What brings you to the dental office!
The Healthline website has a good section on oral Pain with many reference sources available at the end that you can use to get more into this topic.
Organization of this Chapter
Basics
Types of Oral Pain
Tissues Involved with Oral Pain – 10 tissues
Causes of Pain in the Oral Environment
Bottom Line for Pain
………………………………………………………………………………………………………………………..
Oral Pain: Basics
When something hurts in your mouth, you would typically do either one of two things: 1. Wait to see if it goes away, taking over-the-counter pain medications as needed; 2. Go to the dentists office to see what is actually wrong.
Of course, certain pains don’t go away, and by the time you get to the dentist’s office, it may require a more invasive and expensive procedure to fix the problem. And, certain pains DO go away, but that is often not a good thing – the body has just given up on you and the problem will continue without your notice until it is too late.
NOTE – there are MANY causes of pain and discomfort in every part of the mouth. Here I will cover only those most familiar to a dentist in practice.
Refer to certain parts of Chapter III.10 for some more details on some of the lesions mentioned here.
Types of Oral Pain:
Certain things hurt when they are touched – by the finger, the periodontal probe of the dentist, or by chewing food. Certain things ache or hurt in a dull way, and it might be a mild ache or a throbbing ache. Sometimes the pain is sharp and even excruciating. The pain may just last for a second or two, or linger. If you drink some cold water and let it swish around the teeth, there might be a short duration pain which we would call “sensitivity”. Or maybe the pain comes from chewing and is sharp or a kind of “itchy” pain. Your teeth might be sensitive to HOT temperatures, and the pain can be short lasting or lingering from heat exposure. If you TAP on a tooth, which is different from chewing, it might produce a sharp pain in the bone underneath the tooth. You may even encounter pain on a tooth only when you RELEASE the pressure of biting on that tooth.
Each of these types of pain tells us something about the cause and the seriousness. Your dentist is knowledgeable in these areas and can help differentiate between the various causes of your pains.
Below are listed the regions where such pains might arise – later we’ll discuss more about the range of CAUSES and possible TREATMENTS.
Tissues Involved with Oral Pain
Soft tissue pain:
Nerves
Tongue
Salivary ducts and glands
Gums
Lips
Muscles
Palate areas – hard and soft
Hard tissue pain:
Bone
Joint
Teeth
Nerve Pain:
This is the most severe in many cases, especially if it has to do with the trigeminal crainial nerve V. This nerve supplies areas around the eyes and cheeks, the gums and teeth and jaws. The cause is generally associated with something putting pressure on the nerve at some point, near the brain or more peripherally. This pressure may originate from a nearby artery, a cyst, a tumor, disruption of the anatomy from a traumatic accident and other possibilities. You would generally be referred to a clinic that specializes in orofacial pain for this condition – which is often extremely painful. In fact, the word “lancinating” is also applied to this kind of pain! You can find out more about it online by searching for trigeminal neuralgia or tic douloureux.
It is possible that nerve pain can originate closer to the teeth as well – and I suspect, although cannot prove, that teeth that have stress exerted on them through clenching, may impinge on a nerve if they are positioned poorly.
Pain on the Tongue:
This could be caused by anything from inflamed taste buds to a fungal infection. Any inflammation of the tongue would be referred to as glossitis. It could also be caused by biting your tongue – either as a one time thing, or repeatedly. The repeatedly thing is often caused by malaligned teeth, but the one-time tongue trauma could be from inattention due to serious distraction, or from a fall or fight. Thrush is a yeast/fungal infection that often causes tongue pain, or burning in the mouth. Fungal infections are not unusual for people on long courses of antibiotics, where the immune system is not as responsive to these types of infections as usual. One disorder that shows up in the mouth and can potentially be an autoimmune disease is lichen planus – which yields a burning sensation of the tongue and other tissues, but also shows up on other parts of the body.
Salivary gland/duct pain:
There are many issues that affect these areas – ranging from mumps to simple duct stones with inflammation. Most often seen in the dentist’s office is the salivary duct stone – which can often come out on it’s own – or with a little manual encouragement by the dentist. Anything that increases the salivary flow might help to dislodge it as well, such as sour candies. When I had a small duct stone under my tongue many years ago, it simply went away on its own – which is the most common thing. More severe situations, or course, require more significant therapies.
Gums:
We’ve discussed periodontitis and gingivitis earlier (Visit Chapter III.2) – but remember these are both inflammatory processes – and inflammation means pain. This is typically a pain to touch, and not a pain that lasts. There are, however, periodontal abscesses that can produce significant pain. When you get a splinter and it swells up and gets inflamed it will eventually form a pocket of pus (I know – that is a disgusting word) which surrounds the splinter and will eventually wash it out. Something similar can happen in the periodontal pocket, where the inflammatory process surrounds the infected calculus in the pocket, and anaerobic bacteria that form them. The exudate (a much nicer term for pus) will wash out through the gumline, but will not take the calculus with it – that is up to the periodontist. It is possible that the tooth itself will have an infection in the pulp, and as this infection extends through the root of the tooth into the bone at the apex, an abscess could start there. It is likely that with such a process where the tooth sits on the bone the tooth will be sensitive to percussion – and perhaps more painful than simple sensitivity. Now – the involvement of the gums in this is that if there is an abscess at the root of the tooth, the exudate can flow out through the gum line, or even through the soft tissue, where it makes a little hole or fistula, into the vestibule with the cheek. OK – you probably have the sense that this would taste horrible, and you’d be correct in this!
Lips:
Again – many disease states affect the lips – but the most common from the dentist’s perspective are the canker sore and the cold sore. These two sores occur on different sides of the lip, or vermillion border – the canker sore on the inside at the junction with the mucosa of the mouth, and the cold sore at the outer edge, where the lip meets the skin. (Visit Chapter III.10 for pictures). The cold sore is also called Herpes Labialis – an infection from a strain of Herpes virus, which will simply show up from time to time, possibly as a response to stress. The canker sore, called an apthus ulcer, is of largely unknown origin. Whether it is related to stress, auto immune response, or otherwise has never been elucidated. It might START due to trauma or irritation, but the process is not exactly clear. If you bite your lip, you might be lucky enough to get TWO, at the sites of penetration of your upper and lower teeth. I once had this exact thing, where the canker sores got worse and eventually joined! Back in those days the most effective cure for these sores was a SILVER NITRATE STICK – where the coating of silver nitrate at the end was rubbed into the sore. The sore goes away within a day, which is great, but it has been my conclusion after a couple experiences like this, that all it does is take ALL of the pain that would be experienced from this sore over a week’s period and concentrate it all into one minute! These days, your dentist can prescribe Kenalog in Orobase. The Orobase simply sticks to the sore and covers it so it is less likely to be painfully perturbed, and this is available over the counter as well. But, the Kenalog part is a steroid which HEALS the sore well over a couple of days. This is a very helpful medication! Bear in mind that Canker Sores can arise in many places in the mouth, not just the lips.
Muscles:
The strong muscles that are responsible for closing the mouth, which extend from the base of the skull and sling under the jaw both on the inside and outside, can certainly get sore from overuse. If you are clenching and grinding your jaw, especially at night, you might well wake up with tired or sore muscles. It is even possible that your muscles can cramp. Some people have experienced an OPENING of the jaw, using the muscles in the neck, which is excessive and uncontrollable, and you just have to await the natural relaxation of these muscles before you can close. But these overuse problems with the muscles are not likely to be addressed to the dentist. If the cramping is continuous and unceasing, the ER may be the best place to go.
Palates – soft and hard:
There are many things that can produce pain in these areas, either in the soft tissue that covers the hard palate, between the upper teeth from left to right, or in the flexible soft palate, which includes the uvula. One example is a cyst – although a cyst, on it’s own does not produce pain. A cyst, which is an inert spherical growth which is surrounded by a dense sack, can put pressure on other areas, and this might cause pain. Nerve pain can originate from the presence of a cyst. Also, a cyst on the palate underlying the relative thin tissue over the bone, can cause a perforation into the mouth, feeling something like a splinter got in there and is simply irritating. Cysts are usually easy to remove in the area of the mouth, but this is certainly not always the case. I’ve also removed embedded corn chips from the roof of a patient’s mouth – so traumatic injury can produce pain. Of course, we’re all familiar with PIZZA MOUTH – that delightful burn one gets when the melted cheese of a slice of pizza sticks to your palate! Soft Palate pain is most often associated with the “sore throat” of a variety of origins, where it spreads from the throat to the palate, making swallowing most difficult.
Bone:
Pain in the bones is not something you ever want to have – at least not the deep pain from within the bone that is due to infections like osteomyelitis, or tumors like osteosarcoma. These are seriously destructive pathologies and, hopefully, will be discovered at an early stage, often by a dentist, before the pain is too noticeable. Pain or discomfort originating from a bony overgrowth, like a torus, is far less disturbing. In fact, the growth of a torus at the center of the palate, or along the inner border of the mandible near the premolars, is quite common and generally not noticed unless restorations like dentures must be done which rest on those areas. A large torus may stretch the covering tissue to a point of fragility and sensitivity, however.
Joint pain:
The joints we are concerned with here are the temporomandibular joints, which have been discussed in an earlier section (visit Chapters II.4 and III.6). These complex joints can be the source of pain or at least annoyance. If your joint clicks or makes a gritty sound every time it’s opened or closed, that can be irritating. If your joint is inflamed, then it can certainly hurt when pressure is put on it. The inflammation can be caused by overuse or trauma. Those with osteoarthritis of the TMJ can suffer particularly with this pain – for now the actual structures of the joint are damaged through a pathological process. Arthritis of the TMJ can also lead to pain in other areas, as it affects occlusion (the bite) and how the teeth move over each other – AND the muscles that may be overworked as the teeth are moved over each other. It is especially important to have any pain associated with the joint checked by your dentist or physician.
Teeth:
Of course, everyone is familiar with the “tooth ache” – at least in hearing of it from friends and relatives. But, what IS this? Mostly this refers to a pain which originates with the nerves INSIDE the tooth, in the pulp. But, it can also describe pain from the area of the bone around the apex of the root of the tooth. There are plenty of nerves in each area, and when there is bacterial invasion and the immune system responds with an inflammatory response, the nerves produce pain due to specific pain-causing chemicals made by the inflammatory process. The body is saying HEY!, you’ve got a problem here. Now – before the infection gets INTO the pulp, it might simply irritate it to the point where there is pulpitis – but potentially reversible. The pain may come and go, and present more as a sensitivity than throbbing pain. Once the infecting bacteria enter the pulp chamber through the decay process, it’s time for action, and your body will let you know. The pain will be of longer duration, potentially throbbing, and the tooth will be sensitive to both cold AND hot. Once the infection gets beyond the apex of the tooth into the bone, you are likely to feel pain on percussion or chewing on the tooth. The only way out of this situation is for the dentist to perform a “root canal”, where the entire contents of the pulp chamber is removed down to the apex. Once the source of the infection is gone, then the tooth will feel much better, and the infection in the bone will resolve on its own. NOTE – however, that a very similar pattern of pain can also be caused by a filling or crown done by the dentist that is too HIGH – that is, it hits the opposing tooth prematurely, before the other teeth touch. This constant trauma produces pain, maybe approaching throbbing pain, with sensitivity to cold, and perhaps even hot. All of this can simply be ended by just adjusting the bite on the restoration – far less expensive than root canal therapy! Any pain must be diagnosed wisely.
Note that if the ROOT of the tooth is exposed to the oral environment through gum recession, the root surface and the nerves that end at the surface, may well be sensitive to cold temperatures. This SENSITIVITY is commonplace and can be arrested largely by clinical procedures and appropriate toothpaste use.
Causes of Pain in the Oral Environment:
Infections:
Bacterial, Viral, Fungal. Bacteria are responsible for dental decay and periodontal disease, both aerobic (air loving) and anaerobic (air hating) bacteria. Viruses of a variety of sorts, which affect other parts of the body, can also affect the oral tissues – including HIV, human papillomavirus, herpes simplex and others. Fungal infections can give rise to burning mouths as in thrush or trench mouth. These infections can involve many of the tissues of the mouth and surrounding areas – not just the teeth and gums.
Blockage:
Mostly having to do with salivary ducts. See Chapter III.10 for a discussion of the Mucocele.
Autoimmune:
This is an extremely complex area, and is covered ably by other sites – but for our purposes recurrent itching or burning sensations in the oral tissues may be caused by autoimmune conditions, where the body’s immune system actually attacks the mucosa of the mouth. Another aspect of this immune problem shows up as rheumatoid arthritis, where the immune system attacks the joints – and this can certainly involve the TMJ.
Cancer and other growths:
While cancer typically doesn’t cause pain on its own, it may be associated with pain due to impingement on surrounding tissues. The PAINLESS ulcer in the mouth, resembling a canker sore, but not hurting, is notoriously suspect for oral cancer – possibly originating from a variety of sources. Also, bone cancer may show up in X-rays as voids in the bone. These voids can be caused by many things, but if cancerous, may cause pain due to impingement on a nerve which runs through the bone. Other growths that may produce pain in surrounding tissues are cysts and tumors that are benign.
Bottom Line for Oral Pain
Everyone’s experience of pain is different. Some people are more sensitive than others. What drives one person crazy may be taken in stride by another.
But – we all feel pain in one way or another. How it is felt is variable, but the causes of the pain and the location of the pain is important to determine – so that something can be done. We would like to TAKE CARE of the cause of pain so that it does not continue or get worse.
We’ve looked at many SOURCES of pain, and CAUSES of pain.
Section IV of this site has a lot to do with the data dentist’s collect to determine what is the source of pain.
Section V of this site is WHAT WE DO TO FIX the problem, so the pain will go away.