A toothache at nine at night. Here is what to do until morning.

Tonight is almost certainly a morning problem

Take the pressure off first. The large majority of toothaches in children will not turn into a crisis between now and sunrise. They are genuinely miserable, they deserve a call, and they still get handled in daylight.

So tonight's job is small. Check for a short list of warning signs, do four things that take the edge off, get some sleep, and call in the morning. Read the next section first. It is the only time sensitive part of this page.

The signs that mean the emergency room now

A few toothaches are not toothaches anymore. They are an infection that has moved past the tooth, and those are measured in hours. Go to the emergency room tonight, without waiting for us to open, if you see any of these:

• Swelling in the face. A cheek puffed out next to the other one, a jawline gone soft and full, or swelling under the chin.
• Swelling around the eye, or an eyelid starting to close on the sore side.
• Fever together with facial swelling. Either alone is worth telling us about. The two together is a hospital trip tonight.
• Trouble swallowing, drooling because swallowing hurts, or a voice gone muffled.
• Any trouble breathing. That one is a 911 call, not a drive.

The same rule covers the other big ones: bleeding you cannot slow with steady, gentle pressure, a blow to the head, or a jaw that will not open, close, or line up properly. Hospitals handle those. We handle the tooth afterward.

If they send you home reassured, that was still the right call. Swelling near a child's airway is what emergency rooms are for.

What helps between now and bedtime

None of that on the list? Then you are in the ordinary awful category, and four things are worth doing.

1. Rinse with warm water. Have your child swish gently and spit. Warm, not hot, and nothing added unless we have told you otherwise.
2. Floss beside the sore tooth. Parents skip it, and it is the step that most often ends the whole evening. Food packed between two back teeth presses on the gum and aches exactly like a cavity does. Ease the floss down on each side of the sore tooth, curve it around the side of the tooth, and lift it out. If a shred of chicken or a popcorn hull comes with it, watch what the pain does.
3. Cold on the outside of the cheek. A wrapped ice pack or a bag of frozen vegetables against the cheek on the sore side, a few minutes at a time. Nothing cold goes inside the mouth, and nothing presses directly onto the tooth.
4. Prop the head up to sleep. An extra pillow, so the head rests higher than the chest. Lying flat sends more pressure toward a sore tooth, part of why toothaches so reliably peak at bedtime.

Never put aspirin, or any other pill, against the gum or the tooth. It is an old kitchen remedy that does not work the way people believe, and it can leave a chemical burn on the soft tissue inside the cheek.

As for anything swallowed: we will not tell you what to give or how much on a web page, for a child we have not examined. That is a real answer, not a dodge. Ask your pediatrician, or ask us when you call. Whatever you give, write down what and when, and tell us at the visit.

Call us at 8, and lead with these

Call (239) 482-2722 the moment the phones open. We are open Monday to Friday, 8 to 5. One number reaches both offices, and a real person answers. If tonight is a Friday night or a weekend, the warning signs above still apply; everything else keeps until the phones open.

The front desk can slot you in faster when you open with the specifics:

• Which side, and whether it is a back tooth or a front one.
• When it started, and whether it has been building.
• Whether the pain woke your child from sleep. Say that part out loud if it happened. Pain that wakes a child from sleep matters more than pain at dinner.
• Any swelling, any fever, and whether either has changed overnight.
• What sets it off: cold, heat, sweets, chewing, or nothing at all.
• Anything you gave, and what time.

If the pain is gone by morning, call anyway

This is the one that costs families a second bad night a week later. A tooth that hurt hard last night and feels fine at breakfast has not repaired itself while everyone slept. A nerve under enough stress can simply go quiet, and quiet is not the same thing as better.

The ache was the warning. Whatever caused it is still there, and it is a far easier fix on a Tuesday morning than in a panic on a Saturday night.

What the fix usually turns out to be

Parents imagine the worst on the drive over, so here is the honest range.

Plenty of toothaches need nothing dramatic. The trapped food came out and that was the story. The gum was irritated. A new molar was pushing through and the tissue over it was sore. Some turn out to be a cavity that has worked in far enough to bother the nerve, and the repair is a filling. Some need a nerve treatment to rescue a tooth worth rescuing, and a tooth like that usually gets a crown afterward to hold it together.

Which one it is comes from looking, sometimes with an X-ray, never from a phone call or a web page. Whatever it turns out to be, your pediatric dentist explains it to you before anything begins, with your child in the room and in language your child can follow. Nothing happens without you.

What to expect at a visit shows the shape of the appointment before you walk in. The rest of the guides for hard nights sit on our dental emergencies page.