Oral / Dental Pain
Oral or dental pain is nociceptive or inflammatory pain arising from structures of the teeth, gingiva, oral mucosa, or jaw, most commonly caused by dental caries, pulpitis, periodontal disease, or abscess.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Dental caries / Pulpitis | Sharp pain with hot/cold/sweet; visible cavity | 「飲凍嘢熱嘢有冇痛？隻牙有冇窿？」 | ~35% |
| Periapical abscess | Localised constant throbbing, tender to percussion, facial swelling | 「敲隻牙痛唔痛？面有冇腫？」 (percussion tenderness on exam) | ~20% | |
| Periodontal disease / Abscess | Throbbing pain, gum swelling, pus, loose tooth | 「牙肉有冇腫？有冇出膿？隻牙有冇鬆咗？」 | ~15% | |
| Serious Not To Miss | Acute maxillary sinusitis | Upper molar pain bilateral, facial pressure worse bending forward, purulent nasal discharge [1] | 「低頭會唔會面痛啲？鼻有冇黃綠色鼻水？」 | ~5% |
| Deep space neck infection / Parapharyngeal abscess | Trismus, high fever, toxic, dysphagia | 「張唔張得開嘴？有冇高燒？」 | ~1% | |
| Oral squamous cell carcinoma | Non-healing ulcer, induration, leukoplakia/erythroplakia, loosen tooth, neck lump [3] | 「口入面有冇損口好耐都唔好？有冇白色或者紅色嘅斑？」 | ~1% | |
| Ludwig's angina | Bilateral submandibular swelling, floor-of-mouth elevation, dysphagia, stridor | 「有冇覺得吞嘢困難或者呼吸唔暢順？」→ EMERGENCY | < 1% | |
| Pitfalls | Cracked tooth syndrome | Sharp pain on biting/releasing bite on hard food | 「咬硬嘢嗰陣痛？放開嗰下最痛？」 | ~8% |
| TMJ dysfunction | Pre-auricular pain, clicking, worse with chewing, no dental pathology found | 「耳仔前面痛唔痛？有冇咯咯聲？張開嘴有冇偏？」 | ~5% | |
| Dry socket (alveolar osteitis) | Severe pain 2–5 days post extraction, empty socket | 「最近有冇剝牙？剝完第幾日開始痛？」 | ~2% | |
| Medication-related osteonecrosis of jaw (MRONJ) | Exposed bone > 8 weeks, current/past bisphosphonate/denosumab [4] | 「有冇食骨質疏鬆藥？口入面有冇見到骨？」 | < 1% | |
| Masquerades | Trigeminal neuralgia | Paroxysmal electric-shock pain in V2/V3, triggered by touch/brushing teeth, pain-free intervals [2] | 「痛係咪好似觸電咁？刷牙或者掂到面會唔會引發？」 | ~3% |
| Herpes zoster (CN V) | Vesicular rash in dermatomal distribution, preceding burning pain | 「面有冇出過水泡？痛之前有冇燒灼感？」 | ~2% | |
| Depression / Atypical facial pain | Chronic bilateral diffuse facial/oral pain, no organic cause, associated low mood, sleep disturbance | 「痛有冇特定位置？心情近排點？瞓得好唔好？」 | ~2% | |
| Referred cardiac pain | Jaw pain on exertion, relieved by rest, cardiac risk factors | 「行路或者上樓梯會唔會下巴痛？休息會唔會好返？」 | ~1% | |
| Trying to Tell Me Something? | Cannot afford dentist / access barrier | Delayed presentation, no regular dental care | 「平時有冇定期睇牙？有冇咩原因冇早啲嚟？」 | ~20% |
| Work/exam stress → bruxism → dental pain | Pain on waking, jaw fatigue, stress at work/school | 「朝早起身隻牙特別痛？有冇磨牙習慣？最近壓力大唔大？」 | ~10% | |
| Health anxiety / fear of oral cancer | Patient noticed an ulcer or white patch and fears the worst | 「你係咪擔心呢個痛係唔好嘅嘢？」 | ~5% |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Greeting, introduction, set agenda | 「你好，我係今日負責嘅醫生。請問我可以點稱呼你？今日想了解吓你嘅情況，大概傾幾分鐘，可以嗎？」 | Friendly opening + permission → interpersonal marks |
| 0:30–2:00 | HPI with SOCRATES – site, onset, character, radiation, aggravating/relieving, timing, severity, associated Sx | 「隻牙痛咗幾耐？邊度最痛？痛嘅感覺係點——陣痛定持續痛？食嘢或者飲凍嘢會唔會痛啲？有冇腫面、發燒、或者流膿？」 | Captures chief complaint + symptom analysis comprehensively |
| 2:00–3:00 | Red flags + targeted systems review – trismus, numbness, weight loss, neck lump, bleeding, non-healing ulcer | 「有冇覺得張嘴困難？面或者嘴唇有冇痺？有冇口入面生嘢唔好？頸有冇摸到粒嘢？體重有冇輕咗？」 | Screens for oral malignancy, Ludwig's angina, sinusitis |
| 3:00–3:45 | PMH, DH, allergy, FH – DM, bisphosphonates, recent dental procedures, smoking/alcohol/betel nut | 「以前有冇乜嘢大病？而家食緊乜嘢藥？有冇食骨質疏鬆藥？有冇藥物敏感？有冇煙酒或者食檳榔？」 | MRONJ risk, immunosuppression, oral cancer risk factors |
| 3:45–4:30 | ICE + hidden agenda – Ideas, Concerns, Expectations | 「你自己覺得呢個痛係乜嘢原因？最擔心啲咩？你今日嚟最希望醫生幫到你啲咩？」 | Directly maps to Q3; uncovers hidden concern (e.g. fear of cancer, can't eat/sleep) |
| 4:30–5:15 | Social/functional impact – eating, sleeping, work, mood | 「呢個痛有冇影響你食嘢、瞓覺、或者返工？有冇因為痛覺得心情低落？」 | Biopsychosocial marks (Q5b) |
| 5:15–5:45 | Summarise, check understanding | 「等我總結吓——你隻（位置）牙痛咗（幾耐），食嘢會痛啲，冇發燒…我有冇漏咗啲咩？」 | Shows active listening, gets correction marks |
| 5:45–6:00 | Close with plan + safety net | 「我會幫你檢查吓，之後可能會轉介你睇牙醫。如果有發燒、面腫大咗、或者張唔開嘴，要即刻返嚟。」 | Safe close + safety-net = marks |
Uncovering the hidden agenda: The symptom is pain, but the patient may have come today because they are worried about oral cancer (saw a non-healing ulcer), or because pain is stopping them eating/sleeping, or they need a dental referral letter, or they fear a medication side-effect (e.g. bisphosphonate jaw necrosis). Always ask: 「其實今日促使你嚟睇醫生，係咪有啲特別擔心？」
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think Of |
|---|---|---|---|---|
| Site | Which tooth/area? Upper or lower? One side? | 「邊隻牙？上面定下面？左定右？」 | Localises pathology; maxillary → think sinusitis | Maxillary sinusitis if upper molars bilateral [1] |
| Onset/Duration | When did it start? Sudden or gradual? | 「幾時開始？突然定慢慢痛起嚟？」 | Acute = pulpitis/abscess; chronic = caries/TMJ/cancer | Acute abscess vs chronic periodontitis |
| Character | Dull ache, throbbing, or sharp shooting? | 「係笠笠痛、陣陣跳住痛、定好sharp好似觸電咁痛？」 | Sharp shooting paroxysmal → trigeminal neuralgia [2] | TN if V2/V3, triggered by touch |
| Aggravating | Worse with hot/cold/sweet? Chewing? Biting? | 「飲凍嘢熱嘢有冇痛啲？咬嘢呢？」 | Hot/cold = reversible/irreversible pulpitis; bite = cracked tooth/periapical abscess | Irreversible pulpitis → needs extraction/root canal |
| Relieving | Does painkiller help? Which one? | 「食止痛藥有冇好啲？食咩藥？食幾多？」 | Analgesic use, NSAID contraindications | Refractory pain → abscess or malignancy |
| Radiation | Does pain go to ear, eye, temple, or throat? | 「痛有冇去到耳仔、眼、太陽穴嗰邊？」 | Referred otalgia from oral/pharyngeal CA [3]; temporal = GCA/TMJ | Oral squamous cell carcinoma, TMJ disorder |
| Swelling | Any facial swelling? Inside-mouth swelling? | 「面有冇腫？口入面有冇腫起？」 | Ludwig's angina, periapical/periodontal abscess | Ludwig's angina if bilateral submandibular → EMERGENCY |
| Fever | Any fever or chills? | 「有冇發燒、發冷？」 | Dental abscess with systemic spread, deep space infection | Sepsis, Ludwig's angina |
| Trismus | Can you open your mouth fully? | 「張得開嘴嗎？有冇覺得張嘴困難？」 | Trismus = red flag for deep space infection or retromolar trigone/oral CA [3] | Oral malignancy, peritonsillar abscess |
| Non-healing ulcer | Any ulcer that won't heal? | 「口入面有冇損口好耐都唔好？」 | Non-healing ulcer > 3 weeks → oral SCC [3] | Oral squamous cell carcinoma |
| Numbness | Any numbness of lip, chin, or face? | 「嘴唇或者面有冇痺？」 | Numb chin syndrome → malignant infiltration of inferior alveolar nerve | Metastatic disease, oral CA |
| Neck lump | Any lump in neck? | 「頸有冇摸到粒嘢？」 | Lymphadenopathy → metastatic oral CA | Oral SCC with nodal spread |
| Weight loss | Any unintentional weight loss? | 「體重有冇無端端輕咗？」 | Constitutional symptom of malignancy | Oral CA, NPC |
| PMH – DM | Do you have diabetes? | 「有冇糖尿病？」 | DM → periodontal disease, poor healing, infection risk | Periodontal abscess, MRONJ risk [4] |
| PMH – osteoporosis | Taking bisphosphonate/denosumab? | 「有冇食骨質疏鬆藥？」 | MRONJ: exposed bone in jaw not healing > 8 weeks [4] | Medication-related osteonecrosis of jaw |
| DH – anticoagulants | Taking blood thinners? | 「有冇食薄血藥？」 | Affects dental procedure planning; withhold 48h for extraction [5] | Bleeding post-extraction |
| Smoking/alcohol/betel | Do you smoke, drink, or chew betel nut? | 「有冇食煙、飲酒、或者食檳榔？」 | Major risk factors for oral SCC, leukoplakia [3][6] | Oral squamous cell carcinoma |
| Recent dental work | Any recent dental procedure? | 「最近有冇睇牙、剝牙？」 | Post-extraction pain (dry socket/alveolar osteitis), endocarditis prophylaxis [7] | Dry socket, MRONJ, IE |
| Functional impact | Can you eat, sleep, work normally? | 「痛到有冇影響食嘢、瞓覺、返工？」 | Biopsychosocial impact for Q5b | Functional impairment |
| Mood | Feeling low or anxious about this? | 「有冇因為呢個痛覺得好煩或者情緒低落？」 | Psychological component Q5b | Anxiety, depression |
Case Report Form Answer Builder
Write in this format: "[Duration] [site] oral/dental pain, [character], aggravated by [factors], associated with [key associated Sx]."
High-yield points to capture:
- Exact site (which tooth/quadrant, gum, floor of mouth)
- Duration, onset, progression
- Character (throbbing, sharp, shooting, dull)
- Aggravating factors (hot/cold, biting, swallowing)
- Relieving factors (analgesics, spontaneous)
- Associated symptoms: swelling, fever, pus, bleeding, trismus, numbness, non-healing ulcer, nasal symptoms
- Prior dental history, recent procedures
- Impact on function (eating, sleeping)
| Likely RFC Examples | How to Phrase |
|---|---|
| Pain not controlled by OTC analgesics | "Worsening dental pain not responding to paracetamol, affecting eating and sleep" |
| Facial swelling / afraid of infection spreading | "Facial swelling causing concern for serious infection" |
| Noticed non-healing ulcer → worried about cancer | "Non-healing oral ulcer for 4 weeks, seeking diagnosis and reassurance" |
| Needs dental referral | "Request for dental referral for definitive treatment" |
Tip: The RFC is NOT the diagnosis. It is why the patient came today — often the tipping point (pain now unbearable, noticed something new, someone told them to come).
| Component | Example Wording |
|---|---|
| Idea | "Patient thinks the pain is from a decayed tooth / infection" |
| Concern | "Worried it might be oral cancer because uncle had mouth cancer" OR "Worried infection will spread" |
| Expectation | "Hopes for pain relief and a dental referral" OR "Wants antibiotics" |
Dental caries with pulpitis (or periapical abscess if swelling/fever present) — the most common cause of oral/dental pain in HK primary care.
Minimum supporting evidence:
- Localised toothache aggravated by hot/cold/sweet
- ± visible cavity or tender tooth on percussion
- ± gum swelling or facial swelling
- If fever + fluctuant swelling → periapical abscess
| DDx | Key Discriminator |
|---|---|
| Periodontal abscess | Gum swelling/pus around a tooth, tooth may be mobile, deep periodontal pocket |
| Acute maxillary sinusitis | Multiple upper teeth painful, facial pressure worse bending forward, purulent nasal discharge [1] |
| Trigeminal neuralgia | Paroxysmal electric-shock pain V2/V3, triggered by innocuous stimuli, pain-free between attacks [2] |
(Alternative DDx if clinical picture fits: TMJ dysfunction, dry socket, oral SCC, pericoronitis of wisdom tooth)
| Domain | Problem |
|---|---|
| Biological | Dental caries/abscess requiring definitive dental treatment (extraction/root canal); risk of infection spread |
| Psychological | Anxiety about pain / fear of cancer / dental phobia causing delayed treatment |
| Social | Impaired eating/nutrition and work absenteeism due to pain; financial barrier to dental care |
| Diagnosis / DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Dental caries / Pulpitis (most likely) | Visible cavity or carious lesion on affected tooth | Inspect oral cavity with pen torch and tongue depressor | Directly visualises the cause; tender to percussion if pulpitis extends to periapical |
| Periapical abscess | Localised gum swelling/fluctuance + tenderness on percussion | Tap the tooth with a tongue depressor; inspect buccal sulcus for swelling | Percussion tenderness and swelling at tooth apex = periapical pathology |
| Periodontal abscess | Pus expressible from gum margin; mobile tooth | Gentle pressure on gum; wiggle tooth | Pus from periodontal pocket + mobility = periodontal abscess |
| Acute maxillary sinusitis | Tenderness over maxillary sinus on palpation | Press firmly over cheek below infraorbital ridge | Sinus tenderness with purulent nasal discharge localises infection to sinus [1] |
| Trigeminal neuralgia | Trigger zone on light touch reproduces pain | Lightly touch the cheek/nasolabial fold with cotton | Allodynic trigger zone reproducing typical shooting pain is pathognomonic [2] |
| Oral SCC | Non-healing ulcer with induration/rolled edges ± surrounding leukoplakia [3] | Inspect oral cavity systematically; palpate neck for lymphadenopathy | Indurated ulcer + fixation = high suspicion for malignancy; neck nodes = metastasis |
| Ludwig's angina | Bilateral submandibular induration, floor-of-mouth elevation, "woody" texture | Bimanual palpation of floor of mouth; inspect submandibular region | Board-like floor of mouth + submandibular swelling = Ludwig's → urgent referral |
| TMJ dysfunction | Pre-auricular tenderness ± clicking on jaw opening | Palpate TMJ while patient opens/closes mouth; feel for crepitus/click | Reproducible click + tenderness without dental pathology = TMJ disorder |
Must-Not-Miss Red Flags — Refer Urgently
- Ludwig's angina: Floor-of-mouth swelling + dysphagia + stridor → A&E immediately (airway emergency)
- Oral SCC: Non-healing ulcer > 3 weeks, induration, leukoplakia/erythroplakia, loose tooth without dental cause, neck lump → urgent ENT/OMFS referral [3]
- Deep space neck infection: Trismus + high fever + toxic → A&E
- Numb chin syndrome: New-onset lower lip/chin numbness → suspect malignant infiltration of inferior alveolar nerve
- Jaw pain on exertion: Could be referred angina → do cardiac workup
Top traps that lose marks:
| Trap | How to Avoid |
|---|---|
| Forgetting to ask about smoking, alcohol, betel nut | These are the #1 risk factors for oral SCC — always ask |
| Missing sinusitis mimicking dental pain | Ask about nasal discharge, bending-forward test, bilateral upper teeth |
| Forgetting bisphosphonate / MRONJ history | Ask ALL patients about osteoporosis drugs, especially post-menopausal women [4] |
| Labelling trigeminal neuralgia as "toothache" | Ask about electric-shock quality, triggers, pain-free intervals — TN has NO dental pathology |
| Not asking about referred cardiac pain | Jaw/mandibular pain on exertion in older patients with risk factors |
| Forgetting to ask about recent dental procedures | Dry socket, post-extraction bleeding, IE prophylaxis issues |
| Writing diagnosis instead of RFC for Q2 | RFC = why they came, not what they have |
| Not performing bimanual oral/submandibular exam | Key sign for Ludwig's and floor-of-mouth pathology |
Shortest safe management line for consultation close:
「我會幫你開止痛藥同消炎藥先控制痛楚，然後轉介你睇牙醫做進一步治療。如果面腫大咗、發高燒、張唔開嘴、或者呼吸有困難，要即刻去急症室。」
(I'll prescribe painkillers ± antibiotics for now and refer you to a dentist. If swelling worsens, you get high fever, can't open your mouth, or have breathing difficulty, go to A&E immediately.)
GC 219 HIGH YIELD: Oral cavity SCC — painless at first, painful when infiltrating nerve; non-healing ulcer; surrounding leukoplakia/erythroplakia; induration or fixation; loosen tooth ± non-healing tooth socket; 15-20% occult nodal metastasis → elective neck dissection [3]
Block A – Osteoporosis notes HIGH YIELD: MRONJ criteria — exposed bone in maxillofacial region not healing within 8 weeks; current/previous antiresorptive or antiangiogenic agents; no radiation history to jaws [4]. Risk factors: age > 65, periodontitis, bisphosphonates > 2 years, smoking, dentures, DM, invasive dental procedures.
High Yield Summary
What to ASK: SOCRATES for pain → hot/cold/biting triggers → swelling/fever/pus → trismus/numbness/non-healing ulcer (red flags) → recent dental work → bisphosphonate use → smoking/alcohol/betel nut → ICE + functional impact + mood.
What to WRITE: Q1: structured HPI with timing + character + triggers + associated Sx. Q2: RFC in the patient's own words (why TODAY). Q3: ICE — always include a cancer/infection concern. Q4: Dental caries with pulpitis (or periapical abscess). Q5a: periodontal abscess, sinusitis, TN. Q5b: biological (infection/caries), psychological (anxiety/dental phobia), social (eating impairment/work absence). Q6: visible cavity or tender-to-percussion tooth.
What NOT to MISS: Ludwig's angina (airway emergency), oral SCC (non-healing ulcer > 3 wk), numb chin, referred cardiac jaw pain, MRONJ in bisphosphonate users.
Active Recall - Family Medicine Clinical Test
[1] MBBS Final MB (Pediatrics) (Felix PY Lai) – Sinusitis clinical manifestation (p.112) [2] Maksim Medicine Notes – Trigeminal neuralgia (p.256); MBBS Final MB (Medicine) (Felix PY Lai) – Trigeminal neuralgia clinical manifestation (p.1156–1158) [3] GC 219. Infections and tumours in pharynx and oral cavity (p.35) [4] Senior notes: Block A - Back pain in an elderly woman – MRONJ criteria and risk factors (p.29) [5] Senior notes: Block A - Clinical pharmacology of antiplatelets and anticoagulation – DOAC withholding for dental procedures (p.4) [6] Ryan Ho Fundamentals – Oral cavity examination: leukoplakia causes and oral ulcers (p.62) [7] Senior notes: Block A - Fever and a murmur – IE prophylaxis for dental procedures (p.42)
General Malaise
General malaise is a nonspecific symptom of overall bodily discomfort, weakness, or feeling of being unwell that often accompanies the onset of various acute or chronic illnesses.
Localised Lump
A localized lump is a discrete, palpable mass confined to a specific anatomical area, arising from abnormal growth or swelling of tissue such as a cyst, abscess, lipoma, or neoplasm.