What are the treatment options for tooth pain?

Treatment for Tooth Pain

NSAIDs, specifically ibuprofen 400mg every 4-6 hours, are the first-line treatment for dental pain due to their superior anti-inflammatory and analgesic properties. 1, 2, 3

Immediate Assessment Priorities

Before initiating treatment, identify these critical features that determine management:

• Pain characteristics: Sharp, persistent pain with temperature sensitivity suggests pulpitis; severe spontaneous pain indicates pulpal involvement requiring urgent dental referral 1, 4
• Percussion tenderness: Firm percussion with a tongue depressor revealing tenderness indicates infection extending into subdental tissue, necessitating immediate dental evaluation 1, 4
• Facial swelling: Any localized facial swelling of dental origin requires immediate dental referral; progressive swelling demands hospital referral for aggressive antibiotic therapy 4
• Post-extraction timing: Pain occurring 24-48 hours after extraction with absent blood clot indicates superficial osteitis (dry socket) 4

Pharmacological Management Algorithm

Step 1: First-Line Analgesia

• Ibuprofen 400mg every 4-6 hours as needed is the preferred initial treatment 1, 2, 3
• NSAIDs provide superior pain relief compared to placebo at 2 hours (11.66mm reduction on 100mm VAS), 6 hours (24.27mm reduction), and 24 hours (21.19mm reduction) 5
• Peak serum levels occur 1-2 hours after administration, providing rapid onset of action 2

Step 2: Alternative if NSAIDs Contraindicated

• Paracetamol (acetaminophen) provides effective analgesia but lacks anti-inflammatory action 3
• Low-quality evidence shows no significant difference between NSAIDs and paracetamol at 24 hours (0.51mm difference on VAS) 5
• Consider paracetamol for patients with NSAID contraindications (GI ulceration history, renal impairment, aspirin sensitivity) 2, 3

Step 3: Severe Pain Management

• Opioid combinations (codeine with paracetamol) should be reserved exclusively for severe pain due to significant side effects 3
• Opioids are indicated only when NSAIDs provide inadequate relief and definitive dental treatment is delayed 3

Timing Considerations

Pre-emptive analgesia (taking ibuprofen before pain onset) provides better pain relief at 2 hours compared to post-treatment administration (11.30mm greater reduction on VAS), though this difference disappears by 6-24 hours 5. For planned dental procedures, consider administering ibuprofen immediately before treatment.

Adjunctive Non-Pharmacological Measures

• Soft diet for 10 days following dental injury or procedures 1
• Avoid temperature extremes with food and drink to prevent sensitivity 1
• Topical measures have limited evidence but may include brief application of cold (not heat, which can worsen inflammation) 6

Critical Pitfalls to Avoid

Do not delay dental referral while managing pain pharmacologically. The "3-D's principle" (diagnosis, dental treatment, drugs) emphasizes that drugs are only adjuncts—definitive dental treatment to remove the cause provides rapid symptom resolution 3. Specific urgent referral indications include:

• Crown fractures with pulp exposure (delay causes pulpal necrosis) 1
• Severe tooth mobility 1
• Dental abscess with facial swelling (risk of airway compromise) 1, 4
• Pain with exposed dentin (requires prompt coverage to prevent bacterial contamination) 1

Special Considerations

Topical anesthetics (benzocaine otic solution, viscous lidocaine) are not recommended for routine dental pain as they may mask progression of underlying disease while suppressing pain 6. Reserve topical anesthetics only for procedure-related pain during aural toilet or specific oral dysesthesia cases 6.

Corticosteroids have extremely limited indications in dentistry and should not be used for routine dental pain management 3. Their use is restricted to very specific inflammatory conditions under specialist guidance.

When Sinusitis May Be the Source

If maxillary posterior tooth pain lacks obvious odontogenic source and patient has concurrent sinus symptoms, consider treating sinusitis before proceeding with dental intervention 7. However, resolve obvious dental pathology first before attributing pain to sinusitis 7.