toothache toothache toothache, also known as dental pain, is pain in the teeth or their supporting structures, caused by dental diseases or pain referred to the teeth by non-dental diseases. when severe it may impact sleep, eating, and other daily activities. toothacheother namesodontalgia, dentalgia, odontodynia, odontogenic pain: 396 "thou hell o' a' diseases" – william hole's illustration for robert burns' poem "address to the toothache" (1897, poem c. 1786).specialtydentistry common causes include inflammation of the pulp, (usually in response to tooth decay, dental trauma, or other factors), dentin hypersensitivity, apical periodontitis (inflammation of the periodontal ligament and alveolar bone around the root apex), dental abscesses (localized collections of pus), alveolar osteitis ("dry socket", a possible complication of tooth extraction), acute necrotizing ulcerative gingivitis (a gum infection), and temporomandibular disorder. 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 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. 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 filling, root canal treatment, extraction, drainage of pus, or other remedial action. the relief of toothache is considered one of the main responsibilities of dentists. toothache is the most common type of pain in the mouth or face.: 125–135 it is one of the most common reasons for emergency dental appointments. in 2013, 223 million cases of tooth pain occurred as a result of dental caries in permanent teeth and 53 million cases occurred in baby teeth. historically, the demand for treatment of toothache is thought to have led to the emergence of dental surgery as the first specialty of medicine. 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 maxillary sinusitis or angina pectoris). there are many possible non-dental causes, but the vast majority of toothache is dental in origin. both the pulp and periodontal ligament have nociceptors (pain receptors), but the pulp lacks proprioceptors (motion or position receptors) and mechanoreceptors (mechanical pressure receptors).: 125–135 consequently, pain originating from the dentin-pulp complex tends to be poorly localized, whereas pain from the periodontal ligament will typically be well localized,: 55 although not always.: 125–135 for instance, the periodontal ligament can detect the pressure exerted when biting on something smaller than a grain of sand (10–30 µm).: 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.: 31 another typical difference between pulpal and periodontal pain is that the latter is not usually made worse by thermal stimuli.: 125–135 dental 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 barometric changes and ionizing radiation. 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.: 36–37 reversible pulpitis is characterized by short-lasting pain triggered by cold and sometimes heat. 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.: 619–627 dentin hypersensitivity dentin hypersensitivity is a sharp, short-lasting dental pain occurring in about 15% of the population, which is triggered by cold (such as liquids or air), sweet or spicy foods, and beverages. teeth will normally have some sensation to these triggers, 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 erosion. the pulp of the tooth remains normal and healthy in dentin hypersensitivity.: 510 many topical treatments for dentin hypersensitivity are available, including desensitizing toothpastes and protective varnishes that coat the exposed dentin surface. treatment of the root cause is critical, as topical measures are typically short lasting.: 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.: 510 periodontal in general, chronic periodontal conditions do not cause any pain. rather, it is acute inflammation which is responsible for the pain. apical periodontitis 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. 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 sterile, non-infectious processes (such as trauma) may not cause any apical periodontitis.: 225 bacterial cytotoxins 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.: 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 radiolucent area around the end of the root, although this does not manifest immediately.: 228 acute apical periodontitis is characterized by well-localized, spontaneous, persistent, moderate to severe pain.: 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.: 125–135 food impaction 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.: 125–135 the usual cause of food impaction is disruption of the normal 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, or relieved immediately by using a tooth pick or dental floss in the involved area.: 125–135 a gingival or periodontal abscess may develop from this situation.: 444–445 periodontal abscess 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 crevices, 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 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.: 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.: 444–445 toothache caused by a periodontal abscess is generally deep and throbbing. the oral mucosa covering an early periodontal abscess appears erythematous (red), swollen, shiny, and painful to touch. 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.: 446–447 the treatment of a periodontal abscess is similar to the management of dental abscesses in general (see: 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. 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 plaque and calculus. acute necrotizing ulcerative gingivitis 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 interdental papillae, and possibly also halitosis (bad breath) and a bad taste. predisposing factors include poor oral hygiene, smoking, malnutrition, psychological stress, and immunosuppression.: 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). 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.: 437–438 pericoronitis clinical & xray correlation of pericoronitisan operculum (green arrow) over a partially erupted lower left third molar tooth. there is minimal inflammation and recurrent swelling.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. 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