Common causes

Toothache is almost always the result of ‘bacterial invasion’  into either the hard or soft tissue of the mouth. It is almost always caused by bacterial invasion of the teeth or gums.

The problem is that by the time a patient perceives or becomes aware of having a problem,  it has already progressed relatively innocuously, unnoticed for quite a while. So by the time the patient is sufficiently aware of the pain, discomfort or other symptoms (e.g. bleeding),  that drive them to the dentist, the disease progress has advanced quote significantly;  the implications of this are explained below.

Because dental disease starts small and unnoticed or is  chosen to be ignored by the patient, it becomes neglected, spread, deepens and results in far more complex, extensive and expensive treatment. At its extreme, unfortunately, this can result in the total loss of one or more teeth.  So that is the obvious reason for taking a preventative approach to dental care, maintenance and so, dental longevity!

Tooth Decay diargam


Common causes and treatment approaches

Tooth disease
  • Increased sensitivity to temperature changes. At that point, this may simply signify a decaying (carious) cavity getting close to the pulp of the tooth (the ‘nerve),  and would require an (often deep) filling.
  • Left untreated, this will progress to more intense and longer-lasting periods of the dental hypersensitivity and the tooth may start to spontaneously ache and even be a little tender to ‘bite on’. By this stage, it is almost certain that the nerve has already been affected and a root canal treatment is quite likely to be advocated.
  • Again, when ignored the condition progresses too far more temperature hypersensitivity, often more to hot than cold. There may be throbbing and the pain will start to either keep the patient awake and/ or wake them up in the night. By now the tooth nerve has ‘died’ and pus has probably started to form in the canal system, possibly already starting already to penetrate past the root ends into the supporting bone.  The tooth itself by now has lost far more of its original crown structure and the ‘hole’ in the crown will be far deeper and larger. Walls of the tooth may also start to crack. Root canal treatment, in this case, will almost certainly save the tooth,  although some ‘lazy’,  inexperienced,  or ‘time-pressed’ ( e.g. NHS) dentists may be a bit ‘keen’ on recommending extraction.
  • A further ‘neglected’ consequence would be the classic ‘fat face’ and increase in malaise and temperature. By this stage, the patient is in a  lot of pain and anxiety. Antibiotics will almost certainly be prescribed,  possibly ‘intramuscularly’.  The infection has gone through the bone into the soft tissues (under the gum, into the cheek and worse still, ‘down the neck’ and is termed an ‘acute abscess’. Even at this stage, the tooth can still often be saved with root canal treatment; although many dentists do advocate extraction …often the ‘easier’’ and certainly ‘less expensive ‘ although more brutal,  aggressive; but certainly less costly treatment.
 Gum disease
  • As so often emphasised in toothpaste advertisements,  the first signs of gum disease (gingivitis) are bleeding gums. This is usually noticed after brushing the teeth and ‘spitting blood’ into the sink or bath. Signs of soft tissue (such as gums) inflammation are redness, tenderness, and some swelling of the gums as well as a tendency to bleed easily; because of the increased blood supply initiated by the inflammatory response . What is this inflammation a response to ?… Infections. The infection is the bacteria in the plaque that accumulates on those tooth surfaces adjacent to the gums…the tooth plaque this is not adequately removed with home care hygiene techniques!  The obvious treatment here is regular professional scaling and possibly even of more importance  – appropriate and adequate home hygiene techniques.
  • Again , left untreated , this relatively superficial gum disease (gingivitis) progresses down the side of the tooth root, destroying more and more of the gum and, more importantly, the supporting bone structure .  Once this happens, it is called periodontitis.  This will require deeper scaling and cleaning sometimes necessitating the use of local anaesthesia.  The treatment may become one of ‘crisis management’ really as it is difficult , if not impossible to make supporting bone ‘grow back’ to any significance… one needs to focus on making sure it never gets worse.
  • Finally, periodontitis left ‘unchecked’ simply progresses , destroying more and more bone support to teeth until there is insufficient support for them to be retained, they ‘wobble’ and then ‘fall out’ Gum disease is the commonest cause of tooth loss. When this happens, more and more people chose (quite appropriately) to go down the route of wanting, accepting and , of course , paying for titanium ‘bionic’ tooth roots that carry dental crowns.
Soft tissue disease
  • This relates to other pathological conditions in the soft tissues: the cheeks, tongue, palate, gums ( other than those due to ‘plaque’);  obviously really serious ( as in ‘life-threatening’ ) conditions such as different forms of mouth cancer .
  • I won’t discuss these here as they are relatively rare. Suffice to say that they need to be ‘looked for, recognised and referred’ by the dentists  to appropriate specialists  (e.g. oral pathologists).


Just remember that almost all dental disease is due to caries;  infection penetrating the crevices of the natural tooth crowns and tracking inwards to the dental nerve(s)  or gum disease,  caused by the accumulation of plaque at the tooth/gum interface. Both conditions are almost entirely preventable/ avoidable just with education and excellent regular professional and home care hygiene techniques!

See Missed Toothache | A London Patient’s Perspective.

clear aligners photo