Management of dental pain in primary care

Patients sometimes present to a medical practitioner with dental pain if they cannot see a dentist.

Doctors need to be aware of the common dental diseases that result in pain so they can help to manage the patient’s symptoms until they are able to see a dentist.

Appropriate advice regarding analgesics for dental pain is important. Paracetamol and ibuprofen are more effective in combination than either of them alone, with or without opioids.

Antibiotics are only indicated as an adjunct to dental treatment when there are signs of systemic involvement, progressive and rapid spread of infection, or when the patient is immunocompromised.

Patients may present to a medical practitioner with dental pain, dento-maxillofacial trauma and treatment-related complications. This happens frequently in emergency departments, but also in general practice.¹ A recent survey found that dental conditions accounted for over 70,000 avoidable hospital admissions in Australia during 2016–17.² Yet, many doctors have limited training in the diagnosis and management of common dental problems.³

Besides referral to a dentist, the medical practitioner can provide appropriate advice regarding analgesics, with consideration of the patient’s medical history (including recent dental treatment), the benefits and risks of the drugs and severity of the pain. It is also important to know when antibiotics should and should not be prescribed.⁴ Community pharmacists also see many patients with dental pain, particularly out of hours, and need guidance about what to advise.

When obtaining a pain history, the mnemonic SOCRATES can be useful:⁵

Site – Where is the pain?

Onset – When did it start?

Character – Can you describe the pain?

Radiation – Does the pain spread anywhere?

Associations – Are there other problems associated with the pain?

Time course – Does the pain follow any pattern? How long does it last?

Exacerbating or relieving factors – Does anything worsen or improve it?

Severity – How bad is the pain?

Dental pain is usually acute, unilateral and localised within the mouth.⁶ It can be exacerbated by thermal or osmotic stimuli or when biting and can present with swelling. Figure 1 indicates where some of the more common conditions that cause dental pain can occur in a tooth.⁷

Pain exacerbated by thermal or osmotic stimuli

The management of dental pain that worsens with thermal or osmotic stimuli (e.g. sweets or acids) is outlined in Fig. 2. If the patient reports sensitivity or sharp, shooting pain to cold, hot or osmotic stimuli lasting only seconds to minutes, the painful tooth is likely to have an inflamed pulp. This should resolve and is called reversible pulpitis. If the inflammation progresses, the pulp may not be able to heal. This results in irreversible pulpitis. In this case, the patient may report dull or throbbing, poorly localised pain of longer duration.⁸

The term dentinal hypersensitivity is used interchangeably with reversible pulpitis as the patient presents with the same symptoms. However, dentinal hypersensitivity is related to exposed dentine.

Occasionally, temporomandibular disorders can arise secondary to pulpitis. This can present as odontogenic and non-odontogenic pain simultaneously.⁹ There is a lack of evidence for the use of antibiotics to reduce pain associated with irreversible pulpitis and the patient should be advised to seek prompt dental treatment.¹⁰

Pain when biting

The management of dental pain from biting is outlined in Fig. 3. When assessing the patient, consider the character and location of the pain. Sharp pain with short duration may be localised to a vital tooth with cracks or dislodged dental restorations.¹¹

When pulp inflammation progresses to pulp necrosis, the symptoms associated with thermal or osmotic stimuli may resolve initially. Dull throbbing pain localised to a tooth with an infected root canal system can then occur when there is inflamed periodontium around the root apex (symptomatic apical peridontitis). Knowing the patient’s history of symptoms and past dental treatment can be useful as pulp inflammation and necrosis usually develop from tooth decay. A patient with a history of root canal therapy can develop symptoms over time if the root canal system remains or becomes re-infected.

Other causes of dull throbbing pain include:

• food impaction – together with bacterial plaque this can result in gingival inflammation7
• bruxism (grinding of teeth)
• temporomandibular disorders
• oral ulceration
• periodontal issues with wisdom teeth (pericoronitis) – this may present with continuous pain localised near a wisdom tooth which is exacerbated by eating or brushing
• acute necrotising ulcerative gingivitis – this results from non-contagious infection of the gums and may present with painful bleeding, ulcerative gingival tissues and halitosis¹²
• dry socket (alveolar osteitis) – this may present with pain 1–4 days after tooth extraction so patients should be asked about recent dental treatment. The pain may radiate to the ear, eye or temporal region and be accompanied by halitosis or an unpleasant taste.⁶

When pain occurs with a temporal pattern (e.g. intermittent pain), it is likely to a have a non-odontogenic cause and the clinician should consider myalgia related to bruxism, cluster headaches or neuropathic pain.¹³ A patient with nocturnal bruxism may report discomfort, fatigue or pain in the jaw muscles and headache, especially in the morning.¹⁴

Pain with swelling

Urgent referral to a dentist is indicated when there is dental pain with swelling. A patient with an acute apical abscess will experience a rapid onset of spontaneous pain, which can sometimes be poorly localised and present with firm or fluctuating swelling in the overlying soft tissues. The tooth is extremely tender when palpated or tapped.¹⁵

The symptoms and clinical presentation of a periodontal abscess can be confused with an acute apical abscess. However, pain from a periodontal abscess is usually localised. From the history, the patient may have had previous periodontal treatment, a history of periodontal abscess or a recent soft tissue trauma sustained during eating. On examination, there may be an ovoid swelling in the gingival tissues along the lateral surface of the root.¹⁶ Suppuration can present spontaneously or when the abscess is pressed.¹⁶ Again, systemic antibiotics are only indicated as an adjunctive treatment when there is systemic involvement or spread of infection, or if adequate drainage cannot be provided.¹⁶

Maxillary sinusitis

The symptoms associated with maxillary sinusitis can mimic pain of pulpal origin and vice versa.¹⁷ The medical history of a patient with sinusitis may reveal recent upper respiratory tract infection, a history of chronic rhinitis or pain associated with air travel.¹⁸ Symptoms can be unilateral or bilateral and are described as a continuous dull pain exacerbated by biting, touch, postural changes or exercise.¹⁹ The patient may also have nasal congestion and discharge, headache, facial pain or fullness, erythema over the cheeks and olfactory disturbance.¹⁹

Maxillary sinusitis may be suspected to have an odontogenic cause when it does not respond to medical therapy and presents with unilateral symptoms and a history of dental or jaw pain. The patient may have a history of dental caries, periodontal disease or complications with surgery in the posterior maxilla.²⁰ If sinusitis of odontogenic cause is suspected, the patient should be directed to a dentist.

Warning signs that can alert the clinician to pain of non-odontogenic origin are listed in the Box.^21-24 Knowing the location and timing of the pain can help to differentiate between musculoskeletal, neuropathic, vascular, primary headache or mixed conditions.⁶

Chronic orofacial pain has a non-odontogenic origin and is characterised by painful regional syndromes with a chronic unremitting pattern.²⁵ The most common example is temporomandibular disorders which can present as unilateral or bilateral, continuous or episodic pain.²¹ The patient may complain of pain in the jaw, temple, inside or in front of the ear, which is modified by jaw movements.²² Fibromyalgia, back pain, chronic fatigue syndrome, depression and headache can be associated with a temporomandibular disorder.²³ Clicking, crepitus, pain, trismus or locking of the temporomandibular joints can present with disruption of the disc movement.²¹ Jaw claudication can potentially be a sign of temporal arteritis and the patient can be referred to an oral maxillofacial surgeon for diagnosis and management.

As non-steroidal anti-inflammatory drugs (NSAIDs) produce analgesic and anti-inflammatory actions by inhibiting cyclooxygenase enzymes, they are the drug of choice for dental pain. Their efficacy has been well supported by systematic reviews.²⁶ Taking ibuprofen and paracetamol together has been recommended because the combination is more effective than either drug alone.²⁷ If NSAIDs are contraindicated, paracetamol or the combination of paracetamol and oxycodone can be recommended. As opioids result in less analgesia and more adverse effects,²⁷ they are only prescribed, as an adjunct to ibuprofen or paracetamol, at the lowest possible dose and shortest duration.

Administration of a dental block may be effective for initial management of severe pain before follow-up with oral analgesics, especially in an emergency department.

Topical local anaesthetics (e.g. 2% lignocaine gel) are effective for temporary pain relief in patients presenting with oral ulceration or painful oral mucosal conditions. However, the patient should be warned about the risk of further trauma when the oral mucosa is numb.²⁸

Antibiotics are only indicated as an adjunct to definitive treatment when there are systemic signs of infection (fever, malaise, lymphadenopathy, trismus), progressive and rapid spread of infection (cellulitis or Ludwig’s angina) or when the patient is immunocompromised.²⁹ Antibiotics for odontogenic infections include:

• phenoxymethylpenicillin or amoxicillin
• amoxicillin with metronidazole
• amoxicillin with clavulanate or clindamycin.²⁹

If the patient presents with spreading dental infection, systemic sepsis or the risk of airway compromise, they will need immediate referral to the emergency department.

Currently, prophylactic antibiotics are only indicated before dental procedures associated with a high risk of bacteraemia such as surgical procedures including extraction for patients with specific conditions such as prosthetic heart valves, previous infective endocarditis, some congenital heart defects, cardiac transplants with subsequent valvopathy and rheumatic fever with high risk of endocarditis.³⁰

Management of dental pain in a medical setting follows specific guidelines for either definitive treatment or to provide relief before referral for dental treatment. Antibiotics are rarely indicated for management of odontogenic infections and are used as adjuncts to dental treatment.

Conflict of interest: none declared

Managing acute dental pain without codeine. Aust Prescr 2020;43:64