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 (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.) 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 (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 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 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.
Pain from a sinus infection 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.
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 from an upper tooth can spread to the nasal sinuses (causing sinusitis) or to a large vein at the base of the brain called the cavernous sinus, causing cavernous sinus thrombosis. Infection of a lower tooth can spread 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.
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).
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).
Some Causes and Features of Toothache
Cause | Common Features* | Tests |
|---|---|---|
Periapical abscess (a collection of pus around the tooth's root that can cause acute or chronic symptoms) | Pain may have begun recently or be longstanding 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† |
Pain that
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† |
Pain in several upper teeth on one side, especially molars and premolars Sensitivity when chewing and when the upper 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 | |
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 of Toothache
Pain relievers
Antibiotics
Treatment of specific causes
Nonprescription pain relievers
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
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
Teething pain
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 Adults: Toothache
Older adults are more prone to cavities of the root surfaces, usually because of receding gums and dry mouth caused by medications. 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 (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.
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.
