What are the recommended management strategies for a toothache?

Management of Toothache

For acute toothache, the primary treatment is addressing the underlying dental pathology through definitive dental procedures (drainage, pulp therapy, or extraction), not antibiotics—antibiotics should only be used when there is evidence of spreading infection or systemic involvement. 1, 2

Initial Assessment and Red Flags

• Immediately assess for airway compromise by checking for dyspnea, stridor, or difficulty swallowing, as maxillofacial infections can cause life-threatening soft-tissue edema 2
• Examine for signs of spreading infection including facial swelling, trismus (difficulty opening mouth), fever, or lymphadenopathy—these require urgent intervention 1, 2
• Cleanse the oral cavity with water or saline before examination to accurately assess the extent of pathology 2
• Look for clinical signs of pulp necrosis: tooth discoloration (gray appearance), gingival abscess (parulis), fistula formation, or localized swelling 1, 2

Diagnostic Approach

• Perform clinical examination searching for signs of pulp necrosis including color changes, fistula, swelling, abscess, or pain 2
• Consider radiographic examination (periapical or panoramic) to identify enlarged pulp chambers, periapical bone loss, or root pathology 2
• Critical pitfall to avoid: Recognize that not all "toothache" is odontogenic—consider nonodontogenic causes if there is inadequate local dental pathology, constant unremitting pain, failure to respond to local anesthetic block, or persistent pain despite reasonable dental therapy 3, 4, 5

Treatment Algorithm Based on Diagnosis

For Reversible Pulpitis (Tooth Sensitivity Without Necrosis)

• Remove the irritant and place appropriate restorative material to seal the tooth 2
• Monitor for signs of pulpal necrosis at follow-up 2
• No antibiotics indicated 1, 2

For Irreversible Pulpitis (Severe Pain, Pulp Exposure)

• Provide immediate pulp therapy to preserve pulp vitality, especially in immature permanent teeth (within 3 years of eruption) 1, 2
• For mature teeth with complete root development, root canal therapy is the treatment of choice 1, 2
• Antibiotics are not indicated for irreversible pulpitis alone 1

For Dental Abscess/Acute Apical Periodontitis

• Establish surgical drainage as the primary treatment (incision and drainage, root canal therapy, or extraction)—this is the definitive management 1, 2
• Antibiotics should not be routinely used for localized dental abscesses when drainage can be achieved 1
• Use antibiotics only when: systemic involvement is present (fever, malaise), infection is spreading into cervicofacial tissues, patient is medically compromised, or drainage cannot be established 1, 2
• When antibiotics are indicated: amoxicillin is first-line for 5 days; amoxicillin-clavulanic acid is second-line 1

For Crown Fractures

• Enamel only (uncomplicated): Smooth the fracture area or leave untreated if smooth; no urgent referral needed 1
• Enamel and dentin exposed (uncomplicated): Refer to dentist within days to cover exposed dentin and reduce bacterial contamination risk 1
• Pulp exposure (complicated): Immediate dental referral for pulp therapy to preserve vitality 1

Supportive Symptomatic Management

• Warm saline rinses to promote drainage and reduce inflammation 2
• Advise avoiding painful stimuli: smoking, alcohol, spicy foods, and hot foods 2
• Consider alcohol-free 0.2% chlorhexidine mouth rinse to reduce bacterial load 2
• Maintain gentle oral hygiene with soft toothbrush and mild fluoride toothpaste 2
• Analgesics for pain control (though specific agents not detailed in guidelines provided)

Critical Pitfalls to Avoid

• Most dangerous error: Failing to recognize potential airway compromise in spreading dental infections 2
• Do not prescribe antibiotics without establishing drainage—antibiotics alone are ineffective for dental abscesses and contribute to antimicrobial resistance 1, 6
• Do not assume all toothache is dental in origin—persistent pain despite adequate dental treatment suggests nonodontogenic causes requiring different management 3, 4, 5
• Avoid performing unnecessary dental procedures (extractions, root canals) when nonodontogenic pain is suspected 4

Follow-up Instructions

• Instruct patients to return immediately for increasing swelling, difficulty breathing or swallowing, or worsening systemic symptoms 2
• Schedule follow-up to monitor for signs of pulpal necrosis in cases of reversible pulpitis or dental trauma 2
• For endodontically treated teeth, monitor for healing and absence of periapical pathology 2