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Toothache - Why Won't My Tooth Pain Go Away?

There are many causes of toothache and pain in the area of the mouth. When experiencing tooth pain and/or swelling, it is important to see your dentist to have the area evaluated. The pain and/or swelling is most often related to a disease process that originates within a particular tooth.

The pulpal tissue within the tooth can be irritated by bacteria, external traumatic events, repetitive or extensive dental procedures, or even periodontal disease which can lead to a toothache. When this irritation occurs, the pulpal tissue reacts by becoming inflamed. Since the pulpal tissues and the tissues supporting the tooth have a rich supply of nerve fibers, the inflammatory process can cause pain as these nerve pathways are stimulated. Additionally, the pulp tissue is encased inside tooth structure and it cannot swell and expand in reaction to injury like tissues in other areas of the body. When the injured pulp tissue attempts to swell within the confined root canal space, the pressure buildup can cause a significant toothache.

Pain originating from the dental pulp can be either "spontaneous" or "elicited." Spontaneous pain occurs without an identifiable stimulus, whereas elicited pain occurs only in specific situations. Elicited pain requires a specific stimulus such as drinking cold or hot fluids or biting on the tooth.

As is typical anywhere in the body, the initial stages of a disease process do not always cause symptoms. Millions of teeth have irreversible pulpal disease yet the patients have no clinical symptoms. Most of these situations will become evident when the dentist obtains a thorough history, does a clinical examination, performs specific tooth tests, and takes a series of well-angulated radiographs. It is important to note that pulpal disease can refer pain to other areas within the head and neck.

If the results of the endodontic examination indicate that root canal disease is not the source of the patient's symptoms, then the dentist must consider other possibilities. When attempting to identify the source or cause of facial pain and/or swelling, the dentist must consider that the symptoms could actually originate in a tooth (endodontic disease), the gum tissues (periodontal disease), the muscles (myofacial pain), the joints (TMJ), the sinuses (sinusitis), or even the surrounding vascular (blood vessels) or nerve tissues. Tooth pain requires an accurate diagnosis so that the proper treatment can be recommended. At times, various medical and dental specialists may need to be consulted before an accurate diagnosis can be determined.

By Clifford J. Ruddle, DDS, in collaboration with Philip M. Smith, DDS

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The Endodontist, the General Dentist and Root Canals

All dental school graduates have basic education and training in the diagnosis and treatment of diseases of the tooth pulp and are licensed to perform a routine root canal procedure.

What Is an Endodontist?

An endodontist is a dentist who has completed an additional two to three-year course of study in an accredited endodontics postdoctoral residency program. In addition to performing routine root canal treatment and tooth pulp treatments, the endodontist has extensive training and experience in the diagnosis and treatment of a wide variety of conditions, such as:

• The differential diagnosis of painful oral and facial conditions in which the origin of the pain is uncertain. In these cases, the root canal dentist is part of a team, which may include other specialists in dentistry as well as medical colleagues, when appropriate.
• Endodontics treatment of teeth involved in cases of oral-facial trauma.
• Endodontic treatment for patients who are medically compromised.
• Endodontics treatment of complex root canal cases, such as teeth that exhibit calcified canals, curved canals, or very long roots.
• Non-surgical re-treatment of teeth that have had previous root canals.
• Surgical treatment of endodontic disease that can be treated in no other way.

There are ethical guidelines that determine what an endodontist can and cannot do. As an example, an endodontics specialist would not place crowns, dentures, or perform orthodontic procedures.

Following the completion of a root canal procedure, a patient is usually referred back to the general dentist. At times, however, in a complex situation it may be necessary for the endodontist to refer a patient to another specialist before the patient returns to their general dentist.

Why Are Patients Referred From a General Dentist to an Endodontist?

Patients are referred from a general dentist to specialist because a dental problem may be so complex that its successful diagnosis and treatment require considering a multitude of complex factors.

A "multidisciplinary" approach allows the patient to have expert opinions from different generalists and specialists so that the best of science, art, and technology can be utilized in a particular set of circumstances.

Oftentimes, an individual dentist is more interested and experienced in some areas of dentistry than in others. A general dentist may choose not to do certain procedures because:

• They do not have the equipment, instruments, or training necessary to do the procedures.
• The time involved to do the procedure well is more than they wish to spend.
• Particular teeth may exhibit complex treatment challenges.
• The patient may have medical or other complicating factors.

In short, the primary consideration for referral is that the patient has the opportunity to have the best diagnosis and the best care available. A patient may be referred from a general dentist to specialist to make certain that this goal is attained.

By Clifford J. Ruddle, DDS, in collaboration with Philip M. Smith, DDS