Dental Pain: Highly Prevalent and Challenging

AUGUST 22, 2016
Kathleen Kenny, PharmD, RPh
Pain is a complex experience encompassing a specific sensation and the reactions to that sensation.1 Orofacial pain is pain localized above the neck, in front of the ears, and below the orbital meatal line, including the area within the oral cavity.2 Approximately 1 in 6 patients report experiencing orofacial pain in the past year to their dentists.3 Although the prevalence of dental pain is high, diagnosis and treatment planning remain challenging. Although acute pain is a common complaint at the dentist’s office, chronic pain (pain lasting longer than 3 months) also occurs.

CAUSES
There are not many causes of dental pain; however, the pain may be poorly localized, referred, and misdiagnosed due to the neural convergence in the jaws and the face.2 The 3 main causes of dental pain are pulpitis, cracked tooth syndrome, and dentin sensitivity.

Pulpitis is inflammation of the dental pulp. Inflammation causes increased pressure within the pulp chamber, an inflexible space. In turn, elevated pressure and inflammatory chemicals activate pulp nociceptors, causing pain. This pressure increase, if not relieved, may cause venous stasis, infection, and tissue necrosis, leading to irreversible damage. Pain from reversible pulpitis is usually described as stabbing or shooting pain in response to hot, cold, or sweet, and typically resolves as soon as the stimuli is removed. Irreversible pulpitis pain tends to be dull and throbbing, and lingers after the stimuli has been removed—which is indicative of pulpal necrosis. Inflammation and infection that progresses through the bottom of the tooth is called an abscess.2

Dentin sensitivity is a result of exposed dentin surfaces. A degree of sensitivity is normal, although pain is not routinely experienced during everyday activities. The pain is described as sharp and of short duration. It is caused by movement of fluid in dentinal tubules in response to osmotic or temperature changes. Dental bleaching, grinding of teeth, gingival recession, and loss of enamel due to acid reflux are common causes of dentin sensitivity.

Cracked tooth syndrome refers to a partial fracture in a tooth, involving dentin with or without the involvement of pulp. A classic sign of cracked tooth syndrome is pain caused by the pressure of biting. This pain is relieved by the release of that pressure. This usually occurs while eating or when chewing on a pencil or a pipe.4

WHEN TO SEEK MEDICAL ATTENTION 
Patients should be advised to seek medical attention if their tooth pain is accompanied by fever, chills, or a rash, any of which may indicate an infection. If the pain is due to an injury to the face or the head, the patient should be advised to seek medical attention. Patients who have difficulty swallowing or excessive pain or bleeding, or whose tooth pain has lasted more than 2 days should also be directed to seek medical attention. Immediate medical attention is also recommended if a patient presents with jaw pain associated with chest pain, which can accompany a myocardial infarction.5

DIAGNOSIS
A dentist will obtain a medical history and perform a physical exam. If necessary, other tests may be done. The medical history will determine specifics such as pain location, type, frequency, duration, onset, exacerbation, remission, severity, and area of radiation. The physical exam will include the tongue, buccal mucosa, floor of the mouth, hard palate, teeth and periodontal tissues, tonsils, temporomandibular joints, airway, ears, salivary glands, and lymph nodes. Other tests include a pulp sensitivity test, a percussion test, probing, a mobility test, palpation, and radiographic examination.6

HOME REMEDIES
OTC pain relievers, such as acetaminophen (APAP), ibuprofen, and naproxen, can be used, as can topical anesthetics, such as Anbesol and Orajel. As with most maladies that have been present for an extended period of time, several home remedies for dental pain exist. The Table shows some remedies, along with their proposed associated properties.5,7

TREATMENT
A dentist may need to perform deep cleaning, filling, a root canal, a crown procedure, or tooth extraction. If an infection is suspected, an antibiotic will be prescribed. The challenge then becomes pain relief.

Nonopioid and opioid analgesics are commonly used for dental pain. When used at conventional doses, nonopioid analgesics, including APAP and nonsteroidal anti-inflammatory drugs (NSAIDs), have been found to be equivalent, if not superior, to opioid analgesics in managing dental pain.8

NSAIDs have greater analgesic and antipyretic potency than anti-inflammatory potency. Higher doses are required to provide an anti-inflammatory effect. No particular NSAID has been shown to be more effective or safer than other NSAIDs. Selective COX-2 inhibitors, such as celecoxib, result in less gastrointestinal toxicity when used on a short-term basis, but lose this advantage as consumption continues. Given its low incidence of adverse effects and unsurpassed efficacy, ibuprofen is generally a reasonable first-line agent.8 NSAIDs are contraindicated in patients with nephropathy, erosive or ulcerative conditions of the gastrointestinal tract, hemorrhagic disorders, or an intolerance or allergy to NSAIDs, or who are receiving anticoagulant therapy. In all cases in which NSAIDs are contraindicated, APAP is the reasonable choice. APAP is equal in potency to aspirin in terms of its analgesic and antipyretic properties, but inferior to ibuprofen and other NSAIDs. Combination treatment with an NSAID and APAP provides greater analgesic effect than either drug alone. In addition, treatment with NSAIDs, APAP, or their combination provides better efficacy when administered around the clock rather than as needed.8

If pain persists after optimized dosing of an NSAID or APAP, or their combination, an opioid should be added. Combination products of oxycodone and APAP or hydrocodone and APAP are commonly used; however, opioid dosing may be better achieved by prescribing each drug separately due to the lack of therapeutic ceiling which exists with NSAIDs and APAP.8

PREVENTION
Tooth decay is a major source of dental pain. Patients should be advised to follow good oral hygiene practices, including brushing with a fluoride toothpaste, flossing twice a day, rinsing with an antiseptic mouthwash, and seeing a dentist twice a year for a checkup and professional cleaning.9


Dr. Kenny earned her doctoral degree from the University of Colorado Health Sciences Center. She has 20+ years’ experience as a community pharmacist and works as a clinical medical writer based out of Colorado Springs, Colorado. Dr. Kenny is also the Colorado Education Director for the Rocky Mountain Chapter of the American Medical Writer’s Association.

References
  1. Oral analgesics for acute dental pain. Dentistry Today website. dentistrytoday.com/pain-management/1566--sp-1090066515. Published July 2, 2002. Accessed January 4, 2016.
  2. Shephard MK, MacGregor EA, Zakrzewska JM. Orofacial pain: a guide for the headache physician. Headache. 2014;54(1):22-39. doi: 10.1111/head.12272.
  3. Frequency of orofacial pain in dental patients. American Dental Association website. ada.org/en/publications/ada-news/2015-archive/september/october-jadas-cover-story-frequency-of-orofacial-pain-in-dental-patients. Published September 25, 2015. Accessed February 2, 2016.
  4. Lynch CD, McConnell RJ. The cracked tooth syndrome. J Can Dent Assoc. 2002;68(8):470-475.
  5. Toothache. EMedicineHealth website. emedicinehealth.com/toothache/article_em.htm. Accessed February 2, 2016.
  6. Wertherell J, Richards L, Sambrook P, Townsend G. Management of acute dental pain: a practical approach for primary healthcare providers. Aust Prescr. 2001;24:144-148.
  7. Home remedies for toothache. Top 10 Home Remedies website. top10homeremedies.com/home-remedies/home-remedies-for-toothache.html. Accessed January 4, 2016.
  8. Becker DE. Pain management: part 1: managing acute and postoperative dental pain. Anesth Prog. 2010;57(2):67-80. doi: 10.2344/0003-3006-57.2.67.
  9. Oral care: dental health and toothaches. WebMD website. webmd.com/oral-health/guide/toothaches. Accessed January


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