Dental

 Pain  Diagnosis  Chart  

Dentin   Cracked   Reversible   Irreversible   Necrotic  
sensitivity   cusp/   Pulpitis   Pulpitis   Non-­‐vital   Notes/  Other  diagnoses  to  
Symptom  /  Sign   tooth   consider  
A  delta  fibers   C  fibers-­‐-­‐-­‐-­‐!        no  viable  
1.  Duration:  How  long  has  it  been  hurting?  
Intermittent,   If  severe,  
         -­‐Days-­‐  determine  level  of  severity,  constant  or  intermittent   X   X  
mild   worsening  
X    

         -­‐  Weeks   X   X   X   X   X    
         -­‐  Months.  Follow  up  with  pattern  of  pain.  Cyclical?   X   X         Consider  TMD,  angina,  sinus  
       -­‐  Past  history  of  one  episode  of  severe  pain,  which  then  dissipated           X    

2.  Onset:  Does  anything  bring  on  the  pain?  Hot  or  cold?  
Only  sometimes,  or  a  sharp,  electric  pain     X          
Biting  
  X         x   Periapical  pain-­‐  take  x-­‐ray;  
Pain:   With  every  bite,  percussion  sensitivity,  or  dull  aching  pain   ?Periodontal  origin.  
Sensitive  to  cold,  less  than  30  sec  linger  after  cold  gone   X   X   X        
Duration         X    
Sensitive  to  hot/cold,  lingers  >  30  seconds  after  stimulus  gone    

3.  Character:  Describe  the  pain  

-­‐  Sharp  or  electric   X   X   X        
-­‐  Dull,  aching           X   X    
-­‐  Throbbing         X   X    
-­‐  Constant       X   X   X    
-­‐  Has  the  pain  ever  been  so  bad  it  woke  you  up  at  night?         X   X    
-­‐  Pain  changes  to  change  in  position         X     Consider  sinus  infection  
        X  
4.  Percussion.  Tooth  is  more  tender  than  adjacent  teeth   Consider  perio,  occlusal  issues  
        X  
5.  Palpation.  Bone  over  apical  area  is  more  tender  than   Looking  for  evidence  of  
Periapical  inflammation  
adjacent  teeth  
  X       X   Check  all  teeth  with  previous  
6.  Periodontal  probing.  Looking  for  deep,  narrow  defect     endo  very  carefully,  esp  on  B/L  
7.  Pulp  Vitality  testing.  Level  of  response  +  duration  (above  in  2)    
       -­‐  Sensitivity  to  puff  of  air,  explorer  scratch   X   X          
Exaggerated  response.  Pt  responds  with  high  level  of  pain     X   X   X   X      
Cold   Normal  response.  Pt  feels  cold,  but  normal  level  of  reaction     X   X        
Test           X   Older  pts  (>65  yo)  may  not  
No  response.  Pt  does  not  respond  after  15-­‐20  seconds  at  all.     respond  on  any  teeth.  
          This  reading  does  not  actually  
Normal  response.  Pt  feels  tingling  in  tooth.  Number  insignificant   tell  you  anything  reliably  
EPT  
Negative  response.  No  sensation  in  the  tooth  at  any  number.             X    

8.  Clinical  exam  
     -­‐  Discolored  tooth           X   Pulp  can  also  be  vital  
     -­‐  Sinus  tract  or  swelling.  Thread  a  gutta  percha  point  through  sinus  tract,  take  another  xray           X   Point  usually  tracks  to  problem  
Tooth   Positive  response.  Sharp  pain  on  bite  or  release,  duplicates  pain     X          
Slooth   Negative  response.  Normal  biting  sensations.   X     X        

9.  Radiographic  exam.  Carefully  eval;  don’t  confuse  with  anatomic  item  

Present,  clearly  associated  with  the  apex  of  a  root           X    
PARL   X   X   X   X   The  cortical  bone  must  be  
Absent   Possible  
significantly  affected  to  show  
     -­‐  Deep  caries  in  proximity  to  pulp       X   X   X    

Pull all information together and diagnose BOTH the pulp and the periapical regions.

Pulpal Diagnoses Periapical Diagnoses

Normal Normal
Reversible Pulpitis Apical Periodontitis
Irreversible Pulpitis -­‐ Symptomatic
-­‐ Symptomatic -­‐ Asymptomatic
-­‐ Asymptomatic Apical Abscess
Necrotic Pulp -­‐ Symptomatic
Previously Initiated -­‐ Chronic
Previously Treated
 

©  Jan K. Mitchell, DDS, MEd