Analgesics in Periodontics

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this presentation concentrates on the pain killers and thier brief mechanism of action

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Analgesics in Periodontics

  1. 1. Presented by Dr Guru Ram Tej. K I yr Post Graduate Dept Of Periodontics
  2. 2.          Introduction Pain/ Algesia Analgesics Classification Opoid analgesics Non opoid analgesics NSAIDs Contra indications Analgesics used in periodontics
  3. 3. The Sumerians wrote of demons and tooth worms causing tooth decay. People would pray to gods such as Shamash, Anu or Ea to cure them of their painful oral afflictions
  4. 4.  “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”
  5. 5. 1. 2. Pain perception Reception to pain
  6. 6. SUBSTANCES RELEASED  SUBSTANCE-P  SERATONIN  HISTAMIINE  BRADYKININ-prostaglandins to act
  7. 7.  SOMATIC NOCIRECEPTORS  VISCERAL NOCICEPTORS
  8. 8.  Trigeminal nerve Semilunar ganglion (g.g) Sensory root Pons Sensory root Ascending fibres Tactile sensibility Descending fibres Pain and Temperature
  9. 9. Each end organ has its pathway into CNS The pain pathway consists of First order neurons Second Third order neurons order neurons
  10. 10.  Cells of posterior nerve root ganglia  A- delta fibres- marginal cells in posterior gray horn  C- fibres- Substantia gelatinosa in posterior gray horn
  11. 11.  The marginal cells and the cells of Substantia gelatinosa form the second order neurons
  12. 12.  Neurons of Thalamic nucleus, reticular formation, tectum and grey matter around aqueduct of sylvius  These neuron axons reach sensory area of cerebral cortex
  13. 13.     SPECIFICITY THEORY  Descartes-1644  Muller-19th century  Von frey-1895 PATTERN THEORY  Gold Scheider-1894 INTENSITY THEORY GATE CONTROL THEORY
  14. 14. • GATE input • GATE output
  15. 15.  Physical (injury)  Emotional (depression)  Behavioural (focusing on pain)
  16. 16.  Physical (medication)  Emotional (happiness, relaxation)  Behavioural (distraction)
  17. 17.   No one has located the actual gate mechanism Still assumes the organic basis
  18. 18. International Association Of Somatic Pain(IASP)  REGION  SYSTEM  TEMPERATURE CHANGE  PATIENT STATEMENT  ETIOLOGY
  19. 19.  Based on duration Acute and chronic  Based on etiology Inflammatory, Nociceptive and Neuropathic pain  Atypical facial pain  Refered pain
  20. 20.  Arising from  Pulp  Peri radicular region  Exposed dentin  Cracked tooth syndrome
  21. 21.  LOCAL ANESTHETICS  ANALGESICS  NSAIDS  OPOIDS  CONSCIOUS SEDATION
  22. 22.   “Analgesics are a class of drugs which obtunds the perception of pain without producing unconsciousness” These act on CNS or the peripheral pain mechanisms
  23. 23.      Oral Intramuscular Injection Intravenous Injection PCA: patient controlled analgesia Other routes Transdermal Sublingual
  24. 24.  Narcotic (opioid / morphine like analgesics)  Non-narcotic (Non opioid / antipyretic / aspirin like analgesics or NSAIDs)
  25. 25. Opium: oldest types of drugs  Opium is extracted from poppy seeds (Papaver somniferum)  16th century - Analgesic qualities  By the 19th century considered “as legitimate as tobacco or tea”
  26. 26.    Agonists: Morphine Pethidine, methadone and propoxyphene. Antagonists: Naloxone Mixed: Butorphanol, nalbuphine, & buprenorphine.
  27. 27. (a)Phenyl piperidine series- pethidine & fentanyl (b)Methadone series- methadone & dextropropoxyphene (c )Benzomorphan series- Pentazocine & cyclazocine (d)Semisynthetic thebaine derivatives: etorphine & buprenorphine
  28. 28.    Mu Kappa Delta
  29. 29.  CHEMICAL NATURE  MECHANISM OF ACTION  MODE OF ACTION  THERAPEUTIC CLASSIFICATION
  30. 30. CHEMICAL CLASSIFICATION  SALICYLATES - Acetyl salicylic acid (aspirin), sodium salicylate, Mg salicylate, choline salicylate, Na thio salicylate.  PROPIONIC ACID DERIVATIVES Ibuprofen, ketoprofen, naproxen, oxaprozin, flurbi profen  INDOLE ACETIC ACID -Indomethacin, sulindac,  SUBSTITUTED ANTHRANILIC ACIDS -Mefenamic acid, meclofenamate Na  PYRROLE ALKANOIC ACID ketorolac  OXICAMS Piroxicam, meloxicam  DIFLUOROPHENYL DERIVATIVES Diflunisal
  31. 31.     ARYL ACETIC ACID Diclofenac ACETIC ACID DERIVATIVES Etodolac NAPHTHYL ACETIC ACID PRODRUGS Nabumetrone PARA-AMINO PHENOL DERIVATIVES Acetaminophen
  32. 32. ACCORDING TO MECHANISM OF ACTION  NON-SELECTIVE COX INHIBITORS Diclofenac, etodolac, indomethacin, ketoprofen, ketorolac, nabumetone, naproxen, oxaprozin, ibuprofen, flurbiprofen, diflunisol, sulindac, tenoxicam, tolmetin  COX-1 INHIBITORS Aspirin, indomethacin, piroxicam, sulindac  COX-2 SELECTIVE INHIBITORS Celecoxib, etoricoxib, meloxicam
  33. 33. THERAPEUTIC CLASSIFICATION  ANALGESICS Aspirin, paracetamol  ANTI-INFLAMMATORY Indomethacin, naproxen, ibuorofen  ANTI-COAGULANTS Aspirin  ANTI-PYRETICS Aspirin, paracetamol, indomethacin, celecoxib, ibuprofen
  34. 34. W.H.O CLASSIFICATION in 2001  A: DRUGS WITH WEAK ANTI-INFLAMMATORY EFFECT Acetaminophen   B: DRUGS WITH MILD TO MODERATE ANTIINFLAMMATORY EFFECT Propionic acid derivatives, anthranilic acid derivatives C: DRUGS WITH MARKED ANTI-INFLAMMATORY EFFECTS Salicylates, acetic acid derivatives, oxicams, diclofenac.
  35. 35.      Prostaglandins were first discovered in1930s by Ulf von Euler During inflammation, pain, fever, Arachidonic acid is liberated from phospholipids fraction of the cell membrane, Arachidonic acid is then enzymatically converted to prostaglandin (pgi2) and thromboxane a2 in presence of enzyme cycloxygenase Cycloxygenase exists in: Cox-1 (constitutive) Cox-2 isoforms (inducible)
  36. 36.  Gastric mucosal damage – peptic ulcer Nausea, vomiting, blood loss in stools (haemotochesia) Epigastric distress Hypersentivity  Salicylism   
  37. 37. Diclofenac sodium Newer analgesic, anti-inflammatory. Antipyretic  Inhibits prostaglandin synthesis,  short lasting antiplatelet action  Neutrophil – production of superoxide dismutase inhibits chemotaxis
  38. 38.  Piroxicam  Meloxicam  Tenoxicam
  39. 39. Ibuprofen  Prostaglandin synthesis inhibition  Anti inflammatory  Anti pyretic  Dosage – 400mg every 6th hourly
  40. 40.    Nausea, dyspepsia, heartburn, vomiting and abdominal pain Gastric ulceration and bleeding can occur in patients using Ibuprofen for prolonged period of up to one year Drug interactions- thiazides and lithium
  41. 41.  Ketorolac  COX 2 inhibition  Free radical scavenging property  Inhibition of TNF- alpha Contra-indications: Patients on anticoagulants  Uses:  Post –operative pain, acute musculoskeletal disorders.
  42. 42.   Indomethacin prostaglandin synthetase epileptics and pregnant women Sulindac
  43. 43.  MEFANAMIC ACID Low efficacy Plasma half life 2-4 hrs
  44. 44.  Paracetamol: (acetaminophen)
  45. 45. Drug Preparations Route Usual Adult Dose (Mg) Pentazocine 30 mg/ml Lactate (Talwin) Intramuscular, Subcutaneous, Intravenous 30 Pentazocine Hcl 50 mg tablets Oral 50 to 100 Meperidine Hcl 25, 50, 75 and 100 mg / ml Intramuscular, Subcutaneous 50 to 100 50 and 100 mg tablets Oral 50 to 100 Morphine Sulfate 8, 10, 15 and 30 mg / Subcutaneous ml 10 to 15 Control Of Pain And Infection, Dent. Clin. North Am. 17 : 417-427, 1973.
  46. 46.  Pearlman et al in 1997- IBUPROFEN  D W Paquette et al in 1997- KETOPROFEN  J M Thomason et al in 1997- ASPIRIN  A B Pablos et al in 2008- MELOXICAM & DS  C Alen Yen et al in 2008-CELECOXIB  Khalid Al-Hezaimi et al in 2011- KETOROLAC TROMETHACINE
  47. 47.  Eli E Machtei et al in 2011
  48. 48.        Essentials of medical pharmacology- KD Tripathi Lippincots illustrated rewiew pharmacology Pharmacology – padmaja uday Kumar JSSN U30S-6979 Enantiospecific inhibition of ligature-induced periodontitis in beagles with topical (S)-ketoprofen: D.W.Paquette J,P.Fioretlini, C Martusceili R,J. Oringer, T H. Howell, J R. McCullough,D.S.Reasner and R. C williams: J Clin periodontol 1997: 24: 521-528. The analgesic efficacy of ibuprofen in periodontal surgery: A multicentre study: B. Pearlman, S. Boyatzis, C. Daly, R. Evans, J. Gouvoussis, J. Highfield, S. Kitchings, V. Liew, S. Parsons, P. Serb, P. Tseng, C. Wallis: Australian Dental Journal 1997;42:5. Aspirin-induced post-gingivectomy haemorrhage: a timely reminder, Thoniason JM, Seymour RA, Murphy P, Brigkam KM, Jones P: Aspirininduced post-gingivectomv haetnorrhage: a timely reminder, J Clin Periodontol 1997; 24: 136-138
  49. 49.     Effect of Meloxicam and diclofenac sodium on peri implant bone healing in rats: AB Pablos, satunino AR, B Konig, Cristiane F, Vera C de Arujo and Patricia R Cury: J periodontol 2008; 79; 300-306. The effect of a selective cycloxygenase-2 inhibitor (Celecoxib) on chronic periodontitis: C Alen Yen, Petros D Damoulis, Paul C Stark, Patricia L Hibberd, Medha Singh and Anthena S Papas. J Periodontol 2008; 79: 104113. Evaluation of novel adhesive film containing ketorolac for post surgery and pain control: a safety and efficacy study: Khalid Al-Hezaimi, Mansour AlAskar, Zuied Selamhe, Jia- Hui Fu, Ibrahim A. Alsarra, and Hom Lay Wang: J periodontol 2011; 82: 963-968 Multiple applications of Flurbiprofen and chlorhexidine chips in patients with chronic periodontitis: a randomized, double blind, parallel, 2- arms clinical trial: Eli E Machtei, Ilan Hirsh, Maher Falah, Eyal Shoshani, Avi Avramoff and Adel Penhasi. J Clin Periodontol 2011; 38: 1037-1043.
  50. 50. Thank You….
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