What are the best management options for a patient with severe dental pain, broken and rotten teeth, who refuses to see a dentist due to concerns about cost?

Management of Severe Dental Pain in a Patient Refusing Dental Care

For a patient with severe dental pain, broken and rotten teeth who refuses dental care due to cost concerns, provide immediate pain control with NSAIDs (ibuprofen as first-line), avoid antibiotics unless signs of spreading infection are present, and systematically address the financial barriers preventing definitive dental treatment through social work referral and community dental resource navigation. 1, 2

Immediate Pain Management

• Prescribe ibuprofen as first-line analgesic for dental pain control, with acetaminophen as an alternative if NSAIDs are contraindicated. 1
• Avoid opioid prescriptions for dental pain, as prescription opioid use can lead to further dental deterioration through xerostomia and dental neglect, creating a worsening cycle. 3
• Provide only palliative treatment until the patient can access definitive dental care, as medical providers cannot resolve the underlying dental pathology. 2

Antibiotic Decision-Making

• Withhold antibiotics unless the patient exhibits signs of spreading infection requiring immediate intervention. 2
• Indiscriminate antibiotic use for dental pain should be avoided to prevent development of resistant microorganisms. 2
• Prescribe antibiotics only if the patient demonstrates extensive gingival or facial swelling suggesting abscess formation, which represents a potentially life-threatening complication. 4, 2

Critical Red Flags Requiring Emergency Intervention

Even with patient refusal, certain presentations demand immediate action:

• Extensive facial swelling, difficulty swallowing, or difficulty breathing indicate potential airway compromise from dental abscess and require emergency department referral regardless of patient preference. 4, 2
• Fever with facial swelling suggests spreading odontogenic infection that can progress to life-threatening complications including Ludwig's angina or cavernous sinus thrombosis. 2
• Inability to close the jaw properly may indicate temporomandibular dislocation requiring immediate reduction. 4

Addressing Financial Barriers

The cost concern represents a surmountable barrier requiring systematic intervention:

• Initiate social work consultation to identify community dental clinics, dental schools, sliding-scale fee programs, and emergency dental assistance programs. 5
• Many dental schools provide substantially reduced-cost care performed by supervised students. 5
• Community health centers often provide dental services on a sliding fee scale based on income. 5
• Some states offer emergency Medicaid dental coverage for adults with acute dental infections. 5

Breaking the Cycle of Dental Avoidance

Research demonstrates that dental fear and avoidance create a vicious cycle where delayed treatment leads to worse dental problems, reinforcing avoidance behavior. 6

• Patients with high dental fear are more likely to delay treatment until symptoms become severe, leading to more extensive dental problems requiring more invasive treatment. 6
• This pattern of symptom-driven visiting (only seeking care for pain or problems) perpetuates dental fear and poor oral health outcomes. 6
• Address the underlying reason for refusal directly: if cost is the barrier, provide concrete financial resources; if dental anxiety is present, discuss sedation dentistry options available at community clinics. 5, 6

Common Pitfalls to Avoid

• Never prescribe repeated courses of antibiotics for recurrent dental pain without definitive dental treatment, as this creates antibiotic resistance without addressing the source. 2
• Do not assume the patient simply "doesn't want" dental care—systematically explore and address the specific barriers (financial, fear, access, previous negative experiences). 5
• Avoid dismissing the patient's concerns about cost, as financial barriers represent legitimate obstacles that require concrete solutions rather than generic advice to "see a dentist." 5
• Do not provide opioids as a bridge to dental care, as this can worsen dental disease and create additional problems. 3

Monitoring and Follow-Up

• Schedule follow-up within 48-72 hours to reassess pain control and confirm the patient has contacted dental resources provided. 2
• If pain worsens or swelling develops despite initial management, this indicates progression requiring urgent dental intervention regardless of cost concerns. 4, 2
• Document the specific financial resources and contact information provided to the patient, and consider direct warm handoff to social work or case management. 5