Toothache and Infection

The most common causes of toothache (see table Some Causes of Toothache Some Causes of Toothache ) 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 extremely sensitive to percussion (eg, 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).

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.

(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). Topical benzocaine can result in methemoglobinemia if used repeatedly or in large amounts and so is usually not recommended.

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.

Older patients are more prone to caries of the root surfaces, usually because of gingival recession and drug-induced xerostomia. Periodontitis often begins in young adulthood; if untreated, tooth pain and loss are common in old age.