Toothache

Toothache may be caused by dental (odontogenic) conditions (such as those involving the dentin-pulp complex or periodontium), or by non-dental (non-odontogenic) conditions (such as maxillary sinusitis or angina pectoris). There are many possible non-dental causes, but the vast majority of toothache is dental in origin. Both the pulp and periodontal ligament have nociceptors (pain receptors), but the pulp lacks proprioceptors (motion or position receptors) and mechanoreceptors (mechanical pressure receptors). whereas pain from the periodontal ligament will typically be well localized, When a tooth is intentionally stimulated, about 33% of people can correctly identify the tooth, and about 20% cannot narrow the stimulus location down to a group of three teeth. Common causes include tooth decay, dental trauma (such as a crack or fracture), or a filling with an imperfect seal. Because the pulp is encased in a rigid outer shell, there is no space to accommodate swelling caused by inflammation. Inflammation therefore increases pressure in the pulp system, potentially compressing the blood vessels which supply the pulp. This may lead to ischemia (lack of oxygen) and necrosis (tissue death). Pulpitis is termed reversible when the inflamed pulp is capable of returning to a state of health, and irreversible when pulp necrosis is inevitable. Dentin hypersensitivity Dentin hypersensitivity is a sharp, short-lasting dental pain occurring in about 15% of the population, which is triggered by cold (such as liquids or air), sweet or spicy foods, and beverages. Teeth will normally have some sensation to these triggers, The pulp of the tooth remains normal and healthy in dentin hypersensitivity. Apical periodontitis Apical periodontitis is acute or chronic inflammation around the apex of a tooth caused by an immune response to bacteria within an infected pulp. It does not occur because of pulp necrosis, meaning that a tooth that tests as if it's alive (vital) may cause apical periodontitis, and a pulp which has become non-vital due to a sterile, non-infectious processes (such as trauma) may not cause any apical periodontitis. or relieved immediately by using a tooth pick or dental floss in the involved area. A variant of the periodontal abscess is the gingival abscess, which is limited to the gingival margin, has a quicker onset, and is typically caused by trauma from items such as a fishbone, toothpick, or toothbrush, rather than chronic periodontitis. The occurrence of a periodontal abscess usually indicates advanced periodontal disease, which requires correct management to prevent recurrent abscesses, including daily cleaning below the gumline to prevent the buildup of subgingival plaque and calculus. Acute necrotizing ulcerative gingivitis Common marginal gingivitis in response to subgingival plaque is usually a painless condition. However, an acute form of gingivitis/periodontitis, termed acute necrotizing ulcerative gingivitis (ANUG), can develop, often suddenly. It is associated with severe periodontal pain, bleeding gums, "punched out" ulceration, loss of the interdental papillae, and possibly also halitosis (bad breath) and a bad taste. Predisposing factors include poor oral hygiene, smoking, malnutrition, psychological stress, and immunosuppression. ANUG is treated over several visits, first with debridement of the necrotic gingiva, homecare with hydrogen peroxide mouthwash, analgesics and, when the pain has subsided sufficiently, cleaning below the gumline, both professionally and at home. Antibiotics are not indicated in ANUG management unless there is underlying systemic disease. Pericoronitis Pericoronitis is inflammation of the soft tissues surrounding the crown of a partially erupted tooth. The lower wisdom tooth is the last tooth to erupt into the mouth, and is, therefore, more frequently impacted, or stuck, against the other teeth. This leaves the tooth partially erupted into the mouth, and there frequently is a flap of gum (an operculum), overlying the tooth. Bacteria and food debris accumulate beneath the operculum, which is an area that is difficult to keep clean because it is hidden and far back in the mouth. The opposing upper wisdom tooth also tends to have sharp cusps and over-erupt because it has no opposing tooth to bite into, and instead traumatizes the operculum further. Periodontitis and dental caries may develop on either the third or second molars, and chronic inflammation develops in the soft tissues. Chronic pericoronitis may not cause any pain, but an acute pericoronitis episode is often associated with pericoronal abscess formation. Typical signs and symptoms of a pericoronal abscess include severe, throbbing pain, which may radiate to adjacent areas in the head and neck, There may be trismus (difficulty opening the mouth), Persons typically develop pericoronitis in their late teens and early 20s, The pain is moderate to severe, and dull, aching, and throbbing in character. The pain is localized to the socket, and may radiate. It normally starts two to four days after the extraction, and may last 10–40 days. set of pain-sensitivity symptoms that may accompany a tooth fracture, usually sporadic, sharp pain that occurs during biting or with release of biting pressure, or relieved by releasing pressure on the tooth. The prognosis for a cracked tooth varies with the extent of the fracture. Those cracks that are irritating the pulp but do not extend through the pulp chamber can be amenable to stabilizing dental restorations such as a crown or composite resin. Should the fracture extend though the pulp chamber and into the root, the prognosis of the tooth is hopeless. Successful root canal therapy is required before periodontal treatment is attempted. Classically, sinusitis pain increases upon Valsalva maneuvers or tilting the head forward. Painful conditions which do not originate from the teeth or their supporting structures may affect the oral mucosa of the gums and be interpreted by the individual as toothache. Examples include neoplasms of the gingival or alveolar mucosa (usually squamous cell carcinoma), conditions which cause gingivostomatitis and desquamative gingivitis. Various conditions may involve the alveolar bone, and cause non-odontogenic toothache, such as Burkitt's lymphoma, and osteomyelitis. Various conditions of the trigeminal nerve can masquerade as toothache, including trigeminal zoster (maxillary or mandibular division), cluster headache, and trigeminal neuropathies. Very rarely, a brain tumor might cause toothache. Another chronic facial pain syndrome which can mimic toothache is temporomandibular disorder (temporomandibular joint pain-dysfunction syndrome), which is very common. Toothache which has no identifiable dental or medical cause is often termed atypical odontalgia, which, in turn, is usually considered a type of atypical facial pain (or persistent idiopathic facial pain). Atypical odontalgia may give very unusual symptoms, such as pain which migrates from one tooth to another and which crosses anatomical boundaries (such as from the left teeth to the right teeth). ==Pathophysiology==

{{multiple image A tooth is composed of an outer shell of calcified hard tissues (from hardest to softest: enamel, dentin, and cementum), and an inner soft tissue core (the pulp system), which contains nerves and blood vessels. The visible parts of the teeth in the mouth – the crowns (covered by enamel) – are anchored into the bone by the roots (covered by cementum). Underneath the cementum and enamel layers, dentin forms the bulk of the tooth and surrounds the pulp system. The part of the pulp inside the crown is the pulp chamber, and the central soft tissue nutrient canals within each root are root canals, exiting through one or more holes at the root end (apical foramen/foramina). The periodontal ligament connects the roots to the bony socket. The gingiva covers the alveolar processes, the tooth-bearing arches of the jaws. Enamel is not a vital tissue, as it lacks blood vessels, nerves, and living cells. The teeth and gums exhibit normal sensations in health. Such sensations are generally sharp, lasting as long as the stimulus. There is a continuous spectrum from physiologic sensation to pain in disease. Pain is an unpleasant sensation caused by intense or damaging events. In a toothache, nerves are stimulated by either exogenous sources (for instance, bacterial toxins, metabolic byproducts, chemicals, or trauma) or endogenous factors (such as inflammatory mediators). The pain pathway is mostly transmitted via myelinated Aδ (sharp or stabbing pain) and unmyelinated C nerve fibers (slow, dull, aching, or burning pain) of the trigeminal nerve, which supplies sensation to the teeth and gums via many divisions and branches. Initially, pain is felt while noxious stimuli are applied (such as cold). Continued exposure decreases firing thresholds of the nerves, allowing normally non-painful stimuli to trigger pain (allodynia). Should the insult continue, noxious stimuli produce larger discharges in the nerve, perceived as more intense pain. Spontaneous pain may occur if the firing threshold is decreased so it can fire without stimulus (hyperalgesia). The physical component of pain is processed in the medullary spinal cord and perceived in the frontal cortex. Because pain perception involves overlapping sensory systems and an emotional component, individual responses to identical stimuli are variable. ==Diagnosis==

The diagnosis of toothache can be challenging, not only because the list of potential causes is extensive, but also because dental pain may be extremely variable, and pain can be referred to and from the teeth. Dental pain can simulate virtually any facial pain syndrome. ==Prevention==

Since most toothache is the result of plaque-related diseases, such as tooth decay and periodontal disease, the majority of cases could be prevented by avoidance of a cariogenic diet and maintenance of good oral hygiene. That is, reduction in the number times that refined sugars are consumed per day and brushing the teeth twice a day with fluoride toothpaste and interdental cleaning. Regular visits to a dentist also increases the likelihood that problems are detected early and averted before toothache occurs. Dental trauma could also be significantly reduced by routine use of mouthguards in contact sports. ==Management==

. Above, deformation of the cheek on the second day. Below, deformation on the third day. There are many causes of toothache and its diagnosis is a specialist topic, meaning that attendance at a dentist is usually required. Since many cases of toothache are inflammatory in nature, over the counter non-steroidal anti-inflammatory drugs (NSAIDs) may help (unless contraindicated, such as with a peptic ulcer). Generally, NSAIDs are as effective as aspirin alone or in combination with codeine. Another risk in persons with toothache is a painful chemical burn of the oral mucosa caused by holding a caustic substance such as aspirin tablets and toothache remedies containing eugenol (such as clove oil) against the gum. The field of regenerative endodontics is now developing ways to clean the pulp chamber and regenerate the soft and hard tissues to either regrow or simulate pulp structure. This has proved especially helpful in children where the tooth root has not yet finished developing and root canal treatments have lower success rates. As samples for microbiologic culture and sensitivity are hardly ever carried out in general dental practice, broad-spectrum antibiotics such as amoxicillin are typically used for a short course of about three to seven days. apical abscess, and they should be used restrictively in dentistry. Local measures such as incision and drainage, and removal of the cause of the infection (such as a necrotic tooth pulp) have a greater therapeutic benefit and are much more important. If abscess drainage has been achieved, antibiotics are not usually necessary. Antibiotics tend to be used when local measures cannot be carried out immediately. In this role, antibiotics suppress the infection until local measures can be carried out. Severe trismus may occur in when the muscles of mastication are involved in an odontogenic infection, making any surgical treatment impossible. Immunocompromised individuals are less able to fight off infections, and antibiotics are usually given. Evidence of systemic involvement (such as a fever higher than 38.5 °C, cervical lymphadenopathy, or malaise) also indicates antibiotic therapy, as do rapidly spreading infections, cellulitis, or severe pericoronitis. Drooling and difficulty swallowing are signs that the airway may be threatened, and may precede difficulty in breathing. Ludwig's angina and cavernous sinus thrombosis are rare but serious complications of odontogenic infections. Severe infections tend to be managed in hospital. ==Prognosis==

Most dental pain can be treated with routine dentistry. In rare cases, toothache can be a symptom representing a life-threatening condition, such as a deep neck infection (compression of the airway by a spreading odontogenic infection) or something more remote like a heart attack. Dental caries, if left untreated, follows a predictable natural history as it nears the pulp of the tooth. First it causes reversible pulpitis, which transitions to irreversible pulpitis, then to necrosis, then to necrosis with periapical periodontitis and, finally, to necrosis with periapical abscess. Reversible pulpitis can be stopped by removal of the cavity and the placement of a sedative dressing of any part of the cavity that is near the pulp chamber. Irreversible pulpitis and pulp necrosis are treated with either root canal therapy or extraction. Infection of the periapical tissue will generally resolve with the treatment of the pulp, unless it has expanded to cellulitis or a radicular cyst. The success rate of restorative treatment and sedative dressings in reversible pulpitis, depends on the extent of the disease, as well as several technical factors, such as the sedative agent used and whether a rubber dam was used. The success rate of root canal treatment also depends on the degree of disease (root canal therapy for irreversible pulpitis has a generally higher success rate than necrosis with periapical abscess) and many other technical factors. ==Epidemiology==

In the United States, an estimated 12% of people reported that they had a toothache at some point in the six months before questioning. Irreversible pulpitis is thought to be the most common reason that people seek emergency dental treatment. ==History, society and culture==

, patron saint for toothaches, holds one of her own extracted teeth in a pair of forceps (Nuremberg Chronicle, Hartmann Schedel, 1493) was the first local anesthetic, but its addictive and other dangerous side effects eventually led to its use being virtually abandoned by modern health care. from 1875. 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 cuneiform, recovered from the Euphrates valley, and dates from around 5000 BC. The belief that tooth decay and dental pain is caused by tooth worms is found in ancient India, Egypt, Japan, and China, it is thought that ancient people suffered less dental decay due to a lack of refined sugars in their diet. On the other hand, diets were frequently coarser, leading to more tooth wear. For example, hypotheses hold 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 also wore amulets to prevent toothache. as in Massinger and Fletcher's play The False One. Toothache also appears in a number of William Shakespeare's plays, such as Othello and Cymbeline. In Much Ado About Nothing, Act III scene 2, when asked by his companions why he is feeling sad, a character replies that he has toothache so as not to admit the truth that he is in love. There is reference to "toothworm" as the cause of toothache and to tooth extraction as a cure ("draw it"). In Act V, scene 1, another character remarks: "For there was never yet philosopher That could endure the toothache patiently." In modern parlance, this translates to the observation that philosophers are still human and feel pain, even though they claim they have transcended human suffering and misfortune. In effect, the character is rebuking his friend for trying to make him feel better with philosophical platitudes. 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 of plants and trees include "toothache" in their common name. 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". Pellitory (Anacyclus pyrethrum) was traditionally used to relieve toothache. , Nepal. In Kathmandu, Nepal, there is a shrine to Vaishya Dev, the Newar god of toothache. The shrine consists of part of an old tree to which sufferers of toothache nail a rupee coin in order to ask the god to relieve their pain. The lump of wood is called the "toothache tree" and is said to have been cut from the legendary tree, Bangemudha. On this street, many traditional tooth pullers still work and many of the city's dentists have advertisements placed next to the tree. The phrase toothache in the bones is sometimes used to describe the pain in certain types of diabetic neuropathy. == Notes ==