Severe Tooth Pain

• Clinical Definition: Necrotic or inflamed pulp with associated inflammatory changes within the supporting structures (periodontium).

• Indications for Urgent Evaluation: Spontaneously throbbing; pain at night; duration of sensitivity to cold or heat > 30 sec.; swelling of face or cheek.

• Major Recovery Options: Root canal (endodontic) treatment followed by placing a dental crown; antibiotic treatment directed toward specific pathogens; extraction.

• Home Care Instructions: Use a warm saline rinse, use available (OTC) analgesics, and avoid chewing near the affected areas.

• Spontaneous Throbbing: The throbbing will be spontaneous (will occur without an outside stimulus), persistent, rhythmic, and deep in the jawbone.

• Thermal Hypersensitivity: There is a sharp, prolonged pain experienced with consumption of hot or cold beverages, such as filter coffee or ice drinks.

• Masticatory Distress: Tenderness experienced upon chewing of typical food items (i.e., crunchy banana chips or hard rice-based snacks).

• Referred Pain: The pain may be referred to the ear, temple, or opposite jaw arch; thus, localizing the area of pain is difficult.

• Fever and Chills: Fever indicates systemic elevation of body temperature secondary to blood-borne spread of local bacterial infection.

• Cervical Lymphadenopathy: Tender enlargement of the cervical lymph nodes located below the jaw or along the neck.

• Signs of Ludwig’s Angina: Submandibular swelling which progresses rapidly enough to compromise either the pathway for swallowing or respiration.

• Purulent Discharge: Spontaneous discharge of foul-tasting purulent exudate at the base of the gum adjacent to the tooth, causing pain.

• Advanced Dental Caries: The continued growth of an un-checked, acidogenic, bacterial plaque that is breaking down the enamel layer on a tooth to enter the dentin tubules.

• Occlusal Trauma: Sudden, acute mechanical stress to a tooth resulting in fracture of the cusp due to chronic bruxism (grinding).

• Defective Restoration: Bacterial invasion from micro-leakage under aging amalgams or crowns.

• Pocketing Periodontitis: Severe pocketing caused by deep infection in the gums, which tracks back into the lateral root canals and into the pulp chamber.

• Dietary Habits: Sticky sweet regional candies (such as sharkkara varattiyathu) eaten frequently but brushed or flossed irregularly.

• Poor Oral Hygiene: Brushing and/or flossing habits inconsistent; therefore, allowing for plaque maturation.

• Clenching Habitually: Stressful lifestyles cause clenching during daytime or at night unconsciously.

• Anomalous Structures: Thin congenital enamel or deep congenital pits and fissures in teeth.

• Visual Examination: Use a light source (bright flashlight) and a mirror to visually examine tooth structure for potential signs of cavity formation, a fractured cusp, or dark grey color changes.

• Percussion Test: Gently tap the suspect tooth with a spoon (handle); if sharp pain is elicited, then you will have inflammation of the PDL.

• Thermal Test: Take a sip of cold water. If the pain continues even after drinking the cold water, then it could be related to inflammation of the gums and/or a periapical cyst/abscess.

• Safety Warning: Do not put crushed up aspirin on your gums, as it can cause severe chemical burns to the mucous membrane.

• Visual/Tactile Examination: Using a dental explorer to probe at the margins of teeth to find areas where there has been trauma resulting in soft dentin or structural fractures.

• Radiographic Evaluation: Intraoral periapical (IOPA) x-ray images and CBCT scan to diagnose the presence of periapical abscesses and bone loss.

• Vitality Testing: Electric pulp testing or applying cold spray to determine if there are live nerves remaining within the tooth or if they have died.

• Periodontal Probing: To determine pocket depth(s) of the roots of the teeth surrounding the area being evaluated by probing all sides of each tooth.

• Mild: Some sensitivity to sweet or cold (intermittently) and reversible pulpitis.

• Moderate: Spontaneous aching pain that is relieved by an OTC analgesic. This indicates irreversible pulpitis.

• Severe: Waking up from severe pain due to a throbbing sensation that does not cease. The pulp has died, and there are signs of a periapical abscess.

• Pulpotomy/Root Canal Treatment: Removing all of the dead and infected pulp tissue from the canal(s), mechanically cleaning the canals, and filling them with a biocompatible material called gutta-percha.

• Protective Crown Placement: Fabricating a custom crown using either zirconia or porcelain-fused-to-metal to replace missing structural components.

• Targeted Pharmacology: Using prescription NSAIDs and specific antibiotics for controlling acute infection flares.

• Surgical Extraction: Atraumatically removing the tooth if it cannot be restored due to extensive damage.

• Cost of Root Canal Treatment: The charges for root canal treatment may vary from ₹3500 to ₹8000 per tooth; the cost is determined by the anatomical complexity of each tooth.

• Charges for Dental Crowns: The cost of a dental crown varies according to the material used (metal ceramic or zirconia), which ranges from ₹4000 to ₹15000.

• Consultation Fees for Emergency Cases: For the initial consultation fee, patients are charged anywhere from ₹300 to ₹1000.

• Subsidies/Nominal Costs Available Under Government Scheme: As part of the government scheme, subsidized or nominal costs of emergency treatments will be available at all State District Hospitals as well as under the wings of government medical colleges.

• A General Dentist (BDS): Provides primary triage and pain-relieving medication prescriptions, as well as simple anterior root canal therapy.

• An Endodontist (MDS): Has specialized training in root canal anatomy with an emphasis on complicated teeth, such as those with calcified canals and/or retreated teeth.

• An Oral and Maxillofacial Surgeon: Is required for managing complex facial infections (cellulitis), removals of difficult-to-extract teeth, and Ludwig’s angina.

• A Prosthodontist: Specializes in precise post-endodontic restorations and complete mouth rehabilitation.

• Emergency (less than 4 hours): Treatment is required if you are experiencing significant facial swelling that is worsening by the hour, an extremely elevated body temperature above 101.5 degrees, or trauma to your mouth that results in an avulsed tooth.

• Same Day (within 24 hours): Treatment is required if you have throbbing pain which wakes you up throughout the night or prevents you from performing normal activities during the day.

• Elective (between 3-5 days): Should be reserved for slight sensitivity of a single tooth that is not painful enough to limit your ability to eat, brush, and floss, or to be able to function normally.

1. Why does my severe toothache seem so much worse at night, especially when I am lying down? 

The reason lies in gravity. The increased hydrostatic blood pressure due to gravity inside the cranial cavity and face increases the pressure within the infected pulp space, increasing contact with nerve endings as well.

2. Will severe toothaches go away without visiting a dentist? 

If the toothache goes away all of a sudden, this usually means that the tooth nerve has been destroyed through necrosis. However, the bacteria causing the toothache will continue to multiply and form a large abscess that can be extremely dangerous.

3. What risks are there in using clove oil (eugenol), which is commonly used as a home remedy for severe tooth pain?

Although clove oil may temporarily reduce pain for areas where dentin is exposed, it will not kill the bacterial infection present in the tooth structure.

• Periapical Abscess: Pus forms in the tooth’s root due to bacteria entering the space where the dead nerve was.

• Trigeminal Neuralgia: Severe facial “shock” type pains can mimic deep dental pain.

• Sinusitis (Maxillary): The maxillary sinus becomes inflamed, causing the referred pressure in your upper molars.

• Post-and-Core Build-up: It is a reinforcement material for the root canal so it will have enough strength for a crown.

• Periodontal Scaling and Root Planing: Cleaning around the gum line to remove plaque that supports gum-related pain.

• Occlusal Night Guard: An acrylic night guard to protect against mechanical wear resulting from bruxism.

Acute odontalgia should receive swift action because delay allows for systemic spread of the pathogens. Modern endodontics employs rotary instruments and apex locators to ensure quick, successful treatments with less time for patients. Ultimately, the long-term outcome is dependent upon timely diagnosis and sealing of the coronal portion of the tooth via a permanent crown. Failure to treat acute odontalgia promptly will result in irreversible bone destruction and serious systemic disease; therefore, acute odontalgia must be considered an urgent medical condition.