(See also Evaluation of the Dental Patient Evaluation of the Dental Patient The first routine dental examination should take place by age 1 year or when the first tooth erupts. Subsequent evaluations should take place at 6-month intervals or whenever symptoms develop... read more 
.)
Etiology of Toothache and Infection
The most common causes of toothache (see table Some Causes of Toothache Some Causes of Toothache Pain in and around the teeth is a common problem, particularly among patients with poor oral hygiene. Pain may be constant, felt after stimulation (eg, heat, cold, sweet food or drink, chewing... read more 
) are
Toothache is usually caused by dental caries and its consequences.
Caries Caries Caries is tooth decay, commonly called cavities. The symptoms—tender, painful teeth—appear late. Diagnosis is based on inspection, probing of the enamel surface with a fine metal instrument... read more 
(tooth decay) causes pain when the lesion extends through the enamel into dentin (resulting in sufficient demineralization of tooth structure to cause a cavitation in the outer surface of the tooth enamel). Pain usually occurs after stimulation from cold, heat, sweet food or drink, or brushing; these stimuli cause fluid to move within dentinal tubules to induce a response in the pulp. As long as the discomfort does not persist after the stimulus is removed, the pulp is likely healthy enough to be maintained. This is referred to as normal dentinal sensitivity, reversible pulpalgia, or reversible pulpitis.
Pulpitis Pulpitis Pulpitis is inflammation of the dental pulp resulting from untreated caries, trauma, or multiple restorations. Its principal symptom is pain. Diagnosis is based on clinical findings, and results... read more is inflammation of the pulp, typically due to advancing caries, cumulative minor pulp damage resulting from previous large restorations, a defective restoration, or trauma. It may be reversible or irreversible. Pressure necrosis frequently results from pulpitis. Pain may be spontaneous or in response to stimulation, particularly heat or cold. In both cases, pain lingers for a minute or longer. Once the pulp becomes necrotic, pain ends briefly (hours to weeks). Subsequently, periapical inflammation (apical periodontitis) or an abscess develops.
Periapical abscess may follow untreated caries or pulpitis. The tooth is exquisitely sensitive to percussion (tapping with a metal dental probe or tongue blade) and chewing. The abscess may point intraorally and eventually drain or may become a cellulitis.
Tooth trauma can damage the pulp. The damage may manifest soon after the injury or up to decades later.
Pericoronitis is inflammation and infection of the tissue between the tooth and its overlying flap of gingiva (operculum). It usually occurs in an erupting wisdom tooth (almost always a lower one).
Complications
Rarely, sinusitis Sinusitis Sinusitis is inflammation of the paranasal sinuses due to viral, bacterial, or fungal infections or allergic reactions. Symptoms include nasal obstruction and congestion, purulent rhinorrhea... read more 
results from untreated maxillary dental infection. More commonly, pain resulting from a sinus infection is perceived as originating in the unaffected teeth adjacent to the sinus, mistakenly creating the impression of a dental origin.
Rarely, cavernous sinus thrombosis Cavernous Sinus Thrombosis Cavernous sinus thrombosis is a very rare, typically septic thrombosis of the cavernous sinus, usually caused by nasal furuncles or bacterial sinusitis. Symptoms and signs include pain, proptosis... read more or Ludwig angina (submandibular space infection Submandibular Space Infection Submandibular space infection is acute cellulitis of the soft tissues below the mouth. Symptoms include pain, dysphagia, and potentially fatal airway obstruction. Diagnosis usually is clinical... read more 
) develops; these conditions are life threatening and require immediate intervention.
Evaluation of Toothache and Infection
History
History of present illness should identify the location and duration of the pain and whether it is constant or present only after stimulation. Specific triggering factors to review include heat, cold, sweet food or drink, chewing, and brushing. Any preceding trauma or dental work should be noted.
Review of systems should seek symptoms of complications, including face pain, swelling, or both (dental abscess, sinusitis); pain below the tongue, difficulty swallowing, and tongue elevation or protrusion (submandibular space infection); pain with bending forward (sinusitis Sinusitis Sinusitis is inflammation of the paranasal sinuses due to viral, bacterial, or fungal infections or allergic reactions. Symptoms include nasal obstruction and congestion, purulent rhinorrhea... read more ); and retro-orbital headache, fever, and vision symptoms (cavernous sinus thrombosis Cavernous Sinus Thrombosis Cavernous sinus thrombosis is a very rare, typically septic thrombosis of the cavernous sinus, usually caused by nasal furuncles or bacterial sinusitis. Symptoms and signs include pain, proptosis... read more ).
Past medical history should note previous dental problems and treatment.
Physical examination
Vital signs are reviewed for fever.
The examination focuses on the face and mouth. The face is inspected for swelling and is palpated for induration and tenderness.
The oral examination includes inspection for gum inflammation and caries and any localized swelling at the base of a tooth that may represent a pointing apical abscess. If no tooth is clearly involved, teeth in the area of pain are percussed for tenderness with a tongue depressor. Also, an ice cube can be applied briefly to each tooth, removing it immediately once pain is felt. In healthy teeth, the pain stops almost immediately. Pain lingering more than a few seconds indicates pulp damage (eg, irreversible pulpitis Pulpitis Pulpitis is inflammation of the dental pulp resulting from untreated caries, trauma, or multiple restorations. Its principal symptom is pain. Diagnosis is based on clinical findings, and results... read more , necrosis). The floor of the mouth is palpated for induration and tenderness, suggesting a deep space infection.
Neurologic examination, concentrating on the cranial nerves, should be done in patients with fever, headache, or facial swelling.
Red flags
Interpretation of findings
Red flag finding of headache suggests sinusitis Sinusitis Sinusitis is inflammation of the paranasal sinuses due to viral, bacterial, or fungal infections or allergic reactions. Symptoms include nasal obstruction and congestion, purulent rhinorrhea... read more , particularly if multiple upper molar and premolar (back) teeth are painful. However, presence of vision symptoms or abnormalities of the pupils or of ocular motility suggests cavernous sinus thrombosis Cavernous Sinus Thrombosis Cavernous sinus thrombosis is a very rare, typically septic thrombosis of the cavernous sinus, usually caused by nasal furuncles or bacterial sinusitis. Symptoms and signs include pain, proptosis... read more .
Fever is unusual with routine dental infection unless there is significant local extension. Bilateral tenderness and swelling of the floor of the mouth suggests Ludwig angina Submandibular Space Infection Submandibular space infection is acute cellulitis of the soft tissues below the mouth. Symptoms include pain, dysphagia, and potentially fatal airway obstruction. Diagnosis usually is clinical... read more .
Difficulty opening the mouth (trismus) can occur with any lower molar infection but is common only with pericoronitis Symptoms and Signs Gingivitis is a type of periodontal disease characterized by inflammation of the gums (gingivae), causing bleeding with swelling, redness, exudate, a change of normal contours, and, occasionally... read more 
.
Isolated dental condition: Patients without red flag findings or facial swelling likely have an isolated dental condition, which, although uncomfortable, is not serious. Clinical findings, particularly the nature of the pain, help suggest a cause (see tables Some Causes of Toothache Some Causes of Toothache Pain in and around the teeth is a common problem, particularly among patients with poor oral hygiene. Pain may be constant, felt after stimulation (eg, heat, cold, sweet food or drink, chewing... read more and Characteristics of Pain in Toothache Characteristics of Pain in Toothache Pain in and around the teeth is a common problem, particularly among patients with poor oral hygiene. Pain may be constant, felt after stimulation (eg, heat, cold, sweet food or drink, chewing... read more ). Because of its innervation, the pulp can perceive stimuli (eg, heat, cold, sweets) only as pain. An important distinction is whether there is continuous pain or pain only on stimulation and, if pain is only on stimulation, whether the pain lingers after the stimulus is removed.
Swelling at the base of a tooth, on the cheek, or both indicates infection, either cellulitis or abscess. A tender, fluctuant area at the base of a tooth suggests a pointing abscess.
Testing
Dental x-rays are the mainstay of testing but can be deferred to a dentist.
The rare cases in which cavernous sinus thrombosis Cavernous Sinus Thrombosis Cavernous sinus thrombosis is a very rare, typically septic thrombosis of the cavernous sinus, usually caused by nasal furuncles or bacterial sinusitis. Symptoms and signs include pain, proptosis... read more or Ludwig angina Submandibular Space Infection Submandibular space infection is acute cellulitis of the soft tissues below the mouth. Symptoms include pain, dysphagia, and potentially fatal airway obstruction. Diagnosis usually is clinical... read more are suspected require imaging studies, typically CT or MRI.
Treatment of Toothache and Infection
Analgesics (see Treatment of Pain Treatment of Pain Nonopioid and opioid analgesics are the main drugs used to treat pain. Antidepressants, antiseizure drugs, and other central nervous system (CNS)–active drugs may also be used for chronic or... read more ) may be given pending dental evaluation and definitive treatment. For severe dental pain, local nerve block injections with bupivacaine hydrochloride and epinephrine 1:200,000 may relieve pain for many hours until the patient receives definitive dental care. A patient who is seen frequently for emergencies but who never receives definitive dental treatment despite availability may be seeking opioids.
Procedure demonstrated by Scott Solow, DDS, Pediatric Dentistry and Orthodontics. Filmed on location at Pediatric Dentistry and Orthodontics Medical Arts Building, Philadelphia, PA.
© Elsevier Inc. All Rights Reserved. This video is for personal informational use. Users are prohibited from copying, reproducing, licensing, subscribing, selling, leasing or distributing this video.
© Elsevier Inc. All Rights Reserved. This video is for personal informational use. Users are prohibited from copying, reproducing, licensing, subscribing, selling, leasing or distributing this video.
© Elsevier Inc. All Rights Reserved. This video is for personal informational use. Users are prohibited from copying, reproducing, licensing, subscribing, selling, leasing or distributing this video.
Procedure demonstrated by Scott Solow, DDS, Pediatric Dentistry and Orthodontics. Filmed on location at Pediatric Dentistry and Orthodontics Medical Arts Building, Philadelphia, PA.
Procedure demonstrated by Scott Solow, DDS, Pediatric Dentistry and Orthodontics. Filmed on location at Pediatric Dentistry and Orthodontics Medical Arts Building, Philadelphia, PA.
(See also How To Do an Emergency Tooth Extraction How To Do an Emergency Tooth Extraction Tooth extraction is done using manual dental instruments, to remove nonviable, nonsalvageable teeth. Adequate anesthesia is important. Postprocedure dry socket is to be prevented. Even when... read more .)
Antibiotics directed at oral flora are given for most disorders beyond irreversible pulpitis (eg, necrotic pulp, abscess, cellulitis). Patients with pericoronitis may also receive an antibiotic. However, antibiotics can be deferred if patients can be seen the same day by a dentist, who may be able to treat the infection by removing the source (eg, by extraction, pulpectomy, or curettage). When antibiotics are used, penicillin or amoxicillin is preferred, with clindamycin the alternative for patients allergic to penicillin.
An abscess associated with well-developed (soft) fluctuance is typically drained through an incision with a #15 scalpel blade at the most dependent point of the swelling. A rubber drain, held by a suture, may be placed. (See How To Drain a Tooth Abscess How To Drain a Tooth Abscess Intraoral incision and drainage of an uncomplicated tooth abscess is done to provide analgesia and limit further and deeper spread of the infection. Periodontal or periapical abscess or cellulitis... read more .)
Pericoronitis or erupting 3rd molars are treated with chlorhexidine 0.12% rinses or hypertonic salt-water soaks (1 tbsp salt mixed in a glass of hot water—no hotter than the coffee or tea a patient normally drinks). The salt water is held in the mouth on the affected side until it cools and then is expectorated and immediately replaced with another mouthful. Three or 4 glasses of salt water a day may control inflammation and pain pending dental evaluation.
Teething pain in young children may be treated with weight-based doses of acetaminophen or ibuprofen. Topical treatments can include chewing hard crackers (eg, biscotti) and chewing on anything cold (eg, gel-containing teething rings).
The rare patient with cavernous sinus thrombosis Cavernous Sinus Thrombosis Cavernous sinus thrombosis is a very rare, typically septic thrombosis of the cavernous sinus, usually caused by nasal furuncles or bacterial sinusitis. Symptoms and signs include pain, proptosis... read more or Ludwig angina Submandibular Space Infection Submandibular space infection is acute cellulitis of the soft tissues below the mouth. Symptoms include pain, dysphagia, and potentially fatal airway obstruction. Diagnosis usually is clinical... read more requires immediate hospitalization, removal of the infected tooth, and culture-guided parenteral antibiotics.
Geriatrics Essentials
Key Points
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Most toothache involves dental caries or its complications (eg, pulpitis, abscess).
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Symptomatic treatment and dental referral are usually adequate.
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Antibiotics are given if signs of an abscess, necrotic pulp, or more severe conditions are present.
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Very rare but serious complications include extension of dental infection to the floor of the mouth or to the cavernous sinus.
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Dental infections rarely cause sinusitis, but sinus infection may cause pain perceived as originating in the teeth.
