It all begins with the phone call: "I’m in terrible pain. I need an appointment ASAP to see the doctor."

managing a patient with toothache

Often we get these calls in the middle of a busy day. Managing patients with acute pain is a crucial cornerstone of most dental practices and this needs to be done methodically, consistently and efficiently every time.

If all aspects of the workflow were to go right, what would that look like? Let's examine the steps behind diagnosis and treatment of a case of acute irreversible pulpitis.

1. ​Gathering information on the patient's condition

The front desk person has to listen with empathy, gather all the required information from the patient and then schedule the most appropriate appointment time.

  • Capture and record the patient's chief complaint in his or her exact words
  • Location, severity and trigger factors of patient's pain
  • New forms or updates to medical and dental history if they are current patients
  • Ask: Does the patient need medicine before this appointment?
  • Help the patient understand financial/paperwork obligations for the visit

2. ​Preliminary evaluation

The assistant reviews all the information. When she seats the patient in the chair, she narrates to them what she knows about the problem. Then she LISTENS to the patient's story.

  • Get an intraoral image of the tooth/quad
  • When the dentist is in the room, narrate the findings. Start by saying the patient's name and then stating the chief complaint in their words
  • Begin the appropriate notes in the chart 

3. Clinical exam checklist

  • Evaluation of soft tissue: Inflammation, swelling or draining fistula
  • Evaluation of teeth: Defective restorations, cracks, decay or fracture
  • Perio-probing: Walk the probe around the circumference of suspect teeth
  • Periapical test by palpation and percussion of all the teeth in the quad and the opposing quad
  • Bite stick test to check for cracked tooth syndrome
  • Pulpal health: Check control teeth and then suspect tooth with Cold test. If results are inconclusive, an Electric Pulp Test can help supplement the diagnosis
  • Radiographic evaluation

4. ​Controlling tooth pain

If the patient is in significant pain, it helps to get it under control with a local anesthetic right away. This option is offered to the patient.

  • Local anesthetic block injection.
  • If patient has not taken a pain medication in the last four hours, offer the appropriate OTC pain medication.

Blocking the transmission of pain to the CNS by giving local anesthesia will help the sensitized central pain receptors to return to normalcy. In addition, ibuprofen combined with acetaminophen helps relieve pain and reduce the local mediators of inflammation.

5. Communicating the diagnosis and treatment plan

With the acute pain in control, the patient is in the right frame of mind to now hear the diagnosis. The following need to be addressed:

  • Diagnosis
  • Endodontic Tx plan
  • Restorative Tx plan
  • Pain management plan

6. ​Initiating most effective, immediate treatment for toothache

In this situation, pulpectomy would be the most ideal immediate treatment.

  • Check adequate anesthesia on the tooth with a Cold Test.
  • If needed, supplement with 4 percent articaine infiltration.
  • Additional long acting anesthesia given as a block helps ensure adequate pain control.
  • Create a small access hole into the pulp chamber and place intra pulpal anesthesia. Keeping the access hole small helps create backpressure, which is necessary for successful intra pulpal injections.
  • Complete pulpectomy under rubber dam.
  • Occlusal reduction.

7. ​Post-pulpectomy home care

Patient is instructed to take the analgesic every four to six hours for the first few days. This allows for consistent blood level of the drug and ensures consistent pain relief. Prescription pain medications follow a flexible protocol. This provides the best pain control with minimal side effects.

  • If the patient can take them, maximize the NSAID dose (i.e 600mg of Ibuprofen q6h).
  • Add acetaminophen if additional pain control is needed.
  • Give the patient the option of narcotic medications, which can be taken in place of acetaminophen if additional pain control is needed.
  • Antibiotics are only needed in selective cases when there is swelling.

8. ​Following up after treatment

A follow-up call that night or the next day goes a long way in ensuring patient comfort and is a great practice builder. Following these eight steps, you can consistently expect successful results.

Vivek Mehta DMD, FAGD, Visiting Faculty, Spear Education. Follow him on Twitter @Mehta_DMD.


Commenter's Profile Image Dr. Sonalika Rungta
October 11th, 2012
Vivek, That was a great article. I know you from the new england master track. Dr Rungta DMD
Commenter's Profile Image Vivek
October 11th, 2012
@Dr. Rungta: Thank you for the compliment.Since you liked the info, I would like to mention the following reference : Hargreaves KM, Keiser K. New advances in the management of endodontic pain emergencies. J Calif Dent Assoc. 2004 The article can be accessed via this link Great information. It explains the rationale of most of the ideas discussed in the article above.
Commenter's Profile Image Nelson E. Smith
April 15th, 2013
Always good to refresh with great information. A great read!
Commenter's Profile Image Ed Lipskis
July 5th, 2013
Great review for pain that turns out to be odontogenic/perio in origin (which it will be 95% of the time). There are Chronic pain patients with referral patterns that go to teeth. Every dentist that treats orofacial or craniofacial pain has seen patients who have ended up with endo on teeth that were the place the patient FELT the pain, but were not the origin of the pain. The sternocleidomastoid, the temporalis, and many other sites refer pain to various teeth. If you numb these (frequently trigger point) areas, the dental pain goes away. Even if root canal therapy is done perfectly in these situations, the perceived dental pain does not diminish. Dr. Janet Travel has the definitive text on this topic. Dentists should be careful about starting procedures on patients in whom the diagnosis seems questionable without having chronic pain issues evaluated.
Commenter's Profile Image Nita Gupta
July 7th, 2013
Thanks Vivek A good capture of relevant points for diagnosis of a simple TOOTHACHE ! How much time do you keep available on a regular day for such emergencies? Nita
Commenter's Profile Image Vivek Mehta
July 7th, 2013
Nita: Usually I like to have about 30 minutes for a toothache emergency
Commenter's Profile Image Vivek Mehta
July 7th, 2013
Ed: Thank you for your comments. You raise some good points.