Analgesis used in pedo
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Here is a comprehensive overview of analgesics used in pediatric dentistry (pedodontics):
Analgesics in Pediatric Dentistry
Classification
Analgesics used in pedo are broadly divided into:
- Non-opioid analgesics
- Opioid analgesics
- Local anesthetics (primary intraoperative analgesia)
1. Non-Opioid Analgesics
These are the first-line drugs for dental pain in children, as per the ADA 2023 clinical practice guideline and AAPD policy on pediatric pain management.
A. NSAIDs
| Drug | Dose | Remarks |
|---|---|---|
| Ibuprofen | 5-10 mg/kg/dose, every 6-8 hrs (max 40 mg/kg/day) | Drug of choice in pedodontics; anti-inflammatory + analgesic |
| Diclofenac | 1-3 mg/kg/day in 2-3 divided doses | Used for moderate pain; available as oral/suppository |
| Ketorolac | 0.5 mg/kg IV/IM (max 15 mg), short-term only | For moderate-severe postoperative pain; not for long-term use |
| Nimesulide | 5 mg/kg/day in 2 divided doses | Preferential COX-2 inhibitor; good for dental pain but hepatotoxicity risk |
| Aspirin | AVOIDED in children <12 yrs | Risk of Reye's syndrome - contraindicated |
Mechanism: Inhibit COX-1 and COX-2 enzymes → reduce prostaglandin synthesis → anti-inflammatory, antipyretic, analgesic effects.
B. Acetaminophen (Paracetamol)
- Dose: 10-15 mg/kg/dose every 4-6 hrs (max 75 mg/kg/day, not exceeding 4 g/day)
- Acts centrally by inhibiting COX enzymes in the CNS
- No anti-inflammatory action - purely analgesic/antipyretic
- Very safe at therapeutic doses; hepatotoxic in overdose
- Combination therapy: Acetaminophen + Ibuprofen together provides superior analgesia versus either alone (alternating or simultaneous)
2. Opioid Analgesics
Used rarely in pediatric dentistry - only for moderate to severe pain refractory to non-opioids, or in special medical conditions (cancer, sickle cell disease, osteogenesis imperfecta, epidermolysis bullosa).
| Drug | Type | Dose | Remarks |
|---|---|---|---|
| Codeine | Natural opioid | 0.5-1 mg/kg every 4-6 hrs | Now AVOIDED - unpredictable metabolism (CYP2D6 polymorphism); FDA black box warning in children post-tonsillectomy/adenoidectomy |
| Morphine | Natural opioid | 0.1-0.2 mg/kg oral every 4 hrs | Reserved for severe pain (oncology, palliative); rarely dental |
| Tramadol | Atypical synthetic opioid | 1-2 mg/kg/dose every 4-6 hrs | Weak mu-agonist + SNRI properties; used occasionally post-op |
| Meperidine (Pethidine) | Synthetic | 1-2 mg/kg | Used in procedural sedation combinations, not preferred alone |
| Fentanyl | Synthetic | Per anesthesia protocol | Only in hospital/OR setting for GA cases |
Important: The AAPD policy states that opioid use for pediatric dental patients should be rare. Codeine is now specifically discouraged due to life-threatening respiratory depression in ultra-rapid CYP2D6 metabolizers.
3. Local Anesthetics (Intraoperative Analgesia)
The cornerstone of pain control during dental procedures:
| Drug | Max Dose (children) | Remarks |
|---|---|---|
| Lidocaine 2% with 1:100,000 epinephrine | 4.4 mg/kg (plain), 7 mg/kg (with epi) | Most widely used; onset 2-3 min, duration 1-2 hrs |
| Articaine 4% with 1:100,000 epi | 7 mg/kg | Better buccal infiltration success; used in children >4 yrs |
| Mepivacaine 3% (plain) | 6.6 mg/kg | Used when vasoconstrictors contraindicated |
| Prilocaine | 6 mg/kg | Avoid in infants <6 months (methemoglobinemia risk) |
| Bupivacaine 0.5% | 1.3 mg/kg | Long-acting; for prolonged post-op pain control |
Topical anesthetics (pre-injection): Benzocaine 20% gel is the standard; lidocaine 2% viscous/gel also used.
4. Preemptive Analgesia
Giving analgesics before the procedure to reduce post-op pain:
- Ibuprofen (10 mg/kg) given 30-60 min before procedure is the most common approach
- Reduces analgesic requirement post-operatively
- Especially useful before pulpectomy, extractions, and pulpotomy
5. WHO Pain Ladder (Applied to Pedo)
| Step | Pain Level | Drug |
|---|---|---|
| Step 1 | Mild | Acetaminophen or NSAID alone |
| Step 2 | Moderate | Acetaminophen + NSAID (combination) |
| Step 3 | Severe | Add weak opioid (tramadol) ± adjuvants |
6. Recent Advances
- Liposomal bupivacaine - extended-release formulation for prolonged post-op analgesia
- Dexmedetomidine - alpha-2 agonist used as adjunct during procedural sedation; reduces analgesic requirements
- Nitrous oxide (N₂O) - mild inhalational analgesic/anxiolytic; widely used in pedo for anxious children (30-50% N₂O in O₂)
- Low-level laser therapy (LLLT) - non-pharmacological adjunct for post-operative pain
Key Points to Remember
- Aspirin is contraindicated in children <12 yrs (Reye's syndrome)
- Codeine is avoided due to FDA warnings on CYP2D6 variability
- Ibuprofen is the NSAID of choice in pedo
- Acetaminophen + Ibuprofen combination is superior to monotherapy for moderate dental pain
- Opioids are last resort - the 2023 ADA guideline specifically recommends against opioids as first-line therapy
- Doses should always be calculated on mg/kg basis in children
- Local anesthesia remains the primary intraoperative pain control method
Key references:
- ADA 2023 Evidence-based Guideline on Acute Dental Pain in Children (PMID: 37634915)
- Carrasco-Labra et al., J Am Dent Assoc, 2023 - Systematic review and practice guideline
- AAPD Policy on Pain Management in Pediatric Patients
- Mohn A et al., "Dental pain in children: pharmacological management," Eur J Paediatr Dent, 2025 (PMID: 40207859)
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