Drugs used for tooth ache
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Drugs Used for Toothache (Odontalgia)
Toothache most commonly results from pulpitis, dental abscess, periradicular periodontitis, or cracked tooth syndrome. Drug management addresses pain relief, infection control, and temporary local anesthesia. Definitive care always requires a dentist.
1. Analgesics (First-Line for Pain Relief)
NSAIDs - Preferred First Choice
The American Dental Association recommends NSAIDs over narcotics for dental pain because they offer the most favorable balance between pain reduction and potential harms.
| Drug | Dose (Adult) | Notes |
|---|---|---|
| Ibuprofen | 400-600 mg every 6-8 hrs | Most commonly used; anti-inflammatory + analgesic |
| Naproxen sodium | 250-500 mg every 8-12 hrs | Longer duration |
| Ketorolac | 10 mg PO or 15-30 mg IM | Short-term use, max 5 days; useful in ED |
| Diclofenac | 50 mg every 8 hrs | Good anti-inflammatory |
NSAIDs are especially effective because dental pain has a strong inflammatory component (prostaglandin-mediated).
Acetaminophen (Paracetamol) - Adjunct
- Dose: 500-1000 mg every 4-6 hrs (max 4 g/day)
- Combines well with ibuprofen for additive analgesia - this combination often outperforms either drug alone
- Recommended when NSAIDs are contraindicated (peptic ulcer, renal impairment)
- The ADA recommends NSAIDs ± acetaminophen as adjunct, preferred over narcotics
Tintinalli's Emergency Medicine, p. 1623: "NSAIDs with or without supplemental acetaminophen are preferred over opiates by the American Dental Association for pain relief."
Opioids - Reserved for Severe/Refractory Pain
Used only when NSAIDs + acetaminophen are insufficient or contraindicated:
| Drug | Notes |
|---|---|
| Codeine | Weak opioid; often combined with paracetamol (co-codamol) |
| Tramadol | Mild-moderate; used short-term when other options fail |
| Hydrocodone / Oxycodone | For severe pain post-extraction or abscess; short course only |
| Morphine | Usually reserved for hospitalized patients |
- Risk of dependence means opioids should be prescribed sparingly and for the shortest duration possible.
2. Local Anesthetics (Temporary but Highly Effective)
Used in the emergency setting or at the dentist for immediate, reliable pain relief:
| Agent | Route | Notes |
|---|---|---|
| Lidocaine (viscous 2%) | Topical in cavity | Applied directly onto tooth or saturated cotton ball in cavity; temporary - do not exceed total dosage |
| Benzocaine | Topical gel (OTC) | Common OTC oral gel; applied to gum; onset ~1 min |
| Lidocaine + epinephrine | Inferior alveolar nerve block | Gold standard in ED/dental office for mandibular pain |
| Articaine, bupivacaine | Dental injection | Used by dentists for longer procedures |
Roberts and Hedges' Clinical Procedures in Emergency, p. 1564: "Another simple method of pain management is to apply viscous lidocaine directly onto the tooth or saturate a small cotton ball with the gel and place it in a cavity."
3. Topical / Home Remedies with Evidence Base
| Agent | Mechanism | Notes |
|---|---|---|
| Clove oil (Eugenol) | Natural phenylpropanoid; analgesic + mild antiseptic | Saturate cotton, apply directly to cavity or gum; relief for ~2-3 hrs; do NOT use repeatedly (risk of nerve damage) |
| 2-Octylcyanoacrylate (tissue adhesive/Super Glue) | Seals exposed dentin from thermal/air stimuli | Anecdotal evidence; lasts <24 hrs; not FDA-approved for intraoral use |
Roberts and Hedges', p. 1564: "Clove oil (containing eugenol) has been a popular and reasonably effective short-term home remedy for an acute toothache or inflamed gingiva."
4. Antibiotics (For Infected Causes - Abscess, Periapical Infection)
Antibiotics do not treat pain directly but are indicated when infection is present (abscess, cellulitis, spreading odontogenic infection). They are not recommended for uncomplicated pulpitis without signs of infection.
| Drug | Dose | Indication |
|---|---|---|
| Amoxicillin | 500 mg TID x 5-7 days | First-line for dental abscess |
| Penicillin V | 500 mg QID x 5-7 days | Narrow spectrum, good for odontogenic organisms |
| Amoxicillin + Clavulanate | 875/125 mg BID | If beta-lactamase-producing organisms suspected |
| Metronidazole | 400-500 mg TID | Add-on for anaerobic cover; often combined with penicillin |
| Clindamycin | 300 mg TID x 5-7 days | Penicillin-allergic patients; good anaerobic coverage |
| Azithromycin | 500 mg day 1, 250 mg x 4 days | Alternative in penicillin allergy |
Goldman-Cecil Medicine: "Dental abscess - Common pathogens: Streptococci, Bacteroides fragilis - Penicillin + metronidazole."
Note: A 2016 systematic review found insufficient evidence that antibiotics reduce pain in irreversible pulpitis in the absence of obvious infection. Antibiotics should not be prescribed routinely for simple pulpitis.
5. Corticosteroids (Adjunct)
- Dexamethasone (4-8 mg IM/PO) - sometimes used peri-operatively for third molar extractions to reduce postoperative swelling and trismus
- Not used as a standalone for toothache but reduces inflammatory edema
Summary Table by Severity
| Severity | Recommended Drugs |
|---|---|
| Mild | Ibuprofen 400 mg PO; or acetaminophen 500-1000 mg; topical benzocaine/eugenol |
| Moderate | Ibuprofen 600 mg + acetaminophen 1 g (combination); local anesthetic block |
| Severe / Abscess | NSAID + acetaminophen + antibiotics (amoxicillin or clindamycin); nerve block; consider opioid short-course if refractory |
| Post-extraction (dry socket) | Eugenol-impregnated gauze packing + NSAIDs |
Key Takeaway: NSAIDs (particularly ibuprofen) combined with acetaminophen are the mainstay of toothache management. Local anesthetics (nerve blocks, viscous lidocaine) provide the most immediate relief. Antibiotics are only warranted when true infection is present. All pharmacological measures are bridges to definitive dental treatment.
Sources: Tintinalli's Emergency Medicine (9th ed.), p. 1621-1623; Roberts and Hedges' Clinical Procedures in Emergency Medicine, p. 1564; Goldman-Cecil Medicine.
What about nimesulide
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PMID: 24672121
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Nimesulide for Toothache
What Is Nimesulide?
Nimesulide is a sulfonanilide-class NSAID with preferential COX-2 selectivity - it sits in the same COX-2 selectivity bracket as diclofenac and meloxicam, intermediate between traditional NSAIDs (like ibuprofen) and the full coxibs (like rofecoxib). It is not available in the USA but is widely used in India, Italy, Portugal, Brazil, and several other countries for acute dental and musculoskeletal pain.
Goodman & Gilman's Pharmacological Basis of Therapeutics: "Some older NSAID compounds - diclofenac, etodolac, meloxicam, and nimesulide (not available in the U.S.) - exhibit selectivity for COX-2 similar to celecoxib."
Mechanism of Action
| Property | Detail |
|---|---|
| Primary action | Preferential inhibition of COX-2 > COX-1, reducing prostaglandin (PGE2) synthesis at the site of dental inflammation |
| COX selectivity level | Intermediate - spares COX-1 more than ibuprofen but less than full coxibs |
| Additional actions | Inhibits neutrophil activation, reduces histamine release, inhibits phosphodiesterase; may have antioxidant properties - all relevant to pulpal/periapical inflammation |
This COX-2 preference is why nimesulide produces good anti-inflammatory and analgesic effects while causing somewhat less GI irritation than non-selective NSAIDs.
Evidence in Dental Pain
A double-blind, randomized, double-dummy trial (Bocanegra et al., 2005 - PMID 24672121) directly compared nimesulide vs. ibuprofen for post-extraction pain after surgical removal of impacted third molars:
| Outcome | Nimesulide 300 mg (once daily) | Ibuprofen 400 mg (every 6 hrs) |
|---|---|---|
| Onset of pain relief | Within 15 min in 52% of patients | Within 15 min in 33% of patients (p=0.03) |
| Pain reduction at 15 min, 45 min, 1 hr | Significantly better than ibuprofen | Lower early relief |
| 24-hour pain control | Effective | Effective |
| Patient-rated effective relief | 82% | 73% (p=0.013) |
| Adverse effects | None reported | None reported |
Key finding: Nimesulide had a faster onset and was rated more effective by patients, with both drugs providing equivalent 24-hour relief. This makes it especially useful for acute dental pain where rapid relief is desired.
Dosing
| Parameter | Details |
|---|---|
| Standard adult dose | 100 mg twice daily (most common) |
| Once-daily formulation | 300 mg once daily (shown effective in dental pain) |
| Maximum duration | 15 days (restricted due to hepatotoxicity risk) |
| Onset of action | ~15-30 minutes |
| Half-life | ~2-5 hours |
| Route | Oral tablets, oral granules/suspension |
Advantages for Dental Pain
- Fast onset - faster than standard ibuprofen at equivalent doses
- Good anti-inflammatory action - effective against pulpitis and periapical inflammation
- Better GI tolerability than non-selective NSAIDs (aspirin, naproxen) due to COX-2 sparing
- Available as granule sachets - dissolves quickly, convenient for patients with jaw pain/trismus
- Often combined with Serratiopeptidase (a mucolytic enzyme) in commercial dental formulations in India for enhanced anti-inflammatory and anti-edematous effect
Risks and Safety Concerns
This is why nimesulide remains controversial and has been banned or restricted in several countries:
Hepatotoxicity (Most Important Risk)
Sleisenger & Fordtran's GI and Liver Disease: "Nimesulide, an NSAID with COX-2 selectivity, has been linked to acute hepatitis and fatal hepatic failure, especially in women, although the overall risk of liver injury is low. Risk factors include increased treatment duration (>30 days) and higher doses."
- Onset: 1-15 weeks (occasionally up to 8 months) after starting
- Pattern: Centrilobular or bridging necrosis, occasionally cholestasis
- Resolution: Usually within 2-17 months after stopping
- Ireland banned it in 2007; Finland withdrew it; EU-wide risk review led to restriction to max 15 days
Other Side Effects
| System | Effect |
|---|---|
| GI | Nausea, dyspepsia (less than non-selective NSAIDs) |
| Renal | Fluid retention, reduced renal blood flow (like all NSAIDs) |
| Cardiovascular | Mild CV risk (intermediate, less than full coxibs) |
| Hypersensitivity | Rash, eosinophilia (especially with hepatic injury) |
Contraindications
- Active liver disease or raised transaminases
- Severe renal impairment
- Children under 12 years (contraindicated - linked to Reye's-like syndrome in early reports)
- Pregnancy (especially third trimester - risk of premature closure of ductus arteriosus)
- History of GI ulcer or NSAID hypersensitivity
- Should not be combined with other hepatotoxic drugs or alcohol
Regulatory Status
| Region | Status |
|---|---|
| India | Available (widely used for dental/acute pain) |
| Italy, Portugal, Greece | Available with restricted indications |
| USA | Not approved/not available |
| UK, Ireland, Finland | Withdrawn |
| EU (remaining countries) | Restricted - max 15 days, contraindicated in liver disease |
Rheumatology (Elsevier, 2022): "Nimesulide is marketed in some countries but has been withdrawn in others."
Bottom Line for Dental Pain
Nimesulide is an effective analgesic for toothache, particularly valued for its fast onset and good anti-inflammatory action. It is a reasonable choice for short-term use (up to 15 days) in adults without liver disease. However, because of hepatotoxicity risk, it should not be the default first choice when ibuprofen + acetaminophen combination (which has a well-established safety record) is adequate. In countries where it is available (like India), it is commonly prescribed by dentists for moderate dental pain, post-extraction pain, and dental abscess-related inflammation - often as nimesulide 100 mg BD for 3-5 days.
Sources: Goodman & Gilman's Pharmacological Basis of Therapeutics; Sleisenger & Fordtran's GI and Liver Disease; Rheumatology (Elsevier, 2022); Bocanegra et al., 2005 [PMID 24672121]
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