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Pain relief for oral surgery Flashcards

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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
What is the benefit of using anti-cholinergic agents as premedication for GA procedures?
* reduce secretions * prevent overactivity of the parasympathetic nervous system
26
Give examples of anticholinergics that can be used as premedication agents for GA?
* atropine sulphate * hyoscine * glycopyrrylate
27
How is diazepam used for GA procedures?
* only as an anxiolytics * not used for pre-op sedative
28
What are the routes of administration for analgesics?
* oral * suppository * IM injection * Cannulation * IV injection
29
What thigh muscle is targetted for IM injection?
Vastus Lateralis
30
Briefly outline the 3 pain characteristics
* 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
Suggest a reason why peak pain experienced approximately 12 hours post-op diminishes rapidly after
this is because less inflammatory mediators are being released
32
How long does swelling usually last and when does it resolve?
* lasts 3-4 days * resolved usually after 7 days
33
What medications are possibly indicated to address post-op swelling? (include dose)
* 4-8mg Dexamethasone IV - steroid * Ice pack * antibiotics
34
When are antibiotics indicated for use in swelling?
* if there is pre-existing pericoronitis or periapical infection * should not be used if there is no systemic indication (fever, lymphadenopathy, malaise)
35
When is discomfort usually the most intense following dental operation?
for the first 24-48 hours becomes less intense and intermittended over several more days
36
Why is the use of lidocaine, articaine and mepivacaine for post operative pain limited?
short duration of action conduction block lasts for 3-5 hours
37
What LA is effective for use to manage post-operative pain and why?
bupivacaine (0.5% bupivacaine with 1: 200 000) because it can block conduction for 8-12 hours
38
When can bupivacaine be used?
third molar surgery to decrease hyper-excitibility in the CNS results in reduced post-op pain and decreased analgesic use
39
Give examples analgesics used for post operative analgesia
* NSAIDs * paracetamol * combine analgesics * opioids
40
Most dental pain and inflammation is successfully relieved by ...
NSAIDs
41
Outline the benefit and caveat of using paracetamol as an analgesic
* antipyretic action * does not have anti-inflammatory effect
42
The difference in anti-inflammatory activity between different NSAIDs is small. True or false Where do differences between NSAIDs arise?
True Differences arise in * incidence and types of adverse effects
43
% of patients will respond to any NSAID
60% those who do not respond to one may respond to another
44
What non-selectiev NSAID has fewer side effects compared to others?
Ibuprofen
45
Outline the analgesics present in the DPF
* 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
Give examples of combination of combination analgesics
* cocodamol * co-dydramol * co-codaprin
47
What dosages are available for co-codamol ?
* 8/500 * 15/500 * 30/500 (500mg for paracetamol)
48
What side effect may result from co-codamol use ?
intestinal disturbances
49
What analgesics are contained in co-dydramol?
* dihydrocodeine * paracetamol
50
What analgesics are contained in co-codamol ?
* codeine phosphate * paracetamol
51
What analgesics are contained in co-codapirin ? What dose is it available in ?
codeine aspirin 8/400 8mg codeine 400mg aspirin
52
What kind of pain is aspirin used for ?
mild to moderate pain
53
What is the suggested dose of aspirin for mild to moderate pain?
300mg oral/300-600mg every 4-6 hours
54
What is the maximum dose of aspirin?
4g per day
55
Aspirin should be taken with food or after food. True of false
True
56
Outline contraindications for aspirin use
* 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
What is the recommended dose for oral suspension/tablets of ibuprofen?
400mg 6-8 hourly
58
What is the maximum dose of ibuprofen?
2.4g
59
What is the recommended dose of diclofenac?
75-100mg per day, oral in 2-3 divided doses it is available in 25mg and 50mg tablets
60
Outline NSAID drug interactions
* warfarin- increases bleeding risk * lithium * corticosteroids * ciclosporin (immunosuppresant) * methotrexate
61
Outline the natural by-products of opium
* morphine * codeine * semi-synthetic derivatives (heroin)
62
Opiates Vs Opioids
Opiates are natural occuring opioids e.g. codeine, morphine and heroin opioids include natural, semi-synthetic and synthetic opioids
63
Outline the side effects of opioid analgesics
* respiratory depression * nausea and vomiting * mental clouding * sedation * euphoria * constipation * hypotension * urinary retention * prutitis
64
What are the benefits of combining opioids with NSAIDs?
* 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
What is PCA?
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
What can be programmed into the pump used for PCA?
a lock out interval- this is when the pump will not allow more boluses to be administered
67
What does TENS stand for? What role does it play in addressing dental pain?
Transcutaneous electrical nerve stimulation its use in oral surgery is not currently practical
68
Suggest an appropriate remit for TENS in dentistry
TMD of muscular origin

MOS Lecture Slides (7 decks)

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