Management

Diagnose the cause of pain and determine a suitable management strategy. The Diagnosis and management of dental pain or infection flowchart illustrates this process for a child with no medical complications. 

• Each patient should also receive an oral health assessment which may be carried out before or after diagnosis and management of pain, depending on its severity.

For primary molars, it may be possible to retain those with pulpitis with irreversible symptoms using pulpotomy rather than extraction. Therefore, consider this treatment option if the child is cooperative. 

For primary molars, where a radiograph shows no clear separation between the carious lesion and the dental pulp, consider carrying out a pulpotomy (see Pulpotomy for primary teeth). 

• It is possible that the carious lesion has encroached significantly on the dental pulp causing irreversible pulpal disease.

For both primary and permanent teeth, where there are symptoms of pain that may be due to food packing or pulpitis with reversible symptoms but the diagnosis is uncertain, place a temporary dressing and review the patient 3-7 days later to check symptoms. 

• Resolution of the symptoms at review will indicate that the pulpitis was reversible and a suitable restoration or crown can be placed. 

If symptoms do not resolve, worsen or an abscess develops then for primary teeth consider extraction or appropriate pulp therapy (pulpotomy or pulpectomy; see Primary tooth - pain or infection) and for permanent teeth a pulpotomy, pulpectomy/root canal therapy or an extraction (see Permanent tooth - pain or infection).

Do not leave dental infection untreated. 

• In some cases, local measures to bring the infection under control may be appropriate (see Local measures).
• Antibiotics are not recommended unless there are signs of spreading infection or systemic symptoms.
• In primary teeth, extraction may be the best option, but in certain circumstances consider referral for pulpectomy (see Primary tooth - pain or infection).

If dental infection is asymptomatic and the child is presently unable to cope with an extraction but judged to be likely to accept treatment with acclimatisation, then, allow up to three months for acclimatisation visits using active behaviour management techniques.

• This approach is not suitable for medically compromised children.

If a child is pre-cooperative or unable to cooperate (due to young age, a learning disability or where behaviour management techniques have been unsuccessful), has multiple affected teeth or the dental infection becomes symptomatic, consider referral to assess suitability for extractions under sedation or general anaesthesia (see Referral).