Toothache

Pain may occur following dental treatment. It is not uncommon after a very large and deep filling has been placed or a dental extraction carried out. The degree of pain is related to the damaged dental tissues (e.g. the surgical removal of an impacted wisdom tooth can be associated with several days of pain or discomfort). Patients must therefore expect to be given suitable medication and advised to follow procedures aimed at promoting rapid healing whilst reducing the discomfort to a minimum. It is most unusual for post-operative pain to last for more than 10 days. In the vast majority of cases medication will not be required for more than three days.

There are other causes of dental pain that simulate toothache in people who otherwise may have good oral hygiene and excellent teeth (e.g. sinusitis can cause pain on one or both sides of the face). Trigeminal (facial) neuralgia can bring stabbing pains that will cause serious incapacity. Deep-seated aches in the jaws may also indicate the presence of disease. Diagnosis may not be easy or certain. It is imperative to see a dentist who may have to refer to a consultant for further tests.

There are many factors that influence the choice of a successful regime for dental pain control. The young and the old require extra care, together with those who may already be taking medication for other medical or dental conditions, and pregnant or nursing mothers. The assessment of the physical and psychological make-up of the patient, together with their past experiences with various forms of pain control, are key to future choices. Allergies, asthma, other contra-indications and short term personal or business activities may also have to be considered.

In the vast majority of emergencies dental pain can be controlled in the short term by one of three simple medicines – paracetamol, aspirin and ibuprofen. All can be purchased without the need for a prescription and are known as Over-the-Counter (OTC) medicines. Only a minority of dental cases will need access to more powerful Prescription-Only Medicines (POM) that can only be supplied by a general medical or dental practitioner.

Effective in pain relief in a wide variety of situations that include headaches, muscular pain, neuralgia, influenza and dental pain, it also reduces raised body temperature. It has remarkably few side effects and is well tolerated in those situations in which aspirin has to be avoided, including in young children.

A useful, safe, analgesic with blood-thinning properties. The fact that aspirin modifies the blood clotting mechanism has to be recognised as an unwelcome side effect for some patients and particularly those who suffer gastrointestinal problems. Aspirin must be avoided in those with peptic ulcers, pregnant women and also in some post-operative situations as it could delay healing. It should not be given to children under the age of 12, to asthmatics or those with a tendency to allergic reactions. The old-fashioned practice of placing an aspirin tablet beside a painful tooth can cause burns and bleeding of the gum and is to be discouraged.

Like aspirin, it has anti-inflammatory properties and is effective in lowering a fever and relieving pain. It is useful in dental pain control as many dental conditions have an inflammatory element. It should not be used in situations that involve gastrointestinal problems, asthma or after surgery.

The use of paracetamol, aspirin, or ibuprofen may well be sufficient to bring pain relief, but other drugs may be even more effective. For example, the addition of opiates such as codeine, either alone or combined with aspirin or paracetamol, will increase significantly the analgesic effects. The same effect occurs when codeine is added to ibuprofen. Caffeine is commonly added and may improve absorption and reduce drowsiness. Research suggests that there may be a benefit to be gained by alternating between aspirin/codeine or paracetamol/codeine combinations and ibuprofen every three hours. Some branded analgesics incorporate antihistamines such as diphenhydramine or doxylamine to improve pain-killing properties.

Manufacturer's instructions should be read carefully and it should be remembered that medication is only a short-term remedy and not a long-term cure for acute pain.

Tooth sensitivity (also known as dentine hypersensitivity) often appears as a painful reaction to temperature changes, pressure, sweet and acidic food or drink. This reaction may be mild and tingling, or sharp and intense. People whose teeth are sensitive often feel pain when they eat or drink things which are very cold. The classic example is eating ice cream, but simply being out in the cold weather is sometimes enough to set off the problem. Sensitivity to touch may also mean that tooth brushing is uncomfortable.

Research shows that one in three people in the UK suffer from sensitive teeth at any one time. Dentine hypersensitivity can occur from 15 to 70 years of age or more, however the age group when it occurs most is between 20 and 40 years.

Triggers of tooth sensitivity and the severity will vary from person to person, although the most common are: -

• Cold food and drinks (e.g. ice cream)
• Over-enthusiastic or incorrect tooth brushing
• Hot food and drinks (e.g. hot tea or coffee)
• Sharp acidic foods (e.g. apples, oranges)

Any teeth can be affected but the most likely are those at the front corners of the mouth. It is suggested that this might be because these are the teeth which tend to be brushed more vigorously causing the wear of protective tooth enamel.

A healthy tooth has a chamber inside it for the tooth pulp, which consists of nerves and blood vessels. A young and healthy tooth has a large pulp chamber where the sensitive nerves are more exposed to temperature or pressure changes from the outside. However, tooth sensitivity can occur at any age. There are two general ways in which this sensitivity can develop:

• Wearing or destruction of the hard, protective outer layer of the tooth crown called enamel. This may be related to:
  1. Biting abnormalities or abnormal tooth grinding
  2. Toothbrush abrasion, i.e. the wearing-away of enamel and/or recession of gums caused by over-enthusiastic or incorrect brushing
  3. Dietary erosion – the destruction of enamel by acidic food and drink or by acid regurgitation from the stomach
  4. Habit – nail biting or the placing of metal objects between the teeth
  5. Attrition – the wearing of enamel by tooth grinding.
• Gum recession exposing the softer porous tooth structures called dentine and cementum. This may be related to:
  1. Chronic gum (periodontal) disease
  2. Surgery – difficult tooth extractions
  3. Incorrect tooth brushing.

Sensitivity and dental pain can also be experienced for a number of other reasons:

• Chipped teeth
• Fractured or cracked fillings
• Dental decay (caries)
• Deep fillings
• Cracked teeth.

Avoidance of this condition is possible if the teeth are cleaned thoroughly but carefully twice a day. Chewing a disclosing tablet (obtainable from the practice) after brushing will show if any plaque is left behind. Using the correct brushing technique is essential and use of a specialist toothpaste formulated for sensitive teeth. If you need advice as to the best technique to use, ask a dentist or hygienist.

Care should be taken with diet: a high intake of acid-containing food and drink such as citrus fruits and fizzy drinks will make teeth more sensitive and can lead to destruction of the tooth enamel. A dental professional can help by:

• Applying fluoride varnish to exposed sensitive dentine or cementum
• Applying a sealer to exposed root surfaces to block the tiny tubes which are exposed or offer treatment that will desensitise the dental nerves (no drilling is required)
• Correcting any bite abnormalities to help reduce the wearing of enamel
• Placing fillings to cover exposed dentine or cementum on root surfaces.