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Caries extending through the enamel into dentin causes pain with stimulation (eg, heat, cold, sweet food or drink). Pain is isolated to a single tooth and usually stops when the stimulus is removed. The patient should avoid the provoking stimuli and seek dental treatment. A simple restoration (filling) usually is curative.
Reversible pulpitis is inflammation of the pulp, typically due to caries, minor pulp damage from previous large restorations, a defective restoration, or trauma. It causes the same symptoms as caries but differs in that the patient has difficulty pinpointing the affected tooth. Treatment is correction of the caries or other cause. Analgesics are often helpful but may mask symptoms that can help isolate the causative tooth.
Irreversible pulpitis causes toothache without stimulation or lingering pain after stimulation. Commonly, the patient has difficulty identifying the involved tooth. The physician can identify the tooth by placing ice on each tooth in the area and removing the ice once the patient feels pain. In healthy teeth, the pain stops almost immediately. Pain lingering more than a few seconds indicates irreversible pulpitis. Uncommonly, cold actually lessens symptoms (suppurative pulpitis), and the patient may present with a glass of ice water from which he regularly sips. Analgesics are needed until a dentist can perform root canal therapy or extraction. A patient who is seen frequently for emergencies but who never obtains definitive dental treatment may be seeking opioids.
Pressure necrosis frequently results from pulpitis, because the pulp is encased in a rigid compartment. Typically, once inflamed pulp becomes necrotic, the previously noted types of pain end. This symptom-free period may last hours to weeks. Subsequently, periapical inflammation and/or infection (apical periodontitis) develops. Infection is usually caused by resident oral bacteria. Apical periodontitis causes pain when chewing or biting. Normally, the patient can indicate the involved tooth. If not, the physician identifies it by tapping the teeth with a metal probe or tongue blade until the pain is reproduced. Antibiotics and analgesics are appropriate if dental care is delayed.
Periapical abscess may follow untreated caries or pulpitis. If the abscess is associated with well-developed (soft) fluctuance, it is drained through incision of the most dependent point of the swelling with a #15 scalpel blade. Rarely, extraoral drainage is used. Infections of < 3 days' duration respond better to penicillin, whereas those lasting > 3 days respond better to clindamycin.
Cellulitis can follow untreated dental infections. Rarely, cavernous sinus thrombosis (see Orbital Diseases: Cavernous Sinus Thrombosis) or Ludwig's angina (see Oropharyngeal Disorders: Submandibular Space Infection) develops. The latter 2 conditions are life threatening and require immediate hospitalization, removal of the infected tooth, and culture-guided parenteral antibiotics.
Sinusitis is suspected if many or all maxillary posterior teeth on one side are sensitive to percussion or if the patient reports pain on bending over with the head down.
Erupting or impacted molars, particularly 3rd molars, can be painful and may cause inflammation of adjacent soft tissue (pericoronitis) that can progress to serious infection. Treatment is with chlorhexidine rinses or hypertonic saltwater soaks (a tablespoon of 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 gargle a day usually controls inflammation and pain until the tooth can be removed. Antibiotics are appropriate if dental care is delayed.
Less common causes of acute perioral swelling include periodontal abscess, infected cysts, antritis, allergy, salivary gland obstruction or infection, and peritonsillar infection. Teething pain in young children may be accompanied by excess salivation and fever. Acetaminophen, appropriate for the weight of the child, helps relieve symptoms.
Last full review/revision November 2005
Content last modified November 2005
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