What is the recommended pain reliever for a pediatric patient experiencing a toothache?

Pain Reliever of Choice for Toothache in Pediatrics

For pediatric toothache, ibuprofen is the preferred first-line analgesic due to its superior efficacy and longer duration of action compared to acetaminophen, with dosing of 5-10 mg/kg every 6-8 hours. 1, 2

Primary Recommendation: Ibuprofen as First-Line

• Ibuprofen (5-10 mg/kg every 6-8 hours) provides more effective pain relief than acetaminophen for dental pain in children, with the added benefit of anti-inflammatory properties that address the underlying inflammatory component of toothache 1, 2

• Ibuprofen demonstrates superior antipyretic efficacy at 2,4, and 6 hours post-treatment compared to acetaminophen, which translates to better overall symptom control when fever accompanies dental pain 2

• The longer dosing interval (every 6-8 hours versus every 4 hours for acetaminophen) improves compliance and provides more consistent analgesia throughout the day 1

Alternative Option: Acetaminophen

• Acetaminophen (10-15 mg/kg every 4 hours) is an acceptable alternative when NSAIDs are contraindicated or unavailable, though it provides comparable but not superior analgesia to ibuprofen 3, 2

• Acetaminophen has the advantage of no effects on renal or gastrointestinal function, making it safer in children with specific comorbidities 4

• Single doses should be in the range of 10-15 mg/kg at 4-hour intervals to maintain therapeutic levels 5

Combination Therapy for Severe Pain

• For moderate to severe toothache, combining ibuprofen with acetaminophen provides enhanced analgesia through complementary mechanisms of action 3

• The combination reduces the need for opioid rescue medications in postoperative dental procedures 3

• Administer both medications on a scheduled basis rather than as-needed to maintain consistent serum levels and optimize pain control 3

Topical Adjunct for Children ≥2 Years

• Benzocaine topical gel can be used as an adjunct for temporary relief in children 2 years and older, applied to the affected area up to 4 times daily 6

• Children under 12 years should be supervised during application, and those under 2 years require consultation with a dentist or physician before use 6

Critical Safety Considerations

• Both ibuprofen and acetaminophen have comparable safety profiles when used at appropriate doses, with no significant difference in minor or major adverse events 2

• However, acetaminophen overdose is reached earlier, is more severe, and is more difficult to manage compared to ibuprofen overdose 1

• Avoid exceeding maximum daily doses: ibuprofen 40 mg/kg/day (maximum 1200 mg/day) and acetaminophen 75 mg/kg/day (maximum 4000 mg/day) 5, 1

Common Pitfalls to Avoid

• Do not underdose based on age-based schedules that fail to account for weight - always calculate doses using mg/kg to ensure therapeutic levels 5

• Do not assume alternating ibuprofen and acetaminophen is always necessary for simple toothache - monotherapy with ibuprofen is often sufficient 1, 2

• Do not delay dental evaluation - analgesics provide symptomatic relief but do not address the underlying dental pathology requiring definitive treatment 3

When to Escalate Care

• If pain persists beyond 48-72 hours despite appropriate analgesic therapy, immediate dental evaluation is mandatory to address the underlying cause 3

• Signs of dental abscess (gingival swelling, increased mobility, parulis) require urgent dental intervention, not just analgesic management 3