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Causes of dental pain or infection

The most common reason for children to experience dental pain is pulpal pathology as a consequence of dental caries. The immune system allows vital dental pulps to cope with some bacterial ingress from a carious lesion through the triggering of an inflammatory response in the region of the pulp closest to the lesion. However, if a progressing carious lesion is not managed, then over time the increasing bacterial infection causes a more extensive and severe inflammatory response in the dental pulp. Eventually, the bacterial infection and the associated increase in tissue pressure overwhelms the ability of the circulatory system to keep the pulp perfused, which will then transition from being vital (perfused), to non-vital and necrotic (no perfusion). Bacteria can then thrive within the necrotic pulpal remnants, and the diffusion of these bacteria and their products through the radicular foramina causes inflammation of the periodontal ligament (hence these teeth becoming tender to percussion and mobile), and a dental abscess.

Clinically, it is useful to divide this process into three stages: pulpitis with reversible symptoms, pulpitis with irreversible symptoms and dental abscess/periradicular periodontitis. However, these do not refer to discrete, well separated stages of pathology, but are on a continuum of unmanaged pulpal disease from mild inflammation through to pulpal necrosis. Clinicians must use their clinical judgement to decide the extent of the pulpal pathology and the appropriate management strategy.

Pain is provoked by a stimulus (e.g. cold, sweet) and relieved when it is removed. The pain is intermittent, difficult for the child to localise and does not tend to affect the child’s sleep. The pulp is still vital and the tooth is not tender to percussion. Management of the carious lesion alone may be enough to resolve the inflammation and allow pulpal healing.

Pain can occur spontaneously but if provoked by a stimulus is typically not relieved when the stimulus is removed. The pain may last for several hours, may be difficult for the child to localise and may keep the child awake at night. The pain may be dull and throbbing, worsened by heat and may be alleviated by cold. There are no signs and symptoms of infection such as sinuses or abscesses or periradicular pathology and the pulp is still vital, although inflamed. Usually the tooth is not tender to percussion. Management of the carious lesion alone is unlikely to resolve the inflammation, and pulp therapy or extraction is necessary.

  • In primary teeth, pulp therapy for the management of pulpitis with irreversible symptoms is confined to the coronal pulp chamber only (pulpotomy).
  • In permanent teeth, pulp therapy for the management of pulpitis with irreversible symptoms can be confined to the coronal pulp chamber only (pulpotomy) or the instrumentation can be extended to include the root canal system (pulpectomy).

When acute, pain is likely to be spontaneous, will keep the child awake at night and can be easily localised by the child. The tooth may show increased mobility and may be tender to percussion. There may be clinical evidence of a sinus, abscess or swelling or radiographic evidence of periradicular pathology. When chronic, the child may not report pain but other signs and symptoms may be present. The infected, necrotic remnants of the dental pulp will continue to cause problems unless managed by pulp therapy or extraction.

  • In both primary and permanent teeth, pulp therapy for the management of dental abscess/periradicular periodontitis will include instrumentation of the pulp chamber and root canal system (pulpectomy).

Signs and symptoms to assist the clinician in diagnosing these stages are given in the Diagnosis and management of dental pain or infection flowchart. However, the following points should be noted.

  • It is possible for pulpal disease to progress from mild inflammation to complete pulpal necrosis without any obvious signs, and without the child reporting symptoms. This is probably a factor of host resistance, which can increase or decrease over time, resulting in previously asymptomatic teeth with pulpal pathology becoming symptomatic.
  • For multi-rooted teeth it is not uncommon to encounter different pathology in individual roots. The root canal with the most advanced pathology will dictate the management strategy.