Can Earache Come From a Tooth?

We often see patients who attend with earache, whose ear is found clear on examination, and whose pain nonetheless continues. The commonest cause of this picture is not the ear itself but the jaw joint just in front of it, or one of the lower back teeth.

What referred pain is

Sensation from certain regions travels to the centre along the same nerve branches. The brain cannot always distinguish exactly which structure a signal came from and perceives the pain in a neighbouring area. This is referred pain.

The jaw, the teeth and the area around the ear are close neighbours in this respect. Pain arising in the lower molars often spreads to the ear, the temple or the neck, and the patient describes the ear as its centre.

Which dental problems refer to the ear

The picture that most often refers to the ear is deep decay or apical inflammation in the lower back teeth. Inflammation around an impacted or partly erupted lower wisdom tooth follows the same route and usually comes with difficulty opening the mouth.

Dry socket after an extraction also produces severe pain radiating to the ear. Here the pain begins two or three days after the extraction and responds poorly to painkillers; these two features distinguish it.

Earache arising from the jaw joint

The jaw joint sits immediately in front of the ear canal, separated only by a thin wall of bone. When there is a problem in the joint or the chewing muscles, the pain feeling as though it comes from inside the ear is a consequence of that proximity.

• Pain that increases on chewing and yawning
• Fullness or pressure in the ear without hearing loss
• Symptoms marked in the morning and easing through the day
• Spread to the temple and the side of the neck
• Pain reproduced by pressing over the joint

How to identify a true ear cause

A genuine ear infection usually involves fever, reduced hearing, discharge from the ear or a recent upper respiratory infection. Pulling the earlobe or pressing the tragus increases the pain.

In dental or joint pain these manoeuvres do not change the pain; chewing, opening wide or tapping the tooth in question, by contrast, clearly provoke it. This simple distinction guides most patients.

Is it different in children?

Middle ear infection is very common in children, so the ear usually takes priority in childhood earache. Even so, referred complaints are not rare in teething infants and in children while the six-year molar is erupting.

Where there is fever, distress and tugging at the ear, paediatric or ENT assessment should come first. If that examination is clear, the teeth are then assessed.

The approach at examination

The dentist tests each tooth in turn, looking for one that could be the source. The jaw joint and chewing muscles are then examined by hand; reproducing the patient's described pain by pressing on a muscle is a strong finding.

A panoramic radiograph is often used here because it shows impacted teeth, apical inflammation and joint structure at once. Where no dental or joint finding emerges the patient is referred to ENT; pain arising in the neck also enters the differential.

Treatment follows the source

Where the pain arises from a tooth, the solution is treatment of that tooth: a filling or root canal treatment for deep decay, root canal treatment for apical inflammation, and cleaning of the area with extraction where needed for pericoronitis.

Where the source is the joint or the muscles the approach differs: reducing load, a night guard, heat and exercises. Antibiotics or extraction bring no benefit in this group; they cause an unnecessary loss.

When not to delay

Where earache is joined by swelling in the face or neck, fever, difficulty swallowing, inability to open the mouth or swelling around the eye, the picture suggests a spreading infection and must not wait.

Pain silenced with painkillers that keeps returning should not be postponed either. The insidious feature of referred pain is that the source is missed for a long time while the problem quietly advances.