“The man with a toothache thinks everyone happy whose teeth are sound.”
-George Bernard Shaw
Toothaches are terrible. Most who have experienced one will validate this notion. It can be one of the worst acute pain events one can endure in life. Even worse, it always seems to happen on a weekend, vacation or in the evening when access to dental care can be difficult. Just ask Tom Hank’s character in the film Cast Away… If only Wilson the volleyball had some dental training!
Most often, dental pain starts out mild (this does not apply to trauma or with recently completed dental work). Typically, a tooth will become sensitive to hot or cold foods and possibly even sweets. The sensitivity will progress and become bothersome with chewing or clenching and eventually, symptoms will worsen.
Cold foods illicit pain that will linger and even throb. The pain will become unbearable and continue as a constant throbbing sensation with intermittent sharp, intense pains that can buckle your knees. Sometimes it will feel as though you cannot even locate the source as it seems to travel to other regions of the mouth. Patients often report that the pain mimics an earache as well. Even after the cold sensitivity subsides, the constant throbbing pain can cause patients to lose sleep and become extremely irritable and miserable.
Typically, this is when I hear from patients and frequently it is after hours or over the weekend. You can hear it in their voice and when you speak to them; their misery is palpable. If left untreated at this stage, a patient can experience facial swelling which can travel down into the neck or up into the cheek and areas surrounding the eyes. This type of progression is when acute dental infections become dangerous to your overall health and need immediate intervention, especially if the patient is having trouble swallowing, breathing or experiences changes in their vision. If any of these symptoms are present, individuals should go to the Emergency Room because the consequences could be severe.
Luckily, most toothaches do not reach this point because the pain is bad enough that they will find their way to a dentist for care. Diagnosing dental needs before they become problems is what we in the dental profession are attempting to do with routine cleanings, dental x-rays, and exams. Preventing people from having this type of experience is important to us, but despite our best efforts, dental problems and pain find a way of causing patients trouble anyway.
So, let us talk about what causes it. For the sake of brevity, I am only going to explain the three most common scenarios I encounter causing acute dental pain.
1. Deep dental decay that is close to the pulp chamber, or what most refer to as the “nerve” of the tooth.
Often a cavity that is left unchecked for a long period of time will advance itself to a point where the causative bacteria will begin invading the nerve chamber. In response to the invasion the body will send its defense mechanism to the area to defend against the infection. This will create inflammation within and around the tooth sparking heightened and lingering cold pain and will begin to make the tooth hurt to chew on. Eventually the “nerve” of the tooth will die and there will be no blood flow into and out of the tooth. White blood cells and inflammatory mediators will congregate around the root tips to wall off the progressing bacterial infection and usually this causes a dental abscess to form. Hopefully, the abscess has an external access through the surrounding bone and gum tissue to drain from. This is called a fistula and if not present, typically swelling will worsen and create more pain and complications.
2. Recent dental restorative work completed to repair a tooth for several reasons.
Large fillings and crown restorations done to repair cavitations, fractures and much more are exceptionally important to have done when needed. However, no medical or dental procedure is without risk. In fact, several studies show completing a crown or large filling on a tooth that has been worked on previously puts the tooth at risk of a nerve problem approximately 10% of the time. I believe the statistics in our office are a bit lower, but it is something that can happen. Most frequently this complication is worth the risk, because without the proper restoration of the tooth, the long-term prognosis is severely decreased.
3. Tooth fracture, both root system and/or the crown portion.
Teeth can break. They are more at risk of breaking when large fillings are holding teeth together without crown restorations. Also, teeth that have previously been root canaled are at a much higher risk of fracturing, especially if it is a tooth that is supporting a dental bridge. When this happens, bacteria traveling down the cracked surface create issues described in the first scenario. The body’s reaction to the crack itself will also illicit a severe pain response. Unfortunately, the only treatment in this scenario is removal of the fractured tooth and possibly the entire bridge.
How do we fix it?
In all three scenarios, a dentist will address the cause of the problem. If it is related to situations one or two, typically a tooth can be saved. Antibiotics are customarily given to reduce the number of pathogenic bacteria present, which will also reduce the body’s immune and inflammatory response. Anti-inflammatory pain reducing medications will be prescribed to alleviate pain and swelling and provide a window of time for comfortable treatment. Treating an infected and/or dying tooth nerve involves cleaning/sterilizing out all dead or dying nerve tissue and bacteria inside of the tooth and sealing all entry points so that the body will no longer recognize there is a problem in the area. This procedure is commonly referred to as a Root Canal. In back teeth, I almost always recommend a crown restoration be done to help prevent the third situation on our list, fracture. This should be completed within 8 months following Root Canal treatment.
In our third scenario, a major component of the tooth has fractured, and the structural integrity of the tooth is undermined. Most of these situations indicate that the tooth should be extracted and eventually replaced with either a dental implant or bridge. This would be determined based on multiple factors that will not be talked about in this post.
If you are experiencing mild dental pain, please contact a dentist to rule out major problems. This could save you major pain and suffering that I promise will change your opinion about coming to the dentist for routine care. It can also save you the cost of more extensive dental treatment that no one likes to budget for.
As always, call and schedule an appointment if you are concerned about problem areas in your mouth!
Andrew Hamilton DDS, FAGD