Grey Areas in Restorative Dentistry: Part 2. The Diagnosis: Dental Pain

Framing the problem

This process begins with the presenting condition of the patient. We can hear patients when we are told a history of the complaint, but if we listen carefully and ask appropriate questions, they will often give us a very good indication of what the problem is. It may be possible to arrive at a provisional diagnosis before even looking in the mouth (Figure 2). So, what is the difference between these two modalities? Hearing is ‘the process, function, or power of perceiving sound’² whereas listening is ‘to hear something with thoughtful attention, to give consideration’.³ And then, the more experienced we become as dentists, the more easily and readily we will pick up important clues from the patient's narrative.

There can be no doubt that the relief of a patient's pain or discomfort is one of the most rewarding aspects of dental practice.

Specific questioning regarding the pain, or the teeth, or the soft tissues can elicit more information leading to a provisional diagnosis.

Pain

Teeth

Swellings

The Socrates acronym is a useful way to structure the clinical questioning (Table 1). So, in a structured examination it is sensible to look at:

The patient

Look at how they care for themselves. How they are dressed and groomed. How they sit. Signs of nerves. Facial expressions. Listen to what they say and how they say it. How they respond to questioning. Assess their ability to explain their problems or to respond to further probing (Figure 3).

The mouth

Look at the state of the hard and soft tissues to get an overall impression of the patient's dental past and present. Lots of dentistry? What quality? Are there any missing teeth, appliances, bridges, crowns or caries? Look at the periodontal condition and any soft-tissue swellings (Figure 4).

The sextant

Look at the area producing symptoms both in its static, intercuspal position and in its dynamic relationship with the opposing jaw in lateral excursions (Figure 5).

The tooth or teeth

Focus on the symptomatic tooth or teeth and make an assessment (Figure 6).

Perhaps the most common presenting oral pain in the dental surgery is that arising from a tooth or teeth, so it becomes vitally important to be able to distinguish the presenting symptoms and signs of pulpal pain. Table 2 covers the range of pulpal conditions and their symptoms and signs.

Table 2. Symptoms, signs and management of pain arising from the pulp. (Reproduced with kind permission from Caplin).5

	Reversible pulpitis	Irreversible pulpitis	Pulpal necrosis	Apical periodontitis	Apical periodontitis with existing root filling	Peri-apical abscess
Pain	Sharp	Aching or throbbing	No	AchingAwareness	AchingAwareness	Boring, aching throbbing when acute Awareness when chronic
Localization	No	No	No	Yes	Yes	Yes
Onset	Thermal or tactile stimulus	Spontaneous or with thermal or tactile stimulus	None	Pressure from occlusal forces or chewing	Pressure from occlusal forces or chewing	Constant
Duration	ShortFew secondsSubsides with cessation of stimulus	Minutes to hours	None	Subsides when pressure is relieved	Subsides when pressure is relieved	Hours to days
Swelling	No	No	No	No	No	Yes, when acute; subsides when chronic
Periostitic	No	No	No	Yes	Yes	Yes, when acute; no when chronic
Buccal tenderness	No	No	No	Yes	Yes	Yes
Management	Deal with exposed dentine, e.g. repair or replace filling	Remove root canal contentsRoot canal treatment or extraction	Remove root canal contentsRoot treatment or extraction	Remove root canal contentsRoot treatment or extraction	Re-treat canal or apical surgery or extraction	Extraction if facial swellingRemove root canal contentsRoot treatment or root canal re-treatment or extraction

However, it is important to bear in mind that pain can arise from any of the tissues associated with the tooth. Periodontal tissue can give rise to acute or chronic pain, and investigation of the state of the periodontium in the region of the complaint should be undertaken with a periodontal probe. This would be to assess pocket depths as well as tooth mobility, which can be an indicator of localized excessive occlusal loading. Such overloading can also result in stress fractures in the tooth itself, which would lead to a pulpal reaction, and so it becomes important to identify the cause of the insult to the pulp (Figures 7 and 8). As indicated above, an occlusal examination is required to assess the stresses on the teeth in question. Where the symptoms are not consistent with pulpal or periodontal pain, other possibilities such as atypical facial pain or TMJ dysfunction should be considered.

The challenge of accurate observation

Visual and tactile observations are only applicable to those structures that are readily accessible, whereas those structures that are beneath the surface can only be assessed by additional investigative procedures.⁷ It is essential to know what the normal appearance looks like to distinguish this from the abnormal, diseased appearance.

Further investigations

Having observed, listened to, questioned, and examined the patient, it may be that a provisional diagnosis can been made and that further investigations are required to give additional information, hopefully leading to a definitive diagnosis. These further tests may comprise sensibility tests, percussion, palpation, application of a dye, transillumination, radiographs, CBCT, temperature assessment and biopsy. However, if a definitive diagnosis can be made following clinical examination, then clearly further investigations are not warranted.

As mentioned, in practice there are two levels of observation: that of the superficial structures and surfaces which are directly visible (e.g. teeth, periodontal tissues, soft tissues) and the deeper tissues and structures. However, even within the visual assessment, there are two levels of observation: one with the naked eye and one with magnification. Experience shows that enhanced vision of carious lesions, restoration margins and tooth fractures aids diagnosis, and there is ample evidence that magnification improves operative procedures.^8-12

Regarding the deeper structures, the practitioner should have a protocol for the taking of radiographs because this will be the most common way of assessing unseen areas. When there is an acute situation, clearly the area to be investigated will be determined by the suspected location of the problem. However, in a non-acute situation, such as a routine examination, consideration should be given to the investigation of teeth that are heavily filled or have indirect restorations in, or over, them. Only then can the status of the tooth or teeth be decided with some degree of certainty (Figure 9).

Re-framing leading to a diagnosis

Once the clinician is satisfied that enough information has been gathered, in most cases of dental pain a definitive diagnosis can be made. It is true to say that ‘there can only be one correct diagnosis but there may be several ways of dealing with the situation’. Should the practitioner be unsure of the diagnosis, it would be prudent to get a second opinion before embarking on irreversible procedures. Undoubtedly, there needs to be a full and frank discussion with the patient regarding the certainty or not of the diagnosis. There may be an incorrect assumption among dentists that to be worthwhile, one must be thoroughly competent and successful in his/her field, which might be taken to mean, practically, arriving at a diagnosis in all clinical situations. With experience comes the ability to be able to say, ‘I don't know’.

Conclusion

Arriving at a diagnosis can be very difficult and requires not only a sequential approach, but in addition, skill, and judgement from the practitioner. ‘Good judgement comes from experience and a lot of experience comes from bad judgement’. From a medico-legal perspective, it is extremely important that a record is kept of the interaction between the practitioner and the patient so that a third party perusing the notes can follow the flow of the complaint, the questioning, the investigations, the reporting of the investigations and the diagnosis. It may transpire that the diagnosis was incorrect but if it was made with as much information as possible, and the symptoms and signs are not clear, then it may be that the best guess is acceptable. As in a math's question, showing the working is as important, if not more so, than the answer!

Clinical conundrums

For these clinical scenarios, what would be the aims of treatment, the range of interventions to achieve these, and how would you choose? List the risks and benefits for each option.

This patient complained of mild aching in the lower right quadrant and some discomfort on chewing. There was buccal tenderness at LR6.

What has happened here and what is the possible diagnosis?

This patient presents in your practice. What history would you expect her to give and what provisional diagnosis would you make before inspecting the mouth?

What further investigations would be appropriate? What if the patient has limited opening?