How should I treat an acute toothache, including analgesia, antibiotics if infection signs, and when to seek dental care?

Acute Toothache Management

For an acute toothache, prioritize immediate dental referral for surgical intervention (root canal therapy, extraction, or incision and drainage) as the definitive treatment, and reserve antibiotics strictly for cases with systemic involvement (fever, malaise, lymphadenopathy) or spreading infection (cellulitis, diffuse swelling). 1, 2, 3

Immediate Pain Management

• Use NSAIDs as first-line analgesia for acute dental pain, as they address both pain and inflammation at the source 4
• Acetaminophen can be added for multimodal analgesia if NSAIDs alone are insufficient 4
• Avoid opioids as first-line therapy; reserve for severe pain unresponsive to non-narcotic options 4
• Pain control does NOT substitute for definitive dental treatment 1, 2

When to Seek Immediate Dental Care

Seek same-day or next-day dental evaluation for: 1, 2, 3

• Any toothache lasting more than 24 hours
• Visible swelling of the gum, face, or jaw
• Tooth sensitivity to hot, cold, or pressure that persists
• Visible tooth damage (fracture, large cavity, loose tooth)
• Pain that interferes with sleep or daily activities

Seek emergency dental care immediately for: 2, 3

• Fever (temperature >38°C/100.4°F)
• Difficulty swallowing or breathing
• Rapidly spreading facial swelling or cellulitis
• Trismus (difficulty opening mouth)
• Malaise, tachycardia, or signs of systemic toxicity

Antibiotic Indications (ONLY with Dental Referral)

Do NOT prescribe antibiotics for uncomplicated toothache without systemic signs. Multiple high-quality studies demonstrate no benefit when antibiotics are added to proper surgical management for localized dental infections. 2, 5

Prescribe antibiotics ONLY when: 1, 2, 3

• Systemic involvement present: fever, malaise, tachycardia, elevated white blood cell count
• Spreading infection: cellulitis, diffuse swelling beyond the immediate tooth area, lymph node involvement
• Medically compromised patients: immunosuppressed, uncontrolled diabetes, significant comorbidities
• Infections extending into cervicofacial tissues or deep fascial spaces

First-Line Antibiotic Regimen (When Indicated)

• Amoxicillin 500 mg orally every 8 hours OR 875 mg every 12 hours for 5-7 days 2, 3
• Alternative: Phenoxymethylpenicillin (Penicillin VK) 500 mg orally four times daily for 5-7 days 2

Penicillin-Allergic Patients

• Clindamycin 300-450 mg orally three times daily for 5-7 days 1, 2, 3
• Caution: Higher risk of Clostridioides difficile infection with clindamycin 2

Treatment Failures or Severe Infections

• Amoxicillin-clavulanate (Augmentin) 875/125 mg orally twice daily for 5-7 days 2
• Consider adding metronidazole to amoxicillin (not as monotherapy) for enhanced anaerobic coverage 2

Critical Pitfalls to Avoid

Never prescribe antibiotics without arranging definitive dental treatment. Antibiotics do not eliminate the source of infection and will only provide temporary relief, leading to recurrence and contributing to antibiotic resistance. 1, 2, 3, 5

Do not delay surgical intervention while waiting for antibiotics to "work." The 2024 Cochrane review found no statistically significant differences in pain or swelling when antibiotics were added to surgical treatment for dental abscesses. 5

Recognize non-odontogenic toothache. If the patient has inadequate local dental cause for pain, constant unremitting pain, or failure to respond to reasonable dental therapy, consider non-dental etiologies (sinusitis, trigeminal neuralgia, cardiac referred pain). 6

Special Populations

Renal Impairment

• Creatinine clearance 10-30 mL/min: Amoxicillin-clavulanate 875/125 mg once daily 2
• Creatinine clearance <10 mL/min: Amoxicillin-clavulanate 875/125 mg once daily 2
• Hemodialysis: Administer dose after each dialysis session 2

Liver Disease

• Acetaminophen is the analgesic of choice for patients with liver dysfunction who abstain from alcohol 4
• Avoid nephrotoxic medications and NSAIDs in advanced cirrhosis 4

Pregnancy

• Amoxicillin and penicillin VK are safe in pregnancy 2
• Avoid doxycycline (contraindicated in pregnancy) 2

Definitive Dental Treatment Options

The dentist will determine appropriate intervention based on tooth restorability: 1

• Root canal therapy: For salvageable teeth with adequate crown structure
• Extraction: For non-restorable teeth with extensive caries or structural compromise
• Incision and drainage: For accessible abscesses requiring immediate decompression