Lingering Toothache

Many of my patients will tell me that the worse pain they have ever felt is the pain of a dental toothache. For most patients a visit to the dentist usually leads to a clear-cut direction of care and a predictable resolution of pain. The solution may require a root canal or extraction. Depending on the location of the toothache, root canal therapy is 95% successful. The remaining 5% that remain symptomatic is the result of the irritated ligaments and bone that supports the tooth. Normal chewing will produce pain. The tooth may throb and wake you out of a sound sleep.  A number of conditions may still persist and the tooth pain now becomes chronic. If you experience tooth pain after a root canal, that lasts for more than two weeks, then the dentist needs to examine the tooth for an untreated canal, a tooth fracture, or possible neurological condition.

When a tooth fracture and untreated canal have both been ruled out medications are the first and most likely therapy to help restore the health of the ligaments and bone.  A dose of antibiotics may be administered to rule out an active dental infection. If the pain persists after dental treatment and antibiotics then the cause of the pain may be neurologic in origin and require a dentist that specializes in this type of pain management or a neurologist. The oral medications of choice are often not easily tolerated by patients and require some creativity in terms of dosage, time of administration, and the need for polypharmacy. Common choices include low-dose tricyclic antidepressants inclusive of amitriptyline, nortriptyline and sinequan. Additional medications such as benzodiazepines, lyrica, gabapentin, baclofen and trileptal are frequently used as well. The amount of medications will vary from case-to-case and may at times require the use of liquid suspensions instead of pills to achieve a balance between effectiveness and side effects. Topical medications used intra or extra orally may be beneficial as well. In situations where an autoimmune influence may be suspected medications called biologics (Enbrel, Humira) may be required. These medications should be prescribed by a rheumatologist whose skills are often essential as part of the pain care team. There are times, however, that response to these therapies is poor and pain continues. At some point in time if the pain just doesn’t get any better you must consider extracting the tooth and hope this solves your problem.

For additional information or a second opinion call Dr. Gottlieb for a consolation without an obligation.