناتشح ض ان اعة. و ٤ ب ث نا

8 HISTORY OF PAIN History of pain includes the following: Chief Complaint Location Onset Chronology Quality Intensity Aggravating factors Precipitating factors Past medical and dental history Psychologic analysis Review of systems ربه ٣ األ ٣ ز ٴ: ا ا ئو ٤ ٤ خ ا ٴ هغ ا جلا ٣ خ ا ز ا ي ٢ ا لح ا ػ ٤ خ ا ؼ ا ا ز ٢ ري ٣ ل األ ا ؼ ا ا ٴ ب ٴخ ا زبه ٣ ا ج ٢ ا ٢ ا بثن

9 Orofacial pain can be basically divided into odontogenic (dental pain) and nonodontogenic pain (nondental). Dental pain may have origin in the pulpal tissue or the periradicular tissue. Nondental pain can be in form of myofacial toothache, vascular headache, cluster headache, sinusitis, trigeminal neuralgia. أل ا ل ١ ا ع ٢ ٣ ٴ أ ٣ و ث هئ ٢ ٤ ا ٠ أ ي ي شأ ع ي شأ غ ش ع. ألنى ان غ ٣ ٴ أ ٣ ؤ ا ت ا ٢ أ ا ظ ؽ ا غنه ٣ خ. ألنى غ ش ا نغ ٣ ٴ أ ٣ ث أ ػ ٢ ع ٢ لاع ػبئ ٢ لاع ػ و ك ١ ا ز بة ع ٤ ة أ ػ ت ض ش ا ز ائ.

10 SOURCES OF ODONTOGENIC PAIN بكه األ ؤ a. Dental Pain of Pulpal Origin ٢ afferent (toward the brain) efferent (away from the brain) أ ا أللنى انغ ي نة انغ ا ت ا ٢ ؿ ٢ ا زؼ ٤ تثؤ ٤ بف ػ ج ٤ خ ا ع A ا ع. C أػ بة ا ت ا ٢ رز ٴ أ ٤ بف اهكح afferent أ ٤ خ ا ٴ ئ خ ػ و األ أ ٤ بف بكهح efferentؽ ٣ خ ( ك ٣ خ( ا ز ٢ ر ظ ا ل ها ا ل ١ ا ٴغ و ١ ك ٢ ا ت. األ ٤ بف ا ك ٣ خ ا بكهحر وٴ رلكن ا ل ك ٢ ا ت ػجورؾو ٣ قال ٣ ب ا ؼ ٤ خ ا ٴ بء ا ز ٢ رؾ ٤ ثب و ٤٣ بد ا ل ٣ خ. أ ٣ ب أهثغ أ اع ا ب ٣ بد ا ؼ ج ٤ خ ر عل ك ٢ ا ت ا ٢ :

11 both pain and touch sensations have been related to free nerve endings but stimulation of the pulp give rise only to pain. Fast pain is ؼط associated انهة with إحاسج ٴ نكA-fibers and slow نحشج pain is with C-fibers. Stimulation of A-fibers produce a sharp, piercing أيا انأل اىنثط ء تشثطتأن اف. C or stabbing sensation while C-fibers produce dull, burning, and aching sensation that is usually harder to. endure كمي ألحغا طتاأنلى ٴانه ظ تؼض نه ا اخ انؼظث ح ا شؼ ستاأنلىفمط. أنلى انغش غ تشثطتأن اف A إحاسج أن اف A ت ت ذنأى حاد حال ة ( افز( أٴ ٴ اخض ت ا إحاسج أن اف Cت ت ذ شؼ س كه م حاسق ي رغ ٴانز اػدج ي انظؼة تح ه.

12 The pulpal pain is of threshold type, that is, no response occurs until threshold level is increased. Pulp may respond to chemical, mechanical, ثخ. ا ت electrical or thermal stimulation but not to ordinary masticatory functions. Pulpal pain cannot be localized أل ا ج ٢ ػزج ١ ث ٴؼ ٠ ػل ع ك ا زغبثخ ؽز ٠ ا ا ٠ ا زؼجخ ا ٴ ٣ ٴ ا ٣ زغ ٤ ت ػ ٠ ا ٴ ٤ غبد ا ؾواه ٣ خ ا ٴ ٤ ب ٤ خ ٤ ا بثوئ ٤ خ ٤ ا ظبئق ا ٴ ؾ االػز ٤ بك ٣ خ. أل ا ج ٢ ال ٣ ٴ رؾل ٣ ل هج ا ٴو ٣. ظ و أ ب ٢ أل له ج ٢ أ ال ٣ جو ٠ لزوح ٣ خث ل ا ٴول اه. ػ ب ٣ قق ٣ جؼ ي ب أ ٣ زو ا ٠ ا ج ٠ ا وثب ٤ خ. by the patient. A basic feature of pain of pulpal origin is that it does not remain the same for long periods. Generally it resolves, becomes chronic or involves the periodontal structure.

13 b. Dental Pain of Periodontal Origin Periodontal pain is deep somatic pain of the musculoskeletal type because of presence of proprioceptor fibers. Patient can localize the pain of periodontal origin. Therefore, periodontal pain presents no diagnostic problems because the offending tooth can be readily identified. This localization can be identified ؽ عنه ٣ خ(: by applying pressure to the tooth axially and laterally. ( صب ٤ ب: األ ا ٢ ؤ ا ظ ؽ ا ٤ خ أل ؽ ا غنه ١ أ ع ل ١ ػ ٴ ٤ ن ع ا ٤ ا ؼ ٢ ث ج ت ع ك أ ٤ بف زوجالد ا ن اه ٣ خ ( ٤ ب ٤ ٤ خ(.. ان ش غ ك تحذ ذي ظذ اأنلى ٴان غ ان ظاب ا األ ؤ ؽ عنه ١ ال ٣ ض خ ر ق ٤ ٤ خ ؽ ٤ ش أ هوع ا ا ٴ بة ٤ ؾلس أل.

14 When the periodontal pain involves many teeth, one may consider occlusal overstressing which could be due to occlusal interferences or parafunctional habits such as bruxism. ػ ل ب ٣ األ ا وثب ٢ ػلح أ ب ٣ ٴ اال زجب ا ٠ ع ك ا جب م ه ٢ أ ػبكا د ؿ ٤ و ظ ٤ ل ٤ خ ض ا يى.

15 PULPAL PAIN 1. DENTINAL SENSITIVITY In the absence of inflammation, dentinal sensitivity is the mildest form of pulp discomfort. The pain is often characterized as a short, sharp, shock and it is brought on by some stimulating factor such as hot or cold, sweet, sour, acid or touch. It is not pathologic, but is rather, fluid flow in the dentinal tubules which stretches or compresses the nerve endings that pass alongside the tubular extensions of the pulp odontoblasts. ألنىانه ث : 1- ا ؾ ب ٤ خ ا ؼبع ٤ خ ا لهعخ األك ٠ االىػبط ا ج ٢. أنلى طف ػادج تأ لظ ش حاد ٴ حذثتغث ة تؼ غ انؼ ايم ان خ شج ض ا جبهك ا بف ا ؾب ا ؾ أ ا ٴ. ٤ و ٢ ثوله ب رلكن ا بئ ك ٢ ا و ٤ بد ا ؼبع ٤ خ ا ز ٢ رٴلك أ ر ا ب ٣ ب د ا ؼ ج ٤ خ ا ز ٢ ر ٴو ػ ٠ اال ز بال د ا ٤ ٤ خ أل ك ز ثال ذ.

16 Dentinal sensitivity may also develop when dentin is exposed from gingival recession or following periodontal surgery. Nerves in these exposed tubules ضخ not only respond to hot, cold, sweet and sour but also to scratching with a finger nail or during tooth brushing. ا ؾ ب ٤ خ ا ؼبع ٤ خ ٣ ٴ أ ر ؤ ػ ل ب ٣ ا ؼبط كبث جترواعغ ا أ عواؽخ ض ٣ خ. ألػ بة ك ٢ ن ا و ٤ بد ا ٴ كخ الر زغ ٤ تكو ٴ ٤ غبد ا ؾواه ٣ خ ا ٴ اك ا ؾب خ ا ؾ حث أ ٣ ب ػ ل ؽي ا ثألبظكو أ أص بء ا زلو ٣.

17 Diagnosis 1. Apply the irritant which starts the painful reaction-hot or cold, sweet or sour or scratching with an instrument. 2. All diagnostic tests such as electric pulp test, percussion and radiographs give normal رؼ ٢ response.... ا ق ٤ ٴ: 1 -ر ج ٤ ن ا ٴ ٤ ظ أ ؽي ا ٤ ؾلس األ. 2- االفجزب ها د ا ز ق ٤ ٤ خ ض ا اوئي ا وثبئ ٢ ا ووع األ ؼخ ز ٤ غخ ج ٤ ؼ ٤ خ.

18 Treatment After diagnosis, dentinal hypersensitivity can be treated by home use of desensitizing dentifrices containing strontium chloride, fluorides and potassium nitrate. Since rapid movement of fluid in the dentinal tubules is responsible for pain by activating intradental sensory nerves, the treatment of hypersensitive teeth should be aimed at reducing the anatomical diameter of the tubules so as to limit the fluid movement. Various agents can be use to occlude the dentinal tubules like varnishes, calcium compounds, fluoride compounds like sodium fluoride, stannous fluoride, iontophoresis, restorative resins and dentin bonding agents. ٴ ٴ ٴ ا ٴؼب غخ: ر ا ؾ ب ٤ خ ا ؼبع ٤ خ ٣ أ رؼب ظك ٢ ا ٴ ي ثب زقلا يؼا ثؼل ا ز ق ٤ يض هحنهح غاع ح ت ح ك ه س ذ عت شٴ ت و انفه س تشاخناث ت اع و. ٴثب أ و ٣ نر ٤ ئ خ ػ األ ػ ا و ٣ ؼخ بئ ك ٢ ا و ٤ بد ا ؼبع ٤ خ ا ؾو خ بة ا ؾ ٤ خث ٤ ا ؼبع ٤ خ كب ؼب غخ ؽ ب ٤ خ األ ب ٣ غت أ ر لف ا ٠ األػ ا ائ. ا وب ا ٴؼخ ا ز و ٣ ؾ ٤ خ و ٤ ب د ا ؼبع ٤ خ زقل ٤ ؽو خ ٤ و جبد ػ ا زلؼكح ٣ أ ر زق ل ل ا و ٤ بد ض ا لبه ك ها ٣ ل ( ؽ اد ه ٣ ي ٣ ٤ خ ك ٣ ك ها ٣ ل زب ا ب ٤ و جبد ا ل ها ٣ ل) اك ا وث ا ؼبع ٢ ا ٤ يه.

19 2. REVERSIBLE PULPITIS In reversible pulpitis, pain occurs when a stimulus (usually cold or sweets) is applied to the tooth. When the stimulus is removed, the pain ceases with in 1 to 2 second, i.e. it should return to normal with removal of cause. The common causes of reversible pulpitis are caries, faulty restorations, trauma or any recent restorative procedures. Pulpal recovery is usually seen if reparative cells in the pulp are adequate. انت اتاخ انهةانشدٴدج األ ك ٢ ا ز بثبد ا ت ا وك كح أنى حاد حذث ػ ذيا طثك ي ذيا ( اػدج انثشٴدج ) ػه ان غ ٴ ضٴ اأنليىثاششج تؼذ حا ح أٴ اح ت ي سفغ انؼايم ان ذ. ا جت ا وئ ٢ ٤ إل ز بة ا ت ا وك ك ع ك قو ؽ اد ؼ ٤ جخ ا و أ أ ١ اعواءرو ٤ ٴ ٢ ( )٢ ؽل ٣ ش األ ل. ٣ ٴ أ ٣ ؾلسرؼبك ٢ ج ٢ ثي ا ا ؼب ا ٴ جت غ ٴبك ( غ ع ك هلهحرغلكخ ٣ بك ٤ خك ٢ ا ت ا ٢ (. -2

20 Diagnosis Diagnosis is made by careful history and clinical examination. If there is discrepancy between the patient s chief complaint, symptoms and clinical examination, obtain more information from the patient. It is important to note that both pulpal and periapical diagnosis should be made before treatment is initiated. If tooth is sensitive to percussion, then look for bruxism and hyperocclusion. انتشخ ض انتشخ ض ث تا نفحض انغش ش ٴانمظح ا ن شػ ح ا عت ز اب ان ش غ. ٴي ان او ء ارشاكم انف ح صانهث ح ٴ ح ل انزس ح لثم انثذءت ان ؼانزح.

21 Treatment 1. Removal of the cause if present (caries, fractured restoration, exposed dentinal tubules). 2. If recent operative procedure or trauma has taken place, then postpone the additional treatment and observe the tooth. 3. If pulp exposure is detected, go for root canal treatment. هح...( ٴ جت ( ا قو ا ؾ ا د ا ا ؼب غخ 1- اى ا خ ا ؼب ا ءاد ٤ خ ؽل ٣ ضخ رئ ع ب أ اعوا 2- ثؾب خ ع ك ه ا ؼب غخ ٣ واهت ا. ك ٢ ؽب ؽل س ا ب ف ج ٢ أ اىك ٣ بك ا ؾب خ ه ثٴؼب غخ ج ٤ خ ه ٣ خ.

22 3. IRREVERSIBLE PULPITIS Irreversible pulpitis develops, if inflammatory process progresses to involve pulp. Patient may have history of spontaneous pain or exaggerated response to hot or cold that lingers even after the stimulus is removed. The involved tooth usually presents an extensive restoration and/or caries. 3 -انت اتاخ انهة غ ش انش دٴدج. ٣ ز ه ػ لرول ا ؾب خ ال ز بث ٤ خ ز ٴ ا ت. هل ٣ ا ٴو ٣ ٴر د الو ػف ح أٴ اعت زاتحشذ ذجنه ذاثناسد ٴانز غت ش ح ت تؼذ ااصنح انؼايمان ذ ا ا ٴ ب ةهل ٣ ؾ ١ ؽ ح ج ٤ وح / أ قو.

23 Diagnosis Diagnosis is usually made after taking thorough history and clinical examination of the patient. 1. Patient usually gives a history of spontaneous pain. 2. Tooth is hypersensitive to hot or cold that is prolonged in duration.. هل ٣ ز و vital. 3. Pulp may be vital or partially 4. In certain cases of irreversible pulpitis, the patient may arrive at the dental clinic with a glass of ice/cold water. In these جبهكpain cases, cold actually alleviates the patient s and ا thus, ٴبء can be used as a diagnostic test. Cooling of the dentin and the resultant contraction of the fluid in the tubules relieves the pressure on pulpal nerve fibers caused by edema and inflammation of the pulp. ٣ ج ٠ ا ز ق ٤ ٴ ثؼل أفن ه خ و ٤ خ ب خ غ ا لؾ ا و ٣ و ٣ خ االفجزب ها د ا ؾ ٤ ٣ خ. أ ػل ١ أ ضب ه زٴو لزوح ثؼلهكغ ا ؼب ا ٴ ٤ ظ ا ٠ أ ب أفو. ا ت هل ٣ ؽ ٢ ث ب أ عيئ ٢. ك ٢ ثؼ ا ؾبال د هل ٣ ا و ٣ ؼ ٤ بكح غ ؤ ا أ ا ض ظ ا ن ١ ٣ قلق أل )ػ و ٣ نرو ٤ ٴ ا ك اف ا (

24 Treatment Complete removal of pulpal tissue should be done, i.e. endodontic therapy. ا ؼب غخ إلى ا خ ا ب خ ت ا ٢ ) ؼب غ خ عن ه ا (

25 4. NECROTIC PULP It results from continued degeneration of an acutely inflamed pulp. Literal meaning of necrosis is death, that is pulpal tissue becomes dead because of untreated pulpal inflammation. In pulpal necrosis, there is progressive breakdown of cellular organization with no reparative function. It is frequently associated with apical radiolucent lesion. In case of multirooted teeth, one root may contain partially vital pulp, whereas other roots may be nonvital. ا ن ١ ٣ أ ٣ عيئ ٤ ب أ ب ال بئؼب أ رقضو ٣ ب. 4- ا ت ا ٴزٴ د ٣ ؤ ا زل ه ا ٴ ز ا ت ا ٴ ز ت.

26 Diagnosis 1. Tooth is usually asymptomatic; may give moderate to severe pain on biting pressure (It is not symptom of necrotic pulp but it indicates inflammation). 2. Pulp tests show negative response but in case of multirooted ا ز ق ٤ ٴ results. teeth, it can give false positive 1- ا ػبكح ؿ ٤ و ػو ٣ ٢ ٴ أ حذث أنى يت عط إن ش ذ ذ ػ ذ انؼ غ أٴ انؼغط ( نا ٤ ػو ز ٴ د ا ج ٢ (. ك ٢ ثؼ ا ؾبالد ا بكهح ٣ ؾلس أ ػ لر ب ا ٴ اك ا بف خ )ث جت رٴلك ا بىا د (. 2- ا لؾ ا ج ٤ الرؼ ٢ ا زغبث خ ك ٢ ؽب خ األ ب زلؼكح ا غن ه هلرؼ ٢ ا زغبثخ ا ٣ غبث ٤ خ فب ئخ.

27 Treatment Complete removal of pulpal tissue that is root canal treatment. ا ٴؼب غخ اإلىا خ ا ب خ ٤ ظ ا ج ٢ ا ٴز ٴ د ك ٢ ٤ ب م ا ٴؼب غخ ا ج ٤ خ غن ه.

28 Pulp stones ٤ بد ا ج ٤ خ ا ؾ ك ٢ أؿ ت ا ؾبالدر ا ؾ ٠ انهث حغ ش يؤن ح هل ر جت آال ز ؼجخ ج ٴخ ك ٢ أؽغب ب ا ج ٤ وح ث جت ب ػ ٠ ا ب ٣ بد ا ؼ ج ٤ خ ا اهؼخثغ اه ب. 29

29 ا نغ ا ن ظذ ٴع ( كغشحذتح( cracked Tooth 30 ا ا وئ ٤ ٤ خ ٢ أنى حاد يفارئ ػ ذ ان ؼغف ب ػ ل ا ؼ ػ ٠ ا ز ٴو ؿ ٤ و ل و.٣ أ ٣ ؼو ا ٴو ٣ ثؾ ب ٤ خ أ أ ٢

30 ٴ ٴ ظ ؽ ا غنه ٣ خ ا ا ز لع أ ػبكح ٣ ج ٤ ت أ ٣ ٴ ٤ يث ٤ ا ز بة ا ا غنه ٣ خ ٤ زغ ٤ ت ا ا ٴ ب ةثب ز ب ةك ٢ ا ظ ؽ هح. ا ؾلثخ ا تغ غ ان ظش ػ ان مطح ان فح طح. ث ٤ ٴب ػ ل ػ ٠ كؾ ا ووع ا ؼ أ وك ٢ ا ؾلثخهب األ ػ ل ر ج ٤ ن كؾ ٢ ا ووع لع ك ٢ ا ع ك ؾلثخ اؽلح أ عيء ا. ا ؼ The clinician can often differentiate between periradicular periodontitis and a cracked tooth or fractured cusp. If periradicular periodontitis is present, the tooth will respond with pain to percussion and biting tests regardless of where the pressure is applied to the coronal part of the tooth. A cracked tooth يؼ or fractured تاتز ا cusp ٤ will elicit pain only when the percussion or bite test is applied in a certain direction to one cusp or section of the tooth. 31

31 PERIODONTAL PAIN 1. ACUTE APICAL PERIODONTITIS It is the inflammation of periodontal ligament which is caused by tissue damage, extension of pulpal pathology or occlusal trauma. Tooth may be elevated out of the socket because of the built up fluid pressure in the periodontal ligament. Pain remains until the bone is resorbed, fluid is drained or irritants are removed. األنى ح ل انغ ( انشتا ط ( ا ز بثبد ا ظ ؽ ا غنه ٣ خ )ؽ ا نه ٣ خ( ا ؾبكح ا ز بة ا وثب ا ٢ ا ق ٢ ث جت أم ٣ خ ٤ غ ٤ خ ا زلاك ا ٴ و ا ج ٢ أ ه ا جبه ٢ ٣. ٴ أ ٣ ز ب ا ك ٢ ق ث جت ا زؾخ. أل ٣ جو ٠ ؽز ٠ ا ز ب ا ؼظ أ ر و ٣ ق ا ائ أ اى ا خ ا ؼب ا ٴ جت. -1

32 ٴ Diagnosis 1. Check for decay, fracture lines, swelling, hyperocclusion or sinus tracts. 2. Patient has moderate to severe pain on percussion. 3. Mobility may or may not be present. 4. Pulp tests are essential and their results must be correlated with other diagnostic information in order to determine if inflammation is of pulpal origin or from occlusal trauma. 5. Radiographs may show no change or widening of periodontal ligament space in some cases. ٴ ٴ ا ز ق ٤ و م خ ا جبم ه ٢. 1- اثؾش ػ ا قو ف ا ٠ ل ٣ ل ٣ ؼب ٢ أ ز ا ٴو ٣ 2-٣ أال رؾلس ؽو خك ٢ ا 3-٣ ا لؾ ا ؾ ٣ ٤ خ ب خ ٣ غت أ رؾ زبئغ ب غ ا ؼ بد 4- بة ج ٢ أ ه له اال ز ٤ خ األفو ؽز ٠ ٣ ؾلك ا ز ق ٤ ا جبه ٢. 5- األ ؼخ هلرظ و ر ؼب هثب ٤ بك ٢ ثؼ ا ؾبالد )ػ ٠ األؿ ت ر ظ و )

33 Treatment 1. Complete removal of pulp. 2. Occlusal adjustment. ان اؼنزح 1- ياؼنزح ل ح 2- تؼ ذ االطثاق

34 2. ACUTE PERIAPICAL ABSCESS Acute periapical abscess is an acute inflammation of periapical tissue characterized by localized accumulation of pus at the apex of a tooth. It is a painful condition that results from an advanced necrotic pulp. Patients usually relate previous painful episode from irreversible pulpitis or necrotic pulp. Swelling, tooth mobility and fever are seen in advanced cases. 2- انخشا د انزس ٴ انحاد ا ز بة بؽكك ٢ ا ظ ؽ ا نه ٣ خ ٣ ٴز ٤ يثزغ ٴغ غ و ٤ ؼ ػ ل مه ح ا. ٢ ؽب خ ئ ٴخ برغخ ػ رو ل ا ت ا ٴز ٴ د. ا ٴو ٠ بػكح ٤ و ٣ ا ٠ وب غ أ ٴ ٤ خ بثوخ ا ز بة ت ؽبك أ ر ٴ د ج ٢. م خ ؽو خك ٢ ا أ ؽ ٠ ٣ ٴ أ ر ب لك ٢ ا ؾبالد ا ٴ زول خ.

35 ٴ Diagnosis 1. Spontaneous dull, throbbing or persistent pain is present. 2. Tooth is extremely sensitive to percussion. 3. Mobility may be present. 4. On palpation, tooth may be sensitive. 5. Vestibular or facial swelling in seen in these patients. 6. Pulp tests show negative results. ا ز ق ٤ 1- أ ػ ل ١ ٤ بث أ و ٤ ( زٴو(. 2- ا ؽ ب عالرغب ا ووع. 3- هل ر عل ؽو خ 4- ا غ ٣ ٴ أ ٣ ؾلس أ ٴب. 5- م خ ك ٤ ي ٣ خ 6 -الفزج بهاد ا ج ٤ خ ج ٤ خ.

36 Treatment 1. Drainage 2. Complete extirpation of pulp. 3. Appropriate analgesics and antibiotics if necessary. ا ٴؼب غخ ر و ٣ ق ا و ٤ ؼ ا زئ ب ا ت ق بد أ بك اد ؽ ٣ ٤ خ اما ب بى و هح.

37 3. CHRONIC APICAL PERIODONTITIS It is caused by necrotic pulp which results from prolonged inflammation that erodes the cortical plate making a periapical lesion visible on the radiograph. The lesion contains granulation tissue consisting of fibroblasts and collagen. 3- انت اتاخ ان غ ذ ح ل انزسٴ ح ان ضي ح ٣ جج ا ت ا ٴز ٴ د ا ن ١ ٣ زظ ػ اال ز ب ة ٣ األ ل ا ن ١ ٣ آ ا ل ٤ ؾخ ا وب ٤ خ ٴب ٣ غؼ ا ٥ كخ وئ ٤ خ ؼبػ ٤ ب. الكخ ر ٤ ظ ؽج ٤ ج ٢.

38 ٴ Diagnosis 1. It is usually asymptomatic but in acute phase may cause a dull, throbbing pain. 2. Pulp tests show nonvital pulp. 3. There is no pain on percussion. 4. Radiographically, it is usually associated with periradicular radiolucent changes. ا ز ق ٤ 1- ؿ ٤ و ػو ٢ ػبكح ك ٢ ؽب خ االؽزالك ٣ ٴ أ ٣ بى أ ٤ بث. 2- ا لؾ ا ؾ ٣ ٤ خ ج ٤ خ 3- ا ووع ج ٢ 4- ؼبػ ٤ ب ع كر ٤ و اد بكخ.

39 ا قواط ؽ ا ٢ Acute Gingival Abscess 40 ٣ - - ٣ ز ه ا قواط ا ض ١ ا ؾبك أ ا قواط ؽ ا ٢ اإل زب ا ٴ ٴزل ا غ ٤ ة ا ض ٣ خ أ ؽ ا ٤ خ. ب ل ث ضوح ػ ل و ٠ ا و ٣ و أ إل جب م ا و و ١. - أ ك ٢ ا ػ ل ا ؾ و خ أ ا ؼ,٣ ٴ أ ٣ ز اعل ا زلبؿ ؼ ٢ ك ٢ ا ض ش ا زبع ٢ ا غن ه األ ب ا ٴ بثخ ر ؽ ٤ خ ػبكح ٣ ظ و ا جو ؽ ا ٢ ع ك و ٣ نث ٤ ا غ ٤ ت ا ض ١ ا قواط. -

40 انت ا د Pericoronitis ٴ ٴ ٴ 41 ظ ؽ ا زبع ٤ خ ا ٴاوكوخ ألهؽباء ٥ فنح ا ز اط ؽب خ ا ز بث ٤ خ ازب ٤ خ قث ٣ ز األهؽبء ا ضب ضخ ا ل ٤ خ ) ب ثب جي ؽ )ف ٣ ؾل ٢ ؽو خ ا لي ا ل ٢ يى ػ ؼ ثخك ٢ ا ؾ ا ج غ غ ظ ا ز جخ ا ٤ خ أ اإلؿالم ػ ٠ ا اؽ وا ه ا زجبط غ أ ػ ل ا وؽ ا ٥٠ فنحثب جي ؽ ا ٴ ٴ أ ٣ ز ؼغ األ ا ٠ ا ؼ ن أ األم ٣ ٴ أ ٣ قز ث خ غ األ ا ج ٢.

41 42 Impacted teeth األ ب ا ٴ ٴوح ا ٴ ٴ أ ر ج األ ب ا ٴ ٴوح ر اط غ أ فل ٤ ق ز غ أ ل ٣ ل ز ؼغ ا ٠ األم أل ب ا ؼ ٣ خ ا ل ٤ خ ا لؽ ا ٴ وخ ا ق بئ ٤ خ ه ٣ ؼ تث ٴض ش ا ز ائ

42 SOURCES OF NONODONTOGENIC PAIN Tooth aches of nondental origin are usually suspected when patient convincingly reports that pain is usually felt in this particular tooth. But dentist should be aware of this fact that some tooth aches felt in the tooth/ teeth do not originate from these structures. There are many structures in the head and neck region which can stimulate pain. Such types of pain are classified under heterotrophic pain. Heterotrophic pain can be defined as any pain felt in an area other than its true source. يظاد اأنلى غ ش ع ان شأ ٣ غت ػ ٠ ج ٤ ت أل ب أ ٣ ٴب ثؾو ٤ وخ أ ثؼ أ عبع أل ب ال ر ؤ ب. ؽ ٤ ش ٣ عل ض ٤ و ا ج ٠ ك ٢ ا وأ ا وهجخ ٣ أ رؼ ٢ ن األ. ض نا األال ر ق رؾذ ا ( Heterotopic pain أ زجن ب ٣ و ) ٴ ك أ ؼش ف تأ أ نأى شؼش ت ف ي طمح أخش غ ش يظذس انحم م.

43 Heterotopic Pain Any pain that is felt in an area other than its true source is heterotopic pain. There are three types of heterotopic pain: referred, central, and projected.105,106 Referred pain is pain felt in an area innervated by a nerve different from the one that mediates the primary pain. Referred pain cannot be provoked by stimulation of the area where the pain is felt; rather, it is brought on by manipulation of the primary source of Pain In addition, referred pain cannot be arrested unless the primary source of pain is anesthetized. أل ا ٴ زجن أ ١ أ ٣ ؼوث ك ٢ لخ ٤ ذ ٢ له ا ؾو ٤ و ٢. الصخ أ اع: ا ؾ referred ا ٴو ي ١ central ا ٴ و projected أل ا ؾ أ ٣ ؾ ث ك ٢ وخرؼ تثؼ ت آفو ؿ ٤ و ا ؼ ت ا ن ١ ٣ ز األ األ ٢, أل ا ؾ ال ٣ ٴ ا زؾ به ك ٢ ا ٴ وخ ا ز ٢ ٣ ؾ ث ب م ي ٣ ز له األ ب ٢.ثبأل بكخ ا ٠ م ي األ ا ؾ ال ٣ ٴ ا ٣ وبك االثزقل ٣ و ا ٴ له األ ٢ أل.

44 Odontogenic Referred Pain In this pain originates from pulpally involved tooth and is referred to adjacent teeth/tooth or proximating deep and superficial structures. For example, pain from pulpal involvement of mandibular second or third molar is referred to ear. This pain is diagnosed by selective anesthesia technique. انلى ان ح لي يذظس ع : Odontogenic Referred Pain أنلىف ز انحانح شأ ي نة ان غ ان ظاب ٴ ح ل إن األع ا ان ٴازسج أ ٴ انث انتشش ح ح انؼ مح ان زاٴسج. ػه عث م ان خال الون ة ان غ ألسحا اءنخا ح ٴ اناخنخح انغفه حت ح ل إن األ ر. ٴ ك االعتؼا ح تناتخذ ش إل تمائ ف انتشخ ض.

45 Nonodontogenic Referred Pain In this pain originates from deep tissues, muscles, joints, ligaments, etc. and is perceived at a site away from its origin. Pain arising from musculoskeletal organs is deep, dull, aching and diffuse type. Pain form cutaneous origin is of sharp, burning and localized. (For example, pain of maxillary sinusitis and may result pain in maxillary premolars.) أل ا ؾ ؿ ٤ و ٢ ا ٴ ؤ: Nonodontogenic Referred Pain ٴ ك ٢ ن ا ؾب خاأل ٣ ؤ ا ظ ا ؼ ٤ وخ ٴلب األهث خ... ٣ ؼو ث ك ٢ ا ؼ الد ا له. أ خثؼ ٤ لح ػ أل ا ن ١ ٣ ؤ اػ بء ا ٤ ا ؼ ٢ ٣ ٤ ا عغ ا ٴ ز و. ا ع ا ؼ ٴ ٤ ن ا ؤ ع ل ١ ٣ ؽبك ؽبه م ث ٤ ٴب األ غ.

46 Overall, one can classify the nonodontogenic reasons for toothache into five broad groups of pain disorders: 1. Musculoskeletal and other nonprogressive pains arising from somatic structures 2. Neurovascular pain, otherwise known as headache disorders 3. Neuropathic pains 4. Pain of purely psychologic origin, otherwise known as psychogenic toothache 5. Pain associated with a pathologic process ٴ ٴ له ر ٤ ق أ ج ة األ ا ٢ ثب ؼ ٣ ال اوثبد غٴ ػبد ؿ ٤ و ٢ ا ٠ ف أل ٴ ٤ خ: ٤ خ ٤ ػ ٤ خر ؤ ا ج ٠ ا غ ل ٣ خ 1- ال د ا لاػ ٤ خ( 2- أال ػ ج ٤ خ ػبئ ٤ خ )اال ثاوب ج ٢ 3- ال إلػزال ا ؼ ؤ ل ٢ بك ٢ ( أ ا ا ل ٢ ( 4- أ ٴو ٤ خ 5- أ زواكن غ ا ؼ ٤ خ ا

47 Myofascial Toothache Any deep somatic tissue in the head and neck region has tendency to induce referral pain in the teeth. In these structures, pains of muscular origin appear to be the most common. Muscles which are commonly affected are masseter, temporalis but in some cases medial, and lateral pterygoid and digastric muscles are also affected. أ ا ا ؼ ٢ ا ع ٢ Myofascial Toothache أ ١ ٤ ظ ػ ٴ ٤ نك ٢ وخ ا و أ ا وهجخ ا ولهح ػ ٠ اؽلاس أ ؾ ك ٢ األ ب. ن ا ج ٠ األال ا ٴ ؤ ا ؼ ٢ ٢ األ ضو ب لح. ا ؼ ال د األ ضورؤصوا ٢ ا ؼ خ ا ٴب خ ا لؿ ٤ خ ك ٢ ثؼ ا ؾبالد ا ؼ الد ا غ بؽ ٤ خ األ ٤ خ ا ؽ ٤ خ ماد ا ج. ٤ انز اح ح األ غ ح ٴا ن حش ح

48 Characteristic Findings of Muscular Toothache are: 1., diffuse, dull and constant pain. 2. Pain increases with function of masticatory muscles. For example, pain is increased when chewing is done because of effect on masseter muscle. 3. Palpation of the involved muscles at specific points (trigger points) may induce pain. *Trigger points are hyperexcitable muscle tissues which may feel like taut bands. or knots 4. Usually arise with or without pulpal or periradicular pathology. 5. Tooth pain is not relieved by anesthetizing the tooth; rather local anesthesia given at affected muscle may reduce the toothache. ف بئ ٴ أل ا ٢ ؤ ػ ٢-1 أ ز و ٤ صبث ذ. 2-٣ ياكك األ غ ػ ال د ا ٴ ؾ. 3- ع ا ؼ ال د ا ٴز ه خ ك ٢ وب ؼ ٤ خ )وب ى بك ٣ خ ) ٣ أ ٣ ؾلس أ ٴب. ا وب ا ي بك ٣ خ )ا وبكؽخ أل ( ظ ػ ك ٤ خبئوخ اال ضزبهح ا ز ٢ ٣ أ رؾ ؼول. 4- ػبكح ب ٣ ؤ أل ث ع ك أ ػل ع ك و ج ٢ أ ك ٢ ا ظ ؽ ا غنه ٣ خ. 5- أ ا ال ٣ ي ث ا خ ا زقل ٣ و ا ٴزؤصو ث ثب زقل ٣ و ا ٴ ؼ ٢ ك ٢ ا ؼ خ ا ٴ ججخ أل.

49 Diagnosis of these muscular pains as nonodontogenic tooth is purely based on lack of symptoms after diagnostic tests such as pulp testing, percussion and local anesthesia block. ا ز ق ٤ أل ا ٢ ػ ٠ أ ؤ ػ ٢ ٣ ئ ػ ٠ كو لا األػوا ػ ل اعواء الزفج بهاد ا لؾ ا ؾ ٣ ٤ خ ػ ٠ األ ب ا ٴزؤصوح )ا جو كح ا ق خ ا وائي ا وثبئ ٢ ا وو ع ا لؾ ثب زقل ٣ و(.

50 Several therapeutic options used in the management of these muscular pain are: i. Restriction of functional activities within painless limit ii. Occlusal rearrangement iii. Deep massage iv. Spray and stretch technique v. Ultrasound therapy vi. Local anesthesia at the site of trigger points vii. Analgesics viii. Anxiolytics. ا ق ٤ به اد ا ؼالع ٤ خ زلث ٤ و ض ن ا ؾبالد: رو ٤ ٴ ا لؼب ٤ خ ا ؼ ٤ خ ك ٢ ؽبخ األ رؼل ٣ اال جب م بط ػ ٴ ٤ ن همام اد ا ٴؼب غخثبألع حي ك م ا ر ٤ خ ا زقل ٣ و ك ٢ ب ن ا وب ا وبكؽخ أل بد ي ٣ الد ا و ن. Anxiolytics

51 Neurovascular Toothache The most common neurovascular pain in the mouth and face is migraine. This category of pain includes three subdivisions of primary headache. These are: i. Migraine ii. Tension type headache iii. Cluster headache. ع رو ا ٠ أ األ ب ؤ ػبئ ٢ ػ ج ٢ : Neurovascular Toothache ا ال ا ػبئ ٤ خ ا ؼ ج ٤ خك ٢ ا ل ا الصخ أ اع ا لاع ٢ : ا و ٤ وخ. ا لاع ا ػبئ ٢ ا ز رو ١. ا لاع ا ؼ و ك ١.

52 These neurovascular entities can produce relatively localized pains that match with sign and symptoms with the toothache. These accompanying toothaches are usually mistaken for true odontogenic pains and can be treated as separate entities. Unfortunately there are several clinical characteristics that could misguide clinician in diagnosis and treatment. ٴ ٴ ؼخ ا ا ػبئ ٤ خ ا ؼ ج ٤ خ ٣ أ ر جت أال ب ن األ و ا ال بد أال األ ب. ال األ ب ج ٤ ب ا ز ٢ رؾب ٢ أػو ث ٤ ب ث ٤ أ األ ب ا ٴ بؽجخ ن ا ؾبالد بػكح ب ٣ ز ا ق ا ؾو ٤ و ٢ رؼب ظ ػ ٠ نا األ ب. ا ج ٤ ت و ٣ و ٣ خ ا ز ٢ ر ع ء ا ؾظ بى ػلح ف بئ ٤ ٴ ا ٴؼب غخ. ثبالرغب ا قب ئ أص بء ا ز ق

53 The following characteristics are usually found common in neurovascular toothache are: 1. The pain is deep, throbbing, spontaneous in onset, variable in nature and pulsatile. These are characteristics which simulate pulpal pain. 2. The pain is predominantly unilateral. 3. Accompanying toothache shows periods of remission that imitates the pain-free episodes or temporal behavior found in neurovascular pain. 4. Headache is considered as the main symptom. It is most often accompanied by toothache. ا ق بئ ٴ ا زب ٤ خ بئؼ أل األ ب ا ػبئ ٢ ا ؼ ج ٢ : 1- أل ػ ٴ ٤ ن بث ػل ١ ك ٢ ثلا ٣ ز ز ع بفكن ك ٢ ج ٤ ؼز. ن ا ق بئ ٴ ر ج األ ا ج ٢. 2- أل أبؽك ١ ا غب ت )ث ج ن(. 3- ال األ ب ا ٴاوكوخر ظ وكزوا د ل ء رؾب ٢ ا لزواد ا قب ٤ خ األ أل ا ػبئ ٢ ا ؼ ج ٢. 4-٣ ؼزجو ا لاع ا ؼ و ا وئ ٢ ٤. ا ن ١ ؿب جب ٣ ز اوكن ثؤ أ ب.

54 5. Recurrence is characteristic finding in neurovascular pain. Sometimes, the pain may undergo remission after dental treatment has been performed in these teeth. It usually appears for certain period of time and may even spread to adjacent teeth, opposing teeth or the entire face. 6. Autonomic effects such as nasal congestion, lacrimation, rhinorrhea and edema of the eyelids and face is seen. Sometimes edema of the eyelids and face might lead to confusion in diagnosis as these features bear a resemblance to abscess. 5- ك أظلنى ف بئ ٴ األ ا ػبئ ٢ ا ؼ ج ٢. ثؼ األؽ ٤ ب ٣ ل األ ثؼل ا ٴؼب غخ ا ٤ خ. بػكح ب ٣ ؼب ك ا ظ هثؼل لح ى ٤ خ ؼ ٤ خ ؽز ٠ ٣ ٴ اال ز ب ه ا ٠ األ ب ا ٴغب هح ا ٴ وبث خ أ ب ا ع. 6- هل ر ب ل ثؼ األصبه ا قب خ ض ازؽوب األ ق ا ل غ ال األ ق م خ ا غ ل. ثؼ األؽ ٤ ب م خ ا غ ل ا ع ٣ ٴ أ ر و ك ا ٠ ا زجب ك ٢ ا ز ق ٤ ؽ ٤ ش ٣ بث ا قواط.

55 Migraine Migraine has been divided into two main types: 1. Migraine with aura. 2. Migraine without aura. (aura) ا و ٤ وخ رو ا و ٤ وخ ا ٠ ػ ٤ : و ٤ وخ غ ب خ ػ ٤ ٤ خ و ٤ وخثل ب خ

56 Features of Migraine Commonly found between the age group years. Visual auras are most common. These usually occur minutes prior to the onset of headache pain. (Migraine with aura.) Pain is usually unilateral, pulsatile or throbbing in nature More common in females Patient usually experiences nausea, vomiting, photophobia Various drugs used in the management of migraine are sumatriptan, β-blockers, tricyclic antidepressants and calcium channel blockers. ظب و ا و ٤ وخ: ر ب لك ٢ ا لئبد ا ؼ ٴو ٣ خ خ. ب خ ا وإ ٣ خ بئؼخ. ػبكح ب رؾلس كه ٤ وخ هج ثلا ٣ خ آال ا لاع. األ أبؽك ١ ا غب تفبكن ب ث ك ٢ ج ٤ ؼز. ا ٴو ٣ ؼو ٠ ث ض ٤ ب أه ٤ بء ا ق ف ا ء. أك ٣ خ زلؼكحر زق ل ك ٢ رلث ٤ و ا و ٤ وخ ض : sumatriptan, β-blockers, tricyclic antidepressants and calcium channel blockers.

57 CLUSTER HEADACHE Commonly found in the age group years Cluster headaches derive their name from the temporal behavior and usually occur in series, i.e. one to eight attacks per day More common in males than females Pain is unilateral, excruciating and continuous in nature and usually found in orbital, supraorbital or temporal region Autonomic symptoms such as nasal stuffiness, lacrimation, rhinorrhea or edema of eyelids and face are usually found Standard treatment is inhalation of 100 percent oxygen. ا لاع ا ؼ و ك ١ : CLUSTER HEADACHE ٴ خ ٣ ب لث ٤ ا ى أل ٢ ؽ ٤ ش ٣ ؾلس ػبكح ث ا زن ا غٴب دك ٢ ا ٤. خ 8-1 أ ضو ٤ ػب ػ ل ا ن ه زٴوث ج ٤ ؼ ز أل أؽبك ١ ا غب ت جوػ ) بؽ ( ا لؽ. ٣ عل ػبكح ك ٢ وخ ا ؼ ٤ رؾ ذ ا ؼ ٤ ض اؽوزب األ ق ا ل غ ٤ ال األ ق أػوا م خ ا غل ا ع ػبكح بر عل. أ غ ٤. ا ؼب غخ ا ٴؼزبكح ا ز ب م %100

58 CARDIAC TOOTHACHE Severe referred pain felt in mandible and maxilla from area outside the head and neck region is most commonly from the heart. Cardiac pain is clinically characterized by heaviness, tightness or throbbing pain in the substernal region which commonly radiates to left shoulder, arm, neck and mandible. Cardiac pain is most commonly experienced on the left side rather than right. In advanced stages, the patient may complain of severe pain and rubs the jaw and chest. In present time, dentist should be aware of incidence of jaw pain that is occurring in number of patients secondary to cardiac pain. CARDIAC TOOTHACHE أ ى األع ا ي ي شأ لهث : أ ؾ ؽبك ٣ ؼوث ك ٢ وخ ا لي ا ل ٢ ا ؼ ١ وخ أفو ؿ ٤ و ا وأ ا ؼ ن ٤ ؤر ٢ ػ ٠ األؿ ت ا و ت. ٴ ٴ وخ ٤ ن أ أ ب ث ك ٢ أل ا و ج ٢ ٣ ز ٴ ٤ ي و ٣ و ٣ بثضو ا ن ١ ٣ ز ؼغ ا ٠ ا زق األ ٣ و ا ن هاع ا وهجخ رؾذ ا و ا لي ا ل ٢. أل ا و ج ٢ ٣ ؼوث ك ٢ ا غ خ ا ٤ و )ػ ٠ األؿ ت(. ك ٢ لأ ٣ ل ي أال ؽبكح ع ا ٴواؽ ا زول خ ا و ٣ هل ٣ له ك ا ل ٢. ػ ٠ ػ و ٣ غت ػ ٠ ج ٤ ت األ ب أ ٣ هذ ا ؾب ك ٢ ا ثؾبال د اال بثخثؤ ا لي ا ن ١ ٣ ؾلس غ ػلك ا ٴو ٠ رب ٤ أل ا و ت.

59 Sometimes, patient presents dental complaints as the chief complaint rather than having pain in substernal region, it creates confusion in diagnosis for dental pain. A lack of dental cause for dental pain should always be an alerting sign. Anesthetizing the lower jaw or providing dental treatment does not decrease the tooth pain, it indicates that primary source of pain is not the tooth. Usually the cardiac toothache is decreased by taking rest or a dose of sublingual nitroglycerin. A complete medical history should be taken when cardiac toothache is suspected and should be immediately referred to cardiac unit in hospital. ك ٢ ثؼ ا ؾبالد ٣ ؤر ٢ ا ٴو ٣ ث هئ ٢ ٤ غ هئ ٤ ٤ خ ٤ خ ٤ أ ك ٢ وخ رؾذ ا وٴ ٴب ٣ ق ن ا زجب ك ٢ ا ز ق ٤ ٴ. ػ ل ع ك جت ٢ أل ٣ غت أ ٣ ج ا ج ٤ ت.رقل ٣ و ا لي ا ل ٢ أ أ ١ ؼب غخ رقلق األ ا ٢ ٴب ٤ و ٣ ا ٠ أ ل ه األ ٤ األ ب.بػكح أ ا ا و ج ٢ ٣ و ٴ غأفن ا زو ؿ ٤ ٤ و ٣ رؾذ ا ب. ه خ و ٤ خ ػب خ ب خ ٣ غت أ رئف ن غ رؾ ٣ ا ٴو ٣ ٴ ل ٠ ك ٢ ؽب ا ي ثؾب خ ه ج ٤ خ.

60 In brief, the following characteristics of cardiac toothache are: 1. Pain is of sudden in onset, gradually increasing in intensity, diffuse with cyclic pattern that vary in intensity from mild to severe. 2. Tooth pain is increased with physical activities. 3. Chest pain is usually associated. 4. Pain is not relieved by anesthesia of lower jaw or by giving analgesics. ثبفز ب ه ا ق بئ ٴ ا زب ٤ خ رٴ ٤ ي أ ا ا و ج ٢ : أل لبعئثجلا ٣ ز ٣ ز بػلثب لح ٣ ز و ث ٴ ك ه ١ غ رب ٣ وك ٢ ا لح فل ٤ ق ا ٠ ل ٣ ل. ٣ يكاك األ غ ا غ ل ا لؼب ٤ خ ا غ ل ٣ خ أ واكنك ٢ ا ل ه. أل ال ٣ ق ق غ ا زقل ٣ و أ ثب ٴ ب د.

61 NEUROPATHIC PAIN Neuropathic pain is usually caused by abnormalities in the neural structures themselves. Neuropathic pain is sometimes misdiagnosed as psychogenic pain because local factors cannot be visualized. Neuropathic pain can be classified into different categories: i. Neuralgia ii. Neuritis iii. Neuropathy نأى االػتالل انؼظث PAIN: NEUROPATHIC ٴ ٴ ٴ انؼ ظث ح فغ ا.ثؼ أ نى شأ تغث ةيشعف ناث قٴ ف ؤ ػ ٠ أ أ األؽ ٤ ب أ اػ ال األػ بة ٣ ؼ ٤ خ ا ز ٢ ر ل و ع كاد ا ؤ ل ٢ ث جت ؿ ٤ بة ا ن األ. قثالس غ ػبد: بة ٣ أ ٣ أ اػزال األػ ج ٢ ) neuralgia بة ( أل ا ؼ ا ؼ neuritis ا ز بة األػ بة neuropathy و األػ ب ة

62 Neuralgia Paroxysmal, unilateral, severe, stabbing or lancinating pain, usually are the characteristics of all paroxysmal neuralgias. The pain is usually of short duration and lasts for few seconds. انؼ ظاب Neuralgia ثب د أ ٴ ٤ خ ل ٣ لح أؽبك ٣ خ ا غب ت األ ا ؾب ك ا افي ا بػ ر ٴ ٤ ي ثب د ا ؼ بثب د. األ ػبك ح ه ٤ و ٣ زٴو ؼلح ص ا ٢.

63 Trigeminal Neuralgia It is also known as Tic Doulourex which has literal meaning of painful jerking Usually characterized by paroxysmal, unilateral, sharp, lancinating pain typically confined to one or more branches of 5th cranial nerve Even slight stimulation of Trigger points may elicit sharp, shooting pain ػظابيخهج ا نت ائى Trigeminal Neuralgia ٴ ا ز ٢ ب Doulourex Tic ٣ ؼوف أ ٣ ب ثب ؼ ٠ )ػوح ئ ٴخ( بػكح رز ٴ ٤ يث ثبد األ ا ؾبك ا بؽ أبؽك ١ ت ا غب ت ؾ هحث لوع أ أ ضو كو ع ػ ض ش ا ز ائ. ث ٣ ٤ أ ١ رؾو ٣ وب ا وبكؽخ أل بػن.)shooting أ ٣ جلء أ ى بك ١ ؽبك (

64 Sometimes trigger points are present intraorally. These are stimulated upon chewing which may led to diagnosis of odontogenic pain. Intraoral trigger points always create confusion in diagnosis if not properly evaluated Local anesthesia given at the trigger point reduces the attacks It rarely crosses midline Frequently occur in persons over the age of 50 years Attacks generally do not occur at night ك ٢ ثؼ األؽ ٤ ب ا وب ا ي بك ٣ خ ر عل اكف ا ل. ٢ رزؾو أص بء ا ٴ ؾ ٴب ٣ و ك ز ق ٤ ٴ أ له ٢. ا وب ا وبكؽخ أل اكف ا ل رق نكائ ٴب ر ق ٤ ٴ فب ئ اما رو ٤ ث ؾ ٤ ؼ. ا زقل ٣ و ا ٴ ؼ ٢ ػ ل ا وب األ ٴ ٤ خرقل ا غ ٴخ. الرؼجو ا ق ا ٴز اال بك ها. بػكح ا ٴ بث ٤ ك م ا ق ٴ ٤ ا ؼ ٴو. ال رؾلس ا ٴغب د ال ػبكح.

65 Absence of dental etiology along with symptoms of paroxysmal, sharp, shooting pain always alert the dentist to include neuralgia in the differential diagnosis Treatment includes surgical and medicinal. Usually medicinal approach is preferred. It includes administration of carbamazepine, baclofen, phenytoin sodium and gabapentin, etc. ٴ غ ٴخ أ ٴ ٤ خ غ أػوا ؿ ٤ ب ة األ جبة ا ٤ خ ٴو ا زلو ٣ و ٢ ؾب خ ع ك بػوخ ٣ غت أ ر غك ٢ ا ز ق ٤ ػ بة. ا ٴؼب غخ ا ل ائ ٤ خ ثبػ بء ا ٴؼب غخ عواؽ ٤ خ ك ائ ٤ خ. ٣ ل carbamazepine, baclofen, phenytoin sodium and gabapentin, etc

66 Neuritis Neuritis literally means inflammation of nerve. It is usually observed as heterotopic pain in the peripheral distribution of the affected nerve. It may be caused by traumatic, bacterial and viral infection. In neuritis, the inflammatory process elevates the threshold for pricking pain but lowers it for burning pain. نت اب األػظاب Neuritis ٣ ب لبػكح ؤ ب ٣ و )زجن ) pain heterotopic ك ٢ ا لو ع ا ؾ ٤ ٤ خ ؼ ت ا ٴ بة. ٣ ٴ أ ٣ ا جت ه ٢ عوص ٢ أ ك ٤ و ٢.ك ٢ ا ز بثبد األػ ب ة ررولغ ا ؼزج األ ٴ ٤ خثب جخ أل ا ضبهت )االهرغبع ٢ ( ( pricking ) pain ر قل ثب جخ أل ا ؾبهم.

67 The characteristics of pain in neuritis are: 1. Pain has a characteristic burning quality along with easily localization of the site. 2. It may be associated with other sensory effects such as hyperesthesia, hypoesthesia, paresthesia, dysesthesia and anesthesia. 3. Pain is non-pulsatile in nature. 4. Pain may vary in intensity. بئٴ األ ٴ ٤ ال ز بة األػ بة ٢ : ا ق ز غ أ ؽبهم كو ا ؾ هل ٣ ز اوكن غ أػوا ؽ ٤ خ أفو ض ( فله. وٴ ا ؾ ر ٴ ٤ ف ؽ ٢ )ر ؽ األ ؿ ٤ و بث ث ج ٤ ؼز. أل زب ٣ و ا لح.

68 Peripheral neuritis is an inflammatory process occurring along the course of never trunk secondary to traumatic, bacterial, thermal or toxic causes. Neuritis of superior dental plexus has been reported when inflammation of sinus is present. The dental nerves frequently lie just below the lining mucosa or are separated by very thin osseous structure. These nerves are easily involved due to direct extension. Symptoms usually seen along with antral disease are pain, paresthesia and anesthesia of a tooth, gingiva or area supplied by infraorbital nerve. Mechanical ا ز بة األػ بة ا ؾ ٤ ٤ خ ػ ٤ خ ا ز بث ٤ خ رؾلس ػ ٠ ا غنع ا ؼ ج ٢ رب ٤ ألم ٣ خ ه ٤ خ عوص ٤ خ ؽو اه ٣ خ أ أ جبة ٴ ٤ خ. ا ز بة األػ بة ا ل ٤ وح ا ٤ خ ا ؼ ٣ خ غ ػ ل ع ك ا ز ب ةك ٢ ا غ ٤ ت. األػ بة ا ٤ خر ز غ جب وح رؾذ ا ٴقب ٤ خ ا ٴ ٤ خ أ ر ل خ ث جوخ ػظ ٴ ٤ خ هه ٤ وخ علا. ن األػ ب ة ث خ ر ٴ ك ٢ ا ؼ ٤ خ ث جت اال زلاك ا ٴجب و. األػوا ا ز ٢ ر ب ل ك ٢ أ وا ا غ ٤ ة ٢ األ ف ؽ ٢ فلهك ٢ ا ا ضخ أ ا ٴ وخ ا ز ٢ رؼ ت ثب ؼ ت رؾذ ا ؾغبط.

69 nerve trauma is more common in oral surgery cases. It usually arises from inflammation of the inferior dental nerve either due to trauma or infection. ه ا ؼ ت ا ٴ ٤ ب ٢ ٤ بئغ أ ضوك ٢ ا غواؽخ ا ع ٤ خ ػبكح ػ ت ا لي ا ل ٢ ث ز ٤ غخ ا و ا غواؽ ٢ أ اال زب.

70 Acute neuritis cases are always misdiagnosed and remain untreated. Most of the times, dental procedures are done to decrease the symptoms of neuritis as these are difficult to diagnose. These unnecessary dental procedures further act as aggravating factors for neuritis, making it chronic. ا ز ب ة ألػ ب ة ا ؾبككا ٴئب ب ٣ بء ر ق ٣ جو ٠ ثل ٤ ػالط. أ ضو األؽ ٤ ب اعواء اد ٤ خر غي زقل ٤ األػوا. ن ا ٴؼب غب د ؿ ٤ و ا و ه ٣ خك ٤ ٴب ثؼل زؼ ؼ ا لب هٴخ ال ز ب ة األػ ب ة رؾ ٴ ي.

71 TREATMENT OF NEURITIS Treatment of acute neuritis is based on its etiology If bacterial source is present, antibiotics are indicated If viral infection is suspected, antiviral therapy should be started If there is no infections, steroids should be considered. ؼب غخ ا ز بة األػ بةرز ا ٴؼب غخ ثؾ ت ا ؼ ا ا ٴ ججخ ثبػ بء بك اد ؽ ٣ ٤ خ أ بك اد ك ٤ و ٤ خ أ ز ٤ و ئ ٤ ل اد )ك ٢ ؽب ػل ع ك ا زب (.

72 Neuropathy This is the term used for localized and sustained pain secondary to an injury or change in neural structure. Atypical odontalgia has been included in neuropathy. Atypical odontalgia means toothache of unknown cause. It is also known as Phantom tooth pain or dental migraine. Most patients who report with atypical odontalgia usually have multiple dental procedures completed before reaching a final diagnosis. اػتالل ألػ ظاب Neuropathy ٴ ٴ غ ا ٴ زل ٣ ا زب ألم ٣ خ ا ٴ ؼ ٣ زق ل أل ا نا أ األ ب ؿ ٤ و ا ػ ٢ ٣ لف ج ٤ خ. أ ر ٤ وك ٢ ا ج ٤ خ ا ؼ ك ٢ ن ا لئخ. أ اال ب ؿ ٤ و ا ػ ٢ odontalgia( ) Atypical ٣ ؼوف أ ٣ ب له األ ا ٢ ؿ ٤ و ؼو ف. ٣ ؼ ٢ أ أ ا و ٤ وخ ا ٤ خ. ثؤ ا ا جؾ ٢ ( أ ٤ ق ا ) أ األ ب ؿ ٤ و ا ػ ٢ ؼظ ا ٴو ٠ ا ن ٣ ٣ أ غي د ػ ل ؼب غبد زلؼكح هج ػبكح بر ا بئ ٢. ا ز ق ٤

73 Clinical Characteristics of Neuropathy (Atypical Odontalgia) 1. More common in women. 2. Frequently found in 4th or 5th decades of life. 3. Tooth pain remains constant or unchanged for weeks or months. 4. Constant source of pain in tooth with no local etiology. 5. Pain usually felt in these patients is dull, aching and persistent. 6. Most commonly affected teeth are maxillary premolar and molar region. 7. Response to local anesthesia is equal in both pulpal toothache and atypical odontalgia. ا ٴ ٴ ٤ يا د ا و ٣ و ٣ أل ا ؿ ٤ و ا ؿ ٢ : أ ضو ٤ ػب ػ ل ا بء. ث ٤ خ. أ ا ٣ ز ٴوثل ر ٤ و ؼلح أ بث ٤ غ ؽز ٠ أ و. ػل ع ك أم ٣ خ ٤ خك ٢ ا ا ٴزؤ. أل م ج ٤ ؼ خ ٤ خ عؼ خ صبثزخ. أ ضو األ ب أ بث خ ٢ ا اؽي األهؽبء ا ؼ ٣ خ.

74 SINUS OR NASAL MUCOSAL TOOTHACHE Sinus and Nasal Mucosal pain is also another source which can mimic toothache. It is usually expressed as pain throughout the maxilla and maxillary teeth. نأى األع ا ي ي ذظس انز ب ٴان خاط ح األ ف ح SINUS OR NASAL MUCOSAL TOOTHACHE أل قب ٤ خ األ ق ا غ ٤ ت ا ل ٢ ل هآف أل ٣ ؾب ٢ أ األ ب ك ٢ ا لي ا ؼ ١ أ ب.

75 Clinical characteristics of sinus or nasal mucosal toothache are: 1. Fullness or pressure below the eyes. 2. Increased pain when palpation is done over the sinus. 3. Increased pain sensation when head is placed lower than the heart. 4. Local anesthesia of referred tooth/teeth does not eliminated pain while topical anesthesia of nasal mucosa will eliminate the pain if etiology lies in nasal mucosa. 5. Different diagnostic aids used to diagnose sinus disease include paranasal sinus view, computed tomography imaging and nasal ultrasound. نأى األع ا ي ان خا ط ح أل ف ح ٴان ز ة انفك ت ض ب: ٴ رؾ ذ ا ؼ ٤. ا زالء أ ك م ا غ ٤ ت ا ل ٢. ى ٣ بكح أل ثب غ ز ا و ت. أه ى ٣ بكح أل ثؾ ٢ ا وأ ا زقل ٣ و ا ؼ ٢ أل ب ا ٴزؤصوح ال ٣ ي ٣ أل ث ٤ ب رقل ٣ و ا ٴقب ٤ خ األ ل ٤ خ ٣ ي ٣ األ ا ٴؾ. و بئ ر ق ٤ ٤ خ قز لخر زقل ز ق ٤ ا غ ٤ ة.

76 PSYCHOGENIC TOOTHACHE This is a category of mental disorders in which a patient may complain of physical condition without the presence of any physical signs. In these cases, always think of psychogenic toothache. No damage to local tissue is typical in heterotrophic pain entities. It must be noted that psychogenic pain is rare. So, all other possible diagnoses must be ruled out before making the diagnosis of psychogenic pain. أ األ ب ا ل ٢ PSYCHOGENIC TOOTHACHE غ ٴ ػخ اال ثاوب د ا ن ٤ خ ؽ ٤ ش ٣ ا و ٣ ؽب خ بك ٣ خثل ع ك أك خ بك ٣ خ ػ ٠ ع ك ب. ك ٢ ض ن ا ؾبالد ك وكائٴبث ع ك ؽب خ ل ٤ خ. ػ ل ع ك أم ٣ خ ٤ غ ٤ خ ؼ ٤ خ ٴ ٤٣ ي األ ا ٴ ب ٣ و ا ٴ ؤ. ن ا ؾب خ بك هح. ن ي االؽز ٴال د ا ز ق ٤ ٤ خ األفو ٣ غت أ رجؾش هج غ نا ا ز ق ٤ ٴ.

77 The following features are usually found in these diseases are: 1. Pain is observed in multiple teeth. 2. Precipitated by severe psychological stress. 3. Frequent changes in character, location and intensity of pain. 4. Response to therapy varies which can include lack of response or unusual response. 5. Usually referred to psychiatrist for further management. ان خ اظئضناتان ح أنلى انغ ي يظذس ف غ : األ ك ٢ ػلح أ ب. ٣ ز واكن ثبع بك ل ٢ بؽك. ر ٤ وكائ ك ٢ ج ٤ ؼخ لح هغ األ هك ا لؼ ٴؼب غخزجب ٣ ث ٤ ال ز ٤ غخ أ ز ٤ غخ ؿ ٤ و ج ٤ ؼ ٤ خ. ال زو بء. ج ٤ ت ل ٢ ا زؾ ٣

78 duration انؼ ا يم ا ن ف ال ح Aggravating factors ان ذج انحانح condition طث ؼح انألى nature of pain ا جب هك ا بف ال غبع هوع ا بػب د ؽز ٠ أ ٣ ب أ األ ب odontolgia افي بث زو غ ػ ب ة ض ش ا ز ائ trigeminal neuralgia أ بؽ بػ ا ٴ ا قل ٤ ق ػ ٠ ا غ ل أ ا ٴقب ٤ خ ص ا ٢ ؽز ٠ كهبئن بػب د ا ؾ ا ثب د أ بؽك جوػ ك ٢ وخ ا ؼ ٤ ا لؽ لاع ا ؼ و ك ١ Cluster headache ا أ ئهذ ك ٢ ا غ خ ا ٤ و ا لي ا ل ٢ ا غ ل هكبئن ث ٢ ؤ ه ج ٢ cardiogenic ا ز ب ة ا غ ٤ ة sinusitis ٴ ٤ ا وأ هوع األ ب رقل األ ب ا ؼ ٣ خ ٣ أ بؽك بث ا ق ل ٤ خ. بػب د أ ٣ ب