Toothache: approach
- Approach to a complaint
Most toothache is from caries reaching the pulp. The type of pain tells which layer is involved; a few cases are not dental at all, including the heart.
What it is
Toothache is one of the commonest reasons people seek urgent care. Dental causes include dentine sensitivity, reversible and irreversible pulpitis, apical periodontitis and abscess, cracked tooth, periodontal abscess, pericoronitis and dry socket. Non-dental causes can feel exactly like toothache: maxillary sinusitis (several upper back teeth), temporomandibular disorder, trigeminal neuralgia, migraine and cluster headache, giant cell arteritis, and cardiac ischaemia referred to the lower jaw. The aim in medical settings is to control pain, recognise spreading infection and refer for definitive dental treatment.
Red flags
- Facial or neck swelling, trismus, difficulty swallowing or breathing, drooling or fever: spreading infection.
- Jaw pain on exertion relieved by rest, or with sweating or breathlessness: think of angina or myocardial infarction.
- Jaw claudication or new headache after fifty: giant cell arteritis.
- Numb lip or chin, loose teeth without gum disease: think of a tumour.
Step-by-step approach
- Screen for red flags of spreading infection and non-dental causes first.
- Characterise the pain: provoked or spontaneous, brief or lingering, worse on biting, sharp or throbbing, localised or diffuse.
- Look at the teeth and gums: caries, fractures, swelling, sinus tract, a partly erupted third molar, a recent extraction site.
- Tap the teeth and test with cold if possible; press over the sinuses and the TMJ.
- Treat the pain with an NSAID plus paracetamol, give antibiotics only for spreading infection or systemic signs, and refer to the dentist.
Patterns of tooth pain
| Cause | Pain | Clue |
|---|---|---|
| Dentine sensitivity | Sharp, brief, to cold or sweet | Exposed roots or worn enamel |
| Reversible pulpitis | Brief to cold, stops in seconds | Caries or recent filling |
| Irreversible pulpitis | Lingering, spontaneous, night pain | Deep caries; poorly localised |
| Apical periodontitis or abscess | Throbbing, worse on biting | Tender to tap; swelling; no response to cold |
| Maxillary sinusitis | Dull ache in several upper back teeth | Nasal symptoms, worse bending forward |
| Trigeminal neuralgia | Electric shocks for seconds | Triggered by touch; normal teeth |
| Cardiac ischaemia | Lower jaw ache on exertion | Chest pain, sweating, risk factors |
Keys to the differential
- Repeated antibiotics for toothache without swelling fail to relieve pain and delay dental care.
- Pain that cannot be localised to one tooth may come from the pulp, the sinus or another structure.
- In children, also consider erupting teeth, trauma and herpetic gingivostomatitis.
Next step / Initial management
- Uncomplicated toothache: ibuprofen with paracetamol if not contraindicated, and dental referral within days; same-day dental care if pain is severe or there is localised swelling.
- Spreading infection or systemic illness: antibiotics plus urgent dental drainage; any airway sign means emergency referral.
- Suspected cardiac, arteritic or neurological cause: manage and refer along that pathway.
Test yourself
Think of the answer, then tap the question to see it.
Which toothache pattern suggests apical periodontitis or abscess?
Throbbing pain, worse on biting, with a tooth that is tender to tap and does not respond to cold.
Which non-dental cause of lower jaw pain is dangerous to miss?
Cardiac ischaemia (angina or myocardial infarction).
What is the best first-line analgesia for most toothache?
An NSAID such as ibuprofen combined with paracetamol, if not contraindicated.
Elsewhere in DurgiPedia
Connections
In Pharmacology2
Educational content; it does not replace assessment by a dentist or doctor and is not a clinical instruction. For facial or neck swelling with difficulty swallowing or breathing, a knocked-out tooth or bleeding that will not stop, go to an emergency department at once.
Sources: Dental Emergencies (StatPearls Publishing (NCBI Bookshelf), 2022); Oral Facial Infection of Dental Origin: A Guide for the Medical Practitioner (StatPearls Publishing (NCBI Bookshelf), 2025); Cracked Tooth Syndrome (StatPearls Publishing (NCBI Bookshelf), 2024); Pain Management Medications (StatPearls Publishing (NCBI Bookshelf), 2023).
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Representative model, for educational purposes only.