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Section Questions and Answers

Toothache, Pain and a Pain Chart

  1. What is toothache?
  2. What causes toothache?
  3. How does decay cause pain?
  4. How does gum disease cause toothache?
  5. Why is it difficult to identify which tooth is causing the pain?
  6. Why do teeth become sensitive to hot, cold and sweet foods and drinks?
  7. How can decay cause severe, gnawing pain?
  8. What causes severe, throbbing pain that lasts for hours?
  9. What causes a combination of toothache, bad breath and a sour taste in the mouth?
  10. Why does a severe ache sometimes return two days after a tooth has been extracted?
  11. Why should a newly filled tooth continue to be sensitive?
  12. How does food wedged between teeth cause pain?
  13. Why does an impacted tooth cause pain?
  14. Can a cold cause a toothache?
  15. What painful effects could an accident have on the teeth?
  16. Why does a crack in a tooth cause pain?
  17. How can facial pain also cause a toothache?
  18. How is pain controlled?
  19. Toothache / pain chart. What is causing my pain?

"Oral facial pain ... is a major source of diminished quality of life. It is associated with sleep deprivation, depression and multiple adverse social outcomes."

"Most people have experienced acute pain involving teeth and the oral tissues at one time or another." - U.S. Surgeon General's Report

 
1. What is toothache?

  • Toothache is a pain in or around a tooth. It indicates the existence of a problem.

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2. What causes toothache?

  • Toothache is most often caused by tooth decay. Other causes are:
    • Gum disease
    • Trauma or injury
    • Dry socket (infection after extraction)
    • Impacted teeth
    • Malocclusion (teeth out of their normal position)
    • Toothwear
    • Sinusitis
    • Neuralgia
    • A cracked tooth

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3. How does decay cause pain?

  • Decay destroys teeth by dissolving the tooth structure. When only the enamel layer is affected it is quite painless, as the enamel has no nerve supply.
  • However, when decay spreads to the sensitive underlying dentine, the nerves register pain in response to hot, cold and sweet food and drinks.
  • As the decay penetrates deeper into the tooth, the pain increases in intensity.
    It can vary and be described as being:
    • intermittent to persistent or continuous.
    • mild, dull, aching, or gnawing, to throbbing, sharp, intense, piercing, severe, and even excruciating!

Click to enlarge
The spread of decay
and abscess on root

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4. How does gum disease cause toothache?

  • Gum disease can cause toothache by the following sequence of events:
    • Gum disease causes the gum to lose its attachment to the tooth.
    • Food and bacteria can accumulate in the space between the gum and tooth.
    • A periodontal pocket begins to develop in this space.
    • A deep, infected pocket can result in an abscess forming alongside the tooth. This is called a gumboil, and is an abscess in the gum.
    • The pain may be severe and long lasting.
    • Since the area around the tooth is now swollen and infected, chewing can be painful.
    • Temporary relief will arrive when the abscess bursts, but it will re-occur.
  • This condition can only be cured by your dentist.
    Lancing, draining, and antibiotics may be necessary.
    A periodontist may need to treat it if this is not an isolated occurrence.

Click to enlarge
Abscess in the gum
Click to enlarge
Gum disease

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5. Why is it difficult to identify which tooth which is causing the pain?

  • The trigeminal nerve is the great nerve of the face and jaws. All the teeth are linked by branches of the same nerve. A pain may be felt in the upper jaw, when the cause is a tooth in the lower jaw. This is called a 'referred pain'. It occurs when decay within a tooth is the source of the pain.
  • When pain is caused by decay that has spread to the area around a tooth, it is quite simple to locate it. An abscess is an example of this.
  • Careful examination by the dentist will discover which tooth is causing the problem.

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6. Why do teeth become sensitive to hot, cold and sweet foods and drinks?

  • The enamel layer of the tooth does not have a nerve supply, but the underlying dentine does.
  • When the dentine is exposed it will react to hot, cold and sweet foods and drinks. The pain may be mild, and will disappear immediately the cause is removed.
  • The dentine layer is exposed in the early stages of the decay process.
  • Dentine can also be exposed by any of the following:
    • Abrasion. This is the wearing away of the enamel at the gum margin by brushing too vigorously. The dentine in the root is also exposed in this way. The thin covering of cementum on the root is easily worn away.
    • Erosion. This is caused by conditions in which stomach acids are regurgitated into the mouth, and erode the enamel and dentine.
    • Attrition. This is the wearing down of teeth by grinding. It is normal for teeth to show some signs of attrition as we age. Bruxism is the abnormal grinding of teeth.
  • The problem of sensitivity in the early stages can be controlled by using a desensitising toothpaste, and having a desensitising treatment at the dentist.
    The sensitivity caused by decay will be treated by repairing the tooth with a filling.

Click to enlarge
Exposed dentine
at gum margin

See Toothwear

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7. How can decay cause severe, gnawing pain?

  • When the nerves and blood vessels (the pulp) of the tooth are first affected, the pain is intermittent and increases in severity in response to hot and cold foods and drinks.
  • As the decay advances further into the pulp, the pain can be very severe, throbbing and persistent.
  • Bouts of pain can occur from time to time, which can be aggravated by lying down.

Click to enlarge
Illustration of
x-ray showing decay

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8. What causes severe, throbbing pain that lasts for hours?

  • An abscess is usually the cause of a severe throbbing pain. It may be at an early stage or be fully developed:
    • The pain indicates that the pulp has been destroyed by the decay process.
    • A severe spell of pain can be triggered, lasting for hours.
    • The dead tissue forms gases, which react strongly to hot food and drinks.
    • An abscess will also have begun to form at the end of the root, and the gum adjacent to the tooth may be swollen.
    • This condition can cause a fever and a feeling of being unwell.
  • The treatment for this condition is to open the tooth and allow the pus to drain out. Pain relief is instant, but the tooth will still be sensitive, as the area around the end of the root is infected.
    The remedy is a root canal treatment followed by a filling or replacement crown.

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9. What causes a combination of toothache, bad breath and a sour taste in the mouth?

  • This combination of symptoms indicates that an abscess has burst into the mouth. The pus causes a sour taste and bad breath.
  • The tooth will still be sensitive and can be very painful with chewing.
  • Pain and swelling are reduced after the abscess has discharged the pus into the mouth, but treatment must be sought.

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10. Why does a severe ache sometimes return two days after a tooth has been extracted?

  • After a tooth has been extracted, the socket may become infected. This condition is called "Dry Socket".
  • The infection in the socket can cause a more severe pain than the toothache before the extraction.
  • The pain is continuous, piercing, and difficult to control with analgesics.
  • It is a dental emergency and treatment should not be delayed.

See Dry Socket

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11. Why should a newly filled tooth continue to be sensitive?

  • A tooth may remain sensitive for a week or more after it has been filled.
    • This can happen after decay has spread close to the pulp.
    • The dentine near the pulp chamber is very sensitive.
    • It needs time to lay down a protective layer of dentine, after the filling has been completed. This will provide insulation against temperature changes and reduce sensitivity.

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12. How does food wedged between teeth cause pain?

  • Ideally, teeth need to be in firm contact with the teeth in front and behind them.
    This prevents food from packing between the teeth when chewing takes place.
  • When this normal pattern is broken, small spaces can open between the teeth.
    • Food will then be forced into these spaces between the teeth, and into the gum.
    • This sets up an irritation, and the gum becomes inflamed, swollen, red and painful.
    • This inflammation can also spread to other areas around the tooth, and can cause the tooth to become tender on chewing.
  • Toothbrushing and the use of dental floss, interdental sticks or interdental brushes will help to control the problem. It should be corrected by a dentist.

See Cleaning Between the Teeth

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13. Why does an impacted tooth cause pain?

  • A partially impacted or partially erupted wisdom tooth is likely to have a flap of gum over it.
  • Food lodges under the flap and causes an inflammation around the crown of the tooth, which can be very painful.
  • A completely impacted wisdom tooth can cause pain by exerting pressure on the nerves around it, or on the tooth that is blocking its eruption.

Click to enlarge
Impacted wisdom teeth
In lower jaw

See Impacted Teeth

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14. Can a cold cause a toothache?

  • There are spaces or sinuses in the bone, above the upper teeth. The roots of some of these teeth are very close to the sinuses.
  • The nerve supply to the teeth, jaws and to most of the face is provided by branches of the same nerve, the trigeminal nerve.
  • The sinuses often become infected during a head cold, and this sinusitis can cause the upper teeth to ache and feel "on edge."
  • Since the teeth are not the cause of the problem this is also called "a referred pain".
  • When the sinusitis clears up, the toothache will go away.

Click to enlarge
The fine line defining
the sinus

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15. What painful effects could an accident have on the teeth?

  • Accidents can cause damage to teeth, particularly front teeth. The intensity of the pain will depend on the nature and degree of the damage.
  • When a large piece of tooth has broken off, the nerves and blood vessels will be exposed. This is very painful. A root treatment will be needed, followed by the repair of the tooth.
  • When a tooth remains intact but is forced into the jaw, it can damage the nerves and the blood vessels to the tooth at the tip of the root. The following symptoms will be experienced:
    • The tooth will become very sensitive to the slightest pressure.
    • It may also become loose.
    • The dentist will observe the tooth carefully to assess the extent of the damage, and decide on the appropriate treatment.

Click to enlarge
Fracture
Click to enlarge
Major fracture

See Injury to Teeth

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16. Why does a crack in a tooth cause pain?

  • A fine crack or fracture can occur in a heavily filled tooth. When this extends to the pulp chamber it can cause pain on chewing and in response to hot and cold.
  • It is often difficult to find the cause of the pain. A tooth with this problem may have to be extracted.

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17. How can facial pain also cause a toothache?

  • Facial neuralgia is a condition in which pain of varying intensity affects the face.
  • Since the face and teeth share the same nerve supply, it can cause a referred pain to teeth.
  • The cause of the problem is often difficult to discover. The condition is fortunately not common.

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18. How is pain controlled?

  • Analgesics, or pain relievers as they are commonly called, are used to reduce or eliminate pain.
  • They include a variety of substances, which are available either individually or in combination.
  • They are: aspirin, ibuprofen, acetaminophen (in Paracetamol and Tylenol), codeine and morphine.
  • Some analgesics are only available on prescription, but many can be bought over the counter.
  • As a group, these medications have analgesic, antipyretic (fever reducing) and anti-inflammatory properties.

See Analgesics

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19. Toothache / pain chart. What is causing my pain?

Pain chart

Pain severity
+ = Small degree
++ = Medium degree
+++ = High degree
Glossary
Acute = Fast developing
Apical = End of root
Chronic = Slow forming
Periodontal = Around the tooth
Pulp = Nerves and blood vessels of tooth

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