Quality Resource Guide –

Pain Control in Dentistry 5th Edition

www.metdental.com

Page 2

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Provide information, both procedural (what

will be done) and sensory (what may be

experienced), in terms understood by the

patient.

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Assure the patient preoperatively that

intraoperative pain will be controlled with local

anesthesia.

•

Discuss the patient’s previous experiences with

pain and its management.

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Assure the patient that effective postoperative

measures to control pain will be provided.

Although these non-drug measures will likely have

less effect on the experience of pain in the highly

anxious patient, a combination of information, a

calm and competent treatment setting and genuine

assurance that pain will be managed should benefit

most patients.

Analgesic Agents

Analgesic drugs are classified pharmacologically

as opioids or non-opioids.

The latter group is

also commonly referred to as nonsteroidal anti-

inflammatory drugs (NSAIDs). Although these two

groups share the property of analgesia, they differ

markedly not only in their analgesic mechanisms

but in most other actions as well. Within each group,

individual agents vary widely in the degree to which

they exhibit the properties typically associated

with the group. The primary characteristics that

distinguish opioids and NSAIDs are listed in

Table 1

Characteristics of Opioid and Non-steroidal Anti-inflammatory Drugs (NSAIDs)

Characteristic

Opioids

NSAIDS

Analgesia

Site of Action

Cortical Depression

Physical Dependence

Tolerance

Antipyresis

Anti-inflammatory

Specific Antagonists

Yes

Central

Yes

Peripheral*

Yes

Yes^

Acetaminophen may also act centrally

Acetaminophen has little anti-inflammatory activity

the ethical requirement of practitioners to prevent

or obtund suffering, unresolved pain can cause

adverse physiologic consequences, such as

elevation of heart rate and blood pressure in a

patient with underlying coronary artery disease. The

negative impact of pain on mood and coping skills is

well known, as is its effect on job performance and

productivity. Moreover, effective pain management

enhances patient satisfaction and ultimately

retention in the practice as well as referrals.

Although safe and effective analgesic drugs are

available, acute postoperative pain is not always well

managed. The reasons for this range from failure to

treat pain to the selection of ineffective drugs, or use

of inadequate doses or dosing regimens. This Guide

will review current approaches to managing acute

oral pain arising from trauma, disease or operative

dental procedures in adult patients. Intraoperative

pain is typically controlled by the use of local

anesthesia, and is the subject of another Quality

Resource Guide by Dr. Clarence Trummel, titled

Local Anesthetics. Treatment of chronic orofacial

pain associated with complex conditions such as

temporomandibular disorders is beyond the scope

of this presentation.

Nonpharmacologic

Considerations in

Pain Control

Although pain control usually requires analgesic

drugs, the concurrent use of non-drug measures

deserves comment.

Given the affective component

of pain, it is not surprising that psychological factors,

such as fear and anxiety, strongly influence the

experience of pain. Laboratory and clinical studies

show that the sensation of pain is heightened as

anxiety increases. This relationship suggests that

efforts to reduce anxiety should lessen intraoperative

pain and perhaps postoperative pain as well.

Various strategies for allaying anxiety associated

with dental treatment can be used, including

biofeedback, relaxation techniques and hypnosis.

Some of these techniques require special training

and attention to their application. Other measures

are quite simple and should be used with every

dental patient:

•

Present a calm, well-organized staff and

treatment environment.

Non-Steroidal

Anti-Inﬂammatory Analgesics

Aspirin, the prototype drug for this class of

analgesics, was introduced more than 100 years

ago. Since then, a large number of chemically

diverse aspirin-like analgesics have been developed,

e.g., ibuprofen and other propionic acid derivatives.

Like aspirin, these agents also have prominent

anti-inflammatory and anti- pyretic effects, and

the term non-steroidal anti- inflammatory drugs

(NSAIDs) is used to distinguish them from other anti-

inflammatory agents, i.e., glucocorticoids, that lack

specific analgesic effects. Some NSAIDs are more

efficacious or have lesser side effects than aspirin,

and have reduced the once enormous use of aspirin

as an analgesic. Although acetaminophen has little

anti-inflammatory activity, it is typically included in

this category since it has analgesic and antipyretic

effects equivalent to those of aspirin.

Acute pain associated with tissue injury and the

consequent inflammation results from the action of

locally generated inflammatory mediators, such as

prostaglandins, on free nerve endings (nocioceptors).

Aspirin and other NSAIDs appear to relieve

pain and inflammation by inhibiting the enzyme

cyclooxygenase (COX), thus blocking the synthesis

of prostaglandins. Two forms of COX are known:

a constitutive form found in most cells and tissues

(COX-1) and a form induced at sites of inflammation

(COX-2). Aspirin and most NSAIDs inhibit both

COX-1 and COX-2. In the late 1990s, several anti-

inflammatory analgesics, e.g., refocoxib (Vioxx),