II. Pathophysiology
- Tooth enamel (outer tooth layer) is not alive and has no pain sensitivity
- Pain in an intact, non-infected tooth implies exposed dentin or pulp
- Dental Caries erode through enamel and dentin, to inflame the tooth pulp (Pulpitis)
- Reversible Pulpitis (early) is transiently painful to cold and pressure and is treated with dental fillings
- Irreversible Pulpitis (late) is unprovoked, persistent, unrelenting pain and is treated with root canal or extraction
- Pulpitis may become infected or develop an abscess (but Pulpitis itself is not modified by Antibiotics)
III. Causes: Dental
- See Burning Mouth Syndrome
- Dental Caries (reversible or Irreversible Pulpitis)
- Apical Periodontitis or Apical Abscess
- Periodontal Cellulitis
- Pericoronitis (associated with wisdom Tooth Eruption)
- Acute Necrotizing Ulcerative Gingivitis
- Atypical Odontalgia (idiopathic Tooth Pain)
- Food lodged between teeth
- Other Dentoalveolar disorders (e.g. infection, cancer, autoimmune disorders)
-
Dental Trauma
- Tooth Fracture
- Tooth Luxation
- Tooth Avulsion
- Post-surgical (e.g. after root canal or extraction)
- Cracked tooth (or split root syndrome)
- Barodentalgia (air trapped under filling)
- Form of Barotrauma seen in scuba divers
- Iatrogenic (Radiation Therapy, Chemotherapy)
- Pediatric additional causes
- Primary Tooth Eruption or Teething (age 6 months to 2 years old)
- Permanent Tooth Eruption (age 5.5 years to 7 years)
IV. Differential Diagnosis
- Neuropathic
- Trigeminal Neuralgia
- Postherpetic Neuralgia
- Glossopharyngeal neuralgia
- Migraine Headache or Cluster Headache
- Vascular
- Temporal Arteritis (Giant Cell Arteritis) may cause Jaw Claudication
- Cavernous Sinus Thrombosis
- Myocardial Ischemia or infarction (lower jaw)
- Bone and joints
- Osteomyelitis
- Temperomandibular joint dysfunction
- Systemic illness
- Xerostomia causes predisposing to oral pathology
- Systemic Lupus Erythematosus
- Tuberculosis
- Ear, throat, sinus or Salivary Gland referred pain
V. Management
-
Analgesics
- NSAIDs in combination with Acetaminophen
- Example: Ibuprofen 600 mg every 6 hours AND Acetaminophen 1000 mg every 6 hours
- Hydrocodone (Vicodin) may be considered for refractory pain
- Try to avoid Opioids for Dental Pain
- Wisdom Tooth Extraction is the start of Chronic Opioid use in many young adults
- NSAIDs in combination with Acetaminophen
- Acute Dental Pain management
- See Inferior Alveolar Block
- See Periapical Block (Supraperiosteal Dental Anesthesia)
- Temporize (e.g. temporary filling) until definitive dental management
- Referred pain
-
Antibiotics are only indicated for signs of infection (fever, localized swelling, purulent drainage, Trismus, abscess)
- Without signs of infection, Antibiotics are not indicated in Pulpitis (either reversible or irreversible)
- Runyon (2004) Acad Emerg Med 11(12): 1268-71 +PMID: 15576515 [PubMed]
VI. References
- Claudius, Behar and Trahini in Herbert (2015) EM:Rap 15(5): 5-7
- Broderick and Deak (2015) Crit Dec Emerg Med 29(1): 2-8
- Amsterdam in Marx (2002) Rosen's Emergency Med, p. 897
- Degowin (1987) Bedside Diagnostic Exam, p. 74-5
- Delaney (2017) EM:Rap 17(9): 5-7
- Douglass (2003) Am Fam Physician 67(3):511-6 [PubMed]
Images: Related links to external sites (from Bing)
Related Studies
| 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, ｼﾂｳｵﾖﾋﾞﾊﾉｶﾝｶｸｼｮｳｶﾞｲ |
| 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 |
