Vivek NarayanOral Medicine & Radiology

ANALGESICS IN DENTISTRY

IASP defines pain as an unpleasant sensory and emotional experience associated with actual or potential

tissue damage or described in terms of such damage.

Pain – definition

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.

Pain terminologies

Medical management.

Physiatry/physiotherapy.

TENS.

Acupuncture.

Low level laser therapy.

Cognitive behavioral therapy.

Hypnosis.

Pain control

Analgesic – pain reliever, pain killer.

Analgesics

1. NSAIDS (non opioid analgesics) –

mild to moderate pain.

2. Opioid analgesics – severe pain.

Analgesic

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.

Cyclo-oxygenase (COX)Mediators of pain &

inflammation

NSAIDS

NSAIDS

Non selective COX inhibitors

AspirinIndometh

acinIbuprofenDiclofenacPiroxicamKetorolac

Preferential COX 2 inhibitors

Nimesulide

Meloxicam

Nabumetone

Selective COX 2 inhibitors

CelecoxibRofecoxib

Analgesics with poor anti-

inflammatory action

Acetaminophen

Nefopam

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

Aspirin

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.

Ibuprofen

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.

Diclofenac

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.

Acetaminophen

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.

Benzydamine hydrochloride

OPIOIDS

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.

Opioid analgesics

Opioid analgesics

Natural alkaloids

Morphine Codeine

Semisynthetic opiates

HeroinPholcodeine

Hydrocodon

e Oxycodone

Synthetic opioids

PethidineFentanyl

Tramadol

Methyl morphine.

Converted to morphine by the

body.

Effective cough suppressant.

Constipation occurs.

Used after extraction along with

NSAIDS.

Dosage – 30mg – 60mg q4 – 6h.

Codeine

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.

Hydrocodone & oxycodone

Synthetic centrally acting

analgesic.

Indicated for moderate to

severe pain.

Nausea, vomiting, drowsiness,

sedation & fatigue.

50mg – 100mg q4 – 6h

maximum 400mg.

Tramadol

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.

Combination of analgesics

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.

Guidelines for analgesic use

Pain ladder

SEVERE PAIN – strong opioids (morphine, heroin,

oxycodone) + non opioids

MODERATE PAIN – weak opioid (codeine, tramadol) +

non opioids

MILD PAIN – acetaminophen, NSAIDS

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

Anticonvulsants for pain

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.

Common orofacial pain

conditions