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Policy on Pediatric Dental Pain Management

Latest Revision
2022

ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. FDA: U.S. Food and Drug Administration. NSAIDs:
Nonsteroidal anti-inflammatory drugs.

Purpose
The American Academy of Pediatric Dentistry (AAPD) recognizes that children vary greatly in their
cognitive and emotional development, medical conditions, and responses to pain and interventions.
This policy is not intended to provide clinical recommendations, which can be found in AAPD’s best
practice on pain management1; rather, the purpose of this document is to support efforts to prevent or
alleviate pediatric pain and complications from pain medications. Infants, children, adolescents, and
those with special health care needs can and do experience pain; dental-related pain in most patients
can be prevented or substantially relieved. The AAPD further recognizes many therapeutics are
available to treat pain with varying regimens. Recent concerns have developed about toxicities
associated with codeine and the adverse effects of opioid analgesics.

Methods
This policy was developed by the Council on Clinical Affairs, adopted in 20122, and last revised in
20173. This document is an update of the previous version and is based on a review of current dental
and medical literature pertaining to pediatric pain management including a search with PubMed ®/
MEDLINE using the terms: pediatric dental pain management, pediatric pain management, pediatric
postoperative pain management, pediatric analgesic overdose; fields: all; limits: within the last ten
years, humans, all children zero to 18 years, English, clinical trials, and literature reviews. The search
returned 8,031 articles. When data did not appear sufficient or were inconclusive, information included
in this policy was based upon expert and/or consensus opinion by experienced researchers and clinicians.
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Background
Pain assessment is an integral component of the dental history and comprehensive evaluation. A detailed
pain assessment helps the dentist to derive a clinical diagnosis, develop a prioritized treatment plan, and
better estimate analgesic requirements for the patient.4 Assessment of pain indicates the need for
intervention and appropriateness of treatment.4 Assessment of pediatric pain may significantly improve
the patient’s comfort and quality of life.5 Research suggests that undertreatment of pediatric pain can
amplify future pain experience.6 Effective pain management is important in both the short and the
long-term.4 Children with an established dental home have better access for acute and chronic orofacial
pain management. A dental home provides comprehensive care which can assess and manage acute
and chronic oral pain and infection.7

Pain management may range from nonpharmacologic modalities to pharmacological treatment.

Nonpharmacologic therapy includes maintaining a calm environment, encouraging deep breathing, and
employing guided imagery, distraction, play therapy, hypnotherapy, virtual reality, and other (e.g.
acupuncture, transcutaneous nerve stimulation) techniques.1,8 Pharmacologic therapy may consist of
administration of topical and local anesthesia, analgesic medications, and/or mild, moderate, or deep
sedation regimens.8,9 Analgesic selection depends on the individual patient, the extent of treatment, the
duration of the procedure, psychological factors, and the patient’s medical history.10 If moderate to
severe postoperative pain is considered likely, administering an analgesic on a regular schedule for
36 to 48 hours helps to maintain a stable plasma levels of the agent and decreases risk for breakthrough
pain.11,12

Many therapeutics are available for the prevention of pain. Acetaminophen and nonsteroidal anti-
inflammatory drugs (NSAIDs), such as ibuprofen, are considered first line agents in the treatment of acute
mild to moderate postoperative pain.10 Alternating administration of ibuprofen and acetaminophen is
another strategy for pain management in children and may allow lower doses of each individual medication
to be used.11,13,14 Many analgesics have multiple modalities of administration, such as oral, rectal or
intravenous, to accommodate a wide patient population.15 Consideration of these modalities may be
pertinent when treating patients in different environments such as an office-based outpatient setting
versus in the hospital.
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Certain analgesics are contraindicated in the pediatric population due to concerns for toxicity and adverse
reactions. NSAIDs may prolong bleeding time and exacerbate kidney or liver impairment, and
acetaminophen overuse may be associated with hepatotoxicy.10,16 Aspirin-containing analgesics are
contraindicated for pediatric pain management in most situations because, if administered during a viral
illness, the potential exists for a serious condition known as Reye syndrome, a condition that causes
swelling of the liver and brain.15 Although opioid analgesics can be effective for moderate to severe
postoperative pain, there are potential adverse effects (e.g., nausea, emesis, constipation, sedation,
respiratory depression) and diversion.13,17,18 From 2006 to 2018, the opioid dispensing rate for the
pediatric population steadily decreased.19 Persistent opioid use among children and adolescents is a
major concern and represents an important pathway to opioid misuse.20 A 2013 systematic review
found a combination of acetaminophen and ibuprofen provided effective analgesia without the adverse
side effects associated with opioids; the combination of acetaminophen and ibuprofen was shown to be
more effective in combination than either medication alone.14 In 2017, the United States Food and
Drug Administration (FDA) issued a warning to restrict the use of codeine and tramadol in children
and breastfeeding mothers.21

Policy statement
The AAPD recognizes that pediatric dental patients may experience pain as a direct result of their oral
condition or secondary to invasive dental procedures. Inadequate pain control has the potential for
significant physical and psychological consequences, including altering future pain experiences for
these children. Furthermore, pharmacologic agents used in pediatric pain management have potential
for toxicity and adverse reactions, with narcotics at risk for diversion to unintended recipients.
Therefore, the AAPD encourages:
 healthcare professionals to emphasize preventive oral health practices and to implement safe
and effective pre-, intra-, and post-operative approaches to minimize the patient’s risk for pain.
 healthcare practitioners to follow evidence-based recommendations regarding analgesic use by
pediatric patients to minimize untoward reactions and potential for substance misuse.
 additional research to determine safe and effective treatment modalities for acute pain.

References
1. American Academy of Pediatric Dentistry. Pain management in infants, children, adolescents, and
individuals with special health care needs. The Reference Manual of Pediatric Dentistry. Chicago,
Ill.: American Academy of Pediatric Dentistry; PENDING.
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2. American Academy of Pediatric Dentistry. Policy on pediatric pain management. Pediatr Dent
2012;34(special issue):74-5.
3. American Academy of Pediatric Dentistry. Policy on acute pediatric dental pain management. Pediatr
Dent 2017;39(6):99-101.
4. De Leeuw R, Klasser G. American Academy of Orofacial Pain: Guidelines for Assessment, Diagnosis
and Management. 6th ed. Hanover, Ill.: Quintessence Publishing; 2018: 26-49.
5. Zielinksi J, Morawska-Kochman M, Zatonski T. Pain assessment and management in children in the
postoperative period: A review of the most common postoperative pain assessment tools, new
diagnostic methods and the latest guidelines for postoperative pain therapy in children. Adv Clin
Exp Med 2020;29(3):365-74.
6. Cramton R, Gruchala NE. Managing procedural pain in pediatric patients. Curr Opin Pediatr 2012;
24:530-8.
7. American Academy of Pediatric Dentistry. Policy on the dental home. The Reference Manual of
Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; PENDING.
8. Lee GY, Yamada J, Kyololo O, Shorkey A, Stevens B. Pediatric clinical practice guidelines for
acute procedural pain: A systematic review. Pediatr 2014;133(3):500-15.
9. American Academy of Pediatric Dentistry. Use of local anesthesia for pediatric dental patients. The
Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry;
Pending.
10. Laskarides C. Update on analgesic medication for adult and pediatric dental patients. Dent Clin
North Am 2016;60(2):347-66.
11. Chou R, Gordon DB, de Leon-Cassola OA, et al. Guidelines on the management of postoperative pain.
Management of postoperative pain: A clinical practice guideline from the American Pain Society,
American Society of Regional Anesthesia and Pain Medicine, American Society of Anesthesiologists’
Committee on Regional Anesthesia, Executive Committee, and Administrative Counsel. J Pain
2016;17(2):131-57.
12. Sutters KA, Miaskowsk C, Holdridge-Zeuner D, et al. A randomized clinical trial of the efficacy of
scheduled dosing of acetaminophen and hydrocodone for the management of postoperative pain in
children after tonsillectomy. Clin J Pain 2010;26(2):95-103.
13. Liu C, Ulualp SO. Outcomes of an alternating ibuprofen and acetaminophen regimen for pain relief
after tonsillectomy in children. Ann Otol Rhinol Laryngol 2015;124(10):777-81.
14. Moore PA, Hersh EV. Combining ibuprofen and acetaminophen for acute pain management after
third-molar extractions. J Am Dental Assoc 2013;144(8):898-908.
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15. Ruest C, Anderson A. Management of acute pediatric pain in the emergency department. Curr Opin
Pediatr 2016;28(3):298-304.
16. U.S. Food and Drug Administration. Drug Safety Communication: Prescription acetaminophen
products to be limited to 325 mg per dosage unit; boxed warning will highlight potential for severe liver
failure. Available at:”https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-
communication-prescription-acetaminophen-products-be-limited-325-mg-dosage-unit”. Accessed
March 15, 2022.
17. Yaksh TL, Wallace MS. Opioids, analgesia and pain management. In: Brunton LL, Chabner BA,
Knollmann BS, eds. Goodman and Gilman’s the Pharmacological Basis of Therapeutics. 12th ed.
New York, N.Y.: McGraw-Hill; 2010:481-526.
18. Dionne R, Moore PA. Opioid prescribing in dentistry: Keys for safe and proper usage. Contin Educ
Dent 2016;37(1):29-32; quiz 34.
19. Renny MH, Yin SY, Jen V, Hadland SE, Cerda M. Temporal trends in opioid prescribing practices
in children, adolescents, and younger teens in the US from 2006 to 2018. JAMA Pediatrics.
2021:175(10):1043-52.
20. Harbaugh CM, Lee JS, Hu HM, et al. Persistent opioid uses among pediatric patients after surgery.
Pediatrics 2018;141(1):e20172349.
21. U.S. Food and Drug Administration. Drug Safety Communication: FDA restricts use of prescription
codeine pain and cough medicines and tramadol pain medicines in children; recommends against
use in breastfeeding women. Available at: “https://www.fda.gov/Drugs/DrugSafety/ucm549679.htm”.
Accessed March 15, 2022.