|Classification and external resources|
Toothache (also termed dental pain, odontalgia, dentalgia, odontodynia, or odontogenic pain), is pain in the teeth, their supporting structures, or both; caused by dental disease or non-dental disease which is perceived as toothache. The most common cause is pulpitis (inflammation of the tooth pulp), usually as a result of dental decay or dental trauma; and its sequalae, periapical periodontitis and dental abscess. The gums may also be the cause of the pain, e.g. when teeth erupt into the mouth (see teething and pericoronitis), or if a periodontal abscess occurs. Dental causes account for about 95% of all cases of orofacial pain. Rarely, the cause of the pain may not be dental, e.g. maxillary sinusitis which may present as pain felt in the upper teeth at the back of the mouth.
Since the causes of toothache are varied, the treatment is dependent upon the exact cause. In the case of pulpitis, if reversible, a dental filling may suffice to remove the pain; but if irreversible, root canal therapy or dental extraction are generally required. In modern times, toothache is the most common reason for emergency dental appointments, and the relief of toothache is considered one of the main responsibilities of dentists. Historically, the problem of toothache is thought to have lead to the first specialty of medicine, i.e. dental surgery. Over time many different toothache cures have been recorded.
- 1 Definitions
- 2 Differential diagnosis
- 3 Pathophysiology
- 4 Diagnostic approach
- 5 Treatment
- 6 Epidemiology
- 7 History, society and culture
- 8 Research
- 9 Other animals
- 10 See also
- 11 References
- 12 External links
Toothache is pain felt in the teeth. It is the most common type of orofacial pain.
Referred pain is "the perception of pain in one part of the body that is distant from the actual source of the pain." Pain from the teeth can be referred to elsewhere in the head and neck, and pain from elsewhere can be referred so it is perceived to be originating from the teeth (non-odontogenic toothache).
Toothache is most commonly classified as odontogenic and non-odontogenic.
Generally, pulpal pain is poorly localized, and there may be sensitivity to sweet, hot or cold stimuli. The tooth pulp behaves like a visceral structure in terms of how associated pain is perceived.
Pulpitis is inflammation of the dental pulp. This is the most common form of odontogenic pain. This can be either reversible or irreversible. Irreversible pulpitis can be identified by sensitivity and pain lasting longer than fifteen seconds, although an exception to this may exist if the tooth has been recently operated on. Teeth affected by irreversible pulpitis will need either root canal treatment or extraction of the tooth. One form of pulpitis is termed barodontalgia, a dental pain evoked upon changes in barometric pressure, in otherwise asymptomatic but diseased teeth.
- Dentin hypersensitivity is caused by exposed dentin (e.g. as a result of loss of the covering enamel or gingiva).
- Cracked tooth syndrome is a special case because it may cause either pulpal or periodontal pain, the latter if the fracture line involves the periodontal ligament.
In contrast to pulpal pain, pain from the periodontal ligament is generally well localized to one or more teeth, and may be aggravated by biting or putting pressure on the teeth. This is because there are proprioceptors in the periodontal ligament. This makes periodontal pain similar to musculoskeletal pain. The individual is often able to differentiate between pain located at the periapex and lateral periodontal pain. Unlike pulpal pain, peridontal pain is not usually exacerbated by hot or cold stimulae.
A periodontal abscess (also termed a lateral abscess) is a type of dental abscess which involves the periodontium. It is less frequent than a periapical abscess, but it is still a common condition. Unlike the periapical abscess, the the involved tooth is usually vital and without any symptoms of pulpitits (i.e. no thermal or sweet sensitivity). A periodontal abscess usually occurs as a complication of chronic periodontitis, which is normally a painless condition. Chronic periodontitis is characterized by the formation of periodontal pockets. These are pathologically deepened gingival crevices which are greater than 3mm in depth. A periodontal pocket contains subgingival plaque (a bacterial biofilm) and calculus. The periodontal tissues are in a state of inflammation due to the presence of the baceteria and their toxins. Bacteria continually find their way into the soft tissues from the periodontal pocket, but the immune system keeps them in check. If this balace is disrupted, bacteria may start to invade and multiply within the soft tissues (i.e. a true infection), which causes an acute inflammatory response. The body tries to isolate the infection by forming an abscess filled with pus. Therefore, systemic factors which impair immunity such as diabetes predispose t the formation of periodontal abscesses.
If the communication of the periodontal pocket with the rest of the mouth is obstructed, the bacteria become trapped and are more likely to form an abscess. Examples of how this obstruction might occur are food packing into a periodontal pocket. This often happens between teeth that have dental fillings in them, if the contact points have not been shaped correctly. Other causes include periodontal scaling, which causes the gums to tighten around the teeth. If any subgingival calculus has been left in the pocket, a periodontal abscess may then develop. A penetrating injury to the gingiva e.g. with a toothbrush bristle, fishbone or toothpick may also innoculate bacteria in to the soft tissues. Dental trauma may also involve the periodontium and lead to abscess formation.
Toothache caused by a periodontal abscess is generally deep and throbbing. The oral mucosa covering an early periodontal abscess appears erythematous (red), swollen and painful to touch. The surface may be shiny due to stretching of the mucosa over the abscess. Before pus has formed, the lesion will not be fluctuant, and there will be no purulent discharge. There may be regional lymphadenitis. When pus forms, the pressure increases, with increasing pain, until it spontaneously drains relieving the pain. When pus drains into the mouth, a bad taste is perceived. Usually drainage occurs via the periodontal pocket, or else the infection may spread as a cellulitis or a purulent odontogenic infection. Local anatomic factors determine the direction of spread (see fascial spaces of the head and neck). There may be systemic upset, with malaise and pyrexia.
Acute necrotizing ulcerative gingivitis
Gingivitis is usually a painless condition. An acute form of gingivitis/periodontitis can develop, often suddenly, which is associated with severe periodontal pain, bleeding gums and "punched out" ulceration and loss of the interdental papillae. Predisposing factors include poor oral hygiene, smoking, malnutrition, psychological stress and immunosuppression.
Also termed dry socket is a complication of tooth extraction, where the blood clot has been lost and bare bone is exposed. Healing is prolonged and pain is often severe. which is a condition arising after having one or more teeth extracted (especially mandibular wisdom teeth).
Occlusal trauma or overload refers to excessive forces being exerted on the teeth which overload the peridontal ligament, e.g. as may occur with bruxism. Bruxism is parafunctional (abnormal) clenching and grinding of teeth, which may occur during sleep or whilst awake. There may be attrition of the teeth (which may also cause dentin hypersensitivity), Occlusal trauma may even lead to the formation of a periodontal abscess.
Another common cause of occlusal truama may occur after a new dental restoration is placed. Often, new restorations are slightly non-conformative to the existing occlusion, for example they may have a high spot which places more force on the tooth during chewing. A few days of biting on a tooth with a high spot are enough to cause soreness as the periodontal ligament is being overloaded. This situation is easily managed by reducing the high spot.
Tightening of Dental braces may cause periodontal pain, or even the formation of a periodontal abscess.
- Trigeminal neuralgia
- Cytotoxic chemotherapy-induced neuropathy
- Atypical odontalgia is a form of toothache present in apparently normal teeth, or which persists after the supposedly offending tooth has been removed. Some sources consider atypical odontalgia to be a sub-type of atypical facial pain, although others treat them as the same entity. The pain, generally dull, often moves from one tooth to another for a period of 4 months to several years. The cause of atypical odontalgia is not yet clear, and many different theories have been proposed, including theories that the pain is psychogenic in nature. Some form of nerve deafferentation is plausible, but it is likely that AFP and atypical odontalgia are in truth umbrella terms for a collection of multiple different causes of pain which have not been properly diagnosed or are not yet fully understood.
- Referred pain of angina pectoris or a myocardial infarction.
The severity of a toothache can range from a mild discomfort to excruciating pain, which can be experienced either chronically or sporadically. This pain can often be aggravated somewhat by chewing or by hot or cold temperature. Severe pain may be considered a dental emergency.
The most common cause of toothache is pulpitis, usually secondary to dental caries. Untreated, pulpitis generally follows a predictable natural history, with gradual transition and mixed symptomatic expression between the following stages:
- Reversible pulpitis symptoms increasing in severity. Reversible pulpitis is poorly localized.
- Irreversible pulpitis symptoms increasing in severity. Irreversible pulpitis without periapical periodontitis is poorly localized.
- Pulpal necrosis, possibly giving sudden relief of pain from pulpitis
- Acute periapical periodontitis giving pain on biting, and the pain becomes well localized to the involved tooth.
- As the infection and inflammation progresses, a localized dentoalveolar abscess may form causing pain from the pressure of trapped pus within the abscess.
- Most often, the abscess spontaneously drains locally into the mouth. A parulis (gumboil) may form on the alveolus. Once the infection is draining, the pressure decreases and the pain is much reduced or even disappears. There may be a bad taste. However, pressure is required to keep the sinus patent, and the sinus may start to heal over, leading to renewed buildup of pressure with the return of pain. If left untreated, this process becomes cyclic, with periods of worse toothache when the abscess is not draining and under pressure, and periods without any pain when the abscess is draining.
- Sometimes, infection may spread from the region of the periapex as a cellulitis or pyogenic infection. Anatomic factors largely govern the direction of spread. See odontogenic infection and fascial spaces of the head and neck. The most common fascial space involved by dental infections is the buccal space, giving the appearance of a swollen cheek. Again, the pressure in the tissues causes pain, and once the infection drains the majority of the pain will be removed.
- Palpation of the muscles of mastication, which may be tender in TMD and bruxism.
- Percussion of the teeth, usually with the end of a dental mirror. This is carried out both vertically and horizontally, since this may help to distinguish between periapical abscesses and lateral periodontal abscesses respectively.
- Pulp sensitivity tests, usually carried out with a cotton wool pledget sprayed with ethyl chloride to serve as a cold stimulus, or with an electric pulp tester. The air spray from a 3 in 1 syringe can also be used to demonstrate areas of dentin hypersensitivity.
- Gentle probing of the tooth and the gums with a dental probe.
- Radiographs are often utilized.
- Assessment of biting on individual teeth (sometimes helps to localize the problem) or the separate cusps (may help to detect cracked cusp syndrome).
- Less commonly involved tests might include trans-illumination (e.g. to detect congestion of the maxillary sinus or to highlight a crack in a tooth), dyes (also to help visualize a crack).
The treatment is cause-related.
Toothache may occur at any age, in either sex and in any geographic region. Diagnosing and relieving toothache is considered one of the main responsibilities of dentists. Irreversible pulpitis is thought to be the most common reason that people attend for emergency dental treatment. In the United States, an estimated 12% of the general population have suffered from toothache at some point in the preceding 6 months.
History, society and culture
The first known mention of tooth decay and toothache occurs on a Sumerian clay tablet now referred to as the "Legend of the worm". It was written in cuniform, recovered from the Euphrates valley and dates to around 5000 BC. The belief that tooth decay and dental pain was caused by "tooth worm" is found in ancient India, Egypt, Japan, and China, and persists until the Age of Enlightenment.
Although toothache is an ancient problem, it is thought that people suffered less dental decay due to a lack of refined sugars in their diet. On the other hand, diets were frequently more coarse, leading to more tooth wear. For example, it is hypothesized that ancient Egyptians had a lot of tooth wear due to desert sand blown on the wind mixing with the dough of their bread. The Ancient Egyptians wore amulets to prevent toothache. The Ebers papyrus (1500 BC) details a recipe to treat "gnawing of the blood in the tooth", which included fruit of the gebu plant, onion, cake and dough, to be chewed for four days.
In Christianity, Saint Apollonia is the patron saint of persons with toothache and other dental problems. She was an early Christian martyr who was persecuted for her beliefs in Alexandria during the Imperial Roman age. A mob struck her repeatedly in the face until all her teeth were smashed. She was threatened with burning alive unless she renounced Christianity, but instead chose to throw herself onto the fire. Supposedly, toothache sufferers who invoke her name will find relief.
In the fifteenth century, Priest-physician Andrew Boorde describes a method to "deworming technique" for the teeth:
And if it [toothache] do come by worms, make a candle of wax with Henbane seeds and light it and let the perfume of the candle enter into the tooth and gape over a dish of cold water and then you may take the worms out of the water and kill them on your nail.
French anatomist Ambroise Paré recommended the following:
Toothache is, of all others, the most atrocious pain that can torment a man, being followed by death. Erosion (i.e. dental decay) is the effect of an acute and acrid humour. To combat this, one must recourse to cauterization [...] by means of cauterization [...] one burns the nerve, thus rendering it incapable of again feeling or causing pain.
Pellitory (Anacyclus pyrethrum) was traditionally used to relieve toothache.
The Scottish poet, Robert Burns wrote "Address to the Toothache" in 1786, inspired after he suffered from it. The poem elaborates on the severity of toothache, describing it as the "hell o' a' diseases" (hell of all diseases).
A number off plants and trees include "toothache" in their common name. E.g. prickly ash (Zanthoxylum americanum) is sometimes termed "toothache tree", and its bark, "toothache bark"; whilst Ctenium Americanum is sometimes termed "toothache grass" and Acmella oleracea is called "toothache plant".
The phrase "Toothache in the Bones" is sometimes used to describe the pain of diabetic foot with peripheral symmetric polyneuropathy.
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- Joseph C Segen. McGraw-Hill Concise Dictionary of Modern Medicine. 2002 The McGraw-Hill Companies, Inc.
- [editor, Linda Duncan, developmental editor, Courtney Sprehe] (2008). Mosby's dental dictionary. (2nd ed.). St. Louis, Mo.: Mosby. ISBN 978-0323049634.
- Scully, Crispian (2013). Oral and maxillofacial medicine : the basis of diagnosis and treatment (3rd ed.). Edinburgh: Churchill Livingstone/Elsevier. pp. 125–135. ISBN 9780702049484.
- Fedorowicz Z, Keenan JV, Farman AG, Newton T. Antibiotic use for irreversible pulpitis. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD004969. DOI: 10.1002/14651858.CD004969.pub2.
- Wolf, CA; Ramseier, CA (2012). "[The image of the dentist. Part 1: Results of a literature search]". Schweizer Monatsschrift fur Zahnmedizin = Revue mensuelle suisse d'odonto-stomatologie = Rivista mensile svizzera di odontologia e stomatologia / SSO 122 (2): 121–32. PMID 22362180.
- Suddick, RP; Harris, NO (1990). "Historical perspectives of oral biology: a series". Critical reviews in oral biology and medicine : an official publication of the American Association of Oral Biologists 1 (2): 135–51. doi:10.1177/10454411900010020301. PMID 2129621.
- Hargreaves KM, Cohen S (editors), Berman LH (web editor) (2010). Cohen's pathways of the pulp (10th ed.). St. Louis, Mo.: Mosby Elsevier. p. 40. ISBN 978-0-323-06489-7.
- Li, Wei; Huang, Jian Tao; Chen, Xiao Qing; Shi, Rong Hua; Jiang, Lei; Zhao, Yun Fu (2011). "Non-odontogenic toothache revisited". Open Journal of Stomatology 01 (3): 92–102. doi:10.4236/ojst.2011.13015.
- Cawson RA; Odell EW (2008). Cawson's essentials of oral pathology and oral medicine (8th ed.). Edinburgh: Churchill Livingstone. p. 70. ISBN 0702040010.
- Hupp JR, Ellis E, Tucker MR (2008). Contemporary oral and maxillofacial surgery (5th ed.). St. Louis, Mo.: Mosby Elsevier. pp. 619–627. ISBN 9780323049030.
- Merck. Toothache and Infection. The Merck Manuals Online Medical Library.
- Zadik Y, Chapnik L, Goldstein L (June 2007). "In-flight barodontalgia: analysis of 29 cases in military aircrew". Aviat Space Environ Med 78 (6): 593–6. PMID 17571660. Retrieved 2008-07-16.
- Zadik Y (August 2006). "Barodontalgia due to odontogenic inflammation in the jawbone". Aviat Space Environ Med 77 (8): 864–6. PMID 16909883. Retrieved 2008-07-16.
- Magloire, H; Maurin, JC; Couble, ML; Shibukawa, Y; Tsumura, M; Thivichon-Prince, B; Bleicher, F (2010 Fall). "Topical review. Dental pain and odontoblasts: facts and hypotheses". Journal of orofacial pain 24 (4): 335–49. PMID 21197505.
- "Parameter on Acute Periodontal Diseases". Journal of Periodontology 71 (5–s): 863–866. 2000. doi:10.1902/jop.2000.71.5-S.863. PMID 10875694.
- Zadik Y, Vainstein V, Heling I, et al. (September 2010). "Cytotoxic chemotherapy-induced odontalgia: a differential diagnosis for dental pain". J Endod 36 (9): 1588–92. doi:10.1016/j.joen.2010.05.004. PMID 20728733.
- Ingle JI, Bakland LK, Baumgartner JC (editors) (2008). Endodontics (6th ed.). Hamilton, Ontario: BC Decker. pp. 48–52. ISBN 9781550093339.
- "Ancient dentistry". British Dental Association 2010. Retrieved 13 December 2013.
- "Why did the Ancient Egyptians suffer from toothache?". BBC 2013. Retrieved 13 December 2013.
- Burns, Robert. "Address to the toothache". BBC. Retrieved 13 December 2013.
- WebMD Dental Health & Toothaches
- Mayo Clinic Toothache First Aid
- U.S. National Library of Medicine: Toothaches