What are the management options for a toothache in individuals taking prednisone (corticosteroid)?

Management of Toothache in Patients Taking Prednisone

Treat the underlying dental pathology definitively with standard dental care (antibiotics if indicated, root canal therapy, or extraction) while continuing prednisone at the current dose, and use NSAIDs (ibuprofen or naproxen) alone or combined with acetaminophen for pain control.

Immediate Pain Management

For acute dental pain, use NSAIDs as first-line analgesics regardless of concurrent prednisone therapy:

• Ibuprofen or naproxen alone, or combined with acetaminophen, provides effective pain control for dental pain 1
• A single preoperative dose of 40 mg prednisolone reduced post-endodontic pain intensity at 6,12, and 24 hours with a number needed to treat of 4-5, though this is for procedural pain prevention, not ongoing toothache management 2
• Avoid opioids (codeine, tramadol) as they are less effective than NSAIDs for dental pain 1

Critical Dental Evaluation Required

Patients on chronic prednisone require urgent dental assessment to identify the source of tooth pain:

• Dental examination is specifically recommended as part of general care for patients on corticosteroid therapy 3
• Prednisone can mask inflammatory symptoms, potentially allowing dental infections to progress without typical warning signs 4
• Long-term prednisone use (>8 years at high doses) has been associated with complete pulp chamber and root canal calcification, which may complicate endodontic treatment 5

Prednisone Continuation During Dental Treatment

Do not discontinue or adjust prednisone dosing for routine dental procedures:

• Patients on chronic prednisone should continue their maintenance dose through dental treatment to avoid adrenal insufficiency 6
• Short-term prednisone courses (40-60 mg daily) are used for various inflammatory conditions and are generally well-tolerated for 2-4 weeks 3
• The most common side effects of short-term prednisone (<2 weeks) are fluid retention/bloating and insomnia, not severe complications 4

Infection Management Considerations

If dental infection is present, initiate appropriate antibiotic therapy while addressing the source:

• Patients on prednisone have increased infection risk and may require more aggressive antimicrobial management
• Definitive treatment (drainage, extraction, or root canal therapy) remains essential—antibiotics alone are insufficient 1
• Monitor closely for progression, as corticosteroids can dampen the inflammatory response that typically signals worsening infection 4

Special Precautions

Be aware of specific risks in patients on chronic prednisone:

• Hypothalamic-pituitary-adrenal axis suppression occurs with >7.5 mg daily for >3 weeks, requiring stress-dose steroids for major surgical procedures 6
• For routine dental extractions or root canals, continue maintenance prednisone without stress dosing
• Delayed wound healing may occur, requiring closer post-operative follow-up 4
• Osteoporosis prophylaxis should be in place for patients on long-term corticosteroids (>3 months), though this doesn't affect acute dental management 3

What NOT to Do

Avoid these common pitfalls:

• Do not apply topical corticosteroids to exposed pulp or use intracanal corticosteroids—historical studies showed no clear therapeutic benefit and potential for continued inflammation progressing to necrosis 7
• Do not abruptly stop prednisone for dental procedures, as this risks adrenal crisis 6
• Do not rely solely on pain absence as evidence of resolution—corticosteroids can mask symptoms while pathology progresses 7