Severe toothache? The role of antibiotics in dental neuralgia

Toothache (dental neuralgia) is one of the most intense types of pain that can occur in the oromaxillofacial region (the head and neck area) and is often a dental emergency. 

However, the concept of “toothache” is a very broad one, as its manifestations can vary greatly, and the causes are equally diverse. 

Generally, dental conditions, although they present similarly (through pain), have different causes, which is why treatments also differ. The administration of antibiotics is reserved for cases where there is an infection that has been clinically and paraclinically diagnosed and is clearly evident. 

In this article, Dr. Diana Hîrjanu, a resident in Prosthodontics, explains what dental neuralgia is, what causes it and what treatment options are available.

“In order to make a correct diagnosis, it is very important for us, as dentists, to know the type of pain and how long it has been present.” – Dr. Diana Hîrjanu

Toothache can have various causes, ranging from inflammation or infection to nerve disorders, and recognising the symptoms is essential for an accurate diagnosis.

Deep tooth decay

The pain caused by early-stage tooth decay is localised to a single tooth and is short-lived (lasting a few minutes). It may be a response to a trigger, such as sweet or cold foods. 

When tooth decay remains untreated and develops into deep decay, the pain will become much more severe.

“The pain caused by tooth decay is a warning sign that should prompt the patient to see a dentist, as it is an irreversible process,” explains Dr. Diana Hîrjanu.

Tooth pulpitis

Untreated tooth decay can lead to an infection of the nerve (dental pulpitis). In this case, the pain is throbbing, severe, lasts for several hours and is not relieved by standard anti-inflammatories. 

In the early stages, there are no general symptoms such as fever or swelling of the area, but as the condition goes untreated, a pus-filled abscess may develop, along with swelling of the area and a general deterioration in health, including fever and chills. 

“If action is taken quickly, local treatment may be sufficient. The area is cleaned, the pulp chamber is irrigated with antiseptic substances, and root canal treatment is carried out. If an abscess has already formed, requiring intraoral drainage (an incision in the oral cavity), and symptoms such as fever and marked swelling of the area are present, then a course of antibiotics for at least 5 days is necessary, in conjunction with local treatment.” – Dr. Diana Hîrjanu

Periapical granuloma (infection at the tip of the tooth root)

This is a common condition that generally occurs at the tips of the roots of teeth that have already undergone root canal treatment, particularly in those with incomplete endodontic treatment or that have not been fitted with dental crowns.

Generally, this type of condition goes unnoticed by the patient, as it is asymptomatic. Sometimes, there may be sensations of ‘dull’, non-specific pain that is difficult to localise to a single tooth. In advanced stages, fistula formation may occur, whereby the purulent collection travels through the bone and emerges into the oral cavity (towards the cheek, the palate or the tongue). 

“In early, asymptomatic stages, root canal retreatment is recommended, followed by close monitoring and radiological reassessment at 6 and 12 months. In advanced stages, with marked bone loss around the root, tooth extraction is necessary, followed by the insertion of an implant.” – Dr. Diana Hîrjanu

Periodontal abscess 

This is a localised infection in the gum, within an untreated periodontal pocket. Often, food debris accumulates in the interdental spaces, which cannot be removed, leading to infection. 

The pain is throbbing in nature, but not as severe as that caused by pulpitis. Treatment is generally local, involving curettage and rinsing with antiseptic solutions, without the need for antibiotics. 

Any discomfort or toothache should be a reason to visit the dentist. Generally speaking, dental conditions that are diagnosed and treated early minimise risks and complications. 

An emergency is characterised by throbbing, severe pain that radiates to surrounding areas and is accompanied by general symptoms such as a general feeling of being unwell, fever and chills.

Antibiotics are not the first-line treatment for dental neuralgia. 

The pain is relieved by anti-inflammatory and analgesic medication, as well as by local treatment (drainage, irrigation and endodontic treatment). 

The sole role of antibiotics is to treat the infection.

In Romania, self-medication with antibiotics is common. A study carried out in 2025 revealed that 20% of those surveyed had self-administered antibiotics without a prescription for various ailments. 

What are the risks of self-medicating with antibiotics:

1. It fosters antibiotic resistance. The bacteria living in our bodies ‘get used’ to the presence of antibiotics in the blood and become resistant to them. Consequently, in the event of a genuine infection, standard antibiotics may no longer be effective.
2. In the case of a dental problem, taking antibiotics can help mask the symptoms without resolving the underlying issue. 

The only treatments that truly provide relief from toothache are those carried out correctly by a dentist:

1. Root canal treatment;
2. Abscess drainage;
3. Tooth extraction.

Antibiotic and anti-inflammatory treatments are merely supportive.  

It is important to understand that an antibiotic is not a painkiller (it does not directly relieve pain), but rather targets the source of the infection that is putting pressure on the nerve and surrounding tissues.

• The first 24 hours – Usually, no major change is felt. The concentration of the antibiotic in the blood and in the infected tissue is only just beginning to rise.
• After 48 hours (2 days) – This is the period when most patients feel a reduction in throbbing and pressure. The swelling begins to subside, which significantly reduces the pain.
• After 72 hours (3 days) – The infection should be under control, and the pain should be minimal or have disappeared completely.

However, it is very important to understand that the pain may return if the tooth is not treated and that antibiotics do not replace local dental treatment.