[introduction] in dental emergencies, dental pain and swelling of the oral and maxillofacial region are the main causes of dental pulp emergencies. According to statistics, acute dental pain accounts for 56.67% of the total number of emergency cases in the same period, maxillofacial inflammation, trauma and other emergency patients account for 42.99%, and other cases account for 0.34%. The common diseases causing dental emergencies are summarized as follows:
1、 Odontogenic pain
"Toothache is not a disease, but a life-threatening pain". The folk saying can vividly explain the intensity of toothache and the negative attitude in dealing with it. The actual understanding should be that although toothache is not that kind of life-threatening "serious disease", but the pain is intense, which can reach the level of pain. Therefore, how to identify the toothache caused by various reasons and how to quickly and effectively relieve the symptoms of patients are particularly important.
(1) Acute pulpitis
Acute pulpitis, as a kind of pathological changes of irreducible pulpitis, is a common cause of acute dental inflammation. Its clinical characteristics are acute onset and severe pain. Clinically, most of them are the manifestations of acute chronic pulpitis, Acute pulpitis without chronic process usually occurs when the pulp suffers from acute physical injury, chemical stimulation and infection.
[clinical manifestations]: the main symptom of acute pulpitis is severe pain. The nature and clinical manifestations of the pain are specific:
1. Spontaneous and paroxysmal sharp jumping pain
In the early stage of inflammation, the duration of pain is relatively short, and the duration of pain is relatively long. In the late stage of inflammation, the duration of pain is prolonged, lasting for several hours or even a whole day, If the infected dental pulp appears pyogenic symptoms, the patient may have the main complaint of throbbing pain.
2. Unable to locate accurately
When patients have pain attack, they often can't accurately point out the exact location of the teeth, which is caused by the characteristics of the nerve distribution of the pulp. The sensory nerve endings of the pulp are free nerve endings, only pain receptors, but no proprioception. Because of these characteristics, it is difficult for patients with acute pulpitis to point out the teeth to the doctor.
3. Pain of release and involvement
Acute pulpitis patients often can not accurately point out the location of the teeth, but often appear the symptoms of pain in the ear, the front of the temporal or the back of the ear, under the ear and the mandible, which is mainly caused by the complexity of the distribution of the pulp nerve. The pain often radiates along the second or third distribution area of the trigeminal nerve to the upper and lower teeth or the head, temporal and face on the same side of the teeth. The specific manifestations are as follows: the pain in the front of the ear and the front of the temporal, the pain in the back of the ear, under the ear and the jaw, but the pain in the opposite side of the affected tooth will not occur.
4. Hot stimulation is sensitive, cold stimulation can alleviate
In clinic, it is often seen that the patient gargles with cold water for temporary pain relief. During the pain attack period of the affected teeth, the temperature stimulation can aggravate the pain of the patient, and the cold and hot stimulation can stimulate the severe pain of the affected teeth. However, if the pulp has been suppurated or partially necrotic, the affected teeth can show the phenomenon of "hot pain and cold relief". Because cold air or cold water can make the volume of gas produced in the products of pulp diseases shrink, reduce the pressure of pulp cavity and relieve the pain.
5. Changes in posture can aggravate pain
Most patients often have pain at night, or the pain at night is more severe than that during the day. This is mainly due to the aggravation of the pain caused by the change of body position. When the patient lies on his back, the pain is aggravated due to the pressure in the pulp cavity. The patient is often difficult to sleep or wake up from sleep due to the toothache.
6. Have a history of taking painkillers, but the effects are different
Patients with acute pulpitis often have a history of taking painkillers such as "fenbide, Yingtaiqing" before treatment. However, due to individual differences and pathological changes, the effects of patients are not the same.
[clinical examination]
1. Visible tooth defect or deep periodontal blind pocket
Acute pulpitis is often seen in the acute attack of chronic pulpitis in clinic. When patients have typical acute symptoms, chronic inflammation has existed for quite a long time. Usually, deep caries or hard tissue disease near the pulp cavity can be detected, and the crowns or deep periodontal pockets can be found.
2. No response or high sensitivity of electric activity
In the clinical pulp electrical activity test, if the pulp of the affected teeth is in the early stage of inflammation, its response can be sensitive; if it is in the late stage of inflammation, it will be slow or unresponsive.
3. Some teeth may have percussion pain
When pulp inflammation is in the early stage, the affected teeth have no obvious discomfort to percussion, but in the late inflammatory teeth, because the peripheral area of pulp inflammation has spread to the periodontal membrane of the root tip, slight percussion pain in the vertical direction can appear.
4. Determine the available thermal stimulation experiment of tooth position
During the temperature test, the response and sensitivity of the affected teeth are stimulating pain, especially for the thermal stimulation, which can be used to determine the tooth position of the affected teeth.
[key points of diagnosis]
1. Typical acute pulpitis pain symptoms
2. The diseased teeth can be found to have tooth damage or other causes of pulpopathy.
3. Pulp vitality test, especially the results of thermal stimulation test and percussion response can help to locate the affected teeth.
[emergency treatment]
1. Drainage and decompression under local anesthesia
Pain due to acute pulpitis
Because the pain caused by acute pulpitis is mainly caused by the pressure in the pulp cavity, which is too high to force the nerves, it is necessary to open the pulp and drainage in time to reduce the pressure in the pulp cavity and relieve the pain in the teeth. In order to further alleviate the pain of the patients, the painless technique is usually used under local anesthesia, the commonly used anesthetic is 2% procaine or 2% lidocaine, and the anesthesia method can be determined by the position of teeth and the effect of anesthesia.
2. Clove oil cotton ball is opened or sealed with corticosteroids
If it can not be treated thoroughly due to time and conditions, clove oil and cotton ball can be opened or sealed into corticosteroids. Clove oil has a good analgesic and appeasing effect, and corticosteroids have a good hemostatic, antiphlogistic and analgesic effect.
3. When time and conditions permit, pulp can be removed under local anesthesia, and routine root canal treatment can be carried out.
The method of thorough treatment of acute pulpitis is to remove the source of infection, carry out effective root canal treatment, and put an end to reinfection. Under the condition of time and conditions, the pulp tissue and the stimulus of the source of disease that have occurred irrecoverable damage in the pulp cavity can be completely removed, the infection can be eliminated, the root canal can be cleaned and shaped, and the root canal can be filled.
4. Eliminate occlusal trauma
For the affected teeth, they should be adjusted to reduce occlusion, reduce function and rest. Through grinding, the pulp symptoms may be eliminated.
5. Take painkillers or local long-term anesthetics if necessary
Generally, antibiotics or painkillers can be given orally or by injection, or long-acting anesthetics can be injected locally to relieve pain.
(2) Acute periapical periodontitis
Acute periapical periodontitis is a series of reaction process from serous inflammation of periapical periodontal membrane to suppurative inflammation of periapical tissue. It is a continuous process from light to heavy lesions and from small to large lesions. At the peak of the course of disease, it is the local osteomyelitis of alveolar bone, and it can also lead to osteomyelitis of jaw when it is serious.
[clinical manifestations]
1. Long term dull pain, biting pain
In the early stage of the disease, the affected teeth only have slight dull pain, sometimes the affected teeth may complain of biting the affected teeth and feel slightly comfortable. When the periapical tissue disease is not controlled in time, the exudate in periapical membrane is silted up, and the pressure in the periodontal space is increased, resulting in spontaneous and persistent dull pain. When the teeth are occluded, not only the symptoms can not be relieved, but also the burden of the apical tissue is increased due to the occlusal pressure, It stimulates the nerves and causes more severe pain. Because pain is caused by inflammation of periodontal nerve, patients can point out the teeth, and the pain range is limited to the root of the teeth, not to cause dissipation.
2. The affected teeth may have a sense of elongation
Because of the exudate deposition in periapical membrane and the pressure rise in the periodontal space, the patients can feel the obvious elongation of the affected teeth, and feel the early contact between the affected teeth and the opposite teeth.
3. Buccal mucosa swelling
When acute periapical periodontitis develops from serous stage to suppurative stage, due to periapical vascular expansion, serous exudation and tissue edema, the tissue cells of periapical membrane necrosis, dissolution and liquefaction, forming pus. Because of the weakness of buccal tissue structure, pus can break through periosteum and flow into submucous membrane.
4. With fever, discomfort and other systemic symptoms
Due to the release of histamine, serotonin and other chemicals, the increase of vascular permeability, the exudation of inflammatory cells, the edema and tenderness of the root tip, the swelling of lymph nodes, the reduction of systemic resistance under the stimulation of infection, and the absence of timely drainage of the teeth, it is easy to cause fever, discomfort and other systemic symptoms.
5. Taking painkillers can partially relieve pain
For the pain caused by acute periapical periodontitis, it is caused by the exudate in periapical membrane silting up, the pressure in the periodontal space rising, and the periodontal membrane nerve stimulated by inflammation. Therefore, in the absence of timely drainage, taking painkillers can only partially relieve the pain. To completely relieve the pain, it is necessary to open drainage.
[clinical examination]
1. Most of the teeth have turned black and gray, especially the neck
It is often seen that the teeth with acute periapical periodontitis are black gray, which is due to the pulp necrosis of the teeth with acute periapical periodontitis. After the pulp tissue necrosis, the red blood cells break, resulting in the hemoglobin decomposition products into the dentin tubules, resulting in the majority of the teeth with black gray, especially the structure of the enamel tooth bone junction at the neck of the teeth is weak, and the discoloration phenomenon is more obvious.
2. Root tip tenderness, tooth tenderness
In the clinical percussion and palpation of the affected teeth, the tenderness of the root tip and the palpation of the affected teeth may occur, which is due to the accumulation of exudates in the periapical membrane and the increase of the pressure in the periodontal space.
3. Diffuse or fluctuating swelling of buccal root tip
When the acute periapical periodontitis did not open drainage in time, the serous inflammation of periapical tissue continued to develop, resulting in purulent changes, necrosis, dissolution and liquefaction of the tissue cells of periapical membrane, forming pus. Because the buccal tissue structure of the affected tooth is relatively weak, the buccal side of the affected tooth may have diffuse or fluctuating swelling of the root tip.
4. Most of the vitality tests were negative
Because the pulp of most teeth suffering from acute periapical periodontitis has been necrotic, the vitality test of most teeth suffering from acute periapical periodontitis is negative.
5. Periodontal cavity widening, periapical shadow
X-ray examination of the patients' teeth showed that the periodontal cavity was widened, and the periapical area formed by the destruction of alveolar bone in different degrees appeared, showing periapical shadow.
[emergency treatment]
1. Focus on the establishment of drainage channels through the root canal system
For acute periapical periodontitis, first
For acute periapical periodontitis, the first thing is to relieve the pain. The main contradiction lies in the accumulation and diffusion of exudates or pus at the apical stage. The ideal way of drainage is to manually open the drainage channel of the pulp cavity, open the apical hole, so that the exudates and pus can be drained through the root canal, relieve the pressure at the apical and relieve the pain. During emergency treatment, attention should be paid to: a local infiltration anesthesia should avoid the swelling area, * good block anesthesia. B open the pulp correctly and reduce the pain of the affected teeth by fixing them. C is alternately washed with hydrogen peroxide solution and sodium hypochlorite, and the foam produced can take away the secretions of the root canal. D. a sterile cotton ball can be inserted into the pulp chamber to open the pulp cavity, and then routine treatment can be performed after the acute inflammation subsides. In general, the patient will have a follow-up visit 2-3 days after open drainage.
2. Incision and drainage of abscess on buccal side
Acute periapical periodontitis in periosteum or submucous abscess stage should be cut and discharged under local anesthesia. The timing should be in the fourth to fifth day of acute inflammation, with a relatively clear wave motion. When it is not easy to judge, puncture can be performed. When the abscess is deep, the incision can be appropriately enlarged, drainage strip can be placed, and replaced once a day until there is no abscess. Usually, the opening of medullary cavity can be carried out at the same time with the incision and drainage of pus. The timing of incision depends on the specific situation of the affected teeth, and cannot be limited by the time alone.
3. Routine adjustment to reduce the malaise of occlusion
Acute periapical periodontitis is usually caused by trauma in serous stage. It should be adjusted and grinded to reduce the burden and rest. If necessary, local sealing or physical therapy can be used. Through grinding, pulp and periapical symptoms may be eliminated. In addition to relieving symptoms, it can also reduce the chance of vertical fracture.
4. Attention should be paid to fixing the affected teeth during operation
During the operation, in order to reduce the pain and protect the teeth, the vibration of drilling and grinding should be reduced as much as possible, and the teeth can be fixed with hand or impression glue.
5. Appeasement treatment
For root canal injury and chemical stimulation, the irritant should be taken out, the root canal should be washed repeatedly, and the drug should be sealed again to avoid external pollution or reinfection. If it is caused by root canal filling, check the root canal filling. If it is beyond the apical hole, you can remove the root filling material, seal the medicine to appease, and then fill.
6. Oral antibiotics 3D
In clinical treatment, antibiotics are usually given to patients by oral way to promote the regression of apical inflammation and relieve the discomfort of the whole body.
7. Take painkillers orally if necessary.
When the patients can't be treated immediately by open pulp drainage due to the limitation of conditions, they can take the painkillers orally to relieve the pain.
8. Acute extraction
For teeth with acute periapical periodontitis without reservation value, it is necessary to grasp the opportunity to pull out the teeth immediately in the acute inflammatory period and drain the teeth through the alveolus so as to relieve the patients' pain rapidly. In order to prevent the spread of inflammation, systemic medicine must be used at the same time. If subperiosteal abscess has been formed, extraction of teeth for drainage is not urgent. It can be carried out after the acute symptoms subside, because the drainage of periapical part is secondary.
(3) Endodontic treatment of intraoperative pain
With the extensive application of root canal therapy in the treatment of acute pulpitis and acute periapical periodontitis, the occurrence of intraoperative pain in the process of pulp treatment is also increasing, becoming another common type of acute toothache.
[cause]
1. Residual pulp after pulpectomy
In the treatment of acute pulpitis or acute periapical periodontitis and post-traumatic teeth, there is still residual pulp in the root canal after pulpectomy due to the poor operation technology of the operator, the lack of root canal treatment equipment and the complexity of root canal anatomy.
2. Injury of periapical tissue beyond apical hole
In the process of root canal therapy, when using manual or mechanical instruments for root canal preparation, due to the unclear working length or improper operation of the prepared root canal, it is possible to extend the instruments beyond the apical hole, which often leads to the injury of periapical tissue, causing pain during or after treatment.
3. Push the necrotic root pulp tissue out of the apical foramen
When root canal treatment is carried out for the teeth with pulp necrosis, due to the improper root canal preparation method, the "piston" effect of root canal instruments in the root canal, the necrotic substance can be pushed out of the apical hole. At the same time, the necrotic pulp tissue with relatively simple anatomical form of root canal is relatively easy to be pulled out. For the root canal with relatively complex and variable anatomical form, it is relatively difficult to pull out the root pulp tissue with too much force Or improper operation may push the necrotic root pulp tissue out of the apical hole, cause inflammation of the periapical tissue of the affected tooth, and cause the pain of the affected tooth during the operation.
4. The root filling material is beyond the root tip hole
In the process of root canal filling, because of the misjudgment or improper operation of the working length of the root canal, it can cause the overfilling of the root canal filling material. When the solid root canal filling material and the irritant paste filling material overfilling, it will cause the acute inflammation of the periapical tissue of the teeth and the pain during the operation.
5. Obvious trauma after treatment
After dental pulp treatment, when temporary or **** restoration is carried out for the affected teeth, the early contact of occlusion is caused by too high filling of the prosthesis, and the timely and effective adjustment is not carried out, which will lead to the formation of obvious traumatic occlusion, leading to the occurrence of intraoperative pain.
[clinical manifestations]
1. Persistent dull pain and biting pain of the affected teeth during or after operation
Because of the above reasons, pulpitis and acute periapical inflammation can make the affected teeth
2. Some patients may have swelling of adjacent tissues in the affected teeth
Because of the injury of periapical tissue or the pushing of necrotic root pulp tissue out of the periapical pore by the instrument or the filling material out of the periapical pore, it may cause the acute inflammation of periapical teeth. If the acute inflammation of periapical teeth is not effectively treated, some patients may suffer from the swelling of the adjacent tissue of the local teeth.
[emergency treatment]
For the pain of pulp treatment, it is necessary to take timely and effective treatment according to the cause of the disease to reduce the pain of patients.
1. Treatment of pain caused by residual pulp
First of all, under local anesthesia, the residual pulp can be effectively removed, the root canal can be thoroughly washed and sterilized, and the root canal can be sealed. The clove oil paper tip can soothe and relieve pain, and at the same time, the local injection of long-term ******* can relieve pain.
2. Treatment of pain after root canal preparation and sealing
The pain after root canal preparation and drug sealing is mainly caused by acute periapical inflammation caused by the damage of instruments or over filling drugs to the periodontal tissues of the teeth. First, the root canal should be washed thoroughly and drainage should be opened. For the hard reactive mass formed due to inflammatory hyperplasia, hot water can be used to rinse the mouth to promote the mass dissipation. For the fluctuating abscess formed due to the untimely treatment, it is feasible to open drainage When necessary, antibiotics and painkillers can be taken orally to promote inflammation and relieve pain.
3. Treatment of pain caused by over filling of root filling material
For the patients with slight over filling of root filling material, because the pain symptoms are not obvious, they can be reduced to make the teeth rest, reduce the pressure stimulation to the root tip of the teeth, at the same time, they can take antibiotics and corticosteroids orally, reduce the inflammatory reaction and relieve the pain. For patients with obvious overfilling, the root filling material must be removed, the root canal must be rinsed, opened, and sealed. For patients with periapical inflammation, the corresponding treatment measures should be taken according to the degree of the disease. Meanwhile, the patients should be grinded, modified and adjusted to reduce the height of the teeth, so that the teeth can rest and promote the healing.
(4) Acute periodontal abscess
Acute periodontal abscess is not an independent disease, but a common concomitant condition after deep periodontal pocket. It is a localized suppurative inflammation located on the wall of periodontal pocket or deep periodontal tissue, which is generally an acute process.
[pathogenic factors]
1. When the suppurative inflammation on the inner wall of the deep periodontal pocket spreads to the deep connective tissue, and the pus cannot be discharged into the pocket, the abscess in the soft tissue of the pocket wall will be formed.
2. The deep periodontal pockets involving multiple tooth surfaces are tortuous, and the purulent exudates cannot be drained smoothly, especially when the root bifurcation area is involved.
3. When scaling or curettage, the action is rough, and the debris of calculus is pushed into the deep tissue of periodontal pocket, or the gingival tissue is damaged.
4. The curettage of the deep periodontal bag is not complete. Although the mouth of the bag is tight, the inflammation at the bottom of the bag still exists and there is no drainage.
5. Periodontitis can also cause periodontal abscess when the teeth suffer from trauma, or when the root canal and pulp chamber are penetrated laterally and the root is cracked vertically.
6. The body's resistance is decreased or there are serious systemic diseases, such as diabetes, which are prone to periodontal abscess.
[clinical manifestations]
1. Obvious pain
Acute periodontal abscess occurs suddenly. In the early stage of abscess, inflammation infiltrates widely, which makes the tissue tension larger and the pain more intense. It can have pain and throbbing pain.
2. Biting pain
Because of the edema of periodontal ligament, the affected teeth have "floating feeling", and the percussion pain and occlusal pain are obvious
3. Local swelling
An oval or hemispherical swelling of the gingiva is formed on the labiobuccal or lingual palatal sides of the teeth. The gingiva is red, edematous and glossy.
[clinical examination]
1. Local periodontal abscess
The swelling of periodontal tissue in the affected teeth can be found during the clinical examination.
2. Loose teeth and percussion pain
Because of the edema of periodontal ligament, the affected teeth have "floating feeling", the teeth are obviously loose and percussive pain.
3. It is sensitive to temperature stimulation, and most of the teeth have vitality by electrical activity test
Acute periodontal abscess is the pathogen from the periodontal pocket. Its pathological scope is first confined to the periodontal part, so most of the teeth with pulp can not be damaged or slightly damaged, so the teeth with cold and hot stimulation are sensitive, and most of the teeth with electrical activity test have vitality
[emergency treatment]
The treatment principle of acute periodontal abscess is to relieve pain, prevent the spread of infection and drainage of pus. For the emergency treatment of acute periodontal abscess, the following three treatment measures can be taken according to the pathological changes of the pulp.
1. Normal pulp activity
When the pulp activity is normal by temperature test and electrical activity test, it means that the lesion is limited to the periodontal part of the affected tooth, and the periodontal bag can be scraped, washed, and the abscess can be cut and discharged
2. Pulp involvement
When the patient has the symptoms of acute periodontal abscess and the diseases of pulp and periapical, it indicates that the infection of periodontal abscess has retrograde caused pulp infection. When the periodontal abscess is in the middle of the treatment, the pulp should be removed. When the pulp has been tested to be necrotic, the root canal should be cleaned thoroughly and opened to root canal for root canal treatment.
2、 Non odontogenic pain
(1) Trigeminal neuralgia
Trigeminal neuralgia refers to the paroxysmal electric shock like severe pain in the distribution area of trigeminal nerve, which lasts for several seconds to several minutes, with no symptoms during the interval, and can radiate to bone and teeth. In clinic, there are many patients with trigeminal neuralgia who mistakenly think of toothache and seek medical treatment, which needs to be carefully identified.
[clinical manifestations]
1. Women born more than middle-aged
2. Severe "toothache" will occur during the attack
3. Pain is generally limited to one side
4. Pain along the nerve
[pain characteristics]
Trigeminal neuralgia has its own pain characteristics, which can be distinguished from toothache caused by odontogenic diseases.
1. The attack is generally caused by "trigger point". The so-called "trigger point" refers to a small piece of skin or mucous membrane fixed in the trigeminal nerve branch area, which is particularly sensitive. A little touch on this point will immediately cause a pain attack. The pain starts at the "trigger point" and then spreads rapidly to the whole nerve branch. "Trigger point" may be one, but it may also be more than two, generally depending on the number of affected branches.
2. The nature of pain is electric shock, acupuncture, knife cutting or tearing pain. A dull burning or pain after a sudden, brief, sudden cessation. During the attack, the patient makes various special actions to relieve the pain.
3. The attack is mostly in the daytime and seldom at night.
4. The attack time is short, which lasts for several seconds or 1-2 minutes each time and then stops abruptly.
5. The pain appears periodic attack, each attack lasts for weeks or months, and then there is a period of automatic temporary relief.
[differential diagnosis]:
1. According to the characteristics of trigeminal neuralgia
2. Generally, it can not find the tooth diseases that may cause pulpitis, and it is not sensitive to cold and hot stimulation.
3. There was no temperature stimulation pain and periapical inflammation in the interval remission period
4. Carbamazepine can be used for diagnosis. Carbamazepine is an effective drug for trigeminal neuralgia.
(2) Myocardial pain
In clinical, a considerable number of patients with heart disease often come to see a doctor with toothache as the main complaint, so we should take the overall consideration of the patient's body to prevent misdiagnosis and accidents.
[clinical features]
Tooth pain caused by heart disease often has the following characteristics:
1. Cardiogenic jaw pain
The aggregation of coronary atherosclerotic plaques causes vasospasm and angina pectoris, which is often manifested as the pain under the sternum in case of acute onset, accompanied by the pain involved in radiating to the left shoulder and the lower wall, occasionally involving the left mandibular angle of the neck, and some heart diseases may occur in the maxillofacial region
2. Some patients with myocardial infarction had no oral stimulation before the onset of the disease. Sudden and severe tooth pain may occur,
3. Chronic angina pectoris and coronary artery disease may cause moderate tooth pain, which is often related to emotional or physical activity, not to oral stimulation.
[differential diagnosis]
1. Maxillofacial involvement pain often occurs on the left side
2. Paroxysmal squeezing pain sensation in the front of the chest, mainly located in the back of the sternum, can radiate to the precordial area and the ulnar side of the left upper limb, and can be accompanied by indirect pain in the shoulder, back and neck
3. Pain is related to fatigue.
4. ECG and cardiac load test are helpful to distinguish.
5. No teeth were found.
6. Can appear anxiety, fidgety, dyspnea, shock and other symptoms of general discomfort.
(3) Maxillary sinusitis
Clinically, it is common to see the pain of the same side of the maxillary posterior teeth caused by chronic maxillary sinusitis of non odontogenic type, and there is also a considerable part of acute maxillary sinusitis. When suffering from maxillary sinusitis, the maxillary posterior teeth on the affected side may have pain symptoms similar to pulpitis. Because the anatomic part of the apical area of the maxillary posterior teeth is just adjacent to the bottom of the maxillary sinus, and the nerves distributed in the pulp of the area first pass through the lateral wall or the bottom of the maxillary sinus and then enter the apical hole, the acute inflammation in the maxillary sinus may involve the pulp nerves of the corresponding maxillary posterior teeth and cause "toothache", at this time, the pain may also spread to the head and face and be easily misdiagnosed.
[clinical manifestations]
1. The affected teeth show continuous dull to moderate pain
2. Swelling of the corresponding skin on the face
3. The surface skin is sensitive
4. Pain can be aggravated when lying down or bending
5. Pain can spread to the scalp or nose
[clinical examination]
1. Adjacent teeth usually have normal pulp
Because acute maxillary sinusitis is rare, the pulp of adjacent teeth is usually normal when maxillary sinusitis occurs
2. The toothache of general patients is severe, but there is no hot and cold stimulation pain.
3. The affected teeth have tenderness and percussion pain. The maxillary * * and the second molars are obvious, but the teeth themselves have no lesions.
4. Increased pain during eating
Differential diagnosis:
When there is periapical disease in teeth, it is very likely to cause infection of maxillary sinus lining and inflammation of maxillary sinus. At this time, the dental tissue and X-ray examination should be carefully checked to make clear the diagnosis, and the treatment of periapical inflammation and maxillary sinusitis should be carried out at the same time.
(4) Acute gingival papillitis
Acute gingival papillitis refers to the acute nonspecific inflammation with lesions limited to individual interdental papillae. It is a relatively common acute lesion. Clinically, patients often come to see a doctor with toothache as the main complaint, which is easily confused with pulpitis.
[cause]
It is mainly caused by acute inflammation caused by mechanical or chemical stimulation of the interdental papilla.
1. Food impaction
2. Toothpick and other tooth picking instruments damage gingival tissue.
3. Stimulation of fillings, poor restorations and removable dentures.
[clinical manifestations]
1. The papilla between teeth is red and swollen, easy to bleed when touching and sucking.
2. There are spontaneous pain and palpation pain, sometimes it can show moderate cold and hot stimulation pain.
3. The pain of female patients is often aggravated due to menstruation.
[clinical examination]
1. The gingival papilla is bright red and swollen, with obvious palpation pain and easy bleeding.
2. The teeth may have slight percussion pain.
[treatment]
1. Remove local stimulus
2. Eliminate acute inflammation
3. Use anti-bacterial and anti-inflammatory drugs and hydrogen peroxide solution locally.
4. Remove the cause thoroughly.
(5) Pericoronitis of wisdom teeth
Pericoronitis of wisdom teeth refers to the inflammation of soft tissue around the crown when wisdom teeth (the third molar) erupt incompletely or obstruct. Clinically, pericoronitis of lower jaw wisdom teeth is more common. Because the location of the disease is deep in the oral cavity, patients are not easy to find periodontal lesions, and often complain of toothache.
[cause]
Because of the incongruity between the length of jaw and the length of dentition, the position of tooth eruption is not enough, which leads to different degrees of occlusion. During the eruption of impacted wisdom teeth and wisdom teeth, the crowns can be partially or completely covered by gingival flaps. A deep blind bag is formed between the gingival flaps and the crowns. Food and bacteria are easily embedded in the blind bag. In addition, the gums of the crowns are often damaged by chewing food, forming ulcers. When the systemic resistance decreases and the local bacterial virulence increases, it can cause acute attack of pericoronitis, spread directly or by lymphatics, and cause infection of adjacent tissues and organs or fascial space.
[clinical manifestations]
1. At the early stage, the patient felt the pain and discomfort in the posterior area of the affected molar, and the pain increased when chewing, swallowing and opening activities.
2. Local pain may be spontaneous jumping pain or radiation pain in the distribution area of ototemporal nerve.
3. There may be different degrees of mouth opening limitation, or even "teeth closed tightly".
4. May have chills, fever, headache and other systemic symptoms.
[clinical examination]
1. In most cases, incomplete eruption of wisdom teeth can be seen. Probes can be used to detect incomplete eruption of wisdom teeth or impacted teeth under the gingival flap.
2. The soft tissue and gingiva around wisdom teeth are red, accompanied by swelling of different degrees. The inflammatory swelling can affect the palatoglossal arch and the pharyngeal side wall.
3. The margin of the gingival flap is erosive, with obvious tenderness, and pus can be pressed out from the gingival pouch.
4. The adjacent second molar may have percussion pain.
[treatment]
1. Local flushing
The gingival pouch can be rinsed repeatedly with normal saline and hydrogen peroxide solution to remove food debris, necrotic tissue and pus. Iodine glycerin or a small amount of iodine phenol can be placed in the gingival pouch after washing.
2. Incision and drainage
If abscess is formed near the gingival flap, it should be cut in time and drainage strip should be placed.
3. Pericoronal gingival flap resection
For wisdom teeth with enough eruption position and normal teeth position, the Pericoronal gingival flap of wisdom teeth can be removed under local anesthesia to eliminate the blind pocket.
Extraction of mandibular wisdom teeth
(6) Atypical toothache
Atypical toothache is a kind of unexplained persistent pain that occurs on healthy teeth. Its pathogenesis may be related to psychological, vascular, sensory nerve damage and other factors
[clinical manifestations]:
1. No definite features or symptoms
2. The main manifestations of pain are teeth and periodontal tissue
3. Pain area can be moved
4. Most patients take painkillers without effect
5. The pain increases when the body is tired and weak
[pain characteristics]
1. The deep part of the tissue shows continuous dull pain and burning sensation
2. Unable to locate the specific painful tooth position
3. No obvious trigger point for pain
[clinical examination]
Clinical examination showed that the oral cavity was in good condition, the affected teeth had no obvious tooth damage, and the pulp was normal.
[main identification points]
1. Moderate persistent pain, but also burning pain or jumping pain, not affecting sleep
2. Clinical and X-ray examination showed that there was no abnormality in the periodontium of teeth
3. It often occurs in women aged 40-50, and the course of disease can last for many years
4. The pathogenesis may be related to psychological factors. Patients often have changes in psychological function, which is manifested as depression.
(7) Hallucinatory toothache
Patients with hallucinogenic toothache are usually unexplained. Most of them occur after myelograft, apical resection or tooth extraction. The incidence rate after dental pulp treatment is about 3%, which can occur in adult men and women. Clinical observation is not related to psychological factors.
[clinical manifestations]:
1. Persistent dull pain in deep tissue.
2. Occasional spontaneous sharp pain.
3. Chronic cases often can not determine the position of painful teeth.
4. Clinical examination and X-ray were negative.
5. Often misdiagnosed, early improper treatment will complicate the condition.
(8) Herpes zoster
Herpes zoster is a skin and mucous disease caused by herpes zoster virus, which is characterized by vesicles and neuralgia. After 12 years of age, the incidence rate increases with age. The symptoms of early onset are low fever, fatigue, loss of appetite, and so on. The lesions in the oral cavity are trigeminal herpes zoster, and toothache may occur in the prodromal stage, so it is easy to be misdiagnosed as pulpitis clinically.
The clinical manifestations of tooth pain caused by herpes zoster are as follows:
1. It can show the precursory symptoms of pulpitis.
Some patients with herpes zoster may have sudden tooth pain before onset, which is paroxysmal, spontaneous nocturnal pain, accompanied by swelling and burning pain in the left cheek. It is easy to be misdiagnosed as acute pulpitis.
2. Toothache is limited to one side.
3. It can be located on one or more teeth.
4. The pain is sharp, jumping, and there is a gap period.
[clinical examination]:
1. Complete teeth, no caries, no recent trauma history
2. Swelling of the skin can be seen on the cheek and mandible, and there are pain and scattered erythema in flakes and herpes zoster with pale yellow and transparent in clusters of different sizes.
[differential diagnosis]:
Although the pain of herpes zoster is similar to that of pulpitis, there is no heat stimulation pain, which is different from that of pulpitis. Therefore, clinicians should carefully inquire about the history and check carefully to avoid misdiagnosis and delayed treatment. At the same time, research shows that severe pulp symptoms can cause adverse pulp reaction, even necrosis. Early pulp treatment can alleviate severe pulp pain.
(9) Toothache caused by tumor diseases
Oral and maxillofacial tumors may have corresponding pain symptoms due to their own characteristics and location.
Tooth pain caused by tumor diseases generally occurs in the early stage of tumor diseases. Part of the pain is caused by tumor cells infiltrating into alveolar process and jaw bone, causing bone destruction, tooth loosening and pain. The other part is caused by tumor compressing nerve, resulting in pain in tooth area with nerve distribution. Patients with maxillary sinus cancer may have extensive, persistent and diffuse dull pain of maxillary molars in the early stage. Sometimes, the pain is more obvious at night. In the late stage, the loosening and elongation of teeth may occur, which may compress the infraorbital nerve due to swelling, resulting in numbness of the affected cheek, upper lip and maxillary teeth.
The clinical manifestations of tooth pain caused by tumor diseases are as follows:
1. Symptoms very similar to toothache can appear, but no damage of tooth tissue can be detected.
2. The pain can gradually increase with time.
3. Pain has no obvious characteristics and has no specificity.
4. Can form sensory abnormality
The pain of teeth caused by tumor diseases has its own characteristics, but some of the disease sites are hidden and often difficult to find, so it is necessary to seek the assistance of oral surgeons or physicians for diagnosis.
(10) Fictional pain
The so-called fictitious pain is the pain that does not exist in fact. It is the pain that patients describe or create in detail for some purpose.
There are three main clinical conditions:
1. Mental patients without normal consciousness.
Psychotic patients can accurately describe the history of oral and facial pain, but it can not be confirmed by examination and test, but for patients' own consciousness, pain does exist, so patients will insist on treatment.
2. Normal people for their own purposes.
In order to seek sick leave or drug users often use the terms of pain description in professional books to describe his or her pain in detail. During examination, doctors sometimes find out the possible causes of pain, but this situation is self induced or "dental". Such patients will make up a variety of reasons to get doctors' fake strips or strong painkillers.
For such patients, doctors are required to have keen insight to prevent unnecessary medical accidents.
(11) Sphenopalatine neuralgia
Sphenopalatine neuralgia is a kind of acute paroxysmal pain of unknown cause, which is progressive aggravation. Pathologically, it is the result of peripheral vasodilation. The typical pain sites are unilateral maxillary, paranasal sinuses and posterior orbital areas, which are often mistaken as acute pulpitis or periapical abscess of the posterior maxillary teeth.
Main identification points:
1. Unique facial expression - ruddy face, often freckled.
2. Pain is described as a forceps inserted behind the maxilla and eyes, accompanied by nasal congestion, photophobia and tears
3. The symptoms of pain attack at the same time almost every evening, lasting for 30-45 minutes.
4. Failed to find out the teeth, cold and hot stimulation did not trigger pain.
5. During pain attack, oxygen can relieve pain, and pterygopalatine tube block anesthesia can relieve pain.
(12) Sialolithiasis
Sialolithiasis is when the stone develops to a certain size, the salivary duct is blocked, then there is pain symptoms. Sialolithiasis often occurs in submandibular duct, pain can be related to the mandible, resulting in pain much like the pulp pain of the mandibular posterior teeth. The swelling of submaxillary area caused by duct obstruction is often misdiagnosed as lymphadenitis caused by pulp inflammation or periapical inflammation of mandibular posterior teeth.
Main identification points:
1. When eating, the saliva secretion increases and the pain aggravates.
2. It was found that the submandibular duct mouth was congested and swollen, and no saliva flowed out of the duct when the submandibular gland was squeezed.
3. Soreness and strong feeling of stretch.
4. X-ray occlusal film shows calcification in soft tissue, which can be diagnosed.
(13) Acute otitis media
Acute otitis media is common in children, caused by Streptococcus pyogenic infection. The middle ear diffuses and causes jaw pain, which radiates from the ear to the upper and lower posterior teeth.
Main identification points:
1. Acute pain, the patient has severe headache, often accompanied by jumping pain.
2. The gravity factor plays a synergetic role, and the pain of the patient is aggravated when he lowers his head.
3. Otoscopy can confirm the diagnosis of the membrane. The tympanic membrane is often swollen and protruding. Penicillin and other antibiotics are effective.
3、 Oral and maxillofacial swelling
The swelling of the oral and maxillofacial region is mainly caused by cellulitis of the maxillofacial region caused by acute infection of the oral and maxillofacial region. The oral and maxillofacial region is located at the beginning of the digestive tract and the respiratory tract. Because of the cavity of the oral cavity, the nasal cavity and the sinuses, the special anatomical structure of the teeth, the gums and the tonsils, and the temperature and humidity of these parts are suitable for the colonization, breeding and reproduction of bacteria. When the resistance of the whole body is reduced, the cellulitis of the oral and maxillofacial region is It can lead to the occurrence of endogenous or exogenous infection of normal microbial ecological disorders. At the same time, there are many potential spaces and abundant lymph nodes around the face and jaw, which provide a channel for the spread of infection.
The way of oral and maxillofacial infection:
1. Odontogenic pathway is the main source of oral and maxillofacial infection.
2. Adenogenic
3. Damage
4. Blood origin
5. Iatrogenic
[clinical manifestations]
1. In the acute stage of suppurative inflammation, the local symptoms are typical symptoms such as redness, swelling, heat, pain and dysfunction, swelling and pain of lymph nodes in drainage area, but the degree is different due to the location, depth, scope and duration of the disease. In the chronic stage of infection, due to the infiltration of a large number of monocytes in the diseased tissue, the normal tissue is replaced by proliferative fibrous tissue after destruction, and the local area can form a relatively large number of monocytes
2. Systemic symptoms systemic symptoms are different due to the virulence of bacteria and the resistance of the body, and their manifestations are also different. The patients with severe disease and long time, due to metabolic disorders, septicemia, pyemia, lead to multiple organ failure and death.
[treatment]
1. The local treatment should keep the local clean, reduce the local activity, avoid adverse stimulation and prevent the spread of infection. In acute stage, Chinese herbal medicine or oral antibiotics can be applied.
2. Surgical treatment
a. Incision and drainage of abscess when the inflammatory focus has been suppurated and formed abscess, or when the abscess has collapsed and the drainage is not smooth, incision and drainage or expanded drainage should be performed. Local inflammation is obvious, the disease develops rapidly, such as putrefactive necrotizing cellulitis, or the patients with obvious poisoning symptoms can also be cut early.
b. After the inflammation caused by odontogenic infection in oral and maxillofacial area is improved, it is an important problem to remove the teeth, which should not be ignored.
3. When systemic treatment of oral and maxillofacial infection complicated with systemic poisoning symptoms such as fever, chills, obvious white blood cell count or toxic particles, support treatment should be given to the whole body while local treatment is carried out to maintain the balance of water and electrolyte, so as to reduce the poisoning symptoms, and antibiotics should be given in a timely and targeted manner.
4、 Tooth trauma
(1) Dental concussion
Tooth concussion is a mild injury of periodontal ligament, usually not accompanied by tooth tissue defect.
[cause] it is caused by light external force, such as sudden chewing of hard objects when eating.
[clinical manifestations]
1. The affected teeth have discomfort of elongation, slight loosening and percussion pain, and there may be a small amount of bleeding at the gingival margin.
2. The reaction of pulp vitality test is different, usually there is no reaction after injury, but it starts to recover after weeks or months.
[treatment]
1.1-2 weeks to rest the affected teeth.
2. It can reduce occlusion to reduce the burden of teeth
3. Fix the loose teeth.
4. Regular reexamination 1, 3, 6 and 12 months after injury.
(2) Tooth dislocation
It is called tooth dislocation when the teeth are separated from the alveolus by external force. According to the degree of dislocation, it can be divided into incomplete dislocation and total dislocation.
[etiology] collision is a common cause of tooth dislocation.
[clinical manifestations]
1. According to the direction of the external force, it can be detached, embedded and displaced in the direction of lip and tongue.
2. The affected teeth have pain, looseness, displacement and occlusion disorder.
3. X-ray showed that the gap between the root tip and the alveolar fossa was significantly widened.
4. Pulp necrosis, narrowing or disappearance of pulp cavity, and external root resorption may occur after tooth dislocation.
[treatment]
1. Partial dislocated teeth can be reduced under local anesthesia, and then ligated and fixed for 4 weeks. 3
6. 12 months.
2. Root canal therapy was performed two weeks after reduction. For young permanent teeth, it is not allowed to pull out and restore them forcibly, but to wait for their natural eruption.
3. For the completely dislocated teeth, replantation should be carried out within half an hour as much as possible. For those who have been treated for more than two hours, replantation should be done after the root canal treatment in vitro.
(3) Odontoclasis
[cause]
Direct impact is a common cause of tooth fracture.
[clinical manifestations]
1. The anterior teeth of crown fracture can be divided into transverse fracture and oblique fracture, and the posterior teeth can be divided into oblique fracture and longitudinal fracture.
2. Root fracture can be divided into neck 1 / 3, root middle 1 / 3 and root tip 1 / 3.
3. The crown root joint fracture is mostly oblique, and the pulp is often exposed.
[treatment]
1. Crowns with unexposed dentin can polish sharp edges. For the patients with dentin exposure, the corresponding treatment and protection measures should be taken according to the sensitive degree of the teeth. For the teeth with pulp exposure, the pulpectomy or pulpotomy should be taken according to the situation of the teeth and pulp.
2. The treatment of root fracture should first promote its natural healing. Even if the teeth seem to be very stable, they should be fixed with splints as soon as possible. In case of activity.
3. All the crown root fractures which can be treated by root canal and have the indications of post core crown restoration should be preserved as much as possible.