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Toothache ˈtüth-ˌāk

by David F. Murchison, DDS, MMS

Pain in and around the teeth is a common problem, particularly among people with poor oral hygiene. Pain may be constant, felt after stimulation (from heat, cold, sweet food or drink, chewing, or brushing), or both.

Causes

The most common causes of toothache are

  • Cavities

  • Pulpitis

  • Periapical abscess

  • Trauma

  • Wisdom tooth pushing through the gum tissue (causing pericoronitis)

Toothaches are usually caused by tooth decay and its resulting consequences, such as pulpitis and abscess. Tooth decay can be largely prevented by good oral hygiene, which helps remove plaque. Removing plaque helps because the bacteria in plaque produce acid which can damage tooth enamel and dentin.

Cavities (tooth decay) cause pain when they extend through the outer surface of the tooth (enamel) into the hard tissue beneath the enamel (dentin). Pain usually occurs only after stimulation from cold, heat, sweet food or drink, or brushing. The pulp, the living center of a tooth, is likely not irreversibly affected if the pain stops immediately after the stimulus is removed.

Pulpitis (inflammation of the tooth pulp) is typically caused by advanced cavities but also may be due to pulp damage from extensive or defective previous dental work or trauma. Pulpitis may be reversible or irreversible. If heat or cold is applied, the pain may linger for a minute or longer. Pain also may be present without stimulation. Pulp inflammation frequently causes the pulp to die. Once the pulp dies, pain ends briefly (for hours to weeks). Then, pain may come back as the tissue surrounding the root of the tooth becomes inflamed (apical periodontitis) or if a collection of pus (abscess) develops.

A periapical abscess (a collection of pus around the root of the tooth) may occur when infection develops around the root of the tooth after untreated cavities or pulpitis. The tooth is extremely sensitive to tapping with a metal dental probe or tongue blade (percussion) and to chewing. The periapical abscess may come to a head and drain on its own or spread into nearby tissues (cellulitis).

Trauma includes broken or loosened teeth. Tooth trauma can damage the pulp and cause pulpitis, an apical abscess, and sometimes discoloration of the tooth, which may begin soon after the injury or up to decades later.

Pericoronitis is inflammation and infection of the gum around the crown of a tooth, usually a tooth that is just breaking through the gum (erupting) or cannot break through (impacted). It usually occurs around an erupting wisdom tooth (almost always a lower one) but can involve any tooth.

In young children, teething is often a cause of discomfort as the tooth erupts through the gum.

Complications

The main serious complications of disorders that cause toothache involve spread of infection from the area next to the tooth to nearby tissues. Infection can spread to the nasal sinuses (from an upper tooth), to a large vein at the base of the brain, to the cavernous sinus (see Cavernous Sinus Thrombosis), or under the tongue. Infection of the floor of the mouth under the tongue is called Ludwig angina and can cause enough swelling to close off the person's airway. Cavernous sinus thrombosis and Ludwig angina are life threatening and require immediate treatment.

More commonly, pain resulting from a sinus infection is mistakenly perceived as originating in the teeth that are near the sinus—especially if the toothache develops while the person has or recently has had a cold. Additional symptoms suggesting sinusitis are headache and tenderness and swelling of the skin above the affected sinus.

Evaluation

People with tooth pain should see a dentist. The following information can help people decide when a dentist’s examination is needed and help them know what to expect during the evaluation.

Warning signs

In people with a toothache, certain symptoms and characteristics are cause for concern. These signs are warnings that a dental infection may have spread and include

  • Headache and/or confusion

  • Fever

  • Swelling or tenderness of the floor of the mouth

  • Difficulty seeing or double vision


When to see a doctor or a dentist

People who have warning signs and those with swelling around an eye should go to the hospital right away. People who do not have warning signs but who have swelling over the jaw, very severe pain, or drainage of pus from the base of a tooth should see a dentist as soon as possible. Other people who have a toothache should see a dentist at some point, but a delay of several days is not harmful.


What the dentist does

Dentists first ask questions about the person's symptoms and medical history. Dentists then examine the face, mouth, and teeth. What they find during the history and physical examination often suggests a cause of the toothache and the tests that may need to be done (see Table: Some Causes and Features of Toothache).

Some Causes and Features of Toothache

Cause

Common Features*

Tests

Apical abscess (a collection of pus around the tooth's root)

Constant pain that worsens when chewing or biting

Normally, the person can precisely identify the involved tooth

Tooth tender when tapped with a metal probe or tongue depressor (percussed)

Sometimes visible swelling of the gum over the affected root and painful swelling of the adjacent cheek and/or lip

A dentist's examination

Apical periodontitis (inflammation of tissues around the tooth's root)

Features similar to those of apical abscess but less severe and without swelling over the affected root

A dentist's examination

Cavities

Pain that

  • Occurs mainly after brushing or after chewing or swallowing hot, cold, or sweet food or drink

  • Is isolated to a single tooth

  • Usually stops when the stimulus is removed

Usually a visible cavity or a root surface exposed by gum recession or an abrasion

A dentist's examination

Fracture of a tooth

Sharp pain when chewing

Marked sensitivity to cold

A dentist's examination

Pericoronitis (usually involving an erupting or partially impacted wisdom tooth)

Constant dull pain, especially when chewing

Visible swelling, redness, and sometimes pus around the affected tooth

Commonly spasms of the chewing muscles (trismus) may occur and limit opening

A dentist's examination

Pulpitis (inflammation of the tooth pulp)

Pain that occurs without stimulation and/or that lingers for more than a few seconds after stimulation

May have difficulty identifying the affected tooth

A dentist's examination

Sinusitis

Pain in several upper teeth on one side, especially molars and premolars

Sensitivity when chewing and when teeth are tapped (percussed)

Often a nasal discharge and tenderness when the sinus is tapped

Pain when changing positions, especially lowering the head (as when bending down to tie shoe laces)

A doctor's examination, sometimes with CT of the sinuses

A dentist’s examination if no sinusitis is detected

Teething

Discomfort and fussiness during tooth eruption in young children

Commonly drooling and chewing on things (such as the crib rail)

A doctor's examination

*Features include symptoms and the results of the doctor’s examination. Features mentioned are typical but not always present.

Dental x-rays are usually taken.

CT = computed tomography.


Testing

The need for tests depends on what dentists or doctors find during the history and physical examination, particularly whether warning signs are present. However, dental x-rays are usually done. If cavernous sinus thrombosis or Ludwig angina is suspected, an imaging study—typically computed tomography (CT) or magnetic resonance imaging (MRI)—is done.


Treatment

  • Pain relievers

  • Antibiotics

  • Treatment of specific causes

Nonprescription pain relievers (analgesics) such as acetaminophen or ibuprofen can be taken while people await dental evaluation.

Antibiotics such as penicillin or clindamycin are given for disorders such as abscesses, pericoronitis, or cellulitis.

Specific disorders are treated. An abscess is typically drained through an incision with a scalpel blade. A rubber drain, held in place by a stitch, may be placed.

Pericoronitis is treated by rinsing the mouth 3 or 4 times a day with the antiseptic chlorhexidine or salt water (1 tablespoon of salt mixed in a glass of hot water—no hotter than the coffee or tea a person normally drinks). The salt water is held in the mouth on the affected side until it cools and then is spit out and immediately replaced with another mouthful.

Teething pain in young children may be treated with acetaminophen or ibuprofen (dosed by the child's weight). Other options include chewing hard crackers (such as biscotti), applying a benzocaine gel 4 times a day (provided there is no family history of methemoglobinemia, which can make use of benzocaine dangerous), and chewing on anything cold (such as gel-containing teething rings).

The rare person with cavernous sinus thrombosis or Ludwig angina requires immediate hospitalization, removal of the infected tooth, and antibiotics given by vein (intravenously).

Essentials for Older People

Older people are more prone to cavities of the root surfaces, usually because of receding gums. Periodontitis often begins in young adulthood. If untreated, tooth pain and loss are common in old age.

Key Points

  • Most toothaches involve cavities or the resulting complications (such as pulpitis or an abscess).

  • Treatment of symptoms and referral to a dentist are usually adequate.

  • Antibiotics are given if people have an abscess, a tooth with pulp that has died, or more severe conditions.

  • A dental infection that has spread to the floor of the mouth or to the cavernous sinus is a very rare but serious complication.

  • Dental infections rarely cause sinusitis, but a sinus infection may cause pain that feels as though it originates in the teeth.

Resources In This Article

Drugs Mentioned In This Article

  • Generic Name
    Select Brand Names
  • CLEOCIN
  • ADVIL, MOTRIN IB
  • ANBESOL
  • TYLENOL