Pain and analgesics in dentistry Pain is defined as an unpleasant sensation and sensory experience associated wit h actual or potential

tissue damage. Dental pain is the most common symptom that leads to the patient for dental trea tment for relief. This is often acute and may be associated with relatively non-invasive procedure s as simple dental extraction, periodontal or endodontic therapy and traumatic p rocedures that produce prolonged postoperative pain, such as surgical removal of impacted teeth or periodontal bone surgery. Classification of pain Pain can be classified according to the duration and intensity of this. According to the duration ACUTE PAIN Duration: Days, weeks, <3 months Diagnosis: Easy Treatment: Effective Incapacitation: Temporary Causes: CHRONIC PAIN Anxiety Over three months Diffic ult Standing limited success Depression Sharp pain According to their intensity It is important to remember that the pain has been classified into three categor ies according to their severity: Mild, Moderate, Severe, each person perceives p ain differently, so it is the patient who classified their pain. Mild: headache, toothache, laceration, sprain. Moderate: dental abscess, osteoar thritis, lower postoperative pain. Severo: myocardial infarction, herniated disc s, cancer, increased postoperative pain Classification of pain Opiates: morphine type. They are typically used in cases of severe somatic pain. Non-opioid: no-altering and often sufficient for dental pain. ANALGESICS NSAIDs antipyretics Aines Nonsteroidal anti-inflammatory drugs (NSAIDs) are a heterogeneous group of drugs , whose best known representative is Aspirin. They act primarily by inhibiting e nzymes called cyclooxygenases, which are crucial in the production of prostaglan dins, substances that mediate pain. Correspond to the first step WHO analgesic, with paracetamol, which is an NSAID but not itself, is included in this first st ep. In addition to analgesic, NSAIDs are antipyretic, anti-inflammatories and so me antiplatelet agents. They have the disadvantage that can not exceed a ceiling dose of tolerance or treatment due to serious adverse effects Action of NSAIDs BENEFITS OF THE INHIBITION OF PROSTAGLANDIN SYNTHESIS ANTI-INFLAMMATORY EFFECTS ANALGESIA antipyretic Antiplatelet AFFECTION DISADVANTAGES inhibition of prostaglandin synthesis INJURY OF THE GASTRIC MUCOSA. BLEEDING by inhibiting platelet function. LIMITATI ON OF RENAL BLOOD FLOW WITH RETENTION OF SODIUM AND WATER. DELAY OF LABOR. ASMA and anaphylactic reactions NSAIDs

Non-selective COX NAPROXEN PIROXICAM INDOMETHACIN IBUPROFEN DICLOFENAC Ibuprofen. This drug has been widely used for acute and chronic pain and in different doses (200, 400, 600 and 800 mg). Ibuprofen 400 mg has been found to be greater than 650 mg of aspirin and 600 to 1.000 mg of paracetamol. Ibuprofen 400 mg was super ior to 30 mg of codeine in an oral surgery model. No differences were found betw een doses of 400 and 600 mg, higher doses do not provide benefits. Is widely used in dentistry in soft tissue injuries, DECREASE INFLAMMATION AND E DEMA. Patients undergoing orthodontic movement may have some degree of pain, especiall y on days that fit the devices. Dose of 400 mg of ibuprofen was greater than 650 mg of aspirin and placebo in orthodontic patients. AVOID AND ULCERS IN PATIENTS WITH PREGNANCY. Aines No ulceration SIGNIFICANT INJ URY CLINIC PATIENTS ketoprofreno It is an NSAID with analgesic and antipyretic properties. It acts peripherally b y inhibiting the synthesis of prostaglandins and leukotrienes. It is an effectiv e analgesic for the relief of mild to moderate pain at doses of 25-150 mg, 25 mg of ketoprofen have been shown to be therapeutically equivalent to 400 mg of ibu profen in a surgical model oral.18 This drug has been evaluated to test therapeu tic efficacy, followed by a local authority at the site of damage as a strategy to reduce systemic drug exposure. The results of this study show that the admini stration of this NSAID on the site of damage, resulting in analgesia compared wi th oral administration, besides producing less toxic by low levels of circulatin g drug. Diclofenac Analgesic, antipyretic and anti-inflammatory efficacy similar to naproxen. It ha s good tissue penetration EXTENDED THERAPEUTIC EFFECT. SET OUT IN DENTAL PAIN AN D INFLAMMATORY STATES postoperative PROVIDES FAST RELIEF FROM PAIN AND EDEMA. PR ESESENTACIÃ N: 50 and 75 mg VO. SIGNIFICANT Aines No ulceration INJURY CLINIC PATIENTS Diclofenac (29.3%) 461 82 (17.8%) 135 Ketorolac It is the first NSAIDs approved for intramuscular administration for pain manage ment of moderate to severe. Intravenous administration has been successfully use d in pediatric patients. He has been compared with meperidine (100 mg) and morph ine (10 mg) IM in various models showing comparable analgesic efficacy, but with fewer side effects. Local administration of ketorolac injection was used in 52 patients who required pulpotomy. Maxillary or mandibular infiltration of 30 mg o f ketorolac produced significant analgesic effects. Furthermore, injection of ke torolac did not cause local irritation, suggesting that the administration Pyrazolone Potent analgesic and antipyretic QUICK ACTION, BUT SMALL anti-inflammatory actio n. RETIRED BUT NOT IN U.S. IN EUROPE AND LATIN AMERICA.

paracetamol Used to manage mild to moderate pain with analgesic and antipyretic and whose me chanism of action is unclear, possibly inhibiting nitric oxide pathway, NMDA or substance P. There are different reports about its use in dentistry. Paracetamol 500 mg was superior to placebo for the treatment of dental pain associated with third molar extraction, although pain relief was considered mild. A meta-analys is examined the analgesic efficacy of paracetamol 600 mg and 650 showing to be s uperior to placebo in oral surgery procedures. In another study, 1,000 mg parace tamol produced significantly more relief of pain compared to placebo, evaluated 5 hours after surgery. Results of another meta-analysis evaluating paracetamol i n doses of 1,000 mg found a maximum pain relief 4 hours after administration. On the other hand has shown that COX-2 selective inhibitors. The availability of NSAIDs (ibuprofen, ketoprofen, ketorolac) has significantly improved postoperative pain management in dentistry. NSAIDs have demonstrated an algesic effectiveness in cases of acute inflammatory pain. Nevertheless, when NS AIDs are prescribed continuously for several weeks or months, the risks gastroin testinal ulcerations, bleeding and renal toxicity are increased. The administration of aspirin in patients with rheumatoid arthritis results in a decrease of platelet aggregation, whereas COX-2 selective inhibitors do not pro duce this effect. Similarly Selective COX2 inhibitors Meloxicam NIMESULIDE Nimesulide Nimesulide is a nonsteroidal very effective, is also well tolerated compared wit h other NSAIDs. It is safe for some conditions in which other NSAIDs are contrai ndicated and has a rapid onset of action. Nimesulide has been shown to be a pote nt and rapid analgesic in the treatment of a variety of pain conditions is a nov el non-steroidal anti-inflammatory agent with unique properties, belongs to a ne w chemical class, sulfonanilÍdicos derivatives, which are not present in their stru ctures the carboxylic group enol or other NSAIDs. This feature gives it properti es that represent an advantage over other compounds classified as NSAIDs. In con nection therewith, is credited with producing less gastrointestinal upset than o ther NSAIDs, because they do not affect the production of PGE2 COX2 specific inhibitors Celecoxib REFECOXIB Celecoxib Although it has shown some analgesia, results of controlled clinical trials in p atients with acute postoperative pain have not consistently shown pain relief af ter third molar extraction. A dose of 200 mg, celecoxib produces superior analge sia to placebo, but less than ibuprofen 400 mg dose or standard dose of naproxen . Studies are needed to evaluate the analgesic efficacy of celecoxib and test it s usefulness in the management of acute postoperative pain. The dentist should a void using the drug until they accumulate more clinical experience in oral surge ry models. RAFECOXIB rofecoxib, which is about 800 times more selective for COX-2, with a long half l ife of about 20 h, allowing the administration of one tablet per day Rofecoxib 5 0 mg was superior to placebo and at least as effective as ibuprofen 400 or 550 m g naproxen to relieve pain after a tooth extraction In osteoarthritis, 12.5 and

25 mg of rofecoxib per day were as effective as Use of painkillers ï ® Mild to moderate pain with little INFLAMMATION: PARACETAMOL OR LOW DOSES OF IBUP ROFEN. Postextraction O ACUTE PAIN SHORT TERM: Ketorolac, Diclofenac, Nimesulide O ASS. Gastric intolerance to NSAIDs: celecoxib, or acetaminophen. PEDIATRIC: P ARACETAMOL, IBUPROFEN, ASS. PREGNANCY: PARACETAMOL. ï ® ï ® ï ® ï ® Recommendations for pregnant women ï ® ï ® ï ® ï ® Use of NSAIDs at low doses in short courses or occasionally, avoiding them durin g the third trimester and term. Use preferably the shorter half-life NSAIDs to m inimize the accumulation in the fetus. Among NSAID pain relievers, 1st choice pa racetamol, ibuprofen and diclofenac alternatives. Among the opioids, codeine, me peridine, dextropropoxyphene, or morphine.