Anatomical Risks and Common Errors in Dental Anesthetic Techniques

Local anesthesia is one of the safest and most frequently performed procedures in dentistry. When administered correctly, it allows painless treatment while minimizing patient discomfort.

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However, every injection carries anatomical risks because nerves, blood vessels, muscles, and glands are located close to common injection sites.

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Most complications are preventable and result from inaccurate landmark identification, poor needle positioning, excessive force, or insufficient knowledge of anatomy. Understanding these risks helps both dental professionals and patients appreciate why careful technique is essential for safe treatment.

✅ Why Anatomy Matters in Dental Anesthesia
The success of local anesthesia depends on depositing the anesthetic solution near the target nerve without damaging surrounding structures.

Important anatomical structures include:
▪️ Peripheral nerves, which transmit pain sensations.
▪️ Blood vessels, where accidental injection may cause systemic effects or hematoma.
▪️ Muscles, which can become sore or develop temporary trismus after trauma.
▪️ Salivary glands, which may be affected if the injection is placed too far posteriorly.
▪️ Bone landmarks, which guide accurate needle placement.
Even small variations in anatomy between individuals can influence the effectiveness of anesthesia.

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✅ Common Anatomical Risks

1. Injury to Blood Vessels
Blood vessels are present near many injection sites, especially during inferior alveolar nerve blocks.
Possible consequences include:
▪️ Hematoma
▪️ Swelling
▪️ Bruising
▪️ Temporary discomfort

Risk reduction
▪️ Always aspirate before injection.
▪️ Inject slowly.
▪️ Avoid repeated unnecessary needle insertions.

2. Temporary Nerve Injury
Although uncommon, direct contact with nerves may produce temporary:
▪️ Tingling
▪️ Numbness
▪️ Altered sensation (paresthesia)
Permanent nerve injury is very rare.

Risk reduction
▪️ Respect recommended insertion depth.
▪️ Never force the needle against bone or soft tissues.
▪️ Reposition gently if the patient experiences an electric shock sensation.

3. Intravascular Injection
If anesthetic enters a blood vessel, the patient may experience:
▪️ Increased heart rate
▪️ Anxiety
▪️ Palpitations
▪️ Metallic taste
▪️ Dizziness
These effects are usually temporary.

Risk reduction
▪️ Always aspirate.
▪️ Inject over at least 60 seconds per cartridge.

4. Muscle Trauma
Needle penetration through muscles may cause:
▪️ Trismus
▪️ Pain during mouth opening
▪️ Mild inflammation
Symptoms usually improve within several days.

5. Injury to Salivary Glands
A posteriorly misplaced needle during mandibular block anesthesia may reach the parotid gland, temporarily affecting the facial nerve.
Possible signs:
▪️ Temporary facial weakness
▪️ Difficulty closing one eye
▪️ Drooping of facial muscles
Recovery is generally complete within a few hours as the anesthetic wears off.

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✅ Most Common Errors in Dental Anesthetic Techniques

1. Incorrect Landmark Identification
Failure to locate anatomical landmarks is among the leading causes of unsuccessful anesthesia.
Examples include:
▪️ Incorrect needle height
▪️ Wrong insertion angle
▪️ Improper penetration depth

2. Injecting Too Quickly
Rapid injection increases:
▪️ Tissue pressure
▪️ Injection pain
▪️ Risk of tissue injury
A slow injection improves both patient comfort and anesthetic distribution.

3. Failure to Aspirate
Skipping aspiration increases the chance of accidental intravascular injection.
Modern aspirating syringes significantly improve injection safety.

4. Using Excessive Force
Forcing the needle may:
▪️ Bend the needle
▪️ Damage tissues
▪️ Increase patient discomfort
Gentle movements provide greater control.

5. Poor Patient Positioning
Improper positioning makes anatomical landmarks harder to identify.
The patient's head should remain stable and well supported throughout the procedure.

6. Inadequate Knowledge of Anatomical Variations
Not every patient has identical anatomy.
Variations in:
▪️ Mandibular foramen location
▪️ Bone thickness
▪️ Accessory innervation
▪️ Muscle attachments

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✅ Clinical Tips to Reduce Complications
▪️ Review medical history before anesthesia.
▪️ Explain the procedure to reduce anxiety.
▪️ Use appropriate needle length and gauge.
▪️ Identify anatomical landmarks carefully before insertion.
▪️ Aspirate every time before injecting.
▪️ Inject slowly and steadily.
▪️ Avoid multiple unnecessary penetrations.
▪️ Observe the patient after injection.

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💬 Discussion
Although dental local anesthesia has an excellent safety record, technical errors remain the main cause of preventable complications rather than the anesthetic drugs themselves. Most adverse events can be minimized through proper anatomical knowledge, careful patient assessment, slow injection techniques, and consistent aspiration.
Recent evidence also highlights the importance of ultrasound-guided anesthesia in selected clinical settings. While not routinely used in general dental practice, ultrasound may improve needle visualization and reduce complications in complex cases. Additionally, advances such as computer-controlled local anesthetic delivery (CCLAD) systems can enhance patient comfort by regulating injection speed, although correct anatomical technique remains the most critical factor for success.

🎯 Recommendations
▪️ Study anatomical landmarks regularly and refresh injection techniques through continuing education.
▪️ Always aspirate before depositing anesthetic solution to reduce the risk of intravascular injection.
▪️ Inject slowly, allowing tissues to accommodate the anesthetic with less discomfort.
▪️ Recognize anatomical variations, especially during mandibular nerve block procedures.
▪️ Communicate with patients throughout the injection to detect unusual sensations that may indicate needle contact with neural structures.
▪️ Monitor patients after anesthesia and provide clear instructions regarding expected numbness and when to seek professional care if symptoms persist beyond the normal recovery period.

✍️ Conclusion
Dental local anesthesia is highly predictable and safe when performed with sound anatomical knowledge and proper clinical technique. The most common complications—including hematoma, temporary nerve injury, muscle trauma, and intravascular injection—are uncommon and are largely preventable through accurate landmark identification, routine aspiration, slow anesthetic deposition, and careful patient monitoring. Continuous education and adherence to evidence-based protocols remain the best strategies for maximizing patient safety and improving clinical outcomes.

📚 References

✔ Becker, D. E., & Reed, K. L. (2012). Local anesthetics: Review of pharmacological considerations. Anesthesia Progress, 59(2), 90–101. https://doi.org/10.2344/0003-3006-59.2.90
✔ Malamed, S. F. (2020). Handbook of Local Anesthesia (7th ed.). Elsevier.
✔ Meechan, J. G. (2022). Effective local anesthesia for dental procedures. Dental Clinics of North America, 66(1), 1–16.
✔ Reed, K. L., Malamed, S. F., & Fonner, A. M. (2012). Local anesthesia part 2: Technical considerations. Anesthesia Progress, 59(3), 127–137. https://doi.org/10.2344/0003-3006-59.3.127
✔ Santos, C. F., Modena, K. C. S., Giglio, F. P. M., Sakai, V. T., Calvo, A. M., Colombini-Ishikiriama, B. L., Dionísio, T. J., & Sipert, C. R. (2024). Advances in local anesthesia techniques in dentistry: Current evidence and future perspectives. Journal of Clinical Medicine, 13(5), 1294. https://doi.org/10.3390/jcm13051294

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MI Varnish: A Fluoride Varnish Guide - Uses & Benefits

MI Varnish is a professional fluoride varnish designed to help prevent tooth decay, reduce tooth sensitivity, and strengthen enamel.

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It combines 5% sodium fluoride with CPP-ACP (Casein Phosphopeptide-Amorphous Calcium Phosphate) technology, allowing fluoride, calcium, and phosphate to work together to support enamel remineralization.

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Because of its easy application, pleasant taste, and strong clinical evidence, MI Varnish is widely used in preventive dentistry for both children and adults who are at increased risk of dental caries.

🔘 What Is MI Varnish?
MI Varnish is a topical fluoride varnish that adheres to tooth surfaces after application. It slowly releases fluoride while CPP-ACP helps deliver bioavailable calcium and phosphate, the minerals naturally found in healthy tooth enamel.
This combination supports the repair of early enamel damage before cavities become larger.

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🔘 Components
The main ingredients include:

▪️ ▪️ 5% Sodium Fluoride (NaF) (22,600 ppm fluoride)
▪️ CPP-ACP (Casein Phosphopeptide-Amorphous Calcium Phosphate)
▪️ Ethanol-based varnish carrier
▪️ Natural or artificial flavoring agents
▪️ Resin components that improve adhesion to teeth
Important: CPP-ACP is derived from milk casein, so it is not recommended for patients with confirmed milk protein allergy. However, it is generally considered safe for people with lactose intolerance because it contains milk protein rather than lactose.

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🔘 Common Uses
Dentists commonly recommend MI Varnish for:

▪️ Preventing dental caries
▪️ Remineralizing early enamel lesions (white spot lesions)
▪️ Reducing tooth sensitivity
▪️ Protecting newly erupted permanent teeth
▪️ Patients wearing orthodontic braces
▪️ Patients with dry mouth (xerostomia)
▪️ Individuals with high caries risk
▪️ Root surface caries prevention in older adults
▪️ Patients undergoing orthodontic treatment

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🔘 Benefits
The main advantages of MI Varnish include:

▪️ Strengthens tooth enamel
▪️ Helps reverse early enamel demineralization
▪️ Provides fluoride, calcium, and phosphate simultaneously
▪️ Reduces dentin hypersensitivity
▪️ Easy and quick professional application
▪️ Pleasant taste that improves patient acceptance
▪️ Safe for both children and adults when used appropriately
▪️ Remains on teeth for several hours, prolonging fluoride contact

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🔘 Possible Disadvantages
Although generally safe, some limitations should be considered:

▪️ Not suitable for patients with milk protein allergy
▪️ Temporary sticky feeling after application
▪️ Teeth may appear slightly yellow until brushing
▪️ Rare allergic reactions
▪️ Requires professional application
▪️ Does not replace daily tooth brushing or fluoride toothpaste

🔘 Recommended Frequency

Patient Risk	Recommended Frequency
Low risk	Every 6 months
Moderate risk	Every 3–6 months
High risk	Every 3 months
Orthodontic patients	Every 3–6 months
High-risk children	Every 3 months, according to professional assessment

The dentist should determine the most appropriate interval based on the patient's oral health status.

🔘 Aftercare Instructions
After receiving MI Varnish, patients should:

▪️ Avoid hard or crunchy foods for approximately 4–6 hours
▪️ Avoid brushing or flossing until the following morning, or according to the manufacturer's instructions
▪️ Eat soft foods during the first few hours
▪️ Continue normal oral hygiene afterward
▪️ Attend regular dental check-ups

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🔘 Who Should Avoid MI Varnish?
Professional evaluation is recommended before use in patients with:

▪️ Milk protein allergy
▪️ History of hypersensitivity to varnish ingredients
▪️ Extensive ulcerative oral lesions
▪️ Severe oral inflammation requiring other treatment first

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💬 Discussion
Current evidence supports fluoride varnish as one of the most effective professional methods for preventing dental caries. The addition of CPP-ACP in MI Varnish aims to provide calcium and phosphate alongside fluoride, potentially enhancing enamel remineralization in appropriate clinical situations.
While numerous laboratory and clinical studies suggest benefits from CPP-ACP-containing products, systematic reviews indicate that fluoride remains the primary factor responsible for caries prevention, and the additional benefit of CPP-ACP may vary depending on the patient population and clinical conditions. Therefore, MI Varnish should be viewed as part of a comprehensive preventive strategy that includes fluoride toothpaste, dietary control, and regular dental care.

🎯 Recommendations
For the best results:

▪️ Brush twice daily with fluoride toothpaste.
▪️ Limit sugary foods and drinks between meals.
▪️ Visit the dentist regularly for preventive care.
▪️ Follow the professional application schedule recommended by your dentist.
▪️ Inform your dentist about any milk protein allergy before treatment.
▪️ Use MI Varnish as part of a complete caries prevention program rather than as a stand-alone treatment.

✍️ Conclusion
MI Varnish is a scientifically supported fluoride varnish that combines 5% sodium fluoride with CPP-ACP technology to help strengthen enamel, reduce tooth sensitivity, and prevent dental caries. Its ease of application and prolonged fluoride release make it an effective preventive option for both children and adults. Although it offers important benefits, it should always be used as part of a broader preventive dental program that includes good oral hygiene, healthy dietary habits, and routine professional care.

📚 References

✔ American Academy of Pediatric Dentistry. (2024). Fluoride therapy. The Reference Manual of Pediatric Dentistry, 429–434.
✔ Cochrane Oral Health. (2024). Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews.
✔ Reynolds, E. C. (2008). Calcium phosphate-based remineralization systems: Scientific evidence? Australian Dental Journal, 53(3), 268–273. https://doi.org/10.1111/j.1834-7819.2008.00061.x
✔ Walsh, T., Worthington, H. V., Glenny, A. M., Marinho, V. C. C., & Jeroncic, A. (2019). Fluoride toothpastes of different concentrations for preventing dental caries. Cochrane Database of Systematic Reviews, 3, CD007868. https://doi.org/10.1002/14651858.CD007868.pub3
✔ GC Corporation. (2023). MI Varnish Instructions for Use.

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Orthodontic Lacebacks: Advantages, Limitations, and Clinical Uses

Lacebacks are a simple orthodontic technique that uses stainless steel ligature wires to connect the molar tube to the canine bracket.

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Their main purpose is to control canine movement during the initial stages of fixed orthodontic treatment, helping reduce unwanted forward movement of the front teeth while creating better conditions for dental alignment.

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Although lacebacks have been used in orthodontics for decades, modern evidence suggests that their effectiveness depends on proper case selection, correct activation, and overall treatment mechanics. Understanding both their advantages and limitations helps clinicians use this technique more predictably and safely.

🔹 What Are Lacebacks?
A laceback is a thin stainless steel ligature (commonly 0.009" or 0.010") placed from the first molar tube to the canine bracket.
Unlike power chains or closing coil springs, lacebacks are not intended for space closure. Instead, they provide light, continuous forces that help guide canine position while minimizing undesirable tooth movements during alignment.

Their primary objectives include:
▪️ Controlling canine position
▪️ Reducing incisor proclination
▪️ Preserving anchorage
▪️ Improving alignment efficiency

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🔹 Advantages of Lacebacks

1. Better Control of Canine Movement
One of the greatest benefits of lacebacks is improved control of canine positioning during early treatment.
Rather than allowing the canine to drift forward with the aligning archwire, lacebacks help maintain a more favorable position.
Clinical benefit: better space management and more predictable tooth movement.

2. Reduced Incisor Proclination
Patients with moderate or severe crowding often experience unwanted forward tipping of the incisors during alignment.
Lacebacks help reduce this effect by limiting mesial movement of the canines, thereby decreasing the amount of anterior flaring.
This is especially valuable in patients where facial profile preservation is important.

3. Anchorage Preservation
Maintaining posterior anchorage is essential in many orthodontic cases.
Because lacebacks apply relatively light forces, they can assist in preserving anchorage, particularly when combined with appropriate archwire sequencing and anchorage reinforcement.

4. Simple and Cost-Effective Technique
Lacebacks require only:
▪️ Stainless steel ligature wire
▪️ Basic orthodontic instruments
They are inexpensive, easy to place, and can be adjusted during routine appointments.

5. Improved Biomechanical Control
Lacebacks allow clinicians to introduce controlled forces without adding bulky auxiliaries.
This may improve treatment efficiency during the alignment phase when used appropriately.

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🔹 Limitations of Lacebacks

1. Limited Amount of Tooth Movement
Lacebacks are not designed for major canine retraction.
Their forces are relatively small and mainly intended for positional control rather than active space closure.
For significant canine distalization, other mechanics are usually required.

2. Technique Sensitivity
Proper activation is important.
Excessive tightening may:
▪️ Increase unwanted forces
▪️ Produce patient discomfort
▪️ Cause undesirable tooth movement
Insufficient activation, on the other hand, may produce little or no clinical effect.

3. Dependence on Overall Treatment Mechanics
Lacebacks should never be viewed as an isolated treatment method.
Their effectiveness depends on factors such as:
▪️ Archwire sequence
▪️ Bracket prescription
▪️ Friction levels
▪️ Anchorage strategy
▪️ Patient-specific malocclusion

4. Limited Scientific Evidence for Some Claimed Effects
Although lacebacks are widely taught and used in orthodontics, systematic reviews indicate that high-quality clinical evidence remains limited for several of their proposed advantages.
Some reported benefits are supported primarily by clinical experience rather than strong randomized clinical trials.

5. Require Periodic Monitoring
Ligature wires may loosen over time.
Regular orthodontic appointments are necessary to:
▪️ Assess force levels
▪️ Reactivate if needed
▪️ Prevent unwanted changes

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🔹 When Are Lacebacks Most Useful?
Lacebacks are commonly indicated in:

▪️ Moderate dental crowding
▪️ Extraction treatment protocols
▪️ Early alignment phase
▪️ Cases requiring careful anchorage control
▪️ Patients at risk of excessive incisor proclination

🔹 Advantages vs. Limitations

Advantages	Limitations
✔️ Simple technique	⚠️ Limited active tooth movement
✔️ Low cost	⚠️ Requires proper activation
✔️ Good canine control	⚠️ Cannot replace retraction mechanics
✔️ Helps preserve anchorage	⚠️ Depends on overall biomechanics
✔️ May reduce incisor flaring	⚠️ Evidence remains limited for some effects

🔹 Clinical Tips
▪️ Use light activation to avoid excessive force.
▪️ Combine lacebacks with an appropriate archwire sequence for better control.
▪️ Monitor activation regularly at each adjustment visit.
▪️ Do not use lacebacks as the sole method of canine retraction.
▪️ Individualize treatment according to each patient's malocclusion and anchorage requirements.

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💬 Discussion
Lacebacks remain a valuable adjunctive technique in modern orthodontics because they provide simple, inexpensive, and effective control of canine position during early treatment. Their greatest strength lies in guiding tooth movement rather than producing large orthodontic forces.
However, clinicians should recognize that lacebacks are not a substitute for comprehensive biomechanical planning. Current evidence supports their use as part of a broader treatment strategy, while acknowledging that some traditional claims require stronger clinical research. When combined with proper diagnosis, suitable archwire progression, and careful anchorage management, lacebacks can contribute to more predictable orthodontic outcomes.

🎯 Recommendations
▪️ Use lacebacks primarily during the initial alignment phase when canine control is needed.
▪️ Apply gentle, controlled activation to minimize discomfort and avoid undesirable tooth movement.
▪️ Assess each patient's anchorage requirements before selecting this technique.
▪️ Combine lacebacks with evidence-based orthodontic mechanics rather than relying on them alone.
▪️ Review current clinical guidelines and emerging research, as orthodontic biomechanics continue to evolve.

✍️ Conclusion
Lacebacks are a practical and reliable orthodontic auxiliary for controlling canine position, preserving anchorage, and helping reduce unwanted incisor proclination during the early stages of treatment. Their simplicity, affordability, and ease of application make them a useful option in everyday orthodontic practice.
Nevertheless, their clinical effectiveness depends on proper case selection, correct activation, and integration with comprehensive treatment mechanics. Understanding both the advantages and limitations of lacebacks allows clinicians to use them more effectively while maintaining evidence-based patient care.

📚 References

✔ Ireland, A. J., Cunningham, S. J., & Petrie, A. (2021). An introduction to orthodontics (5th ed.). Oxford University Press.
✔ Mitchell, L. (2013). An introduction to orthodontics (4th ed.). Oxford University Press.
✔ Proffit, W. R., Fields, H. W., Larson, B. E., & Sarver, D. M. (2023). Contemporary orthodontics (7th ed.). Elsevier.
✔ Zachrisson, B. U. (2007). Improving orthodontic results in cases with maxillary incisors at risk. American Journal of Orthodontics and Dentofacial Orthopedics, 131(4 Suppl), S111–S123. https://doi.org/10.1016/j.ajodo.2006.02.030
✔ Papageorgiou, S. N., Koletsi, D., Iliadi, A., Peltomäki, T., & Eliades, T. (2019). Treatment outcome with orthodontic extraction protocols: A systematic review of the literature. European Journal of Orthodontics, 41(5), 489–498. https://doi.org/10.1093/ejo/cjy077

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Diclofenac in Dentistry: Uses for Children and Adults

Diclofenac is one of the most commonly prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) in dentistry. It helps reduce pain, inflammation, and swelling after dental procedures or during certain oral diseases.

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Although it is effective, it is not the best option for every patient. Age, medical history, pregnancy, kidney function, stomach health, and cardiovascular risk must always be considered before using it.

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This guide explains when diclofenac is recommended in dentistry for both children and adults, how it works, its pharmacokinetics and pharmacodynamics, and the most important safety recommendations based on current scientific evidence.

✅ What Is Diclofenac?
Diclofenac is an NSAID that relieves pain by reducing the production of substances called prostaglandins, which are responsible for inflammation, pain, and fever.
Unlike antibiotics, diclofenac does not treat infections. Instead, it helps control the symptoms while the underlying dental problem receives proper treatment.

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✅ Pharmacodynamics (How Diclofenac Works)
Diclofenac works by blocking the cyclooxygenase enzymes (COX-1 and COX-2).

These enzymes produce prostaglandins, which are involved in:
▪️ Dental pain
▪️ Inflammation
▪️ Swelling
▪️ Fever

By decreasing prostaglandin production, diclofenac provides:
▪️ Strong pain relief
▪️ Reduction of inflammation
▪️ Less postoperative swelling
▪️ Improved jaw function after surgery
Compared with many NSAIDs, diclofenac has a relatively strong anti-inflammatory effect.

✅ Pharmacokinetics (How the Body Handles Diclofenac)

Parameter	Information
Absorption	Rapid after oral administration.
Bioavailability	Approximately 50–60% due to first-pass hepatic metabolism.
Peak Concentration	Usually reached within 1–2 hours after oral administration.
Protein Binding	More than 99%, mainly bound to albumin.
Metabolism	Primarily metabolized in the liver, mainly by the CYP2C9 enzyme.
Half-life	Approximately 1–2 hours.
Excretion	Eliminated mainly through the urine and bile.

Clinical Note: Although diclofenac has a relatively short plasma half-life, its anti-inflammatory effect lasts longer because the drug accumulates in inflamed tissues, allowing prolonged therapeutic activity at the site of inflammation.

✅ When Is Diclofenac Used in Dentistry?

1. Tooth Extraction
One of the most common indications.

It helps reduce:
Postoperative pain
Inflammation
Facial swelling

It is frequently prescribed after:
Simple extractions
Surgical extractions
Wisdom tooth removal

2. Wisdom Tooth Surgery
Third molar surgery produces considerable inflammation.

Diclofenac can reduce:
▪️ Pain intensity
▪️ Trismus (limited mouth opening)
▪️ Swelling during the first postoperative days

3. Acute Dental Pain
Examples include:

▪️ Symptomatic irreversible pulpitis
▪️ Symptomatic apical periodontitis
▪️ Severe toothache before definitive treatment
Diclofenac relieves pain until procedures such as root canal treatment or extraction are performed.

4. Periapical Inflammation
Patients with inflamed tissues around the tooth root often experience moderate to severe pain.

Diclofenac helps reduce:
▪️ Pressure sensation
▪️ Pain during chewing
▪️ Soft tissue inflammation

5. Periodontal Surgery
After procedures such as:

▪️ Flap surgery
▪️ Gingival grafts
▪️ Crown lengthening
Diclofenac can improve postoperative comfort.

6. Dental Implant Surgery
Many clinicians prescribe diclofenac for:

▪️ Implant placement
▪️ Bone graft procedures
▪️ Sinus lift surgery
Its anti-inflammatory effect may improve postoperative comfort.

7. Orthognathic Surgery
Patients undergoing corrective jaw surgery frequently require NSAIDs as part of multimodal pain management.

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✅ Is Diclofenac Used in Children?
Yes, but only in selected situations and under professional supervision.
Diclofenac is less commonly used in children than ibuprofen, mainly because ibuprofen has a more established pediatric safety profile.

Possible indications include:
▪️ Postoperative dental pain
▪️ Dental trauma
▪️ Oral surgery
The dose must always be calculated according to body weight.
Parents should never give diclofenac without medical or dental advice.

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✅ When Should Diclofenac Be Avoided?
Diclofenac should generally be avoided in patients with:

▪️ History of stomach ulcers
▪️ Gastrointestinal bleeding
▪️ Severe kidney disease
▪️ Severe liver disease
▪️ Uncontrolled hypertension
▪️ Heart failure
▪️ Previous heart attack
▪️ Previous stroke
▪️ NSAID allergy
▪️ Late pregnancy (third trimester)

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✅ Common Side Effects
Most patients tolerate diclofenac well when used for a few days.

Possible adverse effects include:
▪️ Stomach pain
▪️ Heartburn
▪️ Nausea
▪️ Vomiting
▪️ Headache
▪️ Dizziness

Less common but serious complications include:
▪️ Gastrointestinal bleeding
▪️ Kidney injury
▪️ Cardiovascular events
▪️ Severe allergic reactions

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✅ Drug Interactions
Diclofenac may interact with:

▪️ Warfarin and other anticoagulants
▪️ Aspirin
▪️ Other NSAIDs
▪️ Corticosteroids
▪️ ACE inhibitors
▪️ Diuretics
▪️ Lithium
▪️ Methotrexate
Patients should always inform their dentist about all medications they are taking.

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✅ Is Diclofenac Better Than Ibuprofen?
Not necessarily.
Both drugs are effective for dental pain.

In many clinical guidelines:
▪️ Ibuprofen is often preferred because of its favorable safety profile.
▪️ Diclofenac may provide stronger anti-inflammatory effects in selected patients but carries a higher cardiovascular risk, particularly with prolonged or high-dose use.

The choice depends on:
▪️ Medical history
▪️ Age
▪️ Cardiovascular risk
▪️ Gastrointestinal risk
▪️ Kidney function
▪️ Type of dental procedure

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💬 Discussion
Diclofenac remains an effective medication for managing dental pain and inflammation, particularly after surgical procedures such as tooth extractions and implant placement. However, current evidence emphasizes that NSAIDs should be prescribed at the lowest effective dose for the shortest possible duration. While diclofenac offers excellent anti-inflammatory activity, clinicians should carefully evaluate patients with cardiovascular, gastrointestinal, renal, or hepatic conditions before prescribing it. In pediatric dentistry, ibuprofen is generally preferred, and diclofenac should be reserved for carefully selected cases under professional supervision.

🎯 Recommendations
▪️ Use diclofenac only after professional dental evaluation.
▪️ Do not use it to replace definitive dental treatment.
▪️ Follow the prescribed dose and duration exactly.
▪️ Take it with food when appropriate to reduce stomach irritation.
▪️ Avoid combining diclofenac with other NSAIDs unless specifically instructed.
▪️ Inform your dentist about any chronic diseases or medications before treatment.
▪️ Seek immediate medical care if severe stomach pain, black stools, chest pain, difficulty breathing, or allergic reactions occur.

✍️ Conclusion
Diclofenac is an effective anti-inflammatory and pain-relieving medication widely used in dentistry, especially after oral surgery and for managing acute inflammatory dental pain. Although it provides reliable symptom relief, it should always be prescribed based on the patient's individual health profile. Children require special dosing considerations, and many pediatric cases are better managed with ibuprofen. Safe use depends on proper diagnosis, correct dosing, awareness of contraindications, and timely dental treatment to address the underlying cause of pain.

📚 References

✔ Abdel Shaheed, C., Ferreira, G. E., Dmitritchenko, A., et al. (2023). The efficacy and safety of non-steroidal anti-inflammatory drugs for acute pain: An overview of Cochrane reviews. Cochrane Database of Systematic Reviews, 2023(5), CD014345.
✔ Hersh, E. V., Moore, P. A., & Papas, A. S. (2020). Adverse drug interactions involving common prescription and over-the-counter analgesic agents. Clinical Therapeutics, 42(8), 1495–1517.
✔ Moore, P. A., Hersh, E. V., & Papas, A. S. (2022). Pharmacologic management of acute dental pain. Dental Clinics of North America, 66(4), 625–639.
✔ Scottish Dental Clinical Effectiveness Programme. (2022). Drug Prescribing for Dentistry (Dental Clinical Guidance, 4th ed.). Dundee: SDCEP.
✔ American Dental Association. (2024). Evidence-based clinical practice guideline for the pharmacologic management of acute dental pain in adolescents, adults, and older adults. The Journal of the American Dental Association, 155(2), 102–117.
✔ National Institute for Health and Care Excellence. (2020). Non-steroidal anti-inflammatory drugs. NICE Clinical Knowledge Summaries.

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Preventing Malocclusion in Children: Early Interventions

Preventing malocclusion in children is one of the most effective ways to support healthy facial growth, proper chewing, clear speech, and long-term oral health.

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Although genetics play an important role in how the teeth and jaws develop, many orthodontic problems can be reduced or even prevented by identifying harmful habits and growth disturbances at an early age.

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Early interventions do not always mean braces. In many cases, they involve encouraging healthy oral habits, preserving primary teeth, monitoring jaw development, and treating problems before they become more complex. Early action often results in simpler, less invasive, and more cost-effective treatment later in life.

🔹 Why Early Prevention Matters
Children experience rapid jaw growth during the first years of life. During this period, the developing bones are more adaptable, making it easier to guide normal growth.

Early prevention can:
▪️ Reduce the severity of future orthodontic problems
▪️ Guide normal jaw development
▪️ Lower the need for tooth extractions
▪️ Reduce treatment time with braces
▪️ Improve facial balance
▪️ Promote better oral function

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🔹 Main Causes of Malocclusion in Children
Several factors contribute to malocclusion.

Genetic Factors
Some children inherit:
▪️ Small jaws
▪️ Large teeth
▪️ Skeletal discrepancies
▪️ Missing or extra teeth
These factors cannot be prevented but can often be managed with early monitoring.

Environmental Factors
Many preventable conditions influence dental development.
Examples include:
▪️ Thumb or finger sucking
▪️ Prolonged pacifier use
▪️ Tongue thrusting
▪️ Mouth breathing
▪️ Premature loss of primary teeth
▪️ Untreated dental caries
▪️ Dental trauma
▪️ Poor oral habits

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🔹 Early Interventions That Help Prevent Malocclusion

1. Promote Healthy Oral Habits
One of the simplest preventive measures is eliminating habits that place abnormal pressure on the developing teeth and jaws.
Parents should encourage children to stop:
▪️ Thumb sucking after 3 years of age
▪️ Prolonged pacifier use
▪️ Lip sucking
▪️ Nail biting when excessive
The earlier these habits stop, the greater the chance that the bite will develop normally.

2. Preserve Primary Teeth
Baby teeth act as natural space maintainers for permanent teeth.
Early tooth loss due to cavities or trauma may allow neighboring teeth to drift into empty spaces, increasing the risk of crowding.
Preventive strategies include:
▪️ Regular dental examinations
▪️ Fluoride use when appropriate
▪️ Good oral hygiene
▪️ Early treatment of cavities

3. Use Space Maintainers When Needed
If a primary tooth is lost prematurely, a space maintainer may prevent neighboring teeth from moving into the empty space.
This simple appliance helps maintain proper eruption pathways for permanent teeth.

4. Encourage Nasal Breathing
Persistent mouth breathing may alter facial growth and increase the risk of:
▪️ Narrow upper jaws
▪️ Crossbites
▪️ Open bites
▪️ Long-face growth patterns
Children with chronic mouth breathing should be evaluated to identify possible airway problems such as allergies or enlarged adenoids and tonsils.

5. Monitor Tooth Eruption
Regular dental visits allow dentists to detect:
▪️ Delayed eruption
▪️ Impacted teeth
▪️ Extra teeth
▪️ Missing permanent teeth
▪️ Abnormal eruption paths
Early identification often simplifies treatment.

6. Correct Functional Problems Early
Children with:
▪️ Tongue thrust
▪️ Incorrect swallowing patterns
▪️ Speech-related oral habits
may benefit from myofunctional therapy or interdisciplinary management when appropriate.

7. Schedule Early Orthodontic Evaluation
The American Association of Orthodontists recommends that every child receive an orthodontic evaluation by age 7, even if no obvious problem is present.
At this stage, dentists can identify developing skeletal or dental problems before they worsen.

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🔹 Signs Parents Should Watch For
Parents should seek a dental evaluation if they notice:

▪️ Difficulty chewing
▪️ Early or late loss of baby teeth
▪️ Crowded teeth
▪️ Crossbite
▪️ Open bite
▪️ Teeth that do not meet properly
▪️ Persistent thumb sucking
▪️ Mouth breathing
▪️ Speech difficulties related to bite problems
▪️ Jaw shifting during chewing

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🔹 Benefits of Early Intervention
Children who receive timely preventive care may experience:

▪️ Healthier jaw growth
▪️ Improved facial symmetry
▪️ Lower risk of severe crowding
▪️ Better chewing function
▪️ Improved speech development
▪️ Simpler orthodontic treatment
▪️ Lower long-term treatment costs
▪️ Greater self-confidence

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🔹 Can Malocclusion Always Be Prevented?
No. Because genetics strongly influence jaw size and tooth position, not every malocclusion can be prevented.
However, many environmental factors are modifiable, and early intervention can significantly reduce the severity of future orthodontic problems.
The goal is often early guidance rather than complete prevention.

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💬 Discussion
Current scientific evidence supports a preventive and interceptive approach to pediatric orthodontics. While hereditary factors cannot be changed, many childhood habits and environmental influences can be addressed before they permanently affect jaw growth and tooth alignment. Preventive care is most successful when dentists, orthodontists, pediatricians, speech therapists, and parents work together. Regular dental checkups throughout childhood allow clinicians to identify risk factors early and intervene at the most favorable stage of development, improving long-term outcomes while minimizing the need for more complex orthodontic treatment.

🎯 Recommendations
▪️ Schedule the first orthodontic evaluation by age 7.
▪️ Maintain routine dental checkups every six months or as recommended.
▪️ Treat dental caries promptly to preserve primary teeth.
▪️ Discourage prolonged thumb sucking and pacifier use after age 3.
▪️ Encourage nasal breathing and seek medical evaluation for persistent mouth breathing.
▪️ Monitor the eruption of permanent teeth during childhood.
▪️ Use space maintainers when premature loss of primary teeth occurs.
▪️ Promote daily oral hygiene and a balanced diet to support healthy dental development.

✍️ Conclusion
Preventing malocclusion in children begins with early identification, healthy oral habits, and regular professional care. Although genetics influence craniofacial development, many orthodontic problems become more manageable when risk factors are addressed during childhood. Preserving primary teeth, eliminating harmful habits, monitoring eruption patterns, and obtaining an early orthodontic evaluation help guide normal growth and reduce the likelihood of complicated treatment later. A preventive approach benefits not only dental alignment but also oral function, facial development, and overall quality of life.

📚 References

✔ American Association of Orthodontists. (2022). Clinical Practice Guidelines for Orthodontics and Dentofacial Orthopedics. American Association of Orthodontists.
✔ Dean, J. A., Jones, J. E., Vinson, L. A., McDonald, R. E., & Avery, D. R. (2022). McDonald and Avery's Dentistry for the Child and Adolescent (11th ed.). Elsevier.
✔ Graber, L. W., Vanarsdall, R. L., Vig, K. W. L., & Huang, G. J. (2023). Orthodontics: Current Principles and Techniques (7th ed.). Elsevier.
✔ Proffit, W. R., Fields, H. W., Larson, B. E., & Sarver, D. M. (2019). Contemporary Orthodontics (6th ed.). Elsevier.
✔ American Academy of Pediatric Dentistry. (2024). Best Practices: Management of the Developing Dentition and Occlusion in Pediatric Dentistry. Chicago, IL: American Academy of Pediatric Dentistry.

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Advances in Pediatric Endodontics: Bioceramic Sealers for Primary Teeth

Bioceramic sealers are among the most important innovations in pediatric endodontics. They are designed to seal root canals more effectively while being highly compatible with the body's natural tissues.

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In primary (baby) teeth, these materials may improve treatment outcomes by reducing bacterial leakage and supporting healing around the roots.

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Although traditional materials such as zinc oxide-eugenol remain widely used, bioceramic sealers are gaining attention because of their excellent biological properties and sealing ability. However, their use in primary teeth should be based on scientific evidence and careful case selection.

✅ What Are Bioceramic Sealers?
Bioceramic sealers are calcium silicate-based materials developed to seal the root canal after cleaning and shaping. Unlike conventional sealers, they interact with body fluids and can form hydroxyapatite, a mineral naturally found in teeth and bone.

Their main characteristics include:
▪️ Excellent biocompatibility
▪️ Strong sealing ability
▪️ High antibacterial environment due to alkaline pH
▪️ Low shrinkage during setting
▪️ Ability to support tissue healing
These properties make them attractive for both permanent and primary teeth.

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✅ Why Are They Important in Primary Teeth?
Primary teeth have unique characteristics:
▪️ Thin dentin walls
▪️ Complex root canal anatomy
▪️ Physiological root resorption before tooth exfoliation
▪️ Close relationship with the developing permanent tooth

Because of these factors, the ideal filling material should:
▪️ Seal the canal effectively
▪️ Be gentle to surrounding tissues
▪️ Not interfere with normal root resorption
▪️ Reduce the risk of reinfection
Bioceramic sealers aim to meet many of these requirements.

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✅ Main Advantages

1. Excellent Biocompatibility
One of the greatest advantages is that bioceramic sealers are well tolerated by surrounding tissues, reducing inflammation if small amounts extend beyond the root.

2. Superior Sealing Ability
A tight seal prevents bacteria from re-entering the canal system.
A better seal increases the likelihood of long-term treatment success.

3. Antibacterial Properties
Their naturally high pH creates an unfavorable environment for many bacteria responsible for endodontic infections.
Although they do not replace proper canal cleaning, they provide an additional level of protection.

4. Bioactivity
Unlike conventional sealers, bioceramic materials actively interact with surrounding tissues.
They can stimulate mineral deposition and support natural healing.

5. Moisture-Friendly Setting
Primary teeth are often difficult to keep completely dry.
Many bioceramic sealers actually benefit from moisture during their setting reaction, making clinical handling easier.

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✅ Current Limitations
Despite their advantages, several limitations remain.

▪️ Higher cost than traditional materials.
▪️ Limited long-term clinical evidence in primary teeth compared with permanent teeth.
▪️ Some products may not resorb at the same rate as primary tooth roots, an important consideration before widespread use.
▪️ Clinical performance varies depending on the specific formulation.
Therefore, not every bioceramic sealer should automatically replace conventional pediatric materials.

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✅ Current Clinical Applications
Bioceramic sealers are being investigated for:

▪️ Pulpectomy in primary teeth
▪️ Management of infected root canals
▪️ Cases requiring excellent apical sealing
▪️ Teeth with periapical inflammation
Most specialists recommend using them when the clinical situation is appropriate and after considering current scientific evidence.

✅ How Do They Compare with Zinc Oxide-Eugenol?

Feature	Bioceramic Sealers	Zinc Oxide-Eugenol
Biocompatibility	Excellent	Good
Sealing Ability	Very High	Moderate
Bioactivity	Yes	No
Antibacterial Environment	High pH	Moderate
Clinical History	Emerging	Extensive
Cost	Higher	Lower
Long-Term Evidence in Primary Teeth	Growing	Extensive

✅ What Does Current Research Say?
Recent studies suggest that bioceramic sealers provide promising biological and sealing properties in pediatric endodontics. Laboratory and early clinical evidence indicates favorable tissue compatibility and reduced bacterial leakage.
However, researchers consistently emphasize that high-quality long-term clinical trials in primary teeth remain limited. Additional evidence is needed before these materials can be considered the universal first choice for every pulpectomy.

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💬 Discussion
The development of bioceramic sealers represents a significant step forward in pediatric endodontics. Their biological compatibility, sealing capacity, and bioactive behavior offer advantages over many traditional materials.
Nevertheless, primary teeth have unique biological characteristics, particularly physiological root resorption. For this reason, clinicians should evaluate whether a specific bioceramic product is suitable for each case rather than assuming that all formulations behave similarly. Current evidence supports their potential, but continued research is essential to define their long-term role.

🎯 Recommendations
▪️ Select bioceramic sealers according to the clinical indication and manufacturer recommendations.
▪️ Maintain thorough canal cleaning and disinfection, as no sealer can compensate for inadequate treatment.
▪️ Consider the expected root resorption pattern when treating primary teeth.
▪️ Stay updated with new clinical studies as evidence continues to evolve.
▪️ Explain treatment options and expected outcomes clearly to parents or caregivers.

✍️ Conclusion
Bioceramic sealers are an important advancement in pediatric endodontics, offering excellent biocompatibility, superior sealing ability, and bioactive properties that may improve the success of pulpectomy in primary teeth.
While early evidence is encouraging, long-term clinical research is still developing. At present, these materials should be viewed as a valuable option within evidence-based pediatric dentistry rather than a complete replacement for established filling materials.

📚 References

✔ Coll, J. A., Dhar, V., Vargas, K., Chen, C. Y., Crystal, Y. O., & Alvares, O. (2020). Use of non-vital pulp therapies in primary teeth. Pediatric Dentistry, 42(6), 337–349.
✔ Donnermeyer, D., Bürklein, S., Dammaschke, T., & Schäfer, E. (2019). Endodontic sealers based on calcium silicates: A systematic review. Odontology, 107(4), 421–436. https://doi.org/10.1007/s10266-018-0400-3
✔ European Society of Endodontology. (2021). European Society of Endodontology position statement: Management of deep caries and the exposed pulp. International Endodontic Journal, 54(7), 923–934.
✔ Moinzadeh, A. T., Zerbst, W., Boutsioukis, C., Shemesh, H., & Zaslansky, P. (2021). Outcome of bioceramic sealers in endodontic treatment: A review of current evidence. International Endodontic Journal, 54(11), 1977–1994.
✔ Nagendrababu, V., Duncan, H. F., Fouad, A. F., Kirkevang, L. L., Parashos, P., Priya, E., Jayaraman, J., Siqueira, J. F., Jr., & Dummer, P. M. H. (2023). PRILE 2021 guidelines for reporting laboratory studies in Endodontology: Explanation and elaboration. International Endodontic Journal, 56(Suppl. 2), 3–64.
✔ Taha, N. A., Abdulkhader, S. Z., & Al-Qudah, A. A. (2022). Calcium silicate–based root canal sealers: A review of biological and clinical properties. Journal of Clinical Medicine, 11(17), 5067. https://doi.org/10.3390/jcm11175067

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NSAIDs in Pediatric Dentistry: Benefits, Risks, and Updated Clinical Protocols

Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most commonly prescribed medications in pediatric dentistry. They help reduce pain, inflammation, and fever, making children more comfortable after dental procedures or during certain oral infections.

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When used correctly, NSAIDs are safe and effective for most healthy children. However, they are not appropriate for every patient. Dentists must carefully consider the child's age, weight, medical history, allergies, and underlying health conditions before prescribing them.

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This guide explains how NSAIDs work, when they are recommended, their benefits, possible risks, and the latest evidence-based clinical protocols in clear and simple language.

✅ What Are NSAIDs?
NSAIDs (Nonsteroidal Anti-inflammatory Drugs) are medications that reduce:
▪️ Pain
▪️ Inflammation (swelling)
▪️ Fever
They work by blocking enzymes called cyclooxygenases (COX-1 and COX-2), which are responsible for producing prostaglandins—substances involved in pain and inflammation.
Unlike antibiotics, NSAIDs do not treat infections. Instead, they help relieve the symptoms while the underlying dental condition is managed.

✅ Common NSAIDs Used in Pediatric Dentistry
The most frequently used NSAIDs include:

▪️ Ibuprofen (first-choice NSAID for most children)
▪️ Naproxen (less commonly used)
▪️ Ketorolac (reserved for selected short-term situations under professional supervision)
Among these, ibuprofen remains the preferred medication because it has an excellent balance between effectiveness and safety when used at the recommended dose.

✅ Clinical Indications
Dentists may recommend NSAIDs for:

▪️ Postoperative pain after tooth extraction
▪️ Pain following pulpotomy or pulpectomy
▪️ Minor oral surgery
▪️ Dental trauma
▪️ Orthodontic discomfort (selected cases)
▪️ Pain associated with irreversible pulpitis before treatment
▪️ Inflammatory oral conditions causing discomfort
NSAIDs should be used only when clinically indicated, not routinely after every dental procedure.

✅ Benefits of NSAIDs in Children
The main advantages include:

▪️ Excellent pain relief
▪️ Reduction of swelling
▪️ Lower fever when present
▪️ Fast onset of action
▪️ Improved comfort after dental treatment
▪️ Reduced need for opioid medications
Current evidence shows that ibuprofen often provides better pain control than acetaminophen alone for inflammatory dental pain.

✅ Updated Clinical Protocols
Current pediatric dental guidelines recommend:

1. Ibuprofen is the first-line medication
For most healthy children with inflammatory dental pain, ibuprofen is considered the first-choice analgesic, provided there are no contraindications.
Typical pediatric dosage:
▪️ 5–10 mg/kg every 6–8 hours
▪️ Maximum daily dose should never exceed the recommended limit based on the child's weight and age.

2. Weight-Based Dosing Is Essential
Children should never receive adult doses.
Medication should always be prescribed according to:
Body weight
Age
Medical condition
Kidney function
Other medications

3. Use the Lowest Effective Dose
Current recommendations emphasize:
▪️ Use the smallest effective dose
▪️ Treat for the shortest necessary duration
▪️ Reassess persistent pain rather than simply extending medication use.

4. Combining Medications
For moderate or severe pain, dentists may recommend alternating or combining ibuprofen and acetaminophen in selected patients.
Parents should follow professional instructions carefully to avoid dosing errors.

5. Antibiotics Are Not a Substitute
NSAIDs relieve symptoms but do not eliminate the cause of a dental infection.
When infection requires treatment, the child still needs appropriate dental care and, when indicated, antibiotics.

✅ Possible Risks and Side Effects
Although generally safe, NSAIDs may cause:

▪️ Upset stomach
▪️ Nausea
▪️ Vomiting
▪️ Heartburn
▪️ Mild abdominal discomfort

Less common but more serious complications include:
▪️ Gastrointestinal bleeding
▪️ Kidney injury (especially with dehydration)
▪️ Allergic reactions
▪️ Worsening asthma in susceptible children
These complications are uncommon when medications are used appropriately.

✅ Who Should Avoid NSAIDs?
NSAIDs may not be suitable for children with:

▪️ Known NSAID allergy
▪️ Previous severe asthma triggered by NSAIDs
▪️ Active stomach ulcers
▪️ Significant kidney disease
▪️ Severe dehydration
▪️ Certain bleeding disorders
The dentist should always review the child's complete medical history before prescribing any medication.

✅ Tips for Parents
Parents can improve medication safety by:

▪️ Giving the correct dose based on weight
▪️ Using a proper dosing syringe or measuring device
▪️ Avoiding duplicate medications containing NSAIDs
▪️ Encouraging adequate hydration
▪️ Following the prescribed treatment duration
▪️ Contacting the dentist if pain persists beyond the expected recovery period
Never increase the dose without professional advice.
💬 Discussion
Recent clinical guidelines continue to support ibuprofen as the preferred NSAID for managing inflammatory dental pain in children, thanks to its proven effectiveness and favorable safety profile. Modern pain management also emphasizes a multimodal approach, where medication is combined with prompt dental treatment and careful follow-up rather than relying on pain relievers alone.
Healthcare professionals are encouraged to prescribe NSAIDs only when necessary, calculate doses based on body weight, and educate caregivers about proper administration. This approach improves pain control while minimizing the risk of adverse effects.

🎯 Recommendations
▪️ Use ibuprofen as the first-choice NSAID when appropriate.
▪️ Always calculate doses according to the child's weight.
▪️ Prescribe the lowest effective dose for the shortest possible time.
▪️ Do not use NSAIDs to delay necessary dental treatment.
▪️ Review the child's medical history before prescribing.
▪️ Advise parents to seek professional evaluation if pain worsens, swelling increases, or fever persists.
▪️ Encourage regular dental checkups to prevent painful conditions that may require medication.

✍️ Conclusion
NSAIDs remain one of the safest and most effective options for managing pain and inflammation in pediatric dentistry when used correctly. Among them, ibuprofen is the preferred first-line medication for most healthy children because of its strong evidence for effectiveness and safety. Careful weight-based dosing, appropriate patient selection, and adherence to updated clinical protocols help maximize benefits while reducing the risk of complications.

📚 References

✔ American Academy of Pediatric Dentistry. (2024). Policy on pediatric dental pain management. In The Reference Manual of Pediatric Dentistry (2024–2025 ed.). American Academy of Pediatric Dentistry.
✔ American Academy of Pediatric Dentistry. (2024). Useful medications for oral conditions. In The Reference Manual of Pediatric Dentistry (2024–2025 ed.). American Academy of Pediatric Dentistry.
✔ American Dental Association. (2024). Clinical practice guideline on acute pain management in adolescents, adults, and older adults undergoing dental procedures. The Journal of the American Dental Association, 155(2), 102–117. https://doi.org/10.1016/j.adaj.2023.11.009
✔ Cooper, T. E., Heathcote, L. C., Clinch, J., Gold, J. I., Howard, R., Lord, S. M., Schechter, N., Wood, C., Wiffen, P. J., & Eccleston, C. (2017). Antipyretic analgesics for acute pain in children: An overview of systematic reviews. Pain, 158(5), 789–796. https://doi.org/10.1097/j.pain.0000000000000842
✔ World Health Organization. (2023). WHO Model List of Essential Medicines for Children (9th ed.). World Health Organization.

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