Toothache when your dentist can’t find a dental cause

You can point to the teeth that hurt. It aches when you chew or bothers you through the day. Yet your dentist’s assessment hasn’t found a dental problem that explains it.

That can be confusing and frustrating. The pain is real. Sometimes its source lies in the muscles used for chewing.

This is called referred pain. For some people with temporomandibular disorders (TMD), it explains why a healthy tooth can feel painful, like toothache.

Image courtesy of the BMAS

How jaw muscles can cause tooth pain

Referred pain is felt somewhere other than the tissue producing it. Pain signals from the jaw muscles and teeth share processing pathways within the nervous system. This can sometimes make the source difficult to work out.

Two muscles deserve particular attention. The masseter sits along the cheek and jaw angle. The temporalis covers the temple and helps close the jaw.

Experimental research has shown that stimulating jaw muscles can produce pain felt inside the mouth. This includes the tooth and gum regions (Svensson et al., 2003). These studies support muscular referral as a possible explanation. But they don’t tell us how frequently it causes toothache in everyday practice.

Tender areas within these muscles are sometimes called myofascial trigger points. During assessment, pressure over a sensitive trigger point can reproduce pain elsewhere.

The useful finding is whether this brings on your familiar toothache. A sore muscle alone doesn’t establish the cause.

What makes a muscular contribution more likely?

Tooth pain that changes alongside jaw tension gives us a reason to examine the chewing muscles. The same applies when symptoms increase with clenching or prolonged chewing.

Morning jaw soreness can also be relevant. So can a pattern of holding your teeth together while concentrating.

Dental pain can also worsen with chewing, so we need to consider the whole presentation.

We assess jaw movement and examine the muscles around the cheek and temple. We ask where you feel the pressure and whether it resembles your usual pain. Neck assessment is included when your symptoms suggest a relevant contribution.

Research has also identified referred TMD pain in patients with persistent pain after root canal treatment. In one small study, it was the most frequent non-dental diagnosis among those assessed (Nixdorf et al., 2015). This doesn’t mean the original dental treatment was unnecessary. Dental and non-dental pain can coexist.

Start with your dentist

A dental assessment comes first. A normal X-ray alone doesn’t exclude every dental problem. Cracks and problems within the tooth can require further investigation.

If the dental findings don’t adequately explain your symptoms, assessment for a muscular contribution is a reasonable next step. Your dentist and physiotherapist can then work together.

Other conditions can also produce tooth-like pain. These include nerve pain and some headache disorders. Brief electric-shock pain or altered facial sensation needs further assessment. Persistent unexplained pain should prompt a review of the diagnosis.

Where physiotherapy can help

When assessment supports a muscular source, treatment focuses on reducing painful jaw movement and restoring comfortable jaw function.

This can involve hands-on treatment and tailored jaw exercises. We also look at habits such as sustained tooth contact. Learning to notice and release daytime clenching can be a useful part of care.

The 2023 BMJ guideline supports education and exercise for chronic painful TMD. It also supports selected manual treatments (Busse et al., 2023).

That distinction guides how we review progress. We track the tooth pain as well as jaw tenderness and movement. If the muscles feel better but the toothache hasn’t changed, we reconsider the explanation.

At DentalPhysio, we bring more than 25 years of physiotherapy experience to assessing jaw and facial pain. Our approach combines hands-on care with practical strategies you can use between appointments.

If your dentist hasn’t found a sufficient explanation for your tooth pain, contact our Buderim clinic to discuss an assessment. Call 07 3532 8605.

By Lorraine Carroll

References

Busse, J. W., Casassus, R., Carrasco-Labra, A., Durham, J., Mock, D., Zakrzewska, J. M., Palmer, C., Samer, C. F., Coen, M., Guevremont, B., Hoppe, T., Guyatt, G. H., Crandon, H. N., Yao, L., Sadeghirad, B., Vandvik, P. O., Siemieniuk, R. A. C., Lytvyn, L., Hunskaar, B. S., & Agoritsas, T. (2023). Management of chronic pain associated with temporomandibular disorders: A clinical practice guideline. BMJ, 383, e076227. https://doi.org/10.1136/bmj-2023-076227

Nixdorf, D. R., Law, A. S., John, M. T., Sobieh, R. M., Kohli, R., Nguyen, R. H. N., & National Dental PBRN Collaborative Group. (2015). Differential diagnoses for persistent pain after root canal treatment: A study in the National Dental Practice-based Research Network. Journal of Endodontics, 41(4), 457–463. https://doi.org/10.1016/j.joen.2014.12.012

Svensson, P., Bak, J., & Troest, T. (2003). Spread and referral of experimental pain in different jaw muscles. Journal of Orofacial Pain, 17 (3), 214–223. https://doi.org/10.11607/jofph.17214