What are the management options for a patient experiencing a toothache?

Management of Toothache

For acute toothache, immediately assess for dental trauma or infection requiring same-day dental referral, provide NSAIDs (ibuprofen) as first-line pain control, and use topical benzocaine for temporary relief while arranging definitive dental treatment. 1, 2, 3

Immediate Triage and Red Flags

First, determine if the toothache requires same-day dental referral by looking for these critical signs:

• Visible pulp exposure (red tissue in center of tooth fracture) requires immediate dental referral to preserve tooth vitality 4, 1
• Extensive gingival or facial swelling indicates potential abscess formation and requires urgent evaluation 4
• Parulis (gum boil) appearing on gingiva adjacent to the tooth signals pulpal necrosis requiring extraction evaluation 4
• Gingival swelling with increased tooth mobility may indicate pulpal necrosis and periapical abscess 4
• Multiple teeth moving together as a segment suggests alveolar bone fracture requiring immediate repositioning and splinting 4

Pain Management Algorithm

First-Line Treatment

• Prescribe NSAIDs (ibuprofen) as first-line for pain control due to excellent analgesic and anti-inflammatory action 1, 3
• Acetaminophen serves as alternative if NSAIDs are contraindicated, providing effective analgesia though with minimal anti-inflammatory action 3
• Topical benzocaine temporarily relieves toothache pain and can be used as adjunct to systemic analgesics 2

Second-Line Treatment

• Opioids (codeine with paracetamol) should be reserved for severe pain only due to significant side effects 3
• Opioids are powerful analgesics but should not be first-line therapy 3

Supportive Care Measures

• Soft diet for 10 days after any dental injury or procedure 1
• Cold compresses applied externally to reduce swelling 1
• Avoid sucking on pacifiers or digits for 10 days after primary tooth injury 5

Non-Urgent Dental Referral (Within Days)

Refer within a few days rather than immediately for:

• Gray tooth discoloration developing after trauma, indicating pulpal hemorrhage and potential necrosis 4
• Tooth sensitivity with exposed dentin from enamel-dentin fractures to cover exposed dentin and reduce bacterial contamination risk 4, 1
• Enamel-only fractures that need smoothing of sharp edges but are not emergent 1

Critical Pitfalls to Avoid

Warning Signs of Non-Odontogenic Toothache

Be suspicious that pain may not be of dental origin if you observe: 6, 7

• Inadequate local dental cause for the severity of pain 6, 7
• Spontaneous multiple toothaches affecting several teeth simultaneously 6, 7
• Stimulating, burning, non-pulsatile quality rather than typical throbbing dental pain 6, 7
• Constant, unremitting pain that does not vary with triggers 6, 7
• Local anesthetic blocking fails to eliminate the pain 6, 7
• Failure to respond to reasonable dental therapy 6, 7

These patients may have trigeminal neuropathic pain disorders and require different management with gabapentin, tricyclics, or topical anesthetics rather than dental procedures 8

Pediatric-Specific Considerations

• Never replant an avulsed primary tooth, as this risks damage to the underlying permanent tooth germ 4, 9
• Children may not report pain from a necrotic tooth, so caregivers must watch for visual signs including discoloration, swelling, and parulis rather than relying on pain complaints 4
• Suspect non-accidental injury in cases of oral trauma in children younger than 5 years, particularly with severe tooth injury or inconsistent mechanism 4

When to Stop Topical Benzocaine and Seek Further Care

Stop benzocaine use and refer to dentist if: 2

• Sore mouth symptoms do not improve in 7 days 2
• Irritation, pain or redness persists or worsens 2
• Swelling, rash or fever develops 2

The "3-D's" Principle

Remember that drugs are only adjunctive: 3

1. Diagnosis - identify the source and cause of pain 3
2. Dental treatment - remove the cause of the condition for rapid symptom resolution 3
3. Drugs - use only as adjunct to definitive dental treatment 3

Appropriate dental treatment to remove the cause usually provides rapid resolution of symptoms, making pharmacologic management secondary to definitive care 3