What is the recommended emergency care for a toothache?

Emergency Care for Toothaches

For acute toothache presenting to emergency care, immediately assess whether the pain is due to dental trauma (avulsion, fracture, luxation) requiring urgent dental referral, or non-traumatic odontogenic pain requiring analgesics and dental follow-up within 24-48 hours.

Initial Assessment and Triage

The first critical step is determining if the toothache results from acute dental trauma versus non-traumatic causes, as this fundamentally changes management 1.

Look for these specific findings:

• Visible tooth displacement, mobility, or missing tooth - indicates traumatic injury requiring immediate intervention 1
• Bleeding from gingival tissues or socket - suggests trauma 1
• Visible tooth fracture with or without pulp exposure - requires urgent dental referral 1
• Localized gingival swelling or parulis (gum boil) - suggests pulpal necrosis requiring dental care within days 1
• Pain without adequate local dental cause, or pain that is stimulating/burning/nonpulsatile - consider non-odontogenic causes 2

Management of Traumatic Dental Injuries

Avulsed Permanent Tooth (Most Critical)

If a permanent tooth is completely knocked out, immediate replantation at the scene provides the best prognosis, as every minute out of the socket decreases success 3.

Immediate on-site management:

• Handle the tooth only by the crown, never touch the root surface - the root is covered with fragile periodontal ligament fibroblasts essential for reattachment 1, 3
• Rinse briefly under cold running water for less than 10 seconds only if dirty 1, 3
• Immediately reposition the tooth in the socket 3
• Have the patient bite down on clean gauze or cloth to hold it in place 3
• Seek emergency dental care immediately 3

If immediate replantation is not possible, storage medium hierarchy:

1. Hanks Balanced Salt Solution (best) 3
2. Cold cow's milk 1, 3
3. Oral rehydration solutions, propolis, or rice water 3
4. Never use tap water - causes osmotic lysis of root fibroblasts and significantly worsens prognosis 3

Critical pitfall: Do not delay replantation to search for storage media - immediate replantation is always superior to any storage method 3.

Post-replantation care:

• Control bleeding with direct pressure using gauze 1
• Immediate dental referral for flexible splint placement (up to 2 weeks) 3
• Antibiotic prophylaxis: doxycycline for patients over 12 years old (or penicillin/clindamycin if under 12 or penicillin-allergic) 3
• Root canal therapy will be needed within 7-10 days 3

Avulsed Primary Tooth

Do not replant primary teeth - replantation risks damage to the underlying permanent tooth germ 1.

• Clean the bleeding wound with saline or tap water 1
• Apply pressure with gauze to stop bleeding 1
• If the tooth is not found, obtain chest radiograph if breathing difficulties present to rule out aspiration 1

Other Traumatic Injuries Requiring Immediate Dental Referral

Lateral luxation (displaced tooth):

• Gently reposition with digital pressure if displacement is minor 1
• Ensure the tooth does not interfere with occlusion by having patient bite down 1
• Immediate dental referral for splinting (4 weeks for permanent teeth) 1

Extrusive luxation (tooth pushed out):

• Gentle digital pressure to reposition if minor extrusion 1
• Immediate dental referral for splinting if mobile or if extrusion >3mm 1

Intrusive luxation (tooth pushed into socket):

• Permanent teeth: typically reerupt on their own if mild; immediate dental referral for severe cases 1
• Primary teeth: observe for spontaneous reeruption; immediate dental referral for severe intrusion 1

Management of Non-Traumatic Toothache

For toothache without visible trauma, the emergency care approach focuses on pain control and arranging timely dental follow-up 4.

Immediate pain management:

• NSAIDs provide superior pain relief due to anti-inflammatory and analgesic action - ibuprofen 400mg is the standard first-line agent 4
• Acetaminophen 1000mg is an alternative with effective analgesia but less anti-inflammatory action 4, 5
• Reserve opioids (codeine with acetaminophen) for severe pain only due to significant side effects 4

Avoid routine antibiotic prescription unless there is evidence of spreading infection (facial swelling, fever, lymphadenopathy) 1. Most toothaches do not require antibiotics in the emergency setting 1.

Dental referral timing:

• Immediate referral if extensive gingival/facial swelling, fever, or inability to control pain 1
• Within a few days if tooth discoloration or localized parulis develops 1
• Within 24-48 hours for routine odontogenic pain to address the underlying cause 4

Critical Pitfalls to Avoid

• Never delay replantation of an avulsed permanent tooth - time is the most critical prognostic factor 3
• Never store avulsed teeth in tap water - use milk if nothing else is available 3
• Never replant primary teeth - confirm tooth type before replantation 1, 3
• Do not prescribe antibiotics routinely for simple toothache without signs of spreading infection 1
• Consider non-odontogenic causes if pain lacks adequate local dental findings, is constant/unremitting, or fails to respond to local anesthetic blocking 2, 6
• Do not assume all facial neuralgic pain is trigeminal neuralgia - toothache commonly presents with neuralgic features and requires dental evaluation first 6