Dental Pain

US Pharm. 2007;32(5):18-23.

Pharmacists frequently consult with patients who experience dental pain. While the problem may be minor, dental pain often indicates a serious underlying pathology. Pharmacists do not have the necessary skills or equipment to differentiate between benign and serious etiologies. Therefore, referral to a dentist is a virtual necessity for all patients who ask the pharmacist about acute dental pain. 

Categorizing Dental Pain
Dental pain can be categorized using different taxonomies. It may arise from a problem in the tooth or its supporting structures, or it may be due to a problem elsewhere that is misperceived by the patient as originating there (e.g., referred pain). Dental pain can also be classified by etiology. All occurrences require dental referral.

Pain Originating in the Tooth or Periodontium
This type of pain can be due to trauma, a cracked tooth, pulpitis, or a host of other causes.

Trauma: Dental pain may be caused by a traumatic event, perhaps a recent fall, a blow to the face from sports or fighting, or other facial or dental trauma. Trauma may have occurred some time ago, and the patient may have endured longstanding pain.

Cracked Tooth Syndrome: The patient may have "cracked tooth syndrome" from trauma, as well as from tooth grinding, accidental insults (e.g., biting down on an unpopped kernel of corn or a concealed olive pit), or bad habits, such as compulsively chewing ice.¹ In all of these cases, a living tooth can suffer a partial fracture that extends into the dental pulp (connective tissue lying beneath enamel and dentin in the central portion of the tooth housing the nerve). This problem is more common in older patients, whose water may not have been fluoridated when they were young. As a result, many have extensive dental restorations (i.e., fillings). As those restorations age, they are prone to damage. Patients with cracked tooth syndrome feel pain when biting down to chew; the pain usually remits when chewing ceases. Thus, patients often stop chewing on the troublesome side for a period of time. Pharmacists can recommend nonsteroidal nonprescription products as an emergency measure until patients see the dentist. However, pharmacists should stress that ibuprofen or naproxen does not affect the underlying pathology (despite the relief it seems to grant), and the problem will continue to worsen until a professional intervenes.

Reversible Pulpitis: This term refers to inflammation of the dental pulp that can be reversed with a professional appointment.¹ Patients complain of discomfort lasting less than five seconds when the tooth is contacted by cold, an air blast, or ingestion of sweet foods. The cause can be minor (e.g., dentinal hypersensitivity, a new filling, recent dental cleaning) or due to such problems as gingival recession, caries, or a defective restora­ tion. ² If the cause is addressed properly, it may cease. If the patient is unable or unwilling to see a dentist, the tooth may progress to irreversible pulpitis.³

Irreversible Pulpitis: Some tooth problems are too extensive to repair. Perhaps the tooth has developed a large cavity in a previously unfilled area or there is extensive erosion beneath an older amalgam. In these cases, if the damage reaches an area proximal to the pulp, repair cannot be done.¹ Advanced periodontal disease that leads to bone loss may also be the cause. The tooth affected with irreversible pulpitis causes moderate to severe pain and is also painful after cold, heat, or other stimuli, but in this case, the pain lasts for minutes to hours. The pain can be severe and disrupt sleep. Pharmacists should refer these patients to a dentist. The dentist may attempt a root canal--removal of the dental pulp from the center of the tooth. If a root canal is impractical, the tooth may have to be extracted.

Barodontalgia: Barodontalgia is tooth pain resulting from extremes of pressure. Pilots in unpressurized cabins (e.g., high-performance aircraft) experience barodontalgia from low pressures at about 3,000 feet, and scuba divers experience the same problem at the elevated atmospheric pressures encountered 10 meters below the surface and deeper. Investigators hypothesize that tiny air bubbles trapped under a root filling or adjacent to dentin expand or contract.⁴ Patients experience a sensation of sharp or squeezing tooth pain. In the worst case, alveolar mucosa may rupture. If the patient describes a pressure-related problem, referral to a dentist can facilitate restoration of damaged teeth.

Dentinal Hypersensitivity: Beginning at about age 30 years, many people notice that their teeth feel pain when they eat or ingest cold, hot, or sweet foods or drinks, when an air blast is used on a tooth, or when the tooth is contacted by a dental instrument while cleaning. The cause is most often gingival recession, due to such factors as smokeless tobacco use or overzealous brushing.¹ As the gingiva recede, softer tooth roots are exposed.⁵ Teeth are honeycombed with small tubules that pass from the outer enamel into the central dental pulp. The tubules contain a protoplasmic fluid that is able to move to a small degree.⁶ Triggers of discomfort cause the fluid to expand or move inward toward the dental pulp (e.g., dental cleaning, hot fluids) or outward away from the pulp (e.g., drinking cold fluids, an air blast). Patients perceive these fluid microshifts as pain in the areas where gingival recession is present. Products such as Crest Sensitivity Protection or Sensodyne are FDA approved to reduce dentinal hypersensitivity, when used as directed.⁵

Dental Pain Due to Tongue Piercing: The current popularity of voluntary body decoration/ mutilation has gone far beyond ear piercing to include piercing in areas once mutilated only in Third World countries.⁷ One procedure is tongue piercing, a rapidly performed subcutaneous tissue invasion that can lead to serious infectious disease, pain, edema, and pronged bleeding. Postpiercing problems may involve the teeth.Reactions between the metal barbell/stud and dental amalgam materials are similar to those experienced when a person with a filling accidentally bites down on a piece of tinfoil. The barbell ornaments can also smash against teeth with sufficient force to break them.

Referred Dental Pain
Dental pain may occur as a result of extradental causes. For instance, several types of headache can cause pain in the teeth and jaw.⁸ A cluster headache can result in toothache. Migraine and paroxysmal hemicrania can produce pain in the maxillary molars. Hemicrania continua is a headache that can produce toothache in the maxillary premolars. In each case, the dentist may discover that the pain does not originate in the teeth or periodontium. A physician may use diagnostic criteria to identify the type of headache that caused the tooth pain.

Jaw/tooth pain can be caused by trigeminal neuralgia, characterized by pain on one side of the head, in most cases the right side.⁹ The pain occurs in the areas innervated by the trigeminal nerve's mandibular and/or maxillary branch(es). Some patients insist that the pain started without any provoking factor, while others recall that it began after trivial stimulation of the mucosa around the teeth, tongue, or skin (e.g., chewing, yawning). Attacks come in waves of electric-like pain, lasting from a few seconds to several minutes.

Temporomandibular disorders, involving the temporomandibular joints, chewing structures, and other associated areas, may produce dental pain.¹⁰ Appropriate treatment for this condition may encompass such interventions as intraoral appliances, prescription drugs, moist heat, ice, ethyl chloride spray, exercise, physiotherapy, electrotherapy, and iontophoresis.

Assisting the Patient in Finding Dental Care
Many patients see the pharmacy as a "safe harbor" for dental problems, where they are free to seek advice without having to endure examinations, injections, and restorative work. When urged to seek dental care, these patients often have a variety of excuses for why they cannot or would prefer not to do so. With judicious planning, pharmacists can offer assistance in several situations. For patients with inadequate finances, pharmacists can recommend free medical clinics that offer dental services.^11,12 For patients who are new to the area and/or cannot make an appointment with a dentist, the pharmacist can help identify a local dentist who may be able to see patients on an emergency basis when requested by the pharmacist. Patients with dental phobia should be reassured that modern dental professionals are well trained in relatively discomfort-free techniques (e.g., using nitrous oxide, conscious sedation).

Avoid Nonprescription Products
In regard to self-treatment of dental pain, several products contain potassium nitrate for the minor condition of dentinal hypersensitivity, but they carry a label cautioning against use if the problem persists for more than 28 days. No other product is safe and effective in allowing the patient to treat undiagnosed dental pain without first seeing a dentist. A host of products claim to provide relief, but they should neither be stocked nor recommended. These include Red Cross Toothache Medication, containing eugenol, an unapproved and potentially dangerous ingredient when used in an unsupervised manner. Several Orajel products containing benzocaine also promise toothache relief, but benzocaine has never been FDA approved for toothache. Many products claim to allow the patient to temporarily repair lost fillings (e.g., DenTek Temparin) or temporarily secure dental restorations, crowns, caps, bridges, or laminates (e.g., DenTek Thin Set). However, patients often fail to follow package directions and may use these products as a permanent solution in preference to a dental visit. Long-term use could allow caries to invade exposed dentin. Patients purchasing these products must be advised not to forestall a dentist visit. In fact, the best solution is an emergency appointment with the dentist.

References

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8. Alonso AA, Nixdorf DR. Case series of four different headache types presenting as tooth pain. J Endod . 2006;32:1110-1113.

9. Bagheri SC, Farhidvash F, Perciaccante VJ. Diagnosis and treatment of patients with trigeminal neuralgia. J Am Dent Assoc. 2004;135:1713-1717.

10. Shankland WE II. Temporomandibular disorders: standard treatment options. Gen Dent. 2004;52:349-355.

11. Naito M, Yuasa H, Nomura Y, et al. Oral health status and health-related quality of life: a systematic review. J Oral Sci. 2006;48:1-7.

12. Waldman HB, Perlman SP. Dental needs assessment and access to care for adolescents. Dent Clin North Am . 2006;50:1-16.

13. Friedlander AH, Marder SR, Sung EC, et al. Panic disorder: psychopathology, medical management and dental implications. J Am Dent Assoc. 2004;135:771-778.

14. Out-of hospital cardiac arrest--statistics. American Heart Association. Available at: www.americanheart.org/downloadable /heart/1168639579314OUTOFHOSP07.pdf. Accessed March 17, 2007.

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