Tooth Pain

The first step in the diagnosis of tooth pain is to determine whether the pain is of odontogenic origin (caused by tooth).  The dentist uses clinical exam and radiography such as Cone-beam computed tomography for locating periapical lesions, fractures, missed root canal therapy.

If the pain is nonodontogenic in origin, e.g., neuropathic, sinusitis and malignancy, the dentist refers the patient to the specific specialists for additional assessment.

Tooth pain from dental decay is the most common complaint in odontogenic origin. Tooth pain can be described in different ways:
  • mild
  • moderate
  • severe
  • acute
  • chronic
  • sharp shooting
  • burning
  • aching
  • dull
  • throbbing
Tooth pain derives from: 
  1. An exposed nerve caused by tooth decay at the tooth crown or root surface
  2. Infection at the root tip due to decay at the tooth crown or root surface
  3. Periodontal ligament due to gum 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 or old root canal treatment
  10. Tooth eruption
  11. Impacted wisdom tooth
  12. Dry socket after tooth extraction 
  13. Premature occlusal contact between upper and lower teeth
  14. High restoration such as filling, crown, bridges
In most cases, a combination of visual examination and the x-rays help dentist determines 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, a second layer of tooth structure, which may cause sensitivity and pain in some cases. Once the cavity penetrates a pulp chamber at 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

A simple and accurate way to find which tooth is responsible for pain is through sequential stimulus challenge tests.  The test begins by application of a stimulus that initiated the pain according to the patient's complaint to each tooth, one at a time. The most efficient stimuli are biting down pressure, heat and cold application to the suspected tooth.

Examples of the test:
  • If a patient complains about sensitive or pain when biting, the dentist will tap or put pressure on each tooth in that location
  • If a patient complains about sensitive or pain when drinks cold beverages, the dentist will apply cold stimulus to each tooth in that location
1. Symptoms: sharp constant or intermittent pain, increased pain while biting on a certain position or tapping on the tooth, patient cannot locate the pain

Possible causes are:
  • Inflammation of the ligament from supra-occlusion (a condition in which a tooth extends beyond the occlusal plane) due to a new crown, new filling, or localized periodontitis
  • Cracked tooth
  • Acute Pulpitis (Pulpitis is an inflammation of the dental pulp - nerves and blood vessels)
  • Referred pain such as sinusitis may be mistaken for tooth pain in upper molars and pre-molars (referred pain is a feeling of pain in an area away from the actual source of the pain)
Reversible pulpitis
In vital cracked tooth in which the cracked line ends outside of pulp chamber and the nerve has not been affected,  patient may experience a sharp and intense pain of short duration while chewing and biting at a specific location.  This type of pain may subside on its own - this is a reversible pulpitis.  The pulp may recover spontaneously.  It is, usually, asymptomatic until provoked by some external stimuli, e.g., hot, cold, percussion, pressure or sweet.  Once removes the irritant, the pulp returns to its normal, healthy state.

Treatment: If the pulp fully recovers, a dental crown is recommended to prevent further damage to the tooth.

irreversible pulpitis
When a cracked line reaches pulp chamber, it infects pulp chamber with oral microorganisms.  Although, the pulp may still alive at a time, the nerve becomes sensitive to temperature changes (hot and cold but sometimes cold may provide relief). Patient may experience lingering pain even after removing the stimuli. The invaded bacteria prevent pulp tissues to heal, results in pulp necrosis - this is an 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 treating 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 identifying the problem tooth.

Tools used to detect cracked tooth are:
  1. Intra-oral camera - cracked line will be magnified and easily detected 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 a 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.

You can find more information about cracked tooth here
2. Symptom: 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 sinus since they share the same nerves.  Sinus congestion from flu or cold may cause pain in the upper back teeth. Clenching and grinding teeth can also have the same symptom.  Oral examination and patient medical history can assist in proper diagnosis.

3. Symptom: Severe pain 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). The response to electric pulp tester is at lower level 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.

4. Symptom: 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.  The response to electric pulp tester is at higher level than normal tooth.

Possible cause: the tooth may have an abscess at the root tip(s) or around the gums.

  • 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.

5. Symptom: Pain at high altitude as in flights (symptom can be a few hours or days later).  This type of pain called "Aerodontalgia."  This condition occurs in the tooth 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 a long time. It is available over-the-counter. Since it can burn and has bad taste, avoid contacting the tongue, soft tissue during application.

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 a physician, the maximum dose can be 3200 mg.

    Side effects: gastrointestinal ulceration, bleeding, nausea, headache, dizziness and hypertension.  At lower dose, Ibuprofen has the lowest incidence of digestive adverse drug reaction compare to other NSAID.  Compare to Acetaminophen, NSAID's provide a 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 a 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 use Nuromol, combination of 200mg Ibuprofen and 500mg of Paracetamol (Acetaminophen).  According to the company; " Nuromol tablet was shown to offer stronger pain relief than  1000mg paracetamol and 30mg codeine combination". Nuromol should take one tablet every 6 hours (if necessary take two 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 an allergic reaction to ibuprofen, paracetamol, aspirin, and other related painkillers.
It is advised to have Emergency Dental Kit at home or duringtraveling at all time.

Note: an effective regimen for pain is a combination of Acetaminophen and Ibuprofen by alternating every 4 hours between:
  • Acetaminophen (paracetamol) 1000 mg - 2 tabs of extra-strength Tylenol
  • Ibuprofen 400 mg - 2 tabs of Advil.
  1. Do not use this regimen if you have a history of peptic ulcer, liver disease and hypertension.  
  2. Do not use this regimen more than few days
  3. Do not exceed 4000 mg of Tylenol (8 tabs of extra strength Tylenol) in one day
 Learn how to prevent tooth decayed from here.

The process of gums problem can be found  here


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