What is the recommended treatment for dental pain?

Management of Dental Pain

For acute dental pain, ibuprofen 400 mg is the most effective first-line analgesic, providing superior pain relief compared to acetaminophen, aspirin, or acetaminophen-codeine combinations. 1, 2, 3

Primary Treatment Algorithm

Step 1: Identify and Address the Underlying Cause

• Dental pain requires definitive dental treatment (drainage, debridement, extraction, or endodontic therapy) as the cornerstone of management 4, 5
• Examine for dental caries, pulpitis, periodontitis, mobile teeth, or abscess formation 6
• Antibiotics alone without surgical intervention are insufficient and should never be used as sole therapy 4, 5

Step 2: Pharmacologic Pain Management

First-Line: NSAIDs

• Ibuprofen 400 mg every 6-8 hours is the preferred analgesic for moderate to severe dental pain 1, 2, 3
• Ibuprofen 400 mg provides superior analgesia compared to aspirin 650 mg, acetaminophen 600-1000 mg, and acetaminophen-codeine combinations 2, 3
• Naproxen sodium (440 mg loading dose, then 220 mg every 8 hours) is an effective alternative that may provide longer duration of action 7
• NSAIDs should be taken on a fixed schedule (not "as needed") to maintain therapeutic levels and prevent breakthrough pain 2

Second-Line: Acetaminophen-Opioid Combinations

• If NSAIDs are contraindicated (GI intolerance, renal disease, bleeding risk), use acetaminophen 600-1000 mg combined with an opioid (codeine, hydrocodone, or oxycodone) 2, 8
• Acetaminophen alone provides effective analgesia but lacks anti-inflammatory action, making it less effective for dental pain than NSAIDs 8

Combination Therapy for Severe Pain

• For patients not responding to a single agent, prescribe both an NSAID (on fixed schedule) and an acetaminophen-opioid combination (for breakthrough pain) 2
• This approach leverages different mechanisms of action: NSAIDs inhibit prostaglandin synthesis while opioids stimulate endogenous opioid receptors 2

Step 3: Topical Anesthetics for Immediate Relief

• Viscous lidocaine 2% mouthwash or benzocaine topical gel can provide temporary relief while awaiting definitive treatment 6, 9
• Benzocaine is FDA-approved for temporary relief of toothache, sore gums, and pain from minor dental procedures 9
• Apply topical anesthetics before meals if eating is painful 6

When to Add Antibiotics

Antibiotics are indicated ONLY as adjunctive therapy in specific situations:

• Systemic involvement (fever, lymphadenopathy, malaise) 4, 5
• Immunocompromised patients 4, 5
• Diffuse swelling or infection extending to cervicofacial tissues 4, 5
• Following surgical drainage of acute dentoalveolar abscess 10, 4

Antibiotic Selection:

• Amoxicillin 500 mg three times daily for 5 days is first-line 10, 4
• Amoxicillin-clavulanate for inadequate response or severe infections 10, 4
• Clindamycin for penicillin-allergic patients 10, 4

Common Pitfalls to Avoid

• Never prescribe antibiotics without addressing the underlying dental pathology surgically 4, 5
• Avoid "as needed" dosing of analgesics—use fixed-schedule dosing to prevent pain recurrence 2
• Do not use acetaminophen as first-line for inflammatory dental pain; NSAIDs are superior 2, 8, 3
• Do not prescribe opioids alone; they should be reserved for severe pain and combined with acetaminophen 2, 8
• Avoid prolonged antibiotic courses beyond 5 days for routine dental infections 10, 4

Special Considerations

• In patients over 50 years with new-onset facial pain, consider giant cell arteritis as a differential diagnosis 6
• For chronic or atypical dental pain not responding to standard treatment, consider referred pain from masticatory muscles, neuropathic pain, or non-dental causes 6, 11
• Patients with contraindications to NSAIDs (peptic ulcer disease, renal insufficiency, anticoagulation) require alternative strategies with acetaminophen-opioid combinations 2, 8