Acute dental pain in children can stem from various conditions, such as extractions, pulpitis, or apical abscesses. Managing this pain effectively is crucial for improving the child’s comfort and reducing distress for both the patient and their caregivers. Recent clinical practice guidelines developed in 2023 by the American Dental Association,1 in collaboration with leading institutions, emphasize the use of evidence-based, non-opioid strategies to manage acute dental pain in children under 12 years of age. These recommendations aim to minimize the risks associated with opioids while providing effective pain relief tailored to the pediatric population.
Scope of the guidelines
The guidelines address two primary clinical scenarios:
1. Postoperative pain management for simple and surgical tooth extractions.
2. Temporary pain management for toothaches associated with conditions such as symptomatic pulpitis or acute apical abscess, particularly when definitive treatment (e.g., root canal therapy or extractions) is delayed.
By applying a structured framework, these recommendations guide clinicians in selecting safe and effective pharmacologic therapies that align with best practices and patient-specific factors.
Key recommendations for pain management
Postoperative pain:
- First-line therapy: Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen (children >2 years of age), are recommended as the preferred option for managing postoperative dental pain.
- Combination therapy: For enhanced pain control, NSAIDs can be combined with acetaminophen. Evidence supports that this combination is more effective than either medication alone.
- When NSAIDs are contraindicated: Use acetaminophen alone as a safe alternative.
- Caution: Although long-acting local anesthetics like bupivacaine can effectively manage postoperative pain in adults, their use is not recommended in children or individuals with physical or intellectual disabilities due to the heightened risk of self-inflicted injuries, such as lip biting, as advised by the American Academy of Pediatric Dentistry.
Temporary pain relief for toothaches:
- Similar to postoperative pain management, ibuprofen or naproxen used alone or in combination with acetaminophen is effective to temporarily manage pain until definitive treatment is possible. If NSAIDs are contraindicated, use acetaminophen alone.
- Caution: Avoid topical benzocaine products for teething pain in children younger than two years due to risks of methemoglobinemia, as advised by the Food and Drug Administration.
Avoidance of opioids:
- Opioids, such as codeine and tramadol, are contraindicated in children under 12 years due to the risk of severe adverse effects, including respiratory depression and death. These medications are no longer recommended in pediatric dental care.
Practical implications for general dentists
Individualized pain assessment:
Before prescribing analgesics, assess the child’s pain using age-appropriate, validated tools such as the Behavioural Scale (1-3 years), Faces Scale (> 3 years), Visual Analog Scale (> 8 years), or the Numerical Rating Scale (> 8 years). Caregivers should be counselled that some discomfort is normal, and the goal of treatment is to make the pain manageable, not to eliminate it.
Dosage and administration:
Table 1: Medication dosage for acute dental pain in pediatrics
| Age | Weight | Dosage (mg) | |
| Ibuprofen (suspension, tablet)a | kg | lb | |
| 6-11 mo | 5.4-8.1 | 12-17 | 50 |
| 12-23 mo | 8.2-10.8 | 18-23 | 75 |
| 2-3 y | 10.9-16.3 | 24-35 | 100 |
| 4-5 y | 16.4-21.7 | 36-47 | 150 |
| 6-8 y | 21.8-27.2 | 48-59 | 200 |
| 9-10 y | 27.3-32.6 | 60-71 | 250 |
| 11 y | 32.7-43.2 | 72-95 | 300 |
| Acetaminophen (suspension, tablet, oral disintegrating tablet, rectal suppository)b | |||
| 0-3 mo | 2.7-5.3 | 6-11 | 40 |
| 4-11 mo | 5.4-8.1 | 12-17 | 80 |
| 1-2 y | 8.2-10.8 | 18-23 | 120 |
| 2-3 y | 10.9-16.3 | 24-35 | 160 |
| 4-5 y | 16.4-21.7 | 36-47 | 240 |
| 6-8 y | 21.8-27.2 | 48-59 | 320 |
| 9-10 y | 27.3-32.6 | 60-71 | 400 |
| 11 y | 32.7-43.2 | 72-95 | 480 |
| Naproxen/Naproxen sodium (suspension, tablet)c | |||
| >2y | <60 | <132 | 5-6 per kg |
| >2y | >60 | >132 | 250-375 |
| A. Ibuprofen dosing every 6-8h as needed, max daily dose of 40 mg/kg | B. Acetaminophen dosing every 4-6h as needed, max daily dose of 75mg/kg | C. Naproxen dosing every 12h as needed, max daily dose of 1000mg (naproxen) or 1100mg (naproxen sodium) |
- Ensure that doses are calculated based on the child’s weight, not just their age, to avoid overdosing or underdosing.
- Ibuprofen recommended dosages typically range between 4-10 mg/kg every 6–8 hours as needed (single dose not exceeding 400mg), with a maximum daily dose of 40 mg/kg.
- Acetaminophen dosages range from 10-15 mg/kg every 4-6 hours, with a maximum daily dose of 75mg/kg or 4,000 mg.
- Naproxen (only for children >2 years of age) dosage ranges from 5-6 mg/kg every 12 hours, with a maximum daily dose of 1000 mg for naproxen and 1100 mg for naproxen sodium.
– Naproxen sodium is preferred due to its faster onset, higher peak concentration, and lower incidence of adverse drug events.
Caregiver education:
Educate parents or guardians on the importance of closely following prescription instructions. Misuse, even of over-the-counter medications, can lead to significant complications, such as hepatotoxicity with acetaminophen or gastrointestinal issues with NSAIDs.
Long-term safety and efficacy considerations:
The guidelines stress the importance of avoiding unnecessary pharmacologic treatments. Not all extractions or dental procedures require analgesics. Encourage nonpharmacologic interventions, such as applying cold compresses, to complement medication and reduce reliance on analgesics.
The guideline panel also emphasizes the need for ongoing research into pediatric pain management, particularly to explore safer and more effective options for children. Addressing gaps in data, such as the effects of corticosteroids in young patients, will further refine clinical recommendations and enhance patient outcomes.
Conclusion
As frontline providers in pediatric dental care, general dentists play a pivotal role in balancing effective pain management with patient safety. By adopting these evidence-based recommendations, clinicians can confidently manage acute dental pain while reducing the risks associated with opioids. These guidelines empower dentists to provide high-quality, compassionate care that aligns with the best interests of their youngest patients and their families. 
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References
- Carrasco-Labra, A., et al. (2023). Evidence-based clinical practice guideline for the pharmacologic management of acute dental pain in children: A report from the American Dental Association Science and Research Institute, the University of Pittsburgh School of Dental Medicine, and the Center for Integrative Global Oral Health at the University of Pennsylvania. The Journal of the American Dental Association, 154(9), 814-825.e2. https://doi.org/10.1016/j.adaj.2023.06.014
About the author
Dr. Taher was raised in St. John’s, Newfoundland and Labrador. He pursued a Bachelor of Science in Biochemistry at Memorial University before pursuing his dental education at Dalhousie University in Halifax, Nova Scotia. He graduated with a Doctor of Dental Surgery degree in 2022 and subsequently completed a General Practice Residency (GPR) at Mount Sinai Hospital in Toronto. During his GPR, Dr. Taher developed a strong interest in caring for patients with special needs and significant medical complexities, which ultimately led him to pursue advanced training in dental anesthesiology. He is currently the senior resident of the Dental Anesthesiology program at the University of Toronto.