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Control of pain & anxiety /certified fixed orthodontic courses by Indian dental academy


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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit ,or call

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  • 1. CONTROL OF PAIN AND ANXIETY INDIAN DENTAL ACADEMY Leader in continuing dental education
  • 2. PAIN The international association for the study of pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or describe in terms of such damage. “
  • 3. Major disorders causing facial pain Neural - Trigeminal neuralgia Multiple Sclerosis Glossopharyngeal neuralgia Vascular - Temporal arteritis Migraine headache Cluster headache Angina pectoris
  • 4. Musculo Skeletal - TMJ disorders MPDS Eagle’s syndrome Oral / Salivary - Dental Salivary gland Inf/Inflammation Duct blockage Gland tumors ENT related - Otitis / Sinusitis Psychogenic - Atypical facial pain
  • 5. ANXIETY It is an emotional state, unpleasant in nature, associated with uneasiness, discomfort and concern of fear about some defined or undefined future threat.
  • 6. Conscious Sedation A state of mind obtained by IV administration of combination of anxiolytics, sedatives, and hypnotics and /or analgesics that render the patient relaxed, yet allows the patient to communicate, maintain patent airway and ventilate adequately.
  • 7.
  • 8.  There have been remarkable advances in anesthesia and surgical procedures as well as in dental surgery.  These milestones in dental and surgical treatment have made it possible to perform procedures with greater precision, predictability, speed and safety and often without pain.  However despite these advances a common problem that still faces oral and maxillofacial surgeons is patients fear and anxiety regarding the pain and discomfort associated with their treatment.
  • 9. Therefore,  the preoperative, intraoperative postoperative management of pain and anxiety is a challenge faced by oral and maxillofacial  and major surgeons. Research into the basic mechanisms of acute pain and anxiety has led to a number of new strategies that have yielded more precise and controlled forms of anesthesia. - More molecularly focused approach - Target specific receptor sites
  • 10.  This receptor oriented approach has allowed to move from using only inhalation anesthetics or high dose barbiturates for GA.  Safer alternatives and increasingly more specific agents include, -  Benzodiazepines High potency synthetic opioids and propofol Similarly new classes of analgesic drugs such as NSAIDS, Cox-II inhibitors and opoid agonist – antagonists have been developed in managing pain among out patients.
  • 11. GOALS OF THERAPY  Alleviate patients fear and anxiety  Sedate and calm patient intra operatively  Minimize spontaneous movements intraperatively  Alter patients recall (antegrade amnesia)  Maintain protective reflexes (conscious sedation)  Allow rapid and complete recovery in OP settings  Achieve safe and effective pain and anxiety control.
  • 12. Pre emptive / Preventive Strategies  Implementation of strategies to preempt or prevent the pain resulting from surgical procedures or trauma that provoke the release of inflammatory mediators, as well as a cascade of pain inducing substances. - Long acting anesthetics - NSAID’S - Corticosteroids
  • 13.  Another preemptive strategy involves the preoperative control of patients anxiety. In this regard, some clinicians are using the technique of “pre programming” their patients before surgery. This technique effectively shapes patient expectations, primes patients for effective pain management and has the potential to reduce anxiety.
  • 14.
  • 15. Pharmacologic Agents used in Oral Maxillofacial Surgery Surgeons are increasingly using systemic corticosteroids administered on a short term basis to control facial edema and pain in patients having elective bony surgery of the face. (JOMS 50 : 270, 1992)
  • 16. OPIOIDS There is also a role for opioids in the prevention and control of post operative pain. 3 classes of opioids currently used. 1. Single entity agonists (Meperidine or morphine) administered by injection or orally. Because of dose adverse effects, these drugs appear to have OMFS. related limited place in
  • 17. 2. The most widely prescribed type of opioids are those in combination with other analgesic agents Codeine, hydrocodone and oxycodone, in combination with aspirin, acetaminophen or ibuprofen. 3. The opioid agonist antagonists such as the intranasal formulation of butorphanol also have been developed for post operative pain.
  • 18. NSAID’S NSAID’S are another class of analgesic commonly used for mild to moderate pain. A related new class of drugs is the COX-II inhibitors, which deliver pain relief with a significantly lower risk of serious side effects common to chronic NSAID use particularly. - Gastrointestinal perforation - Ulcers and - Bleeding Although variety of newer analgesic agents are used for the control of pain, LA’s, sedative hypnotics, and GA continue to be widely used.
  • 19. Guidelines for Anxiety control & Pain management in OMFS Pain and anxiety control involve the application of various physical, chemical and psychologic modalities aimed at preventing and treating preoperative, intraoperative, and post operative patient anxiety and pain. Organizations Agencies - ADA - WHO - AAOMS - AHCPR - AAP - AAPD - APS
  • 20. The guidelines will be presented in 2 separate categories - Anxiety control - Pain control However it should be noted that techniques focused on one type of control often affect the other.
  • 21. Anxiety Control ADA – has published 3 guidelines for the management of pain and anxiety. ADA divides Pain & Anxiety control into 3 subcategories. 1. Combined inhalation – enteral conscious sedation 2. Parenteral conscious sedation and 3. Combination of deep sedation and GA
  • 22. 1. Guidelines for Combined Inhalational enteral conscious sedation are a. Patient evaluation (ASA classes I – IV) b. Preoperative or preanesthetic informed consent c. 1 additional support person with or without BLS training d. Mandate monitoring by pulse oximetry and periodic evaluation of vital signs.
  • 23. 2. Parenteral Conscious Sedation a. 1 additional support person who must have BLS training b. IV access should be established and maintained c. That a positive pressure O2 system be available d. Patients with CV disease be monitored by continuous ECG.
  • 24. 3. Deep Sedation and GA a. 2 BLS trained person in addition to the surgeon b. Use of in line O2 analyzers and end tidal CO2 monitoring – if not intubated, the patient may have either end tidal CO2 or precordial stethoscope monitoring of respiratory rate. c. Recording the body temperature and vitals signs are taken every 5 minutes
  • 25. AAOMS Have published guidelines for anesthesia divided into 3 categories. 1. Conscious sedation is defined as minimally depressed consciousness, anxiety and or pain. This state is achieved while retaining an independent and continuous airway and response to physical stimuli and verbal commands Full recovery in 12 hours.
  • 26. 2. There are 3 criteria for determining the 2nd category – Deep Sedation. Inability to respond to physical stimuli or verbal commands, partial or complete loss of protective reflexes and the absence of pain, anxiety, awareness and recall. Recovery – 12 hours 3. General Anesthesia Inability to maintain the airway Recovery 12 hours.
  • 27. AAPD AAPD follows the guidelines of AAP. Goals are to achieve sedation levels 1 – 4 based on following functional measures of sedation. Level 1 - Mild sedation (reduction of anxiety) Level 2 - Minimal depression with interaction possible Level 3 - Non interaction but arousal with mild to moderate stimulus Level 4 - Non interaction and non arousal except with intense stimulus
  • 28.  Facilitate quality care  Minimize disruptive behaviour  Promote positive psychologic response to treatment  Promote welfare and safety and  Return to a normal state of safe discharge AAPD provides guidelines for preemptive anxiolytic control by means of oral medication. Preemptive control calls for the administration of minor tranquilizers (hydroxyzin or benzodiazipines).
  • 29. Anti-Anxiety Drugs 1. Benzodiazepines - Diazepam Lorazepam Oxazepam Alprazolam 2. Azapirones - Buspirones Isapirone Gepirone 3. Other sedatives - Hydroxyzine 4. β blocker - Propanolor
  • 30. Drugs commonly used for IV sedation, Sedative hypnotic and anti-anxiety drugs Benzadiazipines - Diazepam, Midozolam Barbiturates Methahexitone - Non Barbiturate Drugs Propofol Ketamine Neurolept analgesics Anti-histamines Promethazine Narcotics Pethidine, Pentazocine, Fentanyl
  • 31. Control of Post Operative Pain Neither ADA nor the AAOMS have published specific guidelines regarding management of acute post operative pain. In 1990 WHO devised an “analgesic ladder”, a stepwise approach to treat mild to severe pain.  Non opioid agents and possibly adjuvants should be used for mild pain.  Opioids with non opioids and possibly adjuvants should be used for mild to moderate pain. Severe pain should be addressed with opioids and if needed, non opioids and adjuvants. 
  • 32. The APS adapted and simplified this “Analgesic Ladder” by recommending that opioids be used when non opioids fail to control pain. The AHCPR published guidelines in 1992 that categorize pain in to 2 levels. - Mild to moderate and - NSAID’S - Moderate to severe - OPIODS
  • 33. The AAOMS combined the guidelines of these three agencies and also addressed 2 levels of post operative pain. - Mild to Moderate - NSAID’S and Low dose Opioid / Non –Opioids - Moderate to Severe - Opioids and Select NSAID’S / Non-Opiods
  • 34. Drug Selection & Use The APS, the AAOMS, and the AHCPR have evaluated and recommended the use of non opioids, including acetaminophen, salicylates / aspirin and NSAID’S for mild pain.   Low dose opioids which include morphine like agonists such as codeine, hydrocodone, oxycodone and mixed agonist / antagonists (such as transnasal butorphanol) are indicated for mild moderate pain.  Opioids for severe pain. The ideal agent to treat moderate to severe pain associated with OMFS should be potent and quick acting.
  • 35. OPIODS RECOMMENDED FOR SEVERE PAIN Morphine like agonists : Morphine, hydrocodone, oxycodone, codeine Mixed Agonist/Antagonists : Butarphanol, Nalbuphine, dezocine Partial Agonist : Buprenorphine
  • 36. The APS, the AHCPR and the AAOMS stipulate an acute pain management schedule for administration of these agents. For dental surgery  Behavioural or anxiolytic therapy for disproportionate anxiety  Oral NSAID’S for simple extraction and  Long acting LA’S and Oral NSAID opioid combinations for OP control of moderate pain.  Where surgery inhibits oral intake, IV – preferred route.  Transnasal administration of analgesics is another alternative to oral medications for the control of post operative pain after O.S.
  • 37. NSAID’S and OPIODS – Safety and usage concerns in the differential treatment of postoperative orofacial pain Post surgical pain can be managed effectively by using specific treatment methods that are well justified by current research. These include, 1. Comprehensive presurgical consultation 2. Consideration of the use of sedation or GA 3. Use of Long acting LA
  • 38. 4. Administration of an oral analgesics prior to surgery 5. Meticulous and careful surgery 6. Administration of perioperative glucocorticoid 7. Post operative convalescence 8. A regularly administered analgesic for 48 – 72hours 9. Consideration of rescue medication 10. Return for evaluation of unusual or unexpected pain.
  • 39. ADVANTAGES OF NSAID’S 1. NSAID’S interfere with the production of prostaglandins in the surgical wound.  Conversion of arachidonic acid into prostaglandins by cyclooxygenase is inhibited  Reduction of prostaglandins in the surgical wound results in a diminished intensity of pain by essentially elevating the threshold at which pain afferent nerves discharge.
  • 40. 2. Effective and useful analgesics for post surgical pain 3. No risk of addiction and abuse potential 4. NSAID’S have a topical effect when applied to the surgical wound and a local effect when injected in or around an area of wounded tissue.
  • 41. Risks associated with the use of NSAID’S  Spontaneous GI hemorrhage  Effect on the genito urinary system  Nephrotoxicity  Dyspepsia  Peptic ulcer  Dysphagia  Abdominal pain Aspirin and NSAID’S have significant risk potential for severe allergic reactions of anaphylaxis. 
  • 42. Other Potential Adverse Effects  CVS (Tachycardia, edema)  CNS (Dizziness, Headache)  Hepatic (increased liver enzymes) have been reported  Bromfenac sodium was recently with drawn because of reported cases of fulminant hepatic necrosis. (JOMS 50; 2004)
  • 43. Advantages associated with the use of opioids  Opioids have been used as analgesic medications for centuries, and are the cornerstone for the management of moderate to severe acute pain.  Opioids have an effect on peripheral sensory nerves  possibility of administering via topical application or local infusion  decrease systemic side effects.  Opioids can be prescribed in combination with NSAID’S for effective pain management.
  • 44. Risks associated with opioids  Patient abuse and dependence  Nausea and vomiting  Gastric intolerance  Constipation  Respiratory depressant effect (So contraindicated in patients with COPD)  Urine retention  CNS (hallucinations, psychomimetic effect)  Hepatic toxicity
  • 45. Drug Interactions A number of drug interactions are associated with analgesics. Many of the interactions occur only after prolonged use. However it is important to determine if patients are taking other medications.
  • 46. Drug Interactions with NSAID’S DRUG INTERACTIONS Antihypertensives (ACE inhibitors, β blockers, duretics) Toxicity Lithium Toxicity Methotrexate Toxicity Digoxin Toxicity Cyclosporine Toxicity Anticonvulsants Toxicity Anticoagulants GI Bleeding Alcohol GI Bleeding Acetaminophen / NSAID’s Nephrotoxicity
  • 47. Drug Interactions with OPIODS DRUG INTERACTIONS Alcohol Sedation Antidiarrheals Constipation Antihypertensives Potentiation of Effect Barbiturates Sedation Carbamazepine Toxicity CNS depressants Sedation Warfarin Increased Coagulations Hypnotics Sedation
  • 48. MPDS It is a functional disorder involving a painful self perpetuating spasm of the masticatory muscles. Pre Disposing Factors • Stress • Clenching and grinding habits • Occlusal abnormalities Muscles found to be commonly involved are • Lateral pterygoid and • Masseter
  • 49. TREATMENT 1. Conservative  Limit parafunctional habits  Warm – hot moist compresses  Soft diet  Limit wide opening  NSAID’S  Inf. Of LA into the trigger point of muscles that are in spasm not containing epinephrine.  Jaw exercises  Opiods 2. Occlusal Splints 3. Biofeed back 4. Nerve Stimulations
  • 50. TENS It is an electrical stimulus which is typically generated from a battery operated device and transmitted to the patient by electrodes applied to the facial skin. TENS blocks pain signals being carried over the small unmyelinated ‘C’ fibers by forming the large myelinated ‘A’ fibers to carry any light touch sensation.
  • 51. TENS may provide pain relief by the physiologic effects of rhythmic muscle movements. The fasiculations of muscles may result in increase in circulation, decrease in edema and decrease in resting muscle activity. Pharmacologic action of TENS may involve the stimulated release of endorphins which are endogenous morphine like substances.
  • 52. ARTICLES
  • 53. The effectiveness of combining analgesic and anxiolytic agents to control pain and anxiety has been evaluated in a multicenter, parallel group, double blinded trial involving 997 ambulatory patients undergoing oral surgery with premedication and LA. JOMS : Vol.10 – 2000, JOHN. R. ZUNIGA
  • 54.  Placebo  Midazolam  Midazolam + Midazolam  Midazolam + Fentanyl  Midazolam + Fentanyl + Methohexital All treatments produced significant reductions in anxiety levels compared with placebo with Midazolam + Fentanyl + Methohexital combination being significantly better than others.
  • 55. Antegrate amnesia was effectively induced and was significant compared with placebo and MDZ + MDZ and MDZ + FEN + MHX producing the most significant amnesia. This study showed that administration of benzodiazipines led to a desired reduction in anxiety, amnesia and high patient acceptance. Greater CNS depression, resulting in better patient cooperation was achieved by adding an opiod or an opiod plus a barbiturate.
  • 56. An open-label evaluation of the efficacy and safety of Stadol NS with Ibuprofen in the treatment of pain after removal of Impacted Wisdom Teeth. JOMS, Vol.10, 2000 -Marvin J, Ladov & Richard K. Stern Robert wood Johnson University Hospital, New Brunswick, NJ. Purpose This study evaluated the efficacy and safety of transnasal butarphanol tartrate in the treatment of patients with moderate to severe pain after oral surgery for the removal of impacted 3rd molars.
  • 57. PATIENTS AND METHODS In this study, 3rd molar extraction was performed on 25 male and 25 female patients. These patients were given Stadol NS (Nasal Spray), 1mg, administered in a single dose every 4 hours as needed. Patients were allowed to remedicate 60- 90mts after the initial dose if required. They also took ibuprofen (400mg) as concomitant medication every 4-6hours for the first 48 hours. Patients recorded pain intensity on a visual analog scale, with 0 representing no pain, to 100 representing the most severe pain.
  • 58. RESULTS Stadol NS significantly reduced pain (by 50%) after 3rd molar extraction within 15 minutes after administration. It had high level of patient acceptance and was well tolerated. CONCLUSION The rapid onset of analgesia and long duration of action shown by Stadol NS in this study, as well as its ease of administration and high level of patient acceptance, suggest that this drug would be an excellent primary choice for the management of pain after 3rd molar extraction and oral surgery in general.
  • 59. THANK YOU!!! Leader in continuing dental education