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 result in 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.

Long Term Opioid Use and Dental Local Anesthesia

Norco opioid pain medication used by dentists

Norco – a common opioid pain medication

As a busy private practice dental office, we are constantly doing dentistry, which involves injections of local anesthesia. Like all dentists, we occasionally encounter a patient and/or tooth that is difficult to get numb. Along this theme, an increasingly common phenomenon we are observing involves difficulty in getting patients numb who are long time users of opioids (often called narcotics).

A common situation is a patient with chronic pain who has been taking an opioid type painkiller long term (such as Percocet, Oxycodone, Oxycontin, etc.). A dental procedure that requires effective local anesthesia is attempted on that patient. During the procedure, it is learned rather quickly that the patient is having difficulty either getting completely numb and/or staying numb. Why is that?

Opioids, Narcotics, Pain Pills, Etc.

The term opioid is derived from the word opium, which is a component of the opium poppy. The raw opium can be processed to produce morphine or heroin – both of which are powerful pain relievers. The term opioid simply means a medication that acts on the opioid receptor.

Opium poppy, the basis for narcotics

The opium poppy – the flower from which morphine and heroin are derived. Image courtesy wikipedia.

Millions of Americans take opioids for both acute and/or chronic pain. For those individuals who take them long term for chronic pain, a tolerance will develop, requiring larger doses. Large doses of opioids taken over time can lead to many long term effects. Many of those effects – constipation, dry mouth, etc. – are well documented. What is not well documented nor well researched is how long term use of these painkillers impacts the effectiveness of local anesthesia.

Long Term Opioid Use and Dental Local Anesthesia

Unfortunately, there is very little “official” information available for practicing dentists and dental students on which to rely. The most widely read and cited textbook on local anesthesia for dentists – A Handbook of Local Anesthesia – by Dr. Stanley Malamed – makes no mention of this phenomenon.

Lidocaine is less effective in opioid users.

Multiple studies have shown lidocaine is less effective in opioid users.

However, a survey of recent research has shown multiple articles which directly and/or indirectly give support to this phenomenon:

  • In this article, opium abusers were compared to non-abusers in their response to lidocaine (lidocaine has replaced novocaine as the local anesthetic of choice in dentistry). The abusers were found to require a longer amount of time for the lidocaine to work. And in addition, a greater amount of lidocaine was required.
  • In this study involving rats, the administration of morphine (an opioid) resulted in a decrease in the potency of lidocaine.
  • In another study involving opium vs. non opium users, chronic users experienced a shorter duration of local anesthesia than non users.

In fact, there is a specific term for a related phenomenon, which is Opioid Induced Hyperalgesia. Basically, those individuals who are chronic users can become MORE sensitive to painful stimuli.

However, despite all of these studies, there remains to be seen a widely accepted theory for a mechanism behind the local anesthesia resistance seen in these individuals.

What This Means for Dental Patients

Unfortunately, because this phenomenon is somewhat new and not well documented, not all dentists are aware of these issues. Some tips:

  • Make sure your dentist is aware of your history. This includes patient with a past history of abuse who are on maintenance doses of naloxone or methadone.
  • Don’t be afraid to say “I’m not numb” or “I can feel this.”
  • If you are still uncomfortable, consider switching offices.

As a modern dental office, we’ve had success treating patients on chronic opioids with either buffered local anesthesia and/or IV sedation. So there are solutions out there – you just have to go out and find them.

I Passed Out at the Dentist. Why?

As a very busy dental office, we’ve seen patients faint more than once. And on the internet, there are tons of comments about patients passing out. In fact, most people mistakenly assume that when something like this happens, it is because they are allergic to something that the dentist used. In nearly all cases, that is an incorrect conclusion.

So, why is it that some people faint and/or pass out at the dentist? And what causes it?

Common Medical Emergencies in Dental Offices

In a widely cited survey, the number one emergency seen in a dental office is fainting – or more appropriately called syncope (sources: here and here). In fact, in one study, syncope accounted for 53% of all emergencies in a dental office (source: here). The second most common emergency is hyperventilation.

fainting at the dentist is not treated as an allergic reaction

Many mistakenly assume that fainting at the dentist is due to an allergic reaction.

To many individuals who’ve had adverse reactions at the dentist, this fact can come as quite a surprise. The scenarios that most patients believe are occurring – usually acute allergic reactions as well as cardiac events – very rarely occur.

Fainting vs. Passing Out vs. Vasovagal Syncope

Generally speaking, the above three terms are all roughly the same, with the term vasovagal syncope being the medically appropriate one. It can be defined as a temporary loss of consciousness due to a decrease in blood flow to the brain.

needle is trigger for syncope at dental office

This is the most common trigger for an episode in a dental office.

Your brain is in constant need of oxygen. If blood flow to the brain is temporarily diminished, you are no longer able to function, and you lose consciousness. In vasovagal syncope, a trigger (such as the sight of a needle) will cause a susceptible individual’s nervous system to over-react and cause certain physiologic changes which can lead to the decrease in blood flow to the brain.

If this happens, it most often results in you falling to the floor, which then puts your head at the same level as your heart. This change in position, along with the removal of the stimulus which caused the episode (more on this later), then allows for adequate blood to flow to your brain, and you very quickly regain consciousness.

Common Triggers of Vasovagal Syncope in a Dental Office

dental drill can cause you to pass out or faint

The dental handpiece or “drill” can cause some to pass out.

A dental office is a unique setting in that the patients walking through the door typically don’t want to be in the office, but they know they have to. This is why passing out episodes occur quite frequently. The most common triggers seen in a dental office include:

  • The sight of the needle (this is the number 1 trigger).
  • The slight sting of the dental injection.
  • The sight of blood.
  • The smell of an office.
  • The high pitched squeal of the dental handpiece.
  • And others.

So, if a trigger is experienced by a susceptible individual, the syncope episode can commence.

A Typical Fainting Episode at the Dentist

Each and every episode of passing out is unique, as is every patient. The following is a classic example of what someone might experience in a vasovagal syncopal episode at the dentist:

  • You don’t like coming to the dentist but you know you have to get a filling. You have been dreading it for over a week.
  • You are called in from the reception area. While walking in, you see a needle that looks large and intimidating.
  • The dentist comes in and says hello. At this point, you’re still thinking about the needle, and you begin to feel somewhat lightheaded.
  • You hear the dentist talking to the assistant but their voices seem muffled. You notice that you are breaking out into a sweat, even though the temperature was perfect just a couple of minutes earlier.
  • You begin to have a feeling of nausea and your thoughts appear fuzzy. Your muscles suddenly feel incredibly weak and you don’t even think you could lift your hand. You attempt to say something but you can’t muster the strength or thoughts to put words together.
  • Your vision appears compromised, first by seeing bright lights, and then with black or cloudy vision. You are sitting upright but all you want to do is lie down…

Next thing you know, the chair is completely reclined and you are lying horizontally in it. The dentist and the assistant are sitting next to you. The dentist is looking at you intently and is feeling your pulse on your wrist. He/she notices you waking up and says:

“Well, it looks like you fainted for a bit. Don’t worry. It happens more often than you think. We’ll keep you reclined for a couple of more minutes and then we’ll slowly bring the chair up.”

Final Thoughts

For the vast majority of patients, passing out will simply never occur. But a small subset are susceptible. We can help by providing:

  • A relaxed and non-judgmental atmosphere.
  • Nearly pain-free injections.
  • IV sedation (but don’t worry – we have ways to get the IV in without you passing out).
  • And more.

Call us at (203) 799 – 2929 or visit this page to request an appointment.

What Kind of Dentist Can Put You to Sleep?

What kind of dentist can put you to sleep? As one of Connecticut’s busiest Sedation Dentistry offices, we get this question a lot. So, we’ll address it first with a quick answer:

Any dentist holding a valid sedation and/or anesthesia license can provide sedation or sleep dentistry.

You may roll your eyes as you read this. But the statement is factually correct – and very relevant. A dentist cannot do twilight sedation or general anesthesia without a special license. And this is an answer we give out when we get phone calls regarding IV sedation and “being put to sleep” in our office.

Sleep dentistry and IV sedation in Orange, CT

Very few dentists in Connecticut can provide sedation to make you to feel like this at your next dental visit. Learn which types of dentists can.

Types of Dentists Who Can Provide Sedation Dentistry

In Connecticut, there are three types of dentists who can “put you to sleep” or do “twilight sedation.”

  1. Dental Anesthesiologists – these are specialized dentists who completed a residency in anesthesia. They are highly qualified to put kids and adults to sleep. They provide the anesthesia only – they do NOT do the dentistry. As a result, they always have to work with another dentist who renders the treatment.
  2. Oral Surgeons – these are dentists who completed a 4 to 6 year surgery residency that includes training in anesthesia. They are highly qualified to provide anesthesia to adults and some kids. However, they only provide sedation for surgical procedures such as dental implants or teeth extractions – so if you want to be sedated for a crown or root canal – an oral surgeon cannot do it.
  3. General Dentists or Periodontists with a Sedation License – these are dentists who completed extra training in anesthesia and then pass an exam to provide sedation. In the cases of general dentists, they are able to do most dental procedures with a patient under sedation. Dr. Nick Calcaterra falls into this category.
IV Sedation dentistry by Dr. Nicholas Calcaterra in Orange, CT

Dr. Nick Calcaterra is a general dentist with the training and license to sedate teenagers and adults.

The common element among the practitioners above is that they all have licenses granted through the state of Connecticut allowing them to provide sedation or put patients to sleep.

So Not All Dentists Can Put You to Sleep?

Correct! In fact, very few dentists in Connecticut have the training and license to sedate you.

If you are going to be sedated by an oral surgeon or dental anesthesiologist – then you can relax – you’ll be in good hands.

If another type of dentist offers or advertises sedation, you should make sure he/she has the proper training and license.

IV Sedation License is required to do sedation dentistry

Interested in being sedated? Make sure your dentist has this license!

 

 

 

 

 

Unfortunately, there are some dentists within the state of Connecticut who offer “sedation” or “sleep dentistry” but who do not possess the license to do so. We strongly suggest you avoid going to those offices. We only recommend you be sedated by an oral surgeon, an anesthesiologist, or other dental provider with a license to do so. Dr. Nick Calcaterra is fully licensed in the State of Connecticut and is a Master in the College of Sedation – the highest level that can be achieved for a general dentist.

To learn more about what it takes to earn a sedation or anesthesia license, you can go to our page here.

Request a sleep dentistry appointment

Want to learn more about IV sedation with one of Connecticut’s premier sedation dentistry offices? An office that routinely completes over 100 cases per year? If yes, call us at (203) 799 – 2929 or visit this page to request an appointment with Dr. Nick Calcaterra.