The information contained on this web site
is for educational purpose only and is not meant to serve as
delivery of professional care. The information in this
Resource Page should not be relied upon to make decisions
about your health that is Dental health. It is not a
substitute for medical or dental advice.
Always consult your dentist about your individual
condition(s) and/or circumstances.
Scared of Going to the Dentist?
The Feel Good Guide to going to the Dentist
Nothing personal Doc - 'I Hate Dentists' - The Feel Good
Guide to Going to Dentist.
If, like most people, you experience some degree of anxiety
when it comes time to see your dentist, the following
suggestions can help you to relax before and during dental
treatment. What's important is to recognise your anxiety,
accept it as a common reaction to an uncertain situation and
learn to master it.
1. Start by sharing your feelings with your dentist and
dental hygienist. Let them know that you are fearful, tense,
or anxious so that they can tailor their treatment and their
pace to your needs. Often, a pain reliever can be given if
it's pain you fear.
2. Set aside a stress-free time for your dental visit - a
time when you won't be rushed, physically strained, or
troubled by other concerns.
3. Being friendly and sociable helps establish trust and
warmth, both of which can do wonders in allaying your fears
and in reducing tension. You might also have a close friend
or family member accompany you to your appointment to make
you more at ease.
4. Try to identify your specific fears and concerns. While
these fears are very understandable, it is important to
recognise that they often are not realistic given the
modern, pain-free techniques now used in dentistry.
5. Get a good night's sleep the day before and eat a light
breakfast the day of your appointment. To allow
unconstrained movement, wear loose, comfortable clothes.
Especially avoid wearing constricting necklines, such as
tight collars.
6. Schedule short dental appointments by having different
procedures performed on different days, if possible. Also
arrange to break from lengthy procedures now and then.
7. Use visualisation to feel more comfortable and relaxed
both before and during a dental visit. You can focus on a
relaxing scene from a favourite vacation spot or activity
and hold it before your "mind's eye" during treatment.
8. During the dental visit, practise distraction and
relaxation techniques to take your mind off the treatment
and to reduce tension. You might focus, for instance, on
such pleasant distractions as soft music or a colorful
poster.
9. Ask the dentist or hygienist to explain each step of the
dental examination or procedure. The more you know about the
reasons for a certain procedure and what will be done during
it, the more confident and relaxed you'll be.
10. Once the dental visit is over, praise yourself for a job
well done! You might also treat yourself to a special reward
for overcoming your dental anxiety.
1. Tell the dentist about your fears. This information will
help the dentist determine how to best manage and address
those fears. By letting the dentist know exactly why the
experience is difficult for you, you will feel more control
in the examination chair.
2. Remember that dental procedures have greatly improved in
the past few years. Modern dentistry offers new methods and
treatment options to make you feel comfortable.
3. Your dentist can explain the entire procedure to you
beforehand, as well as walk you through step-by-step while
the procedure is being performed. You always have the right
to fully understand the work being done on your teeth.
4. Consider additional medication to relax. Many dentists
recommend nitrous oxide, sedation or anti-anxiety medicine
for extremely nervous patients. Find a dentist who offers
these options to help you get through the visit.
5. Find a dentist you are comfortable with and establish a
trusting relationship. There are many personalities in the
dental profession. Find a dentist who makes you feel at ease
and is willing to work with you on your fears.
6. Breathe deeply and try to relax. Some dentists recommend
practicing relaxation techniques before and during the
appointment. Other dentists find that listening to music, or
scheduling an appointment first thing in the morning, before
the stresses of the day add up, also help patients to relax.
7. Talk to the dentist about stopping if you're
uncomfortable. Many of the dentists surveyed said they
establish a signal to "stop" with their patients. This puts
you in control of the procedure and alerts the dentist if
you're uncomfortable or need to take a break during the
appointment.
8. Visit the dentist regularly to prevent problems. For
fearful patients, just going for a check up can be
nerve-wracking, but the more you go to the dentist for
routine cleanings, the more likely you are to avoid larger
problems that result in extensive procedures.
9. Visit the office and talk to the staff before your first
appointment. You should feel free to meet with the dentist
and to ask questions before scheduling your appointment.
Meeting the dentist and his or her staff first will help you
find a dentist you like and trust.
10. Go slow. Dentists are happy to go slow with nervous
patients. If possible, make sure your first visit is a
simple one, such as a cleaning. This will help you build
your relationship with the dentist before going in for a
more difficult procedure.
If you are anxious about dental
treatment then you are not alone. Between 6-14% of the
population avoid attending the dentist because of anxiety
about treatment. Between 45-55% of patients who attended the
dentist are anxious in the dental environment.
The reasons people fear attending the dentist are varied and
include pain, cost of treatment, lack of control while in
the dental chair, embarrassment and fear of the unknown. The
cause of dental anxiety is usually a previous bad
experience, but can be caused indirectly through horror
stories about dental treatment from family, friends and even
the media.
The fear of treatment may appear to the
patient to be irrational, uncontrollable and without obvious
cause. Such patients will only attend for treatment when in
extreme discomfort or never at all. As a result their dental
condition deteriorates to the point where their appearance
is affected. This can cause embarrassment and loss of
self-confidence which in turn can cause problems socially
and at work.
For other patients, the fear is not so
deep seated. They can explain the cause of their anxiety and
can usually control it to some extent. However, they are
still anxious about dental treatment and will try and avoid
it where possible.
Fear of dental treatment can be overcome by a variety of
treatment methods which are described on this website.
When you make the appointment to see the dentist, tell the
receptionist you are nervous about treatment. This first
appointment will usually be to discuss your fears about
treatment and to do an initial examination of your teeth.
From this appointment a provisional treatment plan can be
made. Depending on what you and the dentist decide, this
plan can include one or more of the the treatment methods
outlined below.Initially, you may wish to have treatment
using one or more of these described methods. However, the
ultimate aim should be to reduce your anxiety to a level
that it is possible to have treatment without any
assistance. This is not possible in all cases, but where it
can be achieved it is very satisfying for both patient and
dentist.
There are several methods available to help you overcome
your fears while dental treatment is being done.
These are:
BEHAVIOR MANAGEMENT
This is the simplest method of treatment for nervous
patients. It involves a careful and sympathetic approach
from the dentist, with explanations of what is being done
and allowing the patient control over the procedure.
Some patients may want to bring a friend along for support.
It may also be possible to play relaxing music or to watch a
video while having treatment.
ORAL SEDATION
This involves the use of oral sedative drugs e.g. diazepam,
midazolam, which are taken before treatment. They can also
be taken the night before treatment to help you sleep.
The sedative effect of these drugs is unpredictable and can
vary between individuals. Because the drugs are taken by
mouth it is impossible to quickly increase or decrease the
amount sedation.
They are best used for sedation the night before treatment
to ensure restful sleep or to produce light sedation during
treatment where anxiety levels are low.
While under the effects of the drug, the patient must be
accompanied by a responsible adult and refrain from driving
and operating machinery.
INTRAVENOUS SEDATION
This involves administering a sedative drug in order to
produce a very relaxed state so that treatment can be
carried out. The drug also causes short term memory loss so
that very little of the treatment can be remembered.
The drug is administered through one of the veins in the arm
or hand. The amount of drug given varies between individuals
but enough is injected to produce relaxed state within five
minutes. Because the drug acts very quickly, more can be
given if necessary to increase the feeling of relaxation.
The effects of the drug can last up eight hours after and
the patient must be accompanied by a responsible adult and
refrain from driving, operating machinery or other
responsible activities during this time.
It can be used on most healthy adults but must be avoided in
patients with severe lung disease, some heart problems,
obesity or in pregnancy. It is also not suitable for
children or the elderly.
This type of sedation is very safe as the patient is not
unconscious as in general anaesthesia. It works for the vast
majority of patients and it is a very effective way of
providing dental treatment. It is also very effective in
treating patients who gag easily.
INHALATION SEDATION
This involves giving a mixture of nitrous oxide ('laughing
gas') and oxygen which are inhaled through a rubber face
mask. The nitrous oxide reduces anxiety and improves
co-operation, without causing unconsciousness.
The effects of the nitrous oxide wears off very quickly and
the patient can leave the surgery without the need for an
accompanying adult.
This technique can used for most patients but must be
avoided in those with colds and other respiratory problems,
psychiatric treatment, vitamin B12 deficiency and in
pregnancy. This form of sedation is particularly useful for
treating anxious children.
GENERAL ANAESTHESIA
General anaesthesia (GA) involves being 'put to sleep' in
order to provide dental treatment. It is only available in
hospitals and specialist centres, and must be administered
by a qualified anaesthetist. Because of the slight risks
involved with GA, it is only used where there is no other
option. The procedure is usually limited to adults who are
undergoing complex treatments (e.g. extraction of wisdom
teeth) or are not suitable for the other methods of
treatment described. It is also used to treat anxious
children. Treatment provided under GA is usually limited to
extractions and simple fillings.
HYPNOSIS
This involves the use of hypnotherapy to reduce anxiety.
It is very effective in people who are respond well to
hypnosis. It may involve one or more preliminary sessions
before treatment is attempted. The hypnosis may be done by a
hypnotist working with a dentist or by the dentist if he is
qualified in hypnotherapy.
This type of treatment is not widely available and can be
time consuming and expensive.
PSYCHOTHERAPY
This form of treatment is used to treat a whole range of
phobias and anxiety disorders. The psychotherapist will
initially try and locate the origin of your fears. They will
then follow a program of therapy designed to overcome or
control your anxiety sufficiently for you to undergo dental
treatment.
ACUPUNCTURE
Acupuncture is a medical treatment which can be used to
relieve the symptoms of a variety of physical and
psychological conditions including dental anxiety. Each
patient's case is assessed by the practitioner and treatment
will be tailored to the individual.
Many of us feel extremely anxious when
we think of visiting the dentist. This fear is the cause of
procrastination in scheduling dental appointments, missed or
cancelled appointments, and difficulty in tolerating
procedures during dental care.
Although many dentists will try to convince you that these
fears are unfounded, we believe that there are actually many
good reasons (even aside from painful past dental
experiences) to feel anxious about visiting the dentist. By
understanding these reasons and utilizing our simple
techniques, dental anxiety can become a thing of the past!
The oral cavity is one of the most tender and most
vulnerable parts of our body. We feed ourselves through it
and kiss our loved ones with it--the mouth is literally a
path to our innermost self. The tongue is the only organ in
our body which is fully developed at birth and functions
fully during the first 2 months of life. Our infant lives
are dependent upon it for nourishment, to communicate and
express our feelings, and to explore the world (We all know
how infants just seem to put everything they touch into
their mouths!). During this early part of our lives, we are
helpless and dependent, unable to express ourselves fully,
and vulnerable to pain outside of our control.
Does this describe the feelings aroused by a dental visit?!
During dental care, we place our mouths in a very vulnerable
position. If we feel helpless, these infant experiences of
dependency and vulnerability will arise from our unconscious
minds. The result: anxiety.
A visit to the dentist is unlike any other medical
experience. We place ourselves in a physically vulnerable
position (on our backs), and suspend our usual physical
boundaries by allowing the dentist to "invade" our bodies.
We render ourselves unable to communicate in the usual way
(since our mouths are what's being tended to), and
anticipate pain, while remaining conscious and fully alert.
The physical proximity of the dentist may be perceived as
threatening, and if we add to the mix the negative
associations many of us have with doctors or other authority
figures, it is easy to see how feelings of anxiety might
arise.
Most of us agree that anxiety and fear notwithstanding, the
benefits of timely dental visits far outweigh the cost of
avoiding them. How then, do we cope with the anxiety we feel
when faced with a dental appointment?
Eliminating Acute Anxiety
This exercise is intended to give you control over the
physical discomfort of anxiety.
1. Before your dental
appointment, imagine yourself in the anxiety producing
situation
In order to eliminate anxiety, one must first recognize
the feeling of being anxious.
Sit in a chair in a quiet place and picture yourself in
a stressful situation, dental or non-dental. For
example, a stressful dental situation might be either
anticipating a dreaded dental experience or remembering
a past dental experience. A non-dental example might be
speaking in front of a large group of people.
At first, try standing "outside" of yourself and watch
yourself in the difficult situation. Then try to
experience the situation yourself, looking at it from
the "inside".
Once you feel anxious, or physical discomfort, go on to
#2.
2. Locate where in your body the anxiety 'lives,'
such as a tense neck or back, clenched fists, nervous
stomach, unconsciously holding your breath, or
dizziness. Close your eyes. Pretend to travel inside of
your body and find the place where the stress seems to
"live". This is often the stomach, chest, head, hands or
arms. This area feels different and separate from the
rest of your body.
3. Measure the anxiety on a 1-10 scale. Rate the
degree of discomfort on a scale of 1 to 10, with 10
being the worst. This will allow you to monitor your
progress.
4. This step is important: Explore the "size,
shape, borders and texture" of the anxiety.
The area of discomfort feels different and separate from
the rest of your body. Try to isolate it and explore its
"borders" and "shape". Is it "large" or "small"? "Round"
or "square"? Localized or diffuse? How deep does it go?
All the way to your back? Or is it shallow and just
under the surface? Is it a solid, liquid or gas?
5. Manipulate the anxiety: make it larger,
smaller, softer, etc.
Now that you have a clear idea of the stress you're
feeling, you can do things to change it. First, make it
bigger. Take all the concentration you need to do this,
and when you're ready, rate it on a scale of 1-10. (It
will probably be less than 10.) Then, make the area
smaller, like a golf ball or an egg. Now, you can move
it around, forward and back, or side to side. As you
begin to gain control of the anxiety, you can begin
opening a path from where the anxiety "lives" to your
throat. Now, move the spot of discomfort to your throat,
then take a deep breath and blow it out of your mouth.
6. Re-measure the anxiety. Do your 1-10 rating.
By now, it will probably feel much less!
These steps give you some control over your anxiety, which
enables you to reduce it.
What if
these tactics to overcome the fear of visiting a dentist
don't work?
In some cases a step-by-step desensitization program can
eliminate severe fear of the dentist. Another option is
medication to help you relax for your appointments. Discuss
this possibility with your dentist.
"Your relationship with your dentist is based on trust, and
you should expect to be treated as an individual. Make
requests. Don't hesitate to ask for special treatment.
Some children have a deep-seated fear of dentists, making
dental appointments a traumatizing experience. However, it
is important that children have regular dental checkups.
There are tips for dealing with children who have dental
anxiety or severe dental phobia, including:
Start dental checkups at an early
age, so the child will be comfortable and familiar with
dental appointments.
Enforce good oral hygiene, so trips
to the dentist are minimal.
Be careful not to convey your fears
of the dentist to your child.
Another option
to treat a child's dental anxiety is to find a dentist who
specializes in pediatric care. Pediatric dentists have
special training that allows them to help anxious children
feel safe and secure during dental checkups and procedures.
They also offer kid-friendly offices, so the environment is
inviting and comfortable for children.
If not addressed during younger years, dental anxiety can
develop into severe dental phobia as one gets older. To
prevent bad oral hygiene later in life, the above
suggestions can work to calm your child's fear of dentists.
TOOTHACHE
Rinse the mouth with warm water to clean it out. Use dental
floss to remove any food that might be trapped between the
teeth. Never place an aspirin tablet on the gum beside the
aching tooth. If you can see a definite hole, a small ball
of cotton wool dipped in oil of cloves, squeezed almost dry
and placed in the hole should help. See your dentist as soon
as possible.
ABSCESS ON THE TOOTH
If you have a severe throbbing pain and the tooth feels as
though it is raised out of the socket and is loose, try
using a mouthwash consisting of a teaspoonful of salt in a
glass of warm water. Hold each mouthful for about one minute
and repeat the procedure 3 times daily. Never put heat on
the outside of the face. See your dentist ASAP.
KNOCKED OUT TOOTH
If the tooth is dirty, rinse it gently in running cold tap
water holding the crown (or the part of the tooth visible in
the mouth). Do not scrub it or remove any attached tissue
fragments. Gently insert the tooth in its socket or suck on
it or place in the cheek or under the tongue. If this not
possible, place the tooth in a cup of milk or in a cup of
cool water or placed the tooth on a plastic wrap or wet
towel. Go immediately to your dentist within 30 minutes is
possible. Don't forget to bring the tooth.
BROKEN TOOTH
Gently clean dirt from the injured area with warm water.
Place cold compress on the face, in the area of injured
tooth, to decrease swelling. Go to dentist immediately.
BITTEN TONGUE OR LIP
Apply direct pressure to the bleeding area with a clean
cloth. If swelling is present, apply cold compress. If
bleeding does not stop, go to a hospital emergency room.
PROBLEMS WITH BRACES AND RETAINERS
If a wire is causing irritation, cover the end with a small
cotton ball, beeswax or piece of gauze, until you can get to
the dentist. If a wire gets stuck in the cheek, tongue or
gum tissue, do not attempt to remove it. Go to your dentist
immediately. If an appliance becomes loose or if it breaks
off, take the appliance and the piece and go to dentist.
OBJECTS CAUGHT BETWEEN THE TEETH
Try to remove the object with floss. Guide the floss
carefully to avoid cutting the gums. If you are not
successful in removing the object, go to the Dentist. Do not
try to remove the object with are sharp or pointed object.
Being prepared for a Dental Emergency is no accident. It
takes a little time and thought, but by knowing what to do
before an accident happens, you may someday save a tooth -
yours or someone else's.
A tooth that
causes ongoing pain may be a sign of a serious problem. Use
this chart to communicate with us your Dental Pain
SYMPTOMS
DIAGNOSIS
SELF-CARE
1. Did you have an
injury that knocked out a tooth?
You have TOOTH LOSS
DENTAL EMERGENCY
See your dentist or go to the emergency room right
away. Keep the tooth moist. It's best to keep the
tooth in your mouth until you get to the dentist or
emergency room. The tooth may be saved.
2.Do you have pain that
is specific to one tooth?
Go to Question 5.*
3.Have you
broken or chipped a tooth, or is the tooth loose in
its socket?
Your pain may be from a
FRACTURED, CRACKED or LOOSE TOOTH.
Save any pieces of the
tooth, wrap them in a cool, moist cloth and see your
dentist as soon as possible.
4. Do you
feel pain when you eat cold foods or liquids?
Your pain may be from a
CAVITY.
Make an appointment to
see your dentist. Proper brushing and flossing along
with fluoride rinses and coatings, as suggested by
your dentist, may prevent tooth decay.
*5. Do you
have redness or swelling around one or more teeth,
in your gums or in your face?
You may have a dental
ABSCESS or an INFECTION in a tooth, gums or other
tissues.
URGENT
See your dentist or doctor right away
6. Do you
have redness and swelling in large areas of your
gums, or is the skin inside your mouth peeling?
You may have an
infection such as TRENCH MOUTH, GINGIVITIS or
PERIODONTITIS. A rare drug reaction, STEVENS-JOHNSON
REACTION, may also cause this.
See your dentist or
doctor right away. You may be given antibiotics to
stop the infection. Over-the-counter pain relievers,
such as acetaminophen, may relieve discomfort. Many
of these infections can be prevented with proper
dental care, such as brushing and flossing
regularly.
7. Do you
have headaches, pain near your ear, headaches, or do
you hear a cracking sound when you bite?
Your pain may be from
TEMPOROMANDIBULAR JOINT (TMJ) syndrome, a condition
that affects the jaw.
Try relaxing your jaw
when you are tense or nervous. Stop chewing gum. Try
a mild anti-inflammatory medicine, such as
ibuprofen. If you don't get better, see your
dentist.
For more
information, please talk to your doctor or your
dentist. If you think the problem is serious, call
your doctor or your dentist right away.
This
tool has been reviewed by doctors and is for general
educational purposes only. It is not a substitute
for medical advice. The information in this tool
should not be relied upon to make decisions about
your health. Always consult your dentist about your
individual condition(s) and/or circumstances.
The following observations are intended
as general information for the public based on over one
hundred thousand individual cases over thirty years. This is
not intended to serve as a guide for self-diagnosis or as a
substitute for an examination by a dentist.
Dental Decay
Dental decay is usually painless as it goes thru the enamel,
the outer layer of the tooth.
The tooth can become "sensitive" as decay moves into the
"live" dentin (inner layer) of the tooth....
sensitivity to sweet and sour as well as hot and cold is
common but the tooth should not be continuously "sore" or
"throb". As the decay process gets near the nerve of the
tooth , the intensity and frequency of the symptoms usually
increase.
Once the decay process has reached the nerve of the tooth,
extreme pain can occur at any time...the intensity can range
from moderate to a very severe...extreme throbbing pain can
be continuous and can resist oral pain medication. This kind
of pain could subside during the daylight hours but is typically
much worse during the evening and night. Once a
toothache wakes you from sleep it is often relentless.
Dental Abscess
By definition, a dental abscess is a localized collection of
"pus"or infected material in the area surrounding the root
end of the offending tooth...pressure built up in this area
can cause severe pain that can be referred to other teeth as
well as other areas of the mouth and face. Its not unusual
for the patient not to know for sure where the pain is
coming from or which tooth is the problem. This abscess can
enlarge and extend to surrounding teeth...if the infection
goes through the bone, rapid swelling of the gum and cheek
can occur.
Cracked Tooth Syndrome
A very common problem with "root canal teeth" and teeth with
large fillings .
Toothache due to a crack will start when you chew or put
pressure on the tooth ... it will get worse as the crack
continues to enlarge. ...the fractured piece may feel loose
or actually fall off and an abscess can develop at any time.
Its easy to visualize the mechanics of the problem - picture
an ice cube or piece of glass with a crack.......every time
you apply pressure or tap on top of the ice or glass, the
crack will get bigger until the crack goes completely
through. Pain from a cracked tooth can start as an
occasional" twinge" or "zinger" or it can be sudden and
severe and continuous from the very start.
P-Cor ( Pericoronitis )
This very common and painful condition is usually seen with
a partly erupted wisdom tooth. Because there is not enough
room for the tooth to come in completely, it becomes "stuck"
or "wedged". A pocket or sack develops in the gum tissue
around and behind this tooth. This pocket quickly fills with
bacteria and food debris. Because the mouth is moist, warm
and dark (it's a perfect incubator) an abscess can form
rapidly. This pain can be very severe and continuous, and is
commonly sent to (referred to) the area around the ear. Pain
when opening or even severe limitation when trying to open
the mouth in common. We often see patients coming from an
ear doctor when their real problem was a wisdom tooth.
Wisdom Teeth
Wisdom teeth are the last molars to develop and usually
start to erupt in the late teens. Because they are the very
last teeth, they very commonly become impacted (stuck or
wedged between jaw bone, gum and the adjacent tooth).
Toothache or pain from the wisdom tooth area is one of the
most common emergency problems that we see.
Over 90% of the population has "wisdom tooth" problems due to
lack of room for proper eruption. Wisdom Tooth
Problems encompass many issues including:
Pain Constant pressure in
this sensitive area frequently causes neuralgia-like
pain that can radiate to the ear, side of the face and
upper teeth and spread to the other lower teeth as well.
Headaches are commonly associated with impacted
or partially erupted wisdom teeth.
Destruction of the Next Tooth
-pressure from the wisdom teeth frequently erodes or
dissolves away healthy tooth structure, resulting in
pain and tooth loss
Cysts...fluid -filled sacks
can form and enlarge around impacted wisdom teeth. These
cysts can dissolve jawbone and teeth-they commonly
become infected and cause serious pain
Crowding. Impacted wisdom
teeth can quietly and painlessly push other teeth out of
alignment and ruin years of orthodontic treatment.
Cosmetic correction could require involved orthodontic
work.
Infection-pericoronitis
Gum Abscess (Periodontal Abscess -
Perio Abscess)
This infected tooth may be completely free from decay and
have no filling...it may feel loose and the surrounding gum
can feel swollen ....a bad taste is a common feature . A
defect in the supporting bone along one or more sides of the
tooth forms a "pocket" with the gum that becomes filled with
food and bacterial debris....an abscess can develop
"overnight". Mild sensitivity in the area can escalate to
severe pain and swelling involving several teeth.
Overloaded/Over-stressed Tooth (Hyper Occlusion or
Traumatic Occlusion)
Moderate to sharp discomfort to touch or pressure most
commonly seen after placement of a dental filling or crown
that is too "high".... can be easily corrected by adjusting
the offending filling or crown and bite.
Several dental conditions have
typical symptoms with different types of pain
A detailed history and examination will
identify the cause of dentally-related pain in most
emergency situations. Sharp, shooting pain can be caused by
inflammation in the pulp or exposure of the dentine. Dull
throbbing pain has several causes including ulcerative
gingivitis, dental caries and food impaction. Simple
treatment will usually alleviate the symptoms until patients
can be seen by a dentist.
History and examination
location
type
frequency and duration
onset
exacerbation and remission (for
example the response to heat or cold)
severity
area of radiation.
Associated pathology and referred pain
should also be considered.
The following structures need to be examined carefully in
order to be sure that the pain is of dental origin:
tongue
buccal mucosa
floor of the mouth
hard palate
teeth and periodontal tissues (see
Fig. 1)
tonsils
temporomandibular joints
airway
ears
salivary glands
lymph nodes.
What are the common types of dental pain?
Short, sharp, shooting pain
This type of pain can be generalised or confined to one
region of the mouth. The pain may be due to fluid movement
through open tubules in the dentine or there may be some
initial inflammatory changes in the dental pulp. It can be
caused by caries, dentine exposure on root surfaces, split
cusp, lost or fractured restoration or a fractured tooth.
Patients complain commonly of a sharp pain associated with
hot, cold or sweet stimuli. The pain is only present when a
stimulus is applied. In the case of a cracked cusp, grainy
bread or hard food may create a sharp pain, that may be
spasmodic, on biting or chewing.
With gingival recession, recent scaling, or tooth wear due
to a high acid diet or gastric reflux, there may be
generalised dentine sensitivity. However, with caries,
fractured fillings and cracked cusps, the pain tends to be
localised to the affected tooth.
Intermittent sharp, shooting pains are also symptomatic of
trigeminal neuralgia, so care must be taken not to
mistakenly label toothache as neuralgia.
Treatment
For root sensitivity the use of a desensitising toothpaste
and a reduction in acid in the diet will help resolve the
symptoms. The use of a fluoride mouth-rinse may also help.
In the case of caries, a lost filling or fractured tooth,
coverage of the exposed dentine with a temporary restoration
will usually relieve the symptoms.
Causes of common types of dental pain
Dull, throbbing, persistent pain
This type of pain may have several causes. These include
tooth problems, food impaction, pericoronitis, acute
necrotising ulcerative gingivitis, temporomandibular
disorder, or even maxillary sinusitus.
Painful tooth problems
The most common dental cause of dull, throbbing persistent
pain is caries. In many cases this is recurrent and
associated with an existing restoration. Where the pulp is
affected irreversibly, necrosis may follow with possible
development of a periapical infection. A fractured cusp
involving the pulp, or a large deep restoration may also be
associated with this type of pain. Affected teeth may be
tender to percussion in the later stages of periapical
inflammation.
There is considerable variation in the pain reported by
patients, but it commonly starts as a sharp stabbing pain
that becomes progressively dull and throbbing. At first the
pain may be caused by a stimulus, but it then becomes
spontaneous and remains for a considerable time after
removal of the stimulus. The pain may radiate and be
referred to other areas of the mouth. This type of pain
tends to cause the patient to have difficulty sleeping and
may be exacerbated by lying down. Heat may make the pain
worse whereas cold may alleviate it. The pain may be
intermittent with no regular pattern and may have occurred
over months or years. If there is periapical infection
present, patients may no longer complain of pain in response
to a thermal stimulus, but rather of sensitivity on biting.
Treatment
Treatment of affected teeth will involve either root canal
therapy or tooth removal. In some patients, periapical
inflammation can lead to a cellulitis of the face
characterised by a rapid spread of bacteria and their
breakdown products into the surrounding tissues causing
extensive oedema and pain. If systemic signs of infection
are present, for example, fever and malaise, as well as
swelling and possibly trismus (limitation of mouth opening),
this is a surgical emergency. Antibiotic treatment alone is
not suitable or recommended.
Should antibiotics be prescribed?
While antibiotics are appropriate in the management of
certain dental infections, they are not indicated if the
pain results from inflammatory (non-infective) or
neuropathic mechanisms. The degree of pain is not a reliable
indicator of acute infection.
There is evidence that Australian dentists and doctors are
using antibiotics empirically for dental pain, rather than
making careful diagnoses of the causes of the pain.1 Most
dental emergency situations involve patients with acute
inflammation of the dental pulp or the periapical tissues.
Prescribing antibiotics for these conditions will not remove
the cause of the problem nor destroy the bacteria within the
tooth.
Antibiotics should be limited to patients with malaise,
fever, lymph node involvement, a suppressed or compromised
immune system, cellulitis or a spreading infection, or a
rapid onset of severe infection.
If pus is present, it needs to be drained, the cause
eliminated, and host defences augmented with antibiotics.
The microbial spectrum is mainly gram positive including
anaerobes. Appropriate antibiotics would include a
penicillin or a `first generation' cephalosporin, combined
with metronidazole in more severe cases.
Paracetamol or a non-steroidal anti-inflammatory drug is the
recommended analgesic in the initial treatment of dental
pain.
Food impaction and pericoronitis
Soft tissue problems that may cause dull, throbbing,
persistent pain include local inflammation (acute gingivitis
associated with food impaction) or pericoronitis.
Chronic periodontitis with gradual bone loss, rarely causes
pain and patients may be unaware of the disorder until tooth
mobility is evident. There is quite often bleeding from the
gums and sometimes an unpleasant taste. This is usually a
generalised condition, however, deep pocketing with extreme
bone loss can occur around isolated teeth. Food impaction in
these areas can cause localised gingival pain. Poor contact
between adjacent teeth and the presence of an occluding cusp
forcing food into this gap can also cause a build-up of food
debris and result in gingival inflammation.
Acute pericoronitis involves bacterial infection around an
unerupted or partially erupted tooth and usually affects the
lower third molar (wisdom tooth). The condition is often
aggravated by the upper molar impacting on the swollen flap
of soft tissue covering the unerupted tooth. There may be
trismus.
Treatment
Food debris should be removed and drainage established, if
pus is present. Irrigation with chlorhexidine and rinsing
the mouth with hot salty water is recommended. Early
referral to a dentist is indicated. Cellulitis can develop,
requiring urgent referral to a surgeon.
Acute necrotising ulcerative gingivitis
Acute necrotising ulcerative gingivitis is a rapidly
progressive infection of the gingival tissues that causes
ulceration of the interdental gingival papillae. It can lead
to extensive destruction. Usually young to middle-aged
people with reduced resistance to infection are affected.
Males are more likely to be affected than females, with
stress, smoking and poor oral hygiene being predisposing
factors. Halitosis, spontaneous gingival bleeding, and a
`punched-out' appearance of the interdental papillae are all
important signs.
The patients quite often complain of severe gingival
tenderness with pain on eating and tooth brushing. The pain
is dull, deep-seated and constant. The gums can bleed
spontaneously and there is also an unpleasant taste in the
mouth.
Treatment
As there is an acute infection with mainly anaerobic
bacteria, treatment follows surgical principles and includes
superficial debridement, use of chlorhexidine mouthwashes
and a course of metronidazole tablets. Treating the
contributing factors should prevent a recurrence.
Dry socket
A dull throbbing pain develops two to four days after a
mandibular tooth extraction. It rarely occurs in the
maxilla. Smoking is a major predisposing factor as it
reduces the blood supply. The tissue around the socket is
very tender and white necrotic bone is exposed in the
socket. Halitosis is very common.
Treatment
The area should be irrigated thoroughly with warm saline
solution. If loose bone is present, local anaesthesia may be
necessary to allow thorough cleaning of the socket. Patients
should be shown how to irrigate the area and told to do this
regularly. Analgesics are indicated, but pain may persist
for several days. Although opinion is divided as to whether
or not dry socket is an infective condition, we do not
recommend the use of antibiotics in its management.
Sinusitis
This is caused by infection of the maxillary sinus, usually
following an upper respiratory tract infection. However,
there can be a history of recent tooth extraction leading to
an oro-antral fistula. Patients usually complain of
unilateral dull pain in all posterior upper teeth. All these
teeth may be tender to percussion, but they will respond to
a pulp sensitivity test. There are usually no other dental
signs.
The pain tends to be increased on lying down or bending
over. There is often a feeling of `fullness' on the affected
side. The pain is usually unilateral, dull, throbbing and
continuous. Quite often the patient feels unwell generally
and feverish.
Treatment
Pain originating from the sinus arises mainly from pressure.
Decongestants can help sinus drainage. Antibiotics probably
have only a minor role in mild cases. Referral to an
otorhinolaryngologist for endoscopic sinus surgery may be
indicated in chronic cases.
Avulsed tooth
Avulsed deciduous (baby) teeth are generally not
reimplanted, as they may become fused to the alveolar bone
and impede subsequent emergence of the permanent successor.
It is essential to reimplant permanent teeth as soon as
possible. However, while the tooth is out of the alveolus it
should be stored in a physiological medium, for example,
normal saline, milk, or the vestibule of the mouth.
Before reimplantation, the root surface should be cleaned
gently with normal saline to remove debris, but the root
should not be touched with the fingers. The tooth socket
should be irrigated gently with normal saline to remove any
blood clot that has formed. The tooth should then be
replaced into the socket using minimal pressure, and
splinted to the adjacent teeth with a flexible splint (e.g.
aluminium foil, bluetack).
When a tooth is reimplanted, an antibiotic is prescribed for
five days and a tetanus booster is given if immunisation is
not up to date.
Fractured tooth
If the crown of a tooth is fractured by trauma and the
broken fragment is available, it should be stored in a
physiological medium until a dentist can assess the patient.
Coverage of exposed dentine on the fractured crown with a
temporary restoration is desirable to protect the underlying
pulp tissue.
Placement of temporary restorations
Although it is unlikely that many general medical
practitioners will have temporary filling materials
available in their surgeries, dentine that has been exposed
by caries, a lost filling or tooth fracture can be covered
relatively easily with glass ionomer cement (GIC) or zinc
oxide eugenol (ZOE) materials. Most GIC materials are
dispensed in capsules but a hand-mixed material is
available, consisting of a powder, liquid and conditioner.
The surface of the cavity is painted with the conditioner,
then rinsed and dried, before placement of the filling. Zinc
oxide eugenol materials consist of a powder and liquid (oil
of cloves) that are mixed to a putty-like consistency before
placement in the tooth.
Cavities are the most common reason for tooth ache. They are
caused by dental plaque, a sticky substance made up of food
bits saliva and bacteria. Plaque makes acids that eat away
the enamel on the teeth. A Tooth ache can also be caused by
a bit of food stuck between the gum and the teeth. Tooth
pain can also be caused when the nerve root of a tooth is
irritated. Dental infection, decay, injury, or loss of a
tooth is a few common causes of dental pain. Pain may also
occur after a tooth is pulled out. Pain sometimes originates
from other areas and radiates to the jaw, thus appearing to
be tooth pain.
Symptoms
Sharp pain in the tooth, often when
you bite or chew.
Ache or soreness in the teeth, gums
or jaws.
Bad breath or bad taste in your
mouth due to severe decay.
A loose tooth.
Red, swollen or bleeding gums.
Fever.
Earache.
Swollen glands in the neck.
Severe pain in the jaw.
Prevention
Brush your teeth after meals and
between-meal snacks. Floss at least once a day.
Avoid foods that contain a lot of
sugar. Sugar helps plaque grow.
Do not smoke or use other tobacco
products because it decreases your ability to fight gum
infection and delays healing.
Don't eat any sticky foods, which
damage tooth enamel.
Get your teeth cleaned every 6
months and see a dentist every year.
Ask your dentist or hygienist
whether he or she recommends using a mouthwash that
contains fluoride and ingredients to reduce plaque.
