toothache in children

Toothache in children represents one of the most frequent reasons for emergency dental visits. The underlying causes are often pulpal or periodontal in nature, but the approach to diagnosis and management in pediatric patients differs considerably from that in adults due to anatomical, physiological, and behavioral factors unique to children. A methodical clinical examination, supported by appropriate investigations, is essential for accurate diagnosis and appropriate management.

Introduction

Pain in the dental context is a symptom that can have multiple origins, including pulpal inflammation, periapical infection, or periodontal disease. In children, the diagnosis is often complicated by limited cooperation, communication difficulties, and behavioral anxiety. Understanding the etiology and presenting features of dental pain is crucial for timely intervention and to prevent progression to systemic infection or long-term damage to developing dentition.

The principal goal of the dentist is to determine the state of the affected tooth or teeth and establish whether the pulp is vital or non-vital, and whether the pulpal inflammation is reversible or irreversible. This distinction determines the appropriate emergency and definitive management.

 

Advertisements

History Taking

1. The Pain History

The cornerstone of diagnosis is a thorough pain history. The clinician should inquire about:

  • Onset – When did the pain start?
  • Duration – Is the pain intermittent or continuous?
  • Character – Is it sharp, dull, throbbing, or spontaneous?
  • Stimuli – What triggers the pain (hot, cold, sweet, or pressure)?
  • Relief – What relieves it (analgesics, cold water, or rest)?
  • Severity – How severe is the pain, and how does it affect the child’s daily activities or sleep?

 

Pain from reversible pulpitis is typically short-lasting and stimulus-dependent, whereas pain from irreversible pulpitis tends to be spontaneous, longer-lasting, and may disturb sleep.

2. Behavioral and Parental Considerations

Children’s descriptions of pain can be unreliable. Anxious or fearful children may deny pain in the presence of adults, or parents may exaggerate or misinterpret the symptoms. Thus, corroborating history from both child and parent is necessary.

Additionally, some children may confuse referred pain (e.g., from the ear or sinus) with dental pain, complicating the diagnostic process.

 

Clinical Examination

1. Extraoral Examination

  • Inspection for swelling: Facial asymmetry or localized swelling may suggest an acute periradicular infection.
  • Palpation of lymph nodes: Tender or enlarged submandibular lymph nodes may indicate spreading infection.
  • Temperature: Pyrexia or malaise are systemic signs of infection that require prompt management.

 

2. Intraoral Examination

  • Inspection of soft tissues: Look for localized swelling, sinus tracts, or mucosal ulceration.
  • Tooth surface examination: Identify carious lesions, discoloration, or fractures. A discolored tooth may indicate loss of vitality following trauma.
  • Periodontal status: Check for gingival inflammation, pocketing, or mobility, which may indicate periodontal involvement.

 

3. Percussion Test

Gentle finger pressure or tapping can elicit pain indicative of periradicular inflammation. However, percussion tests can be unreliable in children, as they may overreact or fail to respond consistently. It is essential to compare the affected tooth with a control tooth to assess relative tenderness.

 

Diagnostic Tests

1. Sensibility Testing

Two types of pulp testing are commonly used:

  • Thermal testing: Using cold (ethyl chloride on cotton wool) or heat to stimulate pulpal response.
  • Electrical pulp testing: Applying a mild current to test pulp vitality.

 

A normal vital pulp will elicit a short, sharp pain that ceases immediately upon removal of the stimulus. A prolonged, lingering pain suggests irreversible pulpitis, while a lack of response may indicate pulpal necrosis.

It must be noted that these tests are less reliable in children due to incomplete root formation and the presence of large pulp chambers. False positives can occur due to anxiety or the conduction of current to adjacent teeth.

2. Radiographic Assessment

Radiographs are indispensable for confirming the clinical diagnosis. In children, bitewing radiographs are preferred as they are more comfortable and provide valuable information about caries proximity to the pulp.

  • Bitewings: Ideal for detecting interproximal caries and pulpal involvement.
  • Periapical views: Indicated when periradicular pathology is suspected.
  • Upper standard occlusal radiographs: Useful for anterior teeth when periapical imaging is difficult.

 

Radiographic findings of periradicular radiolucency, widened periodontal ligament space, or loss of lamina dura suggest irreversible pulpal damage or necrosis.

 

Diagnosis

1. Common Diagnostic Categories

Reversible Pulpitis

  • Pain: Fleeting, sharp, and triggered by hot, cold, or sweet stimuli.
  • The pain ceases immediately upon removal of the stimulus.
  • There is no spontaneous pain or tenderness to percussion.
  • Radiographs may show deep caries but no periapical involvement.

 

Irreversible Pulpitis

  • Pain: Longer-lasting, often spontaneous, and may wake the child at night.
  • The tooth may not be mobile or tender to percussion.
  • Thermal tests elicit prolonged pain even after removal of stimulus.
  • The pulp may be hyperemic or partially necrotic.

 

Acute Periradicular Periodontitis

  • Pain: Severe on biting and pressure, localized to the offending tooth.
  • Adjacent tissues may be tender, and the tooth may be slightly mobile.
  • There may be swelling or sinus formation.
  • Radiographs show periradicular radiolucency.

 

The only completely reliable method of diagnosis is histological examination, but in clinical practice, a combination of symptoms, signs, and investigations is sufficient for accurate diagnosis.

 

Management Principles

The management of toothache in children depends on the diagnosis, the degree of pulpal or periradicular involvement, and the child’s ability to cooperate.

1. General Principles

  • Relieve pain and infection as a priority.
  • Preserve the tooth where possible, especially primary molars critical for arch integrity.
  • Minimize trauma to the child by using behavioral management techniques.
  • Plan definitive treatment after stabilization of symptoms.

 

If a child is uncooperative or highly anxious, treatment may be limited to palliative measures during the first visit, with definitive treatment deferred.

 

Specific Management Strategies

1. Reversible Pulpitis

Emergency Management

  • Administer local anesthesia (LA).
  • Remove carious dentine and excavate soft caries.
  • Restore temporarily with zinc oxide eugenol or glass ionomer cement (GIC).
  • If the pulp is exposed but vital, apply a pulp capping material such as calcium hydroxide, Ledermix®, or Odontopaste®.

 

Definitive Management

  • Once symptoms subside, proceed with a pulpotomy or definitive restoration.
  • In cases where the child is uncooperative or the tooth is unrestorable, extraction may be indicated.

 

2. Irreversible Pulpitis

Emergency Management

  • Administer LA.
  • Remove caries and gain access to the pulp chamber.
  • Dress the pulp with zinc oxide eugenol or a sedative dressing.
  • If LA is ineffective (due to necrosis), proceed with pulp extirpation under analgesia.

 

Definitive Management

  • Pulpotomy or pulpectomy depending on the tooth’s condition.
  • Extraction may be required for non-restorable teeth or where cooperation is limited.

 

3. Acute Periradicular Periodontitis

Emergency Management

  • Relieve occlusion if necessary.
  • Prescribe analgesics and antibiotics only if there are systemic symptoms or spreading infection.
  • Establish drainage through the tooth or soft tissues if pus is present.
  • Review after 24 hours to monitor resolution.

 

Definitive Management

  • Extraction of the affected tooth or pulpectomy if feasible after the acute phase resolves.

 

4. Acute Pericoronitis with Facial Swelling

If mild and localized (<38°C):

  • Maintain good oral hygiene and gentle irrigation.
  • Prescribe analgesics.
  • Review frequently to monitor progression.

 

If significant swelling or systemic involvement (>38°C):

  • Immediate referral to a specialist centre.
  • Administer broad-spectrum antibiotics such as amoxicillin and metronidazole.
  • Drain abscess intraorally (I/O) or extraorally (E/O) if indicated.
  • Extraction of the offending tooth once infection resolves.

 

Other Potential Causes of Toothache in Children

1. Sinusitis

Pain from the maxillary sinus can mimic dental pain, particularly in upper molars. The discomfort is typically dull, poorly localized, and may increase with bending forward. Examination reveals no dental pathology.

2. Mucosal Ulceration

Conditions such as recurrent aphthous stomatitis or traumatic ulcers can produce localized oral pain mistaken for toothache. These lesions are visible on inspection and are usually self-limiting.

3. Teething

Teething may cause mild discomfort and irritability but should not be associated with severe pain or systemic symptoms. Other causes should be ruled out if symptoms are significant.

4. Mobility of Deciduous Teeth

Mobility prior to exfoliation can result in mild discomfort, often mistaken for pathological pain. Reassurance is usually sufficient.

 

Special Considerations

1. Behavioral Management

Pediatric patients may present with fear and anxiety that hinder cooperation. The clinician should employ behavior management techniques such as:

  • Tell-Show-Do approach.
  • Positive reinforcement and distraction.
  • Parental presence to enhance comfort.

 

2. Use of Local and General Anesthesia

Local anesthesia remains the mainstay for most procedures. However, general anesthesia (GA) may be indicated in uncooperative children, extensive decay, or multiple extractions.

Careful consideration should be given to the long-term impact of extractions under GA, including loss of arch space and effects on occlusal development.

 

Radiographic Interpretation and Long-Term Planning

A sound understanding of pediatric radiographic interpretation is essential. Beyond identifying pathology, radiographs help assess:

  • Root development and resorption patterns.
  • Presence of underlying permanent teeth.
  • Extent of periapical infection and potential impact on successors.

 

Decisions regarding tooth preservation vs. extraction must consider the child’s age, root resorption status, and importance of the tooth in maintaining arch integrity.

 

Complications of Untreated Dental Infections

Failure to manage dental infections promptly can result in:

  • Cellulitis and facial swelling.
  • Lymphadenitis and systemic infection.
  • Osteomyelitis, though rare in children.
  • Space infections involving submandibular, sublingual, or buccal spaces, which may threaten airway patency.

 

Prompt diagnosis and intervention prevent such complications and reduce the need for hospital admission.

 

Preventive Aspects

While managing acute pain is crucial, prevention remains the cornerstone of pediatric dental care. Key preventive strategies include:

  • Regular fluoride application and sealants.
  • Dietary counseling to limit sugar intake.
  • Education of parents on early signs of decay.
  • Routine dental check-ups to identify caries before symptoms develop.

 

Conclusion

Toothache in children is a multifactorial problem that requires a structured and empathetic approach. Accurate diagnosis is based on a combination of clinical history, examination, diagnostic testing, and radiography. The clinician must differentiate between reversible and irreversible pulpitis and periradicular pathology to determine appropriate treatment.

Equally important is the consideration of the child’s emotional state and level of cooperation, which may dictate the extent of treatment possible during the initial visit.

Effective management not only alleviates pain but also preserves primary dentition, supports normal occlusal development, and instills positive dental attitudes that can last a lifetime.

 

References

  1. Rugg-Gunn AJ, Welbury RR, Hosey MT. Paediatric Dentistry. 5th ed. Oxford: Oxford University Press; 2021.
  2. Cameron AC, Widmer RP. Handbook of Pediatric Dentistry. 6th ed. Elsevier; 2023.
  3. Innes NPT, Evans DJP, Hall N. Pediatric Dentistry: A Clinical Approach. 3rd ed. Wiley-Blackwell; 2022.
  4. McDonald RE, Avery DR, Dean JA. McDonald and Avery’s Dentistry for the Child and Adolescent. 11th ed. Elsevier; 2022.
  5. Pinkham JR, Casamassimo PS, Fields HW, McTigue DJ, Nowak AJ. Pediatric Dentistry: Infancy through Adolescence. 6th ed. Elsevier; 2019.
  6. American Academy of Pediatric Dentistry (AAPD). Guideline on Pulp Therapy for Primary and Immature Permanent Teeth. AAPD Reference Manual 2023–2024.
  7. European Academy of Paediatric Dentistry (EAPD). Guidelines on the Use of Vital and Non-vital Pulp Therapies in Primary Teeth. Eur Arch Paediatr Dent. 2017;18(4):273–280.
  8. Hargreaves KM, Berman LH. Cohen’s Pathways of the Pulp. 12th ed. Elsevier; 2021.
  9. Pine CM, Harris R. Community Oral Health. 3rd ed. Quintessence Publishing; 2019.
  10. Falcolini A, Bani M, et al. Diagnosis and management of pulpal pain in children: an evidence-based review. Int J Paediatr Dent. 2020;30(4):347-356.
  11. Rodd HD, Waterhouse PJ, Fuks AB, Fayle SA, Moffat MA. UK National Clinical Guidelines in Paediatric Dentistry: Pulp Therapy for Primary Molars. Int J Paediatr Dent. 2006;16(S1):15-23.
  12. AAPD. Best Practices: Antibiotic Therapy for Pediatric Dental Patients. AAPD Reference Manual 2023.