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Toothache

Overview

Toothache, or pain in one or more teeth, is a common condition that occurs due to multiple causes. Most cases are directly associated with an injury, abnormality, or infection in the tooth or its supporting tissues. Your teeth are supported inside by an alveolar bone that forms sockets in which the tooth is aligned. Within these sockets, they are held in position by solid fibers called periodontal ligaments that attach the bone with the tooth’s outer surface. Finally, they are covered by a layer of soft tissue called gingiva or gums. Any irregularity within the tooth or its supportive structure can cause toothache. Some causes of a toothache may be of non-dental origin as well.

Causes

The causes of toothache are divided into dental and non-dental, depending on its origin. Dental causes include dental caries, dentin hypersensitivity, pulpitis, periapical abscess, periodontitis, trauma or injury, pericoronitis, and certain other abnormalities.
Pulpitis is one of the most common reasons for a toothache. In simple terms, it is the inflammation of the pulp within a tooth structure. This inflammation can be due to dental caries, mechanical injury, chemical irritation, and thermal or electric shock. Dentin hypersensitivity is another important cause that occurs because of the breakdown of the outer layer enamel. Even a blow of air can be painful for the patient in this case. A periapical abscess occurs at the tip of the tooth root and can make the affected tooth extremely painful to percussion. Trauma or injury can form cracks or split a tooth from in between, resulting in extreme toothache. Food entrapment in between teeth, endodontic lesions, occlusal dysfunction, and pericoronitis can also cause toothache.
Non-dental causes of toothache include migraine, trigeminal neuralgia, myofascial pain, oral carcinoma, sinusitis, and temporomandibular disorders.

Risk Factors And Epidemiology

Poor oral hygiene is a significant factor that can affect your teeth in more than one way. Failure to maintain proper oral hygiene results in excessive plaque and calculus deposition around the teeth. This can increase the risk of caries and gingivitis. High sugar intake in liquid or solid form can be equally damaging to the tooth structure. A dry mouth increases the risk of caries hence toothache as well. Patients with diabetes, xerostomia, or immunocompromising diseases are at a high risk of developing tooth-related problems.
Toothache due to traumatic injury is very common among young children. Although toothache can be experienced at any age, research indicates that it is more commonly observed in individuals aged 18-35 years.

Signs And Symptoms

The signs and symptoms of toothache depend on its cause of origin. Toothache due to pulpitis can cause minor to extreme shock-like pain (primarily upon lying down), hypersensitivity and tenderness. Dentin hypersensitivity can make you extremely sensitive to hot or cold temperatures. Toothache associated with periapical causes can cause pain in the affected tooth when you bite on anything or meet the opposing arch’s teeth. An affected tooth might be mobile as well due to a large abscess or periodontitis. Your dentist must correctly identify the origin and cause of pain before beginning any treatment.

Diagnosis

The primary step to diagnosing the cause of a toothache is to obtain a detailed history from the patient followed by a thorough clinical examination. The symptoms explained by the patient can help in differentiating between different causes of toothache. Clinical examination by a mouth mirror and a probe can tell a lot about the origin of pain. If pulpitis is suspected, the affected tooth is exposed to a hot and cold stimulus, or an electric pulp tester is used to differentiate between reversible and irreversible pulpitis. The interdental areas are carefully examined with a probe to eliminate any accumulated food substances. The back of a mirror can be used to percuss a tooth to identify whether the cause is of a periapical or periodontal origin. Dental x-rays such as PA x-ray, bitewing radiographs, and OPGs are done to visualize the underlying infections that are not visible on clinical examination. 

Differential Diagnosis

Shock-like toothache that initiates upon hot or cold stimulus indicates reversible pulpitis. Spontaneous, prolonged-lasting toothache due to pulpal inflammation indicates irreversible pulpitis. If a tooth hurts upon vertical percussion by a mirror, a periapical infection is suspected, and if it hurts upon horizontal percussion, a periodontal infection is suspected. Toothache that occurs at the far end of the teeth, along with gingival swelling, is indicative of pericoronitis. Other factors that might cause referred teeth pain, such as myofascial pain, trigeminal neuralgia, etc., should be diagnosed by external symptoms.

Treatment

Treatment of toothache is dependent upon the cause of pain. If a tooth has only been affected till its dentin layer and pulp hasn’t been involved yet, a suitable restorative filling with or without a cavity liner is done. In case of a pulpal infection, the most suitable option is to go for a root canal treatment in which the pulp canal is debrided, shaped, and filled closed. The placement of a dental crown often follows this. A dental abscess will require incision and drainage to relieve the toothache. Extra-oral causes of pain need to be treated accordingly after an accurate diagnosis.

Medication

Oral analgesics such as aspirin, diclofenac sodium, naproxen, ibuprofen, etc., are prescribed to reduce the pain of the affected tooth. In case of a periapical infection or a dental abscess, your dentist might prescribe oral antibiotics such as penicillin, metronidazole, etc., to clear off the signs of infection.

Prognosis

If the problem is identified and treated early, the tooth can be saved and continue to function for a long time. In late stages, where the tooth is too damaged to be repaired, it might have to be extracted and replaced with an artificial tooth.

Prevention

The primary prevention method to minimize the chances of toothache is to brush twice a day, floss regularly, clean between your interdental areas, and maintain good oral hygiene. Bi-annual visits to your dentist can also reduce the occurrence of toothache.