What is the appropriate treatment for a patient experiencing a toothache?

Toothache Treatment

For acute toothache, prescribe ibuprofen as first-line pain control, assess for signs requiring immediate dental referral (visible pulp exposure, severe swelling, tooth mobility with aspiration risk), and refer non-urgent cases within days while advising a soft diet. 1

Immediate Pain Management

• Ibuprofen (NSAIDs) is the first-line analgesic for dental pain, with acetaminophen as an alternative if NSAIDs are contraindicated 1
• Avoid prescribing opioids for routine toothache unless severe pain unresponsive to NSAIDs 2
• NSAIDs reduce both pain and inflammation, addressing the underlying inflammatory process in dental pathology 3

Caution: Ibuprofen can cause GI discomfort, ulceration, and bleeding; patients should watch for epigastric pain, melena, or hematemesis 3. Monitor patients on long-term NSAIDs for anemia and check hemoglobin if signs develop 3.

Triage: When to Refer Immediately vs. Within Days

Same-Day/Immediate Dental Referral Required:

• Visible red pulp tissue in the center of a tooth fracture (complicated crown fracture requiring pulp therapy to preserve vitality) 4, 1
• Multiple teeth moving together as a segment, indicating alveolar bone fracture needing repositioning and splinting 4
• Severe tooth mobility with concern for aspiration of the crown portion 4
• Extensive gingival or facial swelling, suggesting abscess formation requiring drainage and antibiotics 4
• Tooth displacement interfering with occlusion (patient cannot close jaw properly or posterior teeth don't interdigitate) 4
• Avulsed permanent tooth (see special protocol below) 4

Dental Referral Within Days (Not Urgent):

• Tooth sensitivity with exposed yellowish dentin from enamel-dentin fractures (cover exposed dentin to prevent bacterial contamination) 4, 1
• Gray tooth discoloration developing after trauma, indicating pulpal hemorrhage and potential necrosis 4
• Enamel-only fractures with sharp edges causing soft tissue injury 5, 1

Conservative Management (No Immediate Referral):

• Smooth enamel-only fractures without sensitivity can be left untreated or smoothed if causing discomfort 5, 1
• Subluxation with mobility but no displacement requires monitoring; refer only if discoloration or gum swelling develops 4

Special Protocol: Avulsed Permanent Tooth

This is a true dental emergency requiring immediate replantation within minutes for optimal prognosis. 4, 6

1. Confirm it is a permanent tooth (never replant primary teeth as this damages the underlying permanent tooth bud) 5, 4
2. Handle by the crown only, never touch the root (covered in fragile fibroblasts needed for reattachment) 5
3. Rinse briefly under cold running water for 10 seconds if dirty 5, 1
4. Replant immediately at the injury site by having the patient bite on cloth to hold it in position 5
5. If replantation not possible, store in cold milk, balanced salt solution, or saliva—never water (causes osmotic lysis of root fibroblasts) 5
6. Refer immediately for flexible splinting (up to 2 weeks) and root canal therapy within 7-10 days 5
7. Prescribe systemic antibiotics: doxycycline for children >12 years, penicillin for <12 years, or clindamycin if penicillin-allergic 5

Supportive Care Instructions

• Soft diet for 10 days after any dental trauma or procedure to minimize mechanical stress 5, 7, 1
• Apply cold compresses to reduce swelling 1
• Maintain good oral hygiene but avoid vigorous brushing of the injured area 5
• Restrict pacifier or digit sucking for 10 days in young children with primary tooth trauma 5

Red Flags: Consider Non-Odontogenic Causes

If toothache persists despite appropriate dental treatment, consider neuropathic pain disorders rather than continuing irreversible dental procedures. 8, 2

Signs suggesting non-dental origin:

• Inadequate local dental cause for the severity of pain 9
• Stimulating, burning, or constant unremitting pain rather than pulsatile 9
• Local anesthetic blocking does not eliminate the pain 9
• Persistent pain over months/years despite multiple dental treatments 9, 8
• Spontaneous multiple toothaches without clear pathology 9

These patients may have atypical odontalgia or trigeminal neuropathic pain requiring medications like gabapentin or tricyclics, not further dental procedures 2.

Follow-Up Monitoring

• Monitor all fractured or traumatized teeth for signs of pulpal necrosis: gray discoloration, gum swelling with increased mobility, or parulis (gum bump) formation 4, 1
• Children may not report pain from necrotic teeth, so caregivers must watch for visual signs rather than relying on pain complaints 4
• Suspect non-accidental injury in children <5 years with severe dental trauma, especially if mechanism is inconsistent 4