A TYPICAL TOOTH ACHE

I feel pain on some of my teeth. I had checked it out with my dentist and found no cause for it. I am still experiencing mild pain and am irritated by it. I want to extract those teeth. Why is my dentist refusing to do it?

A less-common condition is the atypical toothache. The pain is chronic and usually there is no identifiable cause for it. Extracting the teeth usually does not solve the problem, as the pain tends to stay.

Features:

 - distressing continual pain condition from a tooth or teeth

 - pain stays longer than four months

 - tooth/teeth and surrounding gum and bone look normal

Management:

 - medication is the treatment of choice

FACIAL NERVE PAIN (NEURALGIAS)

I suffer from spontaneous sharp, electric-like pain on my face. This can be a number of times a day, of a very short duration. So far the condition has not improved and can even happen when I wash my face or mouth. Is this common?

This could be an uncommon condition of the nerves that tends to affect the older age groups. Most common of these conditions is that termed Trigeminal Neuralgia.

Features:

 - sudden pain of varying intensity on the face or jaw. The pain is triggered by jaw movements or touch.

 - pain is of short duration and can recur several times a day

 - pain can be excruciating but often comes and goes

Causes:

 - no known cause. It is commonly postulated to be due to nerve instability.

Management:

 - medication is the treatment of choice

 - imaging of the head to rule out brain lesions is often indicated

GUM INFECTIONS 

I have had very severe pain, ulcers and bleeding gums for the past three days. My whole mouth is sore and I cannot eat properly. My spouse tells me I have bad breath. What could I be suffering from?

The condition you describe is termed Acute Necrotising Gingivitis. You will need to see a dentist for gum treatment or, if necessary, be referred to a gum specialist.

ACUTE NECROTISING GINGIVITIS

Features:

  - ulcers on tips of gum between teeth and along gum line

  - bleeding gums

  - sudden onset and pain

  - foul odour

  - increased salivation

  - metallic taste

  - repeated infections lead to bone loss or periodontitis, with additional features:

  • enlarged gum margins
  • triangular gaps between teeth
  • gum recession (teeth appear longer)

Causes:

 - bacterial infection

Factors that increase your risk:

  - poor oral hygiene

  - smoking

  - systemic diseases e.g. diabetes

  - stress

Management:

  - proper tooth brushing and mouth rinse

  - professional cleaning of gum areas

  - antibiotics

  - oxidising antiseptics

  - gum surgery

Acute Necrotising Gingivitis

Flossing  - a necessary ritual

I have had pain and gum swelling near my tooth for the past few months. It lasts for a few days and then disappears. Why is this so?

What you have is gum abscess, commonly referred to as  ‘gum boil’. Most gum diseases are without symptoms. However, two conditions feature pain predominantly:

ACUTE PERIODONTAL ABSCESS and ACUTE NECROTISING GINGIVITIS

 1) ACUTE PERIODONTAL ABSCESS

Features:

- localised gum swelling, red and tender to touch

- sudden onset

- increased mobility of tooth

- tooth can be tender on biting

- soreness at site leading to throbbing pain

- pus discharged from the gums

- loss of supporting bone (detectable from X-ray)

 2) ACUTE NECROTISING GINGIVITIS

Features:

- ulcers on tips of gum between teeth and along gum line

- bleeding gums

- sudden onset and pain

- foul odour

- increased salivation

- metallic taste

Repeated infections lead to bone loss or periodontitis, with additional features:

- enlarged gum margins

- triangular gaps between teeth

- gum recession (teeth appear longer)

Causes:

- bacterial infection

Factors that increase your risk:

- poor oral hygiene

- smoking

- systemic diseases e.g. diabetes

- stress

Management:

- proper tooth brushing and mouth rinse

- professional cleaning of gum areas

- antibiotics

- oxidising antiseptics

- gum surgery

IMPACTED WISDOM TOOTH

My last tooth in my lower jaw is causing some discomfort. I can only see part of the tooth and food gets trapped in the overlying gum. Occasionally, the overlying gum swells a little and the side of my neck appears swollen too. Do I need to remove this tooth?

Wisdom teeth appear during early adulthood and in some, the jaw size does not allow its proper eruption. This leads to impaction against the tooth in front of it. Surgical removal of wisdom teeth is a common procedure.

INFECTIONS DUE TO IMPACTED WISDOM TEETH

Features:

  - pain on lower jaw, usually around last molar teeth

  - pain can be acute and mouth opening may be limited

  - possible swelling

  - lymph nodes in the neck may swell

  - touching the region around the molar can be painful

Causes:

  - impaction of wisdom tooth causing food to be trapped

  - infection of overlying gum

  - triangular gaps between teeth

  - decay of wisdom tooth and adjacent tooth

Management:

 - cleansing of the gum area with gargle or mouthwash

  - antibiotic may be required for serious infection

  - extraction or trimming of the opposing tooth to reduce biting on the swollen gum

  - surgical removal of the upper wisdom tooth

  - Swollen gums near wisdom tooth

  - X-ray of an impacted wisdom tooth

JAW OR TEMPOROMANDIBULAR JOINT DISORDERS 

In the past, my jaw has clicked and appears lopsided when I open my mouth. Recently, I noticed my jaw was rather stiff in the mornings and my muscles tend to ache when I chew my food. I fear my jaw may lock on me. Sometimes, I also suffer from headaches. Is this a serious condition?

Not all clicking sounds need to be treated. However, a worsening click, difficulty in opening the mouth and muscle pain may warrant a visit to the dentist.

Features:

  - jaw pain (muscles and joint) on movement or after waking up

  - clicking jaw joints

  - difficulty in opening mouth

  - jaw  ‘stuck’ or locked and dislocated

  - headaches

Causes:

 - subconscious night grinding or clenching of teeth. Most patients who do so are usually unaware.

  - emotional stress and anxiety

  - extraction or trimming of the opposing tooth to reduce biting on the swollen gum

  - bad jaw habits e.g. chewing on hard foods, chewing on one side

  - poor teeth alignment leading to a bad bite

  - systemic diseases e.g. arthritic disorders

Identification:

  - palpable pain on jaw muscles, joint and head

  - limitation in mouth opening

  - excessively worn, cracked teeth, fillings and prostheses

  - X-ray may show bone changes. Magnetic Resonance Imaging may show position of displaced disc.

  - questionnaires on medical and chronic pain history

Management:

  - patient education and reduction of jaw use

  - splints fitted over teeth to reduce further damage

  - medication

  - counselling sessions

  - heat and ultrasound physiotherapy

  - arthrocentesis - jaw joint manipulation

  - arthroscopy - jaw joint surgery aided by miniature camera

  - occlusal rehabilitation to stabilise jaw function

  - Decreased mouth opening

  - Headache can result from night grinding.

MOUTH ULCERS 

I suffer from recurrent mouth ulcers. This affects my eating and even tooth brushing. The discomfort lasts about a week. Is there any way I can hasten the healing? Does gargling with salt solution help?

Ulcers in the mouth can take some time to heal due to constant abrasion with the ulcer site. Application of a gel or paste prescribed by your dentist may help to protect the site from further abrasion. Gargling with mouth rinse or salt solutions will help reduce contamination of the ulcer site.

   APTHOUS ULCERS

Features:

 - single or recurring painful ulcers in the mouth

  - ulcers can range from 2 mm – 10 mm

  - eating is interrupted for a few days

  - persists for 7-14 days

Causes:

  - localised injuries from self-inflicted bites, tooth brushing, etc.

  - stress

Management:

Apthous ulcers usually heal without treatment. However, some may take a longer time to heal and may prevent you from performing basic oral hygiene procedures. Your dentist could help by prescribing steroid ointment or other topical medication.

Minor apthous ulcer

Major apthous ulcer

TOOTH SENSITIVITY 

When I eat food, drink water or suck air through my teeth, I feel a sharp pain on my teeth. This pain lasts for a few minutes or can remain for a while. What could be happening?

A likely cause could be tooth sensitivity.

Features:

  - brief, sharp, painful sensations in teeth during brushing, flossing, eating hot, cold, sweet, sour or acidic foods.

Causes:

  - exposed dentine layer in the crown or root portion of the tooth

  - dental decay

  - fractured or chipped teeth

  - vigorous tooth brushing, causing abrasion to tooth material near the gum line

  - teeth grinding during sleep leading to fractures of tooth portions near the gum line      (abfraction cavities)

  - new fillings or crown and bridgework. Some sensitivity can be expected during the initial periods

Factors that increase your risk:

  - receding gum due to gum disease

  - vigorous tooth brushing

  - excessive chewing of hard foods

  - teeth grinding during sleep (nocturnal bruxism)

Causes:

  - bulimia

  - dry mouth, frequently resulting from radiotherapy to head and neck 

Professional treatment options:

  - application of chemical agents to affected areas

  - restoring worn areas with filling materials

  - crowning severely worn teeth 

Abfraction fractures due to the flaking of enamel from night grinding

TOOTHACHES 

I had a sudden toothache on one tooth. The gums are slightly swollen. I feel the tenderness when I touch it. After a few days it subsided and I ignored it. A few days later, I had the same toothache. What can I do about this?

Sudden excruciating pain or toothache may indicate the deep spread of decay in the tooth. Often, root canal treatment is necessary. If you note mild symptoms on the teeth, a check-up with your dentist will help prevent a bigger problem from occurring.

Features:

  - may start with sensitivity to hot or cold drinks and food

  - sudden pain from tooth or jaw usually of moderate to severe intensity

  - pain may last a few days or longer

  - pain can be related to one tooth or over a wide area

  - painkillers may provide temporary relief

  - swelling could occur

Causes:

  - decayed teeth

  - history of trauma to teeth

  - cracked teeth from excessive wear, chewing on hard foods

Management depending on cause:

  - remove decayed area and protect tooth with filling

  - root canal treatment if decay is extensive and has affected nerve of the tooth

  - drainage of swelling

  - antibiotics for swelling

  - extract tooth if not restorable

  - Front view - the decay is often missed

  - Palatal view shows the decay

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