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Pain management for common types of dental pain

Pain, Dental | April 9, 2015 | Author: The Super Pharmacist

dental, Pain

Pain management for common types of dental pain

Dental pain (more commonly known as toothache) is defined as pain in the teeth and/or their supporting structures as a result of dental disease or non-dental disease that results in pain being referred to the teeth (1). Toothache is most commonly caused by the dental pulp or the ligament surrounding a tooth becoming inflamed. Dental pulp is delicate tissue within the tooth that contains sensitive nerves and blood vessels (2). Dental pain comes in four different categories:

  • Pain on stimulation (e.g. sweet, pressure, hot, cold)
  • Continuous, persistent pain
  • Soft tissue pain (e.g. ulcers)
  • Intermittent aching

Common causes of toothache

Tooth decay is the most common cause of toothache and is a result of plaque build up. Acid within the plaque breaks down the outer layer of the tooth, eventually entering and damaging the dental pulp.

Cracked teeth and broken fillings are also responsible for a significant amount of dental pain, as are receding gums that are common in the later stages of gum disease. As the gum recedes, the more sensitive areas of the tooth root can be exposed, causing significant pain. Similarly, excessive brushing can also cause gums to recede.

Dental abscesses also cause significant pain as a result of bacterial infection in the mouth that causes a build up of pus. This can either occur within the tooth itself (periapical) or in the gap between the tooth and the gum (periodontal). Periapical abscesses develop as a result of dental decay or if the tooth nerve dies as a result of injury or trauma (3). Abscesses around the tooth are often a symptom of gum disease complication, with bacteria forming in parts of the gum that have become detached from the tooth.

Wisdom teeth are also frequently responsible for pain, swelling, cysts and infection in the mouth, and can also cause earache and a stiff neck. Treatment involves irrigating the gum and washing out the area with disinfectant around the tooth, with wisdom tooth removal now largely considered the ‘last resort’ option when pain is recurrent.

Sinusitis, a viral or bacterial infection that results in the inflammation of the lining of the sinuses, can manifest as toothache alongside a blocked or runny nose and facial pain. Research has confirmed that sinusitis is also commonly linked to other dental pain such as gum disease, and it is closely associated with poor oral health (4).

Dysfunction of the tempromandibular joint (TMJ) is caused by teeth grinding, gout or rheumatoid arthritis and causes a tightening or spasm of the jaw muscles. This often manifests as generalised toothache and headaches (5).

Bruxism (teeth grinding) can also bruise the ligament around a tooth, resulting in symptoms that resemble toothache, and hay fever can cause pressure pain in the upper back teeth (6).

Treatment options available for toothache

Dentists use a number of topical anaesthetics to relieve pain caused by dental injections and procedures, applied directly to the skin or inside the mouth. They can be applied in a number of ways and can be found in ointment, gel, spray and adhesive patch form. The most commonly used topical anaesthetics include:

  • Lignocaine (used to reduce pain following an injection or tooth extraction)
  • Benzocaine (used to reduce injection pain)
  • Tetracaine (dissolves in water in water and is used to reduce the gag reflex in patients before taking dental impressions or x-rays)
  • Dyclonine Hydrochloride (produces numbness)

Over-the-counter and prescription options for dental pain

Non-steroidal anti-inflammatory drugs (NSAIDs) are the most commonly used medications for pain control in dentistry (7) and, along with paracetamol, are often the recommended analgesic in the initial treatment of dental pain. In cases where pus or infection is known to be present, prescribed antibiotics will include penicillin (and metronidazole in more severe cases) (8).

Decongestant. Where toothache is related to the sinuses, a topical decongestant can also be used to try and alleviate the pressure that causes the pain associated with sinusitis, although there is little available evidence regarding their efficacy.

The use of a wide range of NSAIDs can occasionally present challenges for dental professionals in making an accurate diagnosis.

A randomised controlled trial of 42 patients, undertaken in the United States in 2014, found that ibuprofen could occasionally mask diagnoses by making individuals asymptomatic. This could be problematic, with an estimated 64-83% of patients attending for dental treatment having taken analgesics before visiting the dentist (9). However, other studies have also stated that the use of ibuprofen before treatment has a number of benefits including the reduction of patient fear of anaesthesia, quicker post-operative recovery and improved pain relief (10).

A comparative study, comparing the use of three different NSAIDs in patients who had undergone treatment for pulpitis, found that the pre-treatment use of ketorolac and tapentadol significantly reduced pain in the post-treatment period when compared to etodolac (11).

An RCT undertaken in India, comparing the use of aspirin, ibuprofen and paracetamol, found them all to be more effective both pre- and post-operatively when orthodontic separator placements were used between teeth compared to no use (12).

An 82 patient study, carried out in Australia, also found codeine-paracetamol to be significantly more effective in controlling dental pain than paracetamol alone (13).

Preventative measures

The best way to prevent toothache is to maintain good oral hygiene at all times, brushing teeth twice a day with fluoride toothpaste and flossing regularly. A healthy, balanced diet will also prevent many visits to the dentist and avoidable infections that result in dental pain. Carefully monitoring and moderating the intake of sugary food and drinks, as well as reducing smoking and drinking, will help reduce the amount of dental problems experienced. It is also recommended that people visit their dentist for a routine check up every six months to identify any early signs of gum disease and tooth decay.

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References

1. Albander JM. (2014). Aggressive and acute periodontal diseases. Periodontol 65(1):7-12

2. Chopra R, Merali R, Paolinelis G, Kwok J. (2014). An audit of antimicrobial prescribing in an acute dental care department Prim Dent J 3(4)24-9

3. Laudenbach JM, Simon Z. (2014). Common dental and periodontal diseases: evaluation and management Med Clin North Am 98(6):1239-60

4. Germain L. (2012). Differential diagnosis of toothache pain. Part 2: nonodontogenic etiologies. Dent Today 31(8):84-86

5. Sousa St, Mello VV, Morais MP et al. (2014). The role of occlusal factors on the occurrence of temporomandibular disorders. Cranio 6:2151090314Y0000000015 [Epub ahead of print]

6. Luzzi V, Ierardo G, Viscogliosi A et al. (2013). Allergic rhinitis as a possible risk factor for malocclusion: a case-control study in children. Int J Paediatr Dent 23(4):274-8

7. Kujan O, Raheel SA, Azzeghaiby S, Alghatani FH, Alshehri M, Taifour S. (2014). An unusual side effect of Ibuprofen post dental therapy: increased erectile and libido activity. J Int Oral Health 6(6):94-5

8. Abbott PV. (2000). Selective and intelligent use of antibiotics and endodontics. Aust End J 26:30-39

9. Read JK, McClanahan SB, Khan AA, Lunos S, Bowles WR. (2014). Effect of ibuprofen on masking endodontic diagnosis. J Endod 40(8):1058-62

10. Kandreli MG, Vadachkoriia NR, Gumberidze NS, Mandzhavidze NA. (2013). Pain management in dentistry. Georgian Med News 225:44-49

11. Sethi P, Agarwal M, Chourasia HR, Singh MP. (2014). Effect of single dose treatment pretreatment analgesia with three different analgesics on postoperative endodontic pain: a randomized controlled trial. J Conserv Dont 17(6):517-21

12. Sudhakar V, Vinodhini TS, Mohan AM, Srinivasan B, Rajkumar BK. (2014). The efficacy of pre- and post-operative analgesics in the management of pain after orthodontic separator placement: A randomized clinical trial.

13. Macleod AG, Ashford B, Voltz M, Williams B, Cramond T, Gorta L, Simpson JM. (2002). Paracetamol  versus paracetamol-codeine in the treatment of post-operative dental pain: a randomized, double-blind, prospective trial. Aust Dent J 47(2):147-51

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