Tooth pain is generally felt as a sharp or aching pain in or around a tooth. It is most frequently caused by an irritation of the nerves within the roots of teeth due to dental caries (cavities), infections of the dental pulp or fractures of the crown and root of the tooth . Other common causes of tooth pain include periodontal (gum) and bone infections or inflammation from wisdom teeth .
In the majority of cases, dental cavities and gum diseases caused by bacteria in the mouth are not painful conditions until they begin to have an effect on the internal structures of the teeth .
Because there are many conditions that lead to similar symptoms as tooth pain, it is important to always seek professional dental assessments for accurate diagnosis. Medical conditions that mimic tooth pain include sinus and ear infections, and pain can also be caused by heart diseases such as angina or myocardial infarctions . Similar symptoms are often caused by trigeminal neuralgia (nerve pain) or an inflammation of the temporomandibular joints (TMJ) and muscles of mastication (chewing), which manifest themselves as headaches and nerve pain .
Structure of the Tooth and the Surrounding Tissues
To understand the causes of tooth pain, it is important to have a basic understanding of the tooth itself. A tooth is divided into two parts. The crown of the tooth is the part that you see in the mouth, above the gum line. The root of the tooth is the part that is below the gum line and that is entrenched in the bone.
The crown is composed of three structures. The enamel on the outside is the hardest substance found in the human body and is the surface that takes the brunt of masticatory forces- namely chewing, which puts an enormous stress on your teeth on a daily basis
. Under the enamel is the dentin, which contains nutritional tubes for the health of the tooth.
The root of the tooth has an outer layer called cementum, which is attached to the bone by a structure of fibers and connective tissue called the periodontal ligament. The cementum receives nutritional support from both the ligament and the innermost structure of the tooth, the dental pulp . The dental pulp extends the whole length of the tooth from the crown down into the root. Nerves from the pulp extend into the bone.
The pulp is primarily made up of soft tissue and nerve endings that can only sense pain. This is the reason why inflammation and subsequent swelling in the pulp (pulpitis) can cause extreme discomfort. Because there is no place in the tooth to allow for this swelling, the pain is accompanied by strangulation and subsequent death of the pulp, leading to a tooth abscess– a collection of pus inside the tooth.
Causes of Tooth Pain
Tooth pain can come from:
- The tooth itself
- The gum and bone surrounding the tooth
- Nerves supplying the area of the tooth
- The Temporomandibular joints and the muscles that move the jaw
- Non-dental causes
1. Pain from the Tooth Itself
A. Mild Pain
A mild pain is often described as a small twinge of pain, or a sudden sensitivity to heat or cold that the patient had not previously suffered from. These mild irritants can be caused by a small cavity, an old leaking filling, or exposure of the root to oral cavity fluids due to recession of the gum that surrounds and protects the tooth . Additionally, clenching or grinding of the teeth can lead to mild pain and sensitivity in the teeth .
If touching the tooth in the area of recession with a fingernail or a metal utensil causes pain, the first step is to switch to a desensitizing mouthwash or toothpaste. These can be found in any local drug store. If the sensitivity is uncomfortable, use an over-the-counter pain medicine, as directed.
Img 3: GUM RECESSION WITH SENSITIVE ROOTS
In addition to the reasons listed above, the pain may be caused by recent trauma or imperfect dental treatment. Contact your dentist for an examination if the sensitivity and pain continues for more than three days in order to evaluate the need for dental work or other options.
B. Moderate Pain
Moderate pain is best described as dental pain that is affected by touch, tapping on the tooth, or chewing. This is usually an indication of the beginnings of infection or inflammation in the dental pulp. Experiencing increasing pain due to thermal changes is another classic sign of pulpal injury.
Pulpal injury can be a direct result of trauma or bacterial infection from a deep carious lesion- a cavity- left untreated. Generally, any contact with the tooth will lead to a spike in pain. The increasing pain comes from swelling in the pulpal tissue, which is completely enclosed by the hard structures of the crown and root of the tooth. When swelling occurs, the pulp nerves are compressed and then slowly die, forming a tooth abscess.
An abscess involves a pus pocket made up of bacteria, dead tissue, and white blood cells that can drain into the mouth, leading to bad breath and a sour taste in your mouth.
In the case of moderate pain, professional help should be obtained. Moderate pain can be initially controlled by over-the-counter or prescription pain medication along with the use of antibiotics to control the swelling and the infection. The dentist will evaluate the need for treatment, including root canal therapy and filling of the carious lesion. Sometimes a dental crown may be recommended, depending on the condition of the tooth .
C. Severe Pain
If the beginning signs of infection in the pulp are ignored, the pain may become severe. Severe pain can also occur if trauma, such as biting down on a piece of hard candy, has caused a crack or fracture in the tooth. The pain is usually a result of an abscess and may be accompanied by fever and localized swelling in the mouth or cheek. The pain can be continuous and severe if there is no drainage of the abscess.
In the situation of severe pain, it is important to seek out immediate medical help. Severe pain should be treated as a medical emergency. Most likely the dentist will prescribe pain medication and antibiotics to reduce the swelling until the symptoms calm down. Your general dentist may treat the cause of the pain, or may refer you to a specialist. While teeth can often be saved in this case, it is not improbable that the tooth may need to be removed in order to deal with the infection. In most cases, fractured teeth need to be removed. In the case of tooth removal, your dentist will discuss the various replacement options .
Once the pain, swelling, and fever have subsided, your dentist may ask you to come in for a follow up visit.
2. Tooth Pain Related to Tissues Surrounding the Tooth
Periodontal disease is an infection of the gum and bone that surrounds the tooth, and leads to tooth pain in the later stages of the disease. Periodontal bone loss can jeopardize the support of the tooth, allowing the infection to spread from the gum into the root of the tooth, which creates a secondary root infection and can transform into a gum abscess. The abscess acts as a dental infection, with all of the same features described in the section on pain from the tooth itself. Periodontal disease can result in tooth loss .
Img 5: Image showing broken carious crown and gum inflammation from plaque and calculus
Early signs of gum disease are relatively easy to discover. Blood on your toothbrush, red and swollen gums, bad breath, loosening or shifting of teeth, and bleeding or pain from chewing are all common indicators of gum disease. Special care should be considered if you also have general health problems such as diabetes, if you are on blood thinners or if you smoke or use chewing tobacco . Gum inflammation can be aggravated by oral contraceptives and also during pregnancy .
Prevention is the best early treatment . Good oral hygiene practices such as brushing three times a day, flossing daily, and rinsing after meals with mouth wash can significantly lower your chances of developing gum disease. Gum health is a good indicator of general health, so a regular visit to the dentist every three to sixth months for cleanings and an oral cancer check is strongly recommended if you find many of the symptoms described above.
Wisdom teeth that develop cavities or are broken can also be a cause of tooth pain. Because they develop later in life, wisdom teeth can cause pain by inflammation of the dental pulp or the gum around the crown of the tooth. Remember, wisdom teeth often remain impacted- underneath the gums or bone- for a significant period of a person’s life. However, partially impacted teeth can lead to gum infection if food becomes caught in the area above the gums. This type of infection can cause swelling and pain extending from the jaw bone into the ears and down to the throat. Fever and abscess can sometimes occur if the early symptoms are not addressed .
Img 6: X-ray showing as impacted Wisdom Tooth on the left side of the photograph, missing teeth and generalized periodontal bone loss. On the right of the photograph the TMJoint shows degenerative change.
There is also a root canaled tooth on the lower jaw.
Initial treatment includes prescribed anti-infective mouthwash like Peridex and antibiotics. In addition, home care options include gargling with warm salt water and using over-the-counter pain medication as directed.
3. Dental Pain Related to Nerves
A sharp, shooting tooth pain that is triggered by touch or cold air on the lips or cheeks may be neuralgia- nerve pain. The most common form of nerve pain is known as Trigeminal Neuralgia, referring to the Trigeminal nerve system that supplies the area of the face, jaws, and teeth. When a patient has Trigeminal Neuralgia, the pain will generally last a few, severe seconds, and then completely disappear until triggered again .
Other types of nerve pains can be caused by injuries to the teeth. These are often hard to diagnose and are categorized as “atypical odontalgias,” a catchall phrase for nerve pains of an unknown type . Your dentist or primary care physician should be contacted to help guide you.
Nerve-related pains generally require a multidisciplinary approach of dentists and physicians, such as neurologists trained in pain management. Medications such as carbamazepine (Tegretol, Epitol) or gabapentin (Neurontin) may be prescribed by your doctor to help with sensitive nerves. Acupuncture and other complementary medical techniques have also been found to be helpful. In extreme cases, surgical intervention or radiofrequency Gamma Knife ablation is suggested .
4. Dental Pain Related to Temporomandibular Joint and Muscle Disorders
In certain cases, pain in a tooth can be caused by the adjacent muscles and joints in the mouth. The temporomandibular joints (TMJ) on either side of the jaw can be found just in front of the openings to your ears. You can feel the joints move every time you open and close your mouth. Injury or inflammation of the joints can create pain in your teeth .
The muscles used for chewing also can lead to pain in individual teeth that are otherwise normal. Trigger Points are specific areas in the muscles that can cause tooth pain in the mild to moderate category with no evidence of tooth injury. These pains come and go, and in many instances can be triggered by applying pressure to the muscle. The most common muscles that lead to this type of pain are those found on the sides of the temples and the clenching muscles on the side of the lower jaw. Clenching or nighttime tooth grinding can create or maintain such trigger points.
Initially, use of wet heat and stretching of the jaw muscles can help. If your dentist has not been able to find a reason for the toothache, they may make you a nighttime dental guard and give you tips on relaxing the muscles. Muscle relaxants and trigger point injections can also be used to see if the tooth pain is being caused by these trigger points. There are many specialists in this type of TMJ pain, and your dentist may refer you to a local expert . Specialists can include neurologists, orofacial pain specialists, oral surgeons or ear, nose and throat (ENT) experts.
5. Tooth Pain Related to Non-Dental Causes
In the absence of an obvious dental reason, tooth pain can also be a symptom of some underlying general health problem that requires medical attention.
Pain in the tooth or jaw with no apparent reason, if accompanied by chest or arm pain and shortness of breath, could be an indicator of an underlying heart condition . Pain accompanied by high fever could be related to a general infection in the body. Pain accompanied by headaches, nausea, or vomiting after a fall or accident could be a neurological problem such as a concussion. In all these cases, seek professional medical help and advice immediately.
Preventing Tooth Pain
Prevention of common dental pain problems starts with good home care and a healthy diet. Some of these common sense precautions will help the average individual from suffering through the stages of tooth pain that are outlined above.
- Reduce the amount of sugar in your diet. Bacteria in your mouth convert sugars into acid, which softens tooth structure and starts the process of dissolving the enamel and dentin of the tooth .
- Rinse your mouth with plain water or a mouthwash after eating to help reduce the acids in your mouth.
- Brushing the teeth two to three times a day to remove food particles prevents dental plaque from attaching to the teeth . Dental plaque is a biofilm that adheres to the crevices of the teeth and reduces the ability of the mouth to fight bacterial infections, leading to gum inflammation. Dental plaque also turns intodental calculus, solid calcified deposits on the teeth that prevent the dental brush bristles from reaching the enamel on the surface. Since dental plaque is colorless, the use of a plaque disclosing solution daily, or at least three times a week, will allow you to confirm the effectiveness of your home care routine.
- Use floss regularly. Infections generally start in between the teeth where the bristles of your brush cannot reach, and flossing is the most effective way to get to them.
- It is up to you to decide if you prefer the use of an automatic or manual toothbrush. The automatic or battery operated brushes generally provide a better cleaning because people tend to brush longer with them. An automatic toothbrush does not require as much force against the tooth as a manual toothbrush, and can now be found in almost all drug stores and supermarkets. Whichever brush you choose, make sure that the bristles are soft in order to avoid causing gouges on the tooth surface over time.
- Use of fluoride toothpaste is recommended to harden the surface of the tooth and to help fight against cavity formation .
- Visit the dentist regularly for true oral hygiene. Generally, a visit every six months is recommended. The dental hygienist or the dentist will do a “cleaning” to remove the calculus that have built up between visits and will polish the teeth to get rid of the dental plaque that remains.
- A semi-annual visit will also allow the dentist to examine your mouth for cavities, gum disease, and jaw problems. Most importantly, it will allow the dentist to perform a cancer check by examining the insides of you cheeks, the tissues on your tongue and throat, and your glands.
- If you have a broken tooth or a filling has fallen out, you must see your dentist in order to have them replaced. Leaving the tooth and gums expose is a risk factor in tissue trauma and oral cancer.
- If you have missing teeth and are having pain related to the muscles and your jaw joints, the dentist may recommend replacing those teeth to help stabilize your bite.
- If you know that you clench or grind your teeth at night, ask your dentist to give you a night guard to prevent wearing, cracking, or fracturing weakened teeth.
Home Care Treatments
Many pharmacies have home remedies that you can begin until you get an appointment with a professional. In all cases you should seek help from your physician or dentist if the symptoms of pain, fever, or swelling do not improve with general home care in two to three days. Even if the symptoms do improve, it is a good idea to schedule an appointment for a check up to make sure the pain has not simply subsided temporarily.
- For pain in a cavity you can pour oil of cloves onto a cotton pellet and place it into the cavity of the tooth. Oil of cloves contains a common dental analgesic and anti-infective called eugenol, which is used to calm the pulp.
- If you have lost a filling and the tongue is being cut on the sharp edges of the tooth, a temporary cavity material available at your local pharmacy can be used to fill the cavity and cover the sharp edges until you can see your dentist.
- If you have gum swelling and pain, over-the-counter pain medications like acetaminophen (Tylenol), ibuprofen (Advil), or aspirin can be used unless you have a medical condition contraindicating their use. You can also apply a numbing gel to the gum, such as Anbesol. Such gels are found at most pharmacies.
- If you have pain in the jaw, the use of ice or heat is advisable. Ice is better for joint injury and heat is better for muscle tension, but try both to see what works. Place a hot or cold pack over the sore area for twenty minutes, taking care not to burn or freeze the skin surface by taking it on and off during this time.
- Muscle rubs like Theraflex, Ben-gay or sports cream can also be rubbed on the cheek muscles to help them to relax. Do not ingest these substances.
- Separating the teeth for a while with a night guard can also help until you can get to the dentist. These are comparable to sports guards used by athletes and are available in most drug and sporting good stores.
As with all medical conditions, the person who can best diagnose your dental pain is the expert- your local dentist.
When You Should See Your Dentist:
- If pain is localized to a tooth or area of the gums
- When you have swelling and pain related to the tooth or the surrounding area of the gums
- If you experience bleeding from the gums
- When a tooth is loosened or feels loose
- If you tap a tooth and it hurts
- If there is pus or an abscess in the area of the tooth, or if you develop a fever
- If you have pain from chewing that lasts longer than a week
- If there is pain in the tooth when you wake up in the morning that gets better during the day. This could be an indication of nighttime tooth grinding.
What the Dentist may do to Diagnose Your Condition:
- At an initial screen the dentist may do some ordinary medical tests, including checking your blood pressure, pulse, and temperature in order to establish your baseline health.
- The dentist will do a clinical examination of your teeth and gums, including using dental instruments to look for cavities, tooth fractures, wear of the teeth, looseness of the teeth, presence of gum infection, and bone loss. He or she will also do a cancer screen in the mouth. The dentist might also need to examine the temporomandibular joints and muscles of the face and feel your neck for swollen or tender glands.
- Based on the clinical findings, the dentist will recommend either a simple individual X- ray of the tooth or teeth to see the presence or absence of cavities, periodontal bone loss, fractures, or infection in the mouth. The dentist may also order a panoramic radiograph, which is a composite X-ray of your jaws and teeth, to look for infections in a larger area and to screen for general dental conditions .
Treatments Given by your Dentist Include:
- If an abscess is discovered, emergency care will include draining the abscess and placing you on an antibiotic for 7 to 10 days and scheduling a follow up visit .
- If you have a cavity, the dentist may choose to do a filling or a root canal depending on the condition of the tooth. You may need to be referred to an endodontist (root canal specialist) if the tooth needs advanced treatment. You may also be put on prophylactic antibiotics and the root canal may require two or even three visits before the tooth is sealed. After a root canal you must get a proper filling or a crown-type restoration on the tooth within a month, or risk the seal leaking and causing you to repeat the root canal.
- If you have a periodontal swelling (red and bleeding gums or pain in the gums) the dentist may choose to treat it with a deep cleaning . The dentist will then place you on a regimen of brushing, flossing, and rubber tipping. If you need long term anti-infective therapy, a prescription mouthwash called chlorhexidine may be prescribed instead of the regular antibiotic therapy of 7 to 10 days. Another option is a long-term, low-grade antibiotic called doxycycline hyclate, which is usually prescribed in 20mg tablets twice a day. In more advanced cases the dentist may ask you to see a periodontist (a gum specialist) if surgical therapy is needed. Again, follow up visits will be required.
- If the tooth is broken or has fracture lines, the treatment is usually extraction performed either by the dentist or a specialist (oral and maxillofacial surgeon). This will require a follow up during the healing phase. Your dentist will recommend a replacement option for the tooth. This could be a dental implant, a bridge, or a partial bridge, depending on your need. If you have your wisdom teeth removed, no replacement is necessary.
You should call your Physician or Local Emergency Services if:
- You start to develop chest symptoms along with tooth pain. These include shortness of breath, sweating, a rapid pulse, feelings of dizziness, weakness or confusion.
- You have a high fever with a rash and swelling in the neck or throat area, and are having difficulty breathing.
- You have a severe headache that coincides with the tooth pain, especially if you do not normally get headaches or if it is particularly different from ones you have experienced in the past.
- You find a lump or mass in your mouth which is painful or which you have not noticed before.
What a Physician can do:
Your physician may ask that you come in to evaluate your symptoms and decide whether you need to be treated or referred to a specialist. You may be sent for further imaging, such as a CT scan or MRI, depending on your symptoms. A full physical with diagnostic tests may be obtained to help make sure your general health is not contributing to your tooth pain. The physician may then ask that you see the dentist or another dental specialist depending on the findings.
Remember, your mouth is an indicator of your general health. Pain is nature’s way of letting you know there is something wrong. While the most common reasons for tooth pain have been covered above, there is no substitution for seeing your dentist or physician. They are the experts in your health, and should be consulted when the need arises.