Acute dental pain in adults - clinical fact sheet and MCQ

Overview

Acute dental pain is primarily inflammatory and arises from dental and orofacial conditions. The most common causes are: 

• odontogenic (tooth related): dental pulp inflammation (pulpitis) due to caries,  loss of dental filling or dental trauma

• periapical infection or inflammation, ie, surrounding region of the apex of the root

• periodontal tissues - usually advanced periodontitis

• pericoronal tissues - usually partially erupted mandibular third molars

• post-extraction complications

Timely referral to a dentist is essential, as dental treatment is the most effective way to manage pain and address underlying pathology.

Brief note on anatomy of tooth and dental caries:

Image credit: Human tooth diagram-en.svg from Wikimedia Commons by K. D. Schroeder, CC-BY-SA 4.0

Enamel: translucent, hardest outer layer, does not contain living cells  and has little capacity to heal itself. Early signs of dental caries appear as white opaque spots.

Dentin: contains hollow tubules with fluid and nerve endings connected to pulp. Tooth pain and sensitivity is due to these dentinal tubules transmitting a stimulus from bacterial, thermal or mechanical insult. Dentin has some capacity to heal, depending on the type of insult. 

Dental pulp: inner most part, nourishes the dentin, contains living connective tissue and neurovascular bundle.

Cementum: thin layer of bone-like structure, covering the root of the tooth. Cementum connects fibers from teeth to alveolar bone and continuously forms throughout the life of a tooth

Dental caries

Image credit: teeth.org.au

Image credit: Tooth_model.jpg from Wikimedia Commons by Xauxa

Caries classification and management system can be found here.

Non-dental conditions, such as trigeminal neuralgia or maxillary sinusitis, can mimic dental pain and should be considered in the differential diagnosis.

Diagnosis of dental pain

1. History and examination:

• pain characteristics: intermittent or continuous, triggered by stimuli, or spontaneous

• associated symptoms: swelling, fever, trismus, or systemic signs of infection

• clinical examination: tenderness, visible caries, abscess formation, or fracture

2. Differential diagnoses: 

• reversible pulpitis: pain triggered by stimuli, (eg, hot, cold, sweet) that resolves when removed

• irreversible pulpitis: severe, persistent pain that continues after stimulus removal

• apical periodontitis: dull ache, pain on biting, tenderness to percussion

• periapical abscess/dental abscess: the concomitant inflammatory response of the dental pulp to bacterial invasion, localised at the apex of the root or periodontal space, to form a thick-walled cavity, containing pus 

• dry socket/alveolar osteitis: onset of pain 1-4 days after dental extraction at the site of extracted tooth, usually self-limiting; risk factors include smoking (more information can be found here)

• temporomandibular disorders: acute unilateral or bilateral pre-auricular pain; mouth opening may be restricted

• trigeminal neuralgia: sharp, electric shock-like pain, often unilateral, unrelated to dental pathology

• maxillary sinusitis: facial pain worsened by head movement, tenderness over the sinuses

3. Red flags:

• spreading odontogenic infection without severe or systemic features: facial swelling and pain following a toothache 

• absence of significant facial swelling and pain, trismus, neck swelling, difficulty swallowing, difficulty breathing, airway compromise, or systemic features of infection

• polymicrobial aetiology, commonly initiated by streptococcus mutans, a gram-positive, facultative anaerobe

• spreading odontogenic infection with severe or systemic features: swelling and pain following a toothache

• presence of significant facial swelling and pain, trismus, neck swelling, difficulty swallowing, difficulty breathing, airway compromise, or systemic features of infection

NB: the rate of spread of odontogenic infection depends on virulence of the organisms (usually a consortium of virulent bacteria), influenced by the anatomy of the area involved, and the immune resistance of the body and presence of systemic risk factors.

• Ludwig’s angina: rare, consisting of bilateral firm cellulitis of the submandibular and sublingual spaces and the submental space in the midline

• is a life-threatening emergency that requires immediate hospitalisation

• presents with massive neck swelling, an elevated floor of the mouth and tongue, difficulty breathing, swallowing, and speaking, and pain on opening the mouth 

• mostly arises from an odontogenic infection 

• can also be caused by trauma or submandibular salivary gland inflammation

• management consists of immediate airway maintenance, surgical draining, extraction of involved teeth, and extensive antibiotic therapy.

4. Investigations GPs can consider: 

• orthopantomogram (OPG): an extraoral radiograph to help exclude serious pathologies such as gross caries, jaw fractures or any hard and soft tissue pathology of the orofacial region in case urgent dental review is not available eg, in remote locations 

Information on OPG interpretation for GPs can be found here.

Management of dental pain

1. General principles:

• dental intervention is the most effective treatment and should be prioritised

• medical management is a temporary measure when dental care is unavailable or delayed

• pain of non-dental origin along with associated systemic symptoms warrants a specialist medical review 

• in general, in otherwise healthy patients, antibiotics are not routinely indicated and should only be used for spreading odontogenic infections and are not a substitute for dental treatment. Consideration for prophylactic antibiotic use for dental treatment are found here.

• suggested therapeutic recommendations are below: 

• metronidazole is commonly used in conjunction with a penicillin because of increased rates of resistance to penicillins in some oral bacteria (eg, Prevotella oralis), OR                                                   

• amoxicillin+clavulanate has adequate anaerobic activity, and can be used as a single preparation, OR

• clindamycin for patients allergic to penicillin 

2. Management based on specific condition:

• reversible pulpitis:

• advise avoidance of stimuli

• cover cavity with an inert material (eg, chewing gum, Blu Tack)

• analgesics and antibiotics are not indicated

• definitive treatment with a dentist involves simple restoration or desensitisation of exposed dentin depending on the cause

• irreversible pulpitis:

• advise avoidance of stimuli

• NSAIDs are preferred for pain relief if no risks and contraindications

• if symptoms are severe, consider local anaesthesia

• definitive treatment with dentist involves root canal therapy or extraction

• apical periodontitis:

• NSAIDs are preferred for pain relief if no contraindications

• urgent dental review needed

• antibiotics are not indicated unless there is a spreading infection

• definitive treatment depending on the cause may involve root canal therapy or extraction or as assessed by the dental practitioner

• antibiotics only if systemic symptoms are present

• spreading odontogenic infection without severe or systemic features:

• offer analgesics—NSAIDs are preferred if the patient can use them

• if dental treatment is not likely to be received within 24 hours, start antibiotic therapy

• advise patient to see the dentist 

• endodontic treatment (root canal) or extraction is needed

• spreading odontogenic infection with severe or systemic features:

• provide appropriate support of airway, breathing and circulation

• arrange urgent transfer to a hospital with an oral and maxillofacial surgeon or other appropriate expert

• surgical intervention and intravenous antibiotic therapy is needed followed by cultures of blood and or pus

• alveolar osteitis (dry socket):

• irrigate socket with warm saline if possible 

• NSAIDs for pain relief and advise the patient to see the dentist who performed the extraction 

• definitive treatment with dentist includes further socket irrigation, socket dressings and analgesia

• temporomandibular disorder (TMD):

• advise jaw rest, soft diet

• avoid excessive jaw movements (eg, .yawning)

• apply warm or cold compresses as appropriate

• NSAIDs are preferred if no contraindications

• advise the patient to see a dentist as soon as possible

3. Analgesia:

• mild to moderate pain:

• ibuprofen 400 mg every 6–8 hours (preferred) ± paracetamol 1000 mg every 4–6 hours (max 4000mg per day)

• severe pain:

• consider adding oxycodone 5 mg every 4–6 hours for the shortest duration possible (maximum 3 days)

• NSAIDs should be avoided in patients with contraindications (eg, gastrointestinal ulcers, renal impairment immunocompromised, patients on blood thinners)

4. Refer to hospital when:

• dental pain and extraoral swelling is worsening with increasing trismus and malaise

• patient is systemically unwell, has a compromised immune system eg, diabetes

• patient presents with difficulty in swallowing, bilateral firm swelling below the neck , elevated tongue, fever, patient unable to swallow eat or drink, periorbital swelling, as all these features indicate spread of odontogenic infection to fascial spaces, causing airway obstruction and life threatening consequences, such as Ludwig's angina or cavernous sinus thrombosis

• patient presents with a facial swelling from trauma to head, face or neck region 

References

Niekrash, C. E., Ferneini, E. M., & Goupil, M. T. (Eds.). (2023). Dental Science for the Medical Professional: An Evidence-Based Approach (First edition.). Springer. https://doi.org/10.1007/978-3-031-38567-4

International Association of Dental Traumatology. 2020 IADT Guidelines for the Evaluation and Management of Traumatic Dental Injuries. 2020. Available at: https://iadt-dentaltrauma.org/guidelines-and-resources/guidelines/. (last accessed March 2025).

Goh R, Lynham A, Beech N. Management of dental infections by medical practitioners. AFP. 2014;43(5):289-291.

Kingon A. Solving dental problems in general practice. AFP. 2009;38(4):211-216.

Therapeutic Guidelines Limited. (2019). Therapeutic guidelines : oral and dental. (Version 3.). Therapeutic Guidelines Limited.

Claim your CPD

After reading the clinical summary above and reviewing the references, complete the quiz to gain 30 minutes of EA CPD and 30 minutes of RP CPD. 

You can either self-report CPD to your CPD home, or Medcast will track your learning via your personal CPD Tracker and you can download and report these points once a year. See our CPD Tracker FAQ.  

Quiz

Please log in or sign up for a free Medcast account to access the case study questions and achieve the CPD credits.