Patients with dental pain presenting to a medical practitioner

If a patient with dental pain presents to a medical practitioner and is unable to see a dentist promptly, interim treatment may be needed—see A guide to differentiating and managing acute dental pain for initial management of common causes of dental pain. However, the medical practitioner should stress the importance of seeing a dentist, because dental treatment is often the definitive treatment of conditions causing dental pain.

If dental review is not immediately available, the medical practitioner may consider a panoramic X-ray—an orthopantomogram (OPG)—to exclude serious pathologies (eg gross dental caries, jaw fractures, jaw lesions such as cysts).

Table 1. A guide to differentiating and managing acute dental pain
Printable table
Description of pain and associated features	Likely cause and suggested management
intermittent dental pain that is experienced when the tooth is exposed to a stimulus (eg hot, cold or sweet food or drinks) and resolves once the stimulus is removed	Likely cause reversible pulpitis
	Initial management by medical practitioners advise the patient to avoid food or drink that provokes pain cover any obvious cavity with an inert material (eg chewing gum, Blu Tack) advise the patient to see a dentist as soon as possible analgesics and antibiotic therapy are not indicated
	Dental treatment simple restoration or desensitisation treatment is required
severe dental pain that is experienced when the tooth is exposed to a stimulus (eg hot, cold or sweet food or drinks) pain persists as a dull throbbing ache after the stimulus is removed, and can become continuous	Likely cause irreversible pulpitis
	Initial management by medical practitioners advise the patient to avoid food or drink that provokes pain offer analgesics —NSAIDs are preferred if the patient can use them cover any obvious cavity with an inert material (eg chewing gum, Blu Tack) if symptoms are severe, consider local anaesthesia of the affected tooth for temporary pain relief (see Local anaesthetics in dentistry) advise the patient to see a dentist as soon as possible antibiotic therapy is not indicated
	Dental treatment endodontic treatment (root canal) or extraction is usually needed
dental pain that presents as a dull throbbing ache, and is not triggered by a stimulus such as hot, cold or sweet food or drinks tooth may be sore to bite on	Likely cause infected root canal system with acute periapical inflammation (apical periodontitis)
	Initial management by medical practitioners offer analgesics—NSAIDs are preferred if the patient can use them advise the patient to see a dentist urgently antibiotic therapy is not indicated for a localised odontogenic infection; however, if dental treatment is not likely to be received within 24 hours, start antibiotic therapy as for spreading odontogenic infection without severe or systemic features
	Dental treatment endodontic treatment (root canal) or extraction is needed
tenderness of the tooth to pressure and on biting	Likely cause fractured or cracked tooth or localised odontogenic infection
	Initial management by medical practitioners advise the patient to see a dentist urgently; it is difficult for medical practitioners to differentiate a fractured tooth from a localised odontogenic infection (even with imaging) without a visible abscess or pus to indicate infection offer analgesics—NSAIDs are preferred if the patient can use them antibiotic therapy is only indicated if a localised odontogenic infection is confirmed and dental treatment is not likely to be received within 24 hours—see spreading odontogenic infection without severe or systemic features for a suggested regimen
	Dental treatment restoration, endodontic treatment (root canal) or extraction is needed
facial swelling and pain following a toothache without any of the following: significant facial swelling and pain, trismus, neck swelling, difficulty swallowing, difficulty breathing, airway compromise or systemic features of infection	Likely cause spreading odontogenic infection without severe or systemic features
	Initial management by medical practitioners 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; otherwise antibiotic therapy is not indicated advise the patient to see a dentist urgently
	Dental treatment endodontic treatment (root canal) or extraction is needed
swelling and pain following a toothache with any of the following: significant facial swelling and pain, trismus, neck swelling, difficulty swallowing, difficulty breathing, airway compromise or systemic features of infection	Likely cause spreading odontogenic infection with severe or systemic features
	Initial management by medical practitioners provide appropriate support of airway, breathing and circulation arrange urgent transfer to a hospital with an oral and maxillofacial surgeon or other appropriate expert
	Dental treatment surgical intervention and intravenous antibiotic therapy is needed—see here
dental pain that worsens when the head is tilted forward	Likely cause maxillary sinusitis
	Initial management by medical practitioners symptomatic therapy is recommended and antibiotics are rarely needed—see Acute rhinosinusitis
	Dental treatment dental treatment is not required
dental pain worsening 1 to 4 days after tooth extraction	Likely cause alveolar osteitis (dry socket)
	Initial management by medical practitioners flush the socket with warm sterile saline until all debris is removed from the socket offer analgesics—NSAIDs are preferred if the patient can use them advise the patient to see the practitioner who performed the extraction urgently antibiotic therapy is not indicated
	Dental treatment further socket irrigation and analgesia may be needed an obtundent dressing may relieve pain
acute onset of severe pain throughout the mouth associated with gingival bleeding and necrosis or ulcers of the interdental papillae halitosis is usually present	Likely cause necrotising gingivitis (previously known as acute necrotising ulcerative gingivitis)
	Initial management by medical practitioners offer analgesics chlorhexidine mouthwash or hydrogen peroxide solution may be used if pain limits the patient’s ability to mechanically clean their teeth advise the patient to see a dentist urgently see also Management of necrotising gingivitis
	Dental treatment thorough local debridement of the gingiva, local irrigation and antibiotic therapy are needed
acute unilateral or bilateral pre-auricular pain mouth opening may be restricted	Likely cause temporomandibular disorder
	Initial management by medical practitioners advise the patient to rest the jaw (eg eat only soft foods) and avoid extreme jaw movements (eg yawning) advise the patient to apply cold or warm compresses, as indicated offer analgesics—NSAIDs are preferred if the patient can use them advise the patient to see a dentist as soon as possible see Temporomandibular disorders for further advice
	Dental treatment if conservative measures fail, referral to an oral medicine specialist or oral and maxillofacial surgeon may be required
Note: NSAIDs = nonsteroidal anti-inflammatory drugs Adapted with permission from The Royal Australian College of General Practitioners from: Kingon A. Solving dental problems in general practice. Aust Fam Physician 2009;38(4)211–16. Available at [URL].