Analgesics in Periodontics

Presented by- Richa Bhosale

I MDS
Department of Periodontics
 CONTENTS
Introduction Mechanism of Action

History Analgesics used in

periodontics
Definition
Contra indications
Pain/ Algesia
Conclusion
Classification of pain
References
Analgesics

Classification
 INTRODUCTION
Effective and safe, pain management is a
primary goal in dental practice.

Control of pain associated with dental or

periodontal disease is a main reason that patients
seek care from dentists.

Many dental procedures are painful, hence,

to control postoperative pain.

Therefore, dentists should use appropriate analgesics to treat

and prevent pain associated with inflammation or surgery.
 HISTORY
Opiates derived from poppy (papaver
somniferum) are used for thousands of years
for medicinal and recreational purposes.

Active substance being Morphine and other

derived substances like Codiene , Heroine.

Laudanum, opium prepared in an alcoholic

solution, was used as a painkiller.
 Romans used plants like
mandrake and belladonna.

Physicians in ancient Greece

regularly used willow bark, which
contains salicylic acid (the active
ingredient of aspirin) to treat pain.
 DEFINITION
Analgesics: A drug that selectively relieves pain
by acting in CNS or peripheral pain mechanism,
without significantly altering consciousness

Pain: An unpleasant sensory and emotional

experience associated with actual or potential
tissue damage.
 Pain is classified into

Based on Duration Based on Location

Acute localized
Chronic Generalized

Based on Intensity
Mild
Moderate
Severe

Based on Course Based on Cause

Continuous Nociceptive
Intermittent Neuropathic

Based on Nature
Short,sharp,shooting
Dull,Throbbing,Persistent
Pain Pathway
Analgesic Pathway
Routes of Administration of Analgesics

Oral
Intramuscular Injection
Intravenous Injection
PCA: patient controlled
analgesia
Other routes
Transdermal
Sublingual
 Classification of Analgesics

A.Opioids / narcotic /
morphine like
analgesics.

B. Nonopioids / non-narcotic /
Antipyretic / aspirin like
analgesics or nonsteroidal
anti-inflammatory drugs.
(NSAIDs)
 Opioid type Analgesics

Natural opium alkaloid

Morphine
Codeine

Semisynthetic derivatives
Heroin
Pholcodine

Synthetic opioids
Pethidine
Tramadol
Methadone
 Morphine
It is a principal alkaloid in opium and needs to be isolated

Strong pain reliever but causes psychological & physical dependancy

Can be administered I.V/ I.M/S.C/Orally

Less effective for dental pain in comparison with NSAIDS hence,used

as additional drugs to boost analgesic effect.

Used as pre-anesthetic medication/to supplement anaesthesia

 Codeine
It is methyl morphine which naturally occurs in opium

Less potent than morphine

More selective cough suppressant

Acute dental pain relief/ post surgery analgesic

Available as cough syrup and also tablets

 Tramadol
Centrally acting analgesic for moderate to severe pain

Alternative analgesic when GI disturbances contraindicate use of

NAIDS

Risk of seizures, drug abuse and anaphylaxis

Limited use in dentistry

Available as
 Classification of NSAIDS

Based on:

CHEMICAL NATURE

MECHANISM OF ACTION

THERAPEUTIC CLASSIFICATION
CHEMICAL CLASSIFICATION

Salicylates:
Acetyl salicylic acid (aspirin), sodium salicylate, Mg salicylate etc

Propionic acid derivatives:

Ibuprofen, ketoprofen, naproxen

Indole acetic acid :

Indomethacin, sulindac

Substituted anthranilic acid:

Mefenamic acid, meclofenamate

Pyrrole alkanoic acid:

ketorolac

OXICAMS:
Piroxicam, meloxicam

Difluorophenyl derivatives:
Diflunisa
 Mechanism Of Action

Prostaglandin Prostacyclin Thromboxane A2 Are produced from

Arachidonic Acid By the enzyme Cyclo-oxygenase

COX-1-vs-2-e1620462346658.png

Induced by cytokines

Generation of PG
Benefits from NSAIDS by prostaglandin synthesis inhibition

1) Analgesia- blocks pain sensitizing mechanism

induced by algesic substances by inhibiting COX-2.
 Hence effective for inflammation associated
pain
Eg: Acute dental /post extraction pain

2) Antipyresis-fever during tissue injury is due to

pyrogens

induces PG production & raises

temperature

NSAIDS block action of pyrogens

3)Anti-inflammatory- most important action of
NSAIDS

 By inhibition of COX-2 mediated

prostaglandin synthesis at the site of
injury

 The potency of various compounds

corresponds with their potency to inhibit
COX

 Apart from PG’s NSAIDS also act on other

mediators like
leukotrienes,cytokines,platelet activating
factor, interlukins, TNF alpha etc
Commonly Used
Analgesics
 Commonly used NSAIDS

Aspirin (salicylates)

It is Acetylsalicylic Acid converted to salicylic acid in

body

Oldest analgesic anti-inflammatory drug

Analgesic effect- by blocking peripheral pain receptors

& prevention of PG mediated sensitization

Reduces fever by promoting heat loss through sweating

and cutaneous vasodilation but does not decrease heat
production

Supresses signs of inflammation like

pain,tenderness,swelling
Analgesic action for painful dental conditions (dose
0.3-0.6gm)

Should be stopped 1 week before extraction & elective

surgeries
Aspirin inhibits Thromboxane A2 synthesis

Acetylates platelet COX irreversibly

Inhibits platelet aggregation

Prolongs bleeding time (almost twice than normal)

Effect lasts almost for a week

Contraindicated in…

Patients with peptic ulcer

Bleeding tendancies

Chronic liver disease

Patients having compromised renal function

patients taking anticoagulants

Pregnancy

Intolerance or allergy to any NSAID

 Acetic Acid Derivative
(KETOROLAC)
Novel analgesic

Anti inflammatory drug

Used in..
Post operative pain
(has equaled efficacy of Morphine no morphine like side effects.)

Dental pain

Acute musculoskeletal pain (15-30mg im or iv)

 Propionic acid derivatives
(Ibuprofen,Naproxen,Ketoprofen)
1st member – Ibuprofen (1969)

Better tolerated alternative to aspirin

Indicated in soft tissue injuries & tooth extraction

*Popular in dentistry & Safe NSAID

Efficacious analgesic but weak anti-inflammatory action and short

lasting anti-platelet effect
 Preferential COX2 inhibitors
(Diclofenac sodium, Aceclofenac)
Most extensively used NSAID

Used for tooth ache & post operative inflammatory conditions and
pain control

Action lasts for 6-8 hours

Dosage ranges from 25mg-100mg

Adverse effects- epigastric pain,nausea,headache

 PARA AMINO PHENOL DERIVATIVES
(PARACETAMOL /Acetaminophen)

Phenacetin
Introduced in 1887 and was extensively used.

Pracetamol
De-ethylated active metabolite of phenacetin came into
common use since 1950

 Promptly acting antipyretic

Analgesic action is like aspirin (raises pain threshold )

Negligible anti-inflammatory action

Effect lasts for 3-5 hours

Most common ‘over the counter’ analgesic
for fever,toothache,muskoskeletal pain

*Safest & can be used in all age groups

Infants
Elderly people
Pregnant women
Lactating females
Pts. With other diseases
Pts. Contraindicated for aspirin
 NSAIDS in Host Modulation
Host is defined as :
“the organism from which a parasite obtains its
nourishment”

Modulation is defined as:

“the alteration of function or status of something in response
to a stimulus or an altered chemical or physical
environment.”

HMT is a means of treating the host side of

the host-bacteria interaction

Concept given by :William et al 1990

Golub et al 1992
The immune-inflammatory response against bacterial plaque can be
viewed as a two-edged sword.

Essentially protective by activativating host immune

inflammatory response

Paradoxically causing significant tissue damage by

breakdown of CT fibers in PDL and resorption of
alveolar bone
Periodontal disease is characterized by high
concentrations of cytokines,MMP’s and prostanoids in
the periodontal tissues.

Host modulation:

Reduces excessive levels of enzymes,cytokines,

prostanoids

Modulates osteoclast osteoblast function

Simultaneously provides benefits for other

inflammatory conditions.
Arachidonic acid metabolism
 PGE2 up-regulates bone resorption by osteoclats

NSAIDS inhibit prostaglandin synthesis

Thereby reducing inflammation & inhibits osteoclastic activity

 Studies have shown that systemic
NSAIDS like Naproxen,
Flurbiprofen,Indomethacin significantly
slowed the rate of alveolar bone
resorption

But unwanted effects associated with NSAIDS are:

Gastrointestinal ulceration

Impaired hemostasis (by platelet aggregation)

Renal & hepatic impairment

Once patients cease taking NSAIDS, a return to or even

acceleration of, the rate of bone loss seen prior to drug
therapy occurs referred to as a “Rebound effect”
 Locally administered agents
NSAIDs

Ketorolac tromethamine
rinse

 S – ketoprofen dentifrice

NEW!!

NO-NSAIDs: Recently described class of

NSAID’s
They are a new class of anti-inflammatory
and analgesic drugs generated by adding a
nitroxybutyl or a nitrosothiol moiety to the
parent NSAID
 Conclusion
NSAIDs have an extremely safe profile when used for
acute dental pain

Most popularly used in terms of pain control

Within a group they tend to have similar characteristics

and tolerability.

There is little difference in clinical efficacy among the

NSAID’s

As a clinician we should have appropriate knowledge

of mechanism of action , pharmacokinetics,
pharmacodynamics, dosage and adverse effects of these
drugs before prescribing the same.
 REFERENCES

Essentials Of Medical Pharmacology 8th Edition 2018 By KD Tripathi

Newman and Carranza's Clinical Periodontology

13th Edition

Drug Therapy in Dental Practice: Nonopioid and Opioid Analgesics

Daniel E.

NO-NSAIDs: From Inflammatory Mediators to Clinical Readouts

Stefano Fiorucci*