Dental pain

Dental Pain (Toothache)

Introduction

Dental pain is discomfort originating from teeth or supporting oral structures. It is most commonly due to dental caries and its complications, but other local or referred causes must also be considered. Toothache is a major reason for emergency visits worldwide, and if untreated, can lead to systemic complications such as sepsis, cellulitis, or even airway obstruction.

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Anatomy of the Tooth

• Enamel: Hard outer layer, insensate.

• Dentin: Softer layer, contains tubules transmitting sensation.

• Pulp: Vascular and nerve-rich tissue, highly sensitive.

• Periodontal ligament: Anchors tooth to alveolar bone, rich in nerve endings.

Pain arises mainly from the dentin–pulp complex and periodontal tissues.

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Causes of Dental Pain

1. Dental Causes

• Dental caries: Decay penetrating enamel → dentin → pulp.

• Pulpitis: Inflammation of pulp (reversible or irreversible).

• Periapical abscess: Infection at tooth root.

• Periodontal disease: Gingivitis, periodontitis causing gum/tooth pain.

• Pericoronitis: Inflammation around erupting wisdom tooth.

• Tooth fracture or trauma.

2. Non-Dental Oral Causes

• Oral ulceration (aphthous, traumatic, herpetic).

• Temporomandibular joint (TMJ) dysfunction.

• Post-dental extraction pain (dry socket).

3. Referred Pain

• Sinusitis (maxillary sinus pain radiating to upper teeth).

• Neuralgias (trigeminal neuralgia).

• Ear or jaw disorders.

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Clinical Presentation

• Dental caries/pulpitis: Sharp pain on chewing or temperature; reversible pulpitis → brief pain; irreversible pulpitis → severe, persistent, throbbing.

• Periapical abscess: Severe localized pain, swelling, tender tooth.

• Periodontal disease: Dull aching, gum swelling, bleeding.

• Pericoronitis: Pain around partially erupted wisdom tooth, trismus, bad taste.

• Trauma/fracture: Sharp pain on biting.

• Referred sinusitis: Dull, diffuse pain in upper teeth with nasal congestion.

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Diagnostic Approach

1. History

• Onset, character (sharp/dull), duration, triggers (heat, cold, chewing).

• Recent dental procedures, trauma, infection.

• Medical history (diabetes, immunosuppression).

2. Examination

• Oral inspection: caries, fractured teeth, swelling, abscess.

• Percussion test (tenderness of tooth).

• Palpation: gingival swelling, fluctuance.

• Mobility of tooth (periodontal disease).

• Check occlusion, TMJ.

3. Investigations

• Dental X-rays: Periapical, bitewing (caries, abscess).

• Panoramic X-ray (OPG): Wisdom teeth, sinus, jaw pathology.

• Blood tests: Rare, unless systemic infection suspected.

• CT/MRI: For deep fascial space infection.

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Management and Treatment

Management depends on cause and severity.

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A. General Principles

• Pain relief.

• Control infection.

• Preserve or restore tooth if possible.

• Definitive dental treatment (filling, root canal, extraction).

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B. Pharmacological Treatment

1. Analgesics

• Paracetamol (acetaminophen): 500–1000 mg orally every 6–8 h (max 4 g/day).

• Ibuprofen: 400 mg orally every 6–8 h (max 2400 mg/day).

• Combination: Paracetamol + Ibuprofen provides synergistic relief.

• Diclofenac: 50 mg orally twice daily if ibuprofen not tolerated.

• Opioids (e.g., codeine 30–60 mg orally every 6 h) for severe pain (short-term, with caution).

2. Antibiotics (only if spreading infection, abscess, cellulitis, systemic symptoms)

• Amoxicillin: 500 mg orally every 8 h for 5–7 days.

• Amoxicillin–clavulanate: 875/125 mg orally twice daily for 5–7 days (if resistant).

• Metronidazole: 400 mg orally every 8 h for 5–7 days (often combined with amoxicillin for anaerobic coverage).

• Clindamycin: 300 mg orally every 6 h (alternative if penicillin allergy).

3. Local Measures

• Warm saline rinses.

• Topical anesthetic gels (lidocaine viscous 2%).

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C. Specific Treatments

1. Dental Caries

• Removal of decayed tissue, restoration with filling.

• Fluoride therapy.

2. Pulpitis

• Reversible: Remove decay, filling.

• Irreversible: Root canal treatment or extraction.

3. Periapical Abscess

• Drainage (via root canal or incision).

• Antibiotics if systemic involvement.

4. Periodontal Disease

• Scaling, root planing.

• Oral hygiene instruction.

• Chlorhexidine 0.12% mouthwash twice daily.

5. Pericoronitis

• Irrigation, debridement.

• Antibiotics if spreading infection.

• Extraction of impacted wisdom tooth if recurrent.

6. Dry Socket (post-extraction alveolar osteitis)

• Irrigation with saline.

• Medicated dressing (eugenol-containing paste).

• Analgesics for pain relief.

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D. Emergency Situations

• Spreading cellulitis, swelling extending to submandibular/neck spaces → risk of airway compromise (Ludwig’s angina).

  • Requires IV antibiotics:

    • Ampicillin–sulbactam 3 g IV every 6 h or

    • Clindamycin 600 mg IV every 8 h.

  • Hospital admission and surgical drainage.

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Complications

• Chronic infection, tooth loss.

• Facial cellulitis, osteomyelitis of jaw.

• Sinusitis (from maxillary teeth).

• Airway obstruction (Ludwig’s angina).

• Sepsis (rare, but life-threatening).

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Prognosis

• Simple caries/pulpitis: Excellent with prompt treatment.

• Abscess: Good if drained; risk of spread if untreated.

• Periodontal disease: Chronic, manageable with oral hygiene.

• Pericoronitis: Recurs until wisdom tooth removed.

• Serious infections: Prognosis depends on early recognition and intervention.

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Patient Education

• Brush teeth twice daily with fluoride toothpaste.

• Floss daily and maintain oral hygiene.

• Regular dental check-ups every 6–12 months.

• Limit sugary foods and drinks.

• Avoid self-medicating with antibiotics without dental consultation.

• Seek immediate care if swelling, fever, or difficulty breathing/swallowing occurs