Why does my tooth hurt?

There can be many reasons a tooth can hurt and sometimes there is actually nothing wrong with the actual tooth.  People often wonder why a tooth hurts when it has had a root canal, or why it only hurts to with pressure but not colds or the other way around.  Others come in confused  by symptoms that are inconsistent.  There are plenty of patients I see that fell a tooth ache but are not sure which tooth or even if it is a top of bottom tooth or even multiple teeth.  There are many thing that can cause a tooth to hurt and only a few sources of tooth pain.

Have you ever been frustrated with trying to figure out why your tooth is hurting?  I will explain the different neural sources of tooth pain and the causes that lead those sources to hurt.

First a very brief anatomy lesson 

http://en.wikipedia.org/wiki/Pulp_(tooth)

The tooth has a hard enamel shell on the top part the sticks out of the gums.  The part of the tooth in the bone, the root of the tooth, is made up of a less hard material called cementum.  Going from the outside in just past the enamel is dentin.  The dentin is softer like the cementum and is more porous. In the center of the tooth is the pulp which consists of the blood vessels and nerve.

Supporting the tooth on the outside is the gingiva or gums.  Inside the gums is the bone and between the bone on the tooth is a ligament.  Tiny nerves inter and exit the tooth from all around the root, but the main nerve exits out of the tip of the root.  This nerve then connects to larger and large parts of the nerve that are connecting to other teeth and even other parts of the mouth.  Eventually the nerves travel all the way back to the brain.


Sources of tooth pain

A tooth will hurt if the nerve is aggravated.  This can happen in many ways but I will narrow it down to four categories:

1. The nerve inside of the tooth is aggravated
2. The nerve in the ligaments and bone surrounding the tooth is aggravated
3. The nerve in the gingiva or gums is aggravated.
4. The nerve is aggravated at a different spot heading back to the brain and is referring back to the tooth.  

Causes of pain: A long list that is a brief view of possible problems.

There are a signs and symptoms that help me as a Dentist to find out what might be causing one of the sources of pain hurt. It is very helpful to know how the tooth is hurting, what causes it to hurt and even when it hurts.  There are also things I can look for and test for that help to find the cause of the pain.  Using both your description of the pain and what we find on x-ray, photos and tests we are able to find the cause of the pain.

What can cause these different sources of pain to actually hurt?  Well the list is long but I will do my best to list some of main causes per category

1.  The nerves inside the teeth can hurt because of: 

• A cavity reaching the never, 
• a crack reaching the nerve, 
• the dentin being exposed from worn enamel, the dentin pores the communicate cold and hot more with the nerve,
• a cavity extending into the dentin causing dentin pore communication of cold, hot and sweets
• swelling in the tooth putting pressure on the nerve from physical trauma
• swelling in the tooth from dental work, Yes we need to do this in order to correct worse current or future problems with tooth, the soon a problem is addressed the lower the chances are 
• a broken tooth exposing the pulp/nerve of the tooth 
• chemical exposure opening pores in the tooth that communicate with the nerve (this is usually from tooth bleaching)

2. The nerves for the ligament and bone can hurt because of:

• an infection from the inside of the inside of the tooth coming outside in the ligament space
• a crack extending down the root of the tooth that is under bone, this can irritate the ligament and the bone
• swelling of the ligament from physical trauma
• swelling of the ligament from a traumatic chewing habits
• swelling of the ligament from an unstable bite when chewing
• loss of bone support cause the tooth to become loose and irritate the remaining bone
• physical trauma that breaks the bone an not the tooth
• abnormal growth in the bone affecting the nerve

3. The nerves in the ginigva (gums) is aggravated:

• Physical trauma to the gums (from multiple sources)
• Chemical trauma to the gums (from multiple sources)
• Burns on the gums
• plaque leading to bacteria infecting the gums 
• Tartar (hard plaque) leading to bacteria infecting the gums but also placing physical presser on the gums
• viral infections, such as cold sores
• fungal infections
• abnormal growth in the gums affecting the nerve

4. The nerves can be aggravated in a different location referring pain to the teeth because:

• Swollen salivary ducts from an infection
• Swollen salivary ducts that are just clogged (for lack of a better laymen term)
• Swollen clenching muscles that refer pain back to the tooth
• Swollen jaw balancing muscles that refer pain back to the tooth
• Tense muscles that refer pain back to the tooth
• Sinus troubles that refer pain back to the tooth
• Any of the first three sources problems getting mixed up in the nerve highway back to the brain that refers pain to another tooth instead of the actual problem tooth

With the many possibilities of tooth pain it's a good thing we take time with our patients so we can get a clear picture of what is going on and why.  This is how we take our patients oral health to a level they did not know could be achieved.

I would love to hear your comments on any confusing dental problems you may have had as well as what happened to help correct it.  For more information about our office please visit www.leathamdental.com

Dr Leatham's life as a Dental patient

One of the reasons I decided to go into Dentistry was because of the benefits I have had in my life because of Dental work.  I am sure many of my patients have wondered just how much I may be able to relate to them.  I will walk you through my life as a dental patient, both before and after Dental School.

My first memory of the Dentist

This is not the actual Dentist's nose hairs
But this is what I remember of him.

I don't remember much of the Dentist from when I was younger.  I was a fairly complacent child and there was a lot of fluoride naturally in the water were I grew up in Logandale Nevada.  I do remember being very excited to get a round sticker with a picture of a tooth on it.   Even more than that was I remember the Dentist's nose hairs.


When I was growing up Dentistry had not adopted as many of the infection control protocols as are used today.  So when I went to the Dentist he did not wear masks, and I remember looking up to a forest of hairs growing out of his nostrils.  Today when I put my mask on for my pediatric patients I will tell them I am going to put no my mask so they won't have to see my nose hairs.  I usually will get a laugh out of their parents.  The kids on the other hand are a tougher crowd to please.

Having a baby tooth pulled
I did have to have a baby tooth pulled when I was young.  I don't remember how young but I do remember it had to come out because it had stayed in longer than it was suppose to.  Of course my Mom could have told me that so I didn't think I had any cavities.

I don't remember the shot so it must have been a painless injection.  I do remember holding my Mother's hand and hearing the sounds of the extraction.  This Dentist must have kept his nostrils trimmed because I don't remember him having the nose hairs.

Two full days in the chair
I have mentioned before that I have a big mouth and had very small teeth.  When I was about to graduate high school my parents invested in getting me teeth that would fit my mouth.  Our family Dentist was taking courses on veneers and I was able to be his patient for one of the courses.  I sat through the work to get eight veneers the procedure is in two parts and because it was in a learning environment it talk longer than usual I believe it was around 6 hours one day and about 3 hours another day a month later.

I didn't mind all that much because I was a teenage boy and his assistant had very pretty eyes.  Although I do remember the numbness wearing off on on of the teeth and not saying anything for about 15 min.  They said I looked a little tense and asked if I could feel the drilling, I nodded and they gave me some more anesthetic.

My wisdom teeth story

The exchange of wisdom teeth stories can be quite the conversation.  People tell their sideways, upside-down impacted wisdom teeth stories along with their bizarre and hilarious behavior after the IV sedation, I don't have any over the top conversation topping tails for my wisdom teeth.  They didn't have enough space to come in, there was only 2, they came out with no complications.

I remember going in to the Oral Surgeons office and them putting me under.  The funny thing was is that after the surgery I did not want to be helped when I was walking, but then I was very excited when I got to ride in the wheel chair.  My Mother drove me home after.  She tells me that I reminded her that I needed stop by the post office and mail some letter about ten times on our 1 hour drive home.  Nothing too complicated or bizarre, sorry for the let down.  I'm sure there are many more exciting wisdom teeth stories out there.


My first cavities
I have a confession to make, The first cavity I ever had was while I was in Dental school,  I actually think I got the cavity in undergraduate from the late night Dr. Pepper and snacks I ate to get a few extra hours of studying in.  To make matters worse my next three cavities were right after Dental school, probably for the same reason, eating junk while studying.
I had a fellow college do the fillings on these teeth and I have had a clean dental bill of health since then.  When I had my fillings done I tried the oraverse to have the numbing reversed and I thought is was fantastic.  By the time I drove a few blocks home I had feeling in my mouth again.

 These are pictures of my 2nd and 3rd cavities ever,
And to my everlasting shame they were found after  I was a Dentist

I blame these cavities on my junk food study habits in Dental school,
Oh the irony!

For more information about our office please go to www.leathamdental.com

What about stains that don't respond to tooth whitening?

A common desire for a healthy looking smile is to have bright teeth.  For most people the different whitening products can do a great job of brightening their smiles'.  Some people have stains that do not respond to the most common methods of whitening.  (see blog post :Ways to whiten your teeth)

Here are some reasons why teeth may night respond to whitening.

Tartar stains

You may notice the yellow on the sides of the teeth mainly
on the bottom teeth in front, these are stains from tartar.

Tartar naturally can build up on your teeth and will appear yellow and chalky.  Tartar builds up mostly between teeth and near the gums.  More brushing will not removed the tartar, it's bound to the tooth.  The Dental hygienist has the tools and skill need to remove the tartar and give you a brighter smile.

Cavities
The by products produced by the bacteria in cavities results in a brown to black appearance.  The tooth will be soft and eventually start to break apart.  Cavities will not whiten with tooth whitening, the cavities need to be removed to get ride of the stain, not to mention all the other problems they can cause.

Demineralized tooth structure
Prior to the tooth getting a cavity it first start to demineralize from the acid it is exposed to. The demineralized tooth with often appear a chalky and different shade of white or even yellow.  These stains are commonly seen once braces are removed because of plaque or other acid exposure build up around the brackets but doesn't extend under.

Staining before microabrasion

After one treatment of microabrasion

These stains will not respond to traditional tooth whitening.  The key here is to remineralize the tooth. There are several ways this can be accomplished including microabrasion and adding a no drill filling that is absorbed into the demineralized area of the tooth.

Fluoride stains
With all the benefits teeth get from fluoride one of the draw backs is that at high levels during tooth development the fluoride can stain the teeth.  The difficulty with fluoride stains is that they are deep in the tooth because the develop into the teeth as they develop from the inside out.  They look similar to the staining of demineralized teeth but with a shiny surface instead of a dull surface.  The no drill filling is not an option but microabrasion can be successful.

Tetracycline stains
The dark grey staining that results from the use of the tetracycline antibiotics during tooth development is one of the most difficult to address.  Again since this occurs during tooth development the staining is deep inside the tooth.  About the only treatment that can get rid of these stains to to crown the teeth with a porcelain crown that has a metal interior that will block out the stain.

Ways to whiten your teeth

A common desire of patients is to have their teeth a brighter shade.  Typically this can be achieved in several ways.

1. First is by a professional in office whitening.  This is a great way to get a quick couple of shades by getting the surface of the tooth whitened.  In our office we spend about 1 hour with this procedure and get about 2-3 shades brighter for most patients.  Since the whitening agent is so strong it needs to be done in office to avoid burning the rest of the mouth.
2. Second is by making custom trays to wear at home.  Some of the benefits to this method is that the longer slower whitening can get deeper into the tooth and give some additional results you can not get from in office whitening.  You can also use the trays for other things such as fluoride gel.
3. Third stock trays are a popular trend now.   This includes whitening strips.  Other companies make similar whitening products we use opalescence which are the same makers of our in office and take home tray whitening products.
4. Fourth is by touch up products.  I will group most other products in this section since there is a plethora of options including: tooth pastes, on the go pins, gum, mouth rinses and the list can continue on.  These may not get a lot done for you unless you have already whitened your teeth and you want to help maintain your smiles new brightness.

There are also some ways which you should not whiten your teeth:

Chemical burn of the gums from hydrogen peroxide

1. Bleaching your teeth with bleach.  A common term for tooth whitening is bleaching your teeth. When you whiten your teeth there is not any bleach involved.  In fact using bleach is very toxic, will burn your gums (if not worse) and will not result in a brighter smile.
2. Using hydrogen peroxide to whiten your teeth.  The concentrations on hydrogen peroxide sold at the store will also burn your gums and create very sensitive teeth.  Whitening agents use a peroxide to whiten your teeth so hydrogen peroxide will get your teeth whiter but the cons of damaging your gums and creating very sensitive teeth can be avoided by other whitening agents.
3. Baking soda is a common one I hear of patients using to clean their teeth to make them brighter.  Baking soda is very abrasive and will not only remove stain from your tooth but it will move some of the actual tooth.

A few random facts about whitening your teeth:

1. Most modern whitening products contain a tooth desensitizer.  This is because whitening products naturally create tooth sensitivity. So something needs to counter that sensitivity.
2. Tooth brightening is probably a better term.  If your teeth looked more white they would also look odd and dull.  This is because the tooth is partly clear and some colors, such as reds and blues, appear in small amounts naturally to help the teeth to look brighter.  Think of a toilet bowl, a very solid white, and it would look horrible as the shade of your teeth.
3. There are some stains that will not whiten by these traditional methods.  They include fluoride stains, tetracycline staining and demineralized teeth. There are other ways to deal with these stains but that is a topic for another day.

The power of a photo: Seeing through the eyes of a Dentist.

I work in a very small world.  The problems that develop on teeth can be microscopic.  In order to help me in this small world I use 2.5X and 4.5X magnification along with a very bright head lamp and mirrors to look into all of the odd angles of the mouth.  Needless to say I see peoples mouths in a completely different way than they do.

It's no wonder that I am able to find many things in my patients mouth that they are unaware of.  This is one of the reasons we take a lot of photos in our office.  We consistently take 9 photos of all our new patients.  We also frequently take photos of things we find during dental surgery and photos of our finished work.

I hope the photos below help to show the difference that a patient might see compared to what I might see with my Dental loops (magnification)

A fairly normal size to look at a tooth
At this size nothing may look troubling

Now try to lean in  a little and you may notice some suspicious dark areas

Zoom in with some low power loops say 2.5X and you may notice a crack

Now lets look at it through some higher power loops say 4.5x the crack at the top of the tooth is now very apparent

Now add a little more light and this a tooth the crack at the top seems obvious.  

This is how I see the tooth as a dentist.  I look at the ridge of the tooth splitting.  I can almost see the bacteria crawling into this crack causing it to stain as the they slowly produce acid causing the tooth to decay as the crack and the bacteria continue on their way to find the nerve.  These problems usually wait to break or cause pain until you are on some cruse ship off the coast of another country.  You final bite into an almond extending the crack into the nerve and will not be able to to eat sleep or even have a cold drink the rest of the trip.  Well at I see similar situations happen fairly regularly. 

My two boys

Can you tel who's who?  One is the new born photo of Jack the other is Scott.

The most excited people get when talking about me is when they are talking about my two boys Jack and Scott.  So here are some photos of them.

This is what Jack thought of Scott when he first met him.

With the extra space around the photos I will fill with a bunch of stories of these two Leatham boys.

But after a few weeks he started to like his little brother.

An interesting thing about Jack and Scott is that I was the second child and had an older brother.  Already Jack and Scott seem to be similar.  Jack has to stay busy all the time like my older brother Mica.  Scott has been more reserved like his Dad.  Must be a second child thing.

Mom and Scott in the deliver room March 6, 2015

Jack wasn't so sure of Scott when he first met him at the hospital.  But after Scott came home Jack made up his mind, Scott was great... For about 2 minutes and then Jack moved on to more interesting things like his trucks.

 Luckily Grandpa Leatham was out to help and Jack had a new best friend to distract him from the needy little thing Mom and Dad brought home one day.

Jack fishing with Dad at the Clark county fair
in Logandale, NV Dr Leatham's home town.

After Grandpa left it didn't take Jack to long to warm up to his little brother.  Now he has been trying to fill Scott in on all he has learned in his 2 1/2 years in this world.

Both of the Leatham boys were ambitious from the start.   Jack was born 6 days early and Scott was born 10 days early.  Jack weigh 8 lbs 9.5 oz and Scott was exactly 1 lb less.  He was also 1.5 in shorter at 19 in. They were both born with a full head of hair. Jack went bald at 4 months then grew blonde hair, even though both Katey and I have dark hair we both have blonde brothers.

Dad and Scott in the delivery room.

Jack going down a carnival slide with Katey.

Another who's who photo of Jack and Scott both when they were newborns.

New Alternatives: What is available for teeth beyond treatment?

Review
In the two previous posts I talked about how we are living longer now than ever before and what that means for you mouth.  We are lucky to be around in a time of great advances in both Medicine and Dentistry.  We can do a great deal more to help keep your teeth than ever before.  Even with all of the available treatments there are times when teeth can not be saved or fixed.  What can be done when this happens?

Dental implants

In the recent history of Dentistry implants have become a great way to replace missing teeth.  In the past if a tooth was missing a bridge was the treatment of choice to replace the missing tooth.  There were several limitations.  First a bridge needs to connect to surrounding teeth.  This means the surrounding teeth need to be drilled on, it also means if there is no tooth behind the missing tooth a bridge is not an option.  The more teeth that were missing the lower the success was of replacing the missing teeth with a bridge.

Implants anchor into the bone so you can avoid drilling on the adjacent teeth in order to anchor to them.  An implant behaves much more like a natural tooth than any other replacement.  In the past dentist's would go to extensive measures with less and less favorable results to avoid loosing teeth because there wasn't a good alternative.  Dental implants now provide a more stable and longer term treatment to options available to Dentists in the past.

Dentures

If your dentures are looking like this we can help.

This patient was afraid a new denture would look nicer

but it might not fit as well. (see photo at end)

Dentures an alternative to no teeth not an alternative to teeth.  What I mean by this is dentures work great and feel great only if you are comparing that to not having teeth.  However with only 5% of the ability to chew as the natural teeth they are a poor replacement for having teeth.  This is a hard reality to process until you make the conversion from teeth to dentures.  Complaints commonly heard are, "The bottom dentures won't stay in.", "I can't chew steak.", "I can't chew salad."  and I have sore spots under the bottom denture."

You will notice I listed the bottom denture twice.  With less bone available to hold onto and a tongue constantly getting in the way, the bottom dentures are what people complain about most. In spite of better materials and a better understanding of how the mouth works there are just some obstacles that continue to cause problems.  An unsupported bottom denture is one of these obstacles.


Implant Denture Combinations

Implants to retain a denture

Denture with connectors

If you were unable to keep your teeth and you still want to eat steak or salad you are in luck.  There is a wide range of treatments involving a combination of implants and dentures.   Two implants placed on the bottom jaw that attach to the denture will make a big difference in the success of dentures.  There are options where even more implants are placed which add even more support to dentures.

Many people still want more even, they want to be able to replace all of their teeth and have them stay fixed in place.  I can understand their desire to have something as close to natural as possible and that would mean not having something that can be removed.  I find it amazing that we have options to anchor replacements for all of the teeth that are fixed in place.  A full functioning, fixed replacement of all the missing teeth can be achieved with 4-6 correctly placed implants on the top and 4-6 correctly placed implants on the bottom.

A Few Final Thoughts

Better that any crown, implant or denture is the natural teeth.  I see patients in my office who are in their 90's and even are over 100 and they have all of their teeth.  Keeping their teeth has greatly improved their quality of life.  If you would like to be one of those people then we can help.  If you fear you have bad teeth, there are simple treatments that can help strengthen teeth and prevent future problems no matter how bad your history has been.

There are many more ways that we can help you to get and keep a stable, healthy mouth.  With today's advances making Dentistry more comfortable, accommodating and predictable there are more reasons for you to come in and see what can be done to give you a better smile.

Final result from the previously shown worn denture.  

The dentures fit so well they are almost hard for the patient 

to take out

#dentures
#tucsondentist