What's causing my Dental Pain? Top 5 hidden Toothaches

Following my previous post on top tips to manage dental emergencies, I thought I'd share with you some of the less common reasons why a patient may be complaining of tooth ache.

1. Temporomandibular Disorder

When I worked in oral surgery, I remember seeing a lot of referrals from GDPs for extractions of wisdom teeth which actually turned out to be TMD

When a patient complains on pain on opening or tightness and pain that radiates up their head or lingers in the pre-auricular region that is worse in the morning you should think TMD (myofacial in origin). When you diagnose this issue, sometimes you get a mixed reaction from patients: some are relieved it is not a tooth issue; others can be disbelieving and still try to focus on a tooth problem rather than accept your diagnosis. In some ways I can sympathise. If there was a tooth problem this can often be solved simply (root canal treatment or extraction for example), but often the management of TMD doesn't offer an immediate cure of pain; rather a gradual improvement over months. 

For those with acute TMD issues I usually advise:
  • Soft diet
  • Jaw exercises and massages
  • Use of topical ibuprofen gel +/- use of systemic NSAIDs
  • Hot or cold packs
  • Resting jaw i.e. cessating any habits like nail biting or pen biting, supporting the jaw when yawning, not opening wide to bite into foods like burgers
  • Use of a bite raising appliance 
To read more about TMD, see my previous post here

2. Sinusitis

Patients who suffer from sinusitis can often have referred pain to their top teeth (particularly their molars). Similar to what I mentioned above, patients can either feel relief or disbelief with this diagnosis. 

In these cases, patients can complain of generalised pain with their top teeth which can feel worse on biting (often their 6s and 7s are TTP), and the pain will feel worse on tilting their head forward. You may also detect a blockage of their nostrils or the patient reports a recent history of cold or flu. On a PA or DPT you may also detect a thickened sinus lining on the affected side. 

For these patients SDCEP Guidelines suggest:
  • Prescription of ephedrine 0.5% spray TDS 7/7
  • Use of steam inhalation 
  • Appropriate analgesia
  • In some cases antibiotics are indicated: either amoxicillin 500mg TDS 7/7 or 100mg doxycycline OD 7/7 (with initial loading dose)
  • In recurrent or persistent cases, refer onto ENT

3. Pericoronitis

You may not think this one is a hidden toothache... it's obvious isn't it? An inflamed operculum around a lower 8 with food packing, facial swelling and suppuration?

But it's not always that obvious. Pericoronitits can affect any tooth (not just wisdom teeth) and can often affect upper 8s too! And sometimes you don't get the clinical symptoms described above. One thing I saw lots last year in oral surgery was an apparently unerupted wisdom tooth giving issues. On closer examination, there is often a pocket distal to the 7 and you can probe the unerupted tooth underneath. The tissues can become pericoronitic in these cases and give pain. 

4. Food packing

Ever got something stuck between your teeth? It's sore isn't it. But if you get lots of food debris (once or twice I've seen lots of floss fibres too) stuck interproximally, it can be very painful! 

In cases like this, there may be a particularly large interproximal space or something causing plaque retention e.g. a fractured filling or carious cavity. Patients complain of pain usually in the gum that is achy and sometimes a bad taste in their mouths. 

Management of this is rather simply: acutely irrigating to remove the food/plaque (either with ultrasonic or chlorhexidine mouthwash) and removing any plaque retentive factors e.g. placing a temporary filling. As well as what you do in your clinic is to advise the patient regarding their oral hygiene e.g. the use of tepes/floss in order to avoid the problem reoccurring. 

5. Cracked teeth

Cracked teeth are so difficult to diagnose sometimes. A lot of the diagnosis of a cracked tooth is listening to a patient's history which can sound a lot like irreversible pulpitis but one of the most important things to listen out for is PAIN ON RELEASE!

Top Tips to help identify a cracked tooth:

  • Use magnification if possible to help identify any cracks
  • Look out for signs elsewhere in the mouth that may give you a clue about whether a patient is bruxing e.g. wear facets, fractured restorations, soft tissue keratosis, tongue scalloping
  • Ask the patient if they have any habits e.g. pen biting 
  • Use a tooth sleuth to identify which cusp may the one affected. If this is not available, use a tongue depressor or a dry cotton wool roll
  • The use of orthodontic bands can help confirm a diagnosis
  • When in doubt refer on... do not feel tempted to drill into a tooth without being sure about the diagnosis!

Ultimately, common problems happen commonly. Always look for the obvious when a patient is complaining of tooth ache, but keep an eye out for some of the above; you'd be surprised!

Do you seen any of these in practice? Leave your comments in the section below!

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