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Pain & analgesics /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 www.indiandentalacademy.com ,or call
0091-9248678078


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  • 1. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  • 2. I: Pain and Analgesics • Pain ”an unpleasant sensory and emotional experience with actual or potential tissue damage or described in terms of such damage” (International Association for the Study of Pain, 1979) • Analgesia absence of pain www.indiandentalacademy.com
  • 3. Pain pathways • Specialized receptors = free nerve endings • Stimulation – Mechanical damage – Extreme temperature – Chemical irritation • Two types of neurons – A-delta: first pain, sharp – C: second pain, dull • Four distinct processes – Transduction, transmission, modulation, perception www.indiandentalacademy.com
  • 4. Tissue damage • Release of chemical substances and enzymes (mediators) that alter the activity and sensitivity of sensory neurons – Prostaglandins, leukotriens: sensitization of receptors – Bradykinin and PGs: stimulate the neurons directly – Histamine: pain, itching • Result – increase in nociceptor activity – Hyperalgesia – Neurogenic edema www.indiandentalacademy.com
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  • 6. Dorsal horn • Wind-up – neurotransmittors causing enhanced excitability and sensitization of dorsal horn cells – Persistent changes – Cause of allodynia (”touch becomes pain”) – Prevented by pre-treatment with e.g opioids www.indiandentalacademy.com
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  • 8. Perception • Somatosensory cortex, cingulate cortex – Sensory discrimination – Emotional response • fear, anxiety and panic • subjective experience • Reticular formation – Increased arousal – Emotional response – Somatic and autonomic motor reflexes • Induction of biological and behavioural changes www.indiandentalacademy.com
  • 9. Perception cont. • Higher vertebrates – Anatomical components for perception of pain – From the last third of embryonic development • Primitive vertebrates – Fish, reptiles, amphibians – avoidance or escape behavior – poorly developed cerebral cortex www.indiandentalacademy.com
  • 10. Pharmacological treatment of pain • • • Periphery-along axons-CNS Single treatment/polymodal Continuosly/ intermittently 1. 2. 3. 4. 5. 6. Regional ane NSAIDs Opioids NMDA-receptor agonists Alpha-2-receptor agonists Other agents www.indiandentalacademy.com
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  • 12. 1. Regional anesthesia • • • • Lidocaine (lignocaine): Xylocain® Bupivacaine: Marcain ® Tricaine: MS-222® Preoperatively and postoperatively • Underuse in small species • Na+channels www.indiandentalacademy.com
  • 13. 1. Regional anesthesia cont. • • Sensory, motor and sympathetic nerves Duration – – • Toxicity – • lipid solubility (bupivacaine > lidocaine) Adrenaline (1: 200,000): cave appendices convulsions, hypotension, ventricular arrhythmia and myocardial depression Application – Local infiltration, mucous membranes, eye, ear, around a nerve, intrapleurally, epidurally www.indiandentalacademy.com
  • 14. 2. NSAIDs • • • • • • • • Non-steroidal anti-inflammatory drugs Reduce synthesis of PGs Cox inhibitors (cyclooxygenase) Diminish nociceptor activation Block peripheral sensitization Antipyretic Anti-hyperalgesic No sedation www.indiandentalacademy.com
  • 15. 2. NSAIDs cont. • • • • • Salicylates (aspirin) Ketoprofen: Romefen® Carprofen: Rimadyl ® PO, SC, IM Gastrointestinal ulceration and renal function disturbances, embryotoxic, prolong bleeding www.indiandentalacademy.com
  • 16. 3. Opioids • Spinal cord – Decreasing neurotransmitter release – Blocking postsynaptic receptors – Activating inhibitory pathways • Receptor subtypes – mu> delta> kappa • Supraspinal analgesia • Peripheral analgesia (prevent nociceptor sensitization) www.indiandentalacademy.com
  • 17. 3. Opioids cont. – – – – – – – Morphine Fentanyl: Leptanal®, Hypnorm® Sufentanil Burprenorphine: Temgesic® Sedation PO, SC, IM, IP Side effects: • • respiratory depression, severe bradycardia, decreased gastric Less from delta agonists www.indiandentalacademy.com HCl secretion
  • 18. 4. NMDA-receptor antagonists • Spinal cord receptors – Repetitive c-fiber activation – Central hyperalgesia • • • • • • Not effective against acute inflammatory pain Effective against prolonged inflammatory pain Neuropathic and cancer pain Abolish the wind-up phenomenon Work in synergy with opioids Ketamine, tiletamine www.indiandentalacademy.com
  • 19. 5. Alpha-2-agonists – – – – – – – – Xylaxine: Rompun® Medetomidine: Domitor® Receptors in the spinal cord and brain Activated by descending noradrenergic pathways Inhibit pre-synaptic calcium influx and neurotransmitter release IM, SC, IP, IV sedation, analgesia, muscle relaxation and anxiolysis Side effects • • • • • • • – Initial hypertension Hypotension Bradycardia Decreased cardiac output Depress insulin release Diuresis Hypothermia Specific antagonist atipamezole: Antisedan® www.indiandentalacademy.com
  • 20. 6. Other agents • Sedatives and tranquillizers – – – – – – – Diazepam, acepromazine, fluanisone Relieve anxiety, decrease stress Minimal respiratory and cardiovascular effects Hypotension, hypothermia GABA (enhancement), dopamine (blockade) Antagonist (flumazenil) SC, IM, IV • Tricyclic antidepressants – Amintryptilline www.indiandentalacademy.com
  • 21. II: Pain management • • • • Prevention: preemptive approach Recognition of pain Choice of substance Drug dose and duration www.indiandentalacademy.com
  • 22. Do animals experience pain? • No direct evidence • Subtle behavioural responses – Complex learning to avoid noxious stimuli – Self-administration of analgesics in chronic pain conditions – Response to analgesics • Assessment central www.indiandentalacademy.com
  • 23. Why treat pain? • Legal and ethical reason • Beneficial for the animal • Beneficial for reserach – Rapid return to normal function – A higher survival rate – Counteract physiological changes • Thoracic and abdominal pain affect ventilation • Reduction in food and water consumption www.indiandentalacademy.com
  • 24. Recognition of pain • Prey animals mask pain • Nocturnal species • Signs to look for – – – – – – – General appearance and condition Attitude, posture and movements Interactions with cage mates Reactions to manipulation Food and water consumption Production of faeces and urine Species-typical signs of pain and distress – Procedure-specific signs www.indiandentalacademy.com
  • 25. Pain during anaesthesia • No consciousness-no pain perception (acute experiment) • Sensory nerve activity and sensitization still possible • Avoid unnecessary postoperative pain! • Recognition of pain during surgery – Spontanous movements – Movemenets in reaction to nociceptive stimulation – Respiration and puls frequency – Blood pressure – Withdrawal reflexeswww.indiandentalacademy.com
  • 26. Postoperative pain • Peripheral sensitization • Central sensitization – Amplification of pain sensation • Surgery – Inflammatory pain – Neuropathic pain • Prevention by preemptive analgesia www.indiandentalacademy.com
  • 27. Drug delivery • Oral delivery – – – – Dosing Consumption Degradation NSAIDs • Aspirin • carprofen – Opioids • buprenorphine • Parenteral delivery – S/c, i/p, i/v, sublingual, rectal www.indiandentalacademy.com
  • 28. Drug Mouse Rat Guinea pig morphine 2-5 mg/kg SC, 4 hourly 2-5 mg/kg SC 4 hourly 2-5 mg/kg SC 4 hourly butorphanol 1-2 mg/kg SC 4 hourly 1-2mg/kg SC 4 hourly 2 mg/kg SC buprenorphine 0.05-0.1 mg/kg SC 8-12 hourly 0.01-0.05 mg/kg SC or IV 0.1-0.25 mg/kg by mouth 8-12 hourly 0.05 mg/kg SC 8-12 hourly carprofen 5 mg/kg SC or by mouth 24 hourly 5 mg/kg SC or by mouth 24 hourly ketoprofen ibuprofen 5 mg/kg SC or by mouth 24 hourly 30 mg/kg by mouth 24 hourly 15 mg/kg by mouth 24 hourly lidocaine 4 mg/kg or 0.4 ml/kg of a 1% solution bupivacaine 1-2 mg/kg or 0.4-0.8 ml/kg of a 0.25% solution amitriptyline 1.2-5 mg/kg SC or IP 3-12 hourly 1-10 mg/kg SC or IP 3-12 hourly imipramine 2.3 mg/kg SC or IP 12-24 hourly 10 mg/kg SC or IP 12-24 hourly www.indiandentalacademy.com
  • 29. Use of local anaesthetics 1. Topical, local infiltration, nerve block • 1. Skin, eye, ear canal, epidurally, periost, Reduction of anesthetic needs Post-operative analgesia Maximum dose for 2. 3. • • lidocaine: 4mg/kg bupivacaine: 2mg/kg www.indiandentalacademy.com
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  • 31. Fish anaeshthesia • MS-222 (tricaine) www.indiandentalacademy.com
  • 32. Use of NSAIDs 1. 2. 3. 4. For mild-moderate pain Acute and chronic pain When opioids are contraindicated Preemptively before inhalation or injection anaeshetsia: carprofen 5. In combination with local anaesthetics or opioids for severe postoperative pain 6. Not in pregnant animals www.indiandentalacademy.com
  • 33. Main use of opioids 1. Preemptive analgesia and sedation – – – 1. Before inhalation anesthesia Before pentobarbital aneshtesia Not before other injectables Intraoperative pain relief (fentanyl) – – – With pentobarbital for acute experiments in pigs Pig cardiac protocols Rodent anesthesia – 1. Hypnorm® (fluanisone + fentanyl) Postoperative pain relief – – Buprenorphine (Temgesic®) after Hypnorm or ketamine combinations Peak duration after 30min www.indiandentalacademy.com
  • 34. Management of postoperative pain • • • • Preemptive analgesia Good surgical technique Sterile technique Supportive therapy – – – – Soft food Long drinking nipples Soft bedding Warm environment • Avoid social isolation www.indiandentalacademy.com
  • 35. Management of postoperative pain cont. • Minor procedures – • single dose of an opioid or NSAID sufficient (preoperatively when possible) More invasive surgery – • Continue treatment for up to 24-36h After major surgery – – – Continue analgesic administration for 36-72 hours Combination therapy • • • Opioid NSAID Local analgesiawww.indiandentalacademy.com
  • 36. Examples of analgesic treatment • Implantation of brain canula rat: – Preemptive buprenorphine 0,05mg/kg – Isoflurane anestesia – Local infiltration with bupivacaine • Ovarioectomy mouse – Ketamine/medetomidine ane – Buprenorphine towards the end of the procedure www.indiandentalacademy.com
  • 37. Examples of analgesic treatment cont. • Arthrodesis lumbar spine rabbit – – – – – – – – – Preemptive carprofen EMLA cream ear Induction of aneasthesia with propofol Maintainance with isoflurane anesthesia Local infiltration with bupivacaine Buprenorphine before recovery Feeding with baby food (carrot, apple) Fluids i/v Continuation of bup for 24-48h and NSAID for 72 or more h www.indiandentalacademy.com
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  • 42. Thank you For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com