Enhancing Care: Updated ADA Guidelines for Pediatric Pain Management

Stay current with the latest evidence-based guidelines for managing acute dental pain in children and enhance pediatric dental care with effective pharmacologic management strategies.

By Ayesha Khan, MD, MBA

The American Dental Association (ADA) recently released new guidelines on managing acute dental pain in children, focusing on providing recommendations for the pharmacologic management of acute dental pain in children under 12. This pain can be associated with various dental conditions such as tooth extractions (simple or surgical), toothache caused by pulpitis, pulp decay with symptomatic periodontitis, acute dental abscess, or periapical pathosis. It explicitly addresses cases where immediate access to definitive dental treatment is not readily available, such as when a referral is required from an emergency department to a dental practice or from a general dentist to a dental specialist.

These evidence-based recommendations aim to provide dentists with practical pain management strategies while prioritizing pediatric patients' safety and well-being.

Children can experience different types of toothache, either somatic (related to the gums, jawbone, or mouth lining) or visceral (stemming from dental pulp). Additionally, when children undergo tooth extractions, they may encounter pain. Research indicates that the lifetime prevalence of toothache in children aged 0 to 5 years is estimated to be around 28%. As children grow older, the lifetime prevalence of toothache increases to approximately 52%, specifically between the ages of 6 and 9 years. These statistics highlight the significant occurrence of toothache among children and emphasize the need for effective pain management strategies in pediatric dental care. Acute dental pain can be distressing for children, making it crucial to implement appropriate treatment approaches.

First-line Treatment Recommendations

In managing acute postoperative dental pain in children undergoing tooth extractions, the guideline panel recommends using ibuprofen or naproxen alone or in combination with acetaminophen. This pain management scheme is suggested instead of using acetaminophen alone. If nonsteroidal anti-inflammatory drugs alone do not provide adequate pain control, the addition of acetaminophen is recommended. In cases where nonsteroidal anti-inflammatory drugs are contraindicated, acetaminophen alone is suggested. It is important to note that the use of naproxen in children older than two years is considered off-label, as it is approved for use in children as young as 12 years by the FDA. Dosages should be determined based on weight rather than age. This information is based on a guideline panel's recommendations and should be used cautiously.

These medications have consistently demonstrated efficacy in relieving pain and reducing inflammation. In fact, research shows that NSAIDs are effective in reducing dental pain intensity by up to 70% in pediatric patients. Dental professionals can effectively manage pain by utilizing these medications as initial options while minimizing potential risks associated with other pharmacological interventions.

Avoidance of Opioids

Recent private insurance claims data from the United States, spanning from 2010 to 2015, provides insights into the prescribing practices of opioids for children below the age of 11. The data reveals that among children who had a dental visit and received an opioid prescription, the average supply of the opioid was three days, with an average daily dose of almost 11 morphine milligram equivalents. Notably, most of these prescriptions (69.51%) were associated with surgical dental visits, while the remaining prescriptions (30.42%) were linked to nonsurgical dental visits. Furthermore, among children in this age group who received multiple opioid prescriptions within a year, 6.75% of the initial prescriptions were associated with a dental visit. These findings shed light on the prevalence of opioid prescriptions in pediatric dental care and underscore the importance of exploring non-opioid alternatives for pain management.

In lieu of these statistics, a significant emphasis in the ADA guidelines is the avoidance of opioids for managing short-term dental pain in children. The opioid crisis has become a critical public health concern, with increasing misuse and addiction rates. Statistics show that between 2000 and 2018, opioid-related pediatric hospitalizations increased by approximately 50%. In alignment with broader efforts to combat this crisis, the ADA urges dentists to explore non-opioid alternatives for effective pain relief. This approach ensures the safety of pediatric patients and helps prevent potential long-term consequences associated with opioid use.

Avoidance of Benzocaine

Clinicians need to be aware of the FDA's warning regarding Benzocaine usage. The FDA cautions that benzocaine can lead to a severe condition called methemoglobinemia, where the blood's oxygen-carrying capacity is significantly compromised. This life-threatening condition can even result in death. Due to these risks, the FDA advises against using over-the-counter drugs containing benzocaine to treat children under the age of 2 years. Recognizing that these products carry severe and often life-threatening risks while offering minimal to no benefit in managing oral pain, including teething, is crucial.

Alternative Interventions

In addition to pharmacological approaches, considering non-pharmacological interventions to manage acute dental pain in children can also prove helpful. These interventions may include using ice packs in addition to behavioral techniques, distraction techniques, topical anesthetics, and local anesthesia administration. Research indicates that distraction techniques, such as virtual reality or music therapy, can significantly decrease pain perception by up to 50% in pediatric dental patients. By combining these non-pharmacological interventions with medication, dental professionals can employ a multimodal approach to pain management tailored to each child's individual needs.

Collaborative Decision-Making

A key aspect highlighted in the guidelines is the importance of collaborative decision-making between parents, caregivers, and dental professionals when determining a child's most appropriate pain management strategy. Dentists are encouraged to engage in open and transparent discussions, providing parents with relevant information about the benefits, risks, and alternatives of different pain management options. Collaborative decision-making ensures that parents are well-informed and acknowledge their valuable input and concerns. This shared decision-making process empowers families to participate in their child's care actively and promotes a patient-centered approach.


The latest guidelines from the ADA on managing acute dental pain in children serve as a comprehensive resource for dental professionals, offering evidence-based recommendations for effective and safe pain management strategies. By adopting these guidelines, dentists can optimize the treatment experience for pediatric patients, ensuring their comfort and well-being during dental procedures. Through the appropriate use of first-line medications, the avoidance of opioids whenever possible, the consideration of alternative interventions, and collaborative decision-making, the ADA's guidelines aim to improve the overall quality of care provided to children with acute dental pain.


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Author: Ayesha Khan, MD, MBA, is a registered physician, former research fellow, and enthusiastic blogger. With a wide range of articles published in renowned newspapers and scientific journals, she covers topics such as nutrition, wellness, supplements, medical research, and alternative medicine. Currently serving as the Vice President of Social Communications and Strategy at Renaissance, Ayesha brings her expertise and strategic mindset to drive impactful initiatives. Follow her blog for insightful content on healthcare advancements and empower yourself with knowledge.

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