Editing Toothache (section)

==Diagnosis==
The diagnosis of toothache can be challenging,<ref name=Sharav2008>{{cite book|vauthors=Sharav Y, Rafael R |title=Orofacial pain and headache|year=2008|publisher=Mosby|location=Edinburgh|isbn=978-0-7234-3412-2|url=https://books.google.com/books?id=t6oAmPp6okgC&q=orofacial+pain}}</ref>{{rp|80,81}} not only because the list of potential causes is extensive, but also because dental pain may be extremely variable,<ref name=Fishman2010>{{cite book|vauthors=Fishman S, Ballantyne J, Rathmell JP |title=Bonica's management of pain.|year=2010|publisher=Lippincott, Williams & Wilkins|location=Baltimore, MD|isbn=978-0-7817-6827-6|url=https://books.google.com/books?id=Pms0hxH8f-sC&q=many+painful+periodontal+conditions&pg=PA975|edition=4th}}</ref>{{rp|975}} and pain can be referred to and from the teeth. Dental pain can simulate virtually any facial pain syndrome.<ref name=Fishman2010 /> However, the vast majority of toothache is caused by dental, rather than non-dental, sources.<ref name=Hargreaves2011 />{{rp|40}} Consequently, the saying "[[horses, not zebras]]"  has been applied to the [[differential diagnosis]] of orofacial pain.<!-- http://faculty.ksu.edu.sa/dr.hanan/booksingle/ch07.pdf --> That is, everyday dental causes (such as pulpitis) should always be considered before unusual, non-dental causes (such as myocardial infarction). In the wider context of orofacial pain, all cases of orofacial pain may be considered as having a dental origin until proven otherwise.<ref name=Fishman2010 />{{rp|975}} The diagnostic approach for toothache is generally carried out in the following sequence: [[Medical history|history]], followed by [[Physical examination|examination]], and [[medical test|investigations]]. All this information is then collated and used to build a clinical picture, and a differential diagnosis can be carried out.

===Symptoms===
The [[chief complaint]], and the onset of the complaint, are usually important in the diagnosis of toothache. For example, the key distinction between reversible and irreversible pulpitis is given in the history, such as pain following a stimulus in the former, and lingering pain following a stimulus and spontaneous pain in the latter. History is also important in recent filling or other dental treatment, and trauma to the teeth. Based on the most common causes of toothache (dentin hypersensitivity, periodontitis, and pulpitis), the key indicators become localization of the pain (whether the pain is perceived as originating in a specific tooth), thermal sensitivity, pain on biting, spontaneity of the pain, and factors that make the pain worse.<ref name=Hargreaves2011 />{{rp|50}}The various qualities of the toothache, such as the effect of biting and chewing on the pain, the effect of thermal stimuli, and the effect of the pain on sleep, are verbally established by the clinician, usually in a systematic fashion, such as using the [[Socrates (pain assessment)|Socrates pain assessment method]] (see table).<ref name=Hargreaves2011 />{{rp|2–9}}

From the history, indicators of pulpal, periodontal, a combination of both, or non-dental causes can be observed. Periodontal pain is frequently localized to a particular tooth, which is made much worse by biting on the tooth, sudden in onset, and associated with bleeding and pain when brushing. More than one factor may be involved in the toothache. For example, a pulpal abscess (which is typically severe, spontaneous and localized) can cause periapical periodontitis (which results in pain on biting). Cracked tooth syndrome may also cause a combination of symptoms. Lateral periodontitis (which is usually without any thermal sensitivity and sensitive to biting) can cause pulpitis and the tooth becomes sensitive to cold.<ref name=Hargreaves2011 />{{rp|2–9}}

Non-dental sources of pain often cause multiple teeth to hurt and have an epicenter that is either above or below the jaws. For instance, cardiac pain (which can make the bottom teeth hurt) usually radiates up from the chest and neck, and sinusitis (which can make the back top teeth hurt) is worsened by bending over.<ref name=Hargreaves2011 />{{rp|56,61}} As all of these conditions may mimic toothache, it is possible that dental treatment, such as fillings, root canal treatment, or tooth extraction may be carried out unnecessarily by dentists in an attempt to relieve the individual's pain, and as a result the correct diagnosis is delayed. A hallmark is that there is no obvious dental cause, and signs and symptoms elsewhere in the body may be present. As migraines are typically present for many years, the diagnosis is easier to make. Often the character of the pain is the differentiator between dental and non-dental pain.{{citation needed|date=April 2014}}

Irreversible pulpitis progresses to pulp necrosis, wherein the nerves are non-functional, and a pain-free period following the severe pain of irreversible pulpitis may be experienced. However, it is common for irreversible pulpitis to progress to apical periodontitis, including an acute apical abscess, without treatment. As irreversible pulpitis generates an apical abscess, the character of the toothache may simply change without any pain-free period.  For instance, the pain becomes well localized, and biting on the tooth becomes painful. Hot drinks can make the tooth feel worse because they expand the gases and likewise, cold can make it feel better, thus some will sip cold water.<ref name=Hargreaves2011 /><ref name=Neville2001 />

===Examination===
The clinical examination narrows the source down to a specific tooth, teeth, or a non-dental cause.  Clinical examination moves from the outside to the inside, and from the general to the specific.  Outside of the mouth, the [[Paranasal sinuses|sinuses]], muscles of the [[Muscles of mastication|face]] and [[Sternocleidomastoid muscle|neck]], the [[temporomandibular joint]]s, and [[cervical lymph node]]s are palpated for pain or swelling.<ref name=Hargreaves2011 />{{rp|9}} In the mouth, the soft tissues of the [[gingiva]], [[mucosa]], [[tongue]], and [[pharynx]] are examined for redness, swelling or deformity.  Finally, the teeth are examined.  Each tooth that may be painful is percussed (tapped), palpated at the base of the root, and probed with a [[dental explorer]] for dental caries and a periodontal probe for [[periodontitis]], then wiggled for mobility.<ref name=Hargreaves2011 />{{rp|10}}

Sometimes the symptoms reported in the history are misleading and point the examiner to the wrong area of the mouth. For instance, sometimes people may mistake pain from pulpitis in a lower tooth as pain in the upper teeth, and ''vice versa''. In other instances, the apparent examination findings may be misleading and lead to the wrong diagnosis and wrong treatment. Pus from a pericoronal abscess associated with a lower third molar may drain along the [[submucosa]]l plane and discharge as a [[parulis]] over the roots of the teeth towards the front of the mouth (a "migratory abscess"). Another example is decay of the tooth root which is hidden from view below the gumline, giving the casual appearance of a sound tooth if careful periodontal examination is not carried out. {{citation needed|date=April 2014}}

Factors indicating infection include movement of fluid in the tissues during palpation (''fluctuance''), [[cervical lymphadenopathy|swollen lymph nodes in the neck]], and fever with an oral temperature more than 37.7&nbsp;°C.{{citation needed|date=April 2014}}

===Investigations===
Any tooth that is identified, in either the history of pain or base clinical exam, as a source for toothache may undergo further testing for vitality of the dental pulp, infection, fractures, or periodontitis.  These tests may include:<ref name=Hargreaves2011 />{{rp|10–19}}

* Pulp sensitivity tests, usually carried out with a cotton wool [[wikt:pledget|pledget]] sprayed with [[ethyl chloride]] to serve as a cold stimulus, or with an [[electric pulp test]]er. The air spray from a three-in-one syringe may also be used to demonstrate areas of dentin hypersensitivity. Heat tests can also be applied with hot [[Gutta-percha]].  A healthy tooth will feel the cold but the pain will be mild and disappear once the stimulus is removed.  The accuracy of these tests has been reported as 86% for cold testing, 81% for electric pulp testing, and 71% for heat testing.  Because of the lack of [[test sensitivity]], a second symptom should be present or a positive test before making a diagnosis.
* [[Radiograph]]s utilized to find dental caries and bone loss laterally or at the apex.
* Assessment of biting on individual teeth (which sometimes helps to localize the problem) or the separate cusps (may help to detect cracked cusp syndrome).

Less commonly used tests might include trans-illumination (to detect congestion of the maxillary sinus or to highlight a crack in a tooth), dyes (to help visualize a crack), a test cavity<!-- need to explain -->, selective anaesthesia and [[Laser Doppler velocimetry|laser doppler flowmetry]].
<gallery mode="packed" heights="110">
File:Cold test with ethyl chloride.jpg|Pulp sensibility test using ethyl chloride (cold stimulus)
File:Electric-pulp-testing.gif|Electric pulp tester
File:Tooth sleuth.jpg|Plastic wedge to identify pain on biting from a fractured tooth
File:Transillumination of tooth marked.jpg|Transillumination demonstrating fracture
File:Tooth decay and abscess xray.png|Decay (green) with apical abscess (blue)
File:Sinugram abscessed tooth.jpg|Gutta-percha point indicating abscess origin
</gallery>

Establishing a diagnosis of nondental toothache is initially done by careful questioning about the site, nature, aggravating and relieving factors, and referral of the pain, then ruling out any dental causes.  There are no specific treatments for nondental pain (each treatment is directed at the cause of the pain, rather than the toothache itself), but a dentist can assist in offering potential sources of the pain and direct the patient to appropriate care. The most critical nondental source is the radiation of [[angina pectoris]] into the lower teeth and the potential need for urgent cardiac care.<ref name=Hargreaves2011 />{{rp|68}}

===Differential diagnoses===
{| class="wikitable" style="border:1px solid #BBB; font-size:80%; margin:0.46em 0.2em"
|-
! Parameter !! Dentin hypersensitivity<ref name=Hargreaves2011 />{{rp|36}} !! Reversible pulpitis<ref name=Hargreaves2011 />{{rp|36}} !! Irreversible pulpitis<ref name=Hargreaves2011 />{{rp|36–37}} !! Pulp necrosis<ref name=Hargreaves2011 />{{rp|37}} !! Apical periodontitis<ref name=Hargreaves2011 />{{rp|37–38}} !! Periodontal abscess !! Pericoronitis!! Myofascial pain !! Maxillary sinusitis
|-
| '''Site'''||Poorly localized ||Poorly localized || Variable; localized or diffuse || No pain || Well localized || Usually well localized || Well localized, associated with partially impacted tooth || Diffuse, often over many muscles ||Back teeth top jaw
|-
| '''Onset''' || Gradual || Variable || Variable || From pain of reversible pulpitis to no pain in days || Gradual, typically follows weeks of thermal pain in tooth || Sudden, no episode of thermal sensitivity || Sudden || Very slow; weeks to months ||Sudden 
|-
| '''Character''' || Sharp, quickly reversible || Sharp, shooting || Dull, continuous pain. Can also be sharp || No pain || Dull, continuous throbbing pain || Dull, continuous throbbing pain ||Sharp, with continuous dull || Dull, aching || Dull, aching, occasional thermal sensitivity in back top teeth
|-
| '''Radiation''' ||Does not cross midline || Does not cross midline || Does not cross midline || N/A || Does not cross midline ||Little, well localized ||Moderate, into jaw/neck || Extensive, neck/temple || Moderate, into other facial sinus areas
|-
| '''Associated symptoms''' || Patient may complain of receding gums and/or toothbrush abrasion cavities ||Can follow restorative dental work or trauma|| Follows period of pain that does not linger || Follows period of spontaneous pain || Tooth may feel raised in socket ||May follow report of something getting "stuck" in gum || Tooth eruption ("cutting") or impacted tooth || Tension headaches, neck pain, periods of stress or episode of mouth open for long period || Symptoms of [[upper respiratory tract infection|URTI]]
|-
| '''Time pattern''' || Hypersensitivity as long as stimulus is applied; often worse in cold weather || Pain as long as stimulus is applied || Lingering pain to hot or cold or spontaneous pain || Absence of pain following days or weeks of intense, well localized pain || Pain on biting following constant dull, aching pain development || Dull ache with acute increase in pain when tooth is moved, minimal thermal sensitivity || Constant dull ache without stimulus || Spontaneous, worse with eating, chewing, or movement of jaw || Spontaneous, worse when head is tipped forward
|-
| '''Exacerbating and relieving factors'''|| Exacerbating: thermal, particularly cold || Exacerbating: thermal, sweet || Simple analgesics have little effect || Prolonged heat may elicit pain|| Same as irreversible pulpitis, or no response to cold, lingering pain to hot, pain with biting or lying down || Tapping tooth makes worse, cleansing area may improve pain || Cleansing area can improve pain || Rest or ice makes pain better, movement and chewing make it worse || Tilting head forward, jarring movements (jumping) make pain worse
|-
| '''Severity'''|| Less severe than pulpitis || Severe, for short periods || Variable; pain dissipates until periapical tissue affected || Severe || Severe || Severe || Mild to severe || Mild to moderate || Mild to severe
|-
| '''Effect on sleep''' || None || None usually || Disrupts sleep || None || Disrupts sleep || Variable, can disrupt sleep || If moderate to severe, will disrupt || Unusual || Unusual
|}

When it becomes extremely painful and decayed the tooth may be known as a [[hot tooth syndrome|hot tooth]].<ref name="endoexperience.com">{{Cite web|url=http://endoexperience.com/documents/HotToothanesthesia.PDF|title = Looking for a File and were Directed Here?}}</ref>