Symptomatic irreversible pulpitis and other orofacial pain: overcoming challenges in diagnosis and management

Abstract

Due to the unique sensory innervation of the teeth and face, orofacial pain can be challenging to diagnose and manage. Odontogenic pain, or 'toothache', is the most common orofacial pain condition and encompasses the vast majority of pain which is presented to dental practitioners. While diagnosis is often straightforward, the clinical picture is occasionally unclear or contradictory, and in these situations, the clinician should be able to consider reasons other than the teeth for the patient's presenting complaint. The primary aim of managing odontogenic pain is to treat the underlying cause, often arising from the dental pulp or periapical tissues; however, several factors can make pre-, intra- and post-operative management of odontogenic pain challenging. This paper will consider key similarities and differences in the clinical presentation of odontogenic pain and other non-odontogenic causes of orofacial pain in order to help practitioners arrive at the correct diagnosis. We discuss evidence-based recommendations for intra- and post-operative management of acute odontogenic pain, and consider the underlying neurophysiological features which make orofacial pain challenging to manage.

Fig. 1

Innervation of the teeth. First-order neurons have cell bodies which reside in the trigeminal ganglion; their axons send signals from the tooth and go on to synapse with second-order neurons in the sub-nucleus caudalis of the trigeminal nuclear complex in the brainstem. Evidence from animal models suggest the presence of an additional route (dashed red line) in which primary trigeminal afferents synapse with second order neurons in the parabrachial nucleus, missing the brainstem, and offering a ‘direct' input to the brain