The diagnosis of<unk>  can be challenging, not only because the list of potential causes is extensive, but also because dental pain may be extremely variable, and pain can be referred to and from the teeth. Dental pain can simulate virtually any facial pain syndrome. However, the vast majority of<unk>  is caused by dental, rather than non-dental, sources. 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. The diagnostic approach for<unk>  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 The chief complaint, and the onset of the complaint, are usually important in the diagnosis of<unk> . 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<unk>  (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.The various qualities of the<unk> , 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). 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<unk> . 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. 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. As all of these conditions may mimic<unk> , 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. 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<unk>  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. Examination 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. 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. 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. 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. Investigations Any tooth that is identified, in either the history of pain or base clinical exam, as a source for<unk>  may undergo further testing for vitality of the dental pulp, infection, fractures, or periodontitis. These tests may include: * 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. File:Cold test with ethyl chloride.Pulp sensibility test using ethyl chloride (cold stimulus) File:Electric-pulp-testing.Electric pulp tester File:Tooth sleuth.Plastic wedge to identify pain on biting from a fractured tooth File:Transillumination of tooth marked.Transillumination demonstrating fracture File:Tooth decay and abscess xray.Decay (green) with apical abscess (blue) File:Sinugram abscessed tooth.Gutta-percha point indicating abscess origin Establishing a diagnosis of nondental<unk>  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<unk>  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. Differential diagnoses Parameter Dentin hypersensitivity Reversible pulpitis Irreversible pulpitis Pulp necrosis Apical periodontitis Periodontal abscess Pericoronitis Myofascial pain Maxillary sinusitis Site Poorly localized Poorly localized Variable; localized or diffuse No pain Well localized Usually well localized Well localized, associated with partially impacted tooth Diffuse, often over many muscles Back teeth top jaw Onset Gradual Variable Variable From pain of reversible pulpitis to no pain in days Gradual, typically follows weeks of thermal pain in tooth Sudden, no episode of thermal sensitivity Sudden Very slow; weeks to months Sudden Character Sharp, quickly reversible Sharp, shooting Dull, continuous pain. Can also be sharp No pain Dull, continuous throbbing pain Dull, continuous throbbing pain Sharp, with continuous dull Dull, aching Dull, aching, occasional thermal sensitivity in back top teeth Radiation Does not cross midline Does not cross midline Does not cross midline N/A Does not cross midline Little, well localized Moderate, into
Toothache
Impacted wisdom teeth
Headache
Tinnitus
Nausea
Dysuria
Dizziness
Weather pains