What are the recommended treatments for a toothache?

Management of Toothache

For acute toothache, use NSAIDs (ibuprofen) alone or combined with acetaminophen as first-line therapy, reserving opioids only when NSAIDs are contraindicated or insufficient, and refer to a dentist urgently if signs of pulpal necrosis or dental emergency are present. 1

Immediate Pain Management

First-Line Pharmacologic Treatment

• NSAIDs provide superior pain relief compared to opioids for acute dental pain, with ibuprofen being the most commonly used agent due to its combined anti-inflammatory and analgesic properties 2, 1
• Combination therapy with NSAIDs plus acetaminophen offers better pain control than either medication alone, with a more favorable safety profile than opioid medications 1
• Acetaminophen alone provides effective analgesia but lacks anti-inflammatory action, making it less ideal for dental pain which typically involves inflammation 2

Second-Line and Adjunctive Options

• Opioids (such as codeine combined with acetaminophen) should be reserved exclusively for severe pain when NSAIDs are contraindicated or provide insufficient relief, due to significant side effects 2, 1
• Topical benzocaine can temporarily relieve toothache pain in adults and children ≥2 years, applied to the affected area up to 4 times daily 3
• Children under 12 years require supervision when using topical anesthetics, and those under 2 years need dentist consultation before use 3

Critical Assessment for Dental Emergencies

Signs Requiring Same-Day/Immediate Dental Referral

• Visible pulp exposure from tooth fracture requires immediate pulp therapy to preserve tooth vitality, particularly in immature permanent teeth 4
• Gingival swelling with increased tooth mobility indicates potential pulpal necrosis and periapical abscess formation requiring urgent evaluation 4
• Parulis (gum boil) appearing adjacent to the tooth signals pulpal necrosis and may necessitate extraction 4
• Gray tooth discoloration developing after trauma indicates pulpal hemorrhage and potential necrosis requiring prompt dental assessment 4, 5
• Multiple teeth moving together as a unit suggests alveolar bone fracture requiring immediate repositioning and splinting 4

Signs Requiring Dental Referral Within Days

• Tooth sensitivity with visible dentin exposure from enamel-dentin fractures should be evaluated within a few days to cover exposed dentin and reduce bacterial contamination risk 4
• Persistent or recurrent toothache over weeks to months without adequate local dental cause may indicate nonodontogenic pain requiring specialized evaluation 6

Diagnostic Approach

Key Clinical Features Suggesting Odontogenic Pain

• The "3-D's" principle guides management: Diagnosis, Dental treatment, and Drugs as adjunct only 2
• Most toothaches requiring analgesics stem from inflammatory processes in pulpal tissues or periodontal structures 2
• Drugs should only serve as adjuncts to definitive dental treatment, which provides the most rapid symptom resolution by removing the underlying cause 2

Red Flags for Nonodontogenic Toothache

• Inadequate local dental cause for the pain intensity 6
• Stimulating, burning, or nonpulsatile quality rather than typical throbbing dental pain 6
• Constant, unremitting pain without variation over time 6
• Spontaneous involvement of multiple teeth simultaneously 6
• Failure to respond to reasonable dental therapy or local anesthetic blocking of the suspected tooth 6
• These features warrant consideration of referred pain from non-dental sources 6

Important Clinical Pitfalls

Common Diagnostic Errors

• Never assume gray tooth discoloration is purely cosmetic—it typically indicates underlying pulpal pathology requiring intervention 7
• Children may not report pain from necrotic teeth, so caregivers must watch for visual signs including discoloration, swelling, and parulis rather than relying on pain complaints 4
• Patients frequently refer pain to previously endodontically-treated teeth that may not be the actual source; a tooth can only be the pain source if objective signs (beyond lack of vitality in treated teeth) are present 8

Medication Safety Considerations

• NSAIDs produce superior analgesia with better safety profiles than opioids for dental pain, making them the clear first choice when not contraindicated 1
• Oral opioids have slow onset, undergo hepatic first-pass metabolism, and commonly cause hyperacidity and gastric irritation 9
• Corticosteroids have limited use in dentistry, reserved only for very specific situations despite their anti-inflammatory properties 2

Post-Treatment Instructions

• Advise soft diet for 10 days following dental trauma 10
• Maintain good oral hygiene with gentle brushing 5
• Routine systemic antibiotics are not indicated for primary tooth trauma unless specific medical conditions require coverage 10