Diagnosing Toothache?

When your turn up with toothache, the dentist will first ask you to describe the problem. We write this in our notes as ‘patient complains of…’ and it provides the basis on which we ask further questions. Think of it like clues to a puzzle; we collect information and narrow in on what the problem is and therefore the potential solution might be. This process is known as taking a ‘history of the presenting complaint’,after which, most of the time, we have a fairly good idea of what is going on.

We will then do a ‘clinical examination’ looking at your mouth, teeth, jaw and gums for any signs of problems and finally do some ‘special tests’ that will provide extra information to hopefully complete the picture.

These tests include X-rays, which provide detailed information about areas that aren’t otherwise visible to us, and vitality tests to assess the state of the nerve and blood supply to questionable teeth.

The dentist then puts all this information together to arrive at a diagnosis. Some diagnoses are obvious, others are not. On occasions, it is not possible to say with much certainty, the cause of the problem and so it may be necessary to wait a few days for symptoms to change or the pain to localize to a particular tooth. Better this, than start work on the wrong tooth- or even taking out the wrong tooth or beginning an unnecessary root canal.

Examples of the questions the dentist may ask are given below and the reasons behind doing so are discussed.

• Question: How long have you had the pain?

Here the dentist is trying to get an idea of the time line of the pain as most pulp (nerve) pain follows a similar course. See the example at the end.

• Question: Does anything start the pain or make it worse; is it sensitive to heat, cold or sweetness, or does it just come on randomly?

Most pain on a tooth starts off with a sensitivity to cold, and sometimes sweet things. This suggests that you have some exposed dentine somewhere. This could be because of caries (a cavity) or because of an exposed root, which doesn’t have the strong enamel lying over the top of it. These are signs of reversible damage to the nerve, i.e. if it’s a cavity, and you place a filling, the nerve will recover and everything will be resolved.

If symptoms come on more with hot or randomly without any stimulus, the tooth is slightly more in question and further along the spectrum to being irreversibly damaged.

It is worth mentioning here that not all decay is accompanied by pain and the importance of routine X-rays to ensure things are picked up in the early stages is very important.

• Question: Where is the pain? Do you know which tooth it is? Is it painful to bite on?

Do you feel it is more in your gum or in your tooth? Is it, next to your tooth, under your tooth or in between your teeth? It is always useful when you can show us the problem area with your finger or point to it with your tongue (which is a little more difficult to do).

In pulpitis, it can often be difficult to tell the dentist where the pain is coming from and it may appear to go from the top jaw to the bottom jaw and sometimes to your ear. The reason you can’t tell is because the nerve inside the tooth doesn’t contain nerve endings that sense movement and pressure. If the problem continues to progress and the area around the tip of the root becomes inflamed, you can easily tell the problem tooth because the ligament that surrounds the root contains many pressure receptors. The location of the pain as you can see gives the dentist valuable information about the state of the nerve. Interestingly, pain will often go up and down between the jaws but will not cross over to the other side.

• Question: How would you describe the pain? Sharp or dull, mild or severe, throbbing… Constant or intermittent

• Question: How long does the pain last when it starts?

If it lasts only a few seconds, then the problem tooth most likely has reversible pulpitis and it is likely a simple filling will be needed. If however, the pain starts lasting minutes or even hours, the nerve is much more questionable.

• Question: Does it hurt most during the day or night? Has it keep you awake at all or disturbed your sleep?

Disturbing your sleep and keeping you awake at night tend to be classic indications of irreversible pulpitis and the need for a root canal or extraction to stop the pain. If you have been woken once, as opposed to repeatedly and been kept up all night, then it is not quite as clear cut.

• Question: Is the pain relieved by medication or by anything else?

Pain is very subjective; some of you will feel a lot more pain than others. More severe pain tends to suggest an irreversible state of the nerve. Often standard painkillers will have a much more of a relieving effect for early reversible pulpitis than the later stages where patients commonly say, “Nothing is touching it!”