Dental pain. Physiology and progression....

Periapical Abcess

       In India one of the most common reason a person seeks dental consult is PAIN!!! An aching tooth will never let you live your day to day routine in peace. We all agree to this fact. Most people manage their pain by popping over the counter pain killers, commonly paracetamol or a combination of paracetamol and ibuprofen. The pain is manged by the person does not understand what is at stake. Due to chronic consumption of pain medication, may lead to drug-induced liver cirrhosis. At the same time the tooth that is creating annoyance is dying. Initially when one experiences pain in the tooth on consumption of cold or sweet food substances, do not ignore!!! It is your tooth that is signalling you to seek professional help. This phase of acute pain is what is known as acute pulpitis
.     The word 'pulpitis' is we break it up in two parts, 'pulp'- dental pulp which is a bundle of blood vessels and nerve fibers and the other half 'itis'- inflammation. The pain is caused due to inflammation of pulp tissue leading to an increased pressure in the root canal.
      The tooth is made up of enamel which forms the outer layer, dentin which is between enamel and pulp tissue.

        Due to accumulation of food/plaque on the tooth or in deep fissures, the micro-organisms tend to dwell and digest carbohydrates. The waste product produced by the micro-organisms is acid. Enamel is mostly made of inorganic substance. Initially, the acid dissolves the superficial layer of enamel leaving a rough surface topography behind. The rough surface accumulates more food particles increasing the microbial load in that area leading to greater amount acid production which in turn further attacks the enamel surface. As this process continues, greater loss of enamel leads to exposure of the dentin layer of the tooth.
      Unlike enamel, the mineral content of dentin is much less and also has a proportional quantity of organic substance rendering it to be more week in resisting the acids. Structurally dentin is made of fine tubules called as dentinal tubules. These tubules contain fluid called as dentinal fluid. The dentinal tubules are connected to enamel on top and the dental pulp in the bottom. The end at which the dental communicates with the pulp contain fine extensions of nerve fibers and odontoblasts. When the dentin is exposed to noxious elements (cold, sweet, hot, etc), the dentinal fluid in the dentinal tubules moves disturbing the nerve fibers entering the dentinal tubules at the pulp end. Due to this the odontoblasts move causing an impulse in the nerve fibers and  generating a senstion of sensitivity/ pain. The pain lasts till the noxious stimuli is present and wears off

This phase of sensitivity/ pain is known as acute pulpitis. Usually this phase may ware off or decrease in intensity due to closing of the dentinal tubules. Some people consume pain medication, use desensitizing pastes and wise ones visit their dentist for tooth restoration.

The process of demineralization continues for the dentin if the tooth is not restored. Eventually the pulp starts to receive noxious stimuli of greater intensity resulting in increased inflammation. The inflammation results in increased pressure in the root canal. This increased pressure may result in obliteration of blood vessels resulting in stasis of blood flow. The root apex of the tooth is  has a narrow opening for the bundle of blood vessels and nerve fibers to enter the root canal. Due to narrow exit point at the apex for the increased pressure in the root canal due to inflammation of the pulp, the pain is intensified and necrosis of the pulpal tissue initiates.

During this time, a person will experience episodes of pain that last for longer duration even after the noxious stimuli is removed. Some may experience relief on contact with cold substances. But the common symptom is continues pain, pain during sleeping, pain when performing vigorous activities. Along with prolonged duration, the pain is of throbbing/ pulsating type that distinguishes from acute pulpitis. If the symptoms persists, the condition is known are Chronic Pulpitis.
If the condition is not treated at this stage, the dental pulp results in necrosis. A necrosed pulp harbors micro-organisms resulting in infection. The infection starts to spread beyond the root apex forming a abscess. The above mentioned condition is experienced by children as well as adults..