MANAGEMENT OF ORAL AND DENTAL PAIN IN CHILDREN
Treatment of pain and suffering should be a priority for all clinicians.
Research shows that children not only experience pain, but that pain produces
long-term consequences. For example, children who undergo repeated painful
procedures as newborns have a higher incidence of chronic pain syndromes later
in life. In addition, inadequate pain control during a medical or dental
procedure diminishes the effect of adequate pain control during future
TYPES OF PAIN
is defined as “an unpleasant sensory and emotional experience.” Pain is
also a subjective experience.
The two types of pain are acute and chronic.
Acute pain is associated with a brief period of tissue injury (a cut) or
inflammation (toothache or dental surgery). The most common type of pain
experienced by children is acute pain resulting from illness, injury, or
Chronic persistent pain describes near-constant pain which continues over
three months or longer.
Suffering occurs when the pain is overwhelming, when the pain leads a
child to feel out of control, when the pain is chronic, or when the source
of pain is unknown.
CAUSES OF ORAL AND DENTAL PAIN
Dental procedures and toothaches cause the release of prostaglandins and
therefore cause pain. Prostaglandins are potent vasodilators and
pro-inflammatory compounds that cause the erythema (redness), pain, and
hyperemia (increased blood flow) associated with trauma or oral tissue
The enzyme cyclooxygenase
converts arachidonic acid to prostaglandins and thromboxanes.
Prostaglandin-synthesis inhibitors (PSI) include acetaminophen (Tylenol),
ibuprofen (Motrin), and aspirin. PSI’s reduce pain because they interfere
with the function of the enzyme cyclooxygenase.
PHYSIOLOGY OF PAIN PERCEPTION
The physiologic events that lead to the perception of pain is called “nociception.”
Nociceptive pain is what a child detects when there is tissue injury or
Nociception can be divided into four processes:
(1) transduction, (2) transmission, (3) modulation, and (4) perception.
Transduction refers to a process in which noxious stimuli are translated
into electrical signals at the sensory nerve endings. The nerves endings are
called primary afferent nociceptors.
A-delta nerve fibers are responsible for the sharp, stabbing pain of a
toothache. This is also known as first pain.
C-polymodal nerve fibers give rise to pain described as dull, aching, and
poorly localized. This is also known as second pain.
FACTORS WHICH INFLUENCE PAIN PERCEPTION IN CHILDREN
Pain has emotional, sensory, behavioral, and cognitive components.
Some of the factors which influence the pain experience in children
Biological factors, psychological factors, cultural factors, temperament,
context, previous experience, pain sensitivity, coping skills, cognitive
development, and parental anxiety.
PAIN ASSESSMENT AND MEASUREMENT IN CHILDREN
Pain assessment is the “fifth vital sign,” and is essential for the
management of pain in children. The assessment of pain begins with taking a
medical history and performing a physical exam to determine the cause of the
pain. Treatment should be directed at both the pain as well as the cause of
The assessment of pain includes measurement. Pain measurement tools
include physiological (heart rate), behavioral, and self-report (pain face
For neonates, infants, children under 4 years of age, and children with
The primary methods of pain assessment are behavioral observational scales.
These scales score limb and body movement, facial expressions, and verbal
responses. Facial expression is the most reliable behavioral pain assessment
measure for this age group.
For children three to eight years old:
Self-reported measures include face
scales, which are a series of photographs or drawings of faces showing
increased degrees of distress. Remember that toddlers and preschoolers may
use words like “hurt” or “owie” to report pain.
For children eight or more years of age:
They can generally use the same visual-analog
pain scales used by adults. They involve rating the intensity of pain on a
OVERVIEW OF MANAGING ORAL AND DENTAL PAIN
The key to managing pain from medical or dental procedures is
anticipation. Effective pain management involves a combination of
pharmacologic, psychologic, cognitive-behavioral, and physical treatments.
Simple measure for dealing with a child in pain include:
Reassurance, explanation, a calm environment, and gentle handling.
Cold or hot packs.
Cognitive-behavioral techniques, such a breathing exercises.
Oral analgesics and pain medication:
Oral forms of pain medication are the most common pharmacologic therapy for
children in pain. They are suitable for mild to moderate pain. Analgesic
treatment should include proper dosing according to: body weight,
physiologic situation, and the medical situation.
Local anesthetics and nerve blocks:
Local anesthetics are used to stop the conduction of pain impulses through
The use of sedatives alone during painful procedures does not provide
analgesia, but makes a child less able to communicate distress.
Behavioral and cognitive intervention:
These techniques are either behavioral (teaching new behaviors), or
cognitive ( teaching new thoughts for coping with pain), or a combination or
This technique involves helping children to focus away from the feared
aspects of a medical or dental procedure.
ORAL ANALGESICS AND PAIN MEDICATIONS
The non-steroidal anti-inflammatory agents (NSAIDs), acetaminophen,
salicylates (aspirin), and weak opioids (codeine) are the most commonly used
analgesic agents for relieving pain in children.
According to the World Health Organization (WHO), mild pain can usually be
controlled with a non-opioid agent. Moderate pain can usually be controlled
with a combination of a non-opioid agent combined with a weak opioid
This is the most widely used antipyretic (fever reducer) and mild analgesic
(pain reliever) for children. Acetaminophen blocks the central production of
prostaglandins, thus producing analgesia (pain relief) with no peripheral
anti-inflammatory action. Therefore, no adverse affects on platelet function
or GI tract occur. Acetaminophen overdose occurs after ingesting as little
as 120 mg/kg, and should be treated with NAC (N-acetylcysteine) at a dose of
70 mg/kg every 4 hours, as early as possible.
This and other NSAIDs (Non-Steroidal Anti-inflammatory Drugs) block the
central as well as the peripheral production of prostaglandins – resulting
in analgesia as well as anti-inflammatory effects. NSAIDs
block the cyclooxygenase enzymes: COX-1
COX-1 helps synthesize the prostaglandins that protect the gastric mucosa,
and help synthesize the thromboxanes that initiate platelet aggregation (
part of blood clotting).
COX-2 leads to the synthesis of the prostaglandins that promote
inflammation, which is undesirable.
The NSAIDS and salicylates should be avoided in patients who have: asthma,
bleeding disorders, gastric ulcers, or surgical bleeding.
Aspirin use in children has declined since the 1970’s after reports of
its association with Reye’s hepatic encephalopathy (Reye’s syndrome).
When acetaminophen or ibuprofen provide insufficient analgesia, a weak
may be added to the analgesic. Weak opioids provide analgesia through
interaction with the mu opioid receptor in the CNS.
Most of the commonly used opioids,
including codeine, activate the mu1 receptor, which is responsible for
analgesia. Activation of the mu2 receptor leads to the undesired effects of:
respiratory depression, sedation, constipation, nausea, and vomiting.
Opioids depress the ventilation rate by depressing the response of the brain
to carbon dioxide.
One of the causes of opioid-induced pruritis (itching) is histamine
release. In severe cases an antihistamine can be administered.
Diphenhydramine (Benadryl) is given at a dose of 0.5 mg/kg for pruritis.
Opioids, such as codeine and meperidine, are contraindicated in children
have acute or chronic respiratory disease, asthma, seizures, or who have
been taking MAO inhibitors within the last 14 days.
Approximately 10% of the codeine is metabolized into morphine, and this 10%
is responsible for all of the analgesic effects of codeine. The analgesic
effect of codeine results from its direct agonistic properties at the mu
If codeine provides insufficient analgesia, the next opioid to consider
using is oxycodone. Oxycodone causes less nauseau and vomiting than codeine.
Percocet contains both oxycodone and acetaminophen.
HOW TO PRESCRIBE ORAL ANALGESICS FOR CHILDREN
10-15 mg/kg every 4-6 hours.
The children’s elixer has an acetaminophen concentration of
10 mg/kg every 6 hours.
The children’s suspension has an ibuprofen concentration of 100mg/5ml.
0.5 – 1.0 mg/kg every 4 hours.
Acetaminophen with codeine elixer is available with 120 mg acetaminophen and
12 mg codeine per 5 ml(teaspoon).
A tablet preparation is available which contains 325 mg acetaminophen with
30 mg of codeine (Tylenol #3).
50-50 mixture of Maalox with diphenhydramine. This mixture is swished in the
mouth every 4 hours, as needed, to control the discomfort of stomatitis or
ulcerative lesions. For younger children, it may be applied with a
LOCAL ANESTHETICS AND NERVE BLOCKS IN CHILDREN
Children should have a comfortable experience when going to the dentist.
Local anesthetics are an important tool for the control of pain and
discomfort during dental treatment. Anesthetics prevent the production and
propagation of nerve signals.
Techniques used to decrease pain during an intraoral injection include:
using a topical anesthetic (benzocaine)
before giving an injection, using a higher-gauge (thinner) needle,
distracting the child by encouraging deep breathing, and by shaking the lip
during the injection.
An imperfect injection technique is the most common cause of problems in
getting a child numb. Another common cause of problems is that local
anesthetics do not work well in an acidic environment - such as an inflamed
or abscessed area. It is therefore sometimes useful to control a dental
infection with antibiotics before a local anesthetic can be successfully
An important requirement for administering a local anesthetic is for the
dentist to be familiar with the manner in which the teeth are innervated.
The dentist should use the smallest possible dose which achieves adequate
anesthesia. The maximum dose for lidocaine
injection in children is 4.5 mg/kg per appointment when children are
Local anesthetics have a low margin of safety between the effective dose
and the toxic dose. The lethal dose for many local anesthetics is only 3
times that of the effective dose. Deaths following local anesthetic
administration are almost always a result of overdose. Since the 1960’s,
dentists have begun using an aspirating
syringe, which has a small internal harpoon that engages the rubber
stopper of the local anesthetic carpule. This technique enables dentists to
aspirate for blood, and see if the needle has inadvertently entered a blood
vessel – before injecting the anesthetic solution.
Bupivicaine (Marcaine) is an amide local anesthetic with a high toxic
potential, and should not be used in children. The duration of anesthesia
with bupivicaine can be as long as 24 hours.
Deaths following local anesthetic administration are almost always the
result of an overdose. For example: a 35 lb child should never receive more
than 2 carpules of 2% lidocaine during a dental appointment.
The most common cause of a true allergic reaction to a local anesthetic is
sensitivity to the preservative in the anesthetic solution. Bisulfites are
widely-used preservatives, and may be the offending agents in a true allergy
to local anesthetic.
CONSCIOUS SEDATION FOR CHILDREN
Some of the drugs used in pediatric conscious sedation include meperidine,
chloral hydrate, midazolam, and ketamine.
The oral route is the oldest of all routes of drug administration, and
still the most commonly used. It is a useful method for managing
uncooperative or fearful children who need dental treatment. The oral route
offers some advantages over other routes, including decreased incidence of
adverse reactions, lower cost, and ease of administration. The disadvantages
of the oral route include prolonged onset time, prolonged duration of
action, and erratic absorption from the GI tract. Most orally administered
drugs demonstrate the highest blood levels at approximately 60 minutes after
ingestion. The absorption of a drug from the GI tract is affected by its
lipid solubility, the pH of the gastric juice, slow gastric emptying time,
inactivation of the drug by the liver, and drug bioavailability.
Oral Demerol and Vistaril:
Demerol (meperidine) is an opioid with a useful sedative side-effect. The
child needs to be NPO for 6 hours to prevent emesis or aspiration.
Contraindications to Demerol use include: asthma, seizures, chronic or acute
respiratory disease, or MAO inhibitor use within the last 14 days.
Mild respiratory depression can be managed by repeatedly waking the patient
and encouraging deep breathing. In urgent situations, assisted ventilation
or an injection of naloxone (Narcan) at 0.01 mg/kg may be needed.
Oral Demerol is administered at a dose of 5.0 mg/kg. Sedative effects are
obvious after 45 to 75 minutes
Vistaril is an effective anti-emetic and is always given when Demerol is
used. The usual dose is 25 mg per appointment.
This is a relatively safe drug to use for sedation, as long as the dose is
appropriate for the child’s weight. The child needs to be NPO for 6 hours
to prevent emesis or aspiration. It is administered nasally at a dose of 0.2
mg/kg. Sedative effects are obvious after 20 minutes. This dose may be
repeated once per sedation visit.
BEHAVIORAL AND COGNITIVE INTERVENTION
Behavioral techniques include: desensitization, positive reinforcement,
Desensitization involves gradually increasing exposure to the feared
stimulus (the treatment room, the needle), while maintaining anxiety at low
levels. This technique requires a great deal of time before it can be
successful, however. Positive
reinforcement involves rewarding a child for any positive behavior, or
even for just coping with the procedure. Rewards include praise, small toys,
Relaxation training teaches children to engage in progressive relaxation of
muscle groups, or teaches controlled breathing.
Cognitive interventions include:
Preparation (tell-show-do), memory change, and hypnosis.
Preparation involves providing children with procedural and sensory
information about the next procedure. Procedural information describes each
step of the procedure. Sensory information includes descriptions of
sensations that a child will experience.
Combined behavioral and cognitive interventions include:
Distraction and modeling/rehearsal.
Distractions include: singing, visual distractions, or shaking the lip
during administration of a dental local anesthetic. Distraction is more
effective in infants and young children than older children.
Modeling and rehearsal involves having an adult or other child demonstrate
positive coping behaviors. In small children, for example, a doll can model
holding still during a procedure.
HYPNOSIS FOR PAIN MANAGEMENT
is useful in calming frightened children and helping them to tolerate
painful procedures. Hypnosis uses suggestion to potentiate therapeutic
action. Suggestion can be delivered verbally, but can also be embedded in
voice tone, facial expression, and what is not said. A good hypnotist
demonstrates deftness in the use of language, voice tone, pacing, and
knowledge of human motivations and anxieties
The primary goals of hypnotherapy are to:
Capture the child’s trust and attention, reduce distress, reframe pain and
distress into something positive, and help the child dissociate from the
pain by using positive suggestion.
Most hypnotic interventions use the natural hypnoidal state of a child in
the emergency room (heightened focus, dependency, constricted perception),
and redirect it.
The hypnotic process involves three stages:
1) Induction. Helping the child dissociate from the environment and helping
him/her become increasingly involved in an imagined fantasy.
2) Deepening. Increasing the dissociation from the pain.
3) Suggestion. Verbally suggesting that the child imagine and find a
favorite place that is safe.
Characteristics of hypnosis intervention include:
1) Place an anchoring hand on the shoulder, arm, or forehead of the patient.
2) Use a calm but direct voice.
3) Pace the rate of speech to the patient’s breathing while gradually
4) Use positive suggestions.
Hypnotic analgesia appears to be regulated by active inhibitory control of
incoming stimuli at the cortical level of the brain.
An article in the Journal of the Canadian Dental Association provides a
brief review of the role of acetaminophen, non-steroidal anti-inflammatory
drugs, and opioids in the management of acute postoperative pain. It also
explains the interplay between analgesics and cyclooxygenase enzymes in the