What is the recommended treatment for a toothache?

Management of Toothache

The primary treatment for toothache is establishing a definitive diagnosis and providing appropriate dental intervention—not antibiotics—with surgical drainage being the cornerstone for abscesses and pulp therapy for pulpitis. 1

Immediate Assessment for Life-Threatening Complications

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

Diagnostic Evaluation

• Perform clinical examination searching for signs of pulp necrosis including color changes, fistula, swelling, abscess, or pain on palpation. 1
• Consider radiographic examination to identify enlarged pulp chambers, periapical bone loss, root fractures, or other root pathology when the crown displays mobility or when severe intrusion is suspected. 2, 1
• Assess whether pain is truly odontogenic—nonodontogenic toothache should be suspected if there is inadequate local dental cause, constant unremitting pain, failure to respond to local anesthetic blocking, or persistent recurrent toothaches over months. 3, 4

Treatment Algorithm Based on Specific Diagnosis

Reversible Pulpitis (Tooth Sensitivity Without Necrosis)

• Remove the irritant and place appropriate restorative material to seal exposed dentin, which reduces discomfort and prevents bacterial contamination. 2, 1
• Do not prescribe antibiotics for reversible pulpitis—they provide no benefit. 1
• Refer to dentist within a few days if dentin is exposed and sensitivity is present; the more sensitive the tooth, the more urgent the referral. 2

Irreversible Pulpitis (Severe Toothache With Vital But Inflamed Pulp)

• Provide immediate pulp therapy to preserve pulp vitality, especially critical in immature permanent teeth (within 3 years of eruption). 2, 1
• For mature teeth with complete root development, root canal therapy is the treatment of choice. 2, 1
• Antibiotics are not indicated for irreversible pulpitis alone—there is no significant difference in pain relief between penicillin and placebo when both groups receive analgesics. 1, 5
• Immediate referral to dentist for definitive pulp therapy is required. 1

Dental Abscess/Acute Apical Periodontitis

• Establish surgical drainage as the primary treatment—this is the key intervention, not antibiotics. 2, 1
• Drainage can be achieved through root canal therapy, tooth extraction, or incision and drainage depending on the clinical scenario. 2, 1
• Do not routinely prescribe antibiotics for localized dental abscesses when drainage can be achieved—antibiotics alone are ineffective and contribute to antimicrobial resistance. 2, 1

When Antibiotics ARE Indicated for Dental Infections

Prescribe antibiotics only when:

• Systemic involvement is present (fever, malaise, lymphadenopathy). 2, 1
• Infection is spreading into cervicofacial tissues or causing cellulitis. 2, 1
• Patient is medically compromised. 2, 1
• Drainage cannot be established. 1

Antibiotic regimen when indicated:

• First choice: Amoxicillin for 5 days. 2, 1
• Second choice: Amoxicillin-clavulanic acid. 2, 1
• For penicillin allergy in children: clindamycin. 2

Symptomatic Pain Management

• Prescribe analgesics for pain control (ibuprofen is commonly used, with acetaminophen with codeine for breakthrough pain). 5
• Recommend warm saline rinses to promote drainage and reduce inflammation. 1
• Consider alcohol-free 0.2% chlorhexidine mouth rinse to reduce bacterial load. 1
• Advise avoiding painful stimuli: smoking, alcohol, spicy foods, and hot foods. 1
• Maintain gentle oral hygiene with soft toothbrush and mild fluoride toothpaste. 1

Critical Pitfalls to Avoid

• Most dangerous error: Failing to recognize potential airway compromise in spreading dental infections—this can be life-threatening. 1
• Do not prescribe antibiotics without establishing drainage—this is the most common error in dental infection management and contributes significantly to antimicrobial resistance while providing no clinical benefit. 2, 1
• Do not assume all facial pain is dental—consider nonodontogenic causes including temporomandibular disorders, primary headaches, trigeminal neuralgia, and referred pain, especially if pain persists despite reasonable dental therapy. 3, 4
• Avoid multiple courses of antibiotics and repeated surgical interventions without proper diagnosis. 4

Post-Treatment Care and Follow-Up

• For the first 10 days after dental trauma or treatment, recommend soft diet and restrict pacifier or digit sucking if applicable. 2
• Instruct patients to return immediately for: increasing swelling, difficulty breathing or swallowing, worsening systemic symptoms, or development of fever. 1
• Schedule follow-up to monitor for signs of pulpal necrosis in cases of reversible pulpitis or dental trauma (watch for gingival swelling, increased mobility, parulis, or tooth discoloration). 2, 1
• For endodontically treated teeth, monitor for healing and absence of periapical pathology. 1
• Systemic antibiotics are not routinely indicated in post-operative care of primary tooth trauma unless the child's medical condition requires coverage. 2