Toothache: Non-obvious causes and effective solutions

When a tooth hurts: primary dental causes

Toothache is one of the most common types of pain that a person encounters. Most often, it is associated with problems directly in the oral cavity. The main dental causes include:

• Pulpitis: Inflammation of the dental pulp (the neurovascular bundle inside the tooth) often causes sharp, intense pain. Studies show that patients with migraine may perceive preoperative pain in irreversible pulpitis differently, but their short-term postoperative pain after root canal treatment does not differ from those who do not suffer from migraine [4]. This highlights the complexity of pain perception and the need for an individualized approach.
• Periodontitis: This is inflammation of the tissues surrounding the tooth root, which can lead to bone tissue destruction and tooth loss. Interestingly, there is a link between periodontitis and migraine, indicating possible common pathophysiological mechanisms, such as neuroinflammation [8].
• Caries: Deep caries reaching the pulp is a frequent cause of pulpitis.
• Dental trauma: Chips, cracks, or tooth dislocations can also cause pain.

Pain in the tooth area: not always a dental problem

Sometimes the pain we perceive as a toothache actually has a non-dental origin. This can significantly complicate diagnosis and treatment, requiring an interdisciplinary approach.

• Temporomandibular joint (TMJ) dysfunction: Pain in the TMJ area can radiate to the teeth, ear, or temple. This is a chronic pain condition often associated with stress, which plays an important role in its development, as is the case with migraine and other chronic primary pain conditions [2]. In cases where conservative treatment is ineffective, ultrasound-guided mandibular nerve (V3) block can be used to relieve pain in TMJ dysfunction, providing immediate and long-lasting relief [3].
• Trigeminal neuralgia: This condition is characterized by severe, shooting facial pain that can be mistaken for a toothache. In rare cases, such pain can develop even after cosmetic procedures, such as lip augmentation with hyaluronic acid. One report describes a rare case of persistent neuralgic pain after hyaluronic acid lip augmentation that required complex treatment [1].
• Shingles (Herpes Zoster Ophthalmicus): Reactivation of the varicella-zoster virus along the trigeminal nerve can cause severe pain similar to migraine and facial rashes. A case was described where a man developed herpes zoster of the ophthalmic branch of the trigeminal nerve after endodontic treatment, which was initially mistaken for postoperative complications. Early recognition and timely referral to a specialist are critical to preventing serious complications, including vision loss [6].
• Migraine: Although migraine is a headache, it can influence pain perception in the maxillofacial region [4] and be comorbid with other pain conditions, including periodontitis [8].

Systemic factors and comorbidities

The link between toothache and general health is becoming increasingly evident. Certain systemic factors and chronic diseases can influence the onset and intensity of pain in the maxillofacial region:

• Stress: Is a key factor in the pathophysiological mechanisms of migraine and plays a significant role in the development and comorbidity with conditions such as fibromyalgia, TMJ dysfunction, and irritable bowel syndrome [2]. Stress management can be an important part of comprehensive treatment.
• Chronic Overlapping Pain Conditions (COPCs): Orofacial pain, including TMJ dysfunction, is often associated with other chronic pain conditions, such as gastrointestinal, gynecological, and urogenital disorders. For example, irritable bowel syndrome (IBS) increases the risk of both the first onset and the chronification of orofacial pain [5].
• Migraine: As mentioned, migraine not only alters pain perception [4] but is also associated with periodontitis [8], which underscores the systemic nature of inflammatory processes.

Diagnosis: how to find the true cause of pain

Accurate diagnosis is the first and most important step toward effective treatment. Given the variety of possible causes, a comprehensive approach is mandatory:

• Dental examination: Initial assessment of the condition of teeth, gums, and surrounding tissues.
• Imaging studies: X-rays, CT, or MRI can help identify dental problems, as well as pathologies of the TMJ or nerve structures. In some cases, for example, when complications after injections are suspected, high-resolution ultrasound of the oral area can be used [1].
• Neurological assessment: If neuralgia or other neurological causes of pain are suspected, a consultation with a neurologist is necessary. It is important to remember that symptoms that are disproportionate or inconsistent with typical dental findings should broaden the differential diagnosis [6].
• Medical history: A detailed interview with the patient about the nature of the pain, its duration, associated symptoms, and general health status.

What to do for a toothache: treatment approaches

Treatment of a toothache depends directly on its cause. Self-medication can be ineffective and even dangerous, so you should always consult a specialist.

• Dental treatment: Pulpitis or periodontitis often requires root canal treatment [4, 6], fillings, or tooth extraction. For periodontitis, professional cleaning and anti-inflammatory therapy are also performed.
• Treatment of TMJ dysfunction: Includes conservative methods (physical therapy, use of occlusal splints, lifestyle changes) and, if necessary, more invasive procedures such as V3 nerve block [3].
• Neuropathic pain therapy: For trigeminal neuralgia or other neuropathic conditions, specific drugs such as pregabalin and palmitoylethanolamide (PEA) may be prescribed [1].
• Treatment of shingles: Systemic antiviral therapy is key to resolving symptoms and preventing complications [6].
• Management of complications after cosmetic procedures: In the case of pain caused by, for example, hyaluronic acid-based fillers, the administration of hyaluronidase, corticosteroids, and non-steroidal anti-inflammatory drugs may be required [1].
• Migraine management: For patients with chronic migraine and tension-type headache, therapy with botulinum toxin (OnabotulinumtoxinA) is effective, reducing levels of pain biomarkers [7].
• Psychological support: Given the role of stress and comorbidity with chronic pain conditions, psychotherapy and relaxation techniques can be beneficial.

Sources

1. Persistent trigeminal neuralgia-like pain after isolated hyaluronic acid lip augmentation: A case report.
2. The role of stress in the comorbidity of migraine and other chronic primary pain conditions.
3. Case report: Management of temporomandibular joint dysfunction pain with V3 nerve block.
4. Migraine is associated with altered preoperative endodontic pain perception and mechanical sensory function, but not with short-term postoperative pain: A prospective clinical study.
5. Are chronic overlapping pain conditions (COPCs) of gastrointestinal, gynecological, and urogenital nature predisposing or maintaining factors for orofacial pain (OFP)? A systematic review.
6. Herpes zoster of the ophthalmic branch of the trigeminal nerve after endodontic treatment: A case report.
7. EXPRESS: Evaluation of pain biomarkers in patients with migraine and tension-type headache before and after botulinum toxin therapy.
8. The association between migraine and periodontitis: A systematic review and meta-analysis.

Disclaimer: The information provided in this article is for reference purposes only and cannot replace professional consultation, diagnosis, or treatment provided by a qualified medical professional. Always seek the advice of your physician or other healthcare provider with any questions regarding your health or medical condition.