What are the recommended immediate interventions and treatments for severe tooth pain and swelling?

Immediate Management of Severe Tooth Pain and Swelling

For severe tooth pain with swelling, immediately refer the patient for same-day dental evaluation while initiating NSAIDs for pain control and considering antibiotics only if there is evidence of spreading infection (cellulitis, facial swelling, or systemic symptoms). 1, 2

Immediate Assessment and Triage

Determine if emergency dental referral is needed by examining for:

• Facial swelling progression – extensive or rapidly spreading facial swelling indicates potential cellulitis or abscess requiring immediate dental or hospital referral 1, 2
• Systemic signs – fever, malaise, or septic appearance warrant aggressive antibiotic therapy and hospital referral 2, 3
• Localized gingival swelling with parulis (gum boil) – signals pulpal necrosis and periapical abscess requiring same-day dental extraction evaluation 1
• Percussion tenderness – firm percussion of the tooth with a tongue depressor revealing severe tenderness indicates infection extending into subdental tissue 2

Pain Management

NSAIDs provide superior analgesia for dental pain due to their anti-inflammatory and analgesic properties:

• Ibuprofen 400-800 mg every 6 hours is the first-line analgesic for dental inflammatory pain 4, 5, 6
• Acetaminophen provides effective analgesia but lacks anti-inflammatory action, making it less ideal for dental infections 4, 6
• Reserve opioids (codeine combinations) only for severe pain unresponsive to NSAIDs due to significant side effects 6

Common pitfall: Do not rely on analgesics alone – definitive dental treatment to remove the source of infection is essential for resolution 6, 7

Antibiotic Considerations

Antibiotics are NOT routinely indicated for localized dental pain and should be reserved for specific situations:

• Prescribe antibiotics when:

  • Facial cellulitis is present (erythema, warmth, spreading swelling) 2, 8
  • Systemic symptoms develop (fever, malaise, sepsis) 2, 3
  • Progressive facial swelling occurs 2

• Do NOT prescribe antibiotics for:

  • Localized dental abscess without spreading infection 8, 7
  • Simple pulpitis or toothache without swelling 7

The vast majority of dental abscesses respond to antibiotic treatment combined with definitive dental management (drainage, root canal, or extraction). 8, 7

Specific Clinical Scenarios

Post-Extraction Pain (24-48 hours after extraction)

• Likely dry socket (alveolar osteitis) – characterized by absence of blood clot in socket and severe local tenderness 2
• Requires dental referral for socket irrigation and medicated dressing, not antibiotics 2

Pericoronitis (Impacted Wisdom Tooth)

• Erythematous, tender gingiva surrounding partially erupted tooth 2
• Localized cases respond to irrigation; secondary cellulitis requires antibiotics and surgical extraction 7
• Immediate dental referral indicated 2

Carious Tooth with Spontaneous Severe Pain

• Site-specific, severe, spontaneous pain indicates pulpal involvement 2
• Percussion tenderness confirms progression to periapical infection 2
• Requires urgent dental referral for root canal therapy or extraction 7

Critical Warning Signs

Immediately refer to emergency department (not just dentist) if:

• Difficulty breathing or swallowing (potential airway compromise) 2
• Rapidly progressive facial swelling 2
• Signs of sepsis (high fever, altered mental status, hypotension) 3

Common pitfall: Dental infections can progress to life-threatening deep space infections – do not underestimate localized facial swelling that appears to be spreading. 2, 8