no pain, big gain - university of british...
TRANSCRIPT
References
1. *Haas D. An Update on Analgesics for the Management of Acute Postoperative Dental Pain. Journal of Cdn Dental Assoc 2002;68(8):476-482
2. Becker D. Drug Therapy in Dental Practice: Opioid and Non-Opiod Analgesics. Anesthesia Progress 2005;52(4):140-149
3. *R.Wynn. Analgesics in Dentistry. Release date 2010. NetCE.com Course 5504
4. R.Dionne. Non-steroidal Anti-inflammatory Drugs for Acute Pain Control. Dental Clinics of North America 1994; 38(4):645-667
5. K.Hargreaves. Drugs for Pain Management in DentistryAustralian Dental Journal Supp. 2005;50:4 (onlinelibrary.wiley.com)
Overview• what? Me bother?• anatomy\physiology• types of drugs available• modes of delivery• individual drugs...+/-'s• generic/brand names, concoctions• practical approach• ask me! concerns/summary
Your office???
Types of magic potions
AcetaminophenNSAIDS (non steroidal anti inflamm drugs)Steroidal AIDSOpiatesTramadolLocal anestheticsAdjuncts (sedatives, gabapentin/pregabalin, antidepressants, anticonvulsants, alpha agonists, ketamine, pot)
Delivery Modes
• Oral (opioid, non-opioid)• Parenteral• Topical• Inhalational • PR
Hey doc! I gotta toothache!!!
Acetaminophen
?central prostaglandin inhibitionhepatotoxicity due to liver metabolite needing glycogen for metabolism.beware in alcoholics, alcohol binges, anorexia, bootcamp dietingantipyretic and analgesic effect plateaus at 1glimit to 4g/day but 2g with above concerns1-2 hrs max effect. Active 4-6 hrsq6hourly unless 'long acting' eg Tylenol Arthritis q8-12very good risk/benefit ratiofirst line therapyok with NSAIDS, opioids
Inflammatory Pathway
NSAIDSanti-inflamm and analgesic properties have plateau (400mg ibuprofen)very effective dental analgesiamany precautions due leukotriene production and COX1 inhibition
-mainly GI (dyspepsia, ulceration) but also asthma, antihypertensive med interference (angiotensin inhibitors eg enalapril), renal toxicity, anti platelet (short acting)most effective if given prior to prostaglandin production or LA wears off
ie pre procedureconsider prescribing on a regular basis for ? two daysbe careful in pregnancy (ductus arteriosus 3rd trimester)no no if renal function down (creatinine >100 gfr<50)avoid ibuprofen and ASA (counteracts anti platelet activity)COX2 and MI/CVA, Celocoxib and sulfa allergyif one doesn't work try anotherpo but also pr, IM and IV (even cream!)
Acetaminophen and NSAID DosingAdults Dose(mg) Frequency Daily Max(mg)Acetaminophen 500-1000 q4-6 4000Celecoxib 200 bid 400Diclofenac 50 tid 150Ibuprofen 200-400 q4-6 2400*Indomethacin 25-50 bid 200Ketoprofen 25-50 q6 300Ketoralac 60 IM once
30 IV once10 po q6 40
Naproxen 250 bid/?tid 1000
Children Dose Freq Max_____________Acetaminophen 10-15mg/kg q4-6 65mg/kg Ibuprofen age 2-12 10mg/kg q6-8
12-18 200mg q4-6 1200
Consider liquid syrup or drops
SteroidsI'm going to pump you up!
Powerful anti inflammatory?underutilizedShort or longer termPrednisone 20mg once then 10 mg x 2Dexamethasone (Decadron) 8 mg loading then 4 mg q8 x 2-3
Opioidsconsider if max NSAID and acetaminophen insufficient. Combine!no plateau but sometimes takes massive doses due tolerancedose dependent resp depression, sedation, constipationdependence in susceptible peoplebeware alcohol (resp dep, sedation) driving, even home from officecodeine, hydrocodone and oxycodone require metabolic conversion
-Chinese etc may lack enzymes-South Asians may be super convertors-antidepressants may hinder (Prozac, Paxil)
hydromorphone, morphine pure but powerful (triplicate prescription)many combination preparations esp with Acetaminophen
Specific Opioidsmorphine 5-10mg IM, 10-20 mg po q4hydromorphone 2-4 mg po q4 (1-2 mg elderly) Dilaudidoxycodone 10-20 mg q4 (oxycontin= long acting now oxyNeo)meperidine (Demerol) metabolite is CNS stim, poor po absorptionpropoxyphene (Darvon) same as meperidine, rarely usedpentazocine (Talwin) agonist-antag rarely used.fentanyl (Duragesic) transdermal patches 50-75 mcg/hr
Tramadolcentrally acting inhibition of transmitter re-uptake, potentiates inhibition pathnot controlled substance with little addiction potential, constipation, sed'nbe careful with seizure disorder, breast feeding 25-50 mg qidcombo with acetaminophen=Tramacet (325mg/37.5mg) max 8/day
Common Formulations/Brand NamesTylenol Extra Strength=500 mg acetamin, usual strength 325 mgTylenol Arthritis=slow release 650mg bid/q12 dosingTylenol 1,2,3,4=300 mg acetamin with 8/15/30/60 mg codeine along with caffeine 15mgEmtec=acetamin 300mg and codeine 30mgPercodan=ASA 325mg and oxycodone 5mgPercocet=acetamin 325mg and oxycodone 2.5-10mgOxycocet=acetamin 325mg and 5mg oxycodoneOxycontin=slow release oxycodone now OxyneoVicodin=acetamin 500mg and hydrocodone 5mgIbuprofen= Advil, MotrinNaproxen= Naprosyn, Anaprox, AleveKetoprofen= OrudisDiclofenac= VoltarenCelocoxib= CelebrexKetoralac= Toradol
Adjuncts
sedativescentral neuromodulation (amitryptilline, carbamazipine)peripheral neuromodulation (clonidine, GABA, pregabalin)nitrous oxide YIPPEE!! pot, doobies, BC Bud, THC Double YIPPEE!ketamine
Sedatives (beware OSA!)
benzodiazepines -lorazepam (Ativan)po, sublingual, long actinglittle resp depressionvariable response0.5-2 mg 1 hour pre-procedure
-triazolam (Halcion)po, short actingpowerful! Careful with alcoh, other seds0.125-0.5 mg ½ hour pre-proc usual dose
. 0.375 mg(0.125in elderly)Avoid in preg, breast feeding
GABA modulation -zopiclone (Imovane)powerful, reliable, po2.5-7.5 mg
Sedatives continuedAntihistamines -dimenhydrinate (Gravol)
po, IM, moderate actionlittle resp depressionvariable, inconsistent but good in kids10-50 mg 1 hour pre-procedure
- hydroxyzine (Atarax)Po Reliable sed'n, ok in kids10-25 mg (kids) 25-50 mg (adults) 1 hour pre-proc
Anti-psychotics -quetiapine (Seroquel) poshort acting, reliable effectnot in breast feeding25 mg 1 hour pre-proc usually
Pot etc
Will be more and more common.Pts love it and and know their individual effect. Let them use?But remember is 'opiate-like' so have to watch concomitant
sedatives and opiates. Be sure pt. is reliable in getting home and not overusing. Consider addiction potential if prescribe opiates post-procedureConsider whether using other street drugs NOT OK. eg. ecstacy,
methamphetamines, cocaine
Ketamine'Dissociative' sedative, analgesic. IV, IM. Mainly for IV sed'n
setting. Potential for abuse. Hallucinations.
Central ModulationMore for chronic pain eg trigeminal neuralgia. Can still use most
analgesics while taking but may have to modify dose.
Peripheral ModulationClonidine (Catepres) 0.1 mg. Variable. Sedating. Can be used short
term individual proceduresGabapentin (Neurontin) 100 mg tid and up. Best for neuropathic pain
eg. Nerve damage, dm neuropathy. Dry mouth, sedation.Pregabalin (Lyrica) 50-75 mg bid. Used instead of Gabapentin less
s/e's.
N2O (laughing gas!)Quick on and off. People LOVE it! Needs apparatus and venting. Can
overdo and lose cooperation of pt. Watch in late pregnancy.
General Approach to Analgesia
If pain expected start with Acetaminophen 500-1000mg 1 hour pre-procedure.Consider addition of NSAID eg. Ibuprofen 400 mg with the acetaminophen. Think of antiplatelet effects, possible bleed
-consider Ketoralac 30mgIf UPTIGHT consider sedative pre-procedure lorazepam 1mg or Triazolam 0.375mg and antihistamine eg hydoxyzine 50mgIf MUCH pain expected get opiate on board early eg, oxycodone 10-20mg or Tramadol 50mg. Post-procedure plan on regular NSAIDS and Acetaminophen for 2 days with opiate for 'rescue' med eg. T3's reg/prnHS sedation Lorazepam (Ativan) 1mg or Triazolam (Halcion) 0.25-0.375 mg or Zopiclone (Imovane) 5-7.5 mg
Helloooooo law suit!
Case Presentations For Discussion
22 yo ♂ healthy allergic sulfa for filling. No meds. Uses pot+ Wimpy and nervous. No ride home. No money (yeah right).26 yo ♀ healthy no allergies for implant. On fertility meds. Pretty laid back. Snores.78 yo ♂ CVA, MI, atrial fib, dm, no allergies for clearance. Takes 'something to water down my blood'. A bit confused but wife very supportive. 6 yo girl healthy for extraction. Spoiled princess nervous mom.
Take Home
Consider potential for painConsdier individual patient ie allergies, co-morbidities, drug HxConsider individual possibilities ie types of drugsConsider timing ie pre-emptive analgesiaConsider post-op Consider life and love (oops; different lecture!)
That's All, Folks!