mal

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Dental Pain Management

• Dr. Tahani Alrhbeni

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Objectives

• Describe the pain pathway and how it relates to
  dental care
• Develop a care plan using opioid medication
• Understand the difference between NSAIDs and
  Tylenol
• Select appropriate follow up plan for a patient

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What You Think
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What They Think
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What is Pain

• An unpleasant sensory and emotional response
  associated with actual or potential tissue damage
  or described in terms of such damage.

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Current Recommendations

• Based on case studies and studies but nothing
  formal
• Structured around use of NSAIDs, Acetaminophen
  and Opioids
• Recommend around the clock treatment for 48 hours
  post procedure then as needed
• Pain peaks 48 hours post procedure

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The Pain Pathway
Available at http//medical-dictionary.thefreedic
tionary.com/nociception
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The Pain Pathway
Brain
Spine
NSAIDs Acetaminophen
Mouth
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NSAIDs

• Analgesic, antipyretic and anti-inflammatory
  properties
• Naproxen, Ibuprofen and Diclofenac have been
  found to reduce pain by almost 50
• Avoid long term use due to increased risk of GI
  and renal issues
• Caution with patients on warfarin due to
  increased bleeding risk

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NSAID mechanism of action
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NSAID Selection
GI Renal Platelet
Cardiac
Naproxen
Diclofenac
Ibuprofen
COX 1
COX 2
Ketorolac
Celecoxib
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Clinical Pearls

• Be aware of other medications and disease states
• Verify a medication record prior to adding any
  new medications
• Patients should take with food
• Be aware of patients who are on warfarin therapy

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Aspirin

• Anti-inflammatory properties at very high doses
• Irreversible inhibition of COX
• Other NSAIDs are transient
• More profound effects on platelet function and GI
  irritation
• Not the best option in many surgical cases

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Aspirin
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Acetaminophen

• Not an NSAID
• No inflammatory properties
• Recommended if patient is taking other
  medications contraindicated with NSAIDs
• Can be used with NSAID for additional benefit
• It has been shown Ibuprofen Acetaminophen
  worked better than either alone

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Acetaminophen

• Caution with unintentional overdose
• Acetaminophen is in EVERYTHING
• Combination opioid medications
• Over the counter cough and cold products
• Max dose is 4 grams daily
• Toxic mid-metabolites can cause hepatic failure

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Acetaminophen
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Ibuprofen
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Diclofenac
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Proton pump inhibitors
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The Pain Pathway
Brain
Opioids
Spine
NSAIDs Acetaminophen
Mouth
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Opioids

• 12 of opioids prescribed come from dentists
• Should only be provided for a short period of
  time
• Caution in patients with history of drug abuse
  and/or alcohol abuse
• Refer patient to pain management, rehab or
  psychological services if needed

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Opioids

• Use if patient does not have adequate pain relief
  with NSAIDs or Acetaminophen
• Opioid/NSAID or Opioid/Acetaminophen recommended
  over pure opioid
• Codeine/Acetaminophen, Hydrocodone/Acetaminophen,
  Oxycodone/Acetaminophen

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Opioids

• Short acting opioids are preferred
• Limited duration of therapy
• Lower risk of opioid induced respiratory
  depression/overdose vs. long acting
• Abuse is possible clinician responsible to
  prescribe appropriately

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Opioids

• Adverse effects
• Constipation, respiratory depression, euphoria,
  fatigue
• Tolerance will develop to everything except
  constipation

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Opioids and Chronic Pain

• Patients with existing chronic opioid use
• Will need higher doses of opioids than opioid
  naïve patients
• Maybe up to 2 times as much
• Initiate discussion with primary care provider
• Both for collaboration as well as determining
  presence of med use agreements
• Requires a more in depth assessment and more care
  in prescribing

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Chronic Post Procedure Pain

• Look for other causes
• Infection, ENT issues
• Consider possible nerve/neuropathic involvement
• Burning, numbing, electric, shooting pain
• Referral to pain management as needed

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Summary

• Review the medication record first
• Be aware of drug-drug and drug disease
  interactions
• Around the clock therapy for 48 hours then as
  needed
• NSAIDs and Acetaminophen first
• Short term use of short acting opioids if needed
• Communicate with primary care

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Topical Corticosteroids
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Topical corticosteroids

• treat mucosal ulceration and inflammation.
• Carefully control chronic use to prevent systemic
  effects.
• The choice of preparation depends on the extent
  and location of the lesions.
• Hydrocortisone oromucosal tablets can be allowed
  to dissolve next to the lesion.
• Beclometasone diproprionate inhaler sprayed twice
  daily onto the affected site and is suitable for
  tongue lesions and accessible areas.
• Betamethasone tablets, dissolved in water and
  used as a mouthwash, are suitable for
  extensive inflammation or ulceration but
  should not be swallowed to minimise the risks of
  systemic effects.

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Topical corticosteroids
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Thank you