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The toothache is so bad I can’t sleep! It’s fine during the day – why does it happen only at night? Why it happens and what we can do about it.

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Are you ever unable to sleep because your tooth hurts so much? Does the pain sometimes hit you as soon as your head hits the pillow? This is a recognized phenomenon and is often caused by periapical periodontitis – inflammation and lesions which appear around the root of the tooth. In severe cases, this pain is sometimes said to be second only to the pain of childbirth.

This kind of nocturnal pain can be really debilitating. Let’s take a look at the causes and possible treatments, as well as ways of hopefully avoiding it in the first place.

1. Nocturnal toothache is caused by a problem around the root of the tooth (periapical periodontitis).

Nocturnal toothache is often caused by periapical periodontitis, which affects the tip of the dental root. If treated effectively, the intense pain and the inability to sleep associated with it can be addressed.
Before we look at the treatment, it’s useful consider what kind of things can actually trigger periapical periodontitis. In this way we can also think about its prevention.

1-1 Tooth decay can spread and infect the roots of the tooth.

As tooth decay progresses, the tooth becomes sensitive to hot and cold things, and can suddenly hurt. As time goes on, these symptoms of sensitivity and pain subside.
Of course, just because the pain has subsided, it doesn’t mean the tooth decay has gotten better. The bacteria which caused the tooth decay is spreading to the bone at the tip of the root, damaging the bone as it goes. This means the pain is not felt – but this is only temporary.

1-2 Symptoms can reappear after treatment

Dental roots are complex structures, so their treatment is not a simple matter. Even after thorough treatment, tiny amounts of pus or grime can build up and cause the problem to worsen again. Generally speaking, root canal treatment is considered to be effective at completely eliminating all infected material and impurities in around 80% of instances.

This means that 1 in 5 of all root canal treatments will leave some traces of this material behind. So even after treatment, these substances can build up and cause inflammation and pain.

1-3 Teeth can break; cracks can appear in dental roots

Grinding or grating your teeth puts pressure on them and can cause them to break or can lead to cracks in the dental roots. Also, other issues can cause your teeth to become fragile or brittle, so that a slight impact can make them break or cause fissures to appear.

When cracks or breaks occur, they provide an opening for the bacteria in the vicinity to enter. The bacteria can then pass through the canal to the root where it can infect it and the surrounding area. When the pus accumulates, the lesions associated with periapical periodontitis are formed, which in turn trigger new bouts of pain.

1-4 Accidents and injuries and their impact on the dental roots can also trigger problems

If something like a ball hits your teeth with significant force, or if you fall down and hit your teeth on the concrete, the nerves can actually be cut off at the root of the tooth, and this can also provide an opportunity for periapical periodontitis to develop. Given the position of our front teeth, they tend to be vulnerable to getting hit or knocked, resulting in significant impact on the dental roots.

When some kind of shock like this is exerted and causes the severing of the nerves, not only is there a risk of periapical periodontitis, discoloration of the tooth itself may also occur, resulting in a blackish tooth.

2. First-aid measures for when night-time pain becomes unbearable

There are various underlying causes for the occurrence of periapical periodontitis. But what can be done should the resulting pain become too intense?

2-1 Taking over-the-counter pain killers

If the pain is intense you should take over-the-counter pain killers. Toothache can be one of the most severe types of pain, so forcing yourself to stoically endure it is just inflicting stress on your body. Over-the-counter medicine can provide a measure of temporary relief.

If you take one of these medications but find the pain isn’t decreasing, or if the pain subsides temporarily but soon comes back, it is important get to a dental clinic as soon as you can. If there is an emergency facility providing night-time or out-of-hours consultations, you should seek treatment. It’s not good to assume that because the medicine isn’t working you can start self-medicating and taking more than the recommended dose or increasing the frequency of the dose.

2-2 Using a cold towel or cold compress to cool the painful tooth

Holding a cold towel or compress (or some kind of medical ice pack) against your cheek around the affected area can be helpful in numbing the pain somewhat. If this is not effective, in some cases putting iced water or ice in your mouth to cool the tooth directly can help dull the pain.

Toothache occurs when the flow of blood inside the tooth increases, placing pressure on the nerves. By cooling the area, the flow of blood can be slowed down, reducing the pressure on the nerves and resulting in an easing of the pain.

2-3 Having root canal treatment at a dental clinic

Sudden pain at night can be tackled by over-the-counter medication and cold towel or compresses. And you may be able to go to emergency clinics if such services are available in your area, but in cases where the pain is bearable, it may make sense to use the first-aid measures mentioned above and wait until regular operating hours to visit a dental clinic for treatment.

Obviously over-the-counter medication and cold compresses only dull the pain. They can help with pain relief, but they don’t actually solve the problem itself, so the pain will keep coming back.

You should by all means use the first-aid measures, but they are just a stop-gap, so you should have root canal treatment done at a dental clinic as soon as possible.

3.Root canal treatment

 How is root canal treatment carried out? And how many times will you have to go to the dentist?

3-1.Extracting the nerve

 The tooth nerve (or the pulp) is removed and the root canal is cleaned and disinfected. As the root of the tooth is a complex structure, great care (and special equipment) is needed to ensure that no pulp is left behind.

3-2.Cleansing the root canal

 A cleansing medication is put into the canal. The canal is sealed and several days are allowed for the cleansing process to take place. If this cleansing process is not fully completed, the periapical periodontitis treatment cannot be carried out, so this process (insertion of medication > sealing up of the canal > leaving it for a few days) is repeated until the cleansing process is complete.

 If one single time turns out to be enough to complete the cleansing process, the root canal treatment can be done in just two sessions. But if the lesions caused by the periapical periodontitis are severe, or if the cleansing process takes time, three or four sessions may be needed, and the total treatment time could take around a month.

3-3.Filling in the canal

 Once the cleaning process is done, the root canal area is sealed up with a special type of rubber. The tooth is then covered with either ceramic or silver and the treatment is complete.

To sum up

 When periapical periodontitis occurs, it can cause very severe pain. In the best case scenario, treatment of issues that lead to the condition should prevent it from occurring, but unfortunately it sometimes isn’t until the intense pain hits that the patient becomes aware of the issue. For this reason, if you have feelings of discomfort or a persistent dull pain which feels like it might be coming from deep inside the tooth, you should go to the dentist.

If you have your teeth cleaned by a dentist to properly remove plaque and tartar, both of which cause gum disease, you can check for gum disease and tooth decay at the same time. In this way any irregularities can be found and treatment can be started earlier rather than later. That’s why it is highly recommended that you make a habit of visiting your dentist regularly.

Key Dental Clinic
2F Yaesu Boueki Building
3-9-1 Akasaka, Minato-ku
Tokyo
Tel: 03 5114 0118
Dr Yasuyuki Kobayashi

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