This document discusses the pharmacological management of pain in the dental care setting. It defines pain and outlines the objectives of understanding pain definition, pharmacological actions of analgesics, a stepwise pain management approach, and adverse effects of analgesics. Nonopioid drugs discussed include acetaminophen and NSAIDs. Opioid analgesics discussed include codeine, oxycodone, hydrocodone, and hydromorphone. The document provides dosing and considerations for the safe use of these drugs to manage dental pain.

1. PharmacologicalPharmacological
Management of Pain InManagement of Pain In
The Dental Care SettingThe Dental Care Setting
Charles Sharkey M.S.,Charles Sharkey M.S.,
M.B.A. Pharm D PharmacyM.B.A. Pharm D Pharmacy
Site ManagerSite Manager

2. Learning ObjectivesLearning Objectives
 At the conclusion of this presentationAt the conclusion of this presentation
a practicing dentist will have ana practicing dentist will have an
improved understanding of theimproved understanding of the
following:following:
 Definition of painDefinition of pain
 Pharmacological actions contrastedPharmacological actions contrasted
for nonopioid and opioid analgesicsfor nonopioid and opioid analgesics
 Stepwise approach to painStepwise approach to pain
managementmanagement
 Adverse effects of analgesicsAdverse effects of analgesics

3. Definition of PainDefinition of Pain
 ““An unpleasant sensory andAn unpleasant sensory and
emotional experience arising fromemotional experience arising from
actual or potential tissue damage oractual or potential tissue damage or
described in terms of such damage”described in terms of such damage”
as stated by The Internationalas stated by The International
Association for the Study of PainAssociation for the Study of Pain
 Large subjective componentLarge subjective component
 Perception and ReactionPerception and Reaction

4. Visiting the DentistVisiting the Dentist
 Pain can be a major cause forPain can be a major cause for
seeking dental careseeking dental care
 Fear of pain is a significant reasonFear of pain is a significant reason
why people avoid a dental visitwhy people avoid a dental visit
 Fact of life is that most dentalFact of life is that most dental
procedures have tissue trauma,procedures have tissue trauma,
inflammation, and pain.inflammation, and pain.

5. AspirinAspirin
 Developed in 1899Developed in 1899
 Inhibits prostaglandin synthesisInhibits prostaglandin synthesis
 Analgesic, anti-inflammatory,Analgesic, anti-inflammatory,
antipyreticantipyretic
 Acute dental pain-mild to moderateAcute dental pain-mild to moderate
 Adverse effect profile is numerousAdverse effect profile is numerous
 Drug InteractionsDrug Interactions

6. AcetaminophenAcetaminophen
 Inhibits prostaglandin synthesis inInhibits prostaglandin synthesis in
the Central Nervous Systemthe Central Nervous System
 Treatment of mild to moderate painTreatment of mild to moderate pain
 Acute postoperative dental pain inAcute postoperative dental pain in
adults, and childrenadults, and children
 Good risk to benefit balanceGood risk to benefit balance

7. AcetaminophenAcetaminophen
 Oral dosage of 500mgs to 1000mgsOral dosage of 500mgs to 1000mgs
every four to six hoursevery four to six hours
 Chronic alcoholism or hepatic diseaseChronic alcoholism or hepatic disease
keep below 2gms orally per daykeep below 2gms orally per day
 Normal patients keep below 4gmsNormal patients keep below 4gms
per day orally.per day orally.
 Analgesic of choice in patients whoAnalgesic of choice in patients who
have a contraindication to NSAID’shave a contraindication to NSAID’s

8. AcetaminophenAcetaminophen
 Analgesic and antipyretic actionsAnalgesic and antipyretic actions
 NO Anti-inflammatory actionsNO Anti-inflammatory actions
 Adverse effects include hepatic, andAdverse effects include hepatic, and
renal dysfunctionrenal dysfunction
 Insufficient by itself for severe painInsufficient by itself for severe pain
 Used in combination with narcoticUsed in combination with narcotic
analgesicsanalgesics

9. AcetaminophenAcetaminophen
 Analgesic of choice when there is aAnalgesic of choice when there is a
contraindication to use of NSAID’s.contraindication to use of NSAID’s.
 Analgesic of choice in all stages ofAnalgesic of choice in all stages of
pregnancy.pregnancy.
 Analgesic of choice in lactation.Analgesic of choice in lactation.
 Analgesic of choice in children, andAnalgesic of choice in children, and
agedaged
 Combination product with otherCombination product with other
drugsdrugs

10. Nonsteroidal Anti-InflammatoryNonsteroidal Anti-Inflammatory
(NSAID’s) Drugs(NSAID’s) Drugs
 Block cyclooxygenase (COX)Block cyclooxygenase (COX)
enzymes responsible for synthesis ofenzymes responsible for synthesis of
mediators such as prostaglandinsmediators such as prostaglandins
 COX-1 and COX-2 enzymesCOX-1 and COX-2 enzymes
 Management of mild, moderate, orManagement of mild, moderate, or
severe dental painsevere dental pain
 Analgesic, anti-inflammatory, andAnalgesic, anti-inflammatory, and
antipyretic effectsantipyretic effects

11. NSAID’ sNSAID’ s
 More than a dozen of these drugsMore than a dozen of these drugs
available either by prescription oravailable either by prescription or
Over The Counter (OTC)Over The Counter (OTC)
 Differences are centered aroundDifferences are centered around
pharmacokinetics, andpharmacokinetics, and
pharmacodynamicspharmacodynamics
 Relatively inexpensive medicationsRelatively inexpensive medications

12. NSAID ClassNSAID Class
 Ibuprofen (Motrin) 400mgs orallyIbuprofen (Motrin) 400mgs orally
every 4 to 6 hours with a maximumevery 4 to 6 hours with a maximum
of 2,400mgs per dayof 2,400mgs per day
 Naproxen 250mgs orally every 6 to 8Naproxen 250mgs orally every 6 to 8
hours with a maximum of 1,375mgshours with a maximum of 1,375mgs
per dayper day
 Etodolac 200mgs-400mgs orallyEtodolac 200mgs-400mgs orally
every 6 to 8 hours with a maximumevery 6 to 8 hours with a maximum
of 1,200mgs per dayof 1,200mgs per day

13. NSAID’s Clinical PearlsNSAID’s Clinical Pearls
 Allergic reactions in hypersensitiveAllergic reactions in hypersensitive
patientspatients
 Careful with anticoagulantsCareful with anticoagulants
 Coingestion with alcohol can lead toCoingestion with alcohol can lead to
GI distress/bleedingGI distress/bleeding
 Careful in Oncology patientsCareful in Oncology patients

14. NSAID’s Clinical PearlsNSAID’s Clinical Pearls
 May be more effective if given earlyMay be more effective if given early
to prevent prostaglandin synthesis.to prevent prostaglandin synthesis.
 Concept of a Loading Dose. UsuallyConcept of a Loading Dose. Usually
double the maintenance dose early.double the maintenance dose early.
 Naproxen 500mgs followed byNaproxen 500mgs followed by
250mgs250mgs
 Preoperative dosesPreoperative doses
 Regular dosing instead of prn dosingRegular dosing instead of prn dosing
for one or two daysfor one or two days

15. Clinical PearlClinical Pearl
 Always maximize the nonopioid doseAlways maximize the nonopioid dose
such as acetaminophen or NSAIDsuch as acetaminophen or NSAID
before adding an opioid.before adding an opioid.
 These no opioid drugs are betterThese no opioid drugs are better
tolerate and have lower adversetolerate and have lower adverse
effect potential than other opioideffect potential than other opioid
drugs in the classdrugs in the class

16. Opioid AnalgesicsOpioid Analgesics
 Centrally acting drugs working at muCentrally acting drugs working at mu
and/or kappa opioid receptorsand/or kappa opioid receptors
 Treatment of moderate to severeTreatment of moderate to severe
pain depending on the drug andpain depending on the drug and
route of administrationroute of administration
 No ceiling on there analgesic effectNo ceiling on there analgesic effect
 Dosing of these drugs is limited byDosing of these drugs is limited by
development of adverse effectsdevelopment of adverse effects

17. Opioid Analgesics-Adverse EffectsOpioid Analgesics-Adverse Effects
 SedationSedation
 Nausea and vomitingNausea and vomiting
 ConstipationConstipation
 MiosisMiosis
 ToleranceTolerance
 Use of these drugs in dental practiceUse of these drugs in dental practice
is short term.is short term.

18. Opioids--CodeineOpioids--Codeine
 First to consider in dentistryFirst to consider in dentistry
 Combination with AcetaminophenCombination with Acetaminophen
 Dose of 30mgs to 60mgs orally everyDose of 30mgs to 60mgs orally every
four to six hoursfour to six hours
 Maximize dose of the nonopioidMaximize dose of the nonopioid
component before increasing opioidcomponent before increasing opioid

19. Opioid--OxycodoneOpioid--Oxycodone
 Next to use if codeine is insufficientNext to use if codeine is insufficient
 Available in combination with aspirinAvailable in combination with aspirin
(Percodan) or Acetaminophen(Percodan) or Acetaminophen
(Percocet)(Percocet)
 Oxycodone 5mgs to 10mgs orallyOxycodone 5mgs to 10mgs orally
every four to six hoursevery four to six hours

20. Opioids—Hydrocodone bitartrateOpioids—Hydrocodone bitartrate
 Hydrocodone bitartrate 5mgs andHydrocodone bitartrate 5mgs and
acetaminophen 500mgs (Vicodin)acetaminophen 500mgs (Vicodin)
 Analgesic combinationAnalgesic combination
 Now a Schedule Two DrugNow a Schedule Two Drug

21. Opioids--HydromorphoneOpioids--Hydromorphone
 Most potent oral agent for dental useMost potent oral agent for dental use
 Reserved for more serious painReserved for more serious pain
 (Dilaudid) 2mgs to 4mgs orally every(Dilaudid) 2mgs to 4mgs orally every
four hours as requiredfour hours as required
 Short-term use onlyShort-term use only

22. Clinical Pearls Drugs to AvoidClinical Pearls Drugs to Avoid
 Propoxyphene napsylate 50mgs-Propoxyphene napsylate 50mgs-
100mgs and Acetaminophen 325mgs100mgs and Acetaminophen 325mgs
(Darvocet-N 50)(Darvocet-N 50)
 Not used anymore due to activeNot used anymore due to active
metabolite, and adverse effectsmetabolite, and adverse effects
 Pentazosine (Talwin) is notPentazosine (Talwin) is not
frequently usedfrequently used

23. A comment about MeperidineA comment about Meperidine
 Meperidine (Demerol) can beMeperidine (Demerol) can be
reserved for patients allergic toreserved for patients allergic to
morphine and codeine derivativesmorphine and codeine derivatives
 Oral agent is not a great choice butOral agent is not a great choice but
can be dosed at 100mgs orally everycan be dosed at 100mgs orally every
four hoursfour hours
 Active metabolitesActive metabolites
 Adverse effect profileAdverse effect profile

24. TramadolTramadol
 Centrally acting agentCentrally acting agent
 Now a Controlled Drug (C4)Now a Controlled Drug (C4)
 Treatment of moderate to severeTreatment of moderate to severe
painpain
 Dosage of 50mgs-100mgs orallyDosage of 50mgs-100mgs orally
every four to six hours. Maximum ofevery four to six hours. Maximum of
400mgs orally per day.400mgs orally per day.
 Nausea, vomiting.Nausea, vomiting.

25. Specific Clinical SituationsSpecific Clinical Situations
 Pregnancy/Lactation=AcetaminophenPregnancy/Lactation=Acetaminophen
 Geriatric=AcetaminophenGeriatric=Acetaminophen
 Oncology=AcetaminophenOncology=Acetaminophen
 Pediatrics=AcetaminophenPediatrics=Acetaminophen

26. Pain Treatment PathPain Treatment Path
 AcetaminophenAcetaminophen
 Nonsteriodal anti-inflammatoryNonsteriodal anti-inflammatory
agentsagents
 CodeineCodeine
 OxycodoneOxycodone
 HydromorphoneHydromorphone
 Use combination therapy whereUse combination therapy where
possiblepossible

27. Guiding PrincipleGuiding Principle
 Analgesics are the second bestAnalgesics are the second best
means of managing dental pain.means of managing dental pain.
Removing the source of the pain withRemoving the source of the pain with
local anesthesia via pulpectomy,local anesthesia via pulpectomy,
extraction, or incision/drainage areextraction, or incision/drainage are
preferred.preferred.
 BOTTOM LINE IS GET TO THE CAUSEBOTTOM LINE IS GET TO THE CAUSE
OF THE PAINOF THE PAIN

28. Internet System For TrackingInternet System For Tracking
Over Prescribing (I-Stop) ActOver Prescribing (I-Stop) Act
 Legislation that requiresLegislation that requires
Commissioner of Health to updateCommissioner of Health to update
Prescription Monitoring ProgramPrescription Monitoring Program
 Electronic ( E ) PrescribingElectronic ( E ) Prescribing
 Controlled Substance ScheduleControlled Substance Schedule
Change for select drugsChange for select drugs
 EducationEducation
 Safe DisposalSafe Disposal

29. I-StopI-Stop
 Legislation passed to combat risingLegislation passed to combat rising
rates of prescription drug abuserates of prescription drug abuse
 E-Prescribing by March 27, 2016E-Prescribing by March 27, 2016
 Consult Prescription MonitoringConsult Prescription Monitoring
Program (PMP) prior to prescribingProgram (PMP) prior to prescribing
controlled substances (C2, C3, C4)controlled substances (C2, C3, C4)
 Hydrocodone is Schedule 2,Hydrocodone is Schedule 2,
Tramadol is now Schedule 4Tramadol is now Schedule 4

30. I-StopI-Stop
 Consult registry within 24 hours ofConsult registry within 24 hours of
prescribingprescribing
 Document consultDocument consult
 Exempt from I-Stop if prescribedExempt from I-Stop if prescribed
quantity is no more than five dayquantity is no more than five day
supply used as directedsupply used as directed

31. AND NOW A TIME FORAND NOW A TIME FOR
QUESTIONSQUESTIONS
 QUESTIONSQUESTIONS