Dental decay is usually painless as it goes thru the enamel, the outer layer of the tooth.
The tooth can become “sensitive” as decay moves into the “live” dentin (inner layer) of the tooth…. sensitivity to sweet and sour as well as hot and cold is common but the tooth should not be continuously “sore” or “throb”. As the decay process gets near the nerve of the tooth, the intensity and frequency of the symptoms usually increase.
Once the decay process has reached the nerve of the tooth, extreme pain can occur at any time…the intensity can range from moderate to a very severe…extreme throbbing pain can be continuous and can resist oral pain medication. This kind of pain could subside during the daylight hours but is typically much worse during the evening and night. Once a toothache wakes you from sleep it is often relentless.
By definition, a dental abscess is a localized collection of “pus” or infected material in the area surrounding the root end of the offending tooth…pressure built up in this area can cause severe pain that can be referred to other teeth as well as other areas of the mouth and face. It’s not unusual for the patient not to know for sure where the pain is coming from or which tooth is the problem. This abscess can enlarge and extend to surrounding teeth…if the infection goes through the bone, rapid swelling of the gum and cheek can occur.
Several dental conditions have typical symptoms with different types of pain
A detailed history and examination will identify the cause of dentally-related pain in most emergency situations. Sharp, shooting pain can be caused by inflammation in the pulp or exposure of the dentine. Dull throbbing pain has several causes including ulcerative gingivitis, dental caries and food impaction. Simple treatment will usually alleviate the symptoms until patients can be seen by a dentist.
What are the common types of dental pain?
Short, sharp, shooting pain
This type of pain can be generalised or confined to one region of the mouth. The pain may be due to fluid movement through open tubules in the dentine or there may be some initial inflammatory changes in the dental pulp. It can be caused by caries, dentine exposure on root surfaces, split cusp, lost or fractured restoration or a fractured tooth.
Patients complain commonly of a sharp pain associated with hot, cold or sweet stimuli. The pain is only present when a stimulus is applied. In the case of a cracked cusp, grainy bread or hard food may create a sharp pain, that may be spasmodic, on biting or chewing.
With gingival recession, recent scaling, or tooth wear due to a high acid diet or gastric reflux, there may be generalised dentine sensitivity. However, with caries, fractured fillings and cracked cusps, the pain tends to be localised to the affected tooth.
Intermittent sharp, shooting pains are also symptomatic of trigeminal neuralgia, so care must be taken not to mistakenly label toothache as neuralgia.
Painful tooth problems
The most common dental cause of dull, throbbing persistent pain is caries. In many cases, this is recurrent and associated with an existing restoration. Where the pulp is affected irreversibly, necrosis may follow with possible development of a periapical infection. A fractured cusp involving the pulp, or a large deep restoration may also be associated with this type of pain. Affected teeth may be tender to percussion in the later stages of periapical inflammation.
There is considerable variation in the pain reported by patients, but it commonly starts as a sharp stabbing pain that becomes progressively dull and throbbing. At first, the pain may be caused by a stimulus, but it then becomes spontaneous and remains for a considerable time after removal of the stimulus. The pain may radiate and be referred to other areas of the mouth. This type of pain tends to cause the patient to have difficulty sleeping and may be exacerbated by lying down. Heat may make the pain worse whereas cold may alleviate it. The pain may be intermittent with no regular pattern and may have occurred over months or years. If there is a periapical infection present, patients may no longer complain of pain in response to a thermal stimulus, but rather of sensitivity on biting.
Treatment of affected teeth will involve either root canal therapy or tooth removal. In some patients, periapical inflammation can lead to cellulitis of the face characterised by a rapid spread of bacteria and their breakdown products into the surrounding tissues causing extensive oedema and pain. If systemic signs of infection are present, for example, fever and malaise, as well as swelling and possibly trismus (limitation of mouth opening), this is a surgical emergency. Antibiotic treatment alone is not suitable or recommended.
Should antibiotics be prescribed?
While antibiotics are appropriate in the management of certain dental infections, they are not indicated if the pain results from inflammatory (non-infective) or neuropathic mechanisms. The degree of pain is not a reliable indicator of acute infection.
There is evidence that Australian dentists and doctors are using antibiotics empirically for dental pain, rather than making careful diagnoses of the causes of the pain. Most dental emergency situations involve patients with acute inflammation of the dental pulp or the periapical tissues. Prescribing antibiotics for these conditions will not remove the cause of the problem nor destroy the bacteria within the tooth.
Antibiotics should be limited to patients with malaise, fever, lymph node involvement, a suppressed or compromised immune system, cellulitis or spreading infection, or rapid onset of severe infection.
If pus is present, it needs to be drained, the cause eliminated, and host defences augmented with antibiotics. The microbial spectrum is mainly gram-positive including anaerobes. Appropriate antibiotics would include penicillin or a `first generation’ cephalosporin, combined with metronidazole in more severe cases.
Paracetamol or a non-steroidal anti-inflammatory drug is the recommended analgesic in the initial treatment of dental pain.
Cracked Tooth Syndrome
A very common problem with “root canal teeth” and teeth with large fillings.
Toothache due to a crack will start when you chew or put pressure on the tooth … it will get worse as the crack continues to enlarge. …the fractured piece may feel loose or actually fall off and an abscess can develop at any time. It’s easy to visualize the mechanics of the problem – picture an ice cube or piece of glass with a crack…….every time you apply pressure or tap on top of the ice or glass, the crack will get bigger until the crack goes completely through. Pain from a cracked tooth can start as an occasional” twinge” or “zinger” or it can be sudden and severe and continuous from the very start.
This very common and painful condition is usually seen with a partially erupted wisdom tooth. Because there is not enough room for the tooth to come in completely, it becomes “stuck” or “wedged”. A pocket or sack develops in the gum tissue around and behind this tooth. This pocket quickly fills with bacteria and food debris. Because the mouth is moist, warm and dark (it’s a perfect incubator) an abscess can form rapidly. This pain can be very severe and continuous and is commonly sent to (referred to) the area around the ear. Pain when opening or even severe limitation when trying to open the mouth in common. We often see patients coming from an ear doctor when their real problem was a wisdom tooth.
Wisdom teeth are the last molars to develop and usually start to erupt in the late teens. Because they are the very last teeth, they very commonly become impacted (stuck or wedged between jaw bone, gum and the adjacent tooth). Toothache or pain from the wisdom tooth area is one of the most common emergency problems that we see.
Over 90% of the population has “wisdom tooth” problems due to lack of room for proper eruption. Wisdom Tooth Problems encompass many issues including:
Pain Constant pressure in this sensitive area frequently causes neuralgia-like pain that can radiate to the ear, side of the face and upper teeth and spread to the other lower teeth as well. Headaches are commonly associated with impacted or partially erupted wisdom teeth.
Destruction of the Next Tooth -pressure from the wisdom teeth frequently erodes or dissolves away healthy tooth structure, resulting in pain and tooth loss
Cysts…fluid -filled sacks can form and enlarge around impacted wisdom teeth. These cysts can dissolve jawbone and teeth-they commonly become infected and cause serious pain
Gum Infection -perio abscess
Gum Abscess (Periodontal Abscess – Perio Abscess)
This infected tooth may be completely free from decay and have no filling…it may feel loose and the surrounding gum can feel swollen ….a bad taste is a common feature. A defect in the supporting bone along one or more sides of the tooth forms a “pocket” with the gum that becomes filled with food and bacterial debris….an abscess can develop “overnight”. Mild sensitivity in the area can escalate to severe pain and swelling involving several teeth.
Moderate to sharp discomfort to touch or pressure most commonly seen after placement of a dental filling or crown that is too “high”…. can be easily corrected by adjusting the offending filling or crown and bite.
Food Impaction and pericoronitis
Soft tissue problems that may cause dull, throbbing, persistent pain include local inflammation (acute gingivitis associated with food impaction) or pericoronitis.
Chronic periodontitis with gradual bone loss, rarely causes pain and patients may be unaware of the disorder until tooth mobility is evident. There is quite often bleeding from the gums and sometimes an unpleasant taste. This is usually a generalised condition, however, deep pocketing with extreme bone loss can occur around isolated teeth. Food impaction in these areas can cause localised gingival pain. Poor contact between adjacent teeth and the presence of an occluding cusp forcing food into this gap can also cause a build-up of food debris and result in gingival inflammation.
Acute pericoronitis involves bacterial infection around an unerupted or partially erupted tooth and usually affects the lower third molar (wisdom tooth). The condition is often aggravated by the upper molar impacting on the swollen flap of soft tissue covering the unerupted tooth. There may be trismus.
Food debris should be removed and drainage established if pus is present. Irrigation with chlorhexidine and rinsing the mouth with hot salty water is recommended. Early referral to a dentist is indicated. Cellulitis can develop, requiring urgent referral to a surgeon.
Acute Necrotising Ulcerative Gingivitis
Acute necrotising ulcerative gingivitis is a rapidly progressive infection of the gingival tissues that causes ulceration of the interdental gingival papillae. It can lead to extensive destruction. Usually young to middle-aged people with reduced resistance to infection are affected. Males are more likely to be affected than females, with stress, smoking and poor oral hygiene being predisposing factors. Halitosis, spontaneous gingival bleeding, and a `punched-out’ appearance of the interdental papillae are all important signs.
The patients quite often complain of severe gingival tenderness with pain on eating and tooth brushing. The pain is dull, deep-seated and constant. The gums can bleed spontaneously and there is also an unpleasant taste in the mouth.
As there is an acute infection with mainly anaerobic bacteria, treatment follows surgical principles and includes superficial debridement, use of chlorhexidine mouthwashes and a course of metronidazole tablets. Treating the contributing factors should prevent a recurrence.
A dull throbbing pain develops two to four days after mandibular tooth extraction. It rarely occurs in the maxilla. Smoking is a major predisposing factor as it reduces the blood supply. The tissue around the socket is very tender and white necrotic bone is exposed in the socket. Halitosis is very common.
The area should be irrigated thoroughly with warm saline solution. If loose bone is present, local anaesthesia may be necessary to allow thorough cleaning of the socket. Patients should be shown how to irrigate the area and told to do this regularly. Analgesics are indicated, but pain may persist for several days. Although opinion is divided as to whether or not dry socket is an infective condition, we do not recommend the use of antibiotics in its management.
This is caused by infection of the maxillary sinus, usually following an upper respiratory tract infection. However, there can be a history of recent tooth extraction leading to an oro-antral fistula. Patients usually complain of unilateral dull pain in all posterior upper teeth. All these teeth may be tender to percussion, but they will respond to a pulp sensitivity test. There are usually no other dental signs.
The pain tends to be increased on lying down or bending over. There is often a feeling of `fullness’ on the affected side. The pain is usually unilateral, dull, throbbing and continuous. Quite often the patient feels unwell generally and feverish.
Pain originating from the sinus arises mainly from pressure. Decongestants can help sinus drainage. Antibiotics probably have only a minor role in mild cases. Referral to an otorhinolaryngologist for endoscopic sinus surgery may be indicated in chronic cases.
DISCLAIMER: The following observations are intended as general information. This is not intended to serve as a guide for self-diagnosis or as a substitute for an examination by a dentist.
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