What is the recommended treatment for tooth pain?

Treatment of Tooth Pain

For acute tooth pain, the primary treatment is identifying and eliminating the underlying dental pathology through definitive dental intervention, with analgesics serving only as adjunctive therapy—NSAIDs (particularly ibuprofen) are the first-line pharmacologic choice, with combination therapy (NSAID plus paracetamol or adding weak opioids like codeine/oxycodone) reserved for moderate to severe pain. 1, 2, 3

Immediate Assessment and Red Flags

Before initiating treatment, you must assess for life-threatening complications:

• Check for airway compromise: Look for dyspnea, stridor, or difficulty swallowing, as maxillofacial infections can cause fatal soft-tissue edema requiring immediate hospital referral 1
• Examine for spreading infection: Facial swelling, trismus, fever, or lymphadenopathy demand urgent intervention and possible hospitalization 1, 4
• Cleanse the oral cavity with water or saline before examination to accurately visualize pathology 1

Diagnostic Approach to Guide Treatment

The specific cause of tooth pain determines the definitive treatment:

• Look for signs of pulp necrosis: Tooth discoloration, gingival abscess, fistula formation, localized swelling, or tenderness to percussion 1, 4
• Perform percussion testing firmly with a tongue depressor—tenderness indicates infection has spread into subdental tissue 4
• Examine for dental caries: Remember that caries may lie beneath intact enamel or between teeth, not always appearing as obvious cavities 4
• Check extraction sites: Pain 24-48 hours post-extraction with absent blood clot and severe local tenderness indicates dry socket (alveolar osteitis) 4
• Assess wisdom teeth: Erythematous, tender gingiva surrounding impacted wisdom teeth suggests pericoronitis 4

Definitive Treatment Algorithm

For Reversible Pulpitis

• Remove the irritant and place restorative material to seal the tooth 1
• Do not prescribe antibiotics—they are not indicated 1

For Irreversible Pulpitis

• Provide immediate pulp therapy to preserve pulp vitality, especially in immature permanent teeth 1
• Root canal therapy is the treatment of choice for mature teeth with complete root development 1
• Antibiotics are not indicated for irreversible pulpitis alone 1

For Dental Abscess/Acute Apical Periodontitis

• Establish surgical drainage as the primary treatment—this is the key intervention 1, 2
• Do not routinely prescribe antibiotics for localized dental abscesses when drainage can be achieved 1
• Use antibiotics only when: systemic involvement is present, infection is spreading into cervicofacial tissues, patient is medically compromised, or drainage cannot be established 1
• When antibiotics are indicated: Amoxicillin for 5 days is first-line; amoxicillin-clavulanic acid is second-line 1

For Impacted Wisdom Teeth

• Surgical removal is the definitive treatment for impacted wisdom teeth causing pain 2

Pharmacologic Pain Management

First-Line Analgesics

• NSAIDs (ibuprofen, aspirin) are the preferred first-line agents due to their combined anti-inflammatory and analgesic action 3, 2
• Oral administration is preferred due to convenience, ease of use, and cost-effectiveness 2, 5
• Moderate-quality evidence shows analgesics reduce pain at 2 hours (mean reduction 11.66 mm on 100 mm VAS), 6 hours (24.27 mm reduction), and 24 hours (21.19 mm reduction) compared to placebo 6

Combination Therapy for Moderate to Severe Pain

• Combine NSAIDs with paracetamol for enhanced analgesia 2, 3
• Add weak opioids (codeine) when NSAIDs plus paracetamol are insufficient 2, 3
• Fixed combinations with opioids (ibuprofen with oxycodone, acetaminophen with oxycodone/hydrocodone) may be necessary for severe pain 2, 5, 7

Dosing Strategy

• Administer at fixed intervals rather than as-needed (prn) when frequent dosing is required—this is more effective 2, 5
• Start early at appropriate doses—pain is easier to prevent than treat 2, 5
• Prescribe limited doses of opioids (48-72 hours worth) to mitigate risks of misuse, as uncomplicated dental pain should improve within this timeframe 5

Special Considerations

• Patients with renal impairment: Use NSAIDs with caution at reduced doses 2
• Check for NSAID contraindications: Renal disease, GI ulcers, bleeding disorders 2

Topical Anesthetics (Limited Role)

• Benzocaine otic solution is available for temporary topical anesthesia but is not FDA-approved for safety, effectiveness, or quality 5, 8
• Do not use topical anesthetics as primary therapy—they may mask progression of underlying disease while suppressing pain 5
• If prescribed, reexamine within 48 hours to ensure the underlying condition is responding appropriately 5
• Contraindicated if tympanostomy tube present or tympanic membrane integrity is uncertain 5

Supportive Measures

• Warm saline rinses to promote drainage and reduce inflammation 1
• Avoid painful stimuli: Smoking, alcohol, spicy foods, hot foods 1
• Consider alcohol-free 0.2% chlorhexidine mouth rinse to reduce bacterial load 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 1
• Do not prescribe antibiotics without establishing drainage—antibiotics alone are ineffective for dental abscesses and contribute to antimicrobial resistance 1
• Do not perform multiple irreversible dental procedures for persistent pain without clear pathology—up to one-third of chronic facial pain patients have undergone unsuccessful irreversible procedures 9
• Consider neuropathic pain (atypical odontalgia, phantom tooth pain) if pain persists despite appropriate dental treatment and no infectious/inflammatory pathology is found 9

Follow-Up Instructions

• Immediate return if: Increasing swelling, difficulty breathing or swallowing, or worsening systemic symptoms develop 1
• Monitor for pulpal necrosis: Parents/caregivers should watch for gingival swelling, increased mobility, or parulis in children who may not report painful symptoms 5
• Schedule follow-up to ensure healing and absence of complications 1