Narrative Review Medicine ®

How should clinicians assess acute dental pain?

A review
Shinpei Matsuda, DDS, PhDa,* , Hayato Itoi, DDSa, Takashi Ryoke, DDSa, Hitoshi Yoshimura, DDS, PhDa

Abstract
Pain is the most common complaint in the dental field and may have a significant impact on the patients’ quality of life. However,
objective pain assessment is sometimes difficult, and medical and dental clinicians may encounter cases of pain in the head and
neck region, making it difficult to establish differential diagnoses. This study aimed to review acute pain in clinical dentistry at
each phase of dental procedures and discuss the current status and issues in the development of acute dental pain assessment
methods in the future. Acute pain in clinical dentistry may differ in nature and modifying conditions of pain at each stage: before
dental procedures, while visiting dentists, and during and after dental procedures. They are related to actual or potential tissue
damage, and may be modified and aided by personal experiences, including psychological and social factors. With respect to the
aging and multinational population and pandemic of infectious diseases, significant breakthroughs in the development of new pain
scales without verbal descriptions are desirable. Furthermore, it is expected that a new pain scale that can be applied to acute
pain in the head and neck regions, including the oral cavity, will be developed.
Abbreviations: COVID-2019 = coronavirus disease 2019, IASP = international association for the study of pain, VAS = visual
analog scale, WHA = world health assembly, WHO = world health organization.
Keywords: acute pain, dental, head and neck regions, pain assessment

1. Introduction In July 2020, the International Association for the Study

Pain, including acute and chronic, is the most common com-
plaint in the dental field and may have a significant impact on
patients’ quality of life.[1,2] The nature and characteristics of
these pains are useful for clinical diagnosis.[1,2] On the other
hand, objective pain assessment is sometimes difficult, and
medical and dental clinicians may encounter cases with pain
in the head and neck region, making it difficult to make differ-
ential diagnoses, including dental infections and inflammatory
diseases, temporomandibular disorders, headaches, trigeminal
neuropathy associated pain, and idiopathic or centralized pain
conditions.[1,2]
Acute pain can occur in the hard and soft tissues of the mouth
in patients of all ages.[3,4] Patients with pain sometimes need to
visit the emergency department and receive analgesics.[3–5] The
American Dental Association recommended that the selection of
oral analgesics and nonsteroidal anti-inflammatory drugs as the
first-line therapy for acute pain management depends on the degree
of expected pain classified into 4 levels as follows: mild, mild to
moderate, moderate to severe, and severe.[4,6–8] This recommenda-
tion was adopted based on studies conducted on postprocedural
acute pain.[4,6–8] In addition, this recommendation suggests that
the management of acute dental pain should be predicted and
classified according to the type of dental intervention.[4,6–8]
of Pain (IASP) announced a change in the definition of pain
as follows; “An unpleasant sensory and emotional experience
associated with, or resembling that associated with, actual or
potential tissue damage,” from the IASP statement in 1979 as
“An unpleasant sensory and emotional experience associated
with actual or potential tissue damage, or described in terms of
such damage.”[9,10] They then appended the detailed statement
that pain is a personal experience influenced by biological, psy-
chological, and social factors, and verbal description is only
one of several behaviors to express pain.[9,10] This announce-
ment was very important for medical or dental professionals
involved in clinical practice and researchers investigating pain.
In May 2021, the World Health Organization (WHO)
adopted World Health Assembly (WHA)74.5 suggesting
the urgent need for improved oral hygiene worldwide.[11–13]
Based on the 17 Sustainable Development Goals in the 2030
Agenda for Sustainable Development, WHA74.5 recommends
recognizing the importance of Goal 3, and interrelationships
between oral health and other sustainable development goals
as follows: Goal 1, Goal 2, Goal 4, and Goal 12.[11,13,14] Poor
oral health is associated with pain and affects quality of life
and social activities.[11,12] Researchers may need to recon-
sider “pain” in the dental field based on the IASP and WHO
statements.[9–12]

This study was funded by the Life Science Innovation Center of University of Fukui Sciences, University of Fukui, 23-3 Matsuokashimoaizuki, Eiheiji-cho, Yoshida-
(Grant No. LSI 22204). gun, Fukui 910-1193, Japan (e-mail: shinpeim@u-fukui.ac.jp).

The authors have no conflicts of interest to disclose.
All data generated or analyzed during this study are included in this published
article [and its supplementary information files].
a
Department of Dentistry and Oral Surgery, Unit of Sensory and Locomotor
Medicine, Division of Medicine, Faculty of Medical Sciences University of Fukui
Fukui Japan.
* Correspondence: Shinpei Matsuda, Department of Dentistry and Oral Surgery,
Unit of Sensory and Locomotor Medicine, Division of Medicine, Faculty of Medical
Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.
This is an open access article distributed under the Creative Commons
Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
How to cite this article: Matsuda S, Itoi H, Ryoke T, Yoshimura H. How should
clinicians assess acute dental pain? A review. Medicine 2022;101:45(e31727).
Received: 25 July 2022 / Received in final form: 18 October 2022 / Accepted:
19 October 2022
http://dx.doi.org/10.1097/MD.0000000000031727

1
Matsuda et al. • Medicine (2022) 101:45Medicine
In the dental field, the authors were concerned that acute pain
was studied less than chronic pain, including orofacial pain and
temporomandibular disorders. In addition, the authors were
concerned that recent clinical research in the dental field, includ-
ing oral health and pain research, has not progressed in relation
to the coronavirus disease 2019 (COVID-2019) pandemic.[15,16]
This study aimed to review acute pain in clinical dentistry at
each phase of dental procedures and to discuss the current status
and issues in the development of acute dental pain assessment
methods in the future, based on the change in the definition of
pain announced by the IASP in 2020.[9,10]
2. Acute pain in clinical dental practice
2.1. Before dental procedure
Acute hard tissue pain in the dental field can occur due to infec-
tious and inflammatory dental diseases such as dental caries,
pulpitis, gingivitis, periodontitis, jaw inflammation, and odon-
togenic maxillary sinusitis.[17,18] In trauma-related cases, pulpi-
tis, fractured teeth, fractures of the jaw or alveolar bone, and
temporomandibular joint damage-related pain must also be
considered.[2,19–21]
The most common type of acute soft tissue pain in dentistry
is stomatitis.[22] In trauma-related cases, soft tissue damage and
injury should be considered.[21] salivary gland-related disorders,
with or without infection, may also present as acute soft tissue
pain.[23]
Considering the definition of pain announced by the IASP in
2020, acute dental pain, including toothache, may be modified by
personal experiences such as mechanical hypersensitivity.[9,10,24]
2.2. Visiting a dentist and during dental procedure
Dental fear and anxiety are not rare conditions, and patients
visiting a dentist may be nervous based on their personal expe-
rience.[25,26] Previous systematic review reported that the prev-
alence of dental fear and anxiety was approximately 10%.[26]
A close association between them and pain sensitivity has
been suggested.[25–27] In addition, the sound of dental treatment
devices, including dental turbines, engines, and scalers may
affect autonomic responses, such as cerebral blood flow and
metabolism, and may induce pain associated with dental fear
and anxiety.[25–29] Furthermore, dental patients are exposed to
uncertainty and vulnerability regarding their future treatment.[30]
During dental procedures, acute pain related to the injection
of dental local anesthesia with actual tissue damage occurs with
or without dental surface anesthesia.[31,32] In addition, the sound
of instruments and devices, as well as damage and pressure to
hard and soft tissues, cannot be completely eliminated. Thus, it
is difficult for dental procedures to completely eliminate pain
via the trigeminal nervous system and pain associated with the
5 senses and personal experience, including dental fear and
anxiety.[25–29,33–35]
Based on the IASP statement in 2020, such as pain is mediated
by “actual or potential tissue damage” and “a personal experi-
ence influenced by psychological and social factors,” previous
reports seem to support that patients’ subjective acute dental
pain may be modified and triggered while visiting dentists and
during dental procedures.[9,10]
2.3. After dental procedure
Tissue damage associated with surgical and nonsurgical dental
procedures often causes acute pain. Acute dental pain after dental
procedures has been advocated to be managed by pre-procedure
analgesia, cold compression, use of long-acting anesthetics, and
drug therapy.[3–8,36] Drug therapies, including acetaminophen,
nonsteroidal anti-inflammatory drugs, and opioids, for acute
2
dental pain are controversial because of their side effects.[3,4,16,37]
Acute dental pain resolves after healing of the damaged tissue
or after routine dental procedures; however, pain persists and
develops into chronic pain in a few cases.[20]
Based on the IASP statement in 2020, the application of
appropriate postoperative analgesic methods for acute dental
pain caused by “actual or potential tissue damage” is important
to prevent the transition to chronic pain.[9,10]
3. Discussion
This review summarizes acute pain that should be considered
in clinical dental practice, considering the definition of pain
announced by the IASP in 2020 at each phase as follows:
before dental procedures, visiting a dentist and during dental
procedures, and after dental procedures.[9,10] Dentists need to
properly assess acute dental pain by considering sensory, emo-
tional, and personal experiences as well as hard and soft tissue
damage.[9,10]
Acute dental pain is caused by infectious or inflammatory
dental disease and dental intervention. The biological character-
istics of acute pain have been reported to depend upon its stimu-
lation, which can be divided into 2 main mechanisms: peripheral
and central stimulatory responses.[17] In dentistry, appropriate
treatment, including endodontics and surgical intervention, is
the first priority for acute dental pain. For these reasons, the
authors considered the possibility that clinical research on the
assessment of acute dental pain might be inadequate compared
to chronic pain. However, during dental procedures with acute
pain, blood pressure fluctuations and vasovagal reflexes may
occur because of changes in the autonomic nervous system.[38,39]
These conditions should be assessed and managed by dentists
before, during, and after dental treatment. However, these are
still important dental clinical problems because they are com-
plex situations related to the subjective psychological state of the
patient and acute dental pain.[38,39] In light of this point of view,
the authors listed and discussed the current status and issues in
the development of acute dental pain assessment methods.
3.1. Development of objective acute dental pain
assessment methods
Objective pain assessment is challenging in clinical dentistry.
Although many studies have been conducted, most have focused
on chronic pain, and there have been few studies on the head
and neck region.[40] Visual analog scale (VAS) has often been
used to assess pain related to dental procedure.[32,41] VAS was
first published in its original form about 100 years ago in the
psychological field and has been used as the “gold standard”
method of objective assessment in various fields.[41,42] VAS is also
important in recent studies on objective methods for assessing
pain in the head and neck region, and no significant break-
throughs have been found in this area.[43,44] There are significant
individual differences in the expression of pain-related images.[45]
Therefore, it is necessary to present the participants with a pic-
ture, diagram, or graphic of the pain in advance to objectively
and quantitatively assess subjective pain.[46] The authors hope
that breakthroughs will be made in the research area of acute
pain assessment methods to replace the VAS, which has been in
use for nearly 100 years.
3.2. Development of acute dental pain assessment
methods without verbal description
Many verbal expressions and multiple questionnaires may be
added to the pain assessment methodology to account for the
subject’s personal experience, which is influenced by biological,
psychological, and social factors.[44,47,48] In this aspect, many pain
Matsuda et al. • Medicine (2022) 101:45www.md-journal.com
studies may run counter the 2020 IASP statement that “verbal
description is only one of several behaviors to express pain.”[9,10]
Furthermore, as exemplified by the Bouba/kiki effect, the image
evoked by the word “Pain” may be affected by the native and
non-native English speakers.[49] Based on the statement of a
change in the definition of pain by IASP in 2020, WHO state-
ment, and experience with the COVID-19 pandemic, it is hoped
that universal and nonverbal pain assessment methods will be
proposed.[9–13,15,16,48] In the future, it is hoped that new acute den-
tal pain assessment methods without verbal descriptions will be
researched and developed.
3.3. Development of acute dental pain assessment
methods using medical and scientific technology
Recently, artificial intelligence has been applied to facial iden-
tification and has been considered to ensure objectivity in the
assessment of pain.[50–52] On the other hand, they may require
a large amount of appropriate training materials, and ethical
issues of data collection and bias in data selection may inter-
vene.[50–52] In addition, studies of acute pain assessment using
functional magnetic resonance imaging have been reported in
recent years.[53,54] Currently, these scientific and medical technol-
ogies are still in the research phase and their application in clin-
ical dentistry may not be realistic. The authors believe that these
methods are at a stage where ethical issues need to be resolved
and evidence collected.
Considering the change in the definition of pain announced
by the IASP in 2020, this narrative review provided detailed
conditions and circumstances of acute pain in each phase
of clinical dental practice.[9,10,55,56] Furthermore, this study
revealed that many issues must be resolved in the develop-
ment of new assessment methods for acute dental pain. With
respect to the global aging and multinational population and
infectious diseases affecting the respiratory system, such as
the COVID-2019 pandemic, significant breakthroughs in
the development of new pain scales without verbal descrip-
tions are desirable for achieving WHA74.5, published by the
WHO.[11]
4. Conclusion
In this review, the authors considered the urgent need for the
development and clinical application of a new objective and uni-
versal pain scale without verbal descriptions, considering global
problems such as the aging of the population, multinationaliza-
tion, and the pandemic of infectious diseases. The authors hope
that significant breakthroughs will be made in the development
of a new pain scale that can be applied to acute pain in clinical
dentistry.
Author contributions
Conceptualization: Shinpei Matsuda.
Writing – original draft: Shinpei Matsuda.
Writing – review & editing: Shinpei Matsuda, Hayato Itoi,
Takashi Ryoke, Hitoshi Yoshimura.
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