A child waking in the night with tooth pain almost always means the tooth needs to be seen — and fairly soon. Night-time pain is a pattern worth paying attention to: saliva flow drops at night, which removes one of the mouth's natural defences against bacteria, and lying down changes the pressure inside a tooth with an inflamed nerve. Both factors make pain that was barely noticeable during the day feel much worse after midnight.
Pulpal inflammation — decay that has reached the nerve
The most common cause of true night-time tooth pain in children is inflammation of the tooth's pulp (the inner nerve and blood supply). This happens when a cavity — left untreated — deepens through the enamel and dentine and reaches the pulp. Once the pulp is involved, the pain tends to:
- Come on spontaneously, without anything triggering it
- Be described as throbbing or intense
- Worsen when lying down
- Wake the child from sleep
- Persist after eating or drinking something hot or sweet
This is not a "wait and see" situation. A tooth with irreversible pulpitis (the clinical term) will not get better on its own. The AAPD's guideline on pulp therapy for primary teeth is clear: when the pulp is infected or irreversibly damaged, pulp treatment (or extraction, if the tooth cannot be saved) is needed. Delaying increases the risk of abscess and spread of infection.
Dental abscess
If the pulp infection is not treated, a collection of pus — a dental abscess — can form at the root of the tooth or in the surrounding gum. Signs include:
- Severe, constant aching pain
- Visible swelling of the gum or face
- The child not wanting to bite down on that side
- Fever in some cases
A swollen face alongside tooth pain means contact us the same day. An abscess in a baby tooth can, in rare cases, spread to surrounding structures or affect the developing permanent tooth underneath.
Teething pain (in younger children)
For children under 3, night-time discomfort is sometimes eruption pain — a new tooth pushing through the gum. Teething pain tends to be diffuse (the child cannot point to a specific tooth), comes and goes over several days, and is accompanied by drooling, chewing and general fussiness. It should not cause the child to wake screaming in sustained pain.
If the pain is intense and localised, or if your child can point to a specific tooth, it is more likely to be decay-related than teething.
Tooth grinding (bruxism)
Some children grind their teeth during sleep — a habit called bruxism. This can cause morning jaw soreness, sensitivity and, over time, wear on the tooth surfaces. Bruxism at night is common in children and usually reduces with age, but it is worth mentioning at the next dental visit so the teeth can be checked for wear.
What to do tonight, before the appointment
- Give an age-appropriate dose of paracetamol or ibuprofen (following the dosing instructions on the packaging) to manage pain until the appointment.
- A cold compress held against the cheek can help with swelling.
- Do not apply clove oil or any pain gel directly to a young child's gum without dental advice.
- If there is facial swelling, contact us the same day rather than waiting for a routine appointment.
Night-time toothache in a child almost always means the tooth needs treatment, not just observation. The earlier it is seen, the simpler the treatment is likely to be.
Sources: American Academy of Pediatric Dentistry, Guideline on Pulp Therapy for Primary and Immature Permanent Teeth, 2023; American Academy of Pediatric Dentistry, Policy on Early Childhood Caries (ECC), 2023.