The Confusing World Of Dental Pain

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I did a search of “survey of most common reasons for going to the dentist” to see what the prime reasons for seeking dental care were. Forty percent of the first ten results were reasons why people avoid the dentist. Sadly, many people avoid going to the dentist, but when teeth start hurting, their motivation goes up. Unfortunately, waiting until you have a toothache is like trying to fix the roof when it is raining; a bad idea.

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In my 30 years of practice, I have found that the pain scale is a useful tool to assess the level of discomfort a patient has. I ask the patient to give me a number from one to ten, where one is barely any pain and ten is the worst pain imaginable. I find that the pain is usually needs to be a five or above before they schedule an appointment. If a patient comes in with a low pain rating, it is usually over concern that it may get worse if ignored and ruin vacation plans. The patient must perceive a consequence, or they won’t see treatment, and pain below a five is generally perceived as inconsequential to the average patient. This is a shame as I have seen many situations where delayed treatment causes complex and expensive treatment that could have been avoided.

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Tooth pain comes in two varieties: acute and chronic. Acute pain can be described as localized one tooth), sharp (7-10 on the scale) and of short duration (seconds). It is generally associated with damaged tooth structure from breakage, decay or trauma. Chronic pain is generally lower in value on the pain scale (6 and below) but persistent (over minutes or hours) and can be local (one tooth) or diffuse (several teeth). The two varieties overlap often confuse patients and dentists alike.

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Acute pain can be caused by temperature changes and sweets or biting pressure. Usually if temperature or sweet sensitivity is involved, then exposed dentin (the sensitive sub-structure of teeth normally covered) is suspected. Recession, missing fillings, wear and broken enamel are the main causes. If biting pressure is the symptom, the causes are eithercan fractures in a filling or tooth that remain in place.

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Chronic pain can often mean that there is an infection. If it is localized and worsens when tapping the tooth, it can mean that there is an infection of the root, gums, or sinus. Gum infections don’t usually hurt to tap on the tooth and could be due to impaction of food or other foreign body under the gums, or periodontitis (gum disease). Since periodontitis is generally symptom-free, pain to pressure is an indication that the tooth is in the end stage and can’t be saved. Pain that is diffuse is almost always due to chronic grinding, clenching or gum chewing, but can be from a form of gum disease called ANUG (acute necrotizing ulcerative gingivitis) that used to go by the name trench mouth. Additional information about tooth pain can be found in my previous posts here and here.

I have kept this as simple as possible and yet you can see determining the source of tooth pain can be very confusing. To help sort things out, you can refer to the chart below. It is not meant to diagnose the cause of a toothache. That should always be done by a licensed dentist.


If you have tooth pain, you should not wait, as the sooner a diagnosis can be made, the quicker the problem can be solved, and the treatment can be simpler and less expensive. Pain medication is not a good long-term strategy. If you need pain medication, it should only be to hold you over until you can be seen by your dentist. I make it a priority to leave time for patients that call with pain so that relief can happen ASAP, and hopefully the procedure will be simpler and less costly.