Pulpal Diseases Classification Essay

For other uses, see Paper (disambiguation).

Paper is a thin material produced by pressing together moist fibres of cellulose pulp derived from wood, rags or grasses, and drying them into flexible sheets. It is a versatile material with many uses, including writing, printing, packaging, cleaning, and a number of industrial and construction processes.

The pulp papermaking process is said to have been developed in China during the early 2nd century CE, possibly as early as the year 105 CE,[1] by the Han court eunuchCai Lun, although the earliest archaeological fragments of paper derive from the 2nd century BCE in China.[2] The modern pulp and paper industry is global, with China leading its production and the United States right behind it.

History

Main article: History of paper

The oldest known archaeological fragments of the immediate precursor to modern paper date to the 2nd century BCE in China. The pulp papermaking process is ascribed to Cai Lun, a 2nd-century CE Han court eunuch.[2]

Its knowledge and uses spread from China through the Middle East to medieval Europe in the 13th century, where the first water powered paper mills were built.[3] Because of paper's introduction to the West through the city of Baghdad, it was first called bagdatikos.[4] In the 19th century, industrialization greatly reduced the cost of manufacturing paper. In 1844, the Canadian inventor Charles Fenerty and the German F. G. Keller independently developed processes for pulping wood fibres.[5]

Early sources of fibre

See also: wood pulp and deinking

Before the industrialisation of the paper production the most common fibre source was recycled fibres from used textiles, called rags. The rags were from hemp, linen and cotton.[6] A process for removing printing inks from recycled paper was invented by German jurist Justus Claproth in 1774.[6] Today this method is called deinking. It was not until the introduction of wood pulp in 1843 that paper production was not dependent on recycled materials from ragpickers.[6]

Etymology

Further information: Papyrus

The word "paper" is etymologically derived from Latinpapyrus, which comes from the Greek πάπυρος (papuros), the word for the Cyperus papyrus plant.[7][8]Papyrus is a thick, paper-like material produced from the pith of the Cyperus papyrus plant, which was used in ancient Egypt and other Mediterranean cultures for writing before the introduction of paper into the Middle East and Europe.[9] Although the word paper is etymologically derived from papyrus, the two are produced very differently and the development of the first is distinct from the development of the second. Papyrus is a lamination of natural plant fibres, while paper is manufactured from fibres whose properties have been changed by maceration.[2]

Papermaking

Main article: Papermaking

Chemical pulping

Main articles: kraft process, sulfite process, and soda pulping

To make pulp from wood, a chemical pulping process separates lignin from cellulose fibres. This is accomplished by dissolving lignin in a cooking liquor, so that it may be washed from the cellulose; this preserves the length of the cellulose fibres. Paper made from chemical pulps are also known as wood-free papers–not to be confused with tree-free paper; this is because they do not contain lignin, which deteriorates over time. The pulp can also be bleached to produce white paper, but this consumes 5% of the fibres; chemical pulping processes are not used to make paper made from cotton, which is already 90% cellulose.

There are three main chemical pulping processes: the sulfite process dates back to the 1840s and it was the dominant method extent before the second world war. The kraft process, invented in the 1870s and first used in the 1890s, is now the most commonly practiced strategy, one of its advantages is the chemical reaction with lignin, that produces heat, which can be used to run a generator. Most pulping operations using the kraft process are net contributors to the electricity grid or use the electricity to run an adjacent paper mill. Another advantage is that this process recovers and reuses all inorganic chemical reagents. Soda pulping is another specialty process used to pulp straws, bagasse and hardwoods with high silicate content.

Mechanical pulping

There are two major mechanical pulps: thermomechanical pulp (TMP) and groundwood pulp (GW). In the TMP process, wood is chipped and then fed into steam heated refiners, where the chips are squeezed and converted to fibres between two steel discs. In the groundwood process, debarked logs are fed into grinders where they are pressed against rotating stones to be made into fibres. Mechanical pulping does not remove the lignin, so the yield is very high, >95%, however it causes the paper thus produced to turn yellow and become brittle over time. Mechanical pulps have rather short fibres, thus producing weak paper. Although large amounts of electrical energy are required to produce mechanical pulp, it costs less than the chemical kind.

De-inked pulp

Paper recycling processes can use either chemically or mechanically produced pulp; by mixing it with water and applying mechanical action the hydrogen bonds in the paper can be broken and fibres separated again. Most recycled paper contains a proportion of virgin fibre for the sake of quality; generally speaking, de-inked pulp is of the same quality or lower than the collected paper it was made from.

There are three main classifications of recycled fibre:.

  • Mill broke or internal mill waste – This incorporates any substandard or grade-change paper made within the paper mill itself, which then goes back into the manufacturing system to be re-pulped back into paper. Such out-of-specification paper is not sold and is therefore often not classified as genuine reclaimed recycled fibre, however most paper mills have been reusing their own waste fibre for many years, long before recycling became popular.
  • Preconsumer waste – This is offcut and processing waste, such as guillotine trims and envelope blank waste; it is generated outside the paper mill and could potentially go to landfill, and is a genuine recycled fibre source; it includes de-inked preconsumer (recycled material that has been printed but did not reach its intended end use, such as waste from printers and unsold publications).[10]
  • Postconsumer waste – This is fibre from paper that has been used for its intended end use and includes office waste, magazine papers and newsprint. As the vast majority of this material has been printed – either digitally or by more conventional means such as lithography or rotogravure – it will either be recycled as printed paper or go through a de-inking process first.

Recycled papers can be made from 100% recycled materials or blended with virgin pulp, although they are (generally) not as strong nor as bright as papers made from the latter.

Additives

Besides the fibres, pulps may contain fillers such as chalk or china clay,[11] which improve its characteristics for printing or writing.[12] Additives for sizing purposes may be mixed with it or applied to the paper web later in the manufacturing process; the purpose of such sizing is to establish the correct level of surface absorbency to suit ink or paint.

Producing paper

Main articles: Paper machine and papermaking

The pulp is fed to a paper machine where it is formed as a paper web and the water is removed from it by pressing and drying.

Pressing the sheet removes the water by force; once the water is forced from the sheet, a special kind of felt, which is not to be confused with the traditional one, is used to collect the water; whereas when making paper by hand, a blotter sheet is used instead.

Drying involves using air or heat to remove water from the paper sheets. In the earliest days of paper making, this was done by hanging the sheets like laundry; in more modern times, various forms of heated drying mechanisms are used. On the paper machine, the most common is the steam-heated can dryer. These can reach temperatures above 200 °F (93 °C) and are used in long sequences of more than forty cans where the heat produced by these can easily dry the paper to less than six percent moisture.

Finishing

The paper may then undergo sizing to alter its physical properties for use in various applications.

Paper at this point is uncoated. Coated paper has a thin layer of material such as calcium carbonate or china clay applied to one or both sides in order to create a surface more suitable for high-resolution halftone screens. (Uncoated papers are rarely suitable for screens above 150 lpi.) Coated or uncoated papers may have their surfaces polished by calendering. Coated papers are divided into matte, semi-matte or silk, and gloss. Gloss papers give the highest optical density in the printed image.

The paper is then fed onto reels if it is to be used on web printing presses, or cut into sheets for other printing processes or other purposes. The fibres in the paper basically run in the machine direction. Sheets are usually cut "long-grain", i.e. with the grain parallel to the longer dimension of the sheet. Continuous form paper (or continuous stationery) is cut to width with holes punched at the edges, and folded into stacks.

Paper grain

All paper produced by paper machines as the Fourdrinier Machine are wove paper, i.e. the wire mesh that transports the web leaves a pattern that has the same density along the paper grain and across the grain. Textured finishes, watermarks and wire patterns imitating hand-made laid paper can be created by the use of appropriate rollers in the later stages of the machine.

Wove paper does not exhibit "laidlines", which are small regular lines left behind on paper when it was handmade in a mould made from rows of metal wires or bamboo. Laidlines are very close together. They run perpendicular to the "chainlines", which are further apart. Handmade paper similarly exhibits "deckle edges", or rough and feathery borders.[13]

Applications

Paper can be produced with a wide variety of properties, depending on its intended use.

  • For representing value:paper money, bank note, cheque, security (see security paper), voucher and ticket
  • For storing information: book, notebook, graph paper, magazine, newspaper, art, zine, letter
  • For personal use: diary, note to remind oneself, etc.; for temporary personal use: scratch paper
  • For communication: between individuals and/or groups of people.
  • For packaging:corrugated box, paper bag, envelope, Packing & Wrapping Paper, Paper string, Charta emporetica and wallpaper
  • For cleaning:toilet paper, handkerchiefs, paper towels, facial tissue and cat litter
  • For construction:papier-mâché, origami, paper planes, quilling, paper honeycomb, used as a core material in composite materials, paper engineering, construction paper and paper clothing
  • For other uses:emery paper, sandpaper, blotting paper, litmus paper, universal indicator paper, paper chromatography, electrical insulation paper (see also dielectric and permittivity) and filter paper

It is estimated that paper-based storage solutions captured 0.33% of the total in 1986 and only 0.007% in 2007, even though in absolute terms, the world's capacity to store information on paper increased from 8.7 to 19.4 petabytes.[14] It is estimated that in 1986 paper-based postal letters represented less than 0.05% of the world's telecommunication capacity, with sharply decreasing tendency after the massive introduction of digital technologies.[14]

Types, thickness and weight

Main articles: Paper size, Grammage, and Paper density

The thickness of paper is often measured by caliper, which is typically given in thousandths of an inch in the United States and in micrometers (µm) in the rest of the world.[15] Paper may be between 0.07 and 0.18 millimetres (0.0028 and 0.0071 in) thick.[16]

Paper is often characterized by weight. In the United States, the weight assigned to a paper is the weight of a ream, 500 sheets, of varying "basic sizes", before the paper is cut into the size it is sold to end customers. For example, a ream of 20 lb, 8.5 in × 11 in (216 mm × 279 mm) paper weighs 5 pounds, because it has been cut from a larger sheet into four pieces.[17] In the United States, printing paper is generally 20 lb, 24 lb, or 32 lb at most. Cover stock is generally 68 lb, and 110 lb or more is considered card stock.

In Europe, and other regions using the ISO 216 paper sizing system, the weight is expressed in grammes per square metre (g/m2 or usually just g) of the paper. Printing paper is generally between 60 g and 120 g. Anything heavier than 160 g is considered card. The weight of a ream therefore depends on the dimensions of the paper and its thickness.

Most commercial paper sold in North America is cut to standard paper sizes based on customary units and is defined by the length and width of a sheet of paper.

The ISO 216 system used in most other countries is based on the surface area of a sheet of paper, not on a sheet's width and length. It was first adopted in Germany in 1922 and generally spread as nations adopted the metric system. The largest standard size paper is A0 (A zero), measuring one square meter (approx. 1189 × 841 mm). A1 is half the size of a sheet of A0 (i.e., 594 mm × 841 mm), such that two sheets of A1 placed side by side are equal to one sheet of A0. A2 is half the size of a sheet of A1, and so forth. Common sizes used in the office and the home are A4 and A3 (A3 is the size of two A4 sheets).

The density of paper ranges from 250 kg/m3 (16 lb/cu ft) for tissue paper to 1,500 kg/m3 (94 lb/cu ft) for some speciality paper. Printing paper is about 800 kg/m3 (50 lb/cu ft).[18]

Paper may be classified into seven categories:[19]

  • Printing papers of wide variety.
  • Wrapping papers for the protection of goods and merchandise. This includes wax and kraft papers.
  • Writing paper suitable for stationery requirements. This includes ledger, bank, and bond paper.
  • Blotting papers containing little or no size.
  • Drawing papers usually with rough surfaces used by artists and designers, including cartridge paper.
  • Handmade papers including most decorative papers, Ingres papers, Japanese paper and tissues, all characterized by lack of grain direction.
  • Specialty papers including cigarette paper, toilet tissue, and other industrial papers.

Some paper types include:

Paper stability

Much of the early paper made from wood pulp contained significant amounts of alum, a variety of aluminium sulfate salts that is significantly acidic. Alum was added to paper to assist in sizing,[20] making it somewhat water resistant so that inks did not "run" or spread uncontrollably. Early papermakers did not realize that the alum they added liberally to cure almost every problem encountered in making their product would eventually be detrimental.[21] The cellulose fibres that make up paper are hydrolyzed by acid, and the presence of alum would eventually degrade the fibres until the paper disintegrated in a process that has come to be known as "slow fire". Documents written on rag paper were significantly more stable. The use of non-acidic additives to make paper is becoming more prevalent, and the stability of these papers is less of an issue.

Paper made from mechanical pulp contains significant amounts of lignin, a major component in wood. In the presence of light and oxygen, lignin reacts to give yellow materials,[22] which is why newsprint and other mechanical paper yellows with age. Paper made from bleachedkraft or sulfite pulps does not contain significant amounts of lignin and is therefore better suited for books, documents and other applications where whiteness of the paper is essential.

Paper made from wood pulp is not necessarily less durable than a rag paper. The aging behavior of a paper is determined by its manufacture, not the original source of the fibers.[23] Furthermore, tests sponsored by the Library of Congress prove that all paper is at risk of acid decay, because cellulose itself produces formic, acetic, lactic and oxalic acids.[24]

Mechanical pulping yields almost a tonne of pulp per tonne of dry wood used, which is why mechanical pulps are sometimes referred to as "high yield" pulps. With almost twice the yield as chemical pulping, mechanical pulps is often cheaper. Mass-market paperback books and newspapers tend to use mechanical papers. Book publishers tend to use acid-free paper, made from fully bleached chemical pulps for hardback and trade paperback books.

Environmental impact

Main articles: Environmental impact of paper and Deforestation

The production and use of paper has a number of adverse effects on the environment.

Worldwide consumption of paper has risen by 400% in the past 40 years[clarification needed] leading to increase in deforestation, with 35% of harvested trees being used for paper manufacture. Most paper companies also plant trees to help regrow forests. Logging of old growth forests accounts for less than 10% of wood pulp,[25] but is one of the most controversial issues.

Paper waste accounts for up to 40% of total waste produced in the United States each year, which adds up to 71.6 million tons of paper waste per year in the United States alone.[26] The average office worker in the US prints 31 pages every day.[27] Americans also use in the order of 16 billion paper cups per year.

Conventional bleaching of wood pulp using elemental chlorine produces and releases into the environment large amounts of chlorinated organic compounds, including chlorinated dioxins.[28] Dioxins are recognized as a persistent environmental pollutant, regulated internationally by the Stockholm Convention on Persistent Organic Pollutants. Dioxins are highly toxic, and health effects on humans include reproductive, developmental, immune and hormonal problems. They are known to be carcinogenic. Over 90% of human exposure is through food, primarily meat, dairy, fish and shellfish, as dioxins accumulate in the food chain in the fatty tissue of animals.[29]

Future

Some manufacturers have started using a new, significantly more environmentally friendly alternative to expanded plastic packaging. Made out of paper, and known commercially as PaperFoam, the new packaging has mechanical properties very similar to those of some expanded plastic packaging, but is biodegradable and can also be recycled with ordinary paper.[30]

With increasing environmental concerns about synthetic coatings (such as PFOA) and the higher prices of hydrocarbon based petrochemicals, there is a focus on zein (corn protein) as a coating for paper in high grease applications such as popcorn bags.[31]

Also, synthetics such as Tyvek and Teslin have been introduced as printing media as a more durable material than paper.

See also

Notes

  1. ^Hogben, Lancelot. "Printing, Paper and Playing Cards". Bennett, Paul A. (ed.) Books and Printing: A Treasury for Typophiles. New York: The World Publishing Company, 1951. pp. 15–31. p. 17. & Mann, George. Print: A Manual for Librarians and Students Describing in Detail the History, Methods, and Applications of Printing and Paper Making. London: Grafton & Co., 1952. p. 77
  2. ^ abcTsien 1985, p. 38
  3. ^Burns 1996, pp. 417f.
  4. ^Murray, Stuart A. P. The Library: An illustrated History. Skyhorse Publishing, 2009, p. 57.
  5. ^Burger, Peter (2007). Charles Fenerty and his paper invention. Toronto: Peter Burger. pp. 25–30. ISBN 9780978331818. OCLC 173248586. 
  6. ^ abcGöttsching, Lothar; Gullichsen, Johan; Pakarinen, Heikki; Paulapuro, Hannu; Yhdistys, Suomen Paperi-Insinöörien; Technical Association of the Pulp and Paper Industry (2000). Recycling fiber and deinking. Finland: Fapet Oy. pp. 12–14. ISBN 9525216071. OCLC 247670296. 
  7. ^πάπυρος, Henry George Liddell, Robert Scott, A Greek-English Lexicon, on Perseus
  8. ^papyrus, on Oxford Dictionaries
  9. ^"papyrus". Dictionary.com Unabridged. Random House. Retrieved 20 November 2008. 
  10. ^Natural Resource Defense Council
  11. ^Appropriate Technology. Intermediate Technology Publications. 1996. 
  12. ^Thorn, Ian; Au, Che On (2009-07-24). Applications of Wet-End Paper Chemistry. Springer Science & Business Media. ISBN 9781402060380. 
  13. ^"Document Doubles" in a virtual museum exhibition at Library and Archives Canada
  14. ^ ab"The World’s Technological Capacity to Store, Communicate, and Compute Information", especially Supporting online material, Martin Hilbert and Priscila López (2011), Science, 332(6025), 60–65; free access to the article through here: martinhilbert.net/WorldInfoCapacity.html
  15. ^"Paper Thickness Chart". Case Paper. Retrieved 2017-05-27. 
  16. ^Elert, Glenn. "Thickness of a Piece of Paper". The Physics Factbook. Retrieved 2017-05-27. 
  17. ^McKenzie, Bruce G. (1989). The Hammerhill guide to desktop publishing in business. Hammerhill. p. 144. ISBN 9780961565114. OCLC 851074844. 
  18. ^"Density of paper and paperboard". PaperOnWeb. Retrieved 31 October 2007. 
  19. ^Johnson, Arthur (1978). The Thames and Hudson manual of bookbinding. London: Thames and Hudson. OCLC 959020143. 
  20. ^Biermann, Christopher J/ (1993). Essentials of pulping and papermaking. San Diego: Academic Press. ISBN 012097360X. OCLC 813399142. 
  21. ^Clark, James d'A. (1985). Pulp Technology and Treatment for Paper (2nd ed.). San Francisco: Miller Freeman Publications. ISBN 0-87930-164-3. 
  22. ^Fabbri, Claudia; Bietti, Massimo; Lanzalunga, Osvaldo. "Generation and Reactivity of Ketyl Radicals with Lignin Related Structures. On the Importance of the Ketyl Pathway in the Photoyellowing of Lignin Containing Pulps and Papers". J. Org. Chem. 2005 (70): 2720–2728. doi:10.1021/jo047826u. 
  23. ^Erhardt, D.; Tumosa, C. (2005). "Chemical Degradation of Cellulose in Paper over 500 years". Restaurator: International Journal for the Preservation of Library and Archival Material. 26: 155. doi:10.1515/rest.2005.26.3.151. 
  24. ^"The Deterioration and Preservation of Paper: Some Essential Facts". Library of Congress. Retrieved 7 January 2015.  
  25. ^Martin, Sam (2004). "Paper Chase". Ecology Communications, Inc. Archived from the original on 19 June 2007. Retrieved 21 September 2007. 
  26. ^EPA (28 June 2006). "General Overview of What's in America's Trash". United States Environmental Protection Agency. Archived from the original on 5 January 2012. Retrieved 4 April 2012. 
  27. ^Groll, T. 2015 In vielen Büros wird unnötig viel ausgedruckt, Zeit Online, 20 June 2015.
  28. ^"Effluents from Pulp Mills using Bleaching – PSL1". ISBN 0-662-18734-2 DSS. Health Canada. 1991. Retrieved 21 September 2007. 
  29. ^"Dioxins and their effects on human health". World Health Organization. June 2014. Retrieved 7 January 2015.  
  30. ^PaperFoam Carbon Friendly Packaging
  31. ^Barrier compositions and articles produced with the compositions cross-reference to related application

References

  • Burns, Robert I. (1996). "Paper comes to the West, 800–1400". In Lindgren, Uta. Europäische Technik im Mittelalter. 800 bis 1400. Tradition und Innovation (4th ed.). Berlin: Gebr. Mann Verlag. pp. 413–422. ISBN 3-7861-1748-9. 
  • Tsien, Tsuen-Hsuin (1985). Needham, Joseph, ed. Paper and Printing. Science and Civilisation in China, Chemistry and Chemical Technology. V (part 1). Cambridge University Press. 
  • "Document Doubles" in Detecting the Truth: Fakes, Forgeries and Trickery, a virtual museum exhibition at Library and Archives Canada

Further reading

  • Alexander Monro, The Paper Trail: An Unexpected History of the World's Greatest Invention, Allen Lane, 2014

External links

Look up paper in Wiktionary, the free dictionary.
Wikimedia Commons has media related to Paper.
Ancient Sanskrit on Hemp based Paper. Hemp Fibre was commonly used in the production of paper from 200 BCE to the Late 1800's.
Card and paper stock for crafts use comes in a wide variety of textures and colors.

Toothache, also known as dental pain,[3] is pain in the teeth and/or their supporting structures, caused by dental diseases or pain referred to the teeth by non-dental diseases.

Common causes include inflammation of the pulp, usually in response to tooth decay, dental trauma, or other factors, dentin hypersensitivity (short, sharp pain, usually associated with exposed root surfaces), apical periodontitis (inflammation of the periodontal ligament and alveolar bone around the root apex), dental abscesses (localized collections of pus, such as apical abscess, pericoronal abscess, and periodontal abscess), alveolar osteitis ("dry socket", a possible complication of tooth extraction, with loss of the blood clot and exposure of bone), acute necrotizing ulcerative gingivitis (a gum infection, also called "trenchmouth"), temporomandibular disorder and others.

Pulpitis is classified as reversible when the pain is mild to moderate and lasts for a short time after a stimulus (for instance, cold or sweet); or irreversible when the pain is severe, spontaneous, and lasts a long time after a stimulus. Left untreated, pulpitis may become irreversible, then progress to pulp necrosis (death of the pulp) and apical periodontitis. Abscesses usually cause throbbing pain. The apical abscess usually occurs after pulp necrosis, the pericoronal abscess is usually associated with acute pericoronitis of a lower wisdom tooth, and periodontal abscesses usually represent a complication of chronic periodontitis (gum disease). Much less commonly, non-dental conditions can cause toothache, such as maxillary sinusitis, which can cause pain in the upper back teeth, or angina pectoris, which can cause pain in the lower teeth.

Toothache is the most common type of orofacial pain[4]:125–135 and, when severe, it is considered a dental emergency, since there may be a significant impact on sleep, eating, and other daily activities. It is one of the most common reasons for emergency dental appointments.[5] Correct diagnosis can sometimes be challenging. The treatment of a toothache depends upon the exact cause, and may involve a filling, root canal treatment, extraction, drainage of pus, or other remedial action. The relief of toothache is considered one of the main responsibilities of dentists.[6] In 2013, 223 million cases of tooth pain occurred as a result of dental caries in permanent teeth and 53 million cases occurred in baby teeth.[7] Historically, the demand for treatment of toothache is thought to have led to the emergence of dental surgery as the first specialty of medicine.[8]

Causes[edit]

Toothache may be caused by dental (odontogenic) conditions (such as those involving the dentin-pulp complex or periodontium), or by non-dental (non-odontogenic) conditions (such as maxillary sinusitis or angina pectoris). There are many possible non-dental causes, but the vast majority of toothache is dental in origin.[9]:{{{1}}}

Both the pulp and periodontal ligament have nociceptors (pain receptors),[10] but the pulp lacks proprioceptors (motion or position receptors) and mechanoreceptors (mechanical pressure receptors).[4]:125–135[11] Consequently, pain originating from the dentin-pulp complex tends to be poorly localized,[11] whereas pain from the periodontal ligament will typically be well localized,[9]:55 although not always.[4]:125–135

For instance, the periodontal ligament can detect the pressure exerted when biting on something smaller than a grain of sand (10-30 µm).[12]:48 When a tooth is intentionally stimulated, about 33% of people can correctly identify the tooth, and about 20% cannot narrow the stimulus location down to a group of three teeth.[9]:31 Another typical difference between pulpal and periodontal pain is that the latter is not usually made worse by thermal stimuli.[4]:125–135

Dental[edit]

Pulpal[edit]

The majority of pulpal toothache falls into one of the following types; however, other rare causes (which do not always fit neatly into these categories) include galvanic pain and barodontalgia.

Pulpitis[edit]

Pulpitis (inflammation of the pulp) can be triggered by various stimuli (insults), including mechanical, thermal, chemical, and bacterial irritants, or rarely barometric changes and ionizing radiation.[13]:{{{1}}} Common causes include tooth decay, dental trauma (such as a crack or fracture), or a filling with an imperfect seal.

Because the pulp is encased in a rigid outer shell, there is no space to accommodate swelling caused by inflammation. Inflammation therefore increases pressure in the pulp system, potentially compressing the blood vessels which supply the pulp. This may lead to ischemia (lack of oxygen) and necrosis (tissue death). Pulpitis is termed reversible when the inflamed pulp is capable of returning to a state of health, and irreversible when pulp necrosis is inevitable.[9]:36–37

Reversible pulpitis is characterized by short-lasting pain triggered by cold and sometimes heat.[11] The symptoms of reversible pulpitis may disappear, either because the noxious stimulus is removed, such as when dental decay is removed and a filling placed, or because new layers of dentin (tertiary dentin) have been produced inside the pulp chamber, insulating against the stimulus. Irreversible pulpitis causes spontaneous or lingering pain in response to cold.[14]:619–627

Dentin hypersensitivity[edit]

Dentin hypersensitivity is a sharp, short-lasting dental pain occurring in about 15% of the population,[15] which is triggered by cold (such as liquids or air), sweet or spicy foods, and beverages.[16] Teeth will normally have some sensation to these triggers,[17] but what separates hypersensitivity from regular tooth sensation is the intensity of the pain. Hypersensitivity is most commonly caused by a lack of insulation from the triggers in the mouth due to gingival recession (receding gums) exposing the roots of the teeth, although it can occur after scaling and root planing or dental bleaching, or as a result of erosion. The pulp of the tooth remains normal and healthy in dentin hypersensitivity.[9]:510

Many topical treatments for dentin hypersensitivity are available, including desensitizing toothpastes and protective varnishes that coat the exposed dentin surface.[15] Treatment of the root cause is critical, as topical measures are typically short lasting.[9]:510 Over time, the pulp usually adapts by producing new layers of dentin inside the pulp chamber called tertiary dentin, increasing the thickness between the pulp and the exposed dentin surface and lessening the hypersensitivity.[9]:510

Periodontal[edit]

In general, chronic periodontal conditions do not cause any pain. Rather, it is acute inflammation which is responsible for the pain.[17]

Apical periodontitis[edit]

Apical periodontitis is acute or chronic inflammation around the apex of a tooth caused by an immune response to bacteria within an infected pulp.[19] It does not occur because of pulp necrosis, meaning that a tooth that tests as if it's alive (vital) may cause apical periodontitis, and a pulp which has become non-vital due to a sterile, non-infectious processes (such as trauma) may not cause any apical periodontitis.[9]:225 Bacterial cytotoxins reach the region around the roots of the tooth via the apical foramina and lateral canals, causing vasodilation, sensitization of nerves, osteolysis (bone resorption) and potentially abscess or cyst formation.[9]:228

The periodontal ligament becomes inflamed and there may be pain when biting or tapping on the tooth. On an X-ray, bone resporption appears as a radiolucent area around the end of the root, although this does not manifest immediately.[9]:228 Acute apical periodontitis is characterized by well-localized, spontaneous, persistent, moderate to severe pain.[4]:125–135 The alveolar process may be tender to palpation over the roots. The tooth may be raised in the socket and feel more prominent than the adjacent teeth.[4]:125–135

Food impaction[edit]

Food impaction occurs when food debris, especially fibrous food such as meat, becomes trapped between two teeth and is pushed into the gums during chewing.[4]:125–135 The usual cause of food impaction is disruption of the normal interproximal contour or drifting of teeth so that a gap is created (an open contact). Decay can lead to collapse of part of the tooth, or a dental restoration may not accurately reproduce the contact point. Irritation, localized discomfort or mild pain and a feeling of pressure from between the two teeth results. The gingival papilla is swollen, tender and bleeds when touched. The pain occurs during and after eating, and may slowly disappear before being evoked again at the next meal,[nb 1] or relieved immediately by using a tooth pick or dental floss in the involved area.[4]:125–135 A gingival or periodontal abscess may develop from this situation.[20]:444–445

Periodontal abscess[edit]

A periodontal abscess (lateral abscess) is a collection of pus that forms in the gingival crevices, usually as a result of chronic periodontitis where the pockets are pathologically deepened greater than 3mm. A healthy gingival pocket will contain bacteria and some calculus kept in check by the immune system. As the pocket deepens, the balance is disrupted, and an acute inflammatory response results, forming pus. The debris and swelling then disrupt the normal flow of fluids into and out of the pocket, rapidly accelerating the inflammatory cycle. Larger pockets also have a greater likelihood of collecting food debris, creating additional sources of infection.[20]:443

Periodontal abscesses are less common than apical abscesses, but are still frequent. The key difference between the two is that the pulp of the tooth tends to be alive, and will respond normally to pulp tests. However, an untreated periodontal abscess may still cause the pulp to die if it reaches the tooth apex in a periodontic-endodontic lesion. A periodontal abscess can occur as the result of tooth fracture, food packing into a periodontal pocket (with poorly shaped fillings), calculus build-up, and lowered immune responses (such as in diabetes). Periodontal abscess can also occur after periodontal scaling, which causes the gums to tighten around the teeth and trap debris in the pocket.[20]:444–445 Toothache caused by a periodontal abscess is generally deep and throbbing. The oral mucosa covering an early periodontal abscess appears erythematous (red), swollen, shiny, and painful to touch.[21]

A variant of the periodontal abscess is the gingival abscess, which is limited to the gingival margin, has a quicker onset, and is typically caused by trauma from items such as a fishbone, toothpick, or toothbrush, rather than chronic periodontitis.[20]:446–447 The treatment of a periodontal abscess is similar to the management of dental abscesses in general (see: Treatment). However, since the tooth is typically alive, there is no difficulty in accessing the source of infection and, therefore, antibiotics are more routinely used in conjunction with scaling and root planing.[22] The occurrence of a periodontal abscess usually indicates advanced periodontal disease, which requires correct management to prevent recurrent abscesses, including daily cleaning below the gumline to prevent the buildup of subgingival plaque and calculus.

Acute necrotizing ulcerative gingivitis[edit]

Common marginal gingivitis in response to subgingival plaque is usually a painless condition. However, an acute form of gingivitis/periodontitis, termed acute necrotizing ulcerative gingivitis (ANUG), can develop, often suddenly. It is associated with severe periodontal pain, bleeding gums, "punched out" ulceration, loss of the interdental papillae, and possibly also halitosis (bad breath) and a bad taste. Predisposing factors include poor oral hygiene, smoking, malnutrition, psychological stress, and immunosuppression.[20]:97–98 This condition is not contagious, but multiple cases may simultaneously occur in populations who share the same risk factors (such as students in a dormitory during a period of examination).[23] ANUG is treated over several visits, first with debridement of the necrotic gingiva, homecare with hydrogen peroxide mouthwash, analgesics and, when the pain has subsided sufficiently, cleaning below the gumline, both professionally and at home. Antibiotics are not indicated in ANUG management unless there is underlying systemic disease.[20]:437–438

Pericoronitis[edit]

Pericoronitis is inflammation of the soft tissues surrounding the crown of a partially erupted tooth.[24] The lower wisdom tooth is the last tooth to erupt into the mouth, and is, therefore, more frequently impacted, or stuck, against the other teeth. This leaves the tooth partially erupted into the mouth, and there frequently is a flap of gum (an operculum), overlying the tooth. Bacteria and food debris accumulate beneath the operculum, which is an area that is difficult to keep clean because it is hidden and far back in the mouth. The opposing upper wisdom tooth also tends to have sharp cusps and over-erupt because it has no opposing tooth to bite into, and instead traumatizes the operculum further. Periodontitis and dental caries may develop on either the third or second molars, and chronic inflammation develops in the soft tissues. Chronic pericoronitis may not cause any pain, but an acute pericoronitis episode is often associated with pericoronal abscess formation. Typical signs and symptoms of a pericoronal abscess include severe, throbbing pain, which may radiate to adjacent areas in the head and neck,[20][25]:122 redness, swelling and tenderness of the gum over the tooth.[26]:220–222 There may be trismus (difficulty opening the mouth),[26]:220–222 facial swelling, and rubor (flushing) of the cheek that overlies the angle of the jaw.[20][25]:122 Persons typically develop pericoronitis in their late teens and early 20s,[27]:6 as this is the age that the wisdom teeth are erupting. Treatment for acute conditions includes cleaning the area under the operculum with an antiseptic solution, painkillers, and antibiotics if indicated. After the acute episode has been controlled, the definitive treatment is usually by tooth extraction or, less commonly, the soft tissue is removed (operculectomy). If the tooth is kept, good oral hygiene is required to keep the area free of debris to prevent recurrence of the infection.[20]:440–441

Occlusal trauma[edit]

Occlusal trauma results from excessive biting forces exerted on teeth, which overloads the periodontal ligament, causing periodontal pain and a reversible increase in tooth mobility. Occlusal trauma may occur with bruxism, the parafunctional (abnormal) clenching and grinding of teeth during sleep or while awake. Over time, there may be attrition (tooth wear), which may also cause dentin hypersensitivity, and possibly formation of a periodontal abscess, as the occlusal trauma causes adaptive changes in the alveolar bone.[20]:153–154

Occlusal trauma often occurs when a newly placed dental restoration is built too "high", concentrating the biting forces on one tooth. Height differences measuring less than a millimeter can cause pain. Dentists, therefore, routinely check that any new restoration is in harmony with the bite and forces are distributed correctly over many teeth using articulating paper. If the high spot is quickly eliminated, the pain disappears and there is no permanent harm.[20]:153,753 Over-tightening of braces can cause periodontal pain and, occasionally, a periodontal abscess.[20]:503

Alveolar osteitis[edit]

Alveolar osteitis is a complication of tooth extraction (especially lower wisdom teeth) in which the blood clot is not formed or is lost, leaving the socket where the tooth used to be empty, and bare bone is exposed to the mouth.[28] The pain is moderate to severe, and dull, aching, and throbbing in character. The pain is localized to the socket, and may radiate. It normally starts two to four days after the extraction, and may last 10–40 days.[13][25]:122[26]:216–217[28] Healing is delayed, and it is treated with local anesthetic dressings, which are typically required for five to seven days.[26]:216–217 There is some evidence that chlorhexidine mouthwash used prior to extractions prevents alveolar osteitis.[28]

Combined pulpal-periodontal[edit]

Dental trauma and cracked tooth syndrome[edit]

Cracked tooth syndrome refers to a highly variable[29] set of pain-sensitivity symptoms that may accompany a tooth fracture, usually sporadic, sharp pain that occurs during biting or with release of biting pressure,[30] or relieved by releasing pressure on the tooth.[9]:24 The term is falling into disfavor and has given way to the more generalized description of fractures and cracks of the tooth, which allows for the wide variations in signs, symptoms, and prognosis for traumatized teeth. A fracture of a tooth can involve the enamel, dentin, and/or pulp, and can be orientated horizontally or vertically.[9]:24–25 Fractured or cracked teeth can cause pain via several mechanisms, including dentin hypersensitivity, pulpitis (reversible or irreversible), or periodontal pain. Accordingly, there is no single test or combination of symptoms that accurately diagnose a fracture or crack, although when pain can be stimulated by causing separation of the cusps of the tooth, it's highly suggestive of the disorder.[9]:27–31 Vertical fractures can be very difficult to identify because the crack can rarely be probed[9]:27 or seen on radiographs, as the fracture runs in the plane of conventional films (similar to how the split between two adjacent panes of glass is invisible when facing them).[9]:28–9

When toothache results from dental trauma (regardless of the exact pulpal or periodontal diagnosis), the treatment and prognosis is dependent on the extent of damage to the tooth, the stage of development of the tooth, the degree of displacement or, when the tooth is avulsed, the time out of the socket and the starting health of the tooth and bone. Because of the high variation in treatment and prognosis, dentists often use trauma guides to help determine prognosis and direct treatment decisions.[31][32]

The prognosis for a cracked tooth varies with the extent of the fracture. Those cracks that are irritating the pulp but do not extend through the pulp chamber can be amenable to stabilizing dental restorations such as a crown or composite resin. Should the fracture extend though the pulp chamber and into the root, the prognosis of the tooth is hopeless.[9]:25

Periodontic-endodontic lesion[edit]

Apical abscesses can spread to involve periodontal pockets around a tooth, and periodontal pockets cause eventual pulp necrosis via accessory canals or the apical foramen at the bottom of the tooth. Such lesions are termed periodontic-endodontic lesions, and they may be acutely painful, sharing similar signs and symptoms with a periodontal abscess, or they may cause mild pain or no pain at all if they are chronic and free-draining.[33] Successful root canal therapy is required before periodonal treatment is attempted.[20]:49 Generally, the long-term prognosis of perio-endo lesions is poor.

Non-dental[edit]

See also: Orofacial pain

Non-dental causes of toothache are much less common as compared with dental causes. In a toothache of neurovascular origin, pain is reported in the teeth in conjunction with a migraine. Local and distant structures (such as ear, brain, carotid artery, or heart) can also refer pain to the teeth.[34]:80,81 Other non-dental causes of toothache include myofascial pain (muscle pain) and angina pectoris (which classically refers pain to the lower jaw). Very rarely, toothache can be psychogenic in origin.[9]:57–58

Disorders of the maxillary sinus can be referred to the upper back teeth. The posterior, middle and anterior superior alveolar nerves are all closely associated with the lining of the sinus. The bone between the floor of the maxillary sinus and the roots of the upper back teeth is very thin, and frequently the apices of these teeth disrupt the contour of the sinus floor. Consequently, acute or chronic maxillary sinusitis can be perceived as maxillary toothache,[35] and neoplasms of the sinus (such as adenoid cystic carcinoma)[36]:390 can cause similarly perceived toothache if malignant invasion of the superior alveolar nerves occurs.[37]:72 Classically, sinusitis pain increases upon Valsalva maneuvers or tilting the head forward.[38]

Painful conditions which do not originate from the teeth or their supporting structures may affect the oral mucosa of the gums and be interpreted by the individual as toothache. Examples include neoplasms of the gingival or alveolar mucosa (usually squamous cell carcinoma),[36]:299 conditions which cause gingivostomatitis and desquamative gingivitis. Various conditions may involve the alveolar bone, and cause non-odontogenic toothache, such as Burkitt's lymphoma,[37]:340infarcts in the jaws caused by sickle cell disease,[39]:214 and osteomyelitis.[40]:497 Various conditions of the trigeminal nerve can masquerade as toothache, including trigeminal zoster (maxillary or mandibular division),[39]:487trigeminal neuralgia,[35]cluster headache,[35] and trigeminal neuropathies.[35] Very rarely, a brain tumor might cause toothache.[34]:80,81 Another chronic facial pain syndrome which can mimic toothache is temporomandibular disorder (temporomandibular joint pain-dysfunction syndrome),[35] which is very common. Toothache which has no identifiable dental or medical cause is often termed atypical odontalgia, which, in turn, is usually considered a type of atypical facial pain (or persistent idiopathic facial pain).[35] Atypical odontalgia may give very unusual symptoms, such as pain which migrates from one tooth to another and which crosses anatomical boundaries (such as from the left teeth to the right teeth).[citation needed]

Establishing a diagnosis of nondental toothache is initially done by careful questioning about the site, nature, aggravating and relieving factors, and referral of the pain, then ruling out any dental causes. There are no specific treatments for nondental pain (each treatment is directed at the cause of the pain, rather than the toothache itself), but a dentist can assist in offering potential sources of the pain and direct the patient to appropriate care. The most critical nondental source is the radiation of angina pectoris into the lower teeth and the potential need for urgent cardiac care.[9]:68

Pathophysiology[edit]

A tooth is composed of an outer shell of calcified hard tissues (from hardest to softest: enamel, dentin, and cementum), and an inner soft tissue core (the pulp system), which contains nerves and blood vessels. The visible parts of the teeth in the mouth — the crowns (covered by enamel) — are anchored into the bone by the roots (covered by cementum). Underneath the cementum and enamel layers, dentin forms the bulk of the tooth and surrounds the pulp system. The part of the pulp inside the crown is the pulp chamber, and the central soft tissue nutrient canals within each root are root canals, exiting through one or more holes at the root end (apical foramen/foramina). The periodontal ligament connects the roots to the bony socket. The gingiva covers the alveolar processes, the tooth-bearing arches of the jaws.[41]:1–5

Enamel is not a vital tissue, as it lacks blood vessels, nerves, and living cells.[17] Consequently, pathologic processes involving only enamel, such as shallow cavities or cracks, tend to be painless.[17] Dentin contains many microscopic tubes containing fluid and the processes of odontoblast cells, which communicate with the pulp. Mechanical, osmotic, or other stimuli cause movement of this fluid, triggering nerves in the pulp (the "hydrodynamic theory" of pulp sensitivity). Due to the close relationship between dentin and pulp, they are frequently considered together as the dentin-pulp complex.[42]:118

The teeth and gums exhibit normal sensations in health. Such sensations are generally sharp, lasting as long as the stimulus.[17] There is a continuous spectrum from physiologic sensation to pain in disease.[17] Pain is an unpleasant sensation caused by intense or damaging events. In a toothache, nerves are stimulated by either exogenous sources (for instance, bacterial toxins, metabolic byproducts, chemicals, or trauma) or endogenous factors (such as inflammatory mediators).[9]:532–534

The pain pathway is mostly transmitted via myelinatedAδ (sharp or stabbing pain) and unmyelinated Cnerve fibers (slow, dull, aching, or burning pain) of the trigeminal nerve, which supplies sensation to the teeth and gums via many divisions and branches.[17] Initially, pain is felt while noxious stimuli are applied (such as cold). Continued exposure decreases firing thresholds of the nerves, allowing normally non-painful stimuli to trigger pain (allodynia). Should the insult continue, noxious stimuli produce larger discharges in the nerve, perceived as more intense pain. Spontaneous pain may occur if the firing threshold is decreased so it can fire without stimulus (hyperalgesia). The physical component of pain is processed in the medullary spinal cord and perceived in the frontal cortex. Because pain perception involves overlapping sensory systems and an emotional component, individual responses to identical stimuli are variable.[9]:474–475

Diagnosis[edit]

The diagnosis of toothache can be challenging,[34]:80,81 not only because the list of potential causes is extensive, but also because dental pain may be extremely variable,[43]:975 and pain can be referred to and from the teeth. Dental pain can simulate virtually any facial pain syndrome.[43] However, the vast majority of toothache is caused by dental, rather than non-dental, sources.[9]:40 Consequently, the saying "horses, not zebras" has been applied to the differential diagnosis of orofacial pain. That is, everyday dental causes (such as pulpitis) should always be considered before unusual, non-dental causes (such as myocardial infarction). In the wider context of orofacial pain, all cases of orofacial pain may be considered as having a dental origin until proven otherwise.[43]:975 The diagnostic approach for toothache is generally carried out in the following sequence: history, followed by examination, and investigations. All this information is then collated and used to build a clinical picture, and a differential diagnosis can be carried out.

Symptoms[edit]

The chief complaint, and the onset of the complaint, are usually important in the diagnosis of toothache. For example, the key distinction between reversible and irreversible pulpitis is given in the history, such as pain following a stimulus in the former, and lingering pain following a stimulus and spontaneous pain in the latter. History is also important in recent filling or other dental treatment, and trauma to the teeth. Based on the most common causes of toothache (dentin hypersensitivity, periodontitis, and pulpitis), the key indicators become localization of the pain (whether the pain is perceived as originating in a specific tooth), thermal sensitivity, pain on biting, spontaneity of the pain, and factors that make the pain worse.[9]:50The various qualities of the toothache, such as the effect of biting and chewing on the pain, the effect of thermal stimuli, and the effect of the pain on sleep, are verbally established by the clinician, usually in a systematic fashion, such as using the Socrates pain assessment method (see table).[9]:2–9

From the history, indicators of pulpal, periodontal, a combination of both, or non-dental causes can be observed. Periodontal pain is frequently localized to a particular tooth, which is made much worse by biting on the tooth, sudden in onset, and associated with bleeding and pain when brushing. More than one factor may be involved in the toothache. For example, a pulpal abscess (which is typically severe, spontaneous and localized) can cause periapical periodontitis (which results in pain on biting). Cracked tooth syndrome may also cause a combination of symptoms. Lateral periodontitis (which is usually without any thermal sensitivity and sensitive to biting) can cause pulpitis and the tooth becomes sensitive to cold.[9]:2–9

Non-dental sources of pain often cause multiple teeth to hurt and have an epicenter that is either above or below the jaws. For instance, cardiac pain (which can make the bottom teeth hurt) usually radiates up from the chest and neck, and sinusitis (which can make the back top teeth hurt) is worsened by bending over.[9]:56,61 As all of these conditions may mimic toothache, it is possible that dental treatment, such as fillings, root canal treatment, or tooth extraction may be carried out unnecessarily by dentists in an attempt to relieve the individual's pain, and as a result the correct diagnosis is delayed. A hallmark is that there is no obvious dental cause, and signs and symptoms elsewhere in the body may be present. As migraines are typically present for many years, the diagnosis is easier to make. Often the character of the pain is the differentiator between dental and non-dental pain.[citation needed]

Irreversible pulpitis progresses to pulp necrosis, wherein the nerves are non-functional, and a pain-free period following the severe pain of irreversible pulpitis may be experienced. However, it is common for irreversible pulpitis to progress to apical periodontitis, including an acute apical abscess, without treatment. As irreversible pulpitis generates an apical abscess, the character of the toothache may simply change without any pain-free period. For instance, the pain becomes well localized, and biting on the tooth becomes painful. Hot drinks can make the tooth feel worse because they expand the gases and likewise, cold can make it feel better, thus some will sip cold water.[9][13]

Examination[edit]

The clinical examination narrows the source down to a specific tooth, teeth, or a non-dental cause. Clinical examination moves from the outside to the inside, and from the general to the specific. Outside of the mouth, the sinuses, muscles of the face and neck, the temporomandibular joints, and cervical lymph nodes are palpated for pain or swelling.[9]:9 In the mouth, the soft tissues of the gingiva, mucosa, tongue, and pharynx are examined for redness, swelling or deformity. Finally, the teeth are examined. Each tooth that may be painful is percussed (tapped), palpated at the base of the root, and probed with a dental explorer for dental caries and a periodontal probe for periodontitis, then wiggled for mobility.[9]:10

Sometimes the symptoms reported in the history are misleading and point the examiner to the wrong area of the mouth. For instance, sometimes people may mistake pain from pulpitis in a lower tooth as pain in the upper teeth, and vice versa. In other instances, the apparent examination findings may be misleading and lead to the wrong diagnosis and wrong treatment. Pus from a pericoronal abscess associated with a lower third molar may drain along the submucosal plane and discharge as a parulis over the roots of the teeth towards the front of the mouth (a "migratory abscess"). Another example is decay of the tooth root which is hidden from view below the gumline, giving the casual appearance of a sound tooth if careful periodontal examination is not carried out.[citation needed]

Factors indicating infection include movement of fluid in the tissues during palpation (fluctuance), swollen lymph nodes in the neck, and fever with an oral temperature more than 37.7 °C.[citation needed]

Investigations[edit]

Any tooth that is identified, in either the history of pain or base clinical exam, as a source for toothache may undergo further testing for vitality of the dental pulp, infection, fractures, or periodontitis. These tests may include:[9]:10–19

  • Pulp sensitivity tests, usually carried out with a cotton wool pledget sprayed with ethyl chloride to serve as a cold stimulus, or with an electric pulp tester. The air spray from a three-in-one syringe may also be used to demonstrate areas of dentin hypersensitivity. Heat tests can also be applied with hot Gutta-percha. A healthy tooth will feel the cold but the pain will be mild and disappear once the stimulus is removed. The accuracy of these tests has been reported as 86% for cold testing, 81% for electric pulp testing, and 71% for heat testing. Because of the lack of test sensitivity, a second symptom should be present or a positive test before making a diagnosis.
  • Radiographs utilized to find dental caries and bone loss laterally or at the apex.
  • Assessment of biting on individual teeth (which sometimes helps to localize the problem) or the separate cusps (may help to detect cracked cusp syndrome).

Less commonly used tests might include trans-illumination (to detect congestion of the maxillary sinus or to highlight a crack in a tooth), dyes (to help visualize a crack), a test cavity, selective anaesthesia and laser doppler flowmetry.

  • Pulp sensibility test using ethyl chloride (cold stimulus)

  • Plastic wedge to identify pain on biting from a fractured tooth

  • Transillumination demonstrating fracture

  • Decay (green) with apical abscess (blue)

  • Gutta-percha point indicating abscess origin

Differential diagnoses[edit]

ParameterDentin hypersensitivity[9]:36Reversible pulpitis[9]:36Irreversible pulpitis[9]:36–37Pulp necrosis[9]:37Apical periodontitis[9]:37–38Periodontal abscessPericoronitisMyofascial painMaxillary sinusitis
SitePoorly localizedPoorly localizedVariable; localized or diffuseNo painWell localizedUsually well localizedWell localized, associated with partially impacted toothDiffuse, often over many musclesBack teeth top jaw
OnsetGradualVariableVariableFrom pain of reversible pulpitis to no pain in daysGradual, typically follows weeks of thermal pain in toothSudden, no episode of thermal sensitivitySuddenVery slow; weeks to monthsSudden
CharacterSharp, quickly reversibleSharp, shootingDull, continuous pain. Can also be sharpNo painDull, continuous throbbing painDull, continuous throbbing painSharp, with continuous dullDull, achingDull, aching, occasional thermal sensitivity in back top teeth
RadiationDoes not cross midlineDoes not cross midlineDoes not cross midlineN/ADoes not cross midlineLittle, well localizedModerate, into jaw/neckExtensive, neck/templeModerate, into other facial sinus areas
Associated symptomsPatient may complain of receding gums and/or toothbrush abrasion cavitiesCan follow restorative dental work or traumaFollows period of pain that does not lingerFollows period of spontaneous painTooth may feel raised in socketMay follow report of something getting "stuck" in gumTooth eruption ("cutting") or impacted toothTension headaches, neck pain, periods of stress or episode of mouth open for long periodSymptoms of URTI
Time patternHypersensitivity as long as stimulus is applied; often worse in cold weatherPain as long as stimulus is appliedLingering pain to hot or cold or spontaneous painAbsence of pain following days or weeks of intense, well localized painPain on biting following constant dull, aching pain developmentDull ache with acute increase in pain when tooth is moved, minimal thermal sensitivityConstant dull ache without stimulusSpontaneous, worse with eating, chewing, or movement of jawSpontaneous, worse when head is tipped forward
Exacerbating and relieving factorsExacerbating: thermal, particularly coldExacerbating: thermal, sweetSimple analgesics have little effectProlonged heat may elicit painSame as irreversible pulpitis, or no response to cold, lingering pain to hot, pain with biting or lying downTapping tooth makes worse, cleansing area may improve pain
Natural history of dental caries and resultant toothache and odontogenic infection.
Apical abscess associated with roots of a lower molar.
An open contact of approximately 1.5 mm shown between two posterior teeth. The meat, at right, was recovered from the open contact more than 8 hours after the person had last eaten meat, even though they had brushed the teeth twice since.
Lateral periodontal abscess (blue arrows) due to a fracture (green arrows)
Mild presentation of ANUG on the gums of the lower front teeth

Clinical & xray correlation of pericoronitis

An operculum (green arrow) over a partially erupted lower left third molar tooth. There is minimal inflammation and recurrent swelling.

A radiograph of the above tooth showing chronic pericoronitis, operculum (blue arrow) and bone destruction (red arrow) from chronic inflammation. Tooth is slightly disto-angular.

Crown-root fracture with pulp involvement (left). Extracted (right).
Discomfort caused by coronary artery disease can radiate to the neck, lower jaw and teeth

1: crown, 2: root, 3: enamel, 4: dentin and dentin tubules, 5: pulp chamber, 6: blood vessels and nerve within root canal, 7: periodontal ligament, 8: apex and periapical region, 9: alveolar bone.

Dentin-pulp complex. 1: tooth/enamel, 2: dentin tubule, 3: dentin, 4: odontoblastic process, 5: predentin, 6: odontoblast, 7: capillaries, 8: fibroblasts, 9: nerve, 10: artery/vein, 11: cell-rich zone, 12: cell-poor zone, 13: pulp chamber.

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