What are the recommended management strategies for acute toothache?

Management of Acute Toothache

For acute toothache management, a combination of ibuprofen and acetaminophen is recommended as first-line pharmacological treatment, with immediate dental referral for definitive treatment of the underlying cause. 1, 2

Initial Assessment and Diagnosis

• Determine the likely cause of toothache:

  • Dental trauma (fracture, luxation, avulsion)
  • Pulpal inflammation/infection
  • Periodontal disease
  • Pericoronitis (inflammation around partially erupted teeth)

• Key clinical findings to assess:

  • Pain characteristics (spontaneous, provoked, constant, intermittent)
  • Presence of swelling, abscess, or parulis (gingival boil)
  • Tooth mobility
  • Tooth discoloration
  • Sensitivity to percussion or temperature

Pharmacological Management

First-Line Treatment

• Combination therapy: Ibuprofen 400mg plus acetaminophen 1000mg every 6 hours as needed 2
  • This combination provides superior pain relief compared to either medication alone
  • Maximum daily dose: Ibuprofen 2400mg, acetaminophen 4000mg

Alternative Options

• Ibuprofen 400mg every 4-6 hours (if acetaminophen is contraindicated)
• Acetaminophen 1000mg every 6 hours (if NSAIDs are contraindicated)
• For children: NSAIDs alone or in combination with acetaminophen at age-appropriate doses 1

Important Cautions

• Avoid opioids for dental pain management when possible
• For children, codeine and tramadol are contraindicated per FDA guidelines 1
• Monitor for acetaminophen toxicity if patient has been self-medicating (maximum 4g/day) 3

Non-Pharmacological Management

For Fractured Teeth

• Uncomplicated enamel fractures: Smooth rough edges if present 4
• Enamel and dentin fractures: Cover exposed dentin to reduce sensitivity and prevent bacterial contamination 4
• Complicated fractures (with pulp exposure): Immediate dental referral 4

For Luxated Teeth

• Minor displacement: Gentle repositioning if possible 5
• Severe displacement: Immediate dental referral 5

For Avulsed Permanent Teeth

• Immediate replantation is the treatment of choice 4
• If replantation not possible, store tooth in milk, Hank's Balanced Salt Solution, or saliva (never water) 4
• Immediate dental referral 5

Definitive Management

• All patients with toothache should be referred for definitive dental treatment
• Timing of referral depends on severity:
  • Immediate (same day): Severe pain, facial swelling, signs of spreading infection, trauma with pulp exposure
  • Urgent (1-2 days): Moderate pain, localized abscess/parulis
  • Routine (within 1 week): Mild pain, uncomplicated fractures

Special Considerations

• For primary (deciduous) teeth:

  • Avulsed primary teeth should NOT be replanted 5
  • For luxated primary teeth, ensure they don't interfere with occlusion 5

• For patients with signs of infection:

  • Consider antibiotics only if systemic involvement (fever, lymphadenopathy, facial swelling)
  • Definitive treatment (pulp therapy, extraction) is essential

Follow-up Care

• Monitor for:

  • Signs of pulpal necrosis (tooth discoloration, parulis formation)
  • Spreading infection (increased swelling, trismus, fever)
  • Persistent pain despite medication (may indicate need for urgent intervention)

• Advise patients on:

  • Soft diet for 10 days after dental procedures 4
  • Good oral hygiene practices
  • Avoiding extremes of temperature with food/drink if tooth is sensitive

Remember that pharmacological management provides only temporary relief. Definitive dental treatment addressing the underlying cause is essential for resolution of toothache.