Dental pain and dental infection
Toothache is fixed by a dentist, not antibiotics. Look under the tongue and check mouth opening for spreading infection.
A 34-year-old man has had toothache in a lower left molar for 4 days. Now the floor of his mouth is swollen and firm, his tongue is pushed up, he can open his mouth only one finger-width, his voice is muffled and he is drooling. Temperature 38.8 °C, pulse 118, SpO₂ 96%.
Is this a dental problem for the morning?
- Airway firstFloor of mouth swelling, raised tongue, drooling, muffled voice, stridor, can't lie flat: Ludwig's angina.
- Spreading infectionIV antibiotics, CT neck, maxillofacial or ENT surgeons and anaesthetist now.
- Simple toothacheAnalgesia and dental referral. Antibiotics don't fix toothache.
- Dental abscessDrainage or extraction by a dentist. Antibiotics only if spreading or systemic.
- AnalgesiaIbuprofen and paracetamol together work well.
- Look in every mouthWhite or red patches, ulcers over 3 weeks, mouth not opening (submucous fibrosis).
- Ask about gutka, naswar, paan and smokingMajor oral cancer risks in Pakistan.
- Floor of mouth swelling or raised tongue
- Trismus
- Difficulty swallowing, breathing or drooling
- Swelling spreading to the neck or eye
- Fever and unwell
- Diabetic or immunosuppressed with spreading infection
- Ludwig's angina
- Parapharyngeal or retropharyngeal abscess
- Cardiac pain referred to the jaw
- Oral cancer
- Peritonsillar abscess (quinsy)
- Trigeminal neuralgia
- Osteonecrosis of the jaw (bisphosphonates)
| Ibuprofen | 400 mg 3 times daily with food (up to 600 mg if needed) |
| Paracetamol | 1 g up to 4 times daily |
| Amoxicillin | 500 mg 3 times daily for 5 days if spreading infection |
| Metronidazole | 400 mg 3 times daily for 5 days (added, or alone if penicillin-allergic) |
| Co-amoxiclav IV | 1.2 g 8-hourly for severe spreading infection |
| Ulcer over 3 weeks | Urgent referral for biopsy |
| Trismus | Mouth opening under 2–3 finger-widths: deep space infection until proven otherwise |
Check every dose against a current drug reference and your hospital protocol.
On this page
Why it matters
Most toothache needs a dentist, not antibiotics. But dental infection can spread into the deep spaces of the neck and block the airway within hours. And in Pakistan, where gutka, naswar and paan are common, oral cancer is one of the commonest cancers: every mouth you look at is a chance to catch it early.
History
- Which tooth, how long, worse with hot or cold (pulpitis), worse on biting (periapical abscess)?
- Swelling, fever, difficulty opening the mouth, swallowing or breathing.
- Wisdom tooth area pain with swelling of the gum (pericoronitis).
- Tobacco and areca: gutka, naswar, paan with tobacco, cigarettes, betel nut.
- Diabetes, immunosuppression, bisphosphonates.
- Jaw pain on exertion with no dental cause: think angina.
Examination
- AirwayVoice, drooling, stridor, can they lie flat? Floor of mouth, tongue position.
- Mouth openingTrismus (under 2–3 finger-widths) suggests deep infection.
- Teeth and gumsDecay, tender tooth on tapping, gum swelling, pus, pericoronitis.
- NeckSwelling, tenderness, lymph nodes.
- Whole mouthUlcers, white or red patches, lumps, fibrous bands (submucous fibrosis).
When is toothache dangerous?
- Analgesia
- dentist for filling, root canal or extraction
- Dentist for drainage or extraction
- antibiotics if spreading
- Ludwig's angina or deep neck infection
- airway team, IV antibiotics, CT, surgery
Ludwig's angina
- Spreading cellulitis of the floor of the mouth (submandibular and sublingual spaces), usually from a lower molar.
- Firm, board-like swelling under the jaw, tongue pushed up and back, drooling, muffled voice, trismus, fever.
- The airway can close suddenly. Keep the patient sitting up, don't lie them flat, call anaesthetics and ENT or maxillofacial surgeons immediately. Awake fibreoptic intubation or surgical airway may be needed.
- IV antibiotics (co-amoxiclav or ceftriaxone with metronidazole), CT neck once the airway is safe, surgical drainage and removal of the tooth.
Differential diagnosis
| Condition | Clues |
|---|---|
| Pulpitis | Sharp pain with hot or cold, no swelling |
| Periapical abscess | Pain on biting, tender tooth, gum swelling |
| Pericoronitis | Partly erupted wisdom tooth, swollen gum flap |
| Dry socket | Severe pain 2–4 days after extraction |
| Sinusitis | Pain in several upper teeth, worse bending forward |
| Temporomandibular joint pain | Clicking, pain on chewing, in front of the ear |
| Trigeminal neuralgia | Electric shocks, triggers (touch, chewing) |
| Angina | Jaw pain on exertion, relieved by rest |
| Oral cancer | Ulcer or lump over 3 weeks, tobacco or areca use |
Oral cancer in Pakistan
- Gutka, naswar, paan with tobacco, areca (betel) nut and smoking cause oral submucous fibrosis, leukoplakia and oral squamous cell carcinoma.
- Red flags: an ulcer not healing in 3 weeks, white (leukoplakia) or red (erythroplakia) patches, a lump, loose teeth without cause, mouth opening getting smaller, neck lumps.
- Refer urgently for biopsy. Advise stopping all tobacco and areca products.
Treatment
Antibiotics don't cure a dental abscess. The pus needs draining and the tooth needs treating or removing.
Common mistakes
- Giving antibiotics for every toothache.
- Sending Ludwig's angina home with oral antibiotics.
- Lying a patient with floor-of-mouth swelling flat.
- Missing an oral cancer by not looking at the whole mouth.
- Calling exertional jaw pain dental.
Frequently asked questions
Do I need antibiotics for toothache?
Usually not. Toothache is treated by a dentist (filling, root canal or extraction). Antibiotics are for spreading infection, fever or swelling.
What is Ludwig's angina?
A spreading infection of the floor of the mouth, usually from a lower molar. It can block the airway and needs emergency treatment.
What is the best painkiller for toothache?
Ibuprofen, often combined with paracetamol.
What are the warning signs of oral cancer?
An ulcer that doesn't heal in 3 weeks, white or red patches, a lump, loose teeth without cause, or difficulty opening the mouth, especially in people who use gutka, naswar, paan or tobacco.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. A man with a lower molar abscess has floor-of-mouth swelling, drooling and trismus. What is the diagnosis?
Answer: Ludwig's angina. Ludwig's angina threatens the airway: airway team, IV antibiotics, surgery.
- Simple dental abscess: Floor of mouth involvement is spreading infection.
- Mumps: No.
- Sialadenitis: Less likely.
- Quinsy: Peritonsillar, not floor of mouth.
2. Which is the best analgesic for simple dental pain?
Answer: Ibuprofen. NSAIDs, often with paracetamol, work best for dental pain.
- Diazepam: No.
- Amoxicillin: Not an analgesic.
- Tramadol first: Not first.
- Codeine alone: Less effective.
3. A man who chews gutka has an ulcer on the cheek for 5 weeks. What is needed?
Answer: Urgent referral for biopsy. An ulcer over 3 weeks in a tobacco or areca user may be cancer.
- Reassure: No.
- Antibiotics: Not infection.
- Antiseptic mouthwash and review in 3 months: Delay.
- Steroid gel only: Not without biopsy.
4. A 50-year-old man from Karachi who chews gutka and naswar has a non-healing ulcer on the buccal mucosa with an indurated edge for 6 weeks. What is the next step?
Answer: Incisional biopsy. Oral squamous cell carcinoma is among the commonest cancers in Pakistani men, driven by smokeless tobacco (gutka, paan with tobacco, naswar), areca nut, smoking and alcohol. Precursors: leukoplakia, erythroplakia (highest risk), oral submucous fibrosis (areca nut — trismus). Any ulcer > 3 weeks needs biopsy. Treat with surgery ± neck dissection and radiotherapy.
- Antifungal gel: Antifungals are not appropriate for a chronic indurated ulcer.
- Review in 3 months: Waiting 3 months delays cancer diagnosis.
- Antibiotics for 2 weeks: Antibiotics delay diagnosis.
5. A 35-year-old man who chews areca nut (chalia) has progressive difficulty opening his mouth, burning with spicy food and blanched fibrous bands in the buccal mucosa. What is the main concern long-term?
Answer: Malignant transformation to SCC. Oral submucous fibrosis: chronic premalignant condition from areca nut (betel quid, gutka, supari, chalia) — burning sensation, blanching, fibrous bands, progressive trismus. Malignant transformation to oral squamous cell carcinoma in ~7–13%. Management: stop areca nut, physiotherapy (mouth-opening exercises), intralesional steroids/hyaluronidase, surgical release; regular surveillance with biopsy of suspicious areas.
- Spontaneous regression: Submucous fibrosis is progressive.
- Temporomandibular dislocation: TMJ dislocation is not the concern.
- Salivary gland stones: Salivary stones are unrelated.
6. A 70-year-old woman with trigeminal neuralgia not controlled by carbamazepine is booked for percutaneous radiofrequency treatment of the trigeminal ganglion. The needle is passed through the cheek towards the skull base. Through which of the following openings does it reach the ganglion?
Answer: Foramen ovale. Percutaneous treatments of the trigeminal ganglion (radiofrequency rhizotomy, glycerol injection or balloon compression) use a needle inserted lateral to the angle of the mouth and aimed under X-ray guidance at the foramen ovale. Passing through the foramen along the mandibular nerve brings the tip into Meckel's cave, where the ganglion lies. The foramen ovale is the only skull base opening on this path large enough and directly continuous with the ganglion.
- Foramen rotundum: Transmits the maxillary nerve into the pterygopalatine fossa; not reachable from the cheek this way.
- Foramen spinosum: Transmits the middle meningeal artery; puncture risks bleeding.
- Superior orbital fissure: Opens into the orbit.
- Stylomastoid foramen: Transmits the facial nerve; far from the trigeminal ganglion.
7. A woman with a trigeminal ganglion schwannoma has numbness of the whole left face and weak chewing. Where does this ganglion lie?
Answer: Meckel's cave at the petrous apex. The trigeminal (semilunar) ganglion lies in a pouch of dura called Meckel's cave (trigeminal cave), over the trigeminal impression near the apex of the petrous temporal bone in the middle cranial fossa. Its sensory branches V1, V2 and V3 leave its anterior border, and the motor root passes beneath it to join V3. A lesion here can affect all three sensory divisions and the muscles of mastication together.
- Lateral wall of the cavernous sinus: Only V1 and V2 run in the cavernous sinus wall, beyond the ganglion.
- Pterygopalatine fossa: Contains the maxillary nerve and pterygopalatine ganglion.
- Cerebellopontine angle cistern: The trigeminal root crosses here, but the ganglion lies further forward.
- Infratemporal fossa: Contains branches of V3 after it leaves the skull.
References and dose sources
- SDCEP — Management of acute dental problems
- NICE CKS — Dental abscess
- Ibuprofen dosing: Drugs.com: Ibuprofen dosage (see also our ibuprofen dose page)
- Paracetamol dosing: Drugs.com: Acetaminophen (paracetamol) dosage (see also our paracetamol dose page)
- Amoxicillin dosing: Drugs.com: Amoxicillin dosage (see also our amoxicillin dose page)
- Metronidazole dosing: Drugs.com: Metronidazole dosage (see also our metronidazole dose page)
- Co-amoxiclav (amoxicillin with clavulanic acid) dosing: Drugs.com: Amoxicillin/clavulanate dosage (see also our co-amoxiclav (amoxicillin with clavulanic acid) dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.