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MOS Lecture Slides > Pain relief for oral surgery > Flashcards

Pain relief for oral surgery Flashcards

1
Q

What is congenital analgesia? Outline some characteristics

A

congenital insensitivity to pain
cognition and sensation are otherwise normal
patients can still feel discriminative touch (though not always temperature)
no detectable physical abnormalities

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2
Q

What is pain?

A

constitutes an emotional response to harmful stimuli

(physical+psychological= amount of pain perceived)

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3
Q

All surgery causes an inflammatory response. True or false

A

True

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4
Q

What are the signs fo acute inflammation ?

A
  • rubor - redness
  • tumour- swelling
  • calor- heat
  • dolor- pain
  • functio laseo- loss of function
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5
Q

Broadly speaking, what are the mediators of pain?

A

substanced released from damaged cells

can be peripheral or central

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6
Q

Give examples of peripheral mediators

A
  • AA; COX1- thromboxane and prostacycline, COX2; leukotrines
  • prostaglandin E series (PGE2)
  • serotonin
  • ATP and adenosine
  • histamine
  • bradykinin
  • interleukins
  • nerve growth factor
  • substance P

these are substances released from damaged cells

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7
Q

Peripheral pain mediators can be released from what types of cells ?

A
  • leucocytes
  • platelets
  • mast cells
  • endothelial cells
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8
Q

What is the role of peripheral mediators?

A
  • dual role in reacting with nerve fibres (A-delta and C fibres) to produce hyperalgesia and nociception
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9
Q

What peripheral nerve mediators are seen to have the most significant impact?

A
  • prostaglandins
  • bradykinine
  • histamine
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10
Q

Outline central pain mediators

A

Amino acids
* aspartate and glutamate
* GABA and glycine

Peptides
* opioid peptides: enkephalins and endorphins
* non opioid peptides

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11
Q

Give examples of non opioid peptides that act as central mediators

A
  • Substance P
  • Vasoactive intestinal peptide (VIP)
  • Cholecystokinin (CCK)
  • Somatostain
  • Bonbesin
  • Neurotensin
  • Calcitonin gene related peptides
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12
Q

What factors can have an impact on pain ?

A
  • swelling
  • intensity of discomfort
  • trismus
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13
Q

The degree of swelling is due to the amount of …

A

tissue damage

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14
Q

The intensity of discomfort is directly related to …

A

amount of surgical trauma carried out

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15
Q

Trismus interferes with …

A
  • normal OH
  • eating habits
  • host response to healing
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16
Q

Factors that impact pain are less intense in what type of patients?

A

young and fit

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17
Q

Deciding on the most appropriate type of anaesthesia depends on …

A
  • MH
  • Pts wishes
  • pt compliance
  • surgical difficulty
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18
Q

What is the goal of patient pain management?

A

is to explain that analgesia will help manage any pain but will not eliminate all soreness

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19
Q

What analgesic can be administered pre-op and is the most effective in delaying the onset and severity of post-op pain with the least side effects?

A

ibuprofen

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20
Q

What is the recomended dose of pre-op ibuprofen and why?

A

400mg
there is no increased analgesic potency above this dose
just increased side effects

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21
Q

What are the ideal properties of premedication for GA?

A
  • alleviate pre-op anxiety
  • provide a degree of post op amnesia
  • make induction and maintenance of anaesthesia smoother
  • reduce the amount of anaesthetic agents required by enhancing their effects
  • provide additional analgesia during surgery and in the post op period
  • reduce salivary and bronchial secretions
  • reduce activity of the parasympathetic nervous system especially in the vagal complex
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22
Q

Give examples of premedication agents

A
  • opioids
  • anxiolytics
  • anticholinergics
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23
Q

Give examples of opioids that can be used as pre-anaesthetic agents

A
  • morphine
  • pethidine
  • papaveretum
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24
Q

Give examples of anxiolytics that can be used as premedication agents

A
  • benzodiazepines (diazepam, lorazepam, temazepam, midazolam)
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25
Q

What is the benefit of using anti-cholinergic agents as premedication for GA procedures?

A
  • reduce secretions
  • prevent overactivity of the parasympathetic nervous system
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26
Q

Give examples of anticholinergics that can be used as premedication agents for GA?

A
  • atropine sulphate
  • hyoscine
  • glycopyrrylate
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27
Q

How is diazepam used for GA procedures?

A
  • only as an anxiolytics
  • not used for pre-op sedative
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28
Q

What are the routes of administration for analgesics?

A
  • oral
  • suppository
  • IM injection
  • Cannulation
  • IV injection
29
Q

What thigh muscle is targetted for IM injection?

A

Vastus Lateralis

30
Q

Briefly outline the 3 pain characteristics

A
  • pain that is usually not severe, can be managed in most cases with mild analgesics (diffuse pain)
  • peak pain experience approximately 12 hours post-op, diminishing rapidly after
  • significant pain, rarely persists longer than 48 hours post op
31
Q

Suggest a reason why peak pain experienced approximately 12 hours post-op diminishes rapidly after

A

this is because less inflammatory mediators are being released

32
Q

How long does swelling usually last and when does it resolve?

A
  • lasts 3-4 days
  • resolved usually after 7 days
33
Q

What medications are possibly indicated to address post-op swelling? (include dose)

A
  • 4-8mg Dexamethasone IV - steroid
  • Ice pack
  • antibiotics
34
Q

When are antibiotics indicated for use in swelling?

A
  • if there is pre-existing pericoronitis or periapical infection
  • should not be used if there is no systemic indication (fever, lymphadenopathy, malaise)
35
Q

When is discomfort usually the most intense following dental operation?

A

for the first 24-48 hours
becomes less intense and intermittended over several more days

36
Q

Why is the use of lidocaine, articaine and mepivacaine for post operative pain limited?

A

short duration of action
conduction block lasts for 3-5 hours

37
Q

What LA is effective for use to manage post-operative pain and why?

A

bupivacaine (0.5% bupivacaine with 1: 200 000) because it can block conduction for 8-12 hours

38
Q

When can bupivacaine be used?

A

third molar surgery to decrease hyper-excitibility in the CNS
results in reduced post-op pain and decreased analgesic use

39
Q

Give examples analgesics used for post operative analgesia

A
  • NSAIDs
  • paracetamol
  • combine analgesics
  • opioids
40
Q

Most dental pain and inflammation is successfully relieved by …

A

NSAIDs

41
Q

Outline the benefit and caveat of using paracetamol as an analgesic

A
  • antipyretic action
  • does not have anti-inflammatory effect
42
Q

The difference in anti-inflammatory activity between different NSAIDs is small. True or false
Where do differences between NSAIDs arise?

A

True

Differences arise in
* incidence and types of adverse effects

43
Q

% of patients will respond to any NSAID

A

60%

those who do not respond to one may respond to another

44
Q

What non-selectiev NSAID has fewer side effects compared to others?

A

Ibuprofen

45
Q

Outline the analgesics present in the DPF

A
  • aspirin - dispersible tabs
  • diclofenac tabs
  • ibuprofen oral suspension and tabs
  • paracetamol (acitomenophen) oral suspension and tabs
  • dihydrocodeine tablets

combination analgesics are not present in DPF

46
Q

Give examples of combination of combination analgesics

A
  • cocodamol
  • co-dydramol
  • co-codaprin
47
Q

What dosages are available for co-codamol ?

A
  • 8/500
  • 15/500
  • 30/500

(500mg for paracetamol)

48
Q

What side effect may result from co-codamol use ?

A

intestinal disturbances

49
Q

What analgesics are contained in co-dydramol?

A
  • dihydrocodeine
  • paracetamol
50
Q

What analgesics are contained in co-codamol ?

A
  • codeine phosphate
  • paracetamol
51
Q

What analgesics are contained in co-codapirin ? What dose is it available in ?

A

codeine
aspirin

8/400

8mg codeine
400mg aspirin

52
Q

What kind of pain is aspirin used for ?

A

mild to moderate pain

53
Q

What is the suggested dose of aspirin for mild to moderate pain?

A

300mg oral/300-600mg every 4-6 hours

54
Q

What is the maximum dose of aspirin?

A

4g per day

55
Q

Aspirin should be taken with food or after food. True of false

A

True

56
Q

Outline contraindications for aspirin use

A
  • peptic ulceration (disturbance of prostaglandin production)
  • renal impairment
  • history of allergy to aspirin (asthma and angioedema)
  • pregnancy and breast feeding- coagulation defects/bleeding tendency
57
Q

What is the recommended dose for oral suspension/tablets of ibuprofen?

A

400mg 6-8 hourly

58
Q

What is the maximum dose of ibuprofen?

A

2.4g

59
Q

What is the recommended dose of diclofenac?

A

75-100mg per day, oral in 2-3 divided doses

it is available in 25mg and 50mg tablets

60
Q

Outline NSAID drug interactions

A
  • warfarin- increases bleeding risk
  • lithium
  • corticosteroids
  • ciclosporin (immunosuppresant)
  • methotrexate
61
Q

Outline the natural by-products of opium

A
  • morphine
  • codeine
  • semi-synthetic derivatives (heroin)
62
Q

Opiates Vs Opioids

A

Opiates are natural occuring opioids e.g. codeine, morphine and heroin

opioids include natural, semi-synthetic and synthetic opioids

63
Q

Outline the side effects of opioid analgesics

A
  • respiratory depression
  • nausea and vomiting
  • mental clouding
  • sedation
  • euphoria
  • constipation
  • hypotension
  • urinary retention
  • prutitis
64
Q

What are the benefits of combining opioids with NSAIDs?

A
  • attack multiple levels of the pain pathway
  • helps reduce the dose of opioid necessary to reach the desired amount of analgesia
  • limits unwated side effects seen with opioid doses
65
Q

What is PCA?

A

patient controlled analgesia
a programmable infusion pump that delivers opioids at a continuous infusion rate (mg per hour) along with patient controlled demand bolus administered IV

66
Q

What can be programmed into the pump used for PCA?

A

a lock out interval- this is when the pump will not allow more boluses to be administered

67
Q

What does TENS stand for? What role does it play in addressing dental pain?

A

Transcutaneous electrical nerve stimulation

its use in oral surgery is not currently practical

68
Q

Suggest an appropriate remit for TENS in dentistry

A

TMD of muscular origin

MOS Lecture Slides (7 decks)

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