Merck Manual

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Bernard J. Hennessy

, DDS, Texas A&M University, College of Dentistry

Reviewed/Revised Jan 2024
Topic Resources

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

  • Cavities

  • Pulpitis

  • Periapical abscess

  • Trauma

  • 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 Cavities (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 .) 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 Gingivitis due to an impacted tooth (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.

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 tissues below the mouth. Submandibular space infection can cause pain and tenderness under the tongue and/or under the jaw, and... read more Submandibular Space Infection 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.

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.

In some situations, the dentist applies an ice cube or a cotton pellet that has been chilled with a dental refrigerant briefly to each tooth. It is removed once pain is felt. In healthy teeth, the pain stops almost immediately. Pain that lingers for more than a few seconds indicates pulp damage (for example, 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 ).

The dentist palpates the floor of the mouth for irregularities, such as thickening, hardening, and/or tenderness, to find signs of a tumor, salivary gland problem, or deep space infection (for example, an abscess).



Treatment of Toothache

  • Pain relievers

  • Antibiotics

  • 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 amoxicillin 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.

Essentials for Older Adults: Toothache

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 (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.

More Information

The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.

  • 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.

Drugs Mentioned In This Article

Generic Name Select Brand Names
7T Gummy ES, Acephen, Aceta, Actamin, Adult Pain Relief, Anacin Aspirin Free, Aphen, Apra, Children's Acetaminophen, Children's Pain & Fever , Children's Pain Relief, Comtrex Sore Throat Relief, ED-APAP, ElixSure Fever/Pain, Feverall, Genapap, Genebs, Goody's Back & Body Pain, Infantaire, Infants' Acetaminophen, LIQUID PAIN RELIEF, Little Fevers, Little Remedies Infant Fever + Pain Reliever, Mapap, Mapap Arthritis Pain, Mapap Infants, Mapap Junior, M-PAP, Nortemp, Ofirmev, Pain & Fever , Pain and Fever , PAIN RELIEF , PAIN RELIEF Extra Strength, Panadol, PediaCare Children's Fever Reducer/Pain Reliever, PediaCare Children's Smooth Metls Fever Reducer/Pain Reliever, PediaCare Infant's Fever Reducer/Pain Reliever, Pediaphen, PHARBETOL, Plus PHARMA, Q-Pap, Q-Pap Extra Strength, Silapap, Triaminic Fever Reducer and Pain Reliever, Triaminic Infant Fever Reducer and Pain Reliever, Tylenol, Tylenol 8 Hour, Tylenol 8 Hour Arthritis Pain, Tylenol 8 Hour Muscle Aches & Pain, Tylenol Arthritis Pain, Tylenol Children's, Tylenol Children's Pain+Fever, Tylenol CrushableTablet, Tylenol Extra Strength, Tylenol Infants', Tylenol Infants Pain + Fever, Tylenol Junior Strength, Tylenol Pain + Fever, Tylenol Regular Strength, Tylenol Sore Throat, XS No Aspirin, XS Pain Reliever
Advil, Advil Children's, Advil Children's Fever, Advil Infants', Advil Junior Strength, Advil Migraine, Caldolor, Children's Ibuprofen, ElixSure IB, Genpril , Ibren , IBU, Midol, Midol Cramps and Body Aches, Motrin, Motrin Children's, Motrin IB, Motrin Infants', Motrin Junior Strength, Motrin Migraine Pain, PediaCare Children's Pain Reliever/Fever Reducer IB, PediaCare Infants' Pain Reliever/Fever Reducer IB, Samson-8
Amoxil, Dispermox, Moxatag, Moxilin , Sumox, Trimox
Betasept, Chlorostat, DYNA-HEX, Hibiclens, Oro Clense , Peridex, Periogard, PerioRx , Perisol
Advocate Pain Relief Stick, Americaine, Anbesol, Anbesol Baby , Anbesol Jr , Banadyne-3, Benzodent, Benz-O-Sthetic, Boil-Ease, Cepacol Sensations, Chloraseptic, Comfort Caine , Dry Socket Remedy, Freez Eez, HURRICAINE, HURRICAINE ONE, Little Remedies for Teethers, Monistat Care, Orabase, OraCoat CankerMelts, Orajel, Orajel Baby, Orajel Denture Plus, Orajel Maximum Strength, Orajel P.M., Orajel Protective, Orajel Severe Pain, Orajel Swabs, Orajel Ultra, Oral Pain Relief , Oticaine , Otocain, Outgro, Pinnacaine, Pro-Caine, RE Benzotic, Topex, Topicale Xtra, Zilactin-B
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