Analgesics in Periodontics
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GOOD AFTERNOON
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Analgesics
Presented byDr Guru Ram Tej. KI yr Post Graduate
Dept Of Periodontics
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Introduction Pain/ Algesia Analgesics Classification Opoid analgesics Non opoid analgesics NSAIDs Contra indications Analgesics used in periodontics
Contents
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Introduction
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The Sumerians wrote of demons and tooth worms causing tooth decay. People would pray to gods such as Shamash, Anu or Ea to cure them of their painful oral afflictions
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“An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”
Pain
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1. Pain perception2. Reception to pain
Two components of pain
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SUBSTANCES RELEASED SUBSTANCE-P SERATONIN HISTAMIINE BRADYKININ-prostaglandins to act
PAIN PERCEPTION
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PAIN RECEPTORS SOMATIC NOCIRECEPTORS
VISCERAL NOCICEPTORS
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PAIN PATHWAYS Trigeminal nerve
Semilunar ganglion (g.g)
Pons
Sensory root
Ascending fibres Descending fibres
Tactile sensibility Pain and Temperature
Sensory root
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PAIN PATHWAYS
Each end organ has its pathway into CNS
The pain pathway consists of
First order neurons
Second order neurons
Third order neurons
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First order neurons
Cells of posterior nerve root ganglia
A- delta fibres- marginal cells in posterior
gray horn
C- fibres- Substantia gelatinosa in posterior
gray horn
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Second order neurons
The marginal cells and the cells of Substantia gelatinosa form the second order neurons
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Third order neurons
Neurons of Thalamic nucleus, reticular
formation, tectum and grey matter around
aqueduct of sylvius
These neuron axons reach sensory area of
cerebral cortex
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SPECIFICITY THEORY Descartes-1644 Muller-19th century Von frey-1895
PATTERN THEORY Gold Scheider-1894
INTENSITY THEORY GATE CONTROL THEORY
THEORIES TO EXPLAIN PAIN
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GATE CONTROL THEORY
• GATE input
• GATE output
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Physical (injury)
Emotional (depression)
Behavioural (focusing on pain)
Factors that OPEN the gate
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Physical (medication)
Emotional (happiness, relaxation)
Behavioural (distraction)
Factors that CLOSE the gate
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No one has located the actual gate mechanism
Still assumes the organic basis
LIMITATIONS
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International Association Of Somatic Pain(IASP) REGION
SYSTEM
TEMPERATURE CHANGE
PATIENT STATEMENT
ETIOLOGY
CLASSIFICATION OF PAIN
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CLASSIFICATION
Based on duration
Acute and chronic
Based on etiology
Inflammatory, Nociceptive and
Neuropathic pain
Atypical facial pain
Refered pain
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Types of DENTAL pain Arising from
Pulp
Peri radicular region
Exposed dentin
Cracked tooth syndrome
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LOCAL ANESTHETICS
ANALGESICS
NSAIDS
OPOIDS
CONSCIOUS SEDATION
MANAGEMENT OF PAIN
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“Analgesics are a class of drugs which obtunds the perception of pain without producing unconsciousness”
These act on CNS or the peripheral pain mechanisms
ANALGESICS
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Oral Intramuscular Injection Intravenous Injection PCA: patient controlled analgesia Other routes
Transdermal Sublingual
ROUTES OF ADMINISTRATION
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Narcotic (opioid / morphine like analgesics)
Non-narcotic (Non opioid / antipyretic /
aspirin like analgesics or NSAIDs)
CLASSIFICATION OF ANALGESICS
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Opium: oldest types of drugs
Opium is extracted from poppy seeds
(Papaver somniferum)
16th century - Analgesic qualities
By the 19th century considered “as
legitimate as tobacco or tea”
Narcotic analgesics
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Agonists: Morphine Pethidine, methadone
and propoxyphene. Antagonists: Naloxone Mixed: Butorphanol, nalbuphine, &
buprenorphine.
OPIOID ANALGESICS:
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SYNTHETIC DERIVATIVES WITH STRUCTURE UNRELATED TO MORPHINE:
(a)Phenyl piperidine series- pethidine & fentanyl
(b)Methadone series- methadone & dextropropoxyphene
(c )Benzomorphan series- Pentazocine & cyclazocine
(d)Semisynthetic thebaine derivatives:etorphine & buprenorphine
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Mu Kappa Delta
OPOID RECEPTORS
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Non-Steroidal Anti Inflammatory Drugs(NSAIDs)
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CHEMICAL NATURE
MECHANISM OF ACTION
MODE OF ACTION
THERAPEUTIC CLASSIFICATION
CLASSIFICATION
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CHEMICAL CLASSIFICATION SALICYLATES - Acetyl salicylic acid (aspirin),
sodium salicylate, Mg salicylate, choline salicylate, Na thio salicylate.
PROPIONIC ACID DERIVATIVES -Ibuprofen, ketoprofen, naproxen, oxaprozin, flurbiprofen
INDOLE ACETIC ACID -Indomethacin, sulindac, SUBSTITUTED ANTHRANILIC ACIDS -
Mefenamic acid, meclofenamate Na PYRROLE ALKANOIC ACID ketorolac OXICAMS Piroxicam, meloxicam DIFLUOROPHENYL DERIVATIVES Diflunisal
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ARYL ACETIC ACID Diclofenac ACETIC ACID DERIVATIVES Etodolac NAPHTHYL ACETIC ACID PRODRUGS
Nabumetrone PARA-AMINO PHENOL DERIVATIVES
Acetaminophen
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ACCORDING TO MECHANISM OF ACTION
NON-SELECTIVE COX INHIBITORS Diclofenac,
etodolac, indomethacin, ketoprofen, ketorolac,
nabumetone, naproxen, oxaprozin, ibuprofen,
flurbiprofen, diflunisol, sulindac, tenoxicam,
tolmetin
COX-1 INHIBITORS Aspirin, indomethacin,
piroxicam, sulindac
COX-2 SELECTIVE INHIBITORS Celecoxib,
etoricoxib, meloxicam
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THERAPEUTIC CLASSIFICATION
ANALGESICS Aspirin, paracetamol
ANTI-INFLAMMATORY Indomethacin, naproxen,
ibuorofen
ANTI-COAGULANTS Aspirin
ANTI-PYRETICS Aspirin, paracetamol,
indomethacin, celecoxib, ibuprofen
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W.H.O CLASSIFICATION in 2001 A: DRUGS WITH WEAK ANTI-INFLAMMATORY
EFFECT Acetaminophen
B: DRUGS WITH MILD TO MODERATE ANTI-INFLAMMATORY EFFECT Propionic acid derivatives, anthranilic acid derivatives
C: DRUGS WITH MARKED ANTI-INFLAMMATORY EFFECTS Salicylates, acetic acid derivatives, oxicams, diclofenac.
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PROSTAGLANDINS Prostaglandins were first discovered
in1930s by Ulf von Euler During inflammation, pain, fever,
Arachidonic acid is liberated from phospholipids fraction of the cell membrane, Arachidonic acid is then enzymatically converted to prostaglandin (pgi2) and thromboxane a2 in presence of enzyme cycloxygenase
Cycloxygenase exists in: Cox-1 (constitutive) Cox-2 isoforms (inducible)
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%
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SALICYLATES
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Gastric mucosal damage – peptic ulcer Nausea, vomiting, blood loss in stools
(haemotochesia) Epigastric distress Hypersentivity
Salicylism
ADVERSE EFFECTS
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Diclofenac sodium
Newer analgesic, anti-inflammatory.
Antipyretic
Inhibits prostaglandin synthesis,
short lasting antiplatelet action
Neutrophil – production of superoxide
dismutase inhibits chemotaxis
ARYL ACETIC ACID DERIVATIVES
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Piroxicam
Meloxicam
Tenoxicam
OXICAM DERIVATIVES
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Ibuprofen Prostaglandin synthesis inhibition Anti inflammatory Anti pyretic
Dosage – 400mg every 6th hourly
PROPIONIC ACID DERIVATIVES
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Nausea, dyspepsia, heartburn, vomiting and abdominal pain
Gastric ulceration and bleeding can occur in patients using Ibuprofen for prolonged period of up to one year
Drug interactions- thiazides and lithium
Side Effects
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Ketorolac COX 2 inhibition Free radical scavenging property Inhibition of TNF- alpha
Contra-indications: Patients on anticoagulants
Uses: Post –operative pain, acute musculoskeletal
disorders.
PYRROLE ALKANOIC ACID DERIVATIVES
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Indomethacin prostaglandin synthetase epileptics and pregnant women
Sulindac
INDOLE ACETIC ACID DERIVATIVES
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MEFANAMIC ACIDLow efficacy
Plasma half life 2-4 hrs
ANTHRANILIC ACID DERIVATIVES
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Paracetamol: (acetaminophen)
PARA-AMINO PHENOL DERIVATIVES
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Drug Preparations Route Usual Adult Dose (Mg)
Pentazocine Lactate (Talwin)
30 mg/ml Intramuscular, Subcutaneous, Intravenous
30
Pentazocine Hcl 50 mg tablets Oral 50 to 100
Meperidine Hcl 25, 50, 75 and 100 mg / ml
Intramuscular, Subcutaneous
50 to 100
50 and 100 mg tablets Oral 50 to 100
Morphine Sulfate 8, 10, 15 and 30 mg / ml
Subcutaneous 10 to 15
Control Of Pain And Infection, Dent. Clin. North Am. 17 : 417-427, 1973.
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Pearlman et al in 1997- IBUPROFEN
D W Paquette et al in 1997- KETOPROFEN
J M Thomason et al in 1997- ASPIRIN
A B Pablos et al in 2008- MELOXICAM & DS
C Alen Yen et al in 2008-CELECOXIB
Khalid Al-Hezaimi et al in 2011- KETOROLAC
TROMETHACINE
USE IN PERIODONTICS
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Eli E Machtei et al in 2011
AS A LDD AND HOST MODULATION
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Essentials of medical pharmacology- KD Tripathi Lippincots illustrated rewiew pharmacology Pharmacology – padmaja uday Kumar JSSN U30S-6979 Enantiospecific inhibition of ligature-induced periodontitis in beagles with
topical (S)-ketoprofen: D.W.Paquette J,P.Fioretlini, C Martusceili R,J. Oringer, T H. Howell, J R. McCullough,D.S.Reasner and R. C williams: J Clin periodontol 1997: 24: 521-528.
The analgesic efficacy of ibuprofen in periodontal surgery: A multicentre study: B. Pearlman, S. Boyatzis, C. Daly, R. Evans, J. Gouvoussis, J. Highfield, S. Kitchings, V. Liew, S. Parsons, P. Serb, P. Tseng, C. Wallis: Australian Dental Journal 1997;42:5.
Aspirin-induced post-gingivectomy haemorrhage: a timely reminder, Thoniason JM, Seymour RA, Murphy P, Brigkam KM, Jones P: Aspirin-induced post-gingivectomv haetnorrhage: a timely reminder, J Clin Periodontol 1997; 24: 136-138
REFERENCES
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Effect of Meloxicam and diclofenac sodium on peri implant bone healing in rats: AB Pablos, satunino AR, B Konig, Cristiane F, Vera C de Arujo and Patricia R Cury: J periodontol 2008; 79; 300-306.
The effect of a selective cycloxygenase-2 inhibitor (Celecoxib) on chronic periodontitis: C Alen Yen, Petros D Damoulis, Paul C Stark, Patricia L Hibberd, Medha Singh and Anthena S Papas. J Periodontol 2008; 79: 104-113.
Evaluation of novel adhesive film containing ketorolac for post surgery and pain control: a safety and efficacy study: Khalid Al-Hezaimi, Mansour Al-Askar, Zuied Selamhe, Jia- Hui Fu, Ibrahim A. Alsarra, and Hom Lay Wang: J periodontol 2011; 82: 963-968
Multiple applications of Flurbiprofen and chlorhexidine chips in patients with chronic periodontitis: a randomized, double blind, parallel, 2- arms clinical trial: Eli E Machtei, Ilan Hirsh, Maher Falah, Eyal Shoshani, Avi Avramoff and Adel Penhasi. J Clin Periodontol 2011; 38: 1037-1043.
REFERENCES
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Thank You….