What causes severe, unexplained tooth pain?

Having an issue that is difficult to diagnose doesn't mean being psychosomatic; pain is a universal sign of a problem

A question posted in Quora asks “What could cause severe unexplained tooth pain?" Read the response from DMD Danish Qadri, and add your own thoughts to the comments.

I hope this answer can help other people who suffer from similar episodes. I have personally had multiple patients with these stories, and it can be debilitating and life-altering. 

First off, you are already in a small subset of the population with a difficult to diagnose issue. This does not mean that you are crazy as some doctors assume after not being able to figure out the problem quickly and as easily as in a textbook.

Pain is a universal sign of a problem. There is no such thing as a "healthy" pain. Pain is a sign of inflammation, infection, or other traumatic injury. The causes of pain are not completely understood in many cases.

What you need to do is to find a doctor/dentist who will sit down and review your entire history. A well taken clinical history and exam can reveal so much more information that blood tests or imaging. Important follow-up questions can reveal many issues that you may have previously thought unrelated to the original episode, which can help to provide your diagnosis. Literally speaking, you need to find yourself a good diagnostician, a la House MD or Sherlock Holmes.

After getting a good history, you need to do diagnostic testing on all of the teeth in this area, and possibly a few on the opposing arch. This will help you isolate if there is a dental (odontogenic) cause for your pain. If you cannot isolate this to a tooth clearly, there is likely a strong nondental (nonodontogenic) cause for your pain. Imaging will help, but nothing with the human body is ever black or white, and there are always shades of gray.

Common dental problems with this type of issue are:

  • Cracked Tooth Syndrome: Sometimes no etiology or cause can be found, but the tooth has suffered a structural failure. A crack has provided a pathway for bacteria to infect the pulp (nerve) and you are now feeling a dull achy type of pain that can increase and decrease, but not throbbing like a heartbeat.
  • Acute or chronic pulpitis: Also caused by bacteria attacking the pulp, but a deep filling or cavity can be found easily.
  • Sinus related pain: Usually differentiated because it is provoked more by biting pressure (usually on upper teeth).
  • TMJ related pain: Usually found on the last one or two teeth on either side, top or bottom, could be worse in the morning than before bed time. Clenching, bruxism and other occlusion (bite) issues can be present as well.

Then you get into the nonodontogenic pain:

  • Myofascial pain: Scott Frey summarizes this in an excellent way. Overuse of certain muscles causes pain in other areas, i.e. referred pain. This can be diagnostically verified by trigger point injections with an anesthetic that should shut the pain down immediately.
  • Neuropathic pain: Caused by some type of injury to a peripheral nerve in the vicinity. Usually the person indicates a "burning" or "electric" type of sensation.
  • Central brain issues: Typically a tumor or other issue with the nerves connecting into the area (much more rare).
  • Cancer: Local cancers or metastasizing lesions from distant parts of the body can cause unexplained pain (even more rare).

There are a subset of dentists who train in being able to identify and treat more difficult patients and cases. They are usually referred to as orofacial pain specialists. See a list of programs here. It is not an accepted specialty within the dental profession as of yet, but it likely will be in another decade.

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