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Pharmacist > Departments > Consult Your Pharmacist

Dental Pain
W. Steven Pray, PhD, DPh
Authors and Disclosures
Posted: 06/29/2007;
Publishing

US

Pharmacist. 2007;32(5):18-23. 2007 Jobson

Pharmacists frequently consult with patients who experience dental

pain. While the problem may be minor, dental pain often indicates a
serious underlying pathology. Pharmacists do not have the necessary
skills or equipment to differentiate between benign and serious
etiologies. Therefore, referral to a dentist is a virtual necessity for all
patients who ask the pharmacist about acute dental pain.
Categorizing Dental Pain

Dental pain can be categorized using different taxonomies. It may arise

from a problem in the tooth or its supporting structures, or it may be due
to a problem elsewhere that is misperceived by the patient as
originating there (e.g., referred pain). Dental pain can also be classified
by etiology. All occurrences require dental referral.
Pain Originating in the Tooth or Periodontium

This type of pain can be due to trauma, a cracked tooth, pulpitis, or a

host of other causes.
Trauma: Dental pain may be caused by a traumatic event, perhaps a
recent fall, a blow to the face from sports or fighting, or other facial or
dental trauma. Trauma may have occurred some time ago, and the
patient may have endured longstanding pain.
Cracked Tooth Syndrome: The patient may have "cracked tooth
syndrome" from trauma, as well as from tooth grinding, accidental
insults (e.g., biting down on an unpopped kernel of corn or a concealed
olive pit), or bad habits, such as compulsively chewing ice. [1] In all of
these cases, a living tooth can suffer a partial fracture that extends into
the dental pulp (connective tissue lying beneath enamel and dentin in
the central portion of the tooth housing the nerve). This problem is more
common in older patients, whose water may not have been fluoridated
when they were young. As a result, many have extensive dental

restorations (i.e., fillings). As those restorations age, they are prone to

damage. Patients with cracked tooth syndrome feel pain when biting
down to chew; the pain usually remits when chewing ceases. Thus,
patients often stop chewing on the troublesome side for a period of
time. Pharmacists can recommend nonsteroidal nonprescription
products as an emergency measure until patients see the dentist.
However, pharmacists should stress that ibuprofen or naproxen does
not affect the underlying pathology (despite the relief it seems to grant),
and the problem will continue to worsen until a professional intervenes.
Reversible Pulpitis: This term refers to inflammation of the dental pulp
that can be reversed with a professional appointment. [1] Patients
complain of discomfort lasting less than five seconds when the tooth is
contacted by cold, an air blast, or ingestion of sweet foods. The cause
can be minor (e.g., dentinal hypersensitivity, a new filling, recent dental
cleaning) or due to such problems as gingival recession, caries, or a
defective restora tion.[2] If the cause is addressed properly, it may
cease. If the patient is unable or unwilling to see a dentist, the tooth
may progress to irreversible pulpitis.[3]
Irreversible Pulpitis: Some tooth problems are too extensive to repair.
Perhaps the tooth has developed a large cavity in a previously unfilled
area or there is extensive erosion beneath an older amalgam. In these
cases, if the damage reaches an area proximal to the pulp, repair
cannot be done.[1] Advanced periodontal disease that leads to bone
loss may also be the cause. The tooth affected with irreversible pulpitis
causes moderate to severe pain and is also painful after cold, heat, or
other stimuli, but in this case, the pain lasts for minutes to hours. The
pain can be severe and disrupt sleep. Pharmacists should refer these
patients to a dentist. The dentist may attempt a root canal--removal of
the dental pulp from the center of the tooth. If a root canal is impractical,
the tooth may have to be extracted.
Barodontalgia: Barodontalgia is tooth pain resulting from extremes of
pressure. Pilots in unpressurized cabins (e.g., high-performance
aircraft) experience barodontalgia from low pressures at about 3,000
feet, and scuba divers experience the same problem at the elevated
atmospheric pressures encountered 10 meters below the surface and
deeper. Investigators hypothesize that tiny air bubbles trapped under a

root filling or adjacent to dentin expand or contract. [4] Patients

experience a sensation of sharp or squeezing tooth pain. In the worst
case, alveolar mucosa may rupture. If the patient describes a pressurerelated problem, referral to a dentist can facilitate restoration of
damaged teeth.
Dentinal Hypersensitivity: Beginning at about age 30 years, many
people notice that their teeth feel pain when they eat or ingest cold, hot,
or sweet foods or drinks, when an air blast is used on a tooth, or when
the tooth is contacted by a dental instrument while cleaning. The cause
is most often gingival recession, due to such factors as smokeless
tobacco use or overzealous brushing.[1] As the gingiva recede, softer
tooth roots are exposed.[5] Teeth are honeycombed with small tubules
that pass from the outer enamel into the central dental pulp. The tubules
contain a protoplasmic fluid that is able to move to a small degree. [6]
Triggers of discomfort cause the fluid to expand or move inward toward
the dental pulp (e.g., dental cleaning, hot fluids) or outward away from
the pulp (e.g., drinking cold fluids, an air blast). Patients perceive these
fluid microshifts as pain in the areas where gingival recession is
present. Products such as Crest Sensitivity Protection or Sensodyne
are FDA approved to reduce dentinal hypersensitivity, when used as
directed.[5]
Dental Pain Due to Tongue Piercing: The current popularity of
voluntary body decoration/ mutilation has gone far beyond ear piercing
to include piercing in areas once mutilated only in Third World countries.
[7] One procedure is tongue piercing, a rapidly performed subcutaneous
tissue invasion that can lead to serious infectious disease, pain, edema,
and pronged bleeding. Postpiercing problems may involve the
teeth.Reactions between the metal barbell/stud and dental amalgam
materials are similar to those experienced when a person with a filling
accidentally bites down on a piece of tinfoil. The barbell ornaments can
also smash against teeth with sufficient force to break them.

Referred Dental Pain

Dental pain may occur as a result of extradental causes. For instance,

several types of headache can cause pain in the teeth and jaw.[8] A
cluster headache can result in toothache. Migraine and paroxysmal
hemicrania can produce pain in the maxillary molars. Hemicrania
continua is a headache that can produce toothache in the maxillary
premolars. In each case, the dentist may discover that the pain does not
originate in the teeth or periodontium. A physician may use diagnostic
criteria to identify the type of headache that caused the tooth pain.
Jaw/tooth pain can be caused by trigeminal neuralgia, characterized by
pain on one side of the head, in most cases the right side. [9] The pain
occurs in the areas innervated by the trigeminal nerve's mandibular
and/or maxillary branch(es). Some patients insist that the pain started
without any provoking factor, while others recall that it began after trivial
stimulation of the mucosa around the teeth, tongue, or skin (e.g.,
chewing, yawning). Attacks come in waves of electric-like pain, lasting
from a few seconds to several minutes.
Temporomandibular disorders, involving the temporomandibular joints,
chewing structures, and other associated areas, may produce dental
pain.[10] Appropriate treatment for this condition may encompass such
interventions as intraoral appliances, prescription drugs, moist heat, ice,
ethyl chloride spray, exercise, physiotherapy, electrotherapy, and
iontophoresis.

Assisting the Patient in Finding Dental Care

Many patients see the pharmacy as a "safe harbor" for dental problems,
where they are free to seek advice without having to endure
examinations, injections, and restorative work. When urged to seek
dental care, these patients often have a variety of excuses for why they
cannot or would prefer not to do so. With judicious planning,
pharmacists can offer assistance in several situations. For patients with
inadequate finances, pharmacists can recommend free medical clinics
that offer dental services.[11,12] For patients who are new to the area
and/or cannot make an appointment with a dentist, the pharmacist can

help identify a local dentist who may be able to see patients on an

emergency basis when requested by the pharmacist. Patients with
dental phobia should be reassured that modern dental professionals are
well trained in relatively discomfort-free techniques (e.g., using nitrous
oxide, conscious sedation).
Avoid Nonprescription Products

In regard to self-treatment of dental pain, several products contain

potassium nitrate for the minor condition of dentinal hypersensitivity, but
they carry a label cautioning against use if the problem persists for more
than 28 days. No other product is safe and effective in allowing the
patient to treat undiagnosed dental pain without first seeing a dentist. A
host of products claim to provide relief, but they should neither be
stocked nor recommended. These include Red Cross Toothache
Medication, containing eugenol, an unapproved and potentially
dangerous ingredient when used in an unsupervised manner. Several
Orajel products containing benzocaine also promise toothache relief,
but benzocaine has never been FDA approved for toothache. Many
products claim to allow the patient to temporarily repair lost fillings (e.g.,
DenTek Temparin) or temporarily secure dental restorations, crowns,
caps, bridges, or laminates (e.g., DenTek Thin Set). However, patients
often fail to follow package directions and may use these products as a
permanent solution in preference to a dental visit. Long-term use could
allow caries to invade exposed dentin. Patients purchasing these
products must be advised not to forestall a dentist visit. In fact, the best
solution is an emergency appointment with the dentist.