Editing Toothache (section)

====Periodontal====
In general, chronic periodontal conditions do not cause any pain.  Rather, it is acute inflammation which is responsible for the pain.<ref name=Napenas2013>{{cite journal|author=Napeñas JJ|title=Intraoral pain disorders.|journal=Dental Clinics of North America|date=July 2013|volume=57|issue=3|pages=429–47|pmid=23809302|doi=10.1016/j.cden.2013.04.004}}</ref>

=====Apical periodontitis=====
[[File:Abscessed tooth periapical radiograph.jpg|thumb|Apical abscess associated with roots of a lower molar.]]
[[Apical periodontitis]] is acute or chronic inflammation around the apex of a tooth caused by an [[immune response]] to bacteria within an infected pulp.<ref name=Segura-Egea2012>{{cite journal|vauthors=Segura-Egea JJ, Castellanos-Cosano L, Machuca G, Lopez-Lopez J, Martin-Gonzalez J, Velasco-Ortega E, Sanchez-Dominguez B, Lopez-Frias FJ |title=Diabetes mellitus, periapical inflammation and endodontic treatment outcome|journal=Medicina Oral Patología Oral y Cirugia Bucal|date=January 1, 2012|pages=e356–e361|doi=10.4317/medoral.17452|pmc=3448330|pmid=22143698|volume=17|issue=2}}</ref> It does not occur because of pulp necrosis, meaning that a tooth that tests as if it's alive (vital) may cause apical periodontitis, and a pulp which has become non-vital due to a [[Sterilization (microbiology)|sterile]], non-infectious processes (such as trauma) may not cause any apical periodontitis.<ref name=Hargreaves2011 />{{rp|225}} Bacterial [[cytotoxin]]s reach the region around the roots of the tooth via the apical foramina and lateral canals, causing [[vasodilation]], sensitization of nerves, [[osteolysis]] (bone resorption) and potentially abscess or cyst formation.<ref name=Hargreaves2011 />{{rp|228}}

The periodontal ligament becomes inflamed and there may be pain when biting or tapping on the tooth. On an X-ray, bone resorption appears as a [[Radiodensity|radiolucent]] area around the end of the root, although this does not manifest immediately.<ref name=Hargreaves2011 />{{rp|228}} Acute apical periodontitis is characterized by well-localized, spontaneous, persistent, moderate to severe pain.<ref name=Scully2013 />{{rp|125–135}} The alveolar process may be tender to [[palpation]] over the roots. The tooth may be raised in the socket and feel more prominent than the adjacent teeth.<ref name=Scully2013 />{{rp|125–135}}

=====Food impaction=====
[[Image:Open contact.jpg|thumb|An [[open contact]] of approximately 1.5 mm shown between two posterior teeth.  The meat, at right, was recovered from the open contact more than 8 hours after the person had last eaten meat, even though they had brushed the teeth twice since.]]
Food impaction occurs when food debris, especially fibrous food such as meat, becomes trapped between two teeth and is pushed into the gums during chewing.<ref name=Scully2013 />{{rp|125–135}} The usual cause of food impaction is disruption of the normal [[embrasure (dentistry)|interproximal contour]] or drifting of teeth so that a gap is created (an [[open contact]]). Decay can lead to collapse of part of the tooth, or a dental restoration may not accurately reproduce the contact point. Irritation, localized discomfort or mild pain and a feeling of pressure from between the two teeth results. The gingival papilla is swollen, tender and bleeds when touched. The pain occurs during and after eating, and may slowly disappear before being evoked again at the next meal,<ref group="nb">This pattern of pain should be distinguished from the "meal time syndrome" of certain [[salivary gland disease]]s.</ref> or relieved immediately by using a tooth pick or dental floss in the involved area.<ref name=Scully2013 />{{rp|125–135}} A gingival or periodontal abscess may develop from this situation.<ref name="Carranza11th"/>{{rp|444–445}}

=====Periodontal abscess=====
[[File:Cracked tooth lateral periodontal abscess.jpg|thumb|right|Lateral periodontal abscess (blue arrows) due to a fracture (green arrows)]]
A [[periodontal abscess]] (lateral abscess) is a collection of pus that forms in the [[gingival sulcus|gingival crevice]]s, usually as a result of chronic periodontitis where the pockets are pathologically deepened greater than 3mm. A healthy gingival pocket will contain bacteria and some [[calculus (dental)|calculus]] kept in check by the [[immune system]]. As the pocket deepens, the balance is disrupted, and an acute inflammatory response results, forming pus. The debris and swelling then disrupt the normal flow of fluids into and out of the pocket, rapidly accelerating the inflammatory cycle.  Larger pockets also have a greater likelihood of collecting food debris, creating additional sources of infection.<ref name="Carranza11th"/>{{rp|443}}

Periodontal abscesses are less common than apical abscesses, but are still frequent.  The key difference between the two is that the pulp of the tooth tends to be alive, and will respond normally to pulp tests. However, an untreated periodontal abscess may still cause the pulp to die if it reaches the tooth apex in a [[periodontic-endodontic lesion]]. A periodontal abscess can occur as the result of tooth fracture, food packing into a periodontal pocket (with poorly shaped fillings), calculus build-up, and lowered immune responses (such as in [[diabetes]]).  Periodontal abscess can also occur after periodontal scaling, which causes the gums to tighten around the teeth and trap debris in the pocket.<ref name="Carranza11th"/>{{rp|444–445}} Toothache caused by a periodontal abscess is generally deep and throbbing. The [[oral mucosa]] covering an early periodontal abscess appears [[erythema]]tous (red), [[Swelling (medical)|swollen]], shiny, and [[hyperalgesia|painful to touch]].<ref name="AAP2000">{{cite journal | title=Parameter on acute periodontal diseases. | author=American Academy of Periodontology | journal=J Periodontol |date=May 2000 | volume=71 | issue=5 | pages=863–6 | pmid=10875694 | doi=10.1902/jop.2000.71.5-S.863| doi-access=free }}</ref>

A variant of the periodontal abscess is the gingival abscess, which is limited to the gingival margin, has a quicker onset, and is typically caused by trauma from items such as a fishbone, toothpick, or toothbrush, rather than chronic periodontitis.<ref name="Carranza11th"/>{{rp|446–447}} The treatment of a periodontal abscess is similar to the management of dental abscesses in general (see: [[Toothache#Treatment|Treatment]]).  However, since the tooth is typically alive, there is no difficulty in accessing the source of infection and, therefore, antibiotics are more routinely used in conjunction with [[scaling and root planing]].<ref name="herrera2002">{{cite journal|title=A systematic review on the effect of systemic antimicrobials as an adjunct to scaling and root planing in periodontitis patients.|journal=Journal of Clinical Periodontology|year=2002|volume=29|pages=136–59; discussion 160–2|pmid=12787214|vauthors=Herrera D, Sanz M, Jepsen S, Needleman I, Roldán S |issue=Suppl 3 |doi=10.1034/j.1600-051X.29.s3.8.x}}</ref> The occurrence of a periodontal abscess usually indicates advanced periodontal disease, which requires correct management to prevent recurrent abscesses, including daily cleaning below the gumline to prevent the buildup of subgingival [[Dental plaque|plaque]] and calculus.

=====Acute necrotizing ulcerative gingivitis=====
[[File:Ulcerative necrotizing gingivitis.jpg|thumb|right|Mild presentation of ANUG on the gums of the lower front teeth]]
Common marginal [[gingivitis]] in response to subgingival plaque is usually a painless condition. However, an acute form of gingivitis/periodontitis, termed [[acute necrotizing ulcerative gingivitis]] (ANUG), can develop, often suddenly. It is associated with severe periodontal pain, bleeding gums, "punched out" ulceration, loss of the [[dental papilla|interdental papillae]], and possibly also [[halitosis]] (bad breath) and a bad taste. Predisposing factors include poor [[oral hygiene]], smoking, malnutrition, psychological stress, and immunosuppression.<ref name="Carranza11th"/>{{rp|97–98}} This condition is not contagious, but multiple cases may simultaneously occur in populations who share the same risk factors (such as students in a dormitory during a period of examination).<ref name=Lindhe2008_2>{{cite book| last1=Lindhe | first1=Jan | last2=Lang | first2=Niklaus P. | last3=Karring | first3=Thorkild|title=Clinical periodontology and implant dentistry|year=2008|publisher=Blackwell Munksgaard|location=Oxford|isbn=978-1-4051-6099-5|pages=413, 459|edition=5th}}</ref> ANUG is treated over several visits, first with [[debridement]] of the necrotic gingiva, homecare with [[hydrogen peroxide]] mouthwash, analgesics and, when the pain has subsided sufficiently, cleaning below the gumline, both professionally and at home. Antibiotics are not indicated in ANUG management unless there is underlying systemic disease.<ref name="Carranza11th">{{cite book | title=Carranza's clinical periodontology 11th edition | publisher=Elsevier Saunders | author=Newman, MG | year=2012 | location=St. Louis, Missouri | isbn=978-1-4377-0416-7}}</ref>{{rp|437–438}}

=====Pericoronitis=====
{{multiple image
| align     = right
| direction = vertical
| header    = Clinical & xray correlation of pericoronitis
| width     = 175
| image1    = 38 pericoronitis with pus.jpg
| alt1      = clinical shot of pericoronitis
| caption1  = An operculum (green arrow) over a partially erupted lower left third molar tooth. There is minimal inflammation and recurrent swelling.
| image2    = 38 pericornitis xray.jpg
| alt2      = xray of pericoronitis
| caption2  = A radiograph of the above tooth showing chronic pericoronitis, operculum (blue arrow) and bone destruction (red arrow) from chronic inflammation. Tooth is slightly disto-angular.
}}
[[Pericoronitis]] is inflammation of the soft tissues surrounding the crown of a partially erupted tooth.<ref name=Douglass2003>{{cite journal|last=Douglass|first=AB|author2=Douglass, JM |title=Common dental emergencies.|journal=American Family Physician|date=February 1, 2003|volume=67|issue=3|pages=511–6|pmid=12588073}}</ref> The lower [[wisdom tooth]] is the last tooth to erupt into the mouth, and is, therefore, more frequently impacted, or stuck, against the other teeth. This leaves the tooth partially erupted into the mouth, and there frequently is a flap of gum (an operculum), overlying the tooth. Bacteria and food debris accumulate beneath the operculum, which is an area that is difficult to keep clean because it is hidden and far back in the mouth. The opposing upper wisdom tooth also tends to have sharp cusps and over-erupt because it has no opposing tooth to bite into, and instead traumatizes the operculum further. Periodontitis and dental caries may develop on either the third or second molars, and chronic inflammation develops in the soft tissues. Chronic pericoronitis may not cause any pain, but an acute pericoronitis episode is often associated with pericoronal abscess formation. Typical signs and symptoms of a pericoronal abscess include severe, throbbing pain, which may radiate to adjacent areas in the head and neck,<ref name="Carranza11th"/><ref name="Fragiskos 2007" />{{rp|122}} redness, swelling and tenderness of the gum over the tooth.<ref name="Wray 2003">{{cite book|vauthors=Wray D, Stenhouse D, Lee D, Clark AJ |title=Textbook of general and oral surgery|year=2003|publisher=Churchill Livingstone|location=Edinburgh [etc.]|isbn=978-0-443-07083-9}}</ref>{{rp|220–222}} There may be [[trismus]] (difficulty opening the mouth),<ref name="Wray 2003" />{{rp|220–222}} facial swelling, and [[rubor]] (flushing) of the cheek that overlies the angle of the jaw.<ref name="Carranza11th"/><ref name="Fragiskos 2007">{{cite book|author=Fragiskos FD|title=Oral surgery|year=2007|publisher=Springer|location=Berlin|isbn=978-3-540-25184-2|url=https://books.google.com/books?id=wJHV_TqpL_sC&q=9783540251842}}</ref>{{rp|122}} Persons typically develop pericoronitis in their late teens and early 20s,<ref name=Zakrzewska2009 />{{rp|6}} as this is the age that the wisdom teeth are erupting. Treatment for acute conditions includes cleaning the area under the operculum with an antiseptic solution, painkillers, and antibiotics if indicated. After the acute episode has been controlled, the definitive treatment is usually by tooth extraction or, less commonly, the soft tissue is removed (operculectomy). If the tooth is kept, good oral hygiene is required to keep the area free of debris to prevent recurrence of the infection.<ref name="Carranza11th"/>{{rp|440–441}}

=====Occlusal trauma=====
[[Occlusal trauma]] results from excessive biting forces exerted on teeth, which overloads the periodontal ligament, causing periodontal pain and a reversible increase in tooth mobility. Occlusal trauma may occur with [[bruxism]], the [[parafunctional habit|parafunctional]] (abnormal) clenching and grinding of teeth during sleep or while awake. Over time, there may be [[attrition (dental)|attrition]] ([[tooth wear]]), which may also cause dentin hypersensitivity, and possibly formation of a periodontal abscess, as the occlusal trauma causes adaptive changes in the [[alveolar bone]].<ref name="Carranza11th"/>{{rp|153–154}}

Occlusal trauma often occurs when a newly placed [[dental restoration]] is built too "high", concentrating the biting forces on one tooth. Height differences measuring less than a millimeter can cause pain. Dentists, therefore, routinely check that any new restoration is in harmony with the bite and forces are distributed correctly over many teeth using [[articulating paper]]. If the high spot is quickly eliminated, the pain disappears and there is no permanent harm.<ref name="Carranza11th"/>{{rp|153,753}} Over-tightening of [[Dental braces|braces]] can cause periodontal pain and, occasionally, a periodontal abscess.<ref name="Carranza11th"/>{{rp|503}}

=====Alveolar osteitis=====
[[Alveolar osteitis]] is a complication of tooth extraction (especially lower wisdom teeth) in which the blood clot is not formed or is lost, leaving the socket where the tooth used to be empty, and bare bone is exposed to the mouth.<ref name=":0">{{Cite journal |last1=Daly |first1=Blánaid Jm |last2=Sharif |first2=Mohammad O. |last3=Jones |first3=Kate |last4=Worthington |first4=Helen V. |last5=Beattie |first5=Anna |date=2022-09-26 |title=Local interventions for the management of alveolar osteitis (dry socket) |journal=The Cochrane Database of Systematic Reviews |volume=2022 |issue=9 |pages=CD006968 |doi=10.1002/14651858.CD006968.pub3 |issn=1469-493X |pmc=9511819 |pmid=36156769}}</ref> The pain is moderate to severe, and dull, aching, and throbbing in character. The pain is localized to the socket, and may radiate. It normally starts two to four days after the extraction, and may last 10–40 days.<ref name=Neville2001 /><ref name="Fragiskos 2007" />{{rp|122}}<ref name="Wray 2003" />{{rp|216–217}}<ref name=":0" /> Healing is delayed, and it is treated with local anesthetic dressings, which are typically required for five to seven days.<ref name="Wray 2003" />{{rp|216–217}} There is some evidence that [[chlorhexidine]] mouthwash used prior to extractions prevents alveolar osteitis.<ref name=":0" />