Toothache is one of the worst pains in the world. It has been known to reduce grown men to tears and many women have been know to say they would rather go through childbirth than have toothache. A large part of this is because we can’t rationalise out the pain in our heads the way we could rationalise pain in our big toe if we caught it on the edge of the bed. 

 

As a dentist, diagnosing and treating pain is a large part of my working life. Broadly speaking, most dental pain fits into one of three categories: 
 

             1. Pain that will not go away and affects your sleep
             2. Pain when you bite into things 
             3. Pain when you eat particular foods, especially sweet, hot and cold

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Why do I get toothache?

In the middle of every tooth lives a nerve (or dental pulp as we dental folk call it). When a

tooth is healthy this nerve is protected by the dentine (the yellow bit of your tooth) and the

enamel (the hard outer layer of your tooth). Together, the enamel and dentine protect the

nerve from big fluctuations in temperature, chemical attack and direct trauma.

Healthy teeth therefore don’t usually hurt. 

The lowest form of dental pain is called ‘dentine sensitivity’ (or hypersensitivity). This is often

the result of loosing some of the enamel of a tooth and exposing some of the dentine

underneath which is more susceptible to changes in temperature which are then conducted

to the nerve. This can also happen when the dentine is exposed due to receding gums in

gum disease. This pain can be like breathing in cold air first thing on a frosty winters day

or biting into an ice-cream. The pain lasts a few moments and then disappears completely.

A sensitive toothpaste like oral-b gum and enamel repair or sensodyne will help create a

protective layer over the exposed dentine which will reduce sensitivity.                                                     A Healthy Tooth

This is similar to the kind of pain you get with tooth decay that hasn’t got to the nerve yet.  In this case, the bacteria in your mouth have eaten through the enamel into the dentine causing the dentine to be exposed, resulting in sensitivity. This is called

reversible pulpitis and a simple filling will usually remove this pain. 

If regular tooth decay is left un-treated, it can grow and eventually starts to encroach on the nerve. As I’m sure you can imagine, the nerve doesn’t like this and reacts quit strongly. In many cases, the nerve will start to die off giving you the kind of pain that keeps you awake in the middle of the night and you feel like there is not enough paracetamol in the world to keep your pain away. This is called irreversible pulpitis. Sadly, for many teeth, when they reach this point, because of the size of the decay, the tooth is unfixable and needs to be removed. In some circumstances it is possible to save a tooth via root canal treatment which removes the nerve from the roots of the tooth and cleans the area to remove all the bacteria.

 

 

 

 

 

 

 

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                 Reversible Pulpitis                                                   Irreversible Pulpitis                                    Peri-apical Periodontitis / Dental Abscess

         Pain when eating hot or cold                                Pain which keeps you up at night                          Tooth is sore to bite on +/- a gum boil    

          Treated by a Regular Filling                     Treated by Root Canal Treatment or Extraction         Treated by Root Canal Treatment or Extraction 

Not everyone gets pain when the nerve of a tooth dies and for some people the first they may know about it is when they notice some discomfort when biting on the tooth, sweeping on the gum or swelling on their face near the tooth. Once this has happened, we know that the dead (or dying) nerve is riddled with bacteria which are chucking toxins out into the bone around your tooth that your body is trying to fight off making an abscess. This is called peri-apical periodontitis and it is the first point at which antibiotics will make any difference to your dental pain, by dealing with the pus. The tooth is sore to bite on because the nerve fibres in the ligament that hold the tooth in the bone are now getting affected by the bacteria in the tooth. The treatment options for this would be to remove the tooth or provide root canal treatment. 

There are a few other potential causes of toothache and these include:
      • Atypical facial pain
      • TMJ pain dysfunction syndrome 
      • Gum disease 
      • Cracked tooth syndrome 
      • Trigeminal neuralgia 
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How can I manage my toothache? 

Here is a step-by-step guide that will help you know what to do when toothache starts.

NUMBER 1: Take the appropriate pain killers

Most dental pain is managed best with a combination of paracetamol and ibuprofen which you can get in most shops over the counter. Alternating these medications seems to provide a decent level of pain relief over a period of time. If you can't take these for a particular reason, take whatever you would normally take for a thumping headache. Alternating Paracetamol and Ibuprofen looks like this:

 

        1g paracetamol dose* taken at:         08:00               12:00               16:00             20:00               |no more doses that day

        400mg ibuprofen dose* taken at:                  10:00               14:00              18:00                          |no more doses that day

*these are doses for a healthy adult, read the packet and check with a pharmacist if you are unsure as to what the right dose is for you.

DO check with a pharmacist if you are unsure whether you can take these
DO keep track of how many of each you have taken each day
DO keep hydrated 
DO NOT eat them like sweets and take more than the recommended daily amount for your age. If you think you have taken too many, it is imperative that you seek medical attention ASAP as you could be suffering irreversible liver damage which is symptom free in the early stages 

NUMBER 2: book in to see a dentist 

As I’ve already said, dental pain comes in many flavours, many of which will not resolve by themselves. The old adage of ‘wait and see’ does not apply here. The sooner you see us, the more we are likely to be able to do to save your tooth and the less invasive it is likely to be.

 

If you don't have an NHS dentist, call 111 and they may be able to find you an emergency appointment. Don't turn up at A&E as they may not be able to help you.

NUMBER 3: If you are given antibiotics, make sure you finish the course AND you book back in for treatment 

Antibiotics are like a sticking plaster for a splinter. They cover up the acute problem, but at some point you will have to fish the splinter out. In the same way, antibiotics deal with an abscess and may even help with some types of dental pain but do not actually kill all the bacteria that caused the pain in the first place.

In other words, once you stop taking the antibiotics, it is only a matter of time before the pain comes back. 

 

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Dental pain needs definitive treatment to eliminate the bacteria causing the pain. This can look like a filling, a root canal treatment, an extraction or even a scale and polish or night guard.

Always remember, dental problems don’t get better by themselves, occasionally they stay the same and usually they get worse if given enough time. More often than not, when dental pain seems to go away, it comes back worse at a later date and is more complex to manage.  

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What does it mean if…

…my toothache is keeping me up at night?

It is likely that you have a nerve that is in the process of dying (irreversible pulpitis) for which you will need root canal treatment or a tooth removed. If you leave this untreated, it is possible that you could wake up one day with a swollen face. 

….my tooth only hurts when I bite on it?

It is likely that you have a tooth with a dead nerve and the beginnings of an abscess (peri-apical periodontitis) for which you will need root canal treatment or a tooth removed. If you leave this untreated, it is possible that you could wake up one day with a swollen face. 

…my tooth only hurts sometimes with sweet or cold?

It is likely you have dentine sensitivity or dental decay (reversible pulpitis) which can be treated with sensitive toothpastes &/or a filling. If this is left untreated, it could become irreversible pulpitis.

…my pain is worst in the morning or after eating

It is likely that you are clenching and grinding your teeth and your pain is coming from your muscles.  Speak to your dentist about this and then may be able to provide you a night guard.

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Post-Treatment Pain Advice

I’ve had an extraction and I’m still in pain. What can I do?

Take painkillers regularly (as above) for the first 3 days and look after your mouth as directed by your dentist. Taking teeth out is a surgical procedure so don’t expect things to be perfect straight away. Avoiding smoking after an extraction will help prevent a dry socket as will tipping your head to the side and doing a salt water ‘soak’ of your extraction socket instead of a vigorous rinse. If after 4 days the pain has not started to improve, see your dentist again.

I had a filling and now my tooth feels sensitive. Why is that?

Many modern fillings can conduct heat and so will bring temperature sensations closer to the nerve than natural tooth tissue. This coupled with the fact that the fillings materials expand and shrink at a different rate to natural tooth tissues means that bigger fillings can be more prone to temperature fillings than a natural tooth. If you are concerned or you fell like it is getting worse, pop in and see your dentist.  

I’ve had root canal treatment but my tooth is still sore to bite on. Why is that?

Because the bone around a tooth can be infected, it can sometimes take a while for the bone to heal after root canal treatment. Sadly, root canal treatment is not totally effective 100% of the time, and there are therefore some times where a tooth does not completely settle despite having had treatment. Sometimes antibiotics can help in these situations to help clear up a lingering infection. If you are concerned at all, speak to your dentist. 

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