Treating dental pain (tooth pain or toothache)

suggest ibuprofen 400 mg one hour before a procedure. Then ibuprofen 400 mg PLUS acetaminophen 500 to 1,000 mg every 6 hours for a day or two, then...

Overview

A toothache or tooth pain is caused when the nerve in the root of a tooth or surrounding a tooth is irritated. Dental (tooth) infection, decay, injury, or loss of a tooth are the most common causes of dental pain. Pain may also occur after an extraction (tooth is pulled out). Pain sometimes originates from other areas and radiates to the jaw, thus appearing to be tooth pain. The most common areas include the jaw joint (temporomandibular joint or TMJ), ear pain, sinuses, and even occasional heart problems.

Pathophysiology

Tooth enamel (outer tooth layer) is not alive and has no pain sensitivity. Pain in an intact, non-infected tooth implies exposed dentin or pulp. Dental Caries erode through enamel and dentin, to inflame the tooth pulp (Pulpitis). Reversible pulpitis (early) is transiently painful to cold and pressure and is treated with dental fillings. Irreversible pulpitis (late) is unprovoked, persistent, unrelenting pain and is treated with root canal or extraction. Pulpitis may become infected or develop an abscess (but pulpitis itself is not modified by antibiotics)

Etiology of dental pain may be due to dental caries (reversible or irreversible pulpitis), apical periodontitis or apical abscess, periodontal cellulitis, food lodged between teeth, Dental trauma AND pediatric causes LIKE primary tooth eruption or teething (age 6 months to 2 years old) and permanent tooth eruption (age 5.5 years to 7 years).

Management

The latest evidence links opioid prescription for wisdom tooth extractions in teens and young adults to a higher risk of later opioid use and misuse. Point to safe and effective non-opioid options for dental pain. For example, suggest ibuprofen 400 mg one hour before a procedure. Then ibuprofen 400 mg PLUS acetaminophen 500 to 1,000 mg every 6 hours for a day or two, then PRN. More patients report pain relief with this combination than either medication alone or with acetaminophen plus oxycodone or codeine. Explain NSAIDs reduce pain and inflammation without significantly increasing bleeding after most dental procedures. But don't recommend NSAIDs for patients taking anticoagulants, clopidogrel plus aspirin, etc. Get our note "Recommendation for safety use of chronic NSAIDs".

Also suggest ice packs against the cheek for up to 15 min as needed. Consider OTC topical anesthetics (benzocaine, etc) as an option used sparingly, short-term until patients can see a dentist, but not for kids. If an opioid is needed, suggest a low-dose, short-acting product, such as hydrocodone/acetaminophen 5/325 mg every 4 to 6 hours PRN plus ibuprofen. Point out that 3 days or less of an opioid is often enough. Finally, refer to dentist.

References

Schroeder AR, Dehghan M, Newman TB, Bentley JP, Park KT. Association of Opioid Prescriptions From Dental Clinicians for US Adolescents and Young Adults With Subsequent Opioid Use and Abuse. JAMA Intern Med. 2019;179(2):145-152.
Moore PA, Ziegler KM, Lipman RD, Aminoshariae A, Carrasco-Labra A, Mariotti A. Benefits and harms associated with analgesic medications used in the management of acute dental pain: An overview of systematic reviews. J Am Dent Assoc. 2018;149(4):256-265.e3.
Gupta N, Vujicic M, Blatz A. Opioid prescribing practices from 2010 through 2015 among dentists in the United States: What do claims data tell us?. J Am Dent Assoc. 2018;149(4):237-245.e6.