Medication Dosage for Toothache
For acute toothache pain, ibuprofen 600 mg three times daily or ibuprofen 400 mg combined with acetaminophen 1000 mg three times daily provides superior pain relief compared to opioid-containing medications and should be the first-line treatment. 1, 2
First-Line Analgesic Therapy
NSAIDs as Primary Treatment
- Ibuprofen 600 mg orally three times daily is the preferred first-line analgesic for dental pain 3, 1
- For children under 12 years, ibuprofen (dose based on weight) alone or combined with acetaminophen is recommended over opioids 2
- NSAIDs work by inhibiting cyclooxygenase enzymes that produce pain-promoting prostaglandins 1
Combination Therapy for Moderate to Severe Pain
- Ibuprofen combined with acetaminophen 500-1000 mg provides additive analgesic effect 1
- The combination can be taken three times daily, with acetaminophen not exceeding 3000-4000 mg total per 24 hours 4, 1
- This combination is more effective than acetaminophen-opioid preparations for dental pain 1
Acetaminophen Monotherapy (When NSAIDs Contraindicated)
- Acetaminophen 650 mg (regular strength) can be taken every 8 hours, maximum 6 caplets (3900 mg) in 24 hours 4
- If NSAIDs cannot be used due to contraindications, acetaminophen 600-1000 mg combined with an opioid (codeine, hydrocodone) may be considered in adults 1
Critical Dosing Strategy
Fixed Schedule vs. As-Needed Dosing
- Analgesics must be taken on a fixed schedule (e.g., every 6-8 hours), NOT on an as-needed basis 1
- Taking medication only when pain returns guarantees the patient will experience breakthrough pain 1
- This scheduled approach maintains therapeutic drug levels and prevents pain recurrence 1
Antibiotics: When and What Dose
Indications for Antibiotics
- Antibiotics are NOT appropriate for toothache alone and should only be prescribed as adjunct to definitive dental treatment 5, 6
- Antibiotics are indicated only when systemic symptoms present (fever, malaise), spreading infection/cellulitis, or in immunocompromised patients 5
Antibiotic Dosing (When Indicated)
- Amoxicillin 500 mg orally three times daily for 5-7 days is first-line for dental infections in non-allergic patients 7, 5
- For penicillin-allergic patients: Clindamycin 300-400 mg orally three times daily for 5-7 days 7, 5
- Azithromycin may be considered when clindamycin is contraindicated 5
Topical Adjunctive Therapy
Topical Anesthetics for Oral Pain
- Benzydamine hydrochloride 0.15% oral rinse can provide short-term pain relief, particularly before eating 3
- Lidocaine viscous 2% or benzocaine gel/spray 20% for temporary relief of localized oral pain 5
- These provide only temporary relief and do not replace systemic analgesics 3
Oral Hygiene Measures
- Chlorhexidine gluconate 0.2% mouthwash for antiseptic effect 3, 5
- Soft diet and soft toothbrush to minimize trauma 3
Opioid Considerations and Contraindications
Opioids Are NOT First-Line
- Opioids should be reserved only for cases where NSAIDs and acetaminophen are ineffective or contraindicated 3, 1
- Codeine and tramadol are contraindicated in children under 12 years per FDA guidelines 2
- When prescribed, opioids should be combined with acetaminophen 600-1000 mg for additive effect 1
Common Pitfalls to Avoid
Critical Errors in Toothache Management
- Do not prescribe antibiotics without definitive dental treatment planned - up to 80% of dental antibiotic prescriptions are unnecessary 5, 6
- Do not use as-needed dosing for analgesics - this guarantees inadequate pain control 1
- Do not prescribe opioids as first-line therapy when NSAIDs are more effective for dental pain 1, 2
- Do not exceed maximum daily acetaminophen dose (4000 mg/24 hours in adults) when using combination products 4