What are the causes of Chest Pain?

What are the causes of chest pain?

Chest pain is one of the most common complaints that will bring a patient to the Emergency Department. Seeking immediate care may be lifesaving, and considerable public education has been undertaken to get patients to access medical care when chest pain strikes. While the patient may be worried about a heart attack, there are many other causes of pain in the chest that the healthcare provider will need to consider. Some diagnoses are life threatening, while others are less dangerous.

Deciding the cause of chest pain is sometimes very difficult and may require blood tests, x-rays, CT scans and other tests to sort out the diagnosis. Often though, a careful history taken by the healthcare provider may be all that is needed to find the answer.

Destruction of enamel

Destruction of enamel

The high mineral content of enamel, which makes this tissue the hardest in the human body, also makes it susceptible to a demineralization process which often occurs as dental caries, otherwise known as cavities.[16] Demineralization occurs for several reasons, but the most important cause of tooth decay is the ingestion of sugars. Tooth cavities are caused when acids dissolve tooth enamel:

Ca10(PO4)6(OH)2(s) + 8H+(aq) → 10Ca2+(aq) + 6HPO42-(aq) + 2H2O(l)

Sugars from candies, soft drinks, and even fruit juices play a significant role in tooth decay, and consequently in enamel destruction. The mouth contains a great number and variety of bacteria, and when sucrose, the most common of sugars, coats the surface of the mouth, some intraoral bacteria interact with it and form lactic acid, which decreases the pH in the mouth.Then, the hydroxylapatite crystals of enamel demineralize, allowing for greater bacterial invasion deeper into the tooth. The most important bacterium involved with tooth decay is Streptococcus mutans, but the number and type of bacteria varies with the progress of tooth destruction.

Furthermore, tooth morphology dictates that the most common site for the initiation of dental caries is in the deep grooves, pits, and fissures of enamel. This is expected because these locations are impossible to reach with a toothbrush and allow for bacteria to reside there. When demineralization of enamel occurs, a dentist can use a sharp instrument, such as a dental explorer, and "feel a stick" at the location of the decay. As enamel continues to become less mineralized and is unable to prevent the encroachment of bacteria, the underlying dentin becomes affected as well. When dentin, which normally supports enamel, is destroyed by a physiologic condition or by decay, enamel is unable to compensate for its brittleness and breaks away from the tooth easily.

The extent to which tooth decay is likely, known as cariogenicity, depends on factors such as how long the sugar remains in the mouth. Contrary to common belief, it is not the amount of sugar ingested but the frequency of sugar ingestion that is the most important factor in the causation of tooth decay.[28] When the pH in the mouth initially decreases from the ingestion of sugars, the enamel is demineralized and left vulnerable for about 30 minutes. Eating a greater quantity of sugar in one sitting does not increase the time of demineralization. Similarly, eating a lesser quantity of sugar in one sitting does not decrease the time of demineralization. Thus, eating a great quantity of sugar at one time in the day is less detrimental than is a very small quantity ingested in many intervals throughout the day. For example, in terms of oral health, it is better to eat a single dessert at dinner time than to snack on a bag of candy throughout the day.

In addition to bacterial invasion, enamel is also susceptible to other destructive forces. Bruxism, also known as clenching of or grinding on teeth, destroys enamel very quickly. The wear rate of enamel, called attrition, is 8 micrometers a year from normal factors. A common misconception is that enamel wears away mostly from chewing, but actually teeth rarely touch during chewing. Furthermore, normal tooth contact is compensated physiologically by the periodontal ligaments (pdl) and the arrangement of dental occlusion. The truly destructive forces are the parafunctional movements, as found in bruxism, which can cause irreversible damage to the enamel.

Other nonbacterial processes of enamel destruction include abrasion (involving foreign elements, such as toothbrushes), erosion (involving chemical processes, such as lemon juice), and possibly abfraction (involving compressive and tensile forces).

Though enamel is described as tough, it has a similar brittleness to glass making it unlike other natural crack-resistant laminate structures such as shell and nacre potentially vulnerable to fracture. In spite of this it can withstand the bite forces as high as 1,000 N many times a day during chewing. This resistance is due in part to the microstructure of enamel which contains processes, enamel tufts, that stabilize the growth of such fractures at the dentinoenamel junction.The configuration of the tooth also acts to reduce the tensile stresses that cause fractures during biting.

Diagnostic caries dentis

Diagnostic Methods
The EPC team evaluated the strength of the evidence describing the performance of diagnostic methods separately for cavitated lesions, lesions involving dentin, enamel lesions, and any lesions. They also separated the evaluations by the surface and tooth type involved. The team found 39 studies reporting 126 histologically validated assessments of diagnostic methods.

* There are few assessments of the performance of any diagnostic methods for primary or anterior teeth, and no assessments of performance on root surfaces. The strength of the evidence describing the performance of any diagnostic method for these teeth and surfaces is poor.
* Among studies assessing diagnostic performance for proximal and occlusal surfaces in posterior teeth, the team rated the strength of the evidence describing the performance of visual/tactile, fiberoptic transillumination (FOTI), and laser fluorescence methods as poor due to the small numbers of studies available.
* They also rated the strength of the evidence for radiographic, visual, and electrical conductance (EC) methods as poor for all types of lesions on posterior proximal and occlusal surfaces. However, these ratings were due less to inadequate numbers of assessments than to variation among reported results. In one instance, the quality of the available studies was the principal reason for the rating.
* For all but EC assessments, specificity of a diagnostic method was generally higher than sensitivity. Thus, false negative diagnoses are proportionally more apt to occur in the presence of disease than are false positive diagnoses in the absence of disease.
* The evidence did not support the superiority of either visual or visual/tactile methods. The number of available assessments was small and there was substantial variation among reports for each method.
* The evidence suggests, but is not conclusive, that some digital radiographic methods offer small gains in sensitivity compared to conventional film radiography on both proximal and occlusal surfaces.
* The evidence also suggests, but is not conclusive, that EC methods may offer heightened sensitivity on occlusal surfaces, but at the expense of specificity.
* The diagnostic performance literature is limited in terms of numbers of available assessments for most diagnostic techniques overall, and especially for primary teeth, anterior teeth and root surfaces, and for visual/tactile and FOTI methods. The literature is further limited by threats to both internal and external validity represented by incomplete descriptions of selection and diagnostic criteria and examiner reliability, the use of small numbers of examiners, nonrepresentative teeth, samples with high lesion prevalence, and a variety of reference standards of unknown reliability.

Management of Noncavitated Carious Lesions