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Exodontia > Pain and analgesia > Flashcards

Pain and analgesia Flashcards

1
Q

Pain definition

A

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage

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2
Q

Pain effects

A

Physiological - systemic
-HR/ BP/ feel unwell
Physiological - emotional
-fear/ anxiety/ upset

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3
Q

If pain is untreated

A

Significant systemic effects

-please remember this and advise upon analgesic use

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4
Q

Management: type of pain

A

Acute or chronic
Site of pain
Cause of pain

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5
Q

Cause of pain

A

Inflammatory e.g. post operative pain / RA
Neuropathic e.g. Trigeminal neuralgia
Vascular e.g. temporal arteritis

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6
Q

Analgesia for pulpitis

A

Where: tooth
Physical cause of pain: inflammation
Acute or chronic: acute
Management: remove cause

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7
Q

Analgesia for periapical abscess

A

Where: perio tissues
Physical cause of pain: inflammation
Acute or chronic: acute
Management: remove cause

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8
Q

Analgesia for trigeminal neuralgia

A

Where: nerve
Physical cause of pain: neuropathic?
Acute or chronic: acute?
Management?

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9
Q

Analgesia for Burning Mouth Syndrome

A

Where: oral mucosa

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10
Q

Analgesia for TMJ

A

Where: joint/ muscles

Acute or chronic: both

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11
Q

Pain can be reduced at any point - peripheral

A

Remove cause: tooth, pulp etc.
Anti-inflammatories
LA

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12
Q

Pain can be reduced at any point - central

A

Distraction, relaxation, cognitive restructuring, CBT
Anti convulsants, depressants, NSAIDS
GA

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13
Q

Pain management: methods

A 
Remove the cause
Medication
Regional anaesthesia: epidural infusion of LA +/- opioid
Nerve blocks with LA +/- opioid
Physical methods
Psychological
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14
Q

Remove the cause

A

Surgery

Splinting

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15
Q

Medication

A

NSAIDS +/-
Paracetamol +/- opioids
Opioids (morphine)

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16
Q

Physical methods

A

Physiotherapy
Manipulation
TENS
Acupuncture

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17
Q

Psychological methods

A

Relaxation
Hyponosis
Psychoprophylaxis/ CBT

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18
Q

The prostaglandin pathway

A

For inflammatory pain
Stimulus –> phospholipase A2 which turns phospholipids into arachidonic acid (steroids and block this pathway)
arachidonic acid –> lipoxygenases –> 12-HETE, 15 HETE, LTA4 –> LTB4, LTC4, LTD4, LTE4
Arachidonic acid –cyclooxygenase (COX-1 and COX-2)–> PGH2 –> PGD2, PGR2, PGF28, PG2, PXA2

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19
Q

Arachidonic Acid pathway

A

Produces inflammatory mediators
Arachidonic acid –> prostaglandins via Cox I and Cox II –> inflammation, pain and swelling
Aspirin and ibuprofin act of Cox 1
Cox II inhibitors act on Cox II
Arachidonic acid –> cytokines –> inflammation, bronchoconstriction, airway obstruction, cell infiltration
5-LO inhibitors, Cys LT inhibitors, TNF antagonists

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20
Q

Action of NSAIDS

A

Act on COX-1 and COX-2
< ability of stomach to protect itself from acid contents, and result is greater propensity to erosion and ulceration (systemic not local)

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21
Q

E1, E2, F1 alpha, F2 alpha

A

> vascular permeability
Cause inflammation - wheal and flare
Contract smooth muscle - uterus/ gut/ bronchi
hyperalgesia in sensory afferent nerve fibres
< gastric acidity

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22
Q

D2

A

> hyperalgesia in sensory afferent nerve fibres

Inhibit platelet adhesion

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23
Q

Thromboxane

A

> vascular permeability

Aggregate platelets

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24
Q

Prostacycline

A

< vascular tone

< platelet adhesion

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25
Cyclo-oxygenases
Catalyse conversion of arachidonic acid to biologically active prostaglandins by cyclooxygenase and peroxidase activity
26
Active prostaglandins physiological functions
``` Protection of GI tract Renal homeostasis Uterine function Embryo implantation and labour Regulation of sleep-wake cycle and body T ```
27
Cyclo-oxygenase-1
Found: most tissues particularly in platelets, stomach and kidney Responsible for production of prostaglandins Cox-1 levels >2-4x by inflammatory stimuli Constitutive, suggesting it synthesises prostaglandins responsible for physiological housekeeping functions including GI protection
28
Prostaglandins
important for responses to circulating hormones and maintenance of gastric mucosal integrity and platelet function
29
Cyclo-oxygenase-2
Predominantly inducible, though is constitutive in kidney, brain, testicles and tracheal epithelia Responsible for biosynthesis of inflammatory prostaglandins Its levels >10-20x through inflammation, particularly in macrophages, monocytes, synoviocytes, chondrocytes, fibroblasts and endothelial cells
30
Cyclo-oxygenases and NSAIDS
``` Conventional NSAIDs (Ibuprofen,diclofenac) inhibit both Cox-1 and Cox-2 to some degree COX2 – major problems, mostly been withdrawn due to increase MI rates ```
31
Analgesic need - operative/ acute pain
On slides
32
NNTs of some common analgesics
Gives number as to how good an analgesics are at reducing pain - NNT of 1: everyone gets pain reduction of 50% - NNT of 2: half pxs get pain reuction of 50%
33
NNTs of some common analgesics (tested on third molar model)
Gives number as to how good an analgesics are at reducing pain - NNT of 1: everyone gets pain reduction of 50% - NNT of 2: half pxs get pain reuction of 50% - best ones: paracetamol 1000+codeine 60, rofecoxib 50, diclofenac 50, naproxen 440 - ibuprofen just below
34
Analgesics in DPF
``` Aspirin tablets dispersible Diclofenac sodium tablets Dihydrocodeine tablets, 30mg Ibuprofen Tablets Ibuprofen Oral Suspension sugar free Paracetamol oral suspension Paracetamol tablets Paracetamol tablets, soluble Also Carbamazepine, diazepam and lidocaine ```
35
OTC NNT's for dental pain
Feminax ultra, nurofen and voltarol are the best
36
Prescribing in disease
``` Liver disease - impaired metabolism Renal disease -< renal excretion -sensitivity to some drugs If concerned telephone GMP ```
37
Prescribing in pregnancy
``` Avoid all drugs in pregnancy if possible 1st trimester congenital malformations (teratogenesis) 2nd/3rd trimester growth and functional development Term/Labour adverse effects on labour/neonate ```
38
NSAID's in pregnancy
``` Avoid all NSAID’s in pregnancy Risk of haemorrhage Closure of ductus arteriosus Pulmonary hypertension of newborn Delayed labour > duration of labour > blood loss in labour ```
39
Prescribing in breastfeeding
For many drugs there is insufficient info Dihydrocodeine - manufacturers concern Ibuprofen/Diclofenac/Paracetamol -too small amt in breastmilk to be a concern Aspirin -Reyes syndrome risk -hypoprothrombinaemia if Vitamin K low
40
Prescribing in children
Neonates (up to 30 days) - don't prescribe Drugs are not extensively tested in children Prescribe according to weight -up to 1 year (1/8 adult dose) -1-5 years (1/4 adult dose) -6-12 years (1/2 adult dose)
41
Paracetamol advantages
``` Well tolerated Anti-pyretic Few side effects Few interactions Available OTC Cheap Overdose potential ```
42
Paracetamol action
``` Oral ingestion Active after ~11 mins T ½ 1-4hours Metabolised in liver Action : COX2 ?3 TRPA -1 receptors ?Central actions ```
43
Taking paracetamol
500mg-1g QDS 4-6hourly No more than 4g in any 24 hours Multiple preparations available Tablets,capsules, elixir -sugar free
44
Paracetamol overdose
``` Overdose occurs frequently - nausea/ vomiting - ref A&E asap 20-30 tablets may be lethal Liver failure/transplant antidote available acetyl Cysteine/parvalex 1998 law re: packet numbers US - methionine added ```
45
Paracetamol caution
Care over OTC preps - cold and flu preps
46
Paracetamol in children
``` Prescribe according to weight 1st month ---- Up to 1 year - 60-120mg 1-5 years - 120-250mg 6-12 years - 250-500mg Sugar free elixirs available ```
47
NSAIDS side effects
``` Less than steroids but other side effects UK annual prescriptions 25 million NSAID-related admissions 12,000 NSAID-related deaths 2,600 -major vascular events -heart failure -cause-specific mortality -upper GI ```
48
Ibuprofen advantages and disadvantages
``` Good efficacy in inflammatory pain Anti-pyretic Major side effects Interactions Available OTC Cheap ```
49
Ibuprofen action
200mg-400mg TDS no more than 2.4g in any 24 hours Multiple preparations available Tablets,capsules,elixir -sugar free
50
Prescribing ibuprofen
``` Do not prescribe in asthmatics Do not prescribe in pregnancy Care in elderly Care in those on aspirin/NSAID’s Care in renal/cardiac patients ```
51
Unintentional paracetamol overdose
Dental pain accounted for 41% of all cases in one stufy 2/3 pxs not registered with dentist All pxs had difficulty accessing emergency dental care
52
Symptoms of paracetamol overdose
Asymptomatic for first 24 hours ***!!!
53
Ibuprofen and NSAID
``` Asthma potentiation GI ulceration/bleed (lowest risk NSAID) -worse with other NSAID -significant in elderly Antithrombo-embolic efficacy (inc bleeding time) Risk of thrombotic events -MI -ibuprofen/diclofenac worst -naproxen best ```
54
Ibuprofen in children
``` Prescribe according to weight (30mg/kg/day in 3-4 divided doses) Under 3 months avoid 3m-1 year: 50mg tds 1-2 years: 50mg tds/qds 3-7 years: 100mg tds/qds 8-12 years: 200mg tds/qds ```
55
Diclofenac
``` Good efficacy in inflammatory pain Anti-pyretic Major side effects / Interactions -Anticoagulants, haemorrhagic disorders,GI, asthma Similar profile to Ibuprofen ```
56
Dose Diclofenac
75 - 150mg daily in divided doses Suppository available for PR use No longer available OTC (3/1000 more major vascular events cf placebo) Pxs with serious underlying heart conditions, such as heart failure, heart disease, circulatory problems or a previous heart attack or stroke should no longer use diclofenac (MHRA, 2015)
57
Aspirin
``` Good efficacy in inflammatory pain Anti-pyretic Major side effects Interactions available OTC cheap DO NOT USE IN UNDER 16 YEARS -Reyes syndrome ```
58
Prescribing aspirin
Rarely prescribed Other NSAID’s better in inflammatory pain Do not use in G6PD deficiency -acute haemolytic anaemia
59
NSAID's dose
The lowest effective dose should be used for the shortest period to control symptoms
60
Proton pump inhibitors
Lansoprazole and Omeprazole etc. | Suppresses stomach acid secretion by specific inhibition of the H+/K+ ATPase ***!!!
61
Opioids
Opiates are naturally occurring alkaloids such as morphine or codeine Opioid receptors within the CNS as well as throughout the peripheral tissues. These receptors are normally stimulated by endogenous peptides (endorphins, enkephalins, and dynorphins) produced in response to noxious stimulation (much more effective in inflammation) Mu, Kappa, Delta, Sigma receptors
62
Opioid analgesics
``` For moderate to severe pain Not v. effective in Dental/inflammatory Mainly used if NSAID’s contra-indicated already on an NSAID warfarin GI symptoms/history of bleed E.g.codeine, tramadol ```
63
Codeine
Weak opioid, active at mu receptor- analgesic potency 50% morphine Half life 2.5-3hrs Above 65mg poorly tolerated
64
Co-codamol
``` For mild to moderate pain Not v. effective in Dental/inflammatory Not “prescribable” on FP10- but available over the counter Mainly used if NSAID’s contra-indicated -already on an NSAID -warfarin -GI symptoms/history of bleed -problems with NSAID ```
65
Co-codamol doses/ strengths
``` Paracetamol and codeine mixture Dose 1-2 tablets 4-6 hourly (max 8/day) three strengths -co-codamol 8/500 -the only OTC preparation -co-codamol 15/500 -co-codamol 30/500 Constipation a side effect ```
66
Hihydrocodeine
For mild to moderate pain Not v. effective in Dental/inflammatory “prescribable” on FP10 Is liable to abuse!
67
Compound analgesics preparations
``` Many available OTC may inc. Paracetamol Often codeine/ paracetamol combination Caffeine ? Enhance analgesic activty Often not in BNF ```
68
Costs
``` NHS Prescription £8.60 to patient OTC significantly cheaper -16-50p for 16 paracetamol/ ibuprofen tablets Private prescription cost significantly more ```
69
Diagnosis specific analgesics
``` Trigeminal neuralgia - carbemazepine Chronic pain - low dose antidepressants - Anticonvulsants - Muscle relaxants Temporal arteritis - steroids ```
70
Prescription of analgesics for post-op pain
1. Adult, routine extraction;PMH - nil - Px 500mg Paracetamol tablets, PO two qds (16) - 200mg Ibuprofen tablets, PO two tds (16) 2. Adult, routine extraction; PMH -Asthma on Ventolin - Paracetamol 500mg tablets, PO two qds 3/7 4-6 hourly 3. Adult, difficult surgical extraction; PMH - nil - px 60mg codeine orally qds 2/7 - 500mg paracetamol two qds (16) - NSAID's? 4. Elderly patient routine extraction;PMH - diabetes on insulin, a statin and aspirin 5. 12 year old child surgical extraction; PMH - nil 6. 8 year old child following routine extraction; PMH - nil 7. Adult, surgical extraction; PMH - MI, no meds 8. Adult, surgical extraction; breastfeeding, no meds

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