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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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Dental Visits - The Endodontic Examination Appointment

On most occasions, the endodontic examination and the endodontic consultation take place at the same visit. Most dentists prefer this. This section will look at each process separately.

What Is the Purpose of the Endodontic Examination?

The purpose of the endodontic examination is to determine the state of health of the pulpal tissues of a tooth or group of teeth. The dentist hopes to collect specific information to assist in diagnosis and treatment planning. During the examination portion of the visit, the dentist will:

• Review the patient's medical history and evaluate the patient's current medical status and in order to determine how it might influence the dental diagnosis and/or treatment plan.
• Review the patient's dental history and, in particular, its relationship to the specific reason for the visit, also called the "chief complaint."
• Perform a thorough clinical examination.
• Perform certain endodontic tooth tests to help establish an accurate diagnosis of the condition of the pulpal tissue.
• Perform a radiographic examination. Two or three different radiographic angles of the same area are often required to adequately visualize the various teeth, the root canal spaces within each tooth, and the surrounding bone and structures. Since a single radiograph is a two-dimensional picture of a three-dimensional object, two or more radiographs with different angulations can provide important additional information. Radiographs reveal many things that the dentist is unable to see with the clinical examination alone.

What Is the Purpose of the Endodontic Consultation?

The purpose of the endodontic consultation is to present a root canal treatment plan to the patient. Once the dentist has collected and evaluated all of the diagnostic information, the goals of the consultation visit are to:

• Share the examination findings and the resultant diagnosis with the patient.
• Discuss the prognosis.
• Discuss the treatment recommendations and any perceived complications.
• Discuss the treatment alternatives and their respective ramifications.
• Discuss the number and length of appointments necessary to complete the recommended treatment.
• Review the cost of the recommended treatment and the various treatment options.
• Answer questions that the patient may have regarding the diagnosis and various treatment options.

On occasion, the dentist may need to consult with other professionals or obtain additional information before all of the goals listed above can be accomplished.

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