Toothache and Infection

Rarely, sinusitis results from untreated maxillary dental infection. More commonly, pain resulting from a sinus infection is perceived as originating in the unaffected teeth adjacent to the sinus, mistakenly creating the impression of a dental origin.

Rarely, cavernous sinus thrombosis or Ludwig angina (submandibular space infection) develops; these conditions are life threatening and require immediate intervention.

History of present illness should identify the location and duration of the pain and whether it is constant or present only after stimulation. Specific triggering factors to review include heat, cold, sweet food or drink, chewing, and brushing. Any preceding trauma or dental work should be noted.

Review of systems should seek symptoms of complications, including face pain, swelling, or both (dental abscess, sinusitis); pain below the tongue, difficulty swallowing, and tongue elevation or protrusion (submandibular space infection); pain with bending forward (sinusitis); and retro-orbital headache, fever, and vision symptoms (cavernous sinus thrombosis).

Past medical history should note previous dental problems and treatment.

Vital signs are reviewed for fever.

The examination focuses on the face and mouth. The face is inspected for swelling and is palpated for induration and tenderness.

The oral examination includes inspection for gum inflammation and caries and any localized swelling at the base of a tooth that may represent a pointing apical abscess. If no tooth is clearly involved, teeth in the area of pain are percussed for tenderness with a tongue depressor. Also, an ice cube or a dental refrigerant–chilled cotton pellet can be applied briefly to each tooth, removing it immediately once pain is felt. In healthy teeth, the pain stops almost immediately. Pain lingering more than a few seconds indicates pulp damage (eg, irreversible pulpitis). The floor of the mouth is palpated for induration and tenderness, suggesting a deep space infection.

Neurologic examination, concentrating on the cranial nerves, should be done in patients with fever, headache, or facial swelling.

Findings of particular concern are

• Headache

• Fever

• Swelling or tenderness of floor of the mouth

• Cranial nerve abnormalities

Red flag finding of headache suggests sinusitis, particularly if multiple upper molar and premolar (back) teeth are painful. However, presence of vision symptoms or abnormalities of the pupils or of ocular motility suggests cavernous sinus thrombosis.

Fever is unusual with routine dental infection unless there is significant local extension.

Bilateral tenderness and swelling of the floor of the mouth suggest Ludwig angina. Difficulty opening the mouth (trismus) can occur with any lower molar infection but is common only with pericoronitis.

Isolated dental condition: Patients without red flag findings or facial swelling likely have an isolated dental condition, which, although uncomfortable, is not serious. Clinical findings, particularly the nature of the pain, help suggest a cause (see tables Some Causes of Toothache and Characteristics of Pain in Toothache). Because of its innervation, the pulp can perceive stimuli (eg, heat, cold, sweets) only as pain. An important distinction is whether there is continuous pain or pain only on stimulation and, if pain is only on stimulation, whether the pain lingers after the stimulus is removed.

Swelling at the base of a tooth, on the cheek, or both indicates infection, either cellulitis or abscess. A tender, fluctuant area at the base of a tooth suggests a pointing abscess.

Dental x-rays are the mainstay of testing but can be deferred to a dentist.

The rare cases in which cavernous sinus thrombosis or Ludwig angina are suspected require imaging studies, typically CT or MRI.

1. 1. Fedorowicz Z, van Zuuren EJ, Farman AG, et al: Antibiotic use for irreversible pulpitis. Cochrane Database Syst Rev (12):CD004969, 2013. doi: 10.1002/14651858.CD004969.pub3. Update in: Cochrane Database Syst Rev 2:CD004969, 2016.