Tooth Pain

The first step in the diagnosis of tooth pain is to determine whether the pain is of odontogenic origin (caused by tooth).  This is accomplished by the combination of clinical and radiographic examinations. Cone-beam computed tomography is a useful tool for locating periapical lesions, fractures, missed root canal therapy. If the pain appears to be nonodontogenic in origin e.g., neuropathic, sinusitis, neurovascular, psychogenic, and malignancy, the patients should be referred to an orofacial pain specialists, neurologists, otorhinolaryngologists for additional assessment.

Tooth pain from dental decay is the most common complaint in odontogenic origin. Tooth pain can be described in a specific way:
  • mild
  • moderate
  • severe
  • acute
  • chronic
  • sharp shooting
  • burning
  • aching
  • dull
  • throbbing
Tooth pain derives from: 
  1. An exposed nerve caused by tooth decay
  2. Infection at the root tip due to decay
  3. Periodontal ligament due to periodontal disease
  4. Other regions such as TMJ, muscle, referred pain
  5. Tooth with recent composite fillings
  6. Filling in deep dental decay
  7. Tooth extracted wound
  8. Cracked or broken tooth
  9. Recent root canal treatment
  10. Tooth eruption
  11. Impacted tooth
  12. Dry socket after tooth extraction
In general, tooth pain refers to pain that arises from dental decay, gums, jaw bone or TMJ.  A visual examination from the dentist combine with an x-ray often can determine where the tooth pain originated.  Sometimes tooth pain originated from other parts e.g., ears and sinus. Therefore, it is necessary to evaluate the problem with a physician as well.

Dental cavity if left untreated, the cavity will penetrate the dentin, the second layer of tooth structure, which may cause sensitivity and pain in some cases. Once the cavity penetrates pulp chamber; the center of the tooth, infection begins. At this stage, the only way to save the tooth is through root canal treatment.  See illustrations (click to enlarge).


Diagnosis of tooth pain

The simple and accurate way to find which tooth is responsible for pain is through sequential stimulus challenge tests.  The test begins by application of stimulus that initiated pain according to the patient's complaint to each tooth, one at a time. The most often stimuli are bite down pressure, heat, and cold. For example; if a patient complains about sensitive or pain when biting, the dentist will tap or put pressure on each tooth;  if a patient complains about sensitive or pain when drinks cold beverages, the dentist will apply cold stimulus.

Sharp constant or intermittent pain, or more pain during biting on a certain position or tapping on the tooth, cannot provide location

Possible causes are:
  • Inflammation of ligament from supraocclusion (a condition in which a tooth extends beyond the occlusal plane) due to new crown, new filling, or localized periodontitis
  • Cracked tooth
  • Acute (severe, rapid onset and short)or subacute (between acute and chronic) due to Pulpitis (inflammation of dental pulp - nerves and blood vessels)
  • Sinusitis may be mistaken for tooth pain in upper molars and pre-molars (referred pain)
In vital cracked tooth in which the nerve has not been affected, a sharp and intense pain of short duration during chewing and releasing of food or biting at a certain position and pain subsides on its own - this is a reversible pulpitis, the pulp may recover spontaneously: it is usually asymptomatic until provoked by some external stimuli (hot, cold, percussion, pressure, or sweet), once the irritant is eliminated, the pulp will return to its normal, healthy state.

When the crack reaches pulp chamber, pulp tissue will be infected, even though the pulp is still alive at a time, the nerve becomes sensitive to temperature changes (hot and cold but sometimes cold may provide relief). Lingering pain even after the stimuli has been removed. The invaded bacteria prevent pulp tissues to heal, resulting in pulp necrosis - this is a irreversible pulpitis, the pulp can not recover from the damage and becomes dead.

Treatment: root canal treatment or extraction.

In non-vital cracked tooth, the pain is vague and the location is difficult to locate until the surrounding structures (ligament, bone and the gums) are involved. Symptom may include tooth tenderness.

When a crack increases in depth, a tooth will fracture; either at the crown or the root, and the pain becomes intensified. The key to treat cracked tooth is early diagnosis. At early stage, the crack is not easy to see and too small to be seen on x-ray, additional tools below seem to be helpful in identify the problem tooth.

Tools used to detect cracked tooth are:
  1. Intra-oral camera - cracked line will be magnified on the screen
  2. Microscopes - high magnify glasses
  3. Fiber optic light
  4. Explorer - a sharp instrument to feel cracked line; difficult to feel a small crack.
  5. Bite stick - use the stick to replicate the symptom, simple procedure but may cause pain and make the symptom worse
  6. Stain 
  7. Hot and cold stimulus
Treatments for non-vital cracked tooth are crown, root canal therapy, or extraction.

More information about cracked tooth can be found here
Dull pain with pressure in upper teeth around sinus areas

Possible cause: the cause can be difficult to determine, it may come from tooth or from sinus since they share the same nerves.  Sinus congestion from flu or cold can cause pain in the upper back teeth and vice versa. Clenching and grinding teeth can also have the same symptom.  Oral examination and patient medical history will assist in proper diagnosis.

Severe pain that varies from continuous throbbing pain to less severe and intermittent attacks.  The severity of pain increase while lying down or change of temperature (hot or cold foods). When use electric pulp tester; the tooth responds at lower levels than normal tooth.

Possible cause if the pain originated from tooth:
  • Deep decay that exposed the nerves or extensive fillings
  • Injury or trauma to the tooth
  • Excessive heat production and dehydration during tooth preparation. 
  • Chemical injury to the exposed dentin
Treatment: pulp capping, root canal therapy or extraction.

Acute constant severe pain or dull aching pain, sensitivity to heat and cold is less striking than in acute pulpitis, and swelling of the gums is sometimes visible. Gum tissue is sensitive to touch.  When use electric pulp tester; the tooth responds at higher levels than normal tooth.This is chronic pulpitis.

Possible cause: the tooth may have abscess at the root tip or around the gums.
Treatment :  If the tooth is the cause of pain: root canal therapy or extraction
                   If the gum is the cause of pain: deep cleaning and other periodontal therapies may be required.

Pain at high altitude as in flights (symptom can be a few hours or days later).  The pain called " Aerodontalgia". This condition occurs in teeth with subclinical pulpitis.

Treatment: root canal therapy, extraction.

Temporary pain reliever at home

1) Clove oil
Place cotton pellet soaked in oil of clove to the exposed area and cover with temporary filling only if there is no pus forms at the root tip.  If there is pus on the root tip, leave the cavity open for drainage.

Clove oil is a natural product that has been used to relieve dental pain for long time, it is available over-the-counter. Avoid contacting the tongue, soft tissue during application; it can burn and has bad taste.

2) Over-the-counter pain pills (work best at the first signs of pain)
  • Moderate pain and inflammation: NSAIDs (Non steroid anti-inflammatory drug), ibuprofen (Advil, Motrin), and other brand names, Aspirin. 
    Dose: take it with food, 400 mg every 4-6 hours, not to exceed 1200 mg, unless under the care of physician, the maximum dose can be 3200 mg.
    Side effects: gastrointestinal ulceration / bleeding, nausea, headache, dizziness, hypertension.  At lower dose Iboprofen have the lowest incidence of digestive adverse drug reaction compare to other NSAID.  Compare to Acetaminophen, NSAID's provide better result in tooth pain relief at lower doses. Ibuprofen and aspirin are platelet inhibitor, high dose can cause the wound to bleed.
  • Mild to moderate pain: Acetaminophen (Paracetamol), brand name-Tylenol and Panadol, provides fast pain reliever and anti-pyretic effect but with little anti-inflammatory action. Acetaminophen can provide an alternative for patient that cannot take NSAIDs or aspirin.

    Dose: 325-650 mg every 4-6 hours. 

    Side effect: large dose can cause liver damage. Do not take this medicine more than 10 days. For pregnant women, acetaminophen is the only analgesic that can be safely taken during pregnancy.
  • Mild to moderate pain in U.K uses Nuromol, combination of 200mg Ibuprofen and 500mg of Paracetamol (Acetaminophen).  According to the company; " Nuromol tablet was shown to offer stronger pain relief than a 1000mg paracetamol and 30mg codeine combination". Nuromol should take 1 tablets every 6 hours (if necessary take 2 tablets) with food, do not exceed 6 tablets in 24 hours and do not take more than 3 days.  Do not take if you are under 18 years, has stomach ulcers, already taking other NSAID and aspirin, and history of allergic reaction to ibuprofen, paracetamol, aspirin , and other related pain killers.
It is advised to have Emergency Dental Kit at home/traveling at all time.

Note: an effective regimen utilizes alternating every 4 hours between 1000 mg of Acetaminophen (paracetamol) - 2 tabs extra-strength Tylenol, not to exceed 4000 mg of Tylenol (8 extra strength) in one day, and 400 mg of ibuprofen - 2 tabs of Advil. This regimen has been shown to provide pain relief. Do not use this regimen if you have history of peptic ulcer, liver disease, hypertension.  Do not take more than few days.

 Learn how to prevent tooth decayed from here.

The process of gums problem can be found  here

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