Management of acute dental pain in adults

Clinical question

Do antibiotics improve outcomes in adult patients presenting with acute dental pain without facial swelling?

Bottom line

Severe toothache is a common problem and toothache without facial swelling is caused by inflammation. Source control and symptom management is appropriate treatment and antibiotics are not indicated, unless there is facial swelling or signs of systemic infection. Inappropriate antibiotic use in dental pain is common—both for antibiotic prescriptions when an antibiotic is not indicated, and for choice and duration of antibiotics where there is an indication. Duration of use should be 5 days. In patients with confirmed penicillin allergy, clindamycin should be avoided due to its association with Clostridioides difficile (C difficile) infection. The Choosing Wisely Canada toolkit “Taking the Bite Out of Tooth Pain”¹ gives succinct information and resources for clinicians and patients to help avoid inappropriate antibiotic use.

Evidence

Dental pain is commonly seen in nondental settings. In Canada, about 1% of annual emergency department (ED) visits are for patients with the primary diagnosis of nontraumatic dental condition (NTDC).² In Ontario, on average, 70,274 visits to physicians and 51,861 to EDs are made each year for NTDCs.³

Dental pain is most commonly caused by irreversible pulpitis, occurring when the enamel and inner dentin of the tooth are destroyed, allowing bacteria to invade the vascularized pulp. The passage of microbial antigens into the confined periapical space causes inflammation (pulpitis) and acute pain. The cortical plate of the alveolar bone may erode, causing a localized periapical abscess. Treatment at this stage is a dental procedure—either root canal therapy or extraction—and if present, incision and drainage of a fluctuant abscess, and pain management.⁴

Antibiotic therapy is not indicated unless infection spreads into the tissue of the head and neck, marked by facial swelling, lymphadenopathy, or fever.⁴ There is no compelling evidence that adjunct antibiotics in combination with appropriate source control reduces pain, swelling, or analgesic use.⁵ A recent Cochrane review found no studies that examined the effect of antibiotics on their own, without dental treatment, for periapical abscess.⁶

Inappropriate antibiotic use to treat dental conditions in outpatient settings by dentists and physicians has been well documented in Canada and internationally.^7,8 Much of the Canadian data comes from British Columbia (BC), where concerning and escalating antibiotic prescribing by dentists was reported, including overuse of clindamycin.⁹ Clindamycin poses an increased risk of C difficile infection: 17 times above baseline, 6 times higher than for penicillins, and 4 times higher than for cephalosporins.¹⁰ Outpatient prescribing data for physicians in BC from 2000 to 2018 compared observed and expected rates of antibiotic prescribing for various conditions.² For adult patients (≥19 years), dental infections received the highest rate of unnecessary antibiotic prescription (56%); this increased to 76% in emergency care.² Although dental conditions are estimated to account for only about 1% of medical prescribing,² physicians have a key role to play in decreasing dental antibiotic prescribing.¹¹

There is a strong association between antibiotic overprescribing and subsequent antimicrobial resistance.¹² Antibiotics can lead to acute adverse patient events and outcomes, including drug allergies, and long-term complications associated with disturbed microbiota.¹³ Since toothache is a common problem, with nearly 1 in 4 adult Canadians self-reporting persistent mouth pain,¹⁴ it is an area where overprescribing should be reduced.

There are many drivers of overuse in health care, including but not limited to the practice environment, culture of professional medicine, culture of health care consumption, and individual patient and clinician factors.¹⁵ Two common drivers are time constraints and patient expectations. Practices with higher daily patient volumes have statistically significantly higher rates of antibiotic prescribing¹⁶ and there is a perception that counselling patients on symptom management is considerably more time consuming than prescribing an antibiotic.¹⁷ Patient expectations can drive overprescribing, in particular with dental pain, where many patients do not have a dentist, cannot afford dental care, or do not have access to emergency dental care.¹⁸ The Canadian Oral Health Survey-Cycle 1, 2023-2024, showed that nearly 25% of Canadians avoided dental care due to cost,¹⁹ including those who had insurance but could not afford co-payments.²⁰ This was greater for young women aged 18 to 34 years (38%) and racialized persons (33%).¹⁹

Approach

“Taking the Bite Out of Tooth Pain”¹ is a useful toolkit for family physicians that uses a standardized approach to patient management. It advises that patients who present with pain with or without a localized abscess should not be prescribed antibiotics and should be referred to a dentist for definitive diagnosis and management. Pain management until dental care is available is appropriate.

When the infection has spread beyond the local area of the tooth root to adjacent tissues, to deep spaces of the head and neck, as evidenced by cellulitis in the oral, facial, or neck tissues, or there are systemic signs of infection, patients require antibiotic therapy and urgent referral to a dentist. A sign of more serious disease is bilateral swelling of the floor of the mouth. This is an important indicator of Ludwig angina, a cellulitis usually arising from an infected lower molar, that can rapidly progress to cause airway obstruction. These patients should be immediately referred to the ED for assessment and intravenous antibiotic therapy.

Antibiotic guidelines (Table 1^1,21-25) suggest amoxicillin or penicillin V potassium for patients without a reported penicillin allergy. For patients with a suspected allergy, the PEN-FAST calculator (https://www.mdcalc.com/calc/10422/penicillin-allergy-decision-rule-pen-fast) can be used for rapid assessment of low-risk reported allergies. Cefuroxime should be prescribed if substantial allergy has not been ruled out. Cefuroxime is also recommended for patients who report prior severe immediate-type reaction, while azithromycin combined with metronidazole is reserved for patients with severe delayed reactions or immediate-type reported cephalosporin allergy.

Table 1.

Antibiotic guidelines: Standardized approach for stable adult outpatients with tooth pain and systemic signs of infection, when antibiotic treatment is recommended.

CONDITION	ANTIBIOTIC TREATMENT
No reported allergy to penicillin, ampicillin, or amoxicillin	500 mg oral amoxicillin every 8 h for 5 days OR 600 mg oral penicillin V potassium every 6 h for 5 days21,22
Nonsevere reported allergy to penicillin, ampicillin, or amoxicillin (eg, uncomplicated rash, itching, nausea, vomiting, diarrhea)23	Implement PEN-FAST* calculator to rule out allergy. If allergy cannot be ruled out: 500 mg oral cefuroxime† every 12 h for 5 days22,24
Severe reported allergy to penicillin, ampicillin, or amoxicillin
Immediate-type reaction (ie, hives, wheeze, shortness of breath, anaphylaxis)24	500 mg oral cefuroxime† every 12 h for 5 days22,24
Other severe reaction to penicillin (eg, delayed-type reactions like Stevens-Johnson syndrome, toxic epidermal necrolysis, or drug reaction with eosinophilia and systemic symptoms) OR severe allergy to other β-lactam (eg, immediate-type reaction to cephalosporin)22,24	Azithromycin (oral loading dose of 500 mg on day 1, followed by 250 mg for an additional 4 days) and 500 mg oral metronidazole every 12 h for 5 days22,24

^*The PEN-FAST calculator is available from https://www.mdcalc.com/calc/10422/penicillin-allergy-decision-rule-pen-fast.

^†Considered non–cross reactive with penicillin.²⁴

Table adapted under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International Licence²⁵ with permission from Choosing Wisely Canada.¹ Copyright Choosing Wisely Canada, 2026.

Patient engagement tools from Choosing Wisely Canada such as an educational poster, toothache prescription—similar to the viral prescription for upper respiratory infections—and a frequently asked questions sheet can help support patients.²⁶ The educational poster contains the key message that antibiotics will not cure most toothaches. Patients can be reassured by physicians explaining that inflammation, not infection, is causing the pain and the best approach is to use anti-inflammatory measures such as compresses, rest, avoidance of chewing, and saltwater rinses. The toothache prescription (Figure 1^1,27) focuses on relieving symptoms rather than using antibiotics. It is a visual reinforcement of the message that antibiotics will not work and is a quick-reference guide for patients to use after they leave the office, providing information about their condition, the recommended course of action to treat symptoms, and next steps. Importantly, it instructs the patient to seek dental assessment and definitive treatment and serves as communication between the physician and the dentist.

Figure 1.

Toothache prescription

Conclusion

Family physicians often see patients with tooth pain and need an approach to management. Most patients have an inflammatory, not infectious, process and pain management and referral to a dentist is appropriate—without use of antibiotics. Best patient management and changing the culture of expectation of antibiotics will require patient and clinician education and collaboration between dentists and physicians.

Choosing Wisely Canada is a campaign designed to help clinicians and patients engage in conversations about unnecessary tests, treatments, and procedures and to help physicians and patients make smart and effective choices to ensure high-quality care is provided. To date there have been 13 family medicine recommendations, but many of the recommendations from other specialties are relevant to family medicine. Articles produced by Choosing Wisely Canada are on topics related to family practice where tools and strategies have been used to implement one of the recommendations and to engage in shared decision making with patients. If you are a primary care provider or trainee who has used Choosing Wisely recommendations or tools in your practice and you would like to share your experience, please contact us at info@choosingwiselycanada.org.