Pain occurring in the mouth is generally tooth related and can be caused by problems with the tooth itself or the gum. Teeth which have not grown fully such as wisdom teeth can also give rise to pain. Tooth pain involves problems with the nerve in the tooth which if still alive but damaged by decay may respond by causing pain which is a dull aching or throbbing nature. Cold or heat in contact with the tooth may notably affect the pain and in the case of significant nerve damage may give rise to a period of minutes or longer of more severe pain. Teeth where there is damage to the gum or an abscess will become distinctly painful to bite on or to any form of pressure. Certain dental pains are notably worsened by lying down and hence sleep may be very much disrupted.
Generally it is easy for your dentist to find the cause of your pain by a combination of questioning you about your pain, visually examining the tooth and perhaps taking an x-ray. Provocation of the pain may also be used by applying heat or cold to the tooth to assess its response or lack of it. Were the pain is present when you visit the dentist but difficult to tell if the tooth is in the top or bottom jaw the dentist may numb the tooth to differentiate between the two possibilities. If there is doubt and both suspected teeth are numb without eliminating the pain, the dentist may consider that the teeth do not seem to be causing the pain and refer you to see a dentist with specialised additional training in Orofacial Pain for diagnosis and treatment or sometimes just for clarification and a second opinion.
At times the dentist although believing the pain is due to the teeth may not be able to precisely tell which tooth is causing the problem and this is a common situation in the early stages of tooth ache. In that case rather than treating the wrong tooth the dentist may prescribe a strong pain-killer to tide you over for a day or two at which time the pain will probably have become more localised and clearer to diagnose.
An Orofacial Pain specialist will review you and ascertain that there is no dental cause for the pain. The most common reason for apparent toothache where there is not a tooth problem is referral of pain from your jaw muscle. In this instance you will not be aware of pain in your jaw but as described in the section on Jaw Problems/ Jaw Muscle Pain soreness in jaw muscle may give rise to a feeling of toothache or in some instances pain in an area where teeth have been removed. With correct treatment the “toothache” should resolve without the tooth itself needing any treatment.
Pain can sometimes occur when a tooth has been extracted and a piece of root was left in the gum, but this is usually only where there is clear evidence of infection associated with the buried root, in which case removal of the root will be required. In most cases where there is a piece of root in the gum this will not cause pain and need not be removed. The same applies to teeth that have never grown and are buried deep in the gum.
NEUROPATHIC PAIN
Your dentist or orofacial pain specialist may diagnose you as suffering from neuropathic pain where there is no dental problem. Neuropathic pain is a pain without reason, which is not to say it is an imaginary pain. Neuropathic pain is very uncommon in the mouth and will usually occur after dental treatment on a tooth or more commonly following a tooth extraction. We do not know why neuropathic pain occurs as it serves no function. It is not caused by the dental treatment and it likely represents a malfunction of the nerves involved. Although it may have initially occurred as a result of an injury or a damaged tooth, by its nature it continues after the problem has been dealt with and healing has taken place. It is believed that in fact the area repairs itself too well, resulting in nerves that have become overly sensitive and will feel pain where they should not for example with very light touch to the area or an exaggerated pain response to a painful stimulus such as a gentle pin-prick.
An analogy to help understand neuropathic pain would be the awareness we might have if we were to wear a wrist band where we never had worn anything on that wrist before. Initially we are very much aware of the presence of the wrist band but this gradually fades as the brain begins to ignore the nerve signals arriving back from the touch of the band on the skin until we are no longer aware of the sense of touch of the band against the skin. In neuropathic pain it would appear that this process is reversed and perhaps healing is overdone to the point that the nerve signals to the brain are actually amplified to the extent that any contact with the area where the neuropathic pain is felt as pain, or even that the area is so sensitive that pain is felt without contact.
MUCOSAL PAIN OR ULCERATION
We are all aware that at time we may develop painful ulcers or sores on the surfaces of our cheek, palate, gums and palate (mucosal surfaces). These generally arise for a reason and may require treatment from your dentist if troublesome.
Note: Any ulcers or sores in the mouth or around the lips, either painful or not, that do not heal within 3-4 weeks should always be examined by your dentist.
Some people may have a normal looking area in the mouth which none the less can be uncomfortable or painful a condition we refer to as Burning Mouth Syndrome.
TONGUE PAIN
The tongue as with other areas of the mouth may have painful lesions. However a condition called Burning Mouth Syndrome (BMS) occurs where the surface of the mouth (most commonly the tongue) may look normal but still feels as though it has been burned by a hot liquid. As with many chronic pain conditions this is found by far more commonly in women and predominantly in those who have passed menopause.
BMS is a condition that develops for no apparent reason and is thought to be a form of spontaneous neuropathic pain. It can in some be associated with vitamin deficiency, anaemia, diabetes and a possible side effect of certain medications, most often a blood pressure medication. However in the vast majority of cases it has no identifiable cause. Allergy to the plastic in dentures is often suspected by patients who are wearing dentures but is usually not the cause. Because many have sought help for the condition and not received a satisfactory explanation, patients are often very concerned that they have an undiagnosed oral cancer. However BMS is not a symptom of cancer.
Some with BMS will find that they wake in the morning with no discomfort and the condition becomes a problem by early afternoon remaining with them until they sleep at night, other will have it at all time when awake. It can be a very difficult condition to control but in some, specialised neuropathic pain medications are effective. Other may get benefit with an old type of anti-depressant medication. Leading to concerns that the patient is being assumed to be depressed and hence the pain. This is not the case. To illustrate this it is found that the modern ant-depressant medications are not effective in dealing with pain.