Some pain sits somewhere in the jaw, cheek, ear or side of the head, and is hard to pin down. We see patients with this kind of vague pain or headache who have already been to an ear, nose and throat doctor, a neurologist and their dentist, and still have no answer. Sometimes the cause is a tooth that did not look like a problem. Sometimes it is not a tooth at all. Either answer is worth having.
Why tooth pain is easy to miss, and easy to blame
Teeth are a common and obvious source of facial pain. A tooth with a hidden problem can be overlooked, and a healthy tooth can be blamed for pain from somewhere else. Researchers who studied this warn that the diagnosis must be confirmed before any treatment that cannot be undone.
Tooth problems that hide
A cracked tooth. The American Association of Endodontists describes erratic pain when chewing, sometimes when you release the bite, or pain with hot and cold. The pain can come and go, and your dentist may have trouble finding the tooth causing it. A crack in a tooth does not heal the way a bone does, and the association stresses early diagnosis. Read more about cracked teeth.
An infection a flat x-ray misses. In one large study, a regular dental x-ray caught only about 55 percent of the root-tip infections a 3D scan found. Endodontists and oral radiologists add that a 3D scan can show one before a flat x-ray does. Read more in no pain, but you need a root canal.
A tooth behind a sinus problem. A review by sinus specialists, endodontists and an infectious disease specialist notes that an infected tooth is one of the most common causes of sinus infection that starts from the teeth. These patients most often have nose and sinus symptoms on one side for more than three months. The authors advise that an endodontist check the teeth with at least a cold test, and ideally a cone beam scan.
A spot on the skin that comes from a tooth
When the nerve inside a tooth dies and becomes infected, the infection can tunnel past the root tip to the skin of the face. There it can look like a bump or a draining spot, easy to mistake for a skin problem.
In one study of 75 patients seen at a dermatology institute over 11 years, the referring doctor had suspected a tooth in only 51 percent of cases. The spot was most often a bump (52 percent), and the most common place was the angle of the jaw (36 percent). It had been there for about eight months on average, with wide variation. The authors say doctors should consider a tooth for any skin lesion on the face, so treatment is not delayed.
How an endodontist works out the cause
The 2025 update of the joint position statement from the American Association of Endodontists and the American Academy of Oral and Maxillofacial Radiology says diagnosis depends on your main complaint, your history, a clinical exam and x-rays. Its scan advice assumes a full exam comes first.
- Tests on the teeth. A cold test shows how the nerve inside a tooth responds. Dr. El-Refai also uses bite tests to help pinpoint a cracked tooth.
- A small-field 3D scan when it is needed. When symptoms or x-ray findings are unclear or contradict each other, the statement recommends a small-field cone beam scan as the first choice for diagnosis. A small scan area means a lower dose and sharper detail than a larger scan. It is not a screening test: the statement says to use it only when a lower-dose regular x-ray cannot answer the question.
A scan has limits too. For a crack running down a root, it usually shows the bone loss around the fracture rather than the crack itself, so it is read together with the exam. In one study cited by the statement, examiners reached an accurate diagnosis in 36 to 40 percent of cases with regular x-rays and 76 to 83 percent with a 3D scan.
When it is not a tooth
Sometimes the honest answer is that a tooth is not the cause. In one study of 88 patients sent for root canal treatment, 88 percent had a problem only inside the tooth. But 9 percent had a tooth problem plus another facial pain problem, and 3 percent had no problem inside the tooth, only pain from elsewhere in the mouth or face.
For pain that continues after a root canal, the statement notes that a 3D scan does better than a flat x-ray at telling a lingering infection apart from a lasting pain with no infection behind it, called atypical odontalgia.
How we approach unexplained tooth and face pain
You do not need a referral to see us. Dr. El-Refai takes her time with your history and the tests, then takes and reads your 3D scan herself and goes through it with you slice by slice on the screen. If a tooth is the cause, we explain your options. If it is not, we tell you so and refer you to the right specialist or physician.
If you have spreading swelling, or any trouble breathing or swallowing, go to an emergency room. Otherwise, see our technology page and tooth pain guide, or contact us to be seen.
