Analgesics and importance of it in dentistry

1. ANALGESICS

2. CONTENTS
1.INTRODUCTION
2.OPIOID ANALGESICS
3.CLASSIFICATION OF OPIOIDS
4.IMPORTANT OPIOID DRUGS
5. OPIOID ANTAGONISTS
6.NON-OPIOID ANALGESICS
7. ACTIONS OF ANALGESICS
8.IMPORTANT NSAIDS’s
9.SELECTIVE COX-2 INHIBITORS
10.PRINCIPLES FOR PRESCRIBING
ANALGESICS.
11.CLINICAL SIGNIFICANCE OF
ANALGESICS IN CONS AND ENDO
12.ADJUVANT DRUGS
13.SPECIAL SITUATION
14.NEUROPATHIC PAIN
15.CONCLUSION

3. ALGESIA /PAIN- Is an ill defined , unpleasant sensation , usually
evoked by an external or internal noxious stimulus
ANALGESIC- A drug that selectively relieves pain by acting in the
CNS or peripheral pain mechanism, without significantly altering
consciousness
Analgesics are divided into two groups-
A. Opioid/ narcotic/ morphine-like analgesics
B. Non-opioid/ non-narcotic/ aspirin-like/ anti-pyretic/ antiinflammatory
analgesics
INTRODUCTION
K.D Tripathi’s essentials of medical pharmacology 6th edition

4. Opium – A dark brown, resinous material obtained from poppy capsule.
It has been known from the earliest times. Serturner, a pharmacist,
isolated the active principle of opium in 1806 and named it ‘morphine’
after the greek god of dreams Morpheus.
In the last century a large number of semisynthetic and synthetic
compounds have been developed with morphine-like, antagonistic and
mixed agonistic-antagonistic properties
OPIOID ANALGESICS
K.D Tripathi’s essentials of medical
pharmacology 6th edition

5. 1. Natural opium alkaloids - Morphine, Codeine
2. Semi-synthetic opiates – Heroin/ Diacetylmorphine
3. Synthetic opioids – fentanyl, Pethidine( meperidine),
methadone, tramadol
CLASSIFICATION OF OPIOIDS
K.D Tripathi’s essentials of medical pharmacology 6th edition

6. Also known as narcotic analgesics
They are more potent than NSAIDs, and used in low doses less than
15mg
They are used most commonly in combination with NSAIDs, to
enhance analgesic effect, and gain an anti-inflammatory action
Some of the common formulation used in dental practice are-
Codeine/ Aspirin
Codeine/ Acetaminophen
Tramadol/ Acetaminophen
Oxycodon/ Acetaminophen( very powerful)
Oxycodon / Ibuprofen ( very powerful)
Ghom’s Textbook of Oral Medicine, 3rd edition

7. Mechanism of action :
Morphine and other opioids produce their effect by acting on
specific opioid receptors through mu(µ), kappa (κ) and delta
(δ)
These receptors are abundant in the CNS and other tissues.
µ receptors – respiratory depressant+ GI
κ receptors- involved in sedation + GI
δ receptors- development of tolerance
Padmaja udaykumar’s Pharmacology for dental and allied health
sciences 4th edition

8. MORPHINE
Pharmacological actions:
Analgesia- Morphine alters both the perception and reaction to pain
 Euphoria, Sedation and hypnosis
Respiration-Morphine produces significant respiratory depression
Cough center- It directly depresses the cough center and thereby suppresses
cough
Nausea and emesis- Directly stimulates the CTZ in the medulla causing
nausea and vomiting
Pupils- Morphine produces miosis
Bradycardia on vagal stimulation
Causes Hypotension
It decreases motility of the gut

9. Precaution and Contraindications-
- Avoid opioids in patients with respiratory insufficiency- chronic
obstructive pulmonary disease (COPD)
-An attack of bronchial asthma can be precipitated by morphine
-Head injury-morphine is contraindicated as it increases CSF pressure
-In hypovolemic shock, morphine further decreases BP
-Opioids potentiates CNS depressants
Acute morphine poisoning – Respiratory depression, pin-point
pupils, hypotension, shock, cyanosis, coma and death.
Specific antidote- Naloxone- 0.4-0.8mg IV repeated every 10-15 min
Padmaja udaykumar’s Pharmacology for dental and allied health sciences
4th edition

10. CODEINE
It is methyl-morphine, occurs naturally in opium, and is partly
converted in the body to morphine.
It is less potent than morphine, also less efficacious, is a partial agonist
at mu opioid receptor with a low ceiling effect.
Depresses cough center in subanalgesic doses
Codeine has less addiction liability and tolerance is uncommon
Constipation is the most common side effect
It is commonly used as antitussive
It is also available in combination with paracetamol for analgesia. It is
to be given at bed time ( CODOPLUS- Codeine 30mg+ paracetamol
500mg )
K.D Tripathi’s essentials of medical pharmacology 6th edition

11. PETHIDINE
Pethidine is a phenylpiperidine derivative of morphine.
Many of its action resembles that of morphine.
Pethidine is 1/10th as potent as morphine. However , efficacy as an analgesic is
equal to morphine
The onset of action is more rapid and duration of action is shorter
It produces corneal anesthesia
It can also be used as preanesthetic medication
It is less constipating
In toxic doses, pethidine produces CNS stimulation with tremors, restlessness
and convulsions instead of sedation. This is because of toxic metabolite-
norpethidine
K.D Tripathi’s essentials of medical pharmacology 6th edition

12. TRAMADOL
Tramadol is a synthetic codeine analog. It is an effective analgesic but its
mechansim of action is not clear
It is used in acute and chronic pain, like postoperative pain and neuralgias
Adverse effects include drowsiness, dryness of mouth, sedation and nausea. It
is a drug of dependence. It may precipitate seizures. It should be avoided in
patients on MAO inhibitors because tremadol inhibits serotonin uptake
Injected IV 100mg tramadol is equianalgesic to 10mg IM morphine, oral
bioavailability is good
K.D Tripathi’s essentials of medical pharmacology 6th edition

13. OPIOID ANTAGONISTS
It acts as a competitive antagonists to all type of opioid receptors
It promptly antagonizes all the action of morphine including respiratory
depression and sedation and precipitates withdrawal syndrome. It also blocks the
action of endogenous opioid peptides- endorphins, enkephalins and dynorphins.
Duration of action is 3-4 hours
Dose- 0.4mg IV
Naloxone is the drug of choice for morphine overdosage
It can also be used for the diagnosis of opioid dependence- it precipitates
withdrawal symptoms
NALOXONE

14. NALTREXONE
Naltrexone is another pure opioid antagonist. It is more potent than naloxone.
It is also used for opioid blockade therapy in post addicts
MIXED AGONISTIC AND ANTAGONISTS
They include pentazocine, cyclazocine, nalbuphine, buprenorphine.
PENTAZOCINE-
It is a K receptor agonist
It has weak antagonistic properties at mu receptors
Central nervous system effects of pentazocine are similar to
morphine.
It is commonly used opioid analgesic especially in postoperative and
chronic pain- abuse liability is less than morphine

15. NON-OPIOID ANALGESICS AND NSAIDs
The first clinical reports on the treatment of fever and pain with salicylate-
containing natural willow bark remedies were made by the English clergyman
Edward Stone in 1763.
Salicylic acid was first synthesised by the German Gerland in 1852 and a year
later the Frenchman Gerhardt synthesised acetylsalicylic acid.
Acetylsalicylic acid was rediscovered by Hoffmann in 1897 and by the turn of
the century it had gained worldwide recognition in the treatment of pain and
rheumatological disorders.

16. NON-OPIOID ANALGESICS AND NSAIDs
A. NON- SELECTIVE COX INHIBITORS( Conventional NSAIDs)
1. Salicylates- aspirin
2. Propionic acid derivatives – Ibuprofen, ketoprofen , Naproxen
3. Anthranilic acid derivatives- Mephenamic acid
4. Aryl acetic acid derivative- Diclofenac
5. Oxicam derivative- Piroxicam, Tenoxicam
6. Pyrrolo-pyrrole derivative- Ketorolac
7. Indole derivative- Indomethacin
8. Pyrazalone derivative – Phenylbutazone, Oxyphenabutazone
B.. PREFERENTIAL COX-2 INHIBITORS:
Nimesulide, Meloxicam
K.D Tripathi’s essentials of medical pharmacology 6th edition

17. C. SELECTIVE COX-2 INHIBITORS-
Celecoxib, Etoricoxib, Parecoxib
D. ANALGESIC-ANTIPYRETICS WITH POOR ANTI-INFLAMMATORY
ACTION-
1.Paraaminophenol derivative- Paracetamol ( Acetaminophen)
2. Pyrazolone derivatives- Metamizol ( Dipyrone), Propiphenazone
3. Benzoxazocine derivative- Nefopam
K.D Tripathi’s essentials of medical pharmacology 6th edition

18. MECHANISM OF ACTION OF NSAID’s
Mainly blocks PG generation
PG- Erthema , Oedema , Fever associated with inflammation and
generate pain by direct action / sensitising pain receptors
PG- produced from arachidonic acid by COX
The main mechanism- inhibition of the enzyme cyclooxygenase (COX-1
and COX-2)
Interferes with the synthesis of PG- blocking impulse generation that
mediates pain
K.D Tripathi’s essentials of medical pharmacology 6th edition

20. PHARMACOKINETICS
Absorption – Absorbed well orally , occurs from lungs and nasal and
oral mucosa , slow and incomplete through GIT
Distribution – Partially bound to plasma proteins
Metabolism – By conjugation with glucuronic acid in the liver
Excretion – By glomerular filteration in urine within 24 hours
K.D Tripathi’s essentials of medical pharmacology 6th edition

21. ACTIONS OF ANALGESICS
1. ANALGESIC ACTION – Blocks pain sensing mechanism induced by brady-
kinin, TNF- alpha , interleukins
2. ANTIPYRETIC ACTION – Blocks the action of pyrogens which in turn
reduces body temperature
3. ANTI-INFLAMMATORY – PG-only mediator of inflammation ; analgesics
blocks PG synthesis
4. DYSMENORRHEA- Blocks PG synthesis in endometrium
5. ANAPHYLACTIC REACTION- Asthma , Urticaria , Swelling or rhinitis
6. ANTIPLATELET AGGREGATORY- Bleeding time is prolonged
7. DUCTUS ARTERIOSUS CLOSURE
K.D Tripathi’s essentials of medical pharmacology 6th edition

22. SOME IMPORTANT ANALGESICS
ASPIRIN
Acetylsalicylic acid
Pharmacological actions –
Analgesics, Antipyretic , Anti-inflammatory
Metabolic effects – Decrease blood sugar levels
Respiration – Hyperventilation in poisoning
CVS- Vasodilation
GIT- epigastric distress, Nausea and vomiting
Blood – Prolongs BT
K.D Tripathi’s essentials of medical pharmacology 6th edition

23. Uses
 Analgesics
 Antipyretic
 Anti-inflammatory
 Acute rheumatic fever
 Post MI
 PDA
 Osteoarthritis
K.D Tripathi’s essentials of medical pharmacology 6th edition

24. ADVERSE EFFECTS
Nausea and vomiting , epigastric distress
Rashes , Urticaria , Asthma , Anaphylaxis
Salicylism – Dizziness, Vertigo , Hyperventilation, reversible impairement
of hearing and vision
Reye’s syndrome – Use of aspirin in children in less than 12 years with
influenza or pox
-Causes life – threatening condition
-Vomiting , lethargy , delirium, coma , even death
-If child survives- irreversible brain damage
- Use of aspirin in children is prohibited in india
 Acute salicylate poisoning- more common in children. Fatal dose in adults
is estimated to be 15-30g, but is considerably lower in children

25. CONTRA-INDICATIONS OF ASPIRIN
1. Peptic ulcer
2. Pregnancy
3. Nursing mother
4. G6PD deficiency – hemolysis
5. Before dental extraction
6. Chronic liver disease
7. Diabetes- aspirin – hypoglycemic action
8. Hepatic damage
9. Chicken pox

26. PHARMACOKINETICS OF ASPIRIN
Absorbed from stomach and small intestine
80% plasma protein binding capacity
Half life at therapeutic dose = 15-20 min
DRUG INTERACTION OF ASPIRIN
Increases toxicity of oral- anticoagulants , heparin , oral anti-
diabetics , phenytoin
Increases action of anti-platelet drugs
Decreases action of beta blockers
Antacid and activated charcoal decreases aspirin absorption
Increases action of insulin and sulphonylureas

27. IBUPROFEN
Propionic acid derivative
Pharmacological actions –Analgesic, Antipyretic and Anti-inflammatory
Uses-
Analgesic (dose-400mg, TDS)
Antipyretic
Anti-inflammatory
Dental inflammation
 RA
Osteoarthritis
Spondylitis
K.D Tripathi’s essentials of medical pharmacology 6th edition

28. ADVERSE EFFECTS AND CONTRAINDICATION
Lesser than aspirin
Gastric discomfort , nausea and vomiting
Headache, dizziness, blurring of vision
Tinnitus, depression may occur
Contraindications –
Peptic ulcer
Pregnant women
Lactating women

29. PHARMACOKINETICS AND DRUG INTERACTIONS
PHARMACOKINETICS
I. 99% bound to plasma protein
II. Half life is 2 hours
III. Can cross BBB, placenta
DRUG INTERACTION-
I. Aggravates actions of aspirin, anti-platelet
II. Decreases action of anti-diuretic, anti-hypertensive. Eg-beta
blocker, thiazide
K.D Tripathi’s essentials of medical pharmacology 6th edition

30. PARACETAMOL
Para-amino phenol derivative
Pharmacological actions- analgesic- antipyretic action but no anti-
inflammatory action
Uses-
Headache, musculo-skeletal pain , dysmenorrhea
First drug of choice for osteoarthritis
Used in patients in whom aspirin is C/I
 Pharmacokinetics- Well absorbed orally
 Plasma half life- 2 hours
 Dose- 0.5-1gm every 6 hours or TDS, 10-15 mg/kg/doses every 4-6
hours in children
 Maximum 5 doses in 1 day

31. ADVERSE EFFECTS-
Prolonged use- liver damage
Acute paracetamol poisoning- Nausea and vomiting, abdominal pain , in
later stages hepatic necrosis, renal tubular necrosis, hyperglycemia and
coma
Treatment- Induce vomiting , gastric lavage; activated charcoal
K.D Tripathi’s essentials of medical pharmacology 6th edition

32. DICLOFENAC
Aryl-acetic acid derivative
Pharmacological action- COX inhibitor , analgesic, antipyretic, anti-
inflammatory
Indication- RA, osteoarthritis, bursitis, post-operative inflammation,
spondylitis
Adverse effect – Epigastric pain , nausea, headache, dizziness, kidney
damage(rare)
Half life- 2 hours
Dose- 100-200mg BID or TDS
Trade name-
T. Diclomax-25mg,50mg, 100mg
T. Voveran- 50mg

33. KETOROLAC
Pyrrolo-pyrrole derivative
Pharmacological action – PG inhibitor, relieves pain by peripheral
mechanism
Indication – Post-operative, dental pain, musculoskeletal pain , migraine
Adverse effect- Epigastric pain , nausea , ulceration , loose stools ,
drowsiness, dizziness
Half life -5-7 hours
Dose- 10-20mg tablets every 6 hours
Trade name –
T. Ketorol- 10mg
T. Toralac – 10mg
Ketanov- 10mg

34. ADVERSE EFFECTS
1. Constipation
2. Respiratory depression
3. Nausea and vomiting
4. Miosis-pin-point pupils
5. Urinary retention
6. CNS effects- stimulation
7. CVS effects – stimulates vagus nerve- bradycardia, postural
hypotension , syncope
8. Apnea- newborns
9. Allergic reaction- rashes, urticaria
10.Miscellaneous – tremors, delirium, sedation, lethargy

35. PRECAUTIONS AND CONTRAINDICATION
1. Infants
2. Head injuries
3. Respiratory insufficiency
4. Bronchial asthma
5. Hypotensive states and hypovolemia
THERAPEUTIC USES
1. Analgesic
2. Preanesthetic medication
3. Relief of anxiety and apprehension- MI and internal bleeding
4. Acute LVF
5. Cough
6. Diarrhea

36. ANTHRANILIC ACID DERIVATIVE ( FENAMATE)
MEPHENAMIC ACID
An analgesic, antipyretic and weaker anti-inflammatory drug, which
inhibits COX as well as antagonises certain actions of PGs.
Mephenamic acid exerts peripheral as well as central analgesic action
Uses- Analgesic in muscle , joint and soft tissue pain where strong
antiinflammatory action is not needed
Effective in dysmenorrhoea
Dose- 250-500mg TDS
Adverse effects- Diarrhoea is the most important dose related , Skin
rashes, dizziness and other CNS manifestation have occured

37. On December 7, the Indian Pharmacopoeia Commission (IPC) issued
a drug safety alert about Meftal, a commonly used non-steroidal anti-
inflammatory drug (NSAID), saying that its constituent, mefenamic acid,
triggers Drug Reaction with Eosinophilia and Systemic Symptoms
(DRESS) syndrome, a severe allergic reaction.

38. With the alert issued, the list of fixed combination drugs banned in in
India in 2023 for human use, as per drugscontrol.org.
1. Nimesulide + Paracetamol Dispersible Tablet
2. Chlopheniramine Maleate + Codeine Syrup
3. Paracetamol + Bromhexine+ Phenylephrine + Chlorpheniramine +
Guaiphenesin
4. Chlorpheniramine + Codeine Phosphate Menthol Syrup
5. fixed dose combination of Paracetamol + Cetirizine + Caffeine
6. fixed dose combination of Paracetamol + Phenylephrine + Caffeine

39. NIMESULIDE
It is a weak inhibitor of PG synthesis with a higher affinity for COX-2 than COX-1.
It inhibits leukocyte function , prevents the release of mediators and in addition has
antihistaminic and antiallergic properties.
Nimesulide has analgesic , antipyretic and anti-inflammatory actions like other
NSAID’s
Adverse effects of nimesulide are gastrointestinal , dermatological ,somnolence and
dizziness
Instances of fulminant hepatic failure have been associated with nimesulide and it
has been withdrawn from Spain and Turkey
Even in india it got banned in the year 2011 much later than other countries.
Dose- 100mg BD
Tradename- NIMULID, NIMEGESIC, NIMODOL

40. SELECTIVE COX-2 INHIBITORS
Selective inhibition of COX-2 was found to be advantageous because COX-2 is
involved in inflammation and COX-1 which is protective on gastroduodenal
mucosa is spared
They also donot inhibit platelet aggregation because COX-1 is involved in
platelet function
Disadvantage- Clinical studies have shown that the use of selective COX-2
inhibitors increases the risk of cardiovascular and cerebrovascular thrombotic
events- may increase the risk of myocardial infarction and stroke
Therefore they are only indicated in patients who cannot tolerate NSAID’s and
are at high risk of developing peptic ulcer

41. CELECOXIB
It is highly selective COX-2 inhibitor
It has good anti-inflammatory, analgesic and antipyretic properties but does not
affect platelet aggregation
It can be useful in acute painful conditions like postoperative pain , dysmenorrhea
and dental pain as well as in osteoarthritis and rheumatoid arthritis in patients who
cannot tolerate NSAID’s
Dose- Anti-inflammatory- 100-200 mg OD-BD

42. PRINCIPLES FOR PRESCRIBING ANALGESICS
Oral route preferred when patient is physically able to take medication
Except in immediate post-operative period , buccal , sublingual , rectal
routes can be considered as alternatives
IM route avoided because it is more painful
IV or SC routes preferred when parenteral route is needed
Mild pain – NSAIDs / Acetaminophen
Moderate pain – Opioid / non- opioid + weak Opioid ( eg. Codeine and
Codeine combination )
Ghom’s Textbook of Oral Medicine, 3rd edition

43. Severe pain – Long –acting opioids ( Oxycontin, methadone ,
morphine, transdermal fentanyl)
Constant pain – around the clock analgesics rather than SOS basis
Intermittent pain- SOS basis
Only one opioid – non-opioid combination analgesic
Only one long-acting opioid analgesic
Appropriate bowel regimen for all patients on opioid analgesics

44. CLINICAL SIGNIFICANCE OF ANALGESICS IN
CONS AND ENDO
A variety of drugs and drug combination are used to treat pre-op and post-
op dental pain .
Pain due to an infected tooth(pulp involvement , periapical lesion ) and
post- operative pain following RCT is common
An accurate understanding of post-op after RCT allows clinicians to predict
and effectively manage it through the prescription of analgesics
Pain killers used are acetaminophen (paracetamol), opioids(rare), NSAIDs+
acetaminophen
Gasner, Noah & Ouanounou, Aviv. (2021). Analgesics and Pain Management Following
Root Canal Therapy. Essentials of Dentistry. 1. 10.5152/EssentDent.2021.21006

45. When defenitive care cannot be delivered immediately
NSAIDs (Ibuprofen), Acetaminophen
Ibuprofen – 400-800mg every 4-8 hours
Antibiotics – not effective pain relievers
PRESCRIBING FOR PRE-OP PAIN
Gasner, Noah & Ouanounou, Aviv. (2021). Analgesics and Pain Management Following
Root Canal Therapy. Essentials of Dentistry. 1. 10.5152/EssentDent.2021.21006

46. PRESCRIBING FOR POST-OP PAIN
Prescription should vary depending on the expected pain severity based on
the procedure performed
Patient factors- presence of any medication contraindications, age,
pregnancy, and a history of substance abuse should be considered
The post-op pain expected following RCT is generally mild to moderate,
can usually be managed with OTC medications such as NSAIDs,
acetaminophen , or a combination of the two
If a greater severity of pain is expected – opioid may be indicated
Gasner, Noah & Ouanounou, Aviv. (2021). Analgesics and Pain Management Following
Root Canal Therapy. Essentials of Dentistry. 1. 10.5152/EssentDent.2021.21006

47. MILD POST-OP PAIN
Expected following most invasive procedures like RCT
OTC analgesic recommended
Ibuprofen and Acetaminophen
If Ibuprofen not C/I -200-400mg every 4-6 hours (max 2.4g )
If C/I, Acetaminophen is indicated -500-1000mg every 4-6 hours( max 4g)
Gasner, Noah & Ouanounou, Aviv. (2021). Analgesics and Pain Management Following
Root Canal Therapy. Essentials of Dentistry. 1. 10.5152/EssentDent.2021.21006

48. SEVERE POST-OP PAIN
Rarely expected following routine RCT, would most likely occur in the
case of complicated surgical endodontics
Opioid + non-opioid analgesic
Codeine/ Oxycodone + Acetaminophen / Ibuprofen
If opioid indicated , then combination should be prescribed for maximum of
48 hours
Gasner, Noah & Ouanounou, Aviv. (2021). Analgesics and Pain Management Following
Root Canal Therapy. Essentials of Dentistry. 1. 10.5152/EssentDent.2021.21006

49. ADJUVANT DRUGS
 They are not considered analgesics and not used as first line analgesic
treatment
 They could be used alone or in combination with pain killers
 Examples of this type of drugs are_
 Caffeine- It can enhance the analgesic effect of aspirin,
acetaminophen, and ibuprofen
 Hydroxyzine (anti-histamine)- Enhances analgesic effect of opioid,
and reduce occurrence of nausea and vomiting related to them
 Corticosteroid_ They has anti-inflammatory action, therefore relieve
pain that has inflammatory origin
Ghom’s Textbook of Oral Medicine, 3rd edition

50. SPECIAL SITUATIONS
Asthmatic patients – acetaminophen
 Pregnant patient – Acetaminophen or codeine/ acetaminophen ( short
term use )
Patients with peptic ulcer , hemophilia , bleeding disorder, or taking
anticoagulants – Acetaminophen
Patients with ischemic heart disease – Morphine
Patients allergic to aspirin – Acetaminophen or opioid / acetaminophen
Patients allergic to codeine – NSAIDs or proxyphene (opioid)
Patients with hepatoxic– Diclofenac
Patients with nephrotoxic- paracetamol
K.D TRIPATHI’S ESSENTIALS OF MEDICAL PHARMACOLOGY 6TH EDITION

51. NEUROPATHIC PAIN
Patient with neuropathic pain such as trigeminal neuralgia is not
responsive to usual analgesic therapy
 Some psychotropic medications are used to manage such pain –
Anti-depressant – amitriptyline, imipramine
Anti- convulsants – carbamazepine , clonazepam , valporic acid,
gabapentin, Lamotrigine, Topiramate and phenytoin
Ghom’s Textbook of Oral Medicine, 3rd edition

52. CONCLUSION
In conclusion, through careful consideration of patient
needs, appropriate dosage and potential side effects, dental
professionals can alleviate discomfort and enhance patient
experience during treatment

53. REFERENCES
1. K.D Tripathi’s essentials of medical pharmacology 6th
edition
2.Ghom’s Textbook of Oral Medicine, 3rd edition
3.Padmaja udaykumar’s Pharmacology for dental and allied
health sciences 4th edition
4.Gasner, Noah & Ouanounou, Aviv. (2021). Analgesics and
Pain Management Following Root Canal Therapy. Essentials of
Dentistry. 1. 10.5152/EssentDent.2021.21006

54. THANK YOU