II. Pathophysiology

  1. Tooth enamel (outer tooth layer) is not alive and has no pain sensitivity
  2. Pain in an intact, non-infected tooth implies exposed dentin or pulp
    1. Dental Caries erode through enamel and dentin, to inflame the tooth pulp (Pulpitis)
    2. Reversible Pulpitis (early) is transiently painful to cold and pressure and is treated with dental fillings
    3. Irreversible Pulpitis (late) is unprovoked, persistent, unrelenting pain and is treated with root canal or extraction
    4. Pulpitis may become infected or develop an abscess (but Pulpitis itself is not modified by antibiotics)

III. Causes: Dental

  1. Dental Caries (reversible or Irreversible Pulpitis)
  2. Apical Periodontitis or Apical Abscess
  3. Periodontal Cellulitis
  4. Pericoronitis (associated with wisdom Tooth Eruption)
  5. Acute Necrotizing Ulcerative Gingivitis
  6. Atypical Odontalgia (idiopathic Tooth Pain)
  7. Food lodged between teeth
  8. Dental Trauma
    1. Tooth Fracture
    2. Tooth Luxation
    3. Tooth Avulsion
    4. Post-surgical (e.g. after root canal or extraction)
    5. Cracked tooth (or split root syndrome)
    6. Barodentalgia (air trapped under filling)
      1. Form of barotrauma seen in scuba divers
  9. Pediatric additional causes
    1. Primary Tooth Eruption or Teething (age 6 months to 2 years old)
    2. Permanent Tooth Eruption (age 5.5 years to 7 years)

IV. Differential Diagnosis

  1. Neuropathic
    1. Trigeminal Neuralgia
    2. Postherpetic Neuralgia
    3. Glossopharyngeal neuralgia
    4. Migraine Headache or Cluster Headache
  2. Vascular
    1. Temporal Arteritis (Giant Cell Arteritis) may cause Jaw Claudication
    2. Cavernous Sinus Thrombosis
    3. Myocardial Ischemia or infarction (lower jaw)
  3. Bone and joints
    1. Osteomyelitis
    2. Temperomandibular joint dysfunction
  4. Systemic illness
    1. Xerostomia causes predisposing to oral pathology
    2. Systemic Lupus Erythematosus
    3. Tuberculosis
  5. Ear, throat, sinus or Salivary Gland referred pain
    1. Acute Sinusitis (Maxillary)
    2. Acute Pharyngitis
    3. Aphthous Ulcer
    4. Sialadenitis or Sialolithiasis
    5. Otitis Media
    6. Otitis Externa

V. Management

  1. Analgesics
    1. NSAIDs in combination with Acetaminophen
    2. Hydrocodone (Vicodin) may be considered for refractory pain
  2. Acute Dental Pain management
    1. See Inferior Alveolar Block
    2. See Periapical Block (Supraperiosteal Dental Anesthesia)
    3. Temporize (e.g. temporary filling) until definitive dental management
  3. Referred pain
    1. See Lower Cervical Intramuscular Injection
  4. Antibiotics are only indicated for signs of infection (fever, localized swelling, purulent drainage, Trismus, abscess)
    1. Without signs of infection, antibiotics are not indicated in Pulpitis (either reversible or irreversible)
    2. Runyon (2004) Acad Emerg Med 11(12): 1268-71 +PMID: 15576515 [PubMed]

VI. References

  1. Claudius, Behar and Trahini in Herbert (2015) EM:Rap 15(5): 5-7
  2. Broderick and Deak (2015) Crit Dec Emerg Med 29(1): 2-8
  3. Amsterdam in Marx (2002) Rosen's Emergency Med, p. 897
  4. Degowin (1987) Bedside Diagnostic Exam, p. 74-5
  5. Delaney (2017) EM:Rap 17(9): 5-7
  6. Douglass (2003) Am Fam Physician 67(3):511-6 [PubMed]

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Ontology: Toothache (C0040460)

Definition (NCI_CTCAE) A disorder characterized by a sensation of marked discomfort in the tooth.
Definition (NCI) A painful sensation originating from a tooth.
Definition (MSH) Pain in the adjacent areas of the teeth.
Concepts Sign or Symptom (T184)
MSH D014098
ICD10 K08.8
SnomedCT 139269003, 196444001, 27355003
English Toothache, Toothaches, TOOTH ACHE, Odontalgia, tooth pain, tooth pain (symptom), Tooth ache, Odontalgias, Toothache NOS, Toothache [Disease/Finding], tooth ache, toothache, Pain;tooth/teeth, toothaches, Tooth pain, Pain in tooth, Dentagra, Dentalgia, Toothache (finding), odontalgia, pain; dental, pain; tooth, tooth; pain, dental pain, dentalgia, tooth/teeth pain
French DOULEUR DENTAIRE, Mal aux dents, Douleur de dent, Douleur dentaire, Odontalgie, Mal de dents
Dutch kiespijn, odontalgie, pijn; kies, pijn; tand, tanden; pijn, tandpijn, Odontalgie, Pijn, tand-, Tandpijn
German Zahnschmerz, ZAHNSCHMERZ, Schmerz, Zahn-, Zahnschmerzen, Odontalgie
Italian Dolore di denti, Dolore ai denti, Mal di denti, Odontalgia
Spanish Dolor de dientes, Dolor de muelas, DIENTES, DOLOR, dentalgia, dolor de dientes (hallazgo), dolor de dientes, odontalgia, odontodinia, Dolor dental, Odontalgia, Dolor de Diente
Swedish Tandvärk
Japanese シツウ, ハイタ, 歯痛
Finnish Hammassärky
Russian ZUBNAIA BOL', ЗУБНАЯ БОЛЬ
Portuguese DOR DENTAL, Dor-de-Dente, Dor de dentes, Dor de Dente, Odontalgia
Czech Bolest zubů, bolesti zubů, zuby - bolest
Polish Ból zębów, Dentalgia, Dentagra
Hungarian Odontalgia, Fogfájás, Fog fájdalma, Fog fájdalom
Norwegian Odontalgi, Tannsmerte, Tannverk, Tannpine

Ontology: Dental pain and sensation disorders (C0851955)

Definition (NCI) A term that refers to disorders that result in pain and abnormal sensation in the teeth and/or periodontal tissues.
Concepts Disease or Syndrome (T047)
Italian Dolore e disturbi della sensibilità dei denti
Japanese 歯痛および歯の感覚障害, シツウオヨビハノカンカクショウガイ
Czech Bolest zubů a poruchy čití
Hungarian Dentális fájdalom és érzet betegségek
English Dental pain and sensation disorders, Dental Pain and Sensation Disorder
Portuguese Dores de dentes e alterações da sensibilidade dentária
Spanish Trastornos dolorosos y sensitivos de los dientes
Dutch tandpijn en -gevoelsstoornissen
French Douleurs dentaires et troubles de sensation
German Zahnschmerzen und -empfindungsstoerungen