If you’re suffering from tooth pain but don’t have any cavities, here’s what our expert has to say

It goes without saying – when you have a toothache, you go to the dentist. But that’s not always all there is to it. Saarbrücken-based dentist Dr Horst Kares, a specialist in tooth pain without an obvious cause, says: «15 per cent of all patients who come to my practice have a toothache. But only slightly more than half of these patients are experiencing pain coming directly from their teeth.» This means that the other half must seek help from another specialist.

Differentiating primary from secondary pain

It’s important to understand the difference between these two types of pain. Toothaches that are a direct result of a problem in the teeth are called odontogenic or primary toothaches. If your teeth hurt, but the pain actually stems from elsewhere, it’s a secondary or non-odontogenic toothache.

In the case of a primary toothache, which is caused by the teeth themselves, the pain usually comes from a cavity or an infraction – a crack in the tooth. Dentists are well acquainted with such odontogenic toothaches. Kares says, «the situation is different with non-odontogenic toothaches, because they are hardly ever discussed in training.» But he specifies that there is one exception to this in practice. «Dentists usually recognise a non-odontogenic toothache caused by sinusitis because it’s very well known.» However, this type of toothache ranks only second among the most common non-odontogenic toothaches. More common is muscle-related tooth pain. And according to Kares, it often goes undiagnosed.

Muscular tooth pain: the #1 culprit

Muscular tooth pain is a consequence of painful cranio-mandibular dysfunction, also known as CMD. «Cranium» is the Latin term for skull, while «mandible» refers to the lower jaw. So CMD is responsible for pain that can spread all throughout your head and face. It’s caused by tension in the muscle fibres in the masticatory muscles (those used for chewing). These tight muscle fibres are known as trigger points and if not relieved, this tension can emanate into your teeth. It’s primarily folks who often clench or grind their teeth (during sleep) who experience this non-odontogenic pain.

How tension in the masticatory muscles could affect your teeth is easily explainable. The nerves of both these muscles and your teeth are located near one another in your central nervous system. When your «chewing» muscles are very tense, the attached nerves produce so much stress in the brainstem that messenger substances are released, irritating the neighbouring tooth neuron. The result? This neuron sends out a «toothache» signal. The problem: patients can’t distinguish where the pain really comes from.

Other causes

Far less common is a toothache that stems from trigeminal neuralgia – a stabbing facial pain – or from irritation of the nervous system. «Both are relatively rare, fortunately», Kares says. «But when they’re the cause of tooth pain, they’re usually very difficult to diagnose and treat; they’re very resistant to therapy.»

Other possible causes of toothaches that aren’t based on tooth decay include: migraine, shingles, cysts, otitis media, psychological causes, the malfunction of salivary glands, and tumors.

Kares points out another important connection, namely between the heart and teeth: «In about 16 per cent of cases of a heart attack, the first symptom is jaw pain. The pain moves from the heart muscle to the teeth and jaw.» In this case, failure to treat the pain could be fatal for the patient. Luckily, this is a rare event. But it emphasises the importance of identifying the underlying cause of pain. Both you and your doctor should take heed if your toothache isn’t caused by a cavity. Good to know, but what exactly can you do as a patient? Pay close attention to the pain in order to give your dentist as much information about it as possible.

What are the warning signs?

Does a secondary toothache feel different than a toothache from a cavity? Not really, says Dr. Kares. «For the patient, the difference is hardly noticeable.» However, there are clues for the dentist. In the article «Proposal of a Classification of Odontalgias», there are a vareity of «key indicators of dental pain suggestive of non-odontogenic sources of pain». They include spontaneous pain in several teeth; burning, non-throbbing pain; persistent (ongoing) pain; lack of significant pain relief after local anesthesia; a severe headache; and regional paresthesia (tingling, numbness).

However, if there’s no clear source of pain, it’s not only difficult for patients to classify the pain but it’s also challenging for professionals. Dr Jeffrey Okeson, a professor at the University of Kentucky’s «Orofacial Pain Center», writes the following in his paper entitled «Non-odontogenic toothache»: «non-odontogenic toothaches...can challenge the diagnostic ability of the clinician.»

What if no cause is found?

If your dentist can’t pinpoint a clear cause of pain and doesn’t know what to do next, it’s a good idea to see a specialist. Kares says: «In Switzerland, there are two experts in the field of non-odontogenic or undiagnosed tooth pain: Prof. Dr Jens Christoph Türp at the University Center for Dentistry Basel (UZB) (page in German) and Dr Dominik Ettlin at the University of Zurich.»

If your pain is rooted in neurological causes, such as trigeminal neuralgia, your next step is to see a neurologist. If it’s ENT-related, such as a sinus infection, you should go to an ENT doctor, whereas if it’s due to muscular tension, you should get orthopedic or physiotherapeutic treatment.

Can you treat a toothache yourself?

For the most common cause of a secondary toothache – muscular pain – you can actually treat it on your own by doing jaw gymnastics (page in German). These targeted exercises can be used to prevent the muscles you use for chewing from triggering pain in the first place; they can also help relax your jaw muscles if they’re already tense.

And for the second most common cause of secondary tooth pain – sinusitis – nasal rinses and a cooling of the inflamed area are recommended. Also helpful, of course, is a trip to the ENT doctor, who can offer other treatment options.