Toothaches and Treatment of Dental Pain

So you see a dentist to try to resolve the pain. In most cases, your dentist can diagnose the pain’s source as the tooth. However, toothaches can be caused by a distant source far away from the tooth that you are feeling pain. A good history taking of the pain and a thorough clinical examination with dental X-ray and adjunctive testing are quintessential for coming up with the correct diagnosis of the cause of the pain. Otherwise, misdiagnosis can happen, resulting in unnecessary treatment, while the disease is not treated and can worsen.

Then we may want to ask what can cause toothaches. In most cases, toothaches are caused by some tooth diseases. The diseases can be:

Cavities
Fractures
Chips
a cracked tooth
severe enamel wear
toothbrush abrasion
pulp exposure
abfraction
inflammation in the pulp (pulpitis)
bacterial infection inside the pulp
pulp stone
chronic irritation (from clenching and grinding)
acute trauma
high occlusion

But sometimes, a toothache can be caused by the supporting bone and tissues. For example:

Inflammation in the gums due to food stuck between the teeth can cause the teeth to ache
abscess in the alveolar bone (the bone surrounding the tooth) at the apex of the tooth
bone fracture
cysts in the jaw
malignant neoplasm in the bone and gums

However, the list of possible causes is not yet exhausted. Toothache can be due to some dysfunction of the nervous system in the following:

Trigeminal neuralgia (Tic Douloureux)
Post-traumatic neuropathy (nerve damage due to cutting or compression)
Burning mouth syndrome

Moreover, orofacial muscles can cause toothache in some instances. When the masticatory muscles are tense and sore, it can also express as toothache and temporal mandibular joint pain (TMJ). Of course, a toothache can also be perceived when there is only a temporal mandibular dysfunction.

Neurovascular pain like migraine can express with toothache together with the typical migraine symptoms.

Paroxysmal hemicrania can be caused by head trauma, a tumor in the brain, or an abnormal tangle of blood vessels. Patients with this disorder can feel pain in a tooth, but the pain usually comes and goes on a periodic pattern.

Sinusitis, heart attack, psychological overlay, and tumors in the central nervous system are all possible factors that can make a patient feel toothache.

A toothache can refer to another tooth. In this case, the patient perceived location of the toothache is actually away from the tooth that causes the pain. It is common to have lower jaw pain or pain from a lower molar, but it comes from an upper molar on the same side, typically a decayed wisdom tooth. This phenomenon is called referred pain.

I usually go to the teeth first to see if there are apparent causes for toothache like cavities, split or cracked teeth, large extensive fillings, fistula, swollen gums, and swollen cheek or face. If there are nothing clinically detectable diseases, then I would do some simple tests like:

wriggling the tooth with my fingers
putting pressure on the tooth with my fingers
tapping the tooth with my mouth mirror handle and placing a cold Q-tip against the suspected tooth to see how the patient feels about the tooth

Reviewing and taking X-rays photos can help to detect some not-so-obvious pathologies and to confirm the diagnosis.

Freezing the suspected tooth can also help confirm whether the pain is indeed from the suspected tooth.

If there is still no definitive evidence to pinpoint the source of the pain, then I will take a good history of the pain and ask the following questions:

When did the pain first start
Can you pinpoint the source or show me the general area where the pain is felt
Is it constant or intermittent
How does it hurt
Has the pain changed in intensity, pattern, or location
Does it get worse at a particular time of the day
Does pressure, light touch temperature change, or posture bring on the pain or make it worse
Did it happen before
Was there swelling before
Is there something you do can help to make the pain less or go away
Was there any trauma to the teeth or jaw

Medical history is also essential to shed some light on the possible causes. Taking multiple medications can undoubtedly cause a dry mouth resulting in hypersensitive teeth. Suppose a patient has a history of chronic sinusitis and/or chronic nasal congestion. In that case, I will suspect the toothache in the upper jaw can be possible from an episode of acute infection in the sinus after ruling out the cause is from the teeth. A patient’s history of neurovascular conditions like migraine and neurological issues like trigeminal neuralgia and paroxysmal hemicrania can be the possible reasons for the toothache. When a person has an acute heart attack, it may manifest with a toothache, together with other symptoms. Although dentists are not typically trained in auscultation and doing electro-echocardiograms, we could suspect if there is a good chance that the toothache is indeed caused by an acute heart attack with a detailed medical history, asking the right questions about the signs and symptoms and clinical examinations.

As a holistic dentist, I need to know pertinent medical conditions and their signs and symptoms related to the orofacial region, understand the drug interactions, anatomy in the head and neck area, and their functions and physiologies. Providing total health in collaboration with other dental and medical colleagues is very satisfactory.