Management of Orodental Pain

Amarender Vadivelu, BDS, MDS

Pain arising in the oral tissues can cause considerable discomfort and interfere with oral function. The teeth are primarily important for mastication of food, and the mouth is the first part of the gastrointestinal tract to initiate digestion process. Other functions of the teeth include facilitating speech, swallowing, and contributing to aesthetics which in turn instills a sense of self-esteem and confidence.

Oro-dental pain as a specific modality (Clark 2006) and a cardinal sign occurs as a result of inflammation and traumatic injuries or as a complication of elective oral and maxillofa-cial surgery. Toothache has been compared with earache and labor pain for its intensity and propensity for acute discomfort.

Common diseases affecting the oral structures are dental caries and gum disease, oral ulcers, and dentine hypersensitivity. The need for regular oral care by the patient and preventive visits to the dental office cannot be overemphasized since the above disorders can lead to a host of complications, which can include intractable pain.

Dental caries is known to be the highest incidence of any disease that besets mankind. Orson had called this the "triple tragic triangle of tooth decay" and had implicated fermentable carbohydrates, oral bacteria, and susceptibility of the individual. Tooth decay can progress by a burrowing effect, ultimately destroying the dentin, and reaches the nerve center of the tooth which constitutes the dental pulp. The dentin plays a vital role by acting as a thermal insulator and helping withstand the extremes of temperature, like having an ice cream or a hot cup of tea.

The concept of remaining dentine thickness (RDT) is of paramount importance in preventing hypersensitivity and pain. Dental caries reduces the dentin thickness and hence the protection afforded against extremes of temperature variations is hampered. Needless to say that dental caries is an infection with organisms like Streptococcus mutans and Lactobacillus acidophilus. Dental caries, if unattended, is progressive and can lead to irreversible damage of the pulp and its attendant complications.

The periphery of the pulp is lined by odontoblasts which send their protoplasmic processes into the dentin. Cavities placed closer to the pulp could injure underlying odontoblasts (Murray et al. 2002).

There is a subodontoblastic nerve plexus in the dental pulp called the plexus of Raschkow. The density of free nerve endings in the dental pulp is very high compared to other parts of

N. Vadivelu et al. (eds.), Essentials of Pain Management,

DOI 10.1007/978-0-387-87579-8_33, © Springer Science+Business Media, LLC 2011

the body, and this accounts for the severe pain felt during tooth infection. Each tooth can be innervated by about 1000 afferent sensory nociceptive neurons which branch extensively.

The tooth dentine has A-beta fibers and A-delta fibers which modulate tactile and pain sensation. The pulp has A-delta and C fibers. The C fibers are polymodal and can respond to mechanical stimulation, cooling, heating, and chemical stimuli in the form of pain.

Conditions affecting the dental pulp as a sequelae to dental caries are pulp hyperemia, acute pulpitis, chronic pulpitis, and acute periapical abscess.

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