Assessing modalities used to alleviate postoperative pain in children receiving dental treatment under general anaesthesia: a systematic review

Postoperative pain is generally a novel experience among paediatric patients. Topical anaesthetics, distraction procedures, and buffering of anaesthetic solutions have been used in reducing the postoperative pain. In this review, the authors assessed various modalities used to alleviate postoperative pain in children’s dental treatment under general anaesthesia. Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) protocol were strictly adhered to in this systematic review. Specific keywords including postoperative pain, general anaesthesia, children, and dental extraction were used in the search for relevant randomized control trial studies in Web of Science, Scopus, and PubMed, and included articles published until June 2021. From a total of 191 abstracts, 21 were reviewed. From the six studies with the usage of non-steroidal anti-inflammatory drugs (NSAIDs) alone or in combination with paracetamol, four observed that the preoperative use of NSAIDs alone or in combination was better than paracetamol alone, one discovered preoperative intravenous paracetamol was better than postoperative intravenous paracetamol, and the remaining study found no difference among various groups. Of two studies comparing the usage of non-steroidal anti-inflammatory drugs with opioid analgesics, one stated intravenous fentanyl in combination was better, while the other study found no difference among groups. The results obtained in this review can be utilized by physicians to control postoperative pain in children undergoing dental treatment under general anaesthesia.

Postoperative pain; General anaesthesia; Dental extraction; Children

[1] Treede RD. The international association for the study of pain definition of pain: as valid in 2018 as in 1979, but in need of regularly updated footnotes. Pain Reports. 2018; 3: e643.

[2] Herbert C. Pain: clinical manual (2nd ed) by M. McCaffrey & C. Pasero. 1999. C. V. Mosby, St Louis. Journal of Clinical Nursing. 2000; 9: 650.

[3] Kiecolt-Glaser JK, Page GG, Marucha PT, MacCallum RC, Glaser R. Psychological influences on surgical recovery: perspectives from psychoneuroimmunology. American Psychologist. 1998; 53: 1209–1218.

[4] International Association for the Study of Pain. IASP announces revised definition of pain. 2020. Available at: https://www.iasp-pain.org/publications/iasp-news/iasp-announces-revised-definition-of-pain/ (Accessed: 15 June 2023).

[5] Clinical Affairs Committee-Behavior Management Subcommittee, American Academy of Pediatric Dentistry. Guideline on behavior guidance for the pediatric dental patient. Pediatric Dentistry. 2015; 37: 57–70.

[6] Macpherson LM, Pine CM, Tochel C, Burnside G, Hosey MT, Adair P. Factors influencing referral of children for dental extractions under general and local anaesthesia. Community Dental Health. 2005; 22: 282–288.

[7] Chung F, Un V, Su J. Postoperative symptoms 24 hours after ambulatory anaesthesia. Canadian Journal of Anaesthesia. 1996; 43: 1121–1127.

[8] Escanilla-Casal A, Ausucua-Ibáñez M, Aznar-Gómez M, Viaño-García JM, Sentís-Vilalta J, Rivera-Baró A. Comparative study of postoperative morbidity in dental treatment under general anesthesia in pediatric patients with and without an underlying disease. International Journal of Paediatric Dentistry. 2016; 26: 141–148.

[9] Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesthesia & Analgesia. 2003; 97: 534–540.

[10] Hosey MT, Macpherson LM, Adair P, Tochel C, Burnside G, Pine C. Dental anxiety, distress at induction and postoperative morbidity in children undergoing tooth extraction using general anaesthesia. British Dental Journal. 2006; 200: 39–43.

[11] Bridgman CM, Ashby D, Holloway PJ. An investigation of the effects on children of tooth extraction under general anaesthesia in general dental practice. British Dental Journal. 1999; 186: 245–247.

[12] Alohali AA, Al-Rubaian N, Tatsi C, Sood S, Hosey MT. Post-operative pain and morbidity in children who have tooth extractions under general anaesthesia: a service evaluation. British Dental Journal. 2019; 227: 713–718.

[13] Fletcher B. Psychological upset in posthospitalized children: a review of the literature. Maternal Child Nursing Journal. 1981; 10: 185–195.

[14] American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on acute pain management. Anesthesiology. 2012; 116: 248–273.

[15] Ip HV, Abrishami A, Peng PW, Wong J, Chung F. Predictors of postoperative pain and analgesic consumption: a qualitative systematic review. Anesthesiology. 2009; 111: 657–677.

[16] Gazal G, Bowman R, Worthington HV, Mackie IC. A double-blind randomized controlled trial investigating the effectiveness of topical bupivacaine in reducing distress in children following extractions under general anaesthesia. International Journal of Paediatric Dentistry. 2004; 14: 425–431.

[17] Gazal G, Mackie IC. A comparison of paracetamol, ibuprofen or their combination for pain relief following extractions in children under general anaesthesia: a randomized controlled trial. International Journal of Paediatric Dentistry. 2007; 17: 169–177.

[18] El Batawi HY. Effect of intraoperative analgesia on children’s pain perception during recovery after painful dental procedures performed under general anaesthesia. European Archives of Paediatric Dentistry. 2015; 16: 35–41.

[19] Marshall S, Ondhia A, Mearns C, Kandiah T. Improving pain management for children having dental extractions under general anaesthesia. The Annals of the Royal College of Surgeons of England. 2020; 102: 733–736.

[20] O’Donnell A, Henderson M, Fearne J, O’Donnell D. Management of postoperative pain in children following extractions of primary teeth under general anaesthesia: a comparison of paracetamol, Voltarol and no analgesia. International Journal of Paediatric Dentistry. 2007; 17: 110–115.

[21] Kharouba J, Hawash N, Peretz B, Blumer S, Srour Y, Nassar M, et al. Effect of intravenous paracetamol as preoperative compared to preventive analgesia in a pediatric dental setting: a prospective randomized study. International Journal of Paediatric Dentistry. 2018; 28: 83–91.

[22] Jensen B. Post-operative pain and pain management in children after dental extractions under general anaesthesia. European Archives of Paediatric Dentistry. 2012; 13: 119–125.

[23] Littlejohn IH, Tarling MM, Flynn PJ, Ordman AJ, Aiken A. Post-operative pain relief in children following extraction of carious deciduous teeth under general anaesthesia: a comparison of nalbuphine and diclofenac. European Journal of Anaesthesiology. 1996; 13: 359–363.

[24] Sheta SA, Al-Sarheed MA, Abdelhalim AA. Intranasal dexmedetomidine vs midazolam for premedication in children undergoing complete dental rehabilitation: a double-blinded randomized controlled trial. Pediatric Anesthesia. 2014; 24: 181–189.

[25] Roelofse JA, Shipton EA, de la Harpe CJ, Blignaut RJ. Intranasal sufentanil/midazolam versus ketamine/midazolam for analgesia/sedation in the pediatric population prior to undergoing multiple dental extractions under general anesthesia: a prospective, double-blind, randomized comparison. Anesthesia Progress. 2004; 51: 114–121.

[26] Roelofse JA, Payne KA. Oral tramadol: analgesic efficacy in children following multiple dental extractions. European Journal of Anaesthesiology. 1999; 16: 441–447.

[27] McIntyre RE, Hardcastle C, Eng RL, Nettel-Aguirre A, Urmson K, Lardner DR, et al. Effect of dexamethasone on postoperative morbidity after dental rehabilitation in children. Canadian Journal of Anesthesia. 2012; 59: 34–40.

[28] Coulthard P, Rolfe S, Mackie IC, Gazal G, Morton M, Jackson-Leech D. Intraoperative local anaesthesia for paediatric postoperative oral surgery pain—a randomized controlled trial. International Journal of Oral and Maxillofacial Surgery. 2006; 35: 1114–1119.

[29] McWilliams PA, Rutherford JS. Assessment of early postoperative pain and haemorrhage in young children undergoing dental extractions under general anaesthesia. International Journal of Paediatric Dentistry. 2007; 17: 352–357.

[30] Townsend JA, Ganzberg S, Thikkurissy S. The effect of local anesthetic on quality of recovery characteristics following dental rehabilitation under general anesthesia in children. Anesthesia Progress. 2009; 56: 115–122.

[31] Jürgens S, Warwick RS, Inglehearn PJ, Gooneratne DS. Pain relief for paediatric dental chair anaesthesia: current practice in a community dental clinic. International Journal of Paediatric Dentistry. 2003; 13: 93–97.

[32] Leong KJ, Roberts GJ, Ashley PF. Perioperative local anaesthetic in young paediatric patients undergoing extractions under outpatient ‘short-case’ general anaesthesia. a double-blind randomised controlled trial. British Dental Journal. 2007; 203: E11–E11.

[33] Sammons HM, Unsworth V, Gray C, Choonara I, Cherrill J, Quirke W. Randomized controlled trial of the intraligamental use of a local anaesthetic (lignocaine 2%) versus controls in paediatric tooth extraction. International Journal of Paediatric Dentistry. 2007; 17: 297–303.

[34] Andrzejowski J, Lamb L. The effect of swabs soaked in bupivacaine and epinephrine for pain relief following simple dental extractionsin children. Anaesthesia. 2002; 57: 281–283.

[35] Atan S, Ashley P, Gilthorpe MS, Scheer B, Mason C, Roberts G. Morbidity following dental treatment of children under intubation general anaesthesia in a day-stay unit. International Journal of Paediatric Dentistry. 2004; 14: 9–16.

[36] Singer AJ, Gulla J, Thode HC. Parents and practitioners are poor judges of young children’s pain severity. Academic Emergency Medicine. 2002; 9: 609–612.

[37] Versloot J, Veerkamp JS, Hoogstraten J. Assessment of pain by the child, dentist, and independent observers. Pediatric Dentistry. 2004; 26: 445–449.

[38] Rømsing J, Møiniche S, Dahl JB. Rectal and parenteral paracetamol, and paracetamol in combination with NSAIDs, for postoperative analgesia. British Journal of Anaesthesia. 2002; 88: 215–226.

[39] McGaw T, Raborn W, Grace M. Analgesics in pediatric dental surgery: relative efficacy of aluminum ibuprofen suspension and acetaminophen elixir. ASDC Journal of Dentistry for Children. 1987; 54: 106–109.

[40] Pickering AE, Bridge HS, Nolan J, Stoddart PA. Double-blind, placebo-controlled analgesic study of ibuprofen or rofecoxib in combination with paracetamol for tonsillectomy in children. British Journal of Anaesthesia. 2002; 88: 72–77.

[41] Dionne R. Additive analgesia without opioid side effects. Compendium of Continuing Education in Dentistry. 2000; 21: 572–577.

[42] St. Charles CS, Matt BH, Hamilton MM, Katz BP. A comparison of ibuprofen versus acetaminophen with codeine in the young tonsillectomy patient. Otolaryngology–Head and Neck Surgery. 1997; 117: 76–82.

[43] Chandrasekharan NV, Dai H, Roos KLT, Evanson NK, Tomsik J, Elton TS, et al. COX-3, a cyclooxygenase-1 variant inhibited by acetaminophen and other analgesic/antipyretic drugs: Cloning, structure, and expression. Proceedings of the National Academy of Sciences of the United States of America. 2002; 99: 13926–13931.

[44] Wynn RL. Update on nonprescription pain relievers for dental pain. General Dentistry. 2004; 52: 94–98.

[45] Acs G, Moore PA, Shusterman S, Needleman HL. The extent of trauma and postextraction pain in children. Pediatric Dentistry. 1988; 10: 210–214.

[46] Moore PA, Acs G, Hargreaves JA. Postextraction pain relief in children: a clinical trial of liquid analgesics. International Journal of Clinical Pharmacology, Therapy, and Toxicology. 1985; 23: 573–577.

[47] Hall N, Edmondson HD. The aetiology and psychology of dental fear. a five-year study of the use of intravenous diazepam in its management. British Dental Journal. 1983; 154: 247–252.

[48] Woolf CJ. Evidence for a central component of post-injury pain hypersensitivity. Nature. 1983; 306: 686–688.

[49] Gill P, Kiani S, Victoria BA, Atcheson R. Preoperative analgesia with local anaesthetic for herniorrhaphy. Anaesthesia. 2001; 56: 414–417.

[50] Enever GR, Nunn JH, Sheehan JK. A comparison of post-operative morbidity following outpatient dental care under general anaesthesia in paediatric patients with and without disabilities. International Journal of Paediatric Dentistry. 2000; 10: 120–125.

[51] Baygin O, Tuzuner T, Isik B, Kusgoz A, Tanriver M. Comparison of preoperative ibuprofen, paracetamol, and placebo administration in reducing post-operative pain in primary tooth extraction. International Journal of Paediatric Dentistry. 2011; 21: 306–313.

[52] Olson NZ, Otero AM, Marrero I, Tirado S, Cooper S, Doyle G, et al. Onset of analgesia for liquigel ibuprofen 400 mg, acetaminophen 1000 mg, ketoprofen 25 mg, and placebo in the treatment of postoperative dental pain. The Journal of Clinical Pharmacology. 2001; 41: 1238–1247.

[53] Melmon K, Carruthers SG, Hoffman BB, Melmon KL, Nierenberg DW. Melmon & Morelli’s essentials of clinical pharmacology. 4th edn. McGraw-Hill: New York. 2000.

[54] Landsdorp D, Vree TB, Janssen TJ, Guelen PJ. Pharmacokinetics of rectal diclofenac and its hydroxy metabolites in man. International Journal of Clinical Pharmacology, Therapy, and Toxicology. 1990; 28: 298–302.

[55] Prescott LF, Roscoe P, Wright N, Brown SS. Plasma-paracetamol half-life and hepatic necrosis in patients with paracetamol overdosage. The Lancet. 1971; 297: 519–522.

[56] Cullen S, Kenny D, Ward OC, Sabra K. Paracetamol suppositories: a comparative study. Archives of Disease in Childhood. 1989; 64: 1504–1505.

[57] Moller PL, Sindet-Pedersen S, Petersen CT, Juhl GI, Dillenschneider A, Skoglund LA. Onset of acetaminophen analgesia: comparison of oral and intravenous routes after third molar surgery. British Journal of Anaesthesia. 2005; 94: 642–648.

[58] Romej M, Voepel-Lewis T, Merkel SI, Reynolds PI, Quinn P. Effect of preemptive acetaminophen on postoperative pain scores and oral fluid intake in pediatric tonsillectomy patients. AANA Journal. 1996; 64: 535–540.

[59] Pickering G, Loriot M, Libert F, Eschalier A, Beaune P, Dubray C. Analgesic effect of acetaminophen in humans: first evidence of a central serotonergic mechanism. Clinical Pharmacology & Therapeutics. 2006; 79: 371–378.

[60] Reuben SS, Bhopatkar S, Maciolek H, Joshi W, Sklar J. The preemptive analgesic effect of rofecoxib after ambulatory arthroscopic knee surgery. Anesthesia & Analgesia. 2002; 94: 55–59.

[61] Ashley PF, Parekh S, Moles DR, Anand P, MacDonald LC. Preoperative analgesics for additional pain relief in children and adolescents having dental treatment. Cochrane Database of Systematic Reviews. 2016; 2016: CD008392.

[62] Mehrotra S. Postoperative anaesthetic concerns in children: postoperative pain, emergence delirium and postoperative nausea and vomiting. Indian Journal of Anaesthesia. 2019; 63: 763.

[63] National Institute for Health and Care Excellence. Fentanyl. 2010. Available at: https://www.nice.org.uk/search?q=fentanyl (Accessed: 15 January 2023).

[64] Wandless JG. A comparison of nalbuphine with morphine for post-orchidopexy pain. Survey of Anesthesiology. 1989; 5: 320.

[65] Krishnan A, Tolhurst-Cleaver CL, Kay B. Controlled comparison of nalbuphine and morphine for post‐tonsillectomy pain. Anaesthesia. 1985; 40: 1178–1181.

[66] Kay B, Lindsay RG, Mason CJ, Healy TEJ. Oral nalbuphine for the treatment of pain after dental extractions. British Journal of Anaesthesia. 1988; 61: 313–317.

[67] Canning HB, Frost DE, McDonald DK, Joyner RW. Comparison of the use of nalbuphine and fentanyl during third molar surgery. Journal of Oral and Maxillofacial Surgery. 1988; 46: 1048–1050.

[68] Errick JK, Heel RC. Nalbuphine a preliminary review of its pharmacological properties and therapeutic efficacy. Drugs. 1983; 26: 191–211.

[69] Wilton NT, Leigh J, Rosen D, Pandit U. Preanesthetic sedation of preschool children using intranasal midazolam. Anesthesiology. 1988; 69: 972–974.

[70] Callado LF, Stamford JA. α2A—but not α2B/C—adrenoceptors modulate noradrenaline release in rat locus coeruleus: voltammetric data. European Journal of Pharmacology. 1999; 366: 35–39.

[71] Primosch RE, Bender F. Factors associated with administration route when using midazolam for pediatric conscious sedation. ASDC Journal of Dentistry for Children. 2001; 68: 233–228.

[72] Berkenbosch JW, Tobias JD. Development of bradycardia during sedation with dexmedetomidine in an infant concurrently receiving digoxin. Pediatric Critical Care Medicine. 2003; 4: 203–205.

[73] Ingersoll-Weng E, Manecke G, Thistlethwaite P. Dexmedetomidine and cardiac arrest. Anesthesiology. 2004; 100: 738–739.

[74] Helmers JH, Noorduin H, Van Peer A, Van Leeuwen L, Zuurmond WW. Comparison of intravenous and intranasal sufentanil absorption and sedation. Canadian Journal of Anaesthesia. 1989; 36: 494–497.

[75] Fitzgibbon D, Morgan D, Dockter D, Barry C, Kharasch ED. Initial pharmacokinetic, safety and efficacy evaluation of nasal morphine gluconate for breakthrough pain in cancer patients. Pain. 2003; 106: 309–315.

[76] Arora P, Sharma S, Garg S. Permeability issues in nasal drug delivery. Drug Discovery Today. 2002; 7: 967–975.

[77] Sunshine A. New clinical experience with tramadol. Drugs. 1994; 47: 8–18.

[78] Dayer P, Collart L, Desmeules J. The pharmacology of tramadol. Drugs. 1994; 47: 3–7.

[79] Schaffer J. Investigation of tramadol for post-operative analgesia in children. Fortschritte Anasthesiology. 1989; 3: 42–45.

[80] Schnabel A, Reichl SU, Meyer-Frießem C, Zahn PK, Pogatzki-Zahn E. Tramadol for postoperative pain treatment in children. Cochrane Database of Systematic Reviews. 2015; 2015: CD009574.

[81] Marinho RO. Abducent nerve palsy following dental local analgesia. British Dental Journal. 1995; 179: 69–70.

[82] Pogrel MA, Bryan J, Regezi J. Nerve damage associated with inferior alveolar nerve blocks. The Journal of the American Dental Association. 1995; 126: 1150–1155.

[83] Al-Bahlani S, Sherriff A, Crawford PJ. Tooth extraction, bleeding and pain control. Journal of the Royal College of Surgeons of Edinburgh. 2001; 46: 261–264.

[84] Quirke W, Bhasker K, Choonara I. A clinical trial of topical application of bupivicaine to reduce post-operative pain following dental extractions. Paediatric and Perinatal Drug Therapy. 2005; 6: 197–199.