Differential diagnosis of toothache to prevent erroneous and unnecessary dental treatment

Toothache represents the most common example of oro-facial pain. Its origin is mostly odontogenic, but several other conditions may mimic dental pain or present themselves as such. Well-known examples are myofascial pain, trigeminal neuropathies like neuralgia and painful post-traumatic trigeminal neuropathic pain, oro-facial neurovascular pains, cardiac pain and sinus disease. This review first discusses the current knowledge on the underlying pathophysiology of heterotopic tooth pain. Afterwards, several conditions potentially presenting as toothache will be illustrated regarding clinical features, diagnosis and management.     

Interindividual differences in the perception of dental stimulation and related brain activity

For identical diagnoses in the trigeminal innervation territory, individual differences have been clinically observed among the symptoms reported, such as dysesthesia and pain. Different subjective perceptions of unpleasantness and pain intensity may have different cortical substrates. The aim of this study was to identify brain areas in which activation depends on the subjective perception (intensity and unpleasantness) of electric dental stimulation. Electrical stimuli of increasing intensity were applied to maxillary canines in 14 healthy volunteers. Ratings for stimulus intensity and unpleasantness perceived across the stimulation session were reported postscan on 11-point numerical scales. The rating values were then included as covariates in the functional magnetic resonance imaging (fMRI) group analysis. Interindividual differences of intensity ratings were reflected in differential activity of the following brain areas: superior parietal lobule, superior temporal gyrus/anterior insula, inferior and middle temporal gyrus, lingual gyrus, anterior cingulate, and caudate nucleus. Differences related to unpleasantness ratings were reflected in the lingual gyrus. In conclusion, differences of perceived intensity between individuals are reflected in the differential activity of a set of brain areas distinct from those regions, reflecting rating differences of unpleasantness.     

Anxiety about dental hygienist treatment

Abstract – Although dental anxiety is a well investigated phenomenon in dental health care, remarkably little is known about anxiety reactions related to treatment carried out by the dental hygienist. In the present study anxiety reactions were measured among 101 patients attending the dental hygienist. General level of anxiety was assessed through the PAQ (Photo Anxiety Questionnaire; S touthard , D e J ongh & H oogstraten , 1991), whereas an additional questionnaire was used to obtain information about specific stimuli and situations that might provoke anxiety in the dental hygienist situation. The results indicated that during dental hygienist treatment only 15% of the patients experienced no feelings of anxiety. Another 15% of the patients reported that a visit to the dental hygienist was more distressing than dental treatment. The level of anxiety appeared to be strongly related to a number of stimuli and situations, with actual pain (78%) and expected pain (67%) major anxiety provoking factors. The relation between pain and anxiety was highly significant, with highly anxious patients having more fear for pain than their low anxious counterparts. Also feelings and sounds of instruments, patient's helplessness and perceived lack of control over what happens were identified as important contributors to anxiety for the dental hygienist treatment. The results of this study suggests that treatment by the dental hygienist is a distressing event for many patients.     

Associations between dental anxiety,dental treatment due to toothache,and missed dental appointments among six to eight-year-old Danish children: a cross-sectional study

The aims of this study were to estimate the prevalence of missed dental appointments among Danish children at 6 to 8 years of age and to examine the association between dental anxiety, dental treatment due to toothache, and missed dental appointments in a population-based cross-sectional study. The study was conducted in four municipalities in the County of North Jutland, Denmark, and included a total of 1235 children (response rate 74.1%). Data on missed dental appointments and toothache were obtained from dental records, and data on dental anxiety from the Children's Fear Survey Schedule–Dental Subscale. Overall, 37.7% of children missed one or more dental appointments, while 17.7% missed two or more appointments. These proportions did not differ by age or gender. Among children with dental anxiety, the adjusted OR for an association with two or more missed dental appointments was 1.32 (95% CI: 0.72–2.40), and among children who had dental treatment due to toothache, the adjusted OR of two or more missed dental appointments was 2.61 (95% CI: 1.63–4.18).     

Catastrophizing, anxiety and pain during dental hygiene treatment

Objectives : This study examined the relations between catastrophizing, dental anxiety, and pain during dental hygiene treatment. Methods: Participants were 78 (32 men, 46 women) consecutive referrals to the Dalhousie University Dental Clinic. All patients were scheduled for a scaling procedure performed by senior dental hygiene students. Following treatment, patients completed the Pain Catastrophizing Scale and the Dental Anxiety Scale – Revised, and were asked to rate the degree of pain they experienced during the scaling procedure. Results: Regression analyses revealed that age and the rumination subscale of the Pain Catastrophizing Scale were signicant predictors of pain, even when controlling for gender, and oral hygiene status. Conclusions: Thendings suggest that excessive focus on pain sensations may be one of the mechanisms by which catastrophizing leads to increased pain. The clinical challenges will be to develop cost- and time-effective means of identifying individuals who catastrophize and to implement interventions to reduce their level of distress.     

Dental caries experience and prevalence of children afraid of dental treatment

The aim of this study was to examine the clinical outcome with regard to dental caries of high self reported dental anxiety in a group of Scottish secondary schoolchildren. 1103 children participated in the study, mean age 14 yr (sd 0.35 yr), and the prevalence of high dental anxiety was 7.1% (95% CI = 5.6%, 8.6%). When these children were compared with their contemporaries their DMFT and all its components were higher but only the mean MT reached statistical significance after adjusting for gender and social class. Children with a high dental anxiety were 62% more likely to have at least 1 missing tooth due to caries. In addition this group when compared to the rest of the study population, had a significantly lower mean number of teeth fissure sealed and a lower proportion of children with sealants. No similar trend was obvious for children who had a high general fear. The dentally anxious more accurately perceived their treatment need and were more likely to defer, cancel or not turn up for dental appointments.     

笑气镇静在儿童牙科焦虑症患者的临床应用

目的:评价笑气吸入对儿童牙科焦虑症患者治疗中的镇静效果。方法:随机选择3～12岁因对牙科恐惧抗拒治疗的患儿138人,给予全程笑气吸入进行治疗的方式,采用自身对照,记录术前术后的镇静情况。观察患儿对治疗的依从性及对治疗的反应。结果:在138例中107位患儿在笑气镇静下顺利完成治疗,31例失败,患儿在术前后治疗依从性和术后反应方面有显著性差异。结论:笑气镇静可以有效提高患儿对牙科治疗的依从性和舒适度。     

Influence of posterior dental arch length on brain activity during chewing in patients with mandibular distal extension removable partial dentures

It is well known that shortened dental arch decreases masticatory function. However, its potential to change brain activity during mastication is unknown. The present study investigates the effect of a shortened posterior dental arch with mandibular removable partial dentures (RPDs) on brain activity during gum chewing. Eleven subjects with missing mandibular molars (mean age, 66·1 years) on both sides received experimental RPDs with interchangeable artificial molars in a crossover trial design. Brain activity during gum chewing with RPDs containing (full dental arch) and lacking artificial molars (shortened dental arch) was measured using functional magnetic resonance imaging. Additionally, masticatory function was evaluated for each dental arch type. Food comminuting and mixing ability and the perceived chewing ability were significantly lower in subjects with a shortened dental arch than those with a full dental arch (P < 0·05). Brain activation during gum chewing with the full dental arch occurred in the middle frontal gyrus, primary sensorimotor cortex extending to the pre‐central gyrus, supplementary motor area, putamen, insula and cerebellum. However, middle frontal gyrus activation was not observed during gum chewing with the shortened dental arch. These results suggest that shortened dental arch affects human brain activity in the middle frontal gyrus during gum chewing, and the decreased middle frontal gyrus activation may be associated with decreased masticatory function.     

Brain responses to stimuli mimicking dental treatment among non‐phobic individuals: A meta‐analysis

Numerous neuroimaging studies have attempted to identify how the brain responds to stimuli mimicking dental treatment in normal non‐phobic individuals. However, results were sometimes inconsistent due to small sample sizes and methodological variations. This meta‐analysis employs standardized procedures to summarize data from previous studies to identify brain regions that were consistently activated across studies, elicited by stimuli such as pictures, sounds, or audiovisual footage mimicking those encountered during dental treatments. A systematic literature search was carried out using PubMed and Scopus. The meta‐analysis analyzed data from 120 healthy subjects from seven neuroimaging studies. We assessed the risk of bias among the included studies with the Risk of Bias Assessment Tool for Nonrandomized Studies. One study appeared to have a high risk of selection bias, whereas the others were considered to have a low risk of bias. Results revealed three clusters of activation with cluster sizes ranging from 768 mm³ to 1,424 mm³. Stimuli mimicking dental treatment consistently activated the bilateral anterior insula; right dorsal anterior cingulate, putamen, and medial prefrontal cortex; and left claustrum. This study confirmed that audio and/or visual stimuli mimicking dental treatment consistently activated the fear‐related brain regions among healthy subjects, mostly consistent with activations from general anxiety but without the involvement of the amygdala.     

根管治疗患者牙科恐惧症的调查分析

目的探讨减轻根管治疗中牙科恐惧（DA）的方法。方法将360名牙髓炎患者分为三组,每组120名。A组患者为口头与书面告知根管治疗内容,B组患者书面告知同时进行心理沟通,C组患者进行书面告知、心理沟通并辅以必兰局部麻醉。采用改良牙科焦虑量表（MDAS）测量三组患者不同治疗时期DA水平的变化,并用视觉模拟量表（VAS）评估三组患者对根管预备的恐惧程度,对根管治疗前后测量数据进行统计学分析。结果随着就诊次数的增加,三组患者的DA值均逐渐下降,其中以C组下降最为明显,其次为B组。同一组内治疗前后DA值均有显著性差异（P<0.01）。三组患者根管预备前的DA值及VAS评估结果也具有显著性差异（P<0.05）。结论心理沟通与麻醉同时应用可显著降低根管治疗中的牙科恐惧。     

Psychological factors and perceptions of pain associated with dental treatment

Although pain during dental treatment has been identified as playing a major role in the onset of dental anxiety and is a major concern of patients when seeking dental care, there have been very few studies of the prevalence of pain during dental treatment and the factors associated with patients' perceptions of pain. This study used data from a longitudinal population-based study to assess the proportion of dental attenders who experienced pain while having dental treatment and the psychological characteristics which predisposed them to experience pain. Of 1422 subjects who completed questionnaires at baseline and five-year follow-up, 96.4% had visited a dentist over the observation period. Two fifths, 42.5%, reported having pain during treatment and one-fifth, 19.1%, had pain that was moderate to severe in intensity. Reports of pain were associated with the types of treatment received, and a number of baseline sociodemographic and psychological factors. In a logistic regression analysis predicting the probability of pain, a variable documenting the number of types of invasive treatment received (restorations, extractions, crowns/bridges, root canal therapy and periodontal treatment/surgery) had the strongest independent effect. Pain was also more likely to be reported by those with previous painful experiences and those who were anxious about dental treatment, expected treatment to be painful and felt that they had little control over the treatment process. Pain was less likely to be reported by those who said they were unwilling to accept or tolerate pain. Younger subjects and those with higher levels of education were more likely to report pain than older subjects and those with a lower educational level. These results indicate that pain is as much a cognitive and emotional construct as a physiological experience. They also have implications for dentists' behaviour when providing dental care.     

Symptoms of depression and anxiety in relation to dental health behavior and self-perceived dental treatment need

The purpose of this study was to investigate the dental health behavior and self-perceived dental treatment need, in relation to depressive symptoms and symptoms of anxiety, among a general population drawn from a sample of 31-yr-old-men and women born in Northern Finland in 1966 (n = 8463). The dental health behavior included toothbrushing frequency and the frequency of dental check-ups. Depressive symptoms, as well as symptoms of anxiety, were determined on the basis of the Symptom Checklist-25 (SCL-25). The participants were also asked about their education and family income. Subjects with a high number of depressive symptoms had lower toothbrushing frequency as well as a lower frequency of dental visits than subjects with no or only a few depressive symptoms. Morover, the self-perceived dental treatment need was more common among those with a high number of depressive symptoms. Symptoms of anxiety were significantly associated with lower toothbrushing frequency. The results support the view that there is an increased risk for impaired dental health among subjects with depressive symptoms or symptoms of anxiety.     

Behavioural science in dentistry. The role of the dental hygienist in prevention and treatment of the fearful dental patient

The prevalence of dental anxiety in the general population seems to be fairly stable, and the incidence is not reduced in spite of more modern treatment methods. Intensive fear often leads to avoidance of care and consequences like poor oral health, psychosocial problems and reduced quality of life. The aetiology of dental anxiety is complex, but is often associated with direct traumatic dental experiences during childhood. These negative experiences are reported as painful/unpleasant and are influenced by the patient's perception of lack of coping and control. The theory of latent inhibition indicates that several positive dental appointments before any invasive or painful treatment sessions may act as a barrier to these perceptions of lack of coping. This paper is presenting a short overview of behavioural science in dentistry and discussing the role of the dental hygienists as potential key personnel in prevention and treatment of dental anxiety.     

'Making dental care possible: a mutual affair': a grounded theory relating to adult patients with dental fear and regular dental treatment

Dental fear is a common and widespread problem, which can cause severe stress. Even so, most patients with dental fear undergo regular dental treatment in spite of their fear and many enjoy good oral health. The aim of this study was to obtain a deeper understanding of how patients with dental fear manage to undergo dental treatment. Fourteen patients with dental fear, who undergo regular dental care, were interviewed. Qualitative analysis of the transcribed interviews was performed according to the principles of grounded theory. A conceptual framework was generated, and the main concern was identified as 'making dental care possible - a mutual affair'. Four additional categories explained how patients handled their dental fear and how dental care became possible. The strategies were labelled 'taking part in a mental wrestling match', 'trust-filled interaction with dental staff', 'striving for control' and 'seeking and/or receiving social support'. The results showed that making dental care possible for patients with dental fear is a mutual challenge that requires interplay between dental staff and patients, involving verbal and non-verbal communication reflecting respect, attention, and empathy. Moreover, a balance between nearness and distance and between professional and personal treatment is required.     

口腔内热水刺激反应的功能性磁共振成像研究

目的:探讨口腔热水刺激时的大脑皮层区域定位.方法:选取13名口腔状况健康的右利手志愿者,56℃热水刺激口腔,并以室温水作为对照.采用口腔热刺激过程(热刺激信号减静息信号)的组块设计方法,采集 .功能性磁共振成像扫描数据并用SPM99软件包进行结果的数据分析.结果:组分析结果显示激活区:左侧丘脑(-6,-11,17)...     

Nuclear Magnetic Resonance Imaging in Endodontics: A Review

Introduction

This review analyzes the increasing role of magnetic resonance imaging (MRI) in dentistry and its relevance in endodontics. Limits and new strategies to develop MRI protocols for endodontic purposes are reported and discussed.

Efficacy of dental implants placed into fibula-free flaps for orofacial reconstruction

OBJECTIVES: The transfer of the osseofasciocutaneus fibula-free flap has become a routine procedure in the reconstruction of comprehensive orofacial defects. Besides its length, major advantages of the fibula-free flap include the trigonal diameter of the fibular bone, which usually allows the placement of dental implants. PATIENTS AND METHODS: In a prospective study, 16 consecutive patients who received free fibula grafts and in total 51 dental implants between 1999 and 2001 were examined. All implants were inserted secondary after bone grafting and loaded after 3 months of submerged healing. The observation period extended 2.5 years on average. The implant success was controlled clinically, radiographically and by resonance frequency analysis. RESULTS: One implant that was located at the interface between the fibula graft and the mandible was lost due to dehiscence and local infection during the healing period. In two other patients, one implant had to remain unexposed as 'sleeper' due to an unfavourable soft tissue situation. The success rate calculated by Kaplan-Meier analysis was 96.1% after an observation period of 1400 days. Resonance frequency analysis (ISQ-values) revealed significant differences related to the orientation (vestibulo-oral/mesio-distal; vo/md) of the transducer unit (P < 0.01). In general, a high primary stability for implants placed in free fibula grafts could be achieved (vo/md 66/74.1), which on average increased slightly during the healing period (vo/md 67.4/75.4) and within 12 month of functional loading (vo/md 72.1/79.9). Additional augmentation with iliac bone grafts or reconstructions with a double barred fibula resulted in an improved reconstruction of the alveolar process, thus allowing superior individual implant positions or angulations, but no elevation of the ISQ-values. CONCLUSION: The fibula-free flap provides a consistent bone graft that allows a reliable and predictable restoration with dental implants.