Why It Can Hurt to Open Your Mouth After a Filling

Every now and then, we get a phone call from a patient who we saw a couple of days earlier. It goes something like this:

I had a filling done on my last tooth on the lower left three days ago. The filling and tooth feel fine, but it hurts to open my mouth, especially if I try to open wide.

We then go on to explain to our patient WHY this is the case and how it is normal.

So why is there pain with opening? There are two major factors.

Dental Injections for Lower Molars

In many cases, the pain while opening is from the injection. For lower molars, most dentists will do a nerve block, which involves a very long needle. See the photo below.

Dental shot for a lower tooth can cause pain while opening

A dental injection used to anesthetize a lower right molar. The needle in this photo is 1 and 1/4 inches long.

As can be seen in the above photo, a needle is inserted into the muscle in the back of the mouth. In most cases, for this injection, the needle goes in nearly to the hub, which would mean approximately 1 and 1/4 inches.

Here’s an analogy: feel your biceps and press it hard enough so you can feel the bone underneath. Then, imagine taking a needle, and inserting it through the biceps, approximately 1 inch, until the needle hits bone. Then, imagine doing that a second time. Don’t you think that moving the arm and using that muscle over the next several days would hurt?

The biceps analogy is very effective. Everyone understands that their arm would be sore. So, if you get an injection back there, or in some cases two, using that muscle in opening and closing can frequently elicit pain for several days afterwards.

Your TMJ (Temporomandibular Joint)

The second source of pain while opening after a filling can be from the actual jaw joint, known as the TMJ (temporomandibular joint). This is the area at which your lower jaw bone connects to the base of the skull.

Your jaw joint was made for all of your daily activities – talking, smiling, eating normal foods, etc. The joint was not designed for “abnormal” tasks such as gum chewing, chewing on ice, or holding your mouth open for your dentist or hygienist to work.

photo of TMJ in a skull which can have pain after opening

The temporomandibular (TMJ) joint. Pain in this joint as well as the muscles and ligaments associated with the joint can occur after a dental visit.

Here’s another analogy: imagine standing on the tips of your toes. Now do this for 5 minute intervals several times, with perhaps 30 second breaks in between. Do this for approximately 45 minutes. Don’t you think that the next day, moving that muscle and the joints would be sore? This assumes you are not a ballet dancer.

A cleaning or a filling of moderate duration will be a lot like the above. Lots of straining to keep your mouth open, which can lead to fatigue and soreness in the muscles and joint. This can then result in pain and soreness on opening for several days.

Some Assumptions

We find that one or both of these reasons are responsible for the pain and soreness approximately 99% of the time. There are other circumstances which can include:

  • Infection of either a tooth or an infection at the injection site.
  • Pain after a surgical procedure such as a lower wisdom tooth extraction.
  • Aphthous ulcers (cold sores) in the back of the throat.
  • Upper respiratory infections, etc.
  • And many others.

Of course there can be other explanations. But for the vast majority of the time, the pain is either from the actual injection or in joint after being open for a prolonged period of time.

Dental Galvanism: Galvanic Shock and Your Teeth

This is certainly an “electrifying” topic (pun intended). After all, learning that electric current can run through your own body can be quite a “shock” to almost anyone!

In dental galvinism, a small amount of electricity is generated when two dissimilar metals in dental restorations make contact, most often when teeth with those metals touch. The result is a harmless but very memorable shock!

There’s Gold in Them Thar Hills

Many years ago, dental gold was the most commonly used material in crowns. In fact, a gold crown was considered the “gold standard” in reliability, especially for back teeth.

Gold onlay which can produce galvanic current if it contacts another metal

Gold onlay on a molar tooth. If this contacts an amalgam, be prepared for a small but real shock!

Dental gold is actually an alloy of many metals. But the biggest component is gold. While gold crowns are not used very frequently anymore, there are still hundreds of thousands – if not a couple of million – Americans with gold in their mouths.

An Amalgamation of Metals

Dental amalgam is a filling material that is still used today. True to its name, it is an amalgam or mixture of many metals. Those metals include silver, mercury, tin, copper, and other elements in trace amounts.

dental amalgam filling that can cause galvanism

Mercury/Silver amalgam fillings on two back teeth. If there’s a gold crown on a tooth below these, look out!

Amalgam is mixed and then placed directly into the the tooth where it will then harden up. With time, the surface will tarnish a bit, but the metal is still exposed and can participate in galvanic shock.

“Current” Explanation on Galvanism

We’ve established that in certain people, there can be two different or dissimilar metals in your mouth. Those metals are bathed in saliva with ions which acts as an ideal conductor of electricity. So what causes the shock?

A silver fork can also produce galvanism.

A silver fork can also produce galvanism.

Certain metals can have what are called electrical potentials. This means that there is the possibility for electrical current to flow to or from that metal. Current can flow if that metal is connected to another, different metal if there is a difference in potential. For example, if a gold crown makes contact with an amalgam filling, current can flow between them because there is a difference in electrical potential between the gold in the gold crown and certain metals in the amalgam filling.

Examples where galvanic shock can occur include:

  1. A gold crown contacting an amalgam filling.
  2. The tine of a silver fork or other utensil contacting a gold crown.
  3. A piece of aluminum foil touching a gold crown or amalgam filling.

When this occurs, a noticeable and memorable shock will occur. If you are not expecting it, you will be very surprised!

How to Treat Dental Galvanism

If this does occur to you, there are different ways to approach it. The easiest way is for your dentist to adjust the filling and/or gold crown so that they can’t touch one another when you chew. If one or both metals become tarnished, the galvanic shock will not occur, but there is no good way to produce a tarnish over the restorations. In more extreme cases, the fillings or crowns can be replaced.

Note: there are many websites and even dentists who claim that dental galvanism can lead to many systemic diseases and other conditions. Proceed with caution should you elect to believe these sources.

The Palatal Injection: Dentistry’s Most Painful Shot

Probably the most frequently commented upon topic on this blog involves what the majority of patients dread the most: the shot. As a result, I’ve posted many articles related to dental injections, including articles on novocaine (no, we don’t use it anymore), epinephrine (the racing heart does not mean you are allergic to it), why some people/teeth are hard to get numb (over ten different reasons), etc.

I’ve also done a two part series on what factors cause some dental injections to hurt more than others (located here and here). However, given the number of comments and questions about palatal injections, it was warranted to create an individual post on what can be considered dentistry’s most painful injection.

What is a Palatal Injection?

This may seem somewhat obvious but it is worth explaining. We’ll start with a photo.

palatal injection photo - most painful dental shot

Injection into the palate on the right side. If it looks painful, it’s because it is painful.

In a palatal injection, local anesthetic is injected into the soft tissue covering the hard palate, just adjacent to the tooth/teeth to be worked upon. It is not an injection into the soft palate nor the uvula. And it is only done for top teeth.

These types of injections are performed when you need the gum tissue on the roof of the mouth to be numb and/or when the procedure requires the tooth to be super numb (like an extraction or root canal). In my experience, for most fillings of upper teeth, palatal injections are NOT needed.

Why Palatal Injections Hurt so Darn Much!

There are two major reasons to explain why these hurt so much:

Tightness/Density – the tissue lining the hard palate is very dense and tight. There’s no “give” to it. The needle initially goes in and is accompanied by a pinch. That pinch is actually not the worst part. The worst part is when the local anesthetic fluid is forced in. There’s literally no room for it because the tissue is so dense. That forcible entry of fluid into this tissue is what causes the pain.

Topical anesthetic does not help with palatal injections

Traditional topical anesthetic does little to help with palatal injections.

Want an analogy? Imagine you have a turkey baster injector. Plunge the injector deep into the breast or thigh. Then try to inject. It will take GREAT force to get even a little fluid into this dense muscle. This is like a palatal injection. Next, move the tip of baster until it is just at the border of the thigh and skin. Then try to inject. There is little to no resistance. Fluid goes in with great ease, taking advantage of the looseness at the skin/muscle junction. This is like most other dental injections.

Traditional Topical Anesthetic Doesn’t Work Well – traditional topical anesthetic, a.k.a numbing jelly, doesn’t penetrate the tissue very easily, regardless of how long you wait. As a result, it exerts little to no effect, thus offering little to no pain relief.

How Palatal Injection Pain Can be Reduced

Fortunately, there are ways to reduce the pain associated with palatal injections. Note, however, that these are all done by the dentist himself/herself (except the last one which involves both dentist and patient).

  1. cotton applicator applying pressure can reduce pain of injection on the palate

    Application of pressure can reduce the pain.

    Waiting – in nearly all cases, if you are going to get an injection on the palate, you will also receive an injection on the cheek side. In many cases, if the dentist waits 10 minutes or so after the “cheek side” injection, some of that local anesthetic will work its way over and partially anesthetize the palate. This will make it so that the palatal injection is less painful.

  2. Pressure – placing firm pressure with a cotton applicator for at 30 seconds can slightly numb or obtund the pain sensation. The pressure is applied on the roof of the mouth right where the injection is going to go.
  3. Super Topical Anesthesia – some dentists will use a pharmacy compounded topical anesthetic that is several times more powerful than traditional topical. Using this correctly can also reduced the pain.
  4. Cold – application of a cold cotton applicator with pressure right before the injection can also reduce the sensation.
  5. Sedation – if you are sedated, you are unlikely to even feel the painful injection, let alone remember it. Sedation dentistry is very effective – I do it routinely in my office.

Not all dentists employ the above techniques. But all dentists are aware of the painful nature of this injection and do their best to only do it when necessary.

 

Nail Biting: Why You Do it and How You Can Stop

I am pleased to have Tsgoyna Tanzman contribute this unique and informative article. See the end of this article for more information on Ms. Tanzman.

Why do People Bite Their Nails?

Simple. The same reason people do anything.

To gain pleasure and/or avoid pain. No matter what we do in life, it nearly always boils down to this simplistic behavior. Whether you’re going after a goal such as getting a dream job or finding your soul mate, we believe the pursuit and attainment of that end goal will make us feel good (pleasure) and help us avoid pain (homelessness and loneliness).

Why do YOU Bite Your Nails?

At some point in your early life there was most likely a condition, perhaps a parent or other significant role model, who bit his or her nails and your duckling brain imprinted it as a means of connection and identification. You felt good. You belonged. Then the next layer of feel good happened when you associated the behavior with more pleasure. In other words, the behavior became a self-soothing event. It rewarded you. You felt calmer.

photo of fingernail worn down from nail biting

The evidence! The wear pattern on this fingernail is consistent with chronic nail biting.

Unbeknownst to you, you activated your parasympathetic nervous system, triggering a cascade of hormones that calmed you down and gave you pleasure. Your brain subconsciously made a connection, conditioning you to connect the two events. Since the brain likes efficiency, it got to work and laid down a neural highway. If I do this (bite my nails) then I get this (pleasure and I avoid pain).

Dental Complications from Nail Biting

Nail biting is complicated because it is both pleasure and pain tied up in a one-two punch. It has the immediate short-term effect of soothing, but it is coupled with some pretty nasty long-term side effects.   Here’s the ugly truth:

  1. Despite the fact that enamel is the strongest substance in your body, your teeth are not meant to be chew nails. Excessive and continual pressure from nail biting can cause your enamel to wear down, chip, fracture and/or misalign your teeth, as well as potentially contribute to temporomandibular joint pain. (TMJ). In fact, the Academy of General Dentistry estimates nail biting can result in up to $4000 more in dental bills. So much for the pleasure principle.
  2. Beneath our nails are some of the most gnarly bacteria, viruses, and fungi. In fact, there are as many as 150 different bacteria that can live under our nails including salmonella and E.coli.
  3. As a nail biter you’re a transporter of bacteria and those bacteria can lead to infections that may lead to gingivitis.
  4. Broken and/or jagged nails can tear or cut the gums. The Mayo Clinic warns that viral infections like herpes and the HPV virus can be transmitted from open cuts to the gums.
Nail biting photo showing characteristic groove with front teeth.

Photo showing a pronounced groove on her two lower front teeth from chronic nail biting. She is in her mid 20s. If this continues, what will her teeth look like in her 40s? Photo Dr. Nicholas Calcaterra.

Despite all of this, people will continue. The logical part of your brain tells you to stop biting your nails. If you’re like most nail biters you’ve already tried “everything.” You’ve tried the bitter nail polish and while it initially worked you strangely overrode the aversion, sufficient to keep biting. You’ve tried rubber bands, Band-Aids, gloves, chewing gum, and exhaustive willpower. You can never punish your way into changing a behavior and expect it to last. These “outer game” strategies are like trying to stop a train going 100 mph.

So How Do You Stop Nail Biting?

Before it begins and from the inside out.

If that just caused you to chomp down, on your very last nail, hold on. One of the first questions I ask my nail biting clients is, “How do you know it’s time to bite.” Most often they immediately answer, “I don’t, it’s unconscious.“

As a Master Practitioner of Neurolinguistic Programming, I know that all behavior is encoded in our brains in patterns we repeat efficiently. Bringing that pattern of behavior to a conscious level right down to the nanosecond, just before the fingers are in the mouth, is the most important first step to effectively altering the pattern. The truth is you’re an expert at biting your nails and everyone has a unique repeatable sequence of events. It may begin with a visual or tactile inspection. Your right thumb is the lead inspector, rubbing each finger to find roughness. Or perhaps you rub your fingers against some fabric. Or you visually inspect for evidence of a hangnail. When we are able to identify a pattern and then consciously decide on a desired different behavior we want, it sets the foundation for making this neurological shift.

How Does Neurolinguistic Programming Help?

Besides being a mouthful of syllables, it’s a method of influencing brain behavior (“neuro”) through the use of language (“linguistic”) and other types of communication to enable a person to “recode” the way the brain responds to stimuli (“programming”) and manifest new and better behaviors. This field of science/psychology came on the scene in the 1970’s and if it were renamed today, it might be called Upgrade Your Operating System.  Why NLP works quickly and effectively is because it scrambles the pattern of behavior, much like scratching a record, rendering it unable to play the same way.  It fixes the bugs and re-patterns the brain to new more desirable behaviors. Using our basic modalities Visual, Auditory, Kinesthetic (feeling), Olfactory (smell) and Gustatory (taste) we are able to modify and shift old behaviors.

If you truly want to stop biting your nails, you have to work from the inside out. Align your subconscious and conscious minds. Re-pattern the behavior and re-condition your associations.

What’s the upside? Healthy aligned teeth, beautiful nails, restored confidence and overall improved health, and you might just save thousands of dollars.

Webmaster’s Note: I hope you enjoyed this article from Tsgoyna Tanzman. If you would like to learn more about this unique approach, visit her website at howtostopbitingnails.com. She offers a complementary “Let’s Get Growing” consultation.