The document discusses pain and its management. It defines pain and describes different types of pain like neuralgia and neuropathic pain. It discusses medical management of pain including medications like NSAIDs, opioids, and anticonvulsants. NSAIDs discussed include aspirin, ibuprofen, and ketorolac. Opioids discussed include morphine, codeine, oxycodone, and tramadol. The document provides dosing information for these medications and strategies for optimizing pain management.

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.