Editing Toothache

{{short description|Medical condition of the teeth}}
{{Use mdy dates|date=December 2018}}
{{good article}}
{{Infobox medical condition (new)
| name            = Toothache
| image           = File:Address to the toothache.jpg
| caption         = ''"Thou hell o' a' diseases"'' – [[William Hole (artist)|William Hole]]'s illustration for [[Robert Burns]]' poem "Address to the Toothache" (1897, poem c. 1786).
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| synonyms       =  Odontalgia,<ref name=Mosby2008>{{cite book |title=Mosby's dental dictionary |year=2008 |publisher=Mosby |location=St. Louis, Mo.|isbn=978-0-323-04963-4 |edition=2nd |vauthors=Duncan L, Sprehe C }}</ref> dentalgia,<ref name=Mosby2008 /> odontodynia,<ref name=Mosby2008 /> odontogenic pain<ref name=Tollison2001>{{cite book |vauthors=Tollison CD, Satterthwaite JR, Tollison JW |title=Practical pain management |year=2001|publisher=Lippincott Williams & Wilkins |location=Philadelphia |isbn=978-0-7817-3160-7 |url=https://books.google.com/books?id=BbmI8FCssdEC&q=toothache+(odontogenic+pain)&pg=PA369 |edition=3rd}}</ref>{{rp|396}}|  field           = [[Dentistry]] 
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<!-- Definition and symptoms -->
'''Toothaches''', also known as '''dental pain''' or '''tooth pain''',<ref name=McGraw-Hill2002>Segen JC. (2002). ''McGraw-Hill Concise Dictionary of Modern Medicine''.  The McGraw-Hill Companies.</ref> is [[pain]] in the [[teeth]] or their supporting structures, caused by [[dental disease]]s or [[referred pain|pain referred]] to the teeth by non-dental diseases. When severe it may impact sleep, eating, and other daily activities.

<!-- Causes and diagnosis -->
Common causes include [[pulpitis|inflammation of the pulp]], (usually in response to [[dental caries|tooth decay]], [[dental trauma]], or other factors), [[dentin hypersensitivity]], [[apical periodontitis]] (inflammation of the [[periodontal ligament]] and [[alveolar bone]] around the [[Root apex (dental)|root apex]]), [[dental abscess]]es (localized collections of [[pus]]), [[alveolar osteitis]] ("dry socket", a possible complication of [[dental extraction|tooth extraction]]), [[acute necrotizing ulcerative gingivitis]] (a gum infection), and [[temporomandibular disorder]].<ref>{{Cite journal|last1=Allison|first1=J. R.|last2=Stone|first2=S. J.|last3=Pigg|first3=M.|date=November 2020|title=The painful tooth: mechanisms, presentation and differential diagnosis of odontogenic pain|journal=Oral Surgery|language=en|volume=13|issue=4|pages=309–320|doi=10.1111/ors.12481|issn=1752-2471|doi-access=free}}</ref>
 
<!-- Diagnosis -->
Pulpitis is reversible when the pain is mild to moderate and lasts for a short time after a stimulus (for instance cold); or irreversible when the pain is severe, spontaneous, and lasts a long time after a stimulus. Left untreated, pulpitis may become irreversible, then progress to [[pulp necrosis]] (death of the pulp) and apical periodontitis. Abscesses usually cause throbbing pain. The apical abscess usually occurs after pulp necrosis, the pericoronal abscess is usually associated with acute [[pericoronitis]] of a lower [[wisdom tooth]], and periodontal abscesses usually represent a complication of [[chronic periodontitis]] (gum disease). Less commonly, non-dental conditions can cause toothache, such as [[sinusitis|maxillary sinusitis]], which can cause pain in the upper back teeth, or [[angina pectoris]], which can cause pain in the lower teeth. Correct diagnosis can sometimes be challenging.

<!-- Treatment, epidemiology, and history -->
Proper [[oral hygiene]] helps to prevent toothache by preventing dental disease. The treatment of a toothache depends upon the exact cause, and may involve a [[dental restoration|filling]], [[root canal treatment]], [[tooth extraction|extraction]], drainage of pus, or other remedial action. The relief of toothache is considered one of the main responsibilities of dentists.<ref name="Wolf2012" /> Toothache is the most common type of [[orofacial pain|pain in the mouth or face]].<ref name=Scully2013>{{cite book|author=Scully C|title=Oral and maxillofacial medicine : the basis of diagnosis and treatment|year=2013|publisher=Churchill Livingstone/Elsevier|location=Edinburgh|isbn=978-0-7020-4948-4|edition=3rd|url=https://books.google.com/books?id=U3WyAFrXVfIC&q=oral+and+maxillofacial+medicine}}</ref>{{rp|125–135}} It is one of the most common reasons for emergency dental appointments.<ref name=Fedorowicz2016>{{Cite journal|last1=Agnihotry|first1=Anirudha|last2=Fedorowicz|first2=Zbys|last3=van Zuuren|first3=Esther J.|last4=Farman|first4=Allan G.|last5=Al-Langawi|first5=Jassim Hasan|date=2016-02-17|title=Antibiotic use for irreversible pulpitis|journal=The Cochrane Database of Systematic Reviews|volume=2|pages=CD004969|doi=10.1002/14651858.CD004969.pub4|issn=1469-493X|pmid=26886473}}</ref> In 2013, 223 million cases of toothache occurred as a result of dental caries in permanent teeth and 53&nbsp;million cases occurred in baby teeth.<ref>{{cite journal|title=Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013.|journal=Lancet|date=August 22, 2015|volume=386|issue=9995|pages=743–800|pmid=26063472|doi=10.1016/S0140-6736(15)60692-4|pmc=4561509 |last1=Vos |first1=Theo |last2=Barber |first2=Ryan M. |last3=Bell |first3=Brad |last4=Bertozzi-Villa |first4=Amelia |last5=Biryukov |first5=Stan |last6=Bolliger |first6=Ian |last7=Charlson |first7=Fiona |last8=Davis |first8=Adrian |last9=Degenhardt |first9=Louisa |last10=Dicker |first10=Daniel |last11=Duan |first11=Leilei |last12=Erskine |first12=Holly |last13=Feigin |first13=Valery L. |last14=Ferrari |first14=Alize J. |last15=Fitzmaurice |first15=Christina |last16=Fleming |first16=Thomas |last17=Graetz |first17=Nicholas |last18=Guinovart |first18=Caterina |last19=Haagsma |first19=Juanita |last20=Hansen |first20=Gillian M. |last21=Hanson |first21=Sarah Wulf |last22=Heuton |first22=Kyle R. |last23=Higashi |first23=Hideki |last24=Kassebaum |first24=Nicholas |last25=Kyu |first25=Hmwe |last26=Laurie |first26=Evan |last27=Liang |first27=Xiofeng |last28=Lofgren |first28=Katherine |last29=Lozano |first29=Rafael |last30=MacIntyre |first30=Michael F. |display-authors=1 }}</ref> Historically, the demand for treatment of toothache is thought to have led to the emergence of [[dentistry|dental surgery]] as the first specialty of medicine.<ref name=Suddick1990 /> 
{{TOC limit}}

==Causes==
Toothache may be caused by ''dental'' (''odontogenic'') conditions (such as those involving the dentin-pulp complex or [[periodontium]]), or by ''non-dental'' (''non-odontogenic'') conditions (such as [[sinusitis|maxillary sinusitis]] or [[angina pectoris]]). There are many possible non-dental causes, but the vast majority of toothache is dental in origin.<ref name=Hargreaves2011>{{cite book|vauthors=Hargreaves KM, Cohen S, Berman LH |title=Cohen's pathways of the pulp|year=2011|publisher=Mosby Elsevier|location=St. Louis, Mo.|isbn=978-0-323-06489-7|url=https://books.google.com/books?id=JI7gSo5zcWEC|edition=10th}}</ref>{{rp}}

Both the pulp and periodontal ligament have [[nociceptor]]s (pain receptors),<ref name=Shephard2014>{{cite journal|vauthors=Shephard MK, MacGregor EA, Zakrzewska JM |title=Orofacial Pain: A Guide for the Headache Physician|journal=Headache: The Journal of Head and Face Pain|date=January 2014|volume=54|issue=1|pages=22–39|doi=10.1111/head.12272|pmid=24261452|s2cid=44571343}}</ref> but the pulp lacks [[proprioceptor]]s (motion or position receptors) and [[mechanoreceptor]]s (mechanical pressure receptors).<ref name=Scully2013 />{{rp|125–135}}<ref name=Cawson2008 /> Consequently, pain originating from the dentin-pulp complex tends to be poorly localized,<ref name="Cawson2008">{{Cite book | isbn = 978-0702040016 | title = Cawson's essentials of oral pathology and oral medicine | last1 = Cawson | first1 = RA | year = 2008 | publisher = Churchill Livingstone | location = Edinburgh | page = 70  }}</ref> whereas pain from the periodontal ligament will typically be well localized,<ref name=Hargreaves2011 />{{rp|55}} although not always.<ref name=Scully2013 />{{rp|125–135}}

For instance, the periodontal ligament can detect the pressure exerted when biting on something smaller than a grain of sand (10–30&nbsp;μm).<ref name=Lindhe2008>{{cite book|title=Clinical periodontology and implant dentistry|year=2008|publisher=Blackwell Munksgaard|location=Oxford|isbn=9781444313048|vauthors=Lindhe J, Lang NP, Karring T |edition=5th}}</ref>{{rp|48}} When a tooth is intentionally stimulated, about 33% of people can correctly identify the tooth, and about 20% cannot narrow the stimulus location down to a group of three teeth.<ref name=Hargreaves2011 />{{rp|31}} Another typical difference between pulpal and periodontal pain is that the latter is not usually made worse by thermal stimuli.<ref name=Scully2013 />{{rp|125–135}}

===Dental===
[[File:Pulpitis-gif.gif|thumb|right|[[Natural history of disease|Natural history]] of dental caries and resultant toothache and odontogenic infection.]]

====Pulpal====
The majority of pulpal toothache falls into one of the following types; however, other rare causes (which do not always fit neatly into these categories) include [[galvanic pain]] and [[barodontalgia]].

====Pulpitis====
[[Pulpitis]] (inflammation of the pulp) can be triggered by various stimuli (insults), including mechanical, thermal, chemical, and bacterial irritants, or rarely [[Aerodontalgia|barometric changes]] and [[ionizing radiation]].<ref name=Neville2001>{{cite book|vauthors=Neville BW, Damm DD, Allen CA, Bouquot JE |title=Oral & maxillofacial pathology|year=2002|publisher=W.B. Saunders|location=Philadelphia|isbn=978-0-7216-9003-2|edition=2nd}}</ref>{{rp}} Common causes include tooth decay, dental trauma (such as a crack or fracture), or a filling with an imperfect seal.

Because the pulp is encased in a rigid outer shell, there is no space to accommodate swelling caused by inflammation. Inflammation therefore increases pressure in the pulp system, potentially compressing the blood vessels which supply the pulp.  This may lead to [[ischemia]] (lack of oxygen) and [[necrosis]] (tissue death). Pulpitis is termed ''reversible'' when the inflamed pulp is capable of returning to a state of health, and ''irreversible'' when [[pulp necrosis]] is inevitable.<ref name=Hargreaves2011 />{{rp|36–37}}

Reversible pulpitis is characterized by short-lasting pain triggered by cold and sometimes heat.<ref name=Cawson2008 /> The symptoms of reversible pulpitis may disappear, either because the noxious stimulus is removed, such as when dental decay is removed and a filling placed, or because new layers of dentin ([[tertiary dentin]]) have been produced inside the pulp chamber, insulating against the stimulus. Irreversible pulpitis causes spontaneous or lingering pain in response to cold.<ref name="Hupp 2008">{{cite book|vauthors=Hupp JR, Ellis E, Tucker MR |title=Contemporary oral and maxillofacial surgery|year=2008|publisher=Mosby Elsevier|location=St. Louis, Mo.|isbn=978-0-323-04903-0|edition=5th}}</ref>{{rp|619–627}}

====Dentin hypersensitivity====
[[Dentin hypersensitivity]] is a sharp, short-lasting dental pain occurring in about 15% of the population,<ref name=Poulsen2006>{{cite journal|vauthors=Poulsen S, Errboe M, Lescay Mevil Y, Glenny AM |title=Potassium containing toothpastes for dentine hypersensitivity.|journal=The Cochrane Database of Systematic Reviews|date=July 19, 2006|volume=2006 |issue=3|pages=CD001476|pmid=16855970|doi=10.1002/14651858.CD001476.pub2|pmc=7028007}}</ref> which is triggered by cold (such as liquids
or air), sweet or spicy foods, and beverages.<ref>{{cite journal|title=Dentin hypersensitivity: Recent trends in management.|journal=[[Journal of Conservative Dentistry]]|date=October 2010|volume=13|issue=4|pages=218–24|pmid=21217949|vauthors=Miglani S, Aggarwal V, Ahuja B |pmc=3010026|doi=10.4103/0972-0707.73385 |doi-access=free }}</ref><!--I don't think the parallelism in this list makes sense anymore -- can all beverages of any type cause toothache? unlikely. Needs to be reworked so that list makes sense--> Teeth will normally have some sensation to these triggers,<ref name=Napenas2013 /> but what separates hypersensitivity from regular tooth sensation is the intensity of the pain. Hypersensitivity is most commonly caused by a lack of insulation from the triggers in the mouth due to [[gingival recession]] (receding gums) exposing the roots of the teeth, although it can occur after [[scaling and root planing]] or [[dental bleaching]], or as a result of [[Acid erosion|erosion]].<ref name=Petersson2013>{{cite journal|title=The role of fluoride in the preventive management of dentin hypersensitivity and root caries.|journal=Clinical Oral Investigations|date=March 2013|volume=17|pages=S63–71|doi=10.1007/s00784-012-0916-9|pmid=23271217|author=Petersson LG|issue=Suppl 1 |pmc=3586140}}</ref> The pulp of the tooth remains normal and healthy in dentin hypersensitivity.<ref name="Hargreaves2011" />{{rp|510}}

Many topical treatments for dentin hypersensitivity are available, including desensitizing toothpastes and protective varnishes that coat the exposed dentin surface.<ref name=Poulsen2006 /> Treatment of the [[root cause analysis|root cause]] is critical, as topical measures are typically short lasting.<ref name=Hargreaves2011 />{{rp|510}} Over time, the pulp usually adapts by producing new layers of dentin inside the pulp chamber called tertiary dentin, increasing the thickness between the pulp and the exposed dentin surface and lessening the hypersensitivity.<ref name=Hargreaves2011 />{{rp|510}}

====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" />

====Combined pulpal-periodontal====
=====Dental trauma and cracked tooth syndrome=====
[[File:Cracked tooth.png|thumb|right|Crown-root fracture with pulp involvement (left). Extracted (right).]]
[[Cracked tooth syndrome]] refers to a highly variable<ref name=Mathew2012>{{cite journal|vauthors=Mathew S, Thangavel B, Mathew CA, Kailasam S, Kumaravadivel K, Das A |title=Diagnosis of cracked tooth syndrome.|journal=Journal of Pharmacy & Bioallied Sciences|date=August 2012|volume=4|issue=Suppl 2|pages=S242–4|pmid=23066261|doi=10.4103/0975-7406.100219|pmc=3467890 |doi-access=free }}</ref> set of pain-sensitivity symptoms that may accompany a tooth fracture, usually sporadic, sharp pain that occurs during biting or with release of biting pressure,<ref name=Banerji2010>{{cite journal|vauthors=Banerji S, Mehta SB, Millar BJ |title=Cracked tooth syndrome. Part 1: aetiology and diagnosis.|journal=British Dental Journal|date=May 22, 2010|volume=208|issue=10|pages=459–63|pmid=20489766|doi=10.1038/sj.bdj.2010.449|doi-access=free}}</ref> or relieved by releasing pressure on the tooth.<ref name=Hargreaves2011 />{{rp|24}} The term is falling into disfavor and has given way to the more generalized description of fractures and cracks of the tooth, which allows for the wide variations in signs, symptoms, and prognosis for traumatized teeth. A fracture of a tooth can involve the enamel, dentin, and/or pulp, and can be orientated horizontally or vertically.<ref name=Hargreaves2011 />{{rp|24–25}} Fractured or cracked teeth can cause pain via several mechanisms, including dentin hypersensitivity, pulpitis (reversible or irreversible), or periodontal pain. Accordingly, there is no single test or combination of symptoms that accurately diagnose a fracture or crack, although when pain can be stimulated by causing separation of the cusps of the tooth, it's highly suggestive of the disorder.<ref name=Hargreaves2011 />{{rp|27–31}} Vertical fractures can be very difficult to identify because the crack can rarely be probed<ref name=Hargreaves2011 />{{rp|27}} or seen on radiographs, as the fracture runs in the plane of conventional films (similar to how the split between two adjacent panes of glass is invisible when facing them).<ref name=Hargreaves2011 />{{rp|28–9}}

When toothache results from [[dental trauma]] (regardless of the exact pulpal or periodontal diagnosis), the treatment and prognosis is dependent on the extent of damage to the tooth, the stage of development of the tooth, the degree of displacement or, when the tooth is avulsed, the time out of the socket and the starting health of the tooth and bone.  Because of the high variation in treatment and prognosis, dentists often use trauma guides to help determine prognosis and direct treatment decisions.<ref name="AAETrauma">{{cite web | url=http://www.nxtbook.com/nxtbooks/aae/traumaguidelines/ | title=The recommended guidelines of the American Association of Endodontists for the treatment of traumatic dental injuries | publisher=American Association of Endodontists | date=September 2013 | access-date=January 17, 2014 | pages=1–15 | archive-date=January 8, 2014 | archive-url=https://web.archive.org/web/20140108050117/http://www.nxtbook.com/nxtbooks/aae/traumaguidelines/ | url-status=dead }}</ref><ref name="traumaguide">{{cite web | url=http://dentaltraumaguide.org | title=Dental Trauma Guide | publisher=Rigshospitalet Region Hospital, Denmark, University of Copenhagen and the International Association of Dental Traumatology | access-date=January 15, 2014}}</ref>

The prognosis for a cracked tooth varies with the extent of the fracture. Those cracks that are irritating the pulp but do not extend through the pulp chamber can be amenable to stabilizing dental restorations such as a crown or [[Dental composite|composite resin]].  Should the fracture extend though the pulp chamber and into the root, the prognosis of the tooth is hopeless.<ref name=Hargreaves2011/>{{rp|25}}

=====Periodontic-endodontic lesion=====
Apical abscesses can spread to involve periodontal pockets around a tooth, and periodontal pockets cause eventual pulp necrosis via accessory canals or the apical foramen at the bottom of the tooth. Such lesions are termed [[Combined periodontic-endodontic lesions|periodontic-endodontic lesion]]s, and they may be acutely painful, sharing similar signs and symptoms with a periodontal abscess, or they may cause mild pain or no pain at all if they are chronic and free-draining.<ref>{{cite journal|last=Singh|first=P|title=Endo-perio dilemma: a brief review.|journal=Dental Research Journal|date=Winter 2011|volume=8|issue=1|pages=39–47|pmid=22132014|pmc=3177380}}</ref> Successful root canal therapy is required before periodontal treatment is attempted.<ref name="Carranza11th"/>{{rp|49}} Generally, the long-term prognosis of perio-endo lesions is poor.

===Non-dental===
[[File:Angina pectoris.png|thumb|right|Discomfort caused by coronary artery disease can radiate to the neck, lower jaw and teeth]]
{{See also|Orofacial pain}}
Non-dental causes of toothache are much less common as compared with dental causes.  In a toothache of neurovascular origin, pain is reported in the teeth in conjunction with a [[migraine]]. Local and distant structures (such as ear, brain, [[carotid artery]], or heart) can also [[referred pain|refer pain]] to the teeth.<ref name=Sharav2008 />{{rp|80,81}} Other non-dental causes of toothache include [[myofascial pain]] (muscle pain) and [[angina pectoris]] (which classically refers pain to the lower jaw).  Very rarely, toothache can be [[psychogenic pain|psychogenic]] in origin.<ref name=Hargreaves2011 />{{rp|57–58}}

Disorders of the [[maxillary sinus]] can be referred to the upper back teeth. The posterior, middle and anterior superior alveolar nerves are all closely associated with the lining of the sinus. The bone between the floor of the maxillary sinus and the roots of the upper back teeth is very thin, and frequently the apices of these teeth disrupt the contour of the sinus floor. Consequently, acute or chronic maxillary [[sinusitis]] can be perceived as maxillary toothache,<ref name=Renton2012 /> and [[neoplasm]]s of the sinus (such as [[adenoid cystic carcinoma]])<ref name=Barnes2009 />{{rp|390}} can cause similarly perceived toothache if malignant invasion of the superior alveolar nerves occurs.<ref name=Regezi2011>{{cite book|vauthors=Regezi JA, Sciubba JJ, Jordan RK |title=Oral pathology : clinical pathologic correlations|year=2011|publisher=Elsevier/Saunders|location=St. Louis, Mo.|isbn=978-1-4557-0262-6|edition=6th}}</ref>{{rp|72}} Classically, sinusitis pain increases upon [[Valsalva maneuver]]s or tilting the head forward.<ref name=Ferguson2014>{{cite journal|last1=Ferguson|first1=M|title=Rhinosinusitis in oral medicine and dentistry.|journal=Australian Dental Journal|date=May 23, 2014|pmid=24861778|doi=10.1111/adj.12193|volume=59|issue=3|pages=289–295|doi-access=free}}</ref>

Painful conditions which do not originate from the teeth or their supporting structures may affect the oral mucosa of the gums and be interpreted by the individual as toothache. Examples include neoplasms of the gingival or [[alveolar mucosa]] (usually [[squamous cell carcinoma]]),<ref name=Barnes2009>{{cite book|author=Barnes L|title=Surgical pathology of the head and neck|year=2009|publisher=Informa healthcare|location=New York|isbn=978-1-4200-9163-2|edition=3rd}}</ref>{{rp|299}} conditions which cause [[gingivostomatitis]] and [[desquamative gingivitis]]. Various conditions may involve the alveolar bone, and cause non-odontogenic toothache, such as [[Burkitt's lymphoma]],<ref name=Regezi2011 />{{rp|340}} [[Infarction|infarct]]s in the jaws caused by [[sickle cell disease]],<ref name=Scully2010>{{cite book|author=Scully C|title=Medical problems in dentistry|year=2010|publisher=Churchill Livingstone|location=Edinburgh|isbn=978-0-7020-3057-4|url=https://books.google.com/books?id=PHLvOVaB0AEC&q=medical+problems+in+dentistry|edition=6th}}</ref>{{rp|214}} and [[osteomyelitis of the jaws|osteomyelitis]].<ref name=Shafer2010>{{cite book|last=Rajendran R|title=Shafer's textbook of oral pathology.|year=2010|publisher=Reed Elsevier|location=[S.l.]|isbn=978-81-312-1570-8}}</ref>{{rp|497}} Various conditions of the trigeminal nerve can masquerade as toothache, including trigeminal [[zoster]] (maxillary or mandibular division),<ref name=Scully2010 />{{rp|487}} [[trigeminal neuralgia]],<ref name=Renton2012>{{cite journal|vauthors=Renton T, Durham J, Aggarwal VR |title=The classification and differential diagnosis of orofacial pain.|journal=Expert Review of Neurotherapeutics|date=May 2012|volume=12|issue=5|pages=569–76|pmid=22550985|doi=10.1586/ern.12.40|s2cid=32890328}}</ref> [[cluster headache]],<ref name=Renton2012 /> and trigeminal [[neuropathy|neuropathies]].<ref name=Renton2012 /> Very rarely, a [[brain tumor]] might cause toothache.<ref name=Sharav2008 />{{rp|80,81}} Another chronic facial pain syndrome which can mimic toothache is [[temporomandibular disorder]] (temporomandibular joint pain-dysfunction syndrome),<ref name=Renton2012 /> which is very common.  Toothache which has no identifiable dental or medical cause is often termed [[atypical odontalgia]], which, in turn, is usually considered a type of atypical facial pain (or persistent idiopathic facial pain).<ref name=Renton2012 /> Atypical odontalgia may give very unusual symptoms, such as pain which migrates from one tooth to another and which crosses anatomical boundaries (such as from the left teeth to the right teeth). {{citation needed|date=April 2014}}

==Pathophysiology==
{{multiple image
| align     = right
| direction = vertical
| width     = 180

| image1    = Cross sections of teeth labels.png|
| caption1  = 1: crown, 2: root, 3: enamel, 4: dentin and dentin tubules, 5: pulp chamber, 6: blood vessels and nerve within root canal, 7: periodontal ligament, 8: apex and periapical region, 9: alveolar bone.

| image2    = Innervation of the dentition.png
| caption2  = V<sup>2</sup>: [[maxillary nerve|maxillary division]] of trigeminal nerve, V<sup>3</sup>: [[mandibular nerve|mandibular division]] of trigeminal nerve, A: the [[superior alveolar nerves]] and [[superior dental plexus|plexus]], B: the [[inferior alveolar nerve]] and [[inferior dental plexus|plexus]] running in the body of the mandible.

| image3    = Pulpal dentin junction.png
| caption3  = Dentin-pulp complex. 1: tooth/enamel, 2: dentin tubule, 3: dentin, 4: odontoblastic process, 5: predentin, 6: [[odontoblast]], 7: capillaries, 8: [[fibroblast]]s, 9: nerve, 10: artery/vein, 11: cell-rich zone, 12: cell-poor zone, 13: pulp chamber.}}
<!-- basic dental anatomy -->
A tooth is composed of an outer shell of [[calcification|calcified]] hard [[Tissue (biology)|tissue]]s (from hardest to softest: [[Tooth enamel|enamel]], [[dentin]], and [[cementum]]), and an inner [[soft tissue]] core (the pulp system), which contains [[nerve]]s and [[blood vessel]]s. The visible parts of the teeth in the mouth – the crowns (covered by enamel) – are anchored into the bone by the [[Dental anatomy#Crown and root|roots]] (covered by cementum). Underneath the cementum and enamel layers, dentin forms the bulk of the tooth and surrounds the pulp system. The part of the pulp inside the crown is the [[pulp chamber]], and the central soft tissue nutrient canals within each root are [[root canal]]s, exiting through one or more holes at the root end ([[apical foramen]]/foramina). The [[periodontal ligament]] connects the roots to the bony socket. The [[gingiva]] covers the [[alveolar process]]es, the tooth-bearing arches of the jaws.<ref name=Kumar2004>{{cite book|title=Textbook of Dental Anatomy and Tooth Morphology|year=2004|publisher=Jaypee Brothers Publishers|isbn=9788180612299|url=https://books.google.com/books?id=vWgQ28cQtRQC&q=Textbook+of+Dental+Anatomy+and+Tooth+Morphology|author=Kumar PS}}{{Dead link|date=August 2024 |bot=InternetArchiveBot |fix-attempted=yes }}</ref>{{rp|1–5}}

<!-- dentin feels pain, enamel doesn't -->
Enamel is not a vital tissue, as it lacks blood vessels, nerves, and living cells.<ref name=Napenas2013 /> Consequently, pathologic processes involving only enamel, such as shallow cavities or cracks, tend to be painless.<ref name=Napenas2013 /> Dentin contains many microscopic tubes containing fluid and the processes of [[odontoblast]] cells, which communicate with the pulp. Mechanical, [[Osmosis|osmotic]], or other stimuli cause movement of this fluid, triggering nerves in the pulp (the "[[Fluid dynamics|hydrodynamic]] theory" of pulp sensitivity).<ref name=Petersson2013 /> Due to the close relationship between dentin and pulp, they are frequently considered together as the ''dentin-pulp complex''.<ref name=Tencate2008>{{cite book|author=Nanci A|title=Oral histology: development, structure, and function.|year=2008|publisher=Mosby|location=St. Louis, Mo.|isbn=978-0-323-04557-5|url=https://books.google.com/books?id=nLW3Ts_TDpEC&q=dentin+pulp+complex&pg=PA191|edition=7th}}</ref>{{rp|118}}

<!-- physiologic sensitivity vs pain from disease -->
The teeth and gums exhibit normal sensations in health. Such sensations are generally sharp, lasting as long as the stimulus.<ref name=Napenas2013 /> There is a continuous spectrum from physiologic sensation to pain in disease.<ref name=Napenas2013 /> Pain is an unpleasant sensation caused by intense or damaging events. In a toothache, nerves are stimulated by either [[exogenous]] sources (for instance, bacterial toxins, [[Metabolism|metabolic]] byproducts, chemicals, or trauma) or [[endogenous]] factors (such as [[inflammation|inflammatory mediators]]).<ref name=Hargreaves2011 />{{rp|532–534}}

<!-- pain pathway from teeth to brain + pain definitions -->
The pain pathway is mostly transmitted via [[myelin]]ated [[A delta fiber|Aδ]] (sharp or stabbing pain) and unmyelinated [[Group C nerve fiber|C]] [[nerve fiber]]s (slow, dull, aching, or burning pain) of the [[trigeminal nerve]], which supplies sensation to the teeth and gums via many divisions and branches.<ref name=Napenas2013 /> Initially, pain is felt while noxious stimuli are applied (such as cold). Continued exposure decreases firing thresholds of the nerves, allowing normally non-painful stimuli to trigger pain ([[allodynia]]). Should the insult continue, noxious stimuli produce larger discharges in the nerve, perceived as more intense pain. Spontaneous pain may occur if the firing threshold is decreased so it can fire without stimulus ([[hyperalgesia]]). The physical component of pain is processed in the [[brainstem|medullary spinal cord]] and perceived in the [[frontal cortex]]. Because pain perception involves overlapping sensory systems and an emotional component, individual responses to identical stimuli are variable.<ref name=Hargreaves2011 />{{rp|474–475}}

==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>

==Prevention==
Since most toothache is the result of [[dental plaque|plaque-related disease]]s, such as tooth decay and periodontal disease, the majority of cases could be prevented by avoidance of a [[cariogenic]] diet and maintenance of good [[oral hygiene]]. That is, reduction in the number times that refined sugars are consumed per day and brushing the teeth twice a day with [[fluoride]] toothpaste and [[Oral hygiene#Interdental brushes|interdental cleaning]]. Regular visits to a dentist also increases the likelihood that problems are detected early and averted before toothache occurs. Dental trauma could also be significantly reduced by routine use of [[mouthguard]]s in [[contact sport]]s.<ref name=Douglass2003 />

==Management==
[[File:Root canal treatment.jpg|thumb|Root canal treatment (blue arrows) carried out on the lower right first molar with temporary restoration in place]]
[[File:Incision and drainage mouth.png|thumb|right|Incision of an abscess above a front tooth and insertion of a [[surgical drain]]]]
[[File:Abces dentaire.jpg|thumb|right|Odontogenic infection involving the [[buccal space]]. Above, deformation of the cheek on the second day. Below, deformation on the third day.]]
{{See also|Dental emergency#Treatment}}
There are many causes of toothache and its diagnosis is a specialist topic, meaning that attendance at a dentist is usually required. Since many cases of toothache are inflammatory in nature, [[Over-the-counter drug|over the counter]] [[non-steroidal anti-inflammatory drug]]s (NSAIDs) may help (unless [[contraindication|contraindicated]], such as with a [[peptic ulcer]]).  Generally, NSAIDs are as effective as [[aspirin]] alone or in combination with [[codeine]].<ref name=Hargreaves2011 />{{rp|41–43}} However, simple analgesics may have little effect on some causes of toothache, and the severe pain can drive individuals to exceed the maximum dose. For example, when [[acetaminophen]] (paracetamol) is taken for toothache, an accidental overdose is more likely to occur when compared to people who are taking acetaminophen for other reasons.<ref name=Vogel2011>{{cite journal|title=Dental pain as a risk factor for accidental acetaminophen overdose: a case-control study.|journal=The American Journal of Emergency Medicine|date=November 2011|volume=29|issue=9|pages=1125–9|doi=10.1016/j.ajem.2010.08.006|pmid=20951526|vauthors=Vogel J, Heard KJ, Carlson C, Lange C, Mitchell G |pmc=3033464}}</ref> Another risk in persons with toothache is a painful chemical burn of the [[oral mucosa]] caused by holding a caustic substance such as aspirin tablets and toothache remedies containing [[eugenol]] (such as [[Oil of cloves|clove oil]]) against the gum.<ref name="Neville2001" /> Although the logic of placing a tablet against the painful tooth is understandable, an aspirin tablet needs to be swallowed to have any pain-killing effect. Caustic toothache remedies require careful application to the tooth only, without coming into excessive contact with the soft tissues of the mouth.{{citation needed|date=April 2014}}

For the dentist, the goal of treatment generally is to relieve the pain, and wherever possible to preserve or restore function. The treatment depends on the cause of the toothache, and frequently a clinical decision regarding the current state and long-term prognosis of the affected tooth, as well as the individual's wishes and ability to cope with dental treatment, will influence the treatment choice. Often, administration of an intra-oral local anesthetic such as [[lidocaine]] and [[epinephrine]] is indicated in order to carry out pain-free treatment. Treatment may range from simple advice, removal of dental decay with a [[dental drill]] and subsequent placement of a filling, to root canal treatment, tooth extraction, or debridement.

===Pulpitis and its sequalae===
In pulpitis, an important distinction in regard to treatment is whether the inflammation is reversible or irreversible. Treatment of reversible pulpitis is by removing or correcting the causative factor. Usually, the decay is removed, and a sedative dressing is used to encourage the pulp to return to a state of health,<ref name=Hargreaves2011 />{{rp|41}} either as a base underneath a permanent filling or as a temporary filling intended to last for a period while the tooth is observed to see if pulpitis resolves. Irreversible pulpitis and its sequalae pulp necrosis and apical periodontitis require treatment with root canal therapy or tooth extraction, as the pulp acts as a [[Locus of infection#Locus|nidus]] of infection, which will lead to a chronic infection if not removed.  Generally, there is no difference in outcomes between whether the root canal treatment is completed in one or multiple appointments.<ref>{{Cite journal |last1=Mergoni |first1=Giovanni |last2=Ganim |first2=Martina |last3=Lodi |first3=Giovanni |last4=Figini |first4=Lara |last5=Gagliani |first5=Massimo |last6=Manfredi |first6=Maddalena |date=2022-12-13 |title=Single versus multiple visits for endodontic treatment of permanent teeth |journal=The Cochrane Database of Systematic Reviews |volume=12 |issue=12 |pages=CD005296 |doi=10.1002/14651858.CD005296.pub4 |issn=1469-493X |pmc=9747194 |pmid=36512807}}</ref> The field of [[regenerative endodontics]] is now developing ways to clean the pulp chamber and regenerate the soft and hard tissues to either regrow or simulate pulp structure. This has proved especially helpful in children where the tooth root has not yet finished developing and root canal treatments have lower success rates.<ref name=Hargreaves2011 />{{rp|602–618}}

Reversible/irreversible pulpitis is a distinct concept from whether the tooth is restorable or unrestorable, e.g. a tooth may only have reversible pulpitis, but has been structurally weakened by decay or trauma to the point that it is impossible to restore the tooth in the long term.{{citation needed|date=April 2014}}

===Dental abscesses===
A general principle concerning dental abscesses is ''[[ubi pus, ibi evacua]]'' ("where there is pus, drain it"), which applies to any case where there is a collection of pus in the tissues (such as a periodontal abscess, pericoronal abscess, or apical abscess). The pus within the abscess is under pressure, and the surrounding tissues are deformed and stretched to accommodate the swelling. This leads to a sensation of throbbing (often in time with the pulse) and constant pain. Pus may be evacuated via the tooth by drilling into the pulp chamber (an endodontic access cavity). Such a treatment is sometimes termed open drainage. Drainage can also be performed via the tooth socket, once the causative tooth is extracted. If neither of those measures succeeds, or they are impossible, [[incision and drainage]] may be required, in which a small incision is made in the soft tissues directly over the abscess at the most dependent point. A surgical instrument such as a pair of tweezers is gently inserted into the incision and opened, while the abscess is massaged to encourage the pus to drain out. Usually, the reduction in pain when the pus drains is immediate and marked as the built up pressure is relieved. If the pus drains into the mouth, there is usually a bad or offensive taste.{{citation needed|date=April 2014}}

===Antibiotics===
Antibiotics tend to be extensively used for emergency dental problems.<ref name="Poveda Roda2007">{{cite journal|author=Poveda Roda R, Bagan JV, Sanchis Bielsa JM, Carbonell Pastor, E|title=Antibiotic use in dental practice. A review.|journal=Medicina Oral, Patologia Oral y Cirugia Bucal|date=May 1, 2007|volume=12|issue=3|pages=E186–92|pmid=17468711|url=http://www.medicinaoral.com/pubmed/medoralv12_i3_p186.pdf}}</ref><ref name=Palmer2003>{{cite journal|author=Palmer NA|title=Revisiting the role of dentists in prescribing antibiotics.|journal=Dental Update|date=December 2003|volume=30|issue=10|pages=570–4|pmid=14710570|doi=10.12968/denu.2003.30.10.570}}</ref> As samples for microbiologic [[culture and sensitivity]] are hardly ever carried out in general dental practice, [[broad-spectrum antibiotic]]s such as [[amoxicillin]] are typically used for a short course of about three to seven days.<ref name="Poveda Roda2007" /> Antibiotics are seen as a "quick fix" by both dentists, who generally only have a very short time to manage dental emergencies, and by patients, who tend to want to avoid treatments (such as tooth extraction) which are perceived negatively. However, antibiotics typically only temporarily suppress an infection, and the need for definitive treatment is only postponed for an unpredictable length of time. An estimated 10% of all antibiotic prescriptions are made by dentists, a major factor in [[antibiotic resistance]].<ref name="Poveda Roda2007" /><ref name=Palmer2003 /> They are often used inappropriately,<ref name=Palmer2003 /> in conditions for which they are ineffective, or their risks outweigh the benefits, such as irreversible pulpitis,<ref name=Fedorowicz2013>{{cite journal|vauthors=Fedorowicz Z, van Zuuren EJ, Farman AG, Agnihotry A, Al-Langawi JH |title=Antibiotic use for irreversible pulpitis|journal=The Cochrane Database of Systematic Reviews|date=December 19, 2013|volume=12|issue=12 |pages=CD004969|pmid=24353116|doi=10.1002/14651858.CD004969.pub3|editor1-last=Fedorowicz|editor1-first=Zbys}}</ref>{{Update inline|reason=Updated version https://www.ncbi.nlm.nih.gov/pubmed/26886473|date = July 2018}} apical abscess,<ref name="Hupp 2008" />{{rp|303}} dry socket,<ref name="Hupp 2008" />{{rp|303}} or mild pericoronitis.<ref name="Hupp 2008" />{{rp|303}} However, the reality is that antibiotics are rarely needed,<ref name=Odell2010>{{cite book|author=Odell EW|title=Clinical problem solving in dentistry|year=2010|publisher=Churchill Livingstone|location=Edinburgh|isbn=978-0-443-06784-6|edition=3rd}}</ref>{{rp|230}} and they should be used restrictively in dentistry.<ref name=Koch2009>{{cite book|vauthors=Koch G, Poulsen S |title=Pediatric dentistry a clinical approach|year=2009|publisher=Wiley-Blackwell|location=Chichester, UK|isbn=978-1-118-68719-2|url=https://books.google.com/books?id=7Xdh8wb6zFsC&q=antibiotics+dentistry&pg=PA164|edition=2nd}}</ref>{{rp|164}} Local measures such as incision and drainage, and removal of the cause of the infection (such as a necrotic tooth pulp) have a greater therapeutic benefit and are much more important.<ref name=Odell2010 />{{rp|230}} If abscess drainage has been achieved, antibiotics are not usually necessary.<ref name="Hupp 2008" />{{rp|303}}

Antibiotics tend to be used when local measures cannot be carried out immediately.<ref name="Hupp 2008" />{{rp|303}} In this role, antibiotics suppress the infection until local measures can be carried out.  Severe trismus may occur in when the [[muscles of mastication]] are involved in an odontogenic infection, making any surgical treatment impossible. [[Immunocompromised]] individuals are less able to fight off infections, and antibiotics are usually given.<ref name=Odell2010 />{{rp|232}} Evidence of systemic involvement (such as a fever higher than 38.5&nbsp;°C, cervical lymphadenopathy, or [[malaise]]) also indicates antibiotic therapy, as do rapidly spreading infections, [[cellulitis]], or severe pericoronitis.<ref name="Hupp 2008" />{{rp|303}}<ref name=Odell2010 />{{rp|232}} [[Drooling]] and [[dysphagia|difficulty swallowing]] are signs that the airway may be threatened, and may precede [[dyspnoea|difficulty in breathing]]. [[Ludwig's angina]] and [[cavernous sinus thrombosis]] are rare but serious complications of odontogenic infections. Severe infections tend to be managed in hospital.{{citation needed|date=April 2014}}

==Prognosis==
Most dental pain can be treated with routine dentistry.  In rare cases, toothache can be a symptom representing a life-threatening condition, such as a deep neck infection (compression of the [[airway]] by a spreading [[odontogenic infection]]) or something more remote like a heart attack.{{citation needed|date=April 2014}}

Dental caries, if left untreated, follows a predictable [[Natural history of disease|natural history]] as it nears the pulp of the tooth.  First it causes reversible pulpitis, which transitions to irreversible pulpitis, then to necrosis, then to necrosis with periapical periodontitis and, finally, to necrosis with periapical abscess.  Reversible pulpitis can be stopped by removal of the cavity and the placement of a [[pulp capping|sedative dressing]] of any part of the cavity that is near the pulp chamber.  Irreversible pulpitis and pulp necrosis are treated with either root canal therapy or extraction.  Infection of the periapical tissue will generally resolve with the treatment of the pulp, unless it has expanded to [[cellulitis]] or a [[radicular cyst]].  The success rate of restorative treatment and sedative dressings in reversible pulpitis, depends on the extent of the disease, as well as several technical factors, such as the sedative agent used and whether a rubber dam was used.  The success rate of root canal treatment also depends on the degree of disease (root canal therapy for irreversible pulpitis has a generally higher success rate than necrosis with periapical abscess) and many other technical factors.<ref name=Hargreaves2011 />{{rp|77–82}}

==Epidemiology==
In the United States, an estimated 12% of people reported that they had a toothache at some point in the six months before questioning.<ref name=Hargreaves2011 />{{rp|40}} Individuals aged 18–34 reported much higher rates toothache than those aged 75 or over.<ref name=Zakrzewska2009 />{{rp|6}} In a survey of Australian schoolchildren, 12% had experienced toothache before the age of five, and 32% by the age of 12.<ref name=Zakrzewska2009 />{{rp|6}} Dental trauma is extremely common and tends to occur more often in children than adults.<ref name=Douglass2003 />

Toothache may occur at any age, in any gender and in any geographic region. Diagnosing and relieving toothache is considered one of the main responsibilities of dentists.<ref name=Wolf2012 >{{cite journal|vauthors=Wolf CA, Ramseier CA |title=[The image of the dentist. Part 1: Results of a literature search]|journal=Schweizer Monatsschrift für Zahnmedizin = Revue Mensuelle Suisse d'Odonto-stomatologie = Rivista Mensile Svizzera di Odontologia e Stomatologia / SSO|year=2012|volume=122|issue=2|pages=121–32|pmid=22362180}}</ref> Irreversible pulpitis is thought to be the most common reason that people seek emergency dental treatment.<ref name=Fedorowicz2013 /> Since dental caries associated with pulpitis is the most common cause, toothache is more common in populations that are at higher risk of dental caries. The prevalence of caries in a population is dependent upon factors such as diet (refined sugars), socioeconomic status, and exposure to fluoride (such as areas without [[water fluoridation]]).<ref name=Zakrzewska2009>{{cite book|author=Zakrzewska JM|title=Orofacial pain|year=2009|publisher=Oxford University Press|location=Oxford|isbn=978-0-19-923669-5|url=https://books.google.com/books?id=0lyL1UOfQX4C&q=orofacial+pain}}</ref>{{rp|6}}

==History, society and culture==
[[File:Nuremberg chronicles f 120r 2.png|thumb|right|[[Saint Apollonia]], patron saint for toothaches, holds one of her own extracted teeth in a pair of forceps ([[Nuremberg Chronicle]], [[Hartmann Schedel]], 1493)]]
[[File:Cocaine for kids.png|thumbnail|right|American advertisement from 1885 offering "instantaneous cure" for toothache with "Cocaine toothache drops".<ref>{{cite web|title=Truly Marvelous Mental Medicine, Early remedies|url=http://www.bonkersinstitute.org/medshow/cocainedrops.html|access-date=February 11, 2014}}</ref> [[Cocaine]] was the first [[local anesthetic]], but its addictive and other dangerous side effects eventually led to its use being virtually abandoned by modern health care.]]
[[File:Carl Bloch, En munk, der spejler sig, 1875, 0073NMK, Nivaagaards Malerisamling.jpg|thumb|A monk with a toothache examines himself in a mirror, painting by [[Carl Bloch]] from 1875.<ref>{{Cite web | title = Carl Bloch, A monk examines himself in a mirror, 1875 | publisher = Nivaagaard Collection | url = http://www.nivaagaard.dk/en/samling-en/carl-bloch-1/}}</ref> ]]
The first known mention of tooth decay and toothache occurs on a [[Sumer]]ian clay tablet now referred to as the "Legend of the worm". It was written in [[cuneiform]], recovered from the [[Euphrates]] valley, and dates from around 5000 BC.<ref name=Suddick1990>{{cite journal|vauthors=Suddick RP, Harris NO |title=Historical perspectives of oral biology: a series|journal=Critical Reviews in Oral Biology and Medicine|year=1990|volume=1|issue=2|pages=135–51|doi=10.1177/10454411900010020301|pmid=2129621|doi-access=free}}</ref> The belief that tooth decay and dental pain is caused by [[tooth worm]]s is found in ancient India, Egypt, Japan, and China,<ref name=Suddick1990 /> and persists until the [[Age of Enlightenment]].  Although toothache is an ancient problem,<ref name=Ingle2008>{{cite book|vauthors=Ingle JI, Bakland LK, Baumgartner JC |title=Endodontics|year=2008|publisher=BC Decker|location=Hamilton, Ontario|isbn=978-1-55009-333-9|url=https://books.google.com/books?id=aV1kEf7mlckC&pg=PA392|edition=6th}}</ref>{{rp|48–52}} it is thought that ancient people suffered less dental decay due to a lack of refined sugars in their diet. On the other hand, diets were frequently coarser, leading to more tooth wear.<ref name="Ancient dentistry">{{cite web|title=Ancient dentistry|url=http://www.bda.org/museum/the-story-of-dentistry/ancient-modern/ancient-dentistry.aspx|publisher=British Dental Association 2010|access-date=December 13, 2013|archive-date=December 14, 2013|archive-url=https://web.archive.org/web/20131214003101/http://www.bda.org/museum/the-story-of-dentistry/ancient-modern/ancient-dentistry.aspx|url-status=dead}}</ref> For example, hypotheses hold that ancient Egyptians had a lot of tooth wear due to desert sand blown on the wind mixing with the dough of their bread.<ref>{{cite web|title=Why did the Ancient Egyptians suffer from toothache?|url=https://www.bbc.co.uk/learningzone/clips/why-did-the-ancient-egyptians-suffer-from-toothache/5158.html|publisher=British Broadcasting Company 2013|access-date=December 13, 2013}}</ref> The ancient Egyptians also wore [[amulet]]s to prevent toothache.<ref name="Ancient dentistry" /> The [[Ebers papyrus]] (1500 BC) details a recipe to treat "gnawing of the blood in the tooth", which included fruit of the gebu plant, onion, cake, and dough, to be chewed for four days.<ref name=Ingle2008 />{{rp|48–52}}

[[Archigenes]] of Apamea describes use of a mouthwash made by boiling [[gallnut]]s and hallicacabum in vinegar, and a mixture of roasted earthworms, [[spikenard]] ointment, and crushed spider eggs.<ref name=Ingle2008 />{{rp|48–52}} [[Pliny the Elder|Pliny]] advises toothache sufferers to ask a frog to take away the pain by moonlight. [[Claudius]]' physician [[Scribonius Largus]] recommends ''"fumigations made with the seeds of the [[hyoscyamus]] scattered on burning charcoal&nbsp; ... followed by rinsings of the mouth with hot water, in this way&nbsp; ... small worms are expelled."''<ref name="Ancient dentistry" />

In Christianity, [[Saint Apollonia]] is the patron saint of toothache and other dental problems. She was an early Christian [[martyr]] who was persecuted for her beliefs in [[Alexandria]] during the [[Roman Empire|Imperial Roman age]]. A mob struck her repeatedly in the face until all her teeth were smashed. She was threatened with being burned alive unless she renounced Christianity, but she instead chose to throw herself onto the fire. Supposedly, toothache sufferers who invoke her name will find relief.<ref name="Ancient dentistry" />

In the 15th century, priest-physician [[Andrew Boorde]] describes a "deworming technique" for the teeth: "''And if it [toothache] do come by worms, make a candle of wax with Henbane seeds and light it and let the perfume of the candle enter into the tooth and gape over a dish of cold water and then you may take the worms out of the water and kill them on your nail."''<ref name=Ingle2008 />{{rp|48–52}}

[[Albucasis]] (Abu al-Qasim Khalaf ibn al-Abbas Al-Zahrawi) used [[cautery]] for toothache, inserting a red-hot needle into the pulp of the tooth.<ref name=Ingle2008 />{{rp|48–52}} The medieval surgeon [[Guy de Chauliac]] used a [[camphor]], [[sulfur]], [[myrrh]], and [[Asafoetida|asafetida]] mixture to fill teeth and cure toothworm and toothache.<ref name=Ingle2008 />{{rp|48–52}} French anatomist [[Ambroise Paré]] recommended: ''"Toothache is, of all others, the most atrocious pain that can torment a man, being followed by death. Erosion (i.e. dental decay) is the effect of an acute and acrid humour. To combat this, one must recourse to cauterization&nbsp; ... by means of cauterization&nbsp; ... one burns the nerve, thus rendering it incapable of again feeling or causing pain."''<ref name=Ingle2008 />{{rp|48–52}}

In the [[Elizabethan era]], toothache was an ailment associated with lovers,<ref>{{cite web|url=http://nfs.sparknotes.com/muchado/page_106.html|title=No Fear Shakespeare: Much Ado About Nothing: Act 3, Scene 2|website=nfs.sparknotes.com|access-date=April 2, 2018|archive-date=March 26, 2018|archive-url=https://web.archive.org/web/20180326005015/http://nfs.sparknotes.com/muchado/page_106.html|url-status=dead}}</ref> as in [[Philip Massinger|Massinger]] and [[John Fletcher (playwright)|Fletcher]]'s play ''[[The False One]]''. Toothache also appears in a number of [[William Shakespeare]]'s plays, such as ''[[Othello]]'' and ''[[Cymbeline]]''. In ''[[Much Ado About Nothing]]'', Act III scene 2, when asked by his companions why he is feeling sad, a character replies that he has toothache so as not to admit the truth that he is in love. There is reference to "toothworm" as the cause of toothache and to tooth extraction as a cure ("draw it"). In Act V, scene 1, another character remarks: ''"For there was never yet philosopher That could endure the toothache patiently."''<ref>{{cite book|author=Shakespeare W|title=Much Ado About Nothing|year=c. 1599|chapter=Act V, scene 1|chapter-url=https://books.google.com/books?id=kwkOAAAAQAAJ&pg=PA129|publisher=In: The Works of William Shakespeare, Globe Edition, London: Macmillan and Co. p. 129 (1866)}}</ref> In modern parlance, this translates to the observation that philosophers are still human and feel pain, even though they claim they have transcended human suffering and misfortune.<ref>{{cite web|url=http://nfs.sparknotes.com/muchado/page_188.html|title=No Fear Shakespeare: Much Ado About Nothing: Act 5, Scene 1, Page 2|website=nfs.sparknotes.com|access-date=April 2, 2018|archive-date=April 3, 2018|archive-url=https://web.archive.org/web/20180403065517/http://nfs.sparknotes.com/muchado/page_188.html|url-status=dead}}</ref> In effect, the character is rebuking his friend for trying to make him feel better with philosophical platitudes.

The Scottish poet, [[Robert Burns]] wrote "Address to the Toothache" in 1786, inspired after he suffered from it. The poem elaborates on the severity of toothache, describing it as the "hell o' a' diseases" (hell of all diseases).<ref>{{cite web|author=Burns R|title=Address to the toothache|url=https://www.bbc.co.uk/arts/robertburns/works/address_to_the_toothache/|publisher=British Broadcasting Company|access-date=December 13, 2013}}</ref>

A number of plants and trees include "toothache" in their common name. Prickly ash ([[Zanthoxylum americanum]]) is sometimes termed "toothache tree", and its bark, "toothache bark"; whilst [[Ctenium Americanum]] is sometimes termed "toothache grass", and [[Acmella oleracea]] is called "toothache plant". Pellitory ([[Anacyclus pyrethrum]]) was traditionally used to relieve toothache.{{citation needed|date=April 2014}}
[[File:Tooth_god(Wasya_Dyo).jpg|thumb|"toothache tree", Vaishya Dev shrine, [[Kathmandu]], [[Nepal]].]]
In [[Kathmandu]], [[Nepal]], there is a shrine to Vaishya Dev, the [[Newa people|Newar]] god of toothache. The shrine consists of part of an old tree to which sufferers of toothache nail a [[rupee]] coin in order to ask the god to relieve their pain. The lump of wood is called the "toothache tree" and is said to have been cut from the legendary tree, Bangemudha. On this street, many traditional tooth pullers still work and many of the city's dentists have advertisements placed next to the tree.<ref>{{cite book|author=Burdett J|title=Godfather of Kathmandu|year=2012|publisher=Constable & Robinson|location=New York|isbn=978-1-4721-0094-8}}</ref>{{page needed|date=April 2014}}<ref>{{cite book|vauthors=Reed D, McConnachie J, Knowles P, Stewart P |title=Nepal|year=2002|publisher=Rough Guides|location=London|isbn=978-1-85828-899-4|edition=5th}}</ref>{{page needed|date=April 2014}}

The phrase ''toothache in the bones'' is sometimes used to describe the pain in certain types of [[diabetic neuropathy]].<ref>{{cite book|vauthors=LeRoith D, Taylor SI, Olefsky JM |title=Diabetes mellitus : a fundamental and clinical text|year=2004|publisher=Lippincott Williams & Wilkins|location=Philadelphia|isbn=9780781740975|url=https://books.google.com/books?id=hgiuDHVUuT4C&q=%22toothache+in+the+bones%22&pg=PA1342|edition=3rd}}</ref>{{rp|1342}}
{{Clear}}

== Notes ==
{{reflist|group="nb"}}

==References==
{{Reflist}}

== External links ==
{{Medical resources
|   DiseasesDB     = 27698 
|   ICD10          = {{ICD10|K|08|8|k|00}} 
|   ICD9           = {{ICD9|525.9}} 
|   ICDO           = 
|   OMIM           = 
|   MedlinePlus    = 
|   eMedicineSubj  = 
|   eMedicineTopic = 
|   MeshID         = D014098 
}}
{{Commons category|Toothache}}
{{Portal|Medicine}}
*{{wiktionary-inline|toothache|tootache}}
*[http://www.webmd.com/oral-health/toothaches WebMD Dental Health & Toothaches]
*[http://www.mayoclinic.com/health/first-aid-toothache/FA00013 Mayo Clinic Toothache First Aid]
*[https://www.nlm.nih.gov/medlineplus/ency/article/003067.htm U.S. National Library of Medicine: Toothaches]

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{{Pain}}

[[Category:Pain]]
[[Category:Headaches]]
[[Category:Medical emergencies]]
[[Category:Orofacial pain]]