The pain is continuous and may be described as extreme, growing, sharp, shooting, or throbbing. Putting pressure or warmth on the tooth may induce extreme pain. The area may be sensitive to touch and possibly swollen as well. This swelling may be present at either the base of the tooth, the gum, and/or the cheek, and sometimes can be reduced by applying ice packs.

An acute abscess may be painless but still have a swelling present on the gum. It is important to get anything that presents like this checked by a dental professional as it may become chronic later.

In some cases, a tooth abscess may perforate bone and start draining into the surrounding tissues creating local facial swelling. In some cases, the lymph glands in the neck will become swollen and tender in response to the infection. It may even feel like a migraine as the pain can transfer from the infected area. The pain does not normally transfer across the face, only upwards or downwards as the nerves that serve each side of the face are separate.

Severe aching and discomfort on the side of the face where the tooth is infected is also fairly common, with the tooth itself becoming unbearable to touch due to extreme amounts of pain.

The main types of dental abscess are:

- Periapical abscess: The result of a chronic, localized infection located at the tip, or apex, of the root of a tooth.

- Periodontal abscess: begins in a periodontal pocket (see: periodontal abscess)

- Gingival abscess: involving only the gum tissue, without affecting either the tooth or the periodontal ligament (see: periodontal abscess)

- Pericoronal abscess: involving the soft tissues surrounding the crown of a tooth (see: Pericoronitis)

- Combined periodontic-endodontic abscess: a situation in which a periapical abscess and a periodontal abscess have combined (see: Combined periodontic-endodontic lesions).

There are four types of abscesses that can involve the periodontal tissues:

1. Gingival abscess—a localized, purulent infection involves only the soft gum tissue near the marginal gingiva or the interdental papilla.

2. Periodontal abscess—a localized, purulent infection involving a greater dimension of the gum tissue, extending apically and adjacent to a periodontal pocket.

3. Pericoronal abscess—a localized, purulent infection within the gum tissue surrounding the crown of a partially or fully erupted tooth. Usually associated with an acute episode of pericoronitis around a partially erupted and impacted mandibular third molar (lower wisdom tooth).

4. combined periodontal/endodontic abscess

The signs and symptoms of pericoronitis depend upon the severity, and are variable:

- Pain, which gets worse as the condition develops and becomes severe. The pain may be throbbing and radiate to the ear, throat, temporomandibular joint, posterior submandibular region and floor of the mouth. There may also be pain when biting. Sometimes the pain disturbs sleep.

- Tenderness, erythema (redness) and Edema (swelling) of the tissues around the involved tooth, which is usually partially erupted into the mouth. The operculum is characteristically very painful when pressure is applied.

- Halitosis resulting from the bacteria putrefaction of proteins in this environment releasing malodorous volatile sulfur compounds.

- Bad taste in the mouth from exudation of pus.

- Intra-oral halitosis.

- Formation of pus, which can be seen exuding from beneath the operculum (i.e. a pericoronal abscess), especially when pressure is applied to the operculum.

- Signs of trauma on the operculum, such as indentations of the cusps of the upper teeth, or ulceration. Rarely, the soft tissue around the crown of the involved tooth may show a similar appearance to necrotizing ulcerative gingivitis.

- Trismus (difficulty opening the mouth). resulting from inflammation/infection of the muscles of mastication.

- Dysphagia (difficulty swallowing).

- Cervical lymphadenitis (inflammation and swelling of the lymph nodes in the neck), especially of the submandibular nodes.

- Facial swelling, and rubor, often of the cheek that overlies the angle of the jaw.

- Pyrexia (fever).

- Leukocytosis (increased white blood cell count).

- Malaise (general feeling of being unwell).

- Loss of appetite.

- The radiographic appearance of the local bone can become more radiopaque in chronic pericoronitis.

A periodontal abscess (also termed lateral abscess, or parietal abscess), is a localized collection of pus (i.e. an abscess) within the tissues of the periodontium. It is a type of dental abscess. A periodontal abscess occurs alongside a tooth, and is different from the more common periapical abscess, which represents the spread of infection from a dead tooth (i.e. which has undergone pulpal necrosis). To reflect this, sometimes the term "lateral (periodontal) abscess" is used. In contrast to a periapical abscess, periodontal abscesses are usually associated with a vital (living) tooth. Abscesses of the periodontium are acute bacterial infections classified primarily by location.

Acute pericoronitis (i.e. sudden onset and short lived, but significant, symptoms) is defined as "varying degrees of inflammatory involvement of the pericoronal flap and adjacent structures, as well as by systemic complications." Systemic complications refers to signs and symptoms occurring outside of the mouth, such as fever, malaise or swollen lymph nodes in the neck.

A phoenix abscess is a dental abscess that can occur immediately following root canal treatment. Another cause is due to untreated necrotic pulp (chronic apical periodontitis). It is also the result of inadequate debridement during the endodontic procedure. Risk of occurrence of a phoenix abscess is minimised by correct identification and instrumentation of the entire root canal, ensuring no missed anatomy.

Treatment involves repeating the endodontic treatment with improved debridement, or tooth extraction. Antibiotics might be indicated to control a spreading or systemic infection.

Acute periapical periodontitis, also termed acute apical periodontitis, acute periradicular periodontitis, or symptomatic periapical periodontitis.

The radiographic features of periapical inflammatory lesions vary depending on the time course of the lesion. Because very early lesions

may not show any radiographic changes, diagnosis of these lesions relies solely on the clinical symptoms . More chronic lesions may show lytic (radiolucent) or sclerotic (radiopaque) changes, or both.

Gingival and periodontal pockets are dental terms indicating the presence of an abnormal depth of the gingival sulcus near the point at which the gingival tissue contacts the tooth.

Necrotic pulp is a finding in dentistry to describe dental pulp within a tooth which has become necrotic. Directly meaning, death of the pulp. It is a finding of interest to dentists as the process of pulp death may be painful causing a toothache.

Sequelae of a necrotic pulp include acute apical periodontitis, dental abscess or radicular cyst and discolouration of the tooth.

Tests for a necrotic pulp include: vitality testing using a thermal test or an electric pulp tester. Discolouration may be visually obvious, or more subtle.

Treatment usually involves endodontics or extraction.

Apical abscesses can spread to involve periodontal pockets around a tooth, and periodontal pockets cause eventual pulp necrosis via accessory canals or the apical foramen at the bottom of the tooth. Such lesions are termed periodontic-endodontic lesions, and they may be acutely painful, sharing similar signs and symptoms with a periodontal abscess, or they may cause mild pain or no pain at all if they are chronic and free-draining. Successful root canal therapy is required before periodonal treatment is attempted. Generally, the long-term prognosis of perio-endo lesions is poor.

The signs and symptoms depend upon the type of OM, and may include:

- Pain, which is severe, throbbing and deep seated.

- Initially fistula are not present.

- No dental pain, but headache or other facial pain, as in the descriptive former term "neuralgia-inducing" (cavitational osteonecrosis).

- Fibromyalgia.

- Chronic fatigue syndrome.

- Swelling. External swelling is initially due to inflammatory edema with accompanying erythema (redness), heat and tenderness, and then later may be due to sub-periosteal pus accumulation. Eventually, subperiosteal bone formation may give a firm swelling.

- Trismus (difficulty opening the mouth), which may be present in some cases and is caused by edema in the muscles.

- Dysphagia (difficulty swallowing), which may be present in some cases and is caused by edema in the muscles.

- Cervical lymphadenitis (swelling of the lymph nodes in the neck).

- Aesthesia or paresthesia (altered sensation such as numbness or pins and needles) in the distribution of the mental nerve.

- Fever which may be present in the acute phase and is high and intermittent

- Malaise (general feeling of being unwell) which may be present in the acute phase

- Anorexia (loss of appetite).

- Leukocytosis (elevated numbers of white blood cells) which may be present in the acute phase

- Elevated erythrocyte sedimentation rate and C reactive protein are sometimes present.

- An obvious cause in the mouth (usually) such as a decayed tooth.

- Teeth that are tender to percussion, which may develop as the condition progresses

- Loosening of teeth, which may develop as the condition progresses.

- Pus may later be visible, which exudes from around the necks of teeth, from an open socket, or from other sites within the mouth or on the skin over the involved bone.

- Fetid odor.

Unlike acute OM in the long bones, acute OM in the jaws gives only a moderate systemic reaction and the person remains surprisingly well. Acute OM of the jaws may give a similar appearance to a typical odontogenic infection, but cellulitis does not tend to spread from the periosteal envelope of the involved bone. If the infection is not controlled, the process becomes chronic and systemic symptoms are usually present, including draining fistulas, loosening of teeth and sequestra formation. Untreated chronic osteomyelitis tends to feature occasional acute exacerbations.

The reported symptoms are very variable, and frequently have been present for many months before the condition is diagnosed. Reported symptoms may include some of the following:

- Sharp pain when biting on a certain tooth, which may get worse if the applied biting force is increased. Sometimes the pain on biting occurs when the food being chewed is soft with harder elements, e.g. seeded bread.

- "Rebound pain" i.e. sharp, fleeting pain occurring when the biting force is released from the tooth, which may occur when eating fibrous foods.

- Pain when grinding the teeth backward and forward and side to side.

- Sharp pain when drinking cold beverages or eating cold foods, lack of pain with heat stimuli.

- Pain when eating or drinking sugary substances.

- Sometimes the pain is well localized, and the individual is able to determine the exact tooth from which the symptoms are originating, but not always.

If the crack propagates into the pulp, irreversible pulpitis, pulpal necrosis and periapical periodontitis may develop, with the respective associated symptoms.

Cracked tooth syndrome refers to a highly variable set of pain-sensitivity symptoms that may accompany a tooth fracture, usually sporadic, sharp pain that occurs during biting or with release of biting pressure, or relieved by releasing pressure on the tooth. The term is falling into disfavor and has given way to the more generalized description of fractures and cracks of the tooth, which allows for the wide variations in signs, symptoms, and prognosis for traumatized teeth. A fracture of a tooth can involve the enamel, dentin, and/or pulp, and can be orientated horizontally or vertically. Fractured or cracked teeth can cause pain via several mechanisms, including dentin hypersensitivity, pulpitis (reversible or irreversible), or periodontal pain. Accordingly, there is no single test or combination of symptoms that accurately diagnose a fracture or crack, although when pain can be stimulated by causing separation of the cusps of the tooth, it's highly suggestive of the disorder. Vertical fractures can be very difficult to identify because the crack can rarely be probed or seen on radiographs, as the fracture runs in the plane of conventional films (similar to how the split between two adjacent panes of glass is invisible when facing them).

When toothache results from dental trauma (regardless of the exact pulpal or periodontal diagnosis), the treatment and prognosis is dependent on the extent of damage to the tooth, the stage of development of the tooth, the degree of displacement or, when the tooth is avulsed, the time out of the socket and the starting health of the tooth and bone. Because of the high variation in treatment and prognosis, dentists often use trauma guides to help determine prognosis and direct treatment decisions.

The prognosis for a cracked tooth varies with the extent of the fracture. Those cracks that are irritating the pulp but do not extend through the pulp chamber can be amenable to stabilizing dental restorations such as a crown or composite resin. Should the fracture extend though the pulp chamber and into the root, the prognosis of the tooth is hopeless.

A person experiencing caries may not be aware of the disease. The earliest sign of a new carious lesion is the appearance of a chalky white spot on the surface of the tooth, indicating an area of demineralization of enamel. This is referred to as a white spot lesion, an incipient carious lesion or a "microcavity". As the lesion continues to demineralize, it can turn brown but will eventually turn into a cavitation ("cavity"). Before the cavity forms, the process is reversible, but once a cavity forms, the lost tooth structure cannot be regenerated.

A lesion that appears dark brown and shiny suggests dental caries were once present but the demineralization process has stopped, leaving a stain. Active decay is lighter in color and dull in appearance.

As the enamel and dentin are destroyed, the cavity becomes more noticeable. The affected areas of the tooth change color and become soft to the touch. Once the decay passes through enamel, the dentinal tubules, which have passages to the nerve of the tooth, become exposed, resulting in pain that can be transient, temporarily worsening with exposure to heat, cold, or sweet foods and drinks. A tooth weakened by extensive internal decay can sometimes suddenly fracture under normal chewing forces. When the decay has progressed enough to allow the bacteria to overwhelm the pulp tissue in the center of the tooth, a toothache can result and the pain will become more constant. Death of the pulp tissue and infection are common consequences. The tooth will no longer be sensitive to hot or cold, but can be very tender to pressure.

Dental caries can also cause bad breath and foul tastes. In highly progressed cases, an infection can spread from the tooth to the surrounding soft tissues. Complications such as cavernous sinus thrombosis and Ludwig angina can be life-threatening.

Periapical cysts begin as asymptomatic and progress slowly. Subsequent infection of the cyst causes swelling and pain. Initially, the cyst swells to a round hard protrusion, but later on the body resorbs some of the cyst wall, leaving a softer accumulation of fluid underneath the mucous membrane.

Larger cysts may cause bone expansion or displace roots. Discoloration of the affected tooth may also occur. Patient will present negative results to electric and ice test of the affected tooth but will be sensitive to percussion. Surrounding gingival tissue may experience lymphadenopathy. The alveolar plate may exhibit crepitus when palpated.

Periapical cysts exist in two structurally distinct classes:

Periapical true cysts - cysts containing cavities entirely surrounded in epithelial lining. Resolution of this type of cyst requires surgical treatment such as a cystectomy.

Periapical pocket cysts - epithelium lined cavities that have an opening to the root canal of the affected tooth. Resolution may occur after traditional root canal therapy.

Cracked tooth syndrome could be considered a type of dental trauma and also one of the possible causes of dental pain. One definition of cracked tooth syndrome is "a fracture plane of unknown depth and direction passing through tooth structure that, if not already involving, may progress to communicate with the pulp and/or periodontal ligament."

Dental plaque is a biofilm or mass of bacteria that grows on surfaces within the mouth. It is a sticky colorless deposit at first, but when it forms tartar, it is often brown or pale yellow. It is commonly found between the teeth, on the front of teeth, behind teeth, on chewing surfaces, along the gumline, or below the gumline cervical margins. Dental plaque is also known as microbial plaque, oral biofilm, dental biofilm, dental plaque biofilm or bacterial plaque biofilm.

Progression and build-up of dental plaque can give rise to tooth decay – the localised destruction of the tissues of the tooth by acid produced from the bacterial degradation of fermentable sugar – and periodontal problems such as gingivitis and periodontitis; hence it is important to disrupt the mass of bacteria and remove it. Plaque control and removal can be achieved with correct daily or twice-daily tooth brushing and use of interdental aids such as dental floss and interdental brushes.

Oral hygiene is important as dental biofilms may become acidic causing demineralization of the teeth (also known as dental caries) or harden into dental calculus (also known as tartar). Calculus cannot be removed through tooth brushing or with interdental aids, but only through professional cleaning.

Loss of attachment:

- By far the most common cause is periodontal disease (gum disease). This is painless, slowly progressing loss of bony support around teeth. It is made worse by smoking and the treatment is by improving the oral hygiene above and below the gumline.

- Dental abscesses can cause resorption of bone and consequent loss of attachment. Depending on the type of abscess, this loss of attachment may be restored once the abscess is treated, or it may be permanent.

- Many other conditions can cause permanent or temporary loss of attachment and increased tooth mobility. Examples include: Langerhans cell histiocytosis.

Increased forces on the tooth:

- Bruxism (abnormal clenching and grinding of teeth) can aggravate attachment loss and tooth mobility if periodontal disease is already present. The tooth mobility is typically reversible and the tooth returns to normal level of mobility once the bruxism is controlled.

- Dental trauma. Luxations, and root fractures of teeth can cause sudden mobility after a blow. Dental trauma may be isolated or associated with other facial trauma.

- Increased biting force on one tooth can cause temporary increased mobility until corrected. A common scenario is a new filling or crown which is a fraction of a millimeter too prominent in the bite, which after a few days causes periodontal pain in that tooth and/or the opposing tooth.

Secondary symptoms of periapical cysts include inflammation and infection of the pulp causing dental caries. This infection is what causes necrosis of the pulp.

Expansion of the cyst causes erosion of the floor of the maxillary sinus. As soon as it enters the maxillary antrum, the expansion rate increases due to available space for expansion. Performing a percussion test by tapping the affected teeth will cause shooting pain. This is often clinically diagnostic of pulpal infection.

Radiographically, it is virtually impossible to differentiate granuloma from a cyst. If the lesion is large it is more likely to be a cyst. Radiographically, both granulomas and cysts appear radiolucent. Many lesions of the mandible in particular appear cystlike in appearance. It is often necessary to obtain a biopsy and evaluate the tissue under a microscope to accurately identify the lesion.

Abrasion is a pathological, non-carious tooth loss that most commonly affects the premolars and canines. Abrasion frequently presents at the cemento-enamel junction and can be caused by many contributing factors, all with the ability to affect the tooth surface in varying degrees.

Sources of abrasion may arise from oral hygiene habits such as toothbrushes, toothpicks, floss, and dental appliance or may arise from other habits such as nail biting, chewing tobacco or another object. Abrasion can also occur from the type of dentifrice being utilized as some have more abrasive qualities such as whitening toothpastes.

The appearance may vary depending on the aetiology of abrasion, however most commonly presents in a V-shaped caused by excessive lateral pressure whilst tooth-brushing. The surface is shiny rather than carious, and sometimes the ridge is deep enough to see the pulp chamber within the tooth itself.

In order for successful treatment of abrasion to occur, the aetiology first needs to be identified and ceased, e.g. overzealous brushing. Once this has occurred subsequent treatment may involve the changes in oral hygiene or toothpaste, application of fluoride to reduce sensitivity or the placement of a restoration to aid in reducing the progression of further tooth loss.

As the original sulcular depth increases and the apical migration of the junctional epithelium has simultaneously occurred, the pocket is now lined by pocket epithelium (PE) instead of junctional epithelium (JE). To have a true periodontal pocket, a probing measurement of 4 mm or more must be clinically evidenced. In this state, much of the gingival fibers that initially attached the gingival tissue to the tooth have been irreversibly destroyed. The depth of the periodontal pockets must be recorded in the patient record for proper monitoring of periodontal disease. Unlike in clinically healthy situations, parts of the sulcular epithelium can sometimes be seen in periodontally involved gingival tissue if air is blown into the periodontal pocket, exposing the newly denuded roots of the tooth. A periodontal pocket can become an infected space and may result in an abscess formation with a papule on the gingival surface. Incision and drainage of the abscess may be necessary, as well as systemic antibiotics; placement of local antimicrobial delivery systems within the periodontal pocket to reduce localized infections may also be considered.

It is classified as supra bony and infra bony based on its depth in relation to alveolar bone.

Intraoral dental sinus (also termed a parulis and commonly, a gumboil) is an oral lesion characterized by a soft erythematous papule (red spot) that develops on the alveolar process in association with a non-vital tooth and accompanying dental abscess. A parulis is made up of inflamed granulation tissue.

Less commonly, dental infections drain onto the surface of the skin, forming a cutaneous sinus of dental origin.

This condition is often resolved by endodontic treatment and does not have indication for antibiotic use. This is a common mistake among health professionals.

The classification is similar to the classification of OM generally, according to the length of time the inflammation has been present and whether there is suppuration (the formation of pus). "Acute osteomyelitis" is loosely defined as OM which has been present for less than one month and "chronic osteomyelitis" is the term used for when the condition lasts for more than one month. Suppurative osteomyelitis of the jaws is uncommon in developed regions, and more common in developing countries. In Europe and the United States, most cases follow dental infections or mandibular fractures. There have been many reported cases occurring in Africa which are coexistent with acute necrotizing ulcerative gingivitis or cancrum oris.

In the pre-antibiotic era, acute OM of the jaws was more extensive. Massive, diffuse infections commonly involved the whole side of the mandible, or the whole of one side and the opposite side as far as the mental foramen. Localized osteomyelitis tended to be described as either "vertical", where a short segment of the body of the mandible from the alveolar crest to the lower border was involved, and "alveolar", where a segment of alveolar bone down to the level of the inferior alveolar canal would sequestrate, including the sockets of several teeth. Treatment with antibiotics has significantly altered the natural history of OM of the jaws. Today, however, the condition is often a hidden infection, due in part to not being visible on most dental X-rays. In addition, some schools of dentistry do not recognize "silent" OM of the jaws—occurrence of the condition without visually obvious manifestations—in their curriculum. In addition, as circulation is intrinsically diminished in jawbones, antibiotics are frequently ineffective.