Tooth pain is one of the most common dental emergencies. It can be due to injury or infection. Dental caries is the most common reason for toothaches. Treatment of a patient with tooth pain depends on the diagnosis of the origin of the pain.
Dental pain can be an aching sensation or throbbing. It can be mild or severe. It can occur spontaneously or be induced by stimuli like thermal changes, contact with sweet, touch or pressure. It can be intermittent or continuous and may be momentary or prolonged.
Types & Causes:
Toothaches can be divided in to two; those that originate from the dental structures (odontogenic toothaches) and those that do not (nonodontogenic toothaches).
The pain can originate from the tooth (pulp) or the supporting periodontal structures.
- Toothaches of pulpal origin: The pain can be dull, aching, throbbing or sharp depending on the condition of pulp. It is usually unilateral and the related tooth is sensitive to percussion and/or temperature changes. This kind of pain gets better or worse and can be reduced or eliminated by a local anesthetic injection in the area.
- Acute pulpal pain: Severe pain, which cannot be localized. If the pain was induced by a stimulus (hot, cold or sweet) it is usually a reversible condition. Removing the caries and placement of a filling is the treatment. Sometimes a temporary filling is needed to heal the tooth. Patient has to come back after few days to get the tooth filled permanently. If the pain was spontaneous and is persistent it means the pulp is severely inflamed and is not a reversible condition. In such cases root canal therapy (RCT) is required before the filling.
- Chronic pulpal pain: In certain conditions injured pulpal tissue may progress from an acute inflammatory phase to chronic phase. The pain responses change from acute pain to milder pain or slight discomfort. This can happen more commonly in young tooth with traumatic injury.
- Recurrent pulpal pain: This is sensed as recurrent sensitivity. The tooth is slightly inflamed and pain threshold is lowered. This causes pain by factors such as sweets, thermal changes, occlusal abuse, change in vascular pressure etc.
- Obscure causes: Split tooth obscured by adjacent teeth making it difficult to see in X-rays, Filling moved in pulpal direction, impacted teeth causing abrasion in adjacent tooth root, periodontal infection leading to pulpal involvement through root canal etc. are to be considered and explored when the tooth ache is obscure.
- Tooth aches of periodontal origin: Pain is dull, aching and occasionally throbbing and more localized than pulpal pain. There is an identifiable periodontal condition associated with it. This kind of pain responds to provocation proportionately. Biting on the tooth increases the pain. Pain can be eliminated by a local anesthetic injection of that area. Causes can be;
- Primary periodontal inflammation due to local trauma like occlusal overload or contact with adjacent impacted tooth. It may also occur after cleaning of teeth, dental treatments, occlusal interferences of opposing teeth etc.
- Spreading inflammation from a nearby trauma or surgical wound.
- Acute inflammation of a preexisting lesion as a result of an injury, food impaction or infection.
- Spread of infection from a pulpal infection causing an abscess.
- When there are several teeth involved occlusal overloading should be considered. It can also be due to clenching and bruxism (grinding of teeth).
Nonodontogenic Toothaches: There will not be an adequate dental cause for the pain. Injection of local anesthetic does not reduce the pain. The reasons are:
- Myofascial pain: A muscle disorder characterized by deep, dull, aching muscle pain that can be associated with referred dental pain. It is not altered by local stimulation of the tooth. Local anesthesia of the tooth does not relieve the pain but anesthetic injection of the involved muscle reduces the toothache.
- Sinus or nasal mucosal origin: Patient reports pressure below the eyes and applying pressure over the involved sinus increases pain. Lowering head or stepping hard on to the heel of the foot increases the pain. Diagnosis can be confirmed by appropriate imaging of the sinus.
- Migraines, Neuropathic pain, nerve disorders like trigeminal neuralgia, Herpes zoster, cardiac pain, tooth pain due to psychogenic origin, multiple sclerosis etc. can be some other reasons for toothaches.
- Before treatment of toothaches it is very important to determine the origin of the pain. Most of the dental origin pain can be treated by dental procedures like fillings, RCT, extraction, occlusal adjustments and medications.
- Patient’s chief complaint is to be reproduced to determine the cause
- Local anesthetic injections are diagnostic.
- Differential diagnosis and referral is very important in nonodontogenic pain.
- “Atypical odontalgia” is a term used to describe toothache without an identifiable cause.