Toothache

Pulpal toothache –
Pulp is a vital tissue which conducts the blood & nerve supply to the tooth. Any damages or irritation to the pulpal tissue causes a pulpal toothache. It can further be divided into the following –

• Acute pulpal toothache – The causes of acute pulpal toothache is a noxious stimulation of the pulpal receptors. The patient cannot accurately localize this kind of a toothache and thus its diagnosis becomes of great challenge to the dentist.
• Chronic pulpal toothache -  If acute pulpal lesion remains untreated it results in an enormous increase in inflammation and thus progresses to chronic pulpal toothache. This generally results from a long-standing low-grade infection or injury to the pulpal tissues.

Periodontal toothache
This occurs due to any injury or infections of the periodontal ligament. The periodontal ligament is a soft tissue strand which connects the root of the tooth to the jaw bone. The periodontal ligament is capable to localize pain. Thus the periodontal toothache is easily localized with no difficulty in diagnosis. It can be easily diagnosed by applying pressure on the tooth.

Cracked tooth syndrome
This type of toothache, occurs when the pain is mild in nature and generally starts by bitting or release of pressure. This can also mimic the nerve pain like as a trigeminal neuralgia.

Aecrodontalgia
This is another type of toothache which occurs due to changes in altitude. This type of a toothache is generally seen in deep sea divers, aviation crew members, frequent travellers, etc as these people are often exposed to change in altitude.

Musculoskeletal pain
Muscles in head & neck can also cause a toothache & vice- versa. The muscles which can cause pain includes.

• masseter muscles.
• temporalis muscles.
• Medial pterygoid muscles.
• sternocleidomastoid muscles.
• splenius capitis muscles.
• trapezius, etc.
• MPDS –  Myofunctional pain dysfunction syndrome is the most common example of a musculoskeletal toothache.

Temporomandibular joint toothache (TMJ)
TMJ deformities can also induce a toothache and can be further classified as below-

• A toothache due to discal pad dislocation. This may occur due to missing teeth and thus displacement of the disc of TMJ. It can be associated with swelling in the face region and a vague toothache in back teeth region.
• A toothache due to capsular pain – It results from the swelling of the temporomandibular joint capsule and may lead to a severe toothache.

Trigeminal neuralgia associated toothache
Trigeminal neuralgia is an extremely painful condition and its unique in humans. This may cause a severe toothache which is difficult to diagnose. Its treatment includes administration of the following drugs as below-

• Trichloroethylene inhalation.
• Tropical capsicine cream.
• Anticholinergic drugs.
• Diphenylhydantoin & anticonvulsant drugs.
• Carbamazepine (Tegretol.)
• Anti-inflammatory drug.
• Surgery in severe cases in the line of treatment followed.

What actually happens during a toothache?

A toothache is a personal experience, and its severity may vary from person to person depending on their dental condition. A toothache is usually described as an aching sensation, sometimes throbbing or you may feel it as a burning sensation too. Pain and fear of pain are one of the strongest motivation for people to seek dental care treatments. The sooner you seek medical treatment the quicker the condition is resolved. It has been observed people who do not go to the dentist often undergo more dental trauma at the right time.

Common symptoms of a toothache:

• Sharp pain while eating. 
• Swelling in the mouth and affected tooth area.
• Bleeding or discharge from the affected area. 
• Throbbing pain in the jaw area. 

When to see the dentist

A toothache generally subsides on its own in 1-2 days. If the sign & symptom of a toothache persists more than 2 days then you are advised to consult a dentist and a physician for any underlying diseases. You may have a locked jaw due to swelling or extreme pain. You are advised not to take any medication yourself as medicines also have certain side effects, this is with special reference to painkillers. Please do not delay in consulting a doctor. 

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The causes for toothache are many they may be due to a cavity, injury, tooth enamel erosion, teeth grinding, dental abscess, tooth sensitivity,  cracked tooth, damaged fillings and gum diseases. You are highly recommended not to self-diagnose and seek the help of a doctor to determine the actual cause of your toothache. 

• Pulpal toothache
  It occurs due to the exposure of the pulpal tissue to saliva or air. The cause of such a toothache could be deep caries, erosion, fracture or splitting of the tooth. Acute pulpal toothache may range from occasional hypersensitivity caused by sweet, hot & cold to spontaneous violent throbbing toothache of intolerable intensity.
   
• Periodontal toothache 
  Periodontal injuries are the main cause of a toothache they may cause trauma, occlusal pressure, excessive contact either with the adjacent tooth. Other reasons are dental treatment like cleaning, tooth interference, high filling and deep fillings, space in between the tooth contact area, etc. It can also result as a sequel of pulpal infection and by direct extension of swelling from the adjacent tooth, sinus cavity and spreading bony infections. When it is observed that a periodontal toothache involves a number of teeth than bruxism or night bitting or clenching is considered as the cause. Overpressure in the back tooth may also result from bony changes and degenerative changes in the TMJ. TMJ is the temporomandibular joints which are the only single joint which connects the lower jaw to the rest of the face. Injuries to TMJ may result in a toothache as well.
   
• Cracked tooth
  This occurs due to a crack or fracture which may extend from different layers of the tooth which are enamel, dentin or pulp & the symptoms vary accordingly. Toothache varies due to the movement of fluid present in the dentin region called a dentinal tubule. This fluid movement is initiated by the pressure changes while we eat from the teeth.

Risk factors 

• Physical Factors
  • Acute injury –
  • The accidental blow of the tooth.
  • Heating due to grinding
  • Vigorous polishing with the dental instrument.
  • Root planning in periodontal therapy.
  • Large metallic restoration
  • Cavity preparation without water spray.
     
• Chronic injury
  • Attrition due tonight clenching or bruxism.
  • Abrasion due to abnormal tooth brushing
     
• Chemical factors
  Medicament applied in dental procedures may also cause damage to pulpal tissue.
   
• Microbial
  Bacterial invasion into the pulp may cause damage to the tooth. Eg. Dental caries
   
• Anachorectic infections
  This occurs when the bacteria present in blood enter pulp and thus causes a toothache and infections.

A toothache can be prevented by decreasing dental caries, pulpal diseases, periodontal diseases, etc from the mouth. Here are a few self-care methods which you can follow to prevent tooth pain:

• limit the quality of sucrose (sugar) consumed in the daily diet.
• reduce in between meals & snacks.
• brush yo ur teeth twice a day.
• use a bacteriocidal mouthwash like chlorhexidine.
• use topical fluoride toothpaste & gels.
• eat fibrous food.
• chew the food properly and the swallow.
• use sugarless chewing gum.
• smooth tooth surface.
• get all cavities filled.

Your dentist will physically examine and perform a panel of tests to explore all the possible causes of you're tooth pain. Dental X-ray is used to get a better overview and exactly find out the origin of a toothache. Sometimes, the cause of a toothache and site of a toothache are different this type is known as referred pain. For these situations, diagnostic tests performed by the dentist are particularly important in accurately detecting the problem.

It may include the following:

• History: The patient generally complains of severing a toothache which continues even after removal of the stimulus.
• Clinical examination: It includes caries exposure in the affected fractured tooth. Changes in colour from white to bluish greyish which gives signs of the vitality of tooth.
• Dental x-rays: X-rays give almost the exact idea of the extent and sensitivity of pulp necrosis

Clinical test 

• Heat test
• Cold test
• Percussion & pressure: when the tooth is pressed, the patient can localize and feel toothcahe. Electric pulp testing may also be used to check the vitality of the tooth.

Bacteriology
Smear of the region may give a due to pulpal necrosis. Bacteria present may be buccal B.denticoa, W recta, villanella, A Israel, S sagius etc.

Treatment of a toothache will depend on the diagnosis.  The dentist usually follows these procedures upon detection as to why a toothache is happening. 

• Draining the pus: The dentist will perform drainage of pus and exudates
• Direct pulp capping: They usually apply a soothering solution or calcium to the pulp to regenerate, generally, iodoform calcium paste is used for this purpose.
• Root canal treatment: It is a very common and well-known procedure. Root canal treatment or RCT includes the removal of damaged & infected pulp & placement of gutta-percha cones inside the pulp cavity. Then it is filled & later capping is done. This is the most conservative treatment of choice followed these days by the dentists.
• Tooth Extraction: Removal of teeth is the last treatment of choice. As per dentists, you should never get your tooth removed unless & until all procedure fail which can save it. Every organ of the human body has its own importance thus care should be taken to maintain oral hygiene. If in case one has to remove the tooth or teeth do not worry, with the advancement in modern dentistry removal of tooth or teeth is easy and painlessly done. 
• Medications: Painkillers are given if a toothache persists, eg. Diclofenac Sodium  (Divon), Ibuprofen, etc. In a few cases, administration of antibiotics such as amoxicillin and augmentin are also prescribed.
• Surgery: Some cases may require Gingivectomy and Gingivoplasty, flap surgeries and grafts placement.

• The sequel of a pulpitis toothache, whether it is acute or chronic may lead to a periodontal toothache.
• A periodontitis toothache may lead to an abscess which has pus formation & can further cause granuloma & cyst formation.
• The above-mentioned conditions can further cause bony deformation often referred to as osteomyelitis that is the focal depth of the bone surrounding the affected tooth. It can progress to cellulitis.
• In severe cases, chronic lesions formed because of toothache may progress to tumours.