PAIN KILLERS IN ODONTOSTOMATOLOGY.
Introduction
Pain management is a daily concern for all practitioners. Pain is in fact the main reason for consultation at dental offices. It generally involves pain that can be relieved by a therapeutic procedure (pulpitis). However, certain situations justify the prescription of an analgesic: infectious pain (desmodontitis, cellulitis, etc.) and postoperative pain (postorthodontic, postendodontic and post-surgical).
Definitions
Pain: is an unpleasant sensory and emotional experience associated with actual or potential bodily harm.
Analgesics: are symptomatic drugs that act non-specifically on painful sensations, which they alleviate or eliminate without acting on their cause.
WHO classification of analgesics:
- Level I analgesics:
Step I analgesics provide satisfactory control of pain when it is classified as mild to moderate. They are also used to combat feverish states.
These are non-opioid analgesics, of very diverse chemical natures. Some oppose the synthesis of prostaglandins which sensitize peripheral nociceptors to the action of other algogenic substances (histamine, bradykinin, etc.).
The main substances used in odontostomatology:
- Salicylate derivatives
Although aspirin is still the most widely used drug, it is losing ground due to its many side effects. It causes digestive disorders (heartburn, nausea, vomiting), ringing in the ears, deafness, headaches, etc., disorders of uric acid metabolism, hemostasis (an antiplatelet action that increases bleeding time) and allergic reactions.
The recommended dosage is 500 mg every 4 hours with a maximum of 4,000 mg/day.
Diflunisal is a salicylate derivative carrying a difluorophenyl group. This substitution enhances the analgesic activity and prolongs the duration of action (8 to 12 hours). It causes fewer gastric disorders than aspirin, but it increases the clearance of uric acid, which makes it contraindicated in cases of a history of lithiasis. It has little effect on platelet function. The recommended dosage is 1,000 mg as an initial dose followed by 500 mg every 12 hours.
PAIN KILLERS IN ODONTOSTOMATOLOGY.
In adults and children weighing more than 50 kg (around 15 years old) | Pain and fever: • 1 g to be repeated if necessary after 4 hours, without exceeding 3 g per day (2 g in the elderly); • Aspirin can be used as an anti-inflammatory in inflammatory rheumatism at a rate of 3 to 6 g maximum per day, to be divided into 3 or 4 doses, spaced at least 4 hours apart. |
In children | The recommended daily dose is approximately: • 60 mg/kg/day, divided into 4 or 6 doses; • approximately 15 mg/kg every 6 hours or 10 mg/kg every 4 hours. There are some forms reserved for infants, such as Aspégic® Nourrissons 100 mg. This presentation is reserved for children weighing 6 to 22 kg (approximately 3 months to 7 years). |
Dosages of aspirin.
- Nonsteroidal anti-inflammatory drugs:
Nonsteroidal anti-inflammatory drugs (NSAIDs) were used mainly for their anti-inflammatory properties in rheumatology and at high doses. It was not until 1983 that they began to be used to treat pain without any anti-inflammatory aim.
A reduction in the administered dose was the effective dose to treat mild or moderate pain.
Ibuprofen was one of the first anti-inflammatory drugs to be offered in this form and has the lowest side effects.
Since then, other molecules have been proposed for the same use such as fenoprofen and ketoprofen.
NSAIDs generally cause the same side effects as aspirin: gastrointestinal disturbances, neurosensory disturbances, allergic manifestations and disturbances of hemostasis, but they are often better tolerated.
NSAIDs are contraindicated in cases of suspected infection or proven sepsis.
The administration of NSAIDs should also take into account the patient’s age, renal function and potentially interacting drugs.
The combination of two NSAIDs should be avoided.
- Nonsteroidal anti-inflammatory drugs of the coxib type
NSAIDs prevent the conversion of arachidonic acid to prostaglandin by inhibiting the enzymes cyclooxygenase 1 and 2.
COX-1 is normally present in the body, while COX-2 is produced at the site of inflammation.
Only inhibition of COX-2 is desirable, but most NSAIDs act on both enzymes, leading to unwanted side effects.
The latest recommendations from the French Agency for the Safety of Health Products (Afssaps) and the pharmaceutical industry restrict the use of coxibs to patients who do not have a history of severe cardiovascular disease.
To date, only celecoxib (Celebrex®) and parecoxib (Dynastat®) are authorized. They are recommended for the treatment of rheumatoid arthritis and osteoarthritis.
Only parecoxib has marketing authorization for postoperative pain. It is for hospital use.
- Paracetamol: (Derivatives of para-aminophenol)
It is now considered the reference analgesic, to be used as first-line treatment in adults and children, due to its favorable benefit/risk ratio.
Has both a peripheral and central mechanism of action.
At therapeutic doses, it benefits from excellent tolerance, particularly digestive. Only rare allergic skin disorders and exceptional incidents of thrombocytopenia can occur.
Two main contraindications: hypersensitivity to paracetamol and hepatocellular insufficiency.
Paracetamol can also be administered intravenously (Perfalgan®). The rapid analgesic action of this form makes it possible to treat acute pain, particularly postoperative pain.
Adverse effects are few. Rare cases of hypersensitivity reactions such as anaphylactic shock (Quincke’s edema, erythema, urticaria) and very exceptional cases of thrombocytopenia, leukopenia and neutropenia.
Paracetamol can be used during pregnancy and breastfeeding at recommended doses for short periods.
Paracetamol exposes patients to little risk of drug interactions. Only one interaction requires precautions for use” with oral anticoagulants. There is, in fact, a risk of increased effect of the oral anticoagulant and of the risk of bleeding in the event of taking paracetamol at maximum doses (4 g/day) for at least 4 days.
PAIN KILLERS IN ODONTOSTOMATOLOGY.
| In adults | 3 g/day, divided into 4 or 6 doses, with an interval of 4 hours between doses. In case of more intense pain, the maximum dosage can be increased to 4 g/day. |
| In children | 60 mg/kg/24 h, to be divided into 4 to 6 doses, i.e. 15 mg/kg every 6 hours or 10 mg/kg every 4 hours. The total dose which should not be exceeded is 80 mg/kg/day in children weighing less than 37 kg and 3 g/day in older children weighing more than 37 kg. |
Paracetamol dosages.
- Floctafenine (Idarac®),
200 mg tablet, has the characteristic of being a pure analgesic, intended for oral use only.
The dosage is 1 tablet per dose to be repeated if necessary without exceeding 4 tablets per day. With an interval of 4 to 6 hours between doses.
In case of severe pain, the dosage will be 2 tablets at the start per dose, then 1 tablet to be repeated if necessary.
Side effects are rare but potentially serious.
- Nefopam (Acupan®):
Analgesic in injectable solution at 20 mg.
This medicine is used intravenously or intramuscularly for the symptomatic treatment of acute painful conditions, including postoperative pain.
Nefopam has no anti-inflammatory or antipyretic action.
Its main disadvantage is that it often causes nausea and vomiting.
2- Level II analgesics:
Step II analgesics are drugs with activity similar to that of
Morphine, while having a lower analgesic power: these are weak opioids, often associated with paracetamol. Fixed combinations of level I and level II analgesics are particularly interesting for controlling pain but obviously have the side effects of each of the two active ingredients combined.
Reserved for moderate to severe pain.
They are suitable, including for children, for at least three situations:
• Failure or ineffectiveness of a step I analgesic;
• Immediate treatment in pathological situations known to be painful (post-traumatic, surgical, etc.);
• Oral treatment as a follow-up after having used injectable morphine.
- Codeine:
Codeine is extracted from opium capsule.
Codeine is a weak opioid that is rapidly metabolized to morphine.
This molecule is widely used in conjunction with paracetamol or aspirin.
Contraindications: hypersensitivity to codeine, productive (or wet) cough, drug addiction, opioid dependence, respiratory failure, asthma, severe heart failure, pregnancy and breastfeeding.
The side effects are the same as those of other opioids, although rarer and more moderate: constipation, drowsiness, dizziness, nausea, vomiting. Exceptionally, cases of bronchospasm, allergic skin reactions or respiratory depression have been observed.
Drug interactions: the combination of codeine is not recommended with morphine agonists-antagonists (nalbuphine, buprenorphine, pentazocine). It is also not recommended with alcohol because of the increased sedative effect of morphine analgesics. Other combinations should be taken into account: other morphine analgesics, benzodiazepines, barbiturates and other central nervous system (CNS) depressants.
PAIN KILLERS IN ODONTOSTOMATOLOGY.
| In adults | 30 to 60 mg, to be repeated if necessary every 4 to 6 hours. |
| In children | Syrup at doses of 1 to 3 mg/kg/day. Not exceeding 6 mg/kg/day in 6 doses in children over 1 year old. At a dose of 10 mg/kg/day, the use of codeine carries a risk of convulsion. This weak opioid is combined with paracetamol in Codoliprane Enfant®, usable from 6 years old or 14 kg (20 mg of codeine and 400 mg of paracetamol per tablet). |
Codeine dosages.
- Tramadol:
A centrally acting analgesic indicated for the relief of moderate to severe pain.
The analgesic power of tramadol is said to be 1/ 6th to 1/10th that of morphine. When combined with level I analgesics, its effectiveness is increased.
There are many contraindications: known hypersensitivity to tramadol, opioids or any of the product’s constituents, alcohol poisoning, severe respiratory failure, severe hepatocellular failure, breastfeeding, epilepsy not controlled by treatment.
Adverse effects: neuropsychiatric disorders such as confusion and, exceptionally, hallucinations and/or delirium. Convulsions have also been described, mainly after administration of high doses.
More frequently: nausea, vomiting, drowsiness, headache, dizziness, excessive sweating, feeling unwell, dry mouth, constipation in case of prolonged use.
More rarely: abdominal pain, rashes, asthenia, euphoria, minor vision disorders and cardiovascular regulation disorders (tachycardia, hypotension, palpitations).
Very rarely: anaphylactic reactions such as urticaria, Quincke’s edema, bronchospasm as well as exceptional cases of anaphylactic shock which can be fatal, respiratory rate disorders or even respiratory depression.
Drug interactions: Monoaminooxidase inhibitors (MAOIs), morphine agonists and antagonists, alcohol, drugs lowering the seizure threshold, neuroleptics.
It is important to inform the patient that treatment with tramadol makes driving vehicles or using machines dangerous.
Pregnancy and breastfeeding: it is preferable not to use it during the first trimester of pregnancy. From the second trimester, cautious use is occasionally possible. During the last trimester, chronic use of tramadol can induce, regardless of the dose, a withdrawal syndrome in the newborn, and risk of respiratory depression. Breastfeeding should be discontinued.
PAIN KILLERS IN ODONTOSTOMATOLOGY.
| Immediate-acting forms | |
| Effervescent forms | Biodalgic® 50 mgTakadol® 100 mgZumalgic® 50 and 100 mgGenerics |
| Injectable forms | Contramal® 100 mg/2 mL Topalgic® 100 mg/2 mL |
| Dry forms | Contramal® 50 mg capsulesOrozamudol® 50 mg capsulesTopalgic® 50 mg capsules |
| Drinkable forms | Contramal® 100 mg/mL Topalgic® 100 mg/mL |
| Long-acting forms | |
| Dry forms | Contramal LP®100, 150 and 200 mgMonoalgic LP® 100, 200 and 300 mgMonocrixo LP® 100, 150 and 200 mgMonotramal LP® 100 and 200 mgTopalgic LP® 100 and 150 mg |
| Associated forms: tramadol/paracetamol | |
| Dry forms | Ixprim®37.5 mg tramadol/325 mg paracetamolZaldiar®37.5 mg tramadol/325 mg paracetamol |
3- Level III analgesics:
Also called strong opioids, they are classified into three distinct groups: pure agonists among which morphine is the reference molecule, partial agonists such as buprenorphine and agonist-antagonists such as nalbuphine.
- Opioid painkillers.
- Morphine:
Morphine is considered the gold standard for high-intensity painkillers.
Its use is suitable for persistent, intense or stubborn pain (particularly in cancerology).
The oral route should be preferred, the injectable route should be reserved for situations where oral administration is not possible.
The usual starting dose for morphine therapy is 60 mg/day.
| Forms | Specialties |
| Immediate-release oral forms | Actiskenan® capsule Oramorph® oral solution Sevredol® film-coated tablet |
| Oral extended-release forms | Moscontin LP® coated tablet Skenan LP® capsule |
| Injectable forms | Morphine® |
Morphine-based specialties
Contraindicated in certain cases: hypersensitivity to morphine or other constituents, children under 6 years old, decompensated respiratory failure, severe hepatocellular failure (with encephalopathy), acute (head trauma and intracranial hypertension in the absence of controlled ventilation), uncontrolled epilepsy, breastfeeding.
Side effects: constipation is inevitable. It must of course be systematically prevented by hygiene and dietary measures and by the use of laxatives.
At the beginning of treatment, nausea, vomiting, drowsiness, dysuria and sweating often appear, these various disorders being most often transient.
Excessive drowsiness and breathing difficulties indicate an overdose that should be managed by stopping treatment.
Drug interactions: morphine derivatives, neuroleptics, barbiturates, anxiolytics, hypnotics (benzodiazepines), sedative antidepressants, central antihypertensives.
During morphine therapy, any consumption of alcohol is obviously not recommended.
- Fentanyl
It is a powerful analgesic that acts in the same way as morphine but has the particularity of providing a rapid and short-term effect.
Its analgesic effect is a hundred times more powerful than that of morphine.
Fentanyl is prescribed for chronic, severe pain that cannot be treated with other opioid painkillers.
Contraindications of morphine include: hypersensitivity to the constituents of the drug, short-term acute post-surgical pain (dose adjustment is impossible in a short time), severe disturbances of the nervous system and people who have never received opioids.
Drug interactions similar to those of morphine should be considered.
There are many side effects:
Heart conditions (such as tachycardia/bradycardia, or even arrhythmia);
Nervous system disorders (including headaches and dizziness);
Diseases of the skin and subcutaneous tissues;
Gastrointestinal disorders (nausea, vomiting, constipation);
Psychiatric conditions (drowsiness, sedation, loss of appetite, nervousness).
- Hydromorphone:
It is an opioid agonist. Its pharmacological effects do not differ markedly from those of morphine.
They are diverse and include analgesia, drowsiness, mood changes, respiratory depression, decreased gastrointestinal motility, nausea and vomiting, and changes in the endocrine and autonomic nervous systems.
Hydromorphone is indicated in the treatment of severe pain of cancer origin, in cases of resistance or intolerance to morphine.
Marketed under the name Sophidone® LP capsules of 4, 8, 16 and 24 mg, its dosage depends on the severity of the pain and the patient’s previous morphine requirements.
A 4 mg dose of hydromorphone has analgesic activity approximately equivalent to 30 mg of morphine sulfate administered orally.
- Oxycodone:
A pure opioid agonist.
Its analgesic action is qualitatively similar to that of morphine.
The therapeutic effect is mainly analgesic, anxiolytic, antitussive and sedative.
This analgesic is indicated in the treatment of severe pain, particularly pain of cancer origin.
Immediate-release oral forms (Oxynorm® and Oxynormoro®) are administered every 4 to 6 hours.
The extended-release forms, under the name Oxycontin®, in doses of 5, 10, 20, 40, 80 and 120 mg, have a duration of action of 12 hours.
There is also an injectable form available at 10 and 50 mg/mL.
- Mixed opioid analgesics
- Buprenorphine
It is a partial agonist, thirty times more powerful than morphine.
Its main advantage is its perlingual administration, in two to three doses per 24 hours.
It is marketed under the name Temgésic® (sublingual tablets dosed at 0.2 mg) and is indicated for severe pain, particularly postoperative pain and neoplastic pain.
Sublingual tablets should not be swallowed or chewed. They should be held under the tongue until dissolved, which usually occurs within 5 to 10 minutes.
The dosage for adults is 1 to 2 tablets per dose, on average three times a day.
In subjects aged over 65 and particularly over 80, the dosage should be reduced by half.
In children aged 7 to 15 years, it should be 6 μg/kg/24 hours.
Finally, an IV form (intravenous route) is reserved for hospital use.
- Nalbuphine
It is a semi-synthetic central analgesic of the morphine agonist/antagonist type of the phenanthrene series. This drug has an analgesic activity equivalent to that of morphine.
It is marketed in the form of an injectable solution dosed at 20 mg/2 mL.
At therapeutic doses, respiratory depression is moderate and does not increase beyond the dose of 0.3 mg/kg (ceiling effect).
In adults, the onset of action is 2 to 3 minutes after intravenous administration and less than 15 minutes after intramuscular or subcutaneous injection.
The duration of action varies between 3 and 6 hours.
In children over one year of age, the onset of action is 2 to 3 minutes after intravenous administration and 20 to 30 minutes after intramuscular or subcutaneous injection.
The duration of action is 3 and 4 hours.
Nalbuphine is commonly used in pediatric postoperative care.
How to prescribe analgesics:
-Choice of a painkiller
To guide the prescriber, the World Health Organization (WHO) has established a hierarchical scale in three successive levels.
The first level concerns low-intensity pain responding to non-opioid analgesics.
The second level is that of minor morphine drugs, codeine or dextropropoxyphene, associated with another active ingredient. The paracetamol-codeine combination occupies a special place in this level.
Step III involves the use of morphine or morphine-based drugs.
This scale, initially proposed for the treatment of cancer pain , cannot be directly used in dentistry.
However, its logic can be applied to dental pain. This is why we propose a hierarchical scale adapted to odontostomatology and based on knowledge of the activity of various classes of analgesics on oral pain .
- Time and method of prescription
Replacing the classic on-demand prescription with a prescription at regular intervals of a fixed dose;
The need to prevent rather than treat after the fact pain occurring after oral surgery and certain endodontic or orthodontic treatments.
Conclusion
Poor postoperative pain management is frequently due to underestimation of pain by the practitioner or inadequate prescription. Inadequate pain management of course results in unnecessary suffering and encourages self-medication.
In odontostomatology, analgesics are very often only a complement to the local surgical procedure which remains essential and identification of the type of pain is therefore essential before any prescription.
PAIN KILLERS IN ODONTOSTOMATOLOGY.
Cracked teeth can be healed with modern techniques.
Gum disease can be prevented with proper brushing.
Dental implants integrate with the bone for a long-lasting solution.
Yellowed teeth can be brightened with professional whitening.
Dental X-rays reveal problems that are invisible to the naked eye.
Sensitive teeth benefit from specific toothpastes.
A diet low in sugar protects against cavities.