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==Definitions==
==Definitions==
Toothache is [[pain]] in the teeth, their [[periodontium|supporting structures]], or both; caused by [[dental disease]] or non-dental disease which is perceived as tooth pain.
[http://stopyourtoothachenow.com/?hop=abushanady Toothache] is [[pain]] in the teeth, their [[periodontium|supporting structures]], or both; caused by [[dental disease]] or non-dental disease which is perceived as tooth pain.


==Differential diagnosis==
==Differential diagnosis==

Revision as of 23:52, 22 December 2013

Toothache
SpecialtyGastroenterology Edit this on Wikidata

Toothache (also termed dental pain,[1] odontalgia,[2] dentalgia,[2] odontodynia,[2] 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.[3] 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,[4] and the relief of toothache is considered one of the main responsibilities of dentists.[5] Historically, the problem of toothache is thought to have lead to the first specialty of medicine, i.e. dental surgery.[6] Over time many different toothache cures have been recorded.

Definitions

Toothache is pain in the teeth, their supporting structures, or both; caused by dental disease or non-dental disease which is perceived as tooth pain.

Differential diagnosis

The layers of the tooth, the pulp and dental decay
The layers of the tooth, the pulp and dental decay

Toothache is the most common facial pain, affecting as much as 12% of the U.S. population in any 6 months period.[7]. Toothache can arise from either dental (odontogenic) sources, such as the teeth and their supporting structures or non-dental (non-odontogenic) sources like the sinuses, muscles and nerves of the face.[8]. In both cases, the pain pathway, from the source of the pain to the brain, is transmitted along nerves (mostly A-delta and C fibres which transmit noxious stimuli), processed in the brainstem and perceived in the frontal cortex.[7] Because pain perception is complex and involves overlapping sensory systems of the body, individual response to the same stimulus will vary greatly. Diagnosis of toothache, therefore must look for specific clues to point source.

Dental sources of pain

Toothache can have two dental sources of pain; either the tooth itself, or its supporting structures (the periodontium)[9]. The tooth is made of enamel over a softer core called dentin. Under the dentin, on the inside of the tooth, the root canal and pulp chamber contain the nerves and blood vessels of a tooth. The pulp structure is soft tissue (compared to the hard tissue of the outer structures) and susceptible to inflammation. The entire structure is supported by the periodontium (made of the periodontal ligament and alveolus bone) and surrounded by gingiva.

As pulp and periodontium are embryologically different, pain originating from each will be perceived differently.[10][11]

Pulpal pain

The pulp of the tooth can cause pain in one, or a combination of ways due to rich innervation of nerve fibres (mostly A-delta and A-beta) that transmit fast, intense bursts of pain. The pulp can be healthy but stimulated through an exposed root such as in dentin hypersensitivity, a cracked tooth can cause pain due to a combination of factors, the pulp can have reversible pulpitis with sensitivity to cold, osmotic changes (sweet, salty or sour), or both, the pulp can have irreversible pulpitis with longer duration and more intense pain to thermal changes or the pulp can be abscessed where noxious byproducts of the dying tissue leave the tooth apex and cause periapical pain.[12]

Pulpitis
Main article: Pulpitis
Decay that has reached the pulp
Decay that has reached the pulp

Collectively, the nerves, blood vessels and other soft tissue inside a tooth are called the pulp and inflammation of the pulp is referred to as pulpitis. The causes for pulpitis can be mechanical, thermal, chemical and bacterial injuries.[13]

Pulpitis is initially difficult to localize to a specific tooth because of a lack of pressure-type receptors in the pulp. Instead, there are pain-type receptors and the pain is perceived in a general area of the face rather than the tooth itself. The analogy being that when a testicle is injured, pain is felt in the abdomen rather than the testicle alone.[14] When the pulp of the tooth becomes inflamed, a pulpitis occurs, nerves become sensitized and a toothache occurs as commonly happens when a cavity gets too large. However, pulpitis can have many causes including a cracked tooth, a leaking filling or trauma.

Pulpitis can be reversible or irreversible. Early inflammation and swelling of the pulp causes sensitivity to cold and sometimes hot.[11] If treated early or if the insult to the pulp is mild, the inflammation subsides, and the symptoms disappear. This is called reversible pulpitis and is usually characterized by short lasting pain to cold. If the pulp swells too much, however, the swelling constricts the vessels at the end of the tooth root and can obstruct the blood supply. The pulp in the root canal and chamber will then die. This type of inflammation is called irreversible pulpitis and is similar in principal to the swelling that occurs in a brain injury. The hallmark of irreversible pulpitis is spontaneous pain or lingering pain to cold. Once the pulp completely dies, there can be a period when the tooth does not hurt unless it is causing periapical periodontitis. After that, the dying tissue, bacteria and gases build up in the pulp chamber and can extend beyond the apex of the tooth. This is referred to as an abscessed tooth. During this time, tooth pain is spontaneous and the tooth becomes tender to bite on as the periapical tissues inflame. Hot drinks can make the tooth feel worse because they expand the gases and likewise, cold can make it feel better. The dental pulp is now necrotic and emergency treatment is required.[15][16]

Dentin hypersensitivity
Main article: Dentin hypersensitivity

Dentin hypersensitivity is sharp, short lasting dental pain triggered by cold drinks, cold air and sweet or spicy foods.[17] It occurs in about 15% of the population,[18] and is most commonly because of gingival recession (receding gums) exposing the roots of the teeth.[19] This may occur with aging, traumatic or excessive toothbrushing habits, or with chronic periodontitis (gum disease). Dentin is normally covered by enamel, cementum or gum tissue. It is softer than enamel and vulnerable to tooth wear. Dentin has many microscopic tubules which contain fluid and communicate with the pulp. It is thought that movement of this fluid stimulates nerves in the pulp (the "hydrodynamic theory" of pulp sensitivty).[20] Fluid movement in dentinal tubules occurs with the various stimulae that are associated with dentin hypersensitivity. Most researchers concur that the pulp is notusually inflamed in this condition, and that nerves in the pulp have not become more sensitive to stimulae,[21][22] but rather that the stimulae have become more intense due to loss of insulating layers of tissues that used to separate dentin from the external environment. Dentin hypersensitivity may also develop after scaling and root planing (a treatment for gum disease where the roots are scraped free of calculus) and dental bleaching.[23] Many treatments for dentin hypersensitivity are available, including various desensitizing toothpastes and protective varnishes that coat the exposed dentin surface. Over time, the pulp adapts to the decreased insulation by producing new layers of dentin inside the pulp chamber (tertiary dentin), thereby increasing the thickness between the pulp and the exposed dentin surface and lessening the hypersensitivity.[24]

Cracked tooth syndrome

Cracked tooth syndrome is the sporadic, sharp pain that occurs when biting and is relieved by releasing pressure on the tooth. It is caused by a fracture of the tooth that includes the enamel, dentin and pulp chamber. Vertical fractures of the teeth can be exceptionally difficult to identify on radiographs, as the fracture runs in the plane of conventional xray films. Imagine two planes of glass lied together, one cannot see the split between them when looking through. Complicating the diagnosis is that a cracked tooth can cause pain due to many mechanisms including dentin hypersensitivity, pulpitis (both reversible and irreversible) or by stimulating the periodontium. Accordingly, the most reliable diagnosis is made when the pain can be stimulated by causing separation of the cusps of the tooth, otherwise, great variation in findings will exist.[25]

Periodontal pain

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.[11] This is because there are proprioceptors in the periodontal ligament. This makes periodontal pain similar to musculoskeletal pain.[26] The individual is often able to differentiate between pain located at the periapex and lateral periodontal pain.[26] Unlike pulpal pain, peridontal pain is not usually exacerbated by hot or cold stimulae.[3]

Apical periodontitis
Main article: Periapical periodontitis

Apical (periapical) periodontitis refers to inflammation of the periodontal ligament.

Periodontal abscess
Main article: Periodontal abscess

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 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. 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.[27] 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.

Another abscess of the periodontium, the gingival abscesss, is distinguished from a periodontal abscess as it is limited to the gingival margin or interdental papillae, with no involvement of the deeper periodontium. In similar with the periodontal abscess, the onset is usually sudden, and the pain is well localized. A penetrating injury to the gingiva e.g. with a toothbrush bristle, fishbone or toothpick may also inoculate bacteria in to the soft tissues and cause an abscess.

Acute necrotizing ulcerative gingivitis
Main article: 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.

Pericoronitis
Main article: Pericoronitis

Tooth eruption may cause pain and inflammation of the gums. Examples are teething, or pericoronitis associated with wisdom teeth.

Alveolar osteitis
Main article: Alveolar osteitis

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

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.

Non-dental sources of pain

Non-odontogenic (non-dental) causes of toothache are much less common and more varied in their origins. As all of these conditions mimic toothache, it is possible that a tooth will be treated before the final, and correct, diagnosis is found. The hallmark of many, is that signs and symptoms beyond the face will exist. The simplest example is neurovascular origin toothache, where pain is reported in the teeth in conjunction with a migraine. As migraines are typically present for many years, the diagnosis is easier to make. Just as disorders of the blood vessels can mimic toothache, so can nerve disorders such as trigeminal neuralgia and herpes zoster. In each case, the character of the pain is the differentiator between dental and non-dental pain. Local structures can also refer pain to the teeth as in the case of muslce pain, angina pectoris (which classically refers pain to the lower jaw), neoplasms of the jaws and sinusitis. Finally, pain can be psychogenic in origin as in the case of Munchausen's syndrome or drug seeking behavior.[28]

Pathophysiology

(Top) Maxillary teeth are innervated via the superior alveolar nerves and mandibular teeth via the inferior alveolar nerve, branches of the maxillary and mandibular divisions of the trigeminal nerve respectively.[29] (Middle) The superior alveolar nerves are termed the anterior superior alveolar nerve, the middle superior alveolar nerve (variably present and not shown in diagram), and the posterior superior alveolar nerve.[29] (Bottom) Cross-sectional anatomy of a tooth.

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:

  1. Reversible pulpitis symptoms increasing in severity. Reversible pulpitis is poorly localized.
  2. Irreversible pulpitis symptoms increasing in severity. Irreversible pulpitis without periapical periodontitis is poorly localized.
  3. Pulpal necrosis, possibly giving sudden relief of pain from pulpitis
  4. Acute periapical periodontitis giving pain on biting, and the pain becomes well localized to the involved tooth.
  5. As the infection and inflammation progresses, a localized dentoalveolar abscess may form causing pain from the pressure of trapped pus within the abscess.
  6. 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.
  7. 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.

Diagnostic approach

  • 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).

Complications

Since simple analgesics have little effect on many causes of toothache, the severe pain can drive individuals to exceed maximum doses. For example, it has been shown that when acetaminophen (paracetamol) is taken for toothache, an accidental overdose is more likely to occur when compared to people who are taking acetaminophen for other reasons.[30]

Treatment

The treatment is cause-related.

Epidemiology

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.[5] Irreversible pulpitis is thought to be the most common reason that people attend for emergency dental treatment.[4] In the United States, an estimated 12% of the general population have suffered from toothache at some point in the preceding 6 months.[24]

History, society and culture

Sculpture of a person with toothache.
An advertisement from 1885 for Cocaine toothache drops.

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.[6] The belief that tooth decay and dental pain was caused by "tooth worm" is found in ancient India, Egypt, Japan, and China,[6] and persists until the Age of Enlightenment.

Although toothache is an ancient problem,[31] 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.[32] 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.[33] The Ancient Egyptians wore amulets to prevent toothache.[32] 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.[31]

Archigenes of Apamea describes use of a mouthwash made by boiling gallnuts and hallicacabum in vinegar, and a mixture of roasted earthworms, spikenard ointment and crushed spider eggs.[31]

Pliny advises toothache sufferers to ask a frog to take away the pain by moonlight. Claudius' physician Scribonius Largus recommends the following:

fumigations made with the seeds of the hyoscyamus scattered on burning charcoal [...] followed by rinsings of the mouth with hot water, in this way [...] small worms are expelled.[32]

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.[32]

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.[31]

Albucasis (Abu al-Qasim Khalaf ibn al-Abbas Al-Zahrawi) used cautery for toothache, inserting a red hot needle into the pulp of the tooth.[31]

The medieval surgeon Guy de Chauliac used camphor, sulfur, myrrh and asafetida mixture to fill teeth and cure toothworm and toothache.[31]

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.[31]

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).[34]

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.

References

  1. ^ Joseph C Segen. McGraw-Hill Concise Dictionary of Modern Medicine. 2002 The McGraw-Hill Companies, Inc.
  2. ^ a b c [editor, Linda Duncan, developmental editor, Courtney Sprehe] (2008). Mosby's dental dictionary (2nd ed.). St. Louis, Mo.: Mosby. ISBN 978-0323049634. {{cite book}}: |author= has generic name (help)CS1 maint: multiple names: authors list (link)
  3. ^ a b Scully, Crispian (2013). Oral and maxillofacial medicine : the basis of diagnosis and treatment (3rd ed.). Edinburgh: Churchill Livingstone/Elsevier. pp. 125–135. ISBN 9780702049484.
  4. ^ a b 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.
  5. ^ a b Wolf, 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. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  6. ^ a b c Suddick, RP (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. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
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  14. ^ Hupp JR, Ellis E, Tucker MR (2008). Contemporary oral and maxillofacial surgery (5th ed.). St. Louis, Mo.: Mosby Elsevier. pp. 619–627. ISBN 9780323049030.{{cite book}}: CS1 maint: multiple names: authors list (link)
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  17. ^ Attention: This template ({{cite pmid}}) is deprecated. To cite the publication identified by PMID 21217949, please use {{cite journal}} with |pmid=21217949 instead.
  18. ^ Attention: This template ({{cite pmid}}) is deprecated. To cite the publication identified by PMID 16855970, please use {{cite journal}} with |pmid=16855970 instead.
  19. ^ Attention: This template ({{cite pmid}}) is deprecated. To cite the publication identified by PMID 23271217, please use {{cite journal}} with |pmid=23271217 instead.
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  21. ^ Attention: This template ({{cite pmid}}) is deprecated. To cite the publication identified by PMID 23269545, please use {{cite journal}} with |pmid=23269545 instead.
  22. ^ Attention: This template ({{cite pmid}}) is deprecated. To cite the publication identified by PMID 21217949, please use {{cite journal}} with |pmid=21217949 instead.
  23. ^ Attention: This template ({{cite pmid}}) is deprecated. To cite the publication identified by PMID 23271217, please use {{cite journal}} with |pmid=23271217 instead.
  24. ^ a b 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. {{cite book}}: |last= has generic name (help)CS1 maint: multiple names: authors list (link)
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  26. ^ a b Li, Wei (2011). "Non-odontogenic toothache revisited". Open Journal of Stomatology. 01 (3): 92–102. doi:10.4236/ojst.2011.13015. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)CS1 maint: unflagged free DOI (link)
  27. ^ Attention: This template ({{cite pmid}}) is deprecated. To cite the publication identified by PMID 10875694, please use {{cite journal}} with |pmid=10875694 instead.
  28. ^ Template:Cite isbn
  29. ^ a b Susan Standring (editor in chief), Neil R. Borley (section editors); et al. (2008). Gray's anatomy : the anatomical basis of clinical practice (40th ed.). [Edinburgh]: Churchill Livingstone/Elsevier. ISBN 978-0443066849. {{cite book}}: |last= has generic name (help); Explicit use of et al. in: |last= (help)
  30. ^ Attention: This template ({{cite pmid}}) is deprecated. To cite the publication identified by PMID 20951526, please use {{cite journal}} with |pmid=20951526 instead.
  31. ^ a b c d e f g Ingle JI, Bakland LK, Baumgartner JC (editors) (2008). Endodontics (6th ed.). Hamilton, Ontario: BC Decker. pp. 48–52. ISBN 9781550093339. {{cite book}}: |last= has generic name (help)CS1 maint: multiple names: authors list (link)
  32. ^ a b c d "Ancient dentistry". British Dental Association 2010. Retrieved 13 December 2013.
  33. ^ "Why did the Ancient Egyptians suffer from toothache?". BBC 2013. Retrieved 13 December 2013.
  34. ^ Burns, Robert. "Address to the toothache". BBC. Retrieved 13 December 2013.
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