25.2 Pediatric Local Anesthesia, Pain Management and Pediatric Oral Surgery
Key Takeaways
Local anesthetic doses for children are calculated by weight: AAPD maximums are 4.4 mg/kg for lidocaine and mepivacaine (300 mg), 7.0 mg/kg for articaine (500 mg) and 6.0 mg/kg for prilocaine (400 mg).
In children the mandibular foramen lies lower than in adults, at or below the occlusal plane, so the inferior alveolar nerve block is given at a lower level.
Codeine and tramadol are contraindicated in children under 12 years, and ibuprofen or paracetamol in weight-based doses is the usual first choice for dental pain.
Antibiotics are indicated for facial cellulitis, fever or rapidly spreading infection, not for localized dental pain; source control by extraction or pulp treatment remains essential.
A small fractured root tip of a primary tooth is often left to resorb rather than risk injuring the developing permanent successor.
Children reach toxic local anesthetic doses quickly, metabolize drugs differently and depend on adults for post-operative care. These questions are often calculations or "most appropriate next step" decisions.
Local Anesthesia in Children
AAPD maximum recommended doses
| Agent | Maximum dose | Absolute maximum |
|---|---|---|
| Lidocaine 2% with epinephrine | 4.4 mg/kg | 300 mg |
| Mepivacaine 3% plain or 2% with vasoconstrictor | 4.4 mg/kg | 300 mg |
| Articaine 4% with epinephrine | 7.0 mg/kg | 500 mg |
| Prilocaine 4% | 6.0 mg/kg | 400 mg |
| Bupivacaine 0.5% | 1.3 mg/kg | 90 mg |
Calculation: mg per cartridge = concentration (mg/mL) x volume. A 2% solution contains 20 mg/mL, so a 1.8 mL cartridge holds 36 mg; a 4% solution contains 40 mg/mL (about 68-72 mg per cartridge).
Example: a 20 kg child: lidocaine 4.4 x 20 = 88 mg, which is about 2.4 cartridges of 2% lidocaine (1.8 mL). Articaine 7 x 20 = 140 mg, about 2 cartridges.
Practical points:
- Use the lowest effective dose; aspirate and inject slowly; record the total dose.
- Plain mepivacaine is absorbed faster and has been involved in pediatric toxicity reports; the vasoconstrictor slows absorption.
- Articaine is not recommended for children under 4 years because of limited data, but buccal infiltration with articaine can anesthetize primary mandibular molars in older children.
- Sedative drugs (opioids, benzodiazepines) add to the toxicity risk of local anesthetics.
- Inferior alveolar nerve block: the mandibular foramen in children lies lower, at or below the occlusal plane, and the ramus is shorter, so the needle is inserted at a lower level than in adults.
Post-anesthetic soft-tissue injury: children may bite or chew the numb lip, cheek or tongue, producing an ulcer that looks like an infection. Warn parents and child, place a cotton roll if appropriate, and avoid unnecessarily long-acting agents. Phentolamine mesylate can shorten soft-tissue anesthesia (approved for children aged 6 years and older who weigh at least 15 kg).
Analgesia
| Drug | Typical pediatric dose | Notes |
|---|---|---|
| Ibuprofen | About 5-10 mg/kg every 6-8 hours | Avoid in some asthma, renal disease, bleeding disorders, dehydration |
| Paracetamol (acetaminophen) | About 10-15 mg/kg every 4-6 hours (maximum daily dose limited by weight) | Hepatotoxic in overdose |
| Codeine, tramadol | Contraindicated under 12 years (FDA 2017), with further restrictions in adolescents | Ultra-rapid metabolism can cause respiratory depression |
| Aspirin | Avoid in children and teenagers | Reye syndrome |
Doses must never exceed adult maximums; check combination products for hidden paracetamol.
Dental Infections and Antibiotics
- Antibiotics are indicated for facial cellulitis, fever or systemic illness, rapidly spreading infection, and in immunocompromised children. They are not indicated for irreversible pulpitis or a localized abscess that has been drained.
- Always treat the source: extract the primary tooth or perform pulpectomy as appropriate.
- Hospital referral: swelling approaching the eye or floor of mouth, difficulty swallowing or breathing, trismus, dehydration, high fever, or a child who looks unwell (intravenous antibiotics, drainage, airway monitoring).
- Doses are weight-based (amoxicillin is first line unless allergic).
Pediatric Oral Surgery
Extraction of primary teeth
- Primary molar roots are thin and flared around the developing premolar; avoid forcing elevators or forceps deep between the roots. Sectioning the tooth can help.
- A small fractured root tip may be left to resorb when removal would risk damaging the successor; tell the parent and monitor radiographically.
- Plan space maintenance after early loss of primary molars (see interceptive orthodontics).
- Post-operative: bite on gauze, avoid biting the numb lip, soft diet, analgesia.
Specific conditions
| Condition | Management |
|---|---|
| Natal and neonatal teeth | Usually part of the primary dentition: keep if stable; extract if very mobile (aspiration risk) or preventing feeding; confirm vitamin K has been given before extraction in the newborn |
| Mesiodens | Remove if it delays eruption of a central incisor, causes displacement or is erupted; then provide space so the incisor can erupt (traction if it does not) |
| Infraoccluded (ankylosed) primary molar | Monitor if a successor is present (usually exfoliates); extract if severely submerged, causing tipping of neighbors or delaying the successor |
| Retained primary tooth with lingually erupting permanent incisor | Extract the primary incisor; the tongue usually moves the permanent tooth forward |
| Maxillary labial frenum | Assess after the permanent canines erupt; frenectomy if a fibrous attachment keeps a diastema open (often after orthodontic closure) |
| Ankyloglossia | Frenotomy if feeding or speech is affected |
| Mucocele, eruption cyst | Excision of mucocele with glands; eruption cysts usually need no treatment |
Exam Traps
- Calculate the maximum dose in mg before counting cartridges.
- Facial swelling with fever needs antibiotics plus source control, and possibly hospital care.
- Codeine is not an option for a 9-year-old.
A healthy 15 kg child needs extractions under local anesthesia with 2% lidocaine with 1:100,000 epinephrine (1.8 mL cartridges). Using the AAPD limit of 4.4 mg/kg, what is the maximum number of cartridges?
About 3.7 cartridges (132 mg)
About 8.3 cartridges (300 mg)
About 0.9 cartridges (33 mg)
About 1.8 cartridges (66 mg)
A 6-year-old returns the day after a restoration on tooth 85 under an inferior alveolar nerve block with a painful, ulcerated swelling of the lower lip on the same side. There is no fever. What is the most likely cause?
An allergic reaction to lidocaine requiring an epinephrine injection now
Primary herpetic gingivostomatitis triggered by the injection needle
Self-inflicted lip biting while the lip was numb after the block
An odontogenic abscess of tooth 85 that needs immediate extraction
Which analgesic is contraindicated for a 9-year-old after a dental extraction?
Paracetamol
Codeine
Ibuprofen
Ibuprofen with paracetamol
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