Editing Toothache (section)

===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 />