If you have ever spent a night on the couch with a hot water bottle and a growing sense of injustice, you already know the pattern. The tooth was manageable all day. You go to bed, and within twenty minutes it is the only thing in the world.
This is one of the most common calls we get first thing in the morning at Biltoft Dental, from Murwillumbah and across the Tweed Valley. People often apologise for not ringing sooner. There is nothing to apologise for. Here is what is actually going on, and what helps.
Why it genuinely is worse at night
It is not your imagination, and it is not that you are being dramatic.
You lie down and the pressure changes. When you are upright, blood drains away from your head easily. Lying flat raises the blood pressure in your head slightly. Inside a tooth, the nerve sits in a sealed chamber of hard tissue with no room to expand. When that nerve is inflamed, a small increase in pressure has nowhere to go, so you feel it as throbbing.
There is nothing else competing for your attention. During the day you have work, kids, traffic, a phone. At 2am there is a ceiling and a tooth. Pain that measured a four at lunchtime measures an eight when it is the only signal arriving.
Your natural anti-inflammatory levels dip overnight. Cortisol follows a daily rhythm and is at its lowest in the small hours, which is also why arthritis and back pain tend to bite overnight.
Whatever you took has worn off. Most people take something around dinner, then wake at 1am or 2am, which is roughly when a standard dose has stopped working.
What actually helps at 2am
Take ibuprofen, or ibuprofen with paracetamol. Dental pain is inflammatory, so an anti-inflammatory usually outperforms paracetamol alone. Taken together at the doses on the packets, they work better than either by itself. Speak to your pharmacist first if you take other medication, have stomach or kidney problems, or are pregnant.
Prop your head up. Two pillows, or sleep in a recliner if you have one. Keeping your head above your heart reduces the pressure that is causing the throb. This sounds too simple to matter and it is one of the most reliable things you can do.
Use cold, never heat. A cold pack against the outside of the cheek, fifteen minutes on and fifteen off. Cold reduces blood flow to the area. Heat does the opposite, and if there is an infection, heat can help it spread.
Rinse with warm salty water. A teaspoon of salt in a cup of warm water, swished gently. It will not cure anything but it settles irritated gum tissue and clears debris from around the tooth.
Keep off that side. Chewing on an inflamed tooth keeps the cycle going.
What does not help, and what makes it worse
Aspirin held against the gum. This one persists through generations and it causes a chemical burn on the gum tissue. Aspirin works through the bloodstream. Swallow it or skip it.
Heat packs on the face. Covered above, but worth repeating because it is the single most common thing people do.
Clove oil in quantity. A tiny amount on a cotton bud can numb briefly. Poured onto the tooth or the gum it irritates the tissue and, in a few cases, causes its own burn.
Alcohol. It thins the blood, disturbs sleep, and interacts with pain relief.
Waiting for it to settle. Which brings us to the important part.
The trap: when the pain stops on its own
Toothache that builds over several days and then vanishes completely feels like recovery. Frequently it is the opposite.
A tooth hurts because the nerve inside is inflamed. If that inflammation continues long enough, the nerve dies. A dead nerve cannot send pain signals, so the tooth goes quiet. The bacteria are still there and now have an undefended space to occupy. Over weeks or months, the infection works its way out of the root tip into the bone, and reappears as a swelling, a bad taste, or an abscess.
The tooth that stopped hurting is often the one that costs the most to fix later. If you have had days of pain that suddenly ended, please still get it checked.
What we do about it
An emergency appointment for toothache is mostly diagnosis. We need to know which tooth, and what stage it is at, because a deep filling and an abscess at the root tip need different treatment and can feel identical to the person in the chair.
That usually means a short conversation about the pattern of the pain, particularly whether it lingers after something cold, a look at the tooth and gum, and a small X-ray. The X-ray does the heavy lifting. It shows what is happening under the filling and around the root.
From there the options are usually to remove the decay and place a filling, to start root canal treatment to take the pressure off a dying nerve, or to remove the tooth if it is too far gone to save. You get an itemised quote before anything begins.
One thing worth saying plainly: antibiotics on their own do not fix a toothache. They can help when infection has spread into the surrounding tissue, but the source is inside the tooth, where the blood supply that carries an antibiotic no longer reaches. That is why a course of tablets often settles things for a fortnight before the pain returns. The tablets buy time. They are not the treatment.
When not to wait until morning
Ring us the same day if you have swelling in the face or jaw, a fever alongside the pain, pain that has stopped you sleeping two nights running, or pain that over-the-counter relief is not touching.
Do not wait for a dental appointment at all if swelling is affecting your breathing or swallowing, spreading towards your eye or down your neck, or you feel generally very unwell. That belongs in a hospital emergency department.
Getting seen
We are open Monday to Friday, 8:00am to 5:00pm, at Level 1, Tweed Arcade, 2 Queen Street in Murwillumbah. Ring (02) 6672 1980 as early in the day as you can. Emergency slots fill from the morning onwards, so a call at 8:30am gives you a much better chance of being seen that day than a call at 3:00pm.
You do not need to be an existing patient. We see people from Uki, Pottsville, Kingscliff and over the Queensland border, including visitors who did not plan on needing a dentist.
For the full rundown on what to do for other dental emergencies, including a knocked-out tooth or a lost filling, see our emergency dentistry page.
Frequently asked questions
Why does my toothache only hurt at night? +
Two things change when you lie down. Blood pressure inside the head rises slightly, which increases pressure on an already inflamed nerve, and there is nothing left to distract you from the pain. It is usually not that the tooth got worse at 10pm. It is that the conditions changed.
What painkiller works best for toothache? +
For most people ibuprofen is more effective for dental pain than paracetamol, because the pain is driven by inflammation. Taking both together at the doses on the packets is more effective again. Check with your pharmacist first if you take other medication, have stomach problems, or are pregnant.
Should I put a heat pack on my face? +
No. Heat encourages swelling and can make an infection spread faster. Use a cold compress on the outside of the cheek for 15 minutes at a time.
My toothache stopped on its own. Am I fine now? +
Not necessarily. Pain that builds for days and then disappears completely can mean the nerve inside the tooth has died. The infection usually continues quietly and shows up later as swelling or an abscess. It is worth having it looked at even once the pain has gone.
When is toothache an emergency? +
Ring us the same day if you have facial swelling, a fever, pain that stops you sleeping two nights running, or pain that does not respond to over-the-counter pain relief. Go to a hospital emergency department if swelling is affecting your breathing or swallowing, or is spreading towards your eye or down your neck.