The tooth is a limb that can cause pain even in healthy people. Although many dental reasons cause pain, many patients describe pain in the mouth, jaw and face as toothache. It is often difficult to distinguish whether the pain originates from the tooth or other structures on the face. For this reason, the characteristics of tooth and facial pain should be known well.
The nerves that provide innervation of the mouth and teeth are the maxillary and mandibular nerves.
Maxillary Nerve: It is the second branch of the Trigeminal Nerve, which is the V. Cranial Nerve. It originates from the anterior border of the Gasser ganglion. It carries entirely sensory fibres. Innervation:
The tooth is a limb that can cause pain even in healthy people. Although many dental reasons cause pain, many patients describe pain in the mouth, jaw and face as toothache. It is often difficult to distinguish whether the pain originates from the tooth or other structures on the face. Therefore, the characteristics of tooth and facial pain should be known well. The nerves that provide innervation of the mouth and teeth are the maxillary and mandibular nerves.
Maxillary Nerve: It is the second of the Trigeminal Nerve, which is the V. Cranial Nerve. is the branch. It originates from the anterior border of the Gasser ganglion. It carries entirely sensory fibres. Innervation:
- Middle part of the face
- Lower eyelids
- Edge of nose
- Upper lip
- Nasopharynx, maxillary sinus, soft palate, tonsil and part of the oral mucosa
- Upper gums and teeth
Anterior (Major) palatine nerve: It arises from the zygomatic branch of the maxillary nerve. It provides innervation of the hard palate to the incisors. It also carries the pain of the gums and the mucosa of this region.
Posterior superior alveolar nerve: It is usually divided from the maxillary nerve into two, rarely a single branch. The posterior surface of the maxilla gives branches to the gums and cheek. It enters the posterior alveolar canals of the maxilla and joins the middle superior alveolar nerve. It innervates the molar teeth by giving three branches.
Middle and anterior superior alveolar branches: The fibers coming from the middle superior alveolar (dental) nerve are in the anterior and posterior branches. It combines with the adjacent fibers to form the superior dental plexus. The anterior superior alveolar branch gives branches to the incisor and canine teeth.
Infraorbital nerve: It is the terminal cutaneous branch of the maxillary nerve. Its superior labial branch innervates the skin covering the upper teeth, oral mucosa and labial glands.
Mandibular nerve: It is the third branch of the trigeminal nerve. It contains sensory and motor fibers. Areas innervated by sensory fibers:
- Ear
- External meatus
- Cheek
- Lower lip
- Lower face
- Cheek, tongue and mastoid cavity mucosa
- Lower teeth and gums
- Mandible and temporomandibular joint
- Duramater and part of the skull
Buccal nerve: It is a small sensory branch arising from the anterior branch of the mandibular nerve. It gives branches to the skin and oral mucosa covering the buccinator muscle.
Auriculotemporal nerve: The articular branches, which are branches of this nerve, carry the sensation of the temporomandibular joint.
Inferior alveolar nerve: It courses together with the inferior alveolar artery. There are two terminal branches. Of these, the incisor nerve provides the innervation of the incisor and canine teeth.
The mental nerve gives branches to the molar and premolar teeth. It exits the mental foramen and gives off branches that receive sensation from the lower lip.
The fibers in the nerves innervating the teeth commonly consist of axons containing A-beta, A-delta and C fibers and a small amount of sympathetic efferents. Sensitivity in the tooth occurs with the rapid fluid movement in the dental tubules and the stimulation of the ends of the A-fibers at the pulp-dentin border or within 0.1-0.2 mm of the dentinal tubules. The resulting sharp pain is very severe and very different from pain occurring in other tissues. This is due to the large amount of nociceptive A fibers in normal tooth tissue and some structural features of the dentin layer. Pulpal inflammation causes special problems in the tooth because this layer is rigid and cannot tolerate the increase in pulpal fluid pressure. C-fibers are located in the pulp and are stimulated by mediators, especially those resulting from inflammation.
Evaluation of Dental and Intraoral Pain
For the correct diagnosis of pain in teeth and surrounding tissues, a good knowledge of anatomy as well as physical examination, laboratory and radiological examinations should be performed together. Defining the patient's history and the character of the pain is the first and most important component of the patient evaluation. A detailed history should be taken regarding the location and spread of the pain. In addition, the nature of the pain, its intensity, frequency, periodicity and duration should be learned. If the pain is not constant, the times when the pain gets worse and worse during the day should be examined. Factors that provoke and soothe pain should also be carefully questioned. A general oral examination should be performed and the response to dental percussion, hot and cold applications should be evaluated. It is very important to compare the positive finding in one tooth with the symmetrical one on the opposite side. In order to determine the exact location of the pain, some physicians also use factors such as the response to electrical stimulation of the pulp or the effect of local anesthetic infiltration on the pain. Radiological examination is also helpful in the diagnosis phase.
Odontogenic Pain:
Toothache or odontalgia originates from the pulp layer of the tooth or the periodontal structures at the root apex (Periodontal ligament and bone)may be caused by exposed dentin layer or root surface, broken external, trauma and iatrogenic reasons.
The tooth consists of enamel, dentin and cementum layers and is connected to the bone that supports it with the Periodontal ligament. Inside this hard box is the pulp, which is the main source of pain in the mouth. Inside the pulp there is a complex network of vessels, lymphatic tissue and nerve tissue. Protection of the pulp depends on the hard tissue outside. When exposed, it is hypersensitive to any contact.
Stimulation of the dental pulp elicits a response similar to that caused by a visceral stimulus. Stimulation of this tissue, the exposed nerve, only results in pain, and the intensity of this pain is independent of the intensity of the stimulus.
Acute Pulpitis:
Injury to the pulp is caused by thermal, mechanical or chemical irritation. it could be. The most common g� The assumed cause is tooth decay. Classic signs of inflammation, such as increased temperature, swelling and pain, may occur and result in pulpal necrosis. The swollen dental pulp becomes more painful as the intradental pressure increases. The most distinctive feature of hyperreactive pulpalgia is its sensitivity to cold. Applying ice to the suspected tooth produces a short, sharp pain that will last slightly longer than the stimulus. This type of discomfort may occur with a new dental restoration. Pulpalgia is usually reversible.
The emergence of pain with heat application is suggestive of a spectrum of pulpal pathology including temporary pulpal hyperemia, pulpal inflammation or necrosis. Typically, there is a delay of a few seconds between the application of heat and the appearance of pain. The discomfort may last for a few seconds after the temperature recedes. The pain is stinging and pulsatile.
In the presence of advanced pulpitis, visual and radiological examination shows tooth decay extending to the dentin and sometimes pulpal tissue.
In the treatment, in cases of slow caries progression, caries removal and tooth repair are performed. While this is sufficient, in more advanced cases, pulpotomy, pulpectomy, and as a last resort, tooth extraction is required. Acetyl salicylic acid and other non-steroidal anti-inflammatory drugs and codeine are effective in the medical treatment of pain.
Periapical and Periodontal Pain (musculoskeletal pain)
The musculoskeletal component of toothache. It originates from the periodontal ligament. This structure connects the tooth to the bone. The periodontal ligament forms a richly innervated synarthroidal joint. Acute periapical abscess is the most common consequence of acute pulpitis due to untreated caries. Purulent material from the necrotic dental pulp drains into this nerve-rich space through the apical foramen. When irritated, in the presence of inflammation or infection, a dull, throbbing pain occurs. This pain can be well localized and provoked. It may take hours. The severity of pain increases in direct proportion to the severity of the inflammatory event, cellular damage, the amount of pus formed, and the extent of the infection. A very distinctive finding in periapical inflammation is the sensitivity of the tooth to percussion. Depending on the severity of periapical pathology Localized tissue erythema, local or widespread cellulitis, trismus, and lymphadenitis may occur together.
Periodontal inflammation or increased pressure on an infected tooth also increases pain. Swelling of the periodontal ligament also causes the tooth to rise slightly from its socket. During chewing, the tooth is exposed to an extra functional load, further exacerbating this problem.
Antibiotic treatment for the abscess, drainage of the abscess, and non-steroidal anti-inflammatory drugs, meperidine and codeine are effective for the pain.
Broken Tooth Syndrome:
This pain may be caused by an incomplete (broken tooth) or a complete tooth fracture (fallen tooth). ) originates from. A fractured tooth causes dental pulp sensitization and pulpitis and creates intense pain in the deep periodontal pockets. This situation is especially seen in molar and premolar teeth. Vertical canal fractures most commonly occur in endodontically treated posterior teeth of patients between the ages of 45-60. An incomplete fracture provokes pain when it involves the dentin layer of a posterior tooth. Caries, improper dental restorations, atypical root canal anatomy may cause this syndrome. The pain is intermittent, short-lived, and a sharp-shock style pain. Side biting and chewing aggravates the pain.
Localization of the dentinal crack is difficult and exact anamnesis, thermal pulp test, and examination of the dentinal walls of the suspected tooth are required. Intra alveolar root fractures can only be detected by x-ray.
Removing the broken piece of the tooth immediately reduces the pain. Root fractures also usually require removal of the tooth.
Dentin and Cementum Pain:
It is thought that the sensitivity of normally healthy teeth depends on the hydrodynamic stimulation of the neural extensions within the exposed dentinal tubules. External dentin and cementum are not innervated. Mechanical, thermal, or chemical (sweet) stimulation is followed by sharp, intermittent pain. Fluoride toothpastes, application of strontium chloride solution and iantophoresis with fluoride are effective in the treatment.
Bruxism Pain:
Bruxism pain is caused by Periodontal Ligament or pulpal inflammation.
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