Toothache, 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 of Toothache
The most common causes of toothache are
Wisdom tooth pushing through the gum tissue (causing pericoronitis)
Toothaches are usually caused by tooth decay (cavities) 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 Cavities Cavities are decayed areas in the teeth, the result of a process that gradually dissolves a tooth’s hard outer surface (enamel) and progresses toward the interior. (See also Overview of Tooth... read more (tooth decay) cause pain when they extend through the outer surface of the tooth (enamel) into the hard tissue beneath the enamel (dentin). (See figure A Look Inside the Tooth A Look Inside the Tooth .) 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.
A Look Inside the Tooth
Pulpitis Pulpitis Pulpitis is painful inflammation of the tooth pulp, the innermost part of the tooth that contains the nerves and blood supply. (See also Overview of Tooth Disorders.) The most common cause of... read more (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 Periapical Abscess A periapical abscess is a collection of pus at the root of a tooth, usually caused by an infection that has spread from a tooth to the surrounding tissues. (See also Overview of Tooth Disorders... read more (a collection of pus around the root of the tooth) may occur when infection leads to death of the pulp and inflammation develops around the root of the tooth. 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 Fractured, Loosened, or Knocked-Out Teeth Fractured, loosened, or knocked-out teeth are some of the urgent dental problems that require prompt attention. Teeth are commonly cracked (fractured), loosened, or knocked out (avulsed) when... read more 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 Gingivitis due to an impacted tooth (pericoronitis) Gingivitis is a mild form of periodontal disease characterized by inflammation of the gums (gingivae). Gingivitis results most often from inadequate brushing and flossing but may result from... read more 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.
Pain from a sinus infection Sinusitis Sinusitis is inflammation of the sinuses, most commonly caused by a viral or bacterial infection or by an allergy. Some of the most common symptoms of sinusitis are pain, tenderness, nasal congestion... read more is commonly misperceived as originating in the upper 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.
The main serious complications of disorders that cause toothache involve spread of infection from the area next to the tooth to nearby tissues. Infection from an upper tooth can spread to the nasal sinuses (causing sinusitis Sinusitis Sinusitis is inflammation of the sinuses, most commonly caused by a viral or bacterial infection or by an allergy. Some of the most common symptoms of sinusitis are pain, tenderness, nasal congestion... read more ) or to a large vein at the base of the brain called the cavernous sinus, causing cavernous sinus thrombosis Cavernous Sinus Thrombosis Cavernous sinus thrombosis is a very rare disorder in which a blood clot (thrombosis) forms in the cavernous sinus (a large vein at the base of the skull). Cavernous sinus thrombosis is usually... read more . Infection of a lower tooth can spread under the tongue. Infection of the floor of the mouth under the tongue is called Ludwig angina Submandibular Space Infection A submandibular space infection is a bacterial infection of the floor of the mouth. Bacteria can spread from an infected lower tooth to the tissue under and around the tongue. People with poor... read more 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.
Evaluation of Toothache
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.
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
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.
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 Cavernous Sinus Thrombosis Cavernous sinus thrombosis is a very rare disorder in which a blood clot (thrombosis) forms in the cavernous sinus (a large vein at the base of the skull). Cavernous sinus thrombosis is usually... read more or Ludwig angina Submandibular Space Infection A submandibular space infection is a bacterial infection of the floor of the mouth. Bacteria can spread from an infected lower tooth to the tissue under and around the tongue. People with poor... read more is suspected, an imaging study—typically computed tomography (CT) or magnetic resonance imaging (MRI)—is done.
Treatment of Toothache
Treatment of specific causes
Nonprescription pain relievers (analgesics) such as acetaminophen or ibuprofen can be taken while people await dental evaluation.
A local nerve block may be done. Local anesthetic is injected to relieve severe pain until the person can see a dentist to have the problem treated.
Antibiotics such as penicillin or clindamycin are given for disorders such as abscesses, pericoronitis, or cellulitis. If cellulitis is suspected, the doctor prescribes antibiotics. If an abscess or pericoronitis is suspected, a dental visit is necessary. If that visit cannot be arranged for the same day, the doctor may start the person on antibiotics.
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), and chewing on anything cold (such as gel-containing teething rings). Over-the-counter teething products containing benzocaine pose serious risks to infants and children and should not be used.
The rare person with cavernous sinus thrombosis Cavernous Sinus Thrombosis Cavernous sinus thrombosis is a very rare disorder in which a blood clot (thrombosis) forms in the cavernous sinus (a large vein at the base of the skull). Cavernous sinus thrombosis is usually... read more or Ludwig angina Submandibular Space Infection A submandibular space infection is a bacterial infection of the floor of the mouth. Bacteria can spread from an infected lower tooth to the tissue under and around the tongue. People with poor... read more 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 and dry mouth Dry Mouth Dry mouth is caused by a reduced or absent flow of saliva. This condition can cause discomfort, interfere with speech and swallowing, make wearing dentures difficult, cause bad breath (halitosis)... read more caused by drugs. Periodontitis Periodontitis Periodontitis is a severe form of gingivitis, in which the inflammation of the gums extends to the supporting structures of the tooth. Plaque and tartar build up between the teeth and gums and... read more often begins in young adulthood. If untreated, tooth pain and loss are common in old age.
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 (and there are signs of infection such as fever, redness, or swelling), or more severe conditions, and if same-day dental care is not available.
A dental infection that has spread to the floor of the mouth or to the cavernous sinus is a very rare but serious complication that requires immediate medical attention.
Dental infections rarely cause sinusitis, but a sinus infection may cause pain that feels as though it originates in the teeth.
The following is an English-language resource that may be useful. Please note that THE MANUAL is not responsible for the content of this resource.
MouthHealthy.org: Provides information on oral health, including nutrition and guidance on selecting products that carry the American Dental Association's seal of approval. There is also advice on finding a dentist and how and when to see one.
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