Clinical Signs and Symptoms of a Toothache

A toothache is oftentimes an excruciating experience that may affect your quality of life and daily function. It may be difficult for you to chew properly, get through the day or even sleep at night when there is untriggered, throbbing pain. When this occurs, it is important to see your dentist for immediate attention.

Possible Causes of Tooth Pain and What You Can Do

Below is a list of common pain symptoms, possible causes and some steps you can take to temporarily alleviate any discomfort prior to your dental visit. 

1. Momentary sensitivity to hot or cold foods
   Possible cause: When the underlying dentine of the tooth is exposed due to enamel wear or initial decay, you may be experiencing dentine hypersensitivity. It is sharp and brief in nature and is triggered by temperature changes in foods or brushing and flossing. It does not linger once the stimulus is removed and does not occur spontaneously.What to do: You can try to apply a desensitizing toothpaste with a soft-bristled toothbrush in the sensitive areas. You may also wish to seek a consultation with your dentist to check for any possible tooth decay or loose fillings.

2. Sensitivity to hot or cold after a dental filling
   Possible cause: After a recent dental filling, there may be heightened sensitivity of the pulp. This is what dentists diagnose as reversible pulpal inflammation. The symptoms are characterized by a short and sharp sensitivity when triggered by temperature changes in foods and do not linger.What to do: Monitor the sensitivity for two to four weeks. If the sensitivity worsens in intensity or has evolved into a dull and lingering ache, see your dentist or an endodontist for a consult.

3. Sharp pain or dull ache when biting
   Possible cause: Sharp pain on biting on foods may be due to decay, loose filling or crack. A dull pain on biting may also signal periapical infection due to pulp necrosis of the tooth.What to do: Seek evaluation by a dentist, who may refer you to an endodontist to determine if there is any pulp disease which will necessitate root canal treatment. If it is just a decay or loose filling, it can be treated with a dental filling. If it is a deep decay or a crack, the tooth may need a root canal treatment.

4. Lingering, throbbing pain (more than 20 seconds) after eating hot or cold foods and spontaneous pain at night
   Possible cause: Lingering ache after a thermal stimulus or unprovoked pain at night (when lying down) may signal irreversible damage of the pulp caused by deep decay, crack or even severe gum disease.What to do: See your dentist or an endodontist as soon as possible to identify the problem tooth. They can remove the inflamed pulpal tissues and retain the tooth with root canal treatment. You may take over-the-counter painkillers in the meantime to break the pain cycle for temporary relief.

5. Swelling or pus around gums
   Possible cause: There may be a dental abscess caused by the surrounding periodontal tissues of the tooth. This may be due to a root canal infection or periodontal (gum) disease. It is not common, but the swelling can progress to the cheeks and the jaw.What to do: Seek a clinical evaluation with your dentist to diagnose the source of the infection. If the abscess is caused by a root canal infection, your endodontist may perform root canal treatment. If the swelling is due to periodontal disease, your dentist will carry out a deep cleaning around the gum region.

Above are the common situations when toothache occurs. There are instances where the patient perceives the pain as toothache, but it is actually caused by structures other than the teeth or the gums. To name a few: Sinusitis, Temporomandibular Disorder (jaw-joint issue) and Myalgia (pain involving the muscles).

Proper Examination and Correct Diagnosis

To treat the toothache, the dentist or the endodontist have to first arrive at the correct diagnosis. 

The diagnosis of a toothache will require a proper understanding of the patient’s pain and careful examination of the tooth. During the examination, the dentist or endodontist will have to conduct a few tests to find out the triggering factors and attempt to reproduce the pain. In addition, they will take radiograph/s to assess the extent of disease and the health of the surrounding structures.

To understand Root Canal Treatment Procedures, you can refer to our other Blog articles.

How can Endodontic Surgery Save Your Tooth?

A non-surgical root canal treatment alone may sometimes be inadequate to save your tooth. In such cases, your endodontists may recommend a surgical treatment. 

What are the instances that require Endodontic Surgery? 

For further diagnosis purpose. Sometimes exploratory surgery may be indicated to locate cracks or possible fractures that could not be detected during non-surgical treatment. During the surgery, your endodontist will be able to examine the surface of the root to arrive at a diagnosis to provide appropriate treatment. 

Non-healing disease. Occasionally, despite adequate non-surgical treatment, a tooth may not heal or have persistent symptoms. The reason for the teeth not responding to previous root canal treatment could be that there are bacteria inside the root or around the root tip that cannot be eradicated by root canal cleaning. And hence, your endodontist may recommend a surgical approach to increase the possibility of saving your tooth. 

When non-surgical retreatment is not possible. In cases where extensive restorative work such as a large post in the canal, has been done, non-surgical root canal retreatment maybe more damaging. A surgical treatment can be a better alternative to save your tooth. 

Remove cysts and perform biopsies. Surgical treatment will be recommended in cases suspicious of a cyst. A cyst can be more sinister than inflammed tissues. The suspected cyst tissue that is removed during surgery will be sent to a laboratory for histological reporting. 

There are other less common scenarios whereby a surgical procedure may be indicated such as repair of a damaged tooth due to resorption (tooth eaten up by the own cells) or perforation (cavity unintentionally created by dentist).

What Is an Endodontic Surgery? 

Endodontic surgery is a day surgery typically performed under local anaesthesia. The most common endodontic surgery is an apicoectomy. In this procedure, the endodontist will lift the gum to expose the underlying bone and remove any diseased tissue. This tissue may be sent for biopsy. The end of the root will then be trimmed off and a small filling will be placed to seal the end of the root canal. Stitches will be placed on the gum to help the tissue heal. 

There are other types of surgical procedures that can be performed such as removal of a root, repairing damaged root surfaces or even removing the tooth and replanting it back in its socket after performing the endodontic procedure outside of the mouth. Depending on your case, your endodontist will be able to recommend the appropriate surgical treatment. 

What precautions do I need to take for the surgery? 

If you’re medically fit, no special precautions will be required prior to the surgery unless otherwise mentioned by your endodontist. 

However, please inform your endodontist if you have any medical illness (e.g.bleeding or clotting disorders), taking any drugs (e.g. blood thinners) or drug allergies. 

What are the risks and complications of Endodontic Surgery?

If the surgery is performed near other vital anatomical structures, there is a risk in injurying these vital structures. The injuries can be sinus perforation which may result in sinusuits. There may be cases of nerve injury that can result in transient numbness. These risks should be discussed with your endodontist prior to your surgery. 

What to expect after Endodontic Surgery?

Slight bleeding is expected immediately after surgery. Pain, swelling and bruising will also be experienced around the operated site. After the swelling subsides, there may be bruise-like mark on the face near the operated site that will recede. 

Painkiller are prescribed to alleviate the pain and swelling. Because we advised against brushing around the wound site, we prescribe  antiseptic mouth rinse for patient to maintain oral hygiene. Antibiotics are commonly prescribed to prevent secondary infection of the wound site. Gauzes are also given to patient for then to stop the bleeding at the wound site. 

Stitches will be removed in 5-7 days. Review appointments will be scheduled thereafter to monitor for healing. 

For more information on post-operative care instructions, you may refer to post-operation advice after endodontic surgery.

Are there alternatives to Endodontic Surgery?

Oftentimes, the only viable alternative to surgery is extraction of the tooth. You may then opt for an implant, bridge, or removable partial denture to replace the extracted tooth. Choosing not to replace the missing tooth is also possible but may result in a decrease in chewing function or shifting of adjacent teeth.  

You may also choose not to defer any treatment but this could lead to potential pain and further loss of surrounding bone which may compromise future treatment. 

Reasons Why You Should Never Ignore A Cracked Tooth

What is a cracked tooth? 

A cracked tooth is an incomplete fracture of the tooth that often manifests as “cracked tooth syndrome”. This is characterized by sharp pain triggered when chewing (biting or release) of tough, grainy foods and heightened sensitivity to hot or cold temperatures. Oftentimes, the pain is erratic and it may be difficult for your dentist to localize the tooth causing the discomfort. 

When the crack has propagated into the pulp space, more severe symptoms such as spontaneous toothache at night and swelling or pus may result.

Diagnosing Cracked Teeth

The provisional diagnosis of a cracked tooth has to be affirmed before any definitive treatment is prescribed. Diagnosing a cracked tooth is more complex than detecting a decayed tooth due to various confounding signs and symptoms. It requires a thorough understanding of the patient’s pain history as well as a detailed clinical examination of the tooth. Endodontists have the expertise and equipment to carry out clinical investigation of cracked teeth to determine the most appropriate course of treatment. 

Cuspal Protection of Cracked Teeth

The type of treatment for cracked teeth depends on the patient’s signs and symptoms, risk factors and extent and location of the crack. 

The hard tissues of a tooth have no regenerative capacity. Thus, a crack in the tooth cannot heal by itself. Elimination or removal of the crack through drilling is also not an option as it will only exacerbate the condition of the tooth. The aim of cracked tooth treatment is to mechanically control the crack and prevent its progression. The only way to control a crack is to place a crown over the cracked tooth.  A crown is a rigid prosthesis that covers the tooth to brace and protect it from further crack progression. 

A picture of an extracted tooth with a crack seen on the root

For cracked teeth with mild and reversible symptoms, an option of crowning the tooth without root canal treatment may be possible. In such cases, a metal band is used to simulate a crown and it is temporarily placed around the tooth. If the symptoms upon biting are alleviated, the band may be replaced by a crown without the need for root canal treatment. 

Root Canal Treatment of Cracked Teeth

Root canal treatment will be required if the tooth presents with severe and persistent signs or symptoms that are not alleviated with banding or crowning. The patient can have persistent symptoms with biting and have severe sensitivity to cold and hot. In some advanced cases, the pulp may be irreversibly damaged due to bacterial progression through the pathway of the crack and the root canal space infected, leading to swelling or abscess formation.

Root canal treatment aims to remove the inflamed or infected pulp from the tooth. During the root canal treatment procedure, the crack can be visualized internally under high magnification using a microscope. This allows the Endodontist to perform a crack assessment to determine the severity of the crack. The deeper the extent of the crack, the poorer the prognosis of the tooth. Following the crack assessment, the Endodontist will present and discuss the objective findings to the patient and an informed decision can be made by the patient after weighing the pros and cons of retaining the cracked tooth. If the patient opts to retain the cracked tooth, completion of root canal treatment will be planned and followed by a crown.

A clinical picture of a tooth during treatment.

Alternative Options for Cracked Teeth

When the crack is too deep and the tooth prognosis deemed poor, extraction will be presented as an alternative option. In spite of cuspal protection from the crown, a tooth with a deep crack may still continue to crack and eventually lead to vertical root fracture. Hence, extraction of teeth with deep and unrestorable cracks is a viable option. After the extraction, a discussion can be made with the dentist regarding possible tooth replacement options – such as implant-supported prosthesis, bridge or removable denture.

Final Advice About Cracked teeth

A cracked tooth diagnosis can be elusive and requires a multi-disciplinary team consisting of an Endodontist and the General Dentist to confirm the diagnosis and treat the tooth. With function and time, a crack on a tooth will propagate further. However, if the cracked tooth is diagnosed and treated promptly, the tooth will have a reasonable long-term prognosis. 

ROOT CANAL TREATMENT PROCEDURE: WHAT SHOULD YOU EXPECT?

Why would I need Root Canal Treatment?

Root canal treatment is a procedure that helps to relieve patients’ toothaches and to clear the infection present inside a tooth. The common reasons for toothaches or infection is tooth decay and cracks. 

How does a toothache come about? A tooth has a chamber and root canal spaces within the center of the tooth, which is where the soft tissues of the pulp are located. Pulps have nerve tissues and when the tooth is damaged by decay or a crack, bacteria can infiltrate into these tissues. It can then become inflamed or infected, giving rise to severe pain commonly known as a toothache. When no treatment is rendered, the infected pulp will affect other tissues such as the jaw bone and the gums. This can potentially cause severe pain of the jaw bone and sometimes swelling of the gums, cheeks or the lips. Root canal treatment is necessary to eliminate the infection and spare the tooth from an extraction. 

It is unfortunate that many people think that root canal treatment is a painful procedure. In fact, the experience of severe pain during and after root canal treatment is unlikely. The fear for root canal treatment usually stems from the lack of knowledge of the procedure itself. With reassurance and explanation from the dentist or the Endodontist, the patient can understand why they need root canal treatment and what can be done to resolve their dental issues and pain.  

Root Canal Treatment Procedure 

Before the Procedure: The dentist or the Endodontist has to make a thorough examination of the teeth so that the painful tooth is correctly identified. There are several examination procedures and some are done to reproduce the symptoms of the painful tooth. A radiograph is also taken to check the tooth and the surrounding tissues. 

Demonstration of Rubber Dam Isolation with a Dummy Training Head.

Preparing The Treatment Area: Anaesthetic injections are necessary for patients before the actual procedure. Patients with long-standing toothaches or severe infection require special attention so that the teeth are properly anaethesized. Endodontists are experienced in this aspect and will be able to employ the appropriate technique according to the severity of the patients’ pain or infection. Once the anaesthetic injection is successfully delivered, the patient should not feel any severe pain during the procedure. 

During root canal treatment, it is important to prevent further contamination of the root canal space. A rubber dam, which is a rubber sheet, is used to isolate the tooth from the rest of mouth, creating a clean environment. The rubber dam and the affected tooth will also be disinfected prior to starting the treatment. 

Picture of a cleaning file fitted on a motor

Creating A Small Hole and Cleaning the Root Canals: After the rubber dam and the affected tooth has been disinfected, the dentist or Endodontist will then drill a small hole on the surface of the affected tooth to access the root canal spaces. If there was decay in the tooth, the decay should be removed before preparing the hole. Once entry to the canal is achieved, the dentist or the Endodontist will use small files and disinfecting solution to clean the canals and remove the infected or inflamed pulp tissues. The cleaning can typically take an hour. Medicament paste is commonly placed in the canal for at least a week and the hole is sealed up with a temporary filling. 

Picture of gutta percha material

Applying Root Canal Fillings: Following the thorough cleaning of the root canal, the dentist or the Endodontist will fill the canal space with a rubber-like material known as gutta percha. Pressure and/or heat is applied to the gutta percha so that the material adapts to the walls of the root canal. A sealer, which is a cement, is placed together with the gutta percha so that it creates a better seal to prevent reinfection of the canals. 

Root Canal Treatment Aftercare: The numbness following anaesthesia can last for a few hours but patients can still consume their meals, with extra care to avoid hot food and eating on the affected side. Patients should also avoid any hard food which may cause fracture of the affected tooth. Daily brushing and flossing should be continued as per normal. 

Root canal treatment is less invasive than an extraction and an implant procedure and patients should not expect any severe pain or swelling. However, patients with severe infection and pain before the procedure should expect the symptoms to subside only after a few days. Painkillers may be prescribed if pain is expected to persist, while antibiotics are only warranted for some cases. 

After the root canal treatment has been completed, the tooth will need a permanent filling or a crown. This restores the tooth to full function. 

Reach Out To Our Root Canal Treatment Specialist Today

If you are currently worried about undergoing a root canal treatment, there is no need to fret. Our Endodontists, the root canal treatment specialists at The Endodontic Office can walk you through the procedure as well as the aftercare. If you have any further questions, please reach out to us through our Contact Page. 

By Dr Helena Koh
Dr Helena Koh is an Endodontist in The Endodontic Office and is accredited as a specialist by the Singapore Dental Council. She has 10 years’ of clinical experience in Root Canal Treatments. 

Root Canal Vs. Extraction: Which Is Better For You?

The dental pulp in teeth can become inflamed or infected as a result of deep caries, cracks, fractures or severe gum disease. Patients may present with pain or a swelling, although at times there may be no symptoms as well. When this occurs, dentists will recommend one of two options – a root canal treatment versus an extraction. The risks and benefits of either treatment option depend greatly on the specific conditions of the individual tooth and patient. Here we share some insight behind how a root canal treatment can save your tooth.

What is root canal treatment?

Root canal treatment involves the disinfection of the root canals in a diseased tooth followed by a filling with a biocompatible material. 

• A thorough examination inclusive of a dental X-ray is performed to determine that a root canal treatment is required.
• Local anaesthetic is administered to numb the affected tooth. 
• A small opening is made through the crown of the tooth.
• Instruments are used to clean the root canals and a medicament may be placed inside the tooth.
• Depending on the complexity of the case, root canal treatment might be completed in a single or multiple visits.
• Finally, biocompatible materials are used to fill the root canals and a permanent filling (core) is placed to close off the opening
• If a crown is required to protect the tooth, we will refer you back to your general dentist for further management
• The tooth is retained in the mouth and functional

When might the tooth be unsuitable for a root canal treatment?

In the following situations, we may recommend an extraction:

• Assessment of the tooth confirms a deep crack
• Decay or a fracture that is too extensive
• Severe bone loss around the tooth
• Signs and symptoms persist despite adequate root canal treatment

In patients with certain medical conditions, we might advise against an extraction even for teeth which are otherwise unsalvageable. These conditions include a history of radiotherapy to the head and neck region, bisphosphonate or anti-resorptive/anti-angiogenic drug use for the treatment of osteoporosis or certain cancers. Please inform your dentist if you have any of these conditions so that the safest treatment option can be planned for you. 

What should I do if I need an extraction?

After a thorough assessment of the diseased tooth, if an extraction is recommended, we will liaise with your referring dentist to complete the extraction for you in a timely manner. Generally, extraction involves the removal of the diseased tooth with forceps but sometimes a minor operation may be required to fully remove the tooth. Extractions are usually performed under local anaesthesia. If several teeth are indicated for extraction, it may be performed under sedation or general anaesthesia. Your dentist will also be able to provide a suitable replacement for your extracted tooth, for example, an implant. 

Our team of root canal specialists at The Endodontic Office are well trained in the diagnosis and treatment of painful teeth. If you are suffering from a toothache, make an appointment to see one of our dentists via appointment@endooffices.com today.