presentation about analgesics in dentistry

1. Vivek Narayan
Oral Medicine & Radiology

2. IASP defines pain as an unpleasant
sensory and emotional experience
associated with actual or potential
tissue damage or described in terms
of such damage.

3.  Algesia/algia – pain.
 Neuralgia - Pain in one or more nerves
and is described as electric shock like
pain with presence of trigger zones.
 Neuropathic pain - Constant burning
type of pain without presence of trigger
zones.
 Allodynia - Pain due to a stimulus which
does not normally provoke pain.
 Hyperalgesia - Extreme reaction to a
stimulus which is normally painful.

4. Medical management.
Physiatry/physiotherapy.
TENS.
Acupuncture.
Low level laser therapy.
Cognitive behavioral therapy.
Hypnosis.

5.  Analgesic – pain reliever, pain killer.
 Analgesics
1. NSAIDS (non opioid analgesics) –
mild to moderate pain.
2. Opioid analgesics – severe pain.

6.  Arachidonic acid pathway.
 COX converts arachidonic acid
to produce,
1. Prostaglandins
2. Thromboxane
3. Prostacyclin
 COX 1 – secretion of mucus,
hemostasis & renal functions –
house keeping functions.
 COX 2 – induced by cytokines &
other stimuli of inflammation.
Mediators of pain &
inflammation

8. NSAIDS
Non selective COX
inhibitors
Aspirin
Indomethacin
Ibuprofen
Diclofenac
Piroxicam
Ketorolac
Preferential COX 2
inhibitors
Nimesulide
Meloxicam
Nabumetone
Selective COX 2
inhibitors
Celecoxib
Rofecoxib
Analgesics with poor
anti-inflammatory
action
Acetaminophen
Nefopam

9.  Acetyl salicylic acid.
 Converted to salicylic acid by the body.
 Acts on peripheral pain receptors.
 Hyperglycemia at toxic doses.
 Hyperventilation, asthma.
 GI irritant, ulcers.
 Prolonged bleeding.
 Dosage - 325 to 650 mg orally every 4
hours as needed, not to exceed 4 g/day

10.  Less effective than aspirin.
 Inhibits PG synthesis.
 Prolongs bleeding time.
 Gastric discomfort.
 Nausea & vomiting.
 Precipitates asthma.
 Indicated in RA, osteoarthritis, soft tissue
injuries & after tooth extraction.
 Dosage – 400mg q4 – 6h. Maximum
2.4g.

11.  Has all analgesic, antipyretic & anti-
inflammatory actions.
 Inhibits PG synthesis.
 Short lasting anti platelet action.
 Good tissue penetration.
 Concentration is 3 times the plasma t1/2 in
synovial fluid .
 Nausea, headache & dizziness.
 Used in arthritis, ankylosing spondyltits.
 Dosage – 50mg – 100mg q4 – 6h not to
exceed 150mg.

12.  Paracetamol.
 Central action & increases pain
threshold.
 Good antipyretic.
 Poor anti-inflammatory.
 No significant adverse effects.
 Used as analgesic for headache &
musculoskeletal pain, osteoarthritis.
 Dosage – 500mg – 1000mg q4 – 6h
not to exceed 4g.

13.  Locally acting NSAIDS.
 Inhibits prostaglandin synthetase.
 Has analgesic & local anesthetic
properties.
 Used for inflammatory conditions
of mouth & throat.
 Contraindicated in hypersensitivity.
 Oral tissue numbness & stinging
sensation may occur.
 Dosage – 0.15% mouthwash to be
used TID.
 Available as TANTUM ORAL RINSE.

15.  Acts on the CNS produces
depression.
 Otherwise called narcotic analgesics.
 Morphine is the prototype drug &
principal opium alkaloid .
 Morpheus – ‘god of dreams’
 Indicated for severe pain conditions.
 Sedation, mental clouding,
constipation, respiratory depression,
tolerance & dependence.

16. Opioid
analgesics
Natural alkaloids
Morphine
Codeine
Semisynthetic
opiates
Heroin
Pholcodeine
Hydrocodone
Oxycodone
Synthetic opioids
Pethidine
Fentanyl
Tramadol

17.  Methyl morphine.
 Converted to morphine by the
body.
 Effective cough suppressant.
 Constipation occurs.
 Used after extraction along with
NSAIDS.
 Dosage – 30mg – 60mg q4 – 6h.

18.  To treat moderate to severe pain.
 As an antitussive to suppress
cough.
 Effect starts after 30 mins & lasts
for 4 – 8hrs.
 Common side effects are nausea,
vomiting, constipation, drowsiness,
dizziness, lightheadedness.
 Dosage – 5mg – 10mg q4 – 6h.

19.  Synthetic centrally acting
analgesic.
 Indicated for moderate to
severe pain.
 Nausea, vomiting, drowsiness,
sedation & fatigue.
 50mg – 100mg q4 – 6h
maximum 400mg.

20.  To use lower doses of drugs.
 Increasing range of action – fast
onset, short acting
(acetaminophen) with a slow
onset, long acting (codeine or
tramadol).
 Targeting different pain
pathways simultaneously.

21.  Eliminate the source of pain, if at all
possible.
 Individualize regimens based on pain
severity and medical history.
 Maximize the non opioid before adding
an opioid.
 Optimize dose and frequency before
switching.
 For NSAIDs, consider,
1. Preoperative dose.
2. Loading dose.
3. Prescribing round-the-clock.
 Avoid chronic use of any analgesic
whenever possible.
 Reduce the dose and duration of any
NSAID or opioid in the elderly.

22. SEVERE PAIN – strong
opioids (morphine, heroin,
oxycodone) + non opioids
MODERATE PAIN – weak
opioid (codeine, tramadol)
+ non opioids
MILD PAIN –
acetaminophen, NSAIDS

23.  Primarily used to treat epilepsy or
seizures.
 MOA – reduces neuronal
hyperexcitability that is fundamental to
seizures.
 Neuralgic & neuropathic pain is also
because of neuronal hyperexcitability.
 Anticonvulsants used,
1. Carbamazepine
2. Oxcarbazepine
3. Phenytoin
4. Valproic acid
5. Lamotrigine
6. Baclofen

24.  Odontogenic infection &
inflammation.
 Post extraction, post surgical pain.
 Cracked tooth syndrome.
 Eagle’s syndrome.
 Neuralgias,
1. Trigeminal neuralgia.
2. Glossopharyngeal neuralgia.
3. Post herpetic neuralgia.
 Fractures – odontogenic &
osteogenic.
 Pain in carcinoma.
 Oral mucosal lesions.