Control Pain Anxiety Dental Procedures

CONTROL OF PAIN AND ANXIETY

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

PAIN
The international association for the study of pain
defines pain as “an unpleasant sensory and emotional
experience associated with actual or potential tissue damage
or describe in terms of such damage. “


Major disorders causing facial pain
Neural

-

Trigeminal neuralgia
Multiple Sclerosis
Glossopharyngeal neuralgia

Vascular

-

Temporal arteritis
Migraine headache
Cluster headache
Angina pectoris

Musculo Skeletal

-

TMJ disorders
MPDS
Eagle’s syndrome

Oral / Salivary

-

Dental
Salivary gland Inf/Inflammation
Duct blockage
Gland tumors

ENT related

-

Otitis / Sinusitis

Psychogenic

-

Atypical facial pain

ANXIETY
It is an emotional state, unpleasant in nature,
associated with uneasiness, discomfort and concern of fear
about some defined or undefined future threat.


Conscious Sedation
A state of mind obtained by IV administration

of

combination of anxiolytics, sedatives, and hypnotics and /or
analgesics that render the patient relaxed, yet allows the
patient to communicate, maintain patent airway and ventilate
adequately.




There have been remarkable advances in anesthesia and
surgical procedures as well as in dental surgery.



These milestones in dental and surgical treatment have
made it possible to perform procedures with greater

precision, predictability, speed and safety and often

without

pain.


However despite these advances a common problem that
still faces oral and maxillofacial surgeons is patients fear
and anxiety regarding the pain and discomfort associated
with their treatment.

Therefore,



the

preoperative,

intraoperative

postoperative management of pain and anxiety is a
challenge faced by oral and maxillofacial


and
major

surgeons.

Research into the basic mechanisms of acute pain and
anxiety has led to a number of new strategies that have
yielded more precise and controlled forms of anesthesia.
-

More molecularly focused approach

-

Target specific receptor sites




This receptor oriented approach has allowed to move from
using only inhalation anesthetics or high dose barbiturates
for GA.



Safer alternatives and increasingly more specific agents
include,
-



Benzodiazepines
High potency synthetic opioids and propofol

Similarly new classes of analgesic drugs such as NSAIDS,
Cox-II inhibitors and opoid agonist – antagonists have
been developed in managing pain among out patients.

GOALS OF THERAPY


Alleviate patients fear and anxiety



Sedate and calm patient intra operatively



Minimize spontaneous movements intraperatively



Alter patients recall (antegrade amnesia)



Maintain protective reflexes (conscious sedation)



Allow rapid and complete recovery in OP settings



Achieve safe and effective pain and anxiety control.

Pre emptive / Preventive Strategies


Implementation of strategies to preempt or prevent the
pain resulting from surgical procedures or trauma that
provoke the release of inflammatory mediators, as well as
a cascade of pain inducing substances.
-

Long acting anesthetics

-

NSAID’S

-

Corticosteroids




Another preemptive strategy involves the preoperative
control of patients anxiety. In this regard, some clinicians
are using the technique of “pre programming” their

patients before surgery.

This technique effectively shapes

patient expectations, primes patients for effective pain
management and has the potential to reduce anxiety.


Pharmacologic Agents used in Oral Maxillofacial
Surgery
Surgeons

are

increasingly

using

systemic

corticosteroids administered on a short term basis to control
facial edema and pain in patients having elective bony
surgery of the face. (JOMS 50 : 270, 1992)


OPIOIDS
There is also a role for opioids in the prevention and
control of post operative pain. 3 classes of opioids currently
used.
1.

Single entity agonists (Meperidine or morphine)

administered by injection or orally. Because of dose
adverse effects, these drugs appear to have
OMFS.

related

limited place in

2.

The most widely prescribed type of opioids are those in
combination with other analgesic agents
Codeine, hydrocodone and oxycodone, in combination
with aspirin, acetaminophen or ibuprofen.

3.

The opioid agonist antagonists such as the intranasal

formulation of butorphanol also have been developed for
post operative pain.

NSAID’S
NSAID’S are another class of analgesic commonly used
for mild to moderate pain. A related new class of drugs is the
COX-II inhibitors, which deliver pain relief with a significantly
lower risk of serious side effects common to chronic NSAID use
particularly.
-

Gastrointestinal perforation

-

Ulcers and

-

Bleeding

Although variety of newer analgesic agents are used for
the control of pain, LA’s, sedative hypnotics, and GA continue to
be widely used.

Guidelines for Anxiety control & Pain management in OMFS
Pain and anxiety control involve the application of various
physical, chemical and psychologic modalities aimed at
preventing and treating preoperative, intraoperative, and post
operative patient anxiety and pain.
Organizations

Agencies

-

ADA

-

WHO

-

AAOMS

-

AHCPR

-

AAP

-

AAPD

-

APS


The guidelines will be presented in 2 separate categories
-

Anxiety control

-

Pain control

However it should be noted that techniques focused on
one type of control often affect the other.


Anxiety Control
ADA – has published 3 guidelines for the management of
pain and anxiety. ADA divides Pain & Anxiety control into 3
subcategories.
1.

Combined inhalation – enteral conscious sedation

2.

Parenteral conscious sedation and

3.

Combination of deep sedation and GA

1. Guidelines for Combined Inhalational enteral conscious
sedation are
a.

Patient evaluation (ASA classes I – IV)

b.

Preoperative or preanesthetic informed consent

c.

1 additional support person with or without BLS training

d.

Mandate monitoring by pulse oximetry and periodic

evaluation of vital signs.

2.

Parenteral Conscious Sedation

a.

1 additional support person who must have BLS training

b.

IV access should be established and maintained

c.

That a positive pressure O2 system be available

d.

Patients with CV disease be monitored by continuous

ECG.

3.

Deep Sedation and GA

a.

2 BLS trained person in addition to the surgeon

b.

Use of in line O2 analyzers and end tidal CO2 monitoring
– if not intubated, the patient may have either end tidal
CO2 or precordial stethoscope monitoring of respiratory
rate.

c.

Recording the body temperature and vitals signs are

taken every 5 minutes

AAOMS
Have published guidelines for anesthesia divided into 3
categories.
1.

Conscious sedation is defined as minimally depressed
consciousness, anxiety and or pain.
This state is achieved while retaining an independent and

continuous airway and response to physical stimuli and verbal
commands
Full recovery in 12 hours.

2.

There are 3 criteria for determining the 2nd category –

Deep Sedation. Inability to respond to physical stimuli or verbal
commands, partial or complete loss of protective reflexes and
the absence of pain, anxiety, awareness and recall.
Recovery – 12 hours
3.

General Anesthesia
Inability to maintain the airway
Recovery 12 hours.

AAPD
AAPD follows the guidelines of AAP.

Goals are to

achieve sedation levels 1 – 4 based on following functional
measures of sedation.
Level 1

-

Mild sedation (reduction of anxiety)

Level 2

-

Minimal depression with interaction possible

Level 3

-

Non interaction but arousal with mild to
moderate stimulus

Level 4

-

Non interaction and non arousal except with
intense stimulus



Facilitate quality care



Minimize disruptive behaviour



Promote positive psychologic response to treatment



Promote welfare and safety and



Return to a normal state of safe discharge
AAPD provides guidelines for preemptive anxiolytic

control by means of oral medication.
Preemptive control calls for the administration of minor
tranquilizers (hydroxyzin or benzodiazipines).

Anti-Anxiety Drugs
1. Benzodiazepines

-

Diazepam
Lorazepam
Oxazepam
Alprazolam

2. Azapirones

-

Buspirones
Isapirone
Gepirone

3. Other sedatives

-

Hydroxyzine

4. β blocker

-

Propanolor


Drugs commonly used for IV sedation, Sedative
hypnotic and anti-anxiety drugs
Benzadiazipines -

Diazepam, Midozolam

Barbiturates

Methahexitone

-

Non Barbiturate Drugs
Propofol
Ketamine
Neurolept analgesics
Anti-histamines
Promethazine
Narcotics
Pethidine, Pentazocine, Fentanyl

Control of Post Operative Pain
Neither ADA nor the AAOMS have published specific
guidelines regarding management of acute post operative pain.
In 1990 WHO devised an “analgesic ladder”, a stepwise
approach to treat mild to severe pain.


Non opioid agents and possibly adjuvants should be used
for mild pain.



Opioids with non opioids and possibly adjuvants should
be used for mild to moderate pain.

Severe pain should be addressed with opioids and if
needed, non opioids and adjuvants.



The APS adapted and simplified this “Analgesic Ladder”
by recommending that opioids be used when non opioids fail to
control pain.
The AHCPR published guidelines in 1992 that categorize
pain in to 2 levels.
-

Mild to moderate and

-

NSAID’S

-

Moderate to severe

-

OPIODS


The AAOMS combined the guidelines of these three
agencies and also addressed 2 levels of post operative pain.
-

Mild to Moderate

-

NSAID’S and Low dose
Opioid / Non –Opioids

-

Moderate to Severe -

Opioids and Select
NSAID’S / Non-Opiods


Drug Selection & Use
The APS, the AAOMS, and the AHCPR have evaluated
and recommended the use of non opioids, including
acetaminophen, salicylates / aspirin and NSAID’S for mild
pain.




Low dose opioids which include morphine like agonists
such as codeine, hydrocodone, oxycodone and mixed
agonist / antagonists (such as transnasal butorphanol)
are indicated for mild moderate pain.



Opioids for severe pain.

The ideal agent to treat moderate to severe pain
associated with OMFS should be potent and quick
acting.

OPIODS RECOMMENDED FOR SEVERE PAIN

Morphine like agonists

:

Morphine, hydrocodone,
oxycodone, codeine

Mixed Agonist/Antagonists :

Butarphanol, Nalbuphine,
dezocine

Partial Agonist

:

Buprenorphine


The APS, the AHCPR and the AAOMS stipulate an acute
pain management schedule for administration of these agents.
For dental surgery

Behavioural or anxiolytic therapy for disproportionate
anxiety


Oral NSAID’S for simple extraction and



Long acting LA’S and Oral NSAID opioid combinations for
OP control of moderate pain.



Where surgery inhibits oral intake, IV – preferred route.


Transnasal administration of analgesics is another
alternative to oral medications for the control of post operative
pain after O.S.

NSAID’S and OPIODS – Safety and usage concerns in the
differential treatment of postoperative orofacial pain
Post surgical pain can be managed effectively by using
specific treatment methods that are well justified by current
research. These include,
1.

Comprehensive presurgical consultation

2.

Consideration of the use of sedation or GA

3.

Use of Long acting LA

4.

Administration of an oral analgesics prior to surgery

5.

Meticulous and careful surgery

6.

Administration of perioperative glucocorticoid

7.

Post operative convalescence

8.

A regularly administered analgesic for 48 – 72hours

9.

Consideration of rescue medication

10.

Return for evaluation of unusual or unexpected pain.

ADVANTAGES OF NSAID’S
1.

NSAID’S interfere with the production of prostaglandins
in the surgical wound.



Conversion of arachidonic acid into prostaglandins by

cyclooxygenase is inhibited


Reduction of prostaglandins in the surgical wound results
in a diminished intensity of pain by essentially elevating
the threshold at which pain afferent nerves discharge.

2.

Effective and useful analgesics for post surgical pain

3.

No risk of addiction and abuse potential

4.

NSAID’S have a topical effect when applied to the

surgical wound and a local effect when injected in or around an
area of wounded tissue.


Risks associated with the use of NSAID’S


Spontaneous GI hemorrhage



Effect on the genito urinary system



Nephrotoxicity



Dyspepsia



Peptic ulcer



Dysphagia



Abdominal pain

Aspirin and NSAID’S have significant risk potential for
severe allergic reactions of anaphylaxis.


Other Potential Adverse Effects


CVS (Tachycardia, edema)



CNS (Dizziness, Headache)



Hepatic (increased liver enzymes) have been reported



Bromfenac sodium was recently with drawn because of
reported cases of fulminant hepatic necrosis.

(JOMS 50; 2004)

Advantages associated with the use of opioids


Opioids have been used as analgesic medications for

centuries, and are the cornerstone for the management of
moderate to severe acute pain.


Opioids have an effect on peripheral sensory nerves 
possibility of administering via topical application or local
infusion  decrease systemic side effects.



Opioids can be prescribed in combination with NSAID’S
for effective pain management.

Risks associated with opioids


Patient abuse and dependence



Nausea and vomiting



Gastric intolerance



Constipation


Respiratory depressant effect (So contraindicated in
patients with COPD)


Urine retention



CNS (hallucinations, psychomimetic effect)



Hepatic toxicity

Drug Interactions
A number of drug interactions are associated with
analgesics. Many of the interactions occur only after prolonged
use. However it is important to determine if patients are taking
other medications.


Drug Interactions with NSAID’S
DRUG

INTERACTIONS

Antihypertensives (ACE inhibitors, β blockers,
duretics)

Toxicity

Lithium

Toxicity

Methotrexate

Toxicity

Digoxin

Toxicity

Cyclosporine

Toxicity

Anticonvulsants

Toxicity

Anticoagulants

GI Bleeding

Alcohol

GI Bleeding

Acetaminophen / NSAID’s

Nephrotoxicity

Drug Interactions with OPIODS
DRUG

INTERACTIONS

Alcohol

Sedation

Antidiarrheals

Constipation

Antihypertensives

Potentiation of Effect

Barbiturates

Sedation

Carbamazepine

Toxicity

CNS depressants

Sedation

Warfarin

Increased Coagulations

Hypnotics

Sedation

MPDS
It is a functional disorder involving a painful self
perpetuating spasm of the masticatory muscles.
Pre Disposing Factors
•

Stress

•

Clenching and grinding habits

•

Occlusal abnormalities

Muscles found to be commonly involved are
•

Lateral pterygoid and

•

Masseter

TREATMENT
1. Conservative

Limit parafunctional habits

Warm – hot moist compresses

Soft diet

Limit wide opening

NSAID’S

Inf. Of LA into the trigger point of muscles that are in
spasm not containing epinephrine.

Jaw exercises

Opiods
2. Occlusal Splints
3. Biofeed back
4. Nerve Stimulations


TENS
It is an electrical stimulus which is typically generated
from a battery operated device and transmitted to the patient
by electrodes applied to the facial skin.
TENS blocks pain signals being carried over the small
unmyelinated ‘C’ fibers by forming the large myelinated ‘A’
fibers to carry any light touch sensation.


TENS may provide pain relief by the physiologic effects
of rhythmic muscle movements.
The fasiculations of muscles may result in increase in
circulation, decrease in edema and decrease in resting
muscle activity.
Pharmacologic action of TENS may involve the
stimulated release of endorphins which are endogenous
morphine like substances.

ARTICLES


The effectiveness of combining analgesic and anxiolytic
agents to control pain and anxiety has been evaluated in a
multicenter, parallel group, double blinded trial involving 997
ambulatory patients undergoing oral surgery with premedication
and LA.
JOMS : Vol.10 – 2000, JOHN. R. ZUNIGA




Placebo



Midazolam



Midazolam + Midazolam



Midazolam + Fentanyl



Midazolam + Fentanyl + Methohexital
All treatments produced significant reductions in anxiety

levels compared with placebo with Midazolam + Fentanyl +
Methohexital combination being significantly better than others.

Antegrate amnesia was effectively induced and was
significant compared with placebo and MDZ + MDZ and MDZ +
FEN + MHX producing the most significant amnesia.
This study showed that administration of benzodiazipines
led to a desired reduction in anxiety, amnesia and high patient
acceptance.
Greater CNS depression, resulting in better patient
cooperation was achieved by adding an opiod or an opiod plus
a barbiturate.

An open-label evaluation of the efficacy and safety of
Stadol NS with Ibuprofen in the treatment of pain
after removal of Impacted Wisdom Teeth.
JOMS, Vol.10, 2000
-Marvin J, Ladov & Richard K. Stern
Robert wood Johnson University Hospital,
New Brunswick, NJ.
Purpose
This study evaluated the efficacy and safety of
transnasal butarphanol tartrate in the treatment of patients with
moderate to severe pain after oral surgery for the removal of
impacted 3rd molars.

PATIENTS AND METHODS
In this study, 3rd molar extraction was performed on 25
male and 25 female patients. These patients were given Stadol
NS (Nasal Spray), 1mg, administered in a single dose every 4
hours as needed.

Patients were allowed to remedicate 60-

90mts after the initial dose if required. They also took ibuprofen
(400mg) as concomitant medication every 4-6hours for the first
48 hours. Patients recorded pain intensity on a visual analog
scale, with 0 representing no pain, to 100 representing the most
severe pain.

RESULTS
Stadol NS significantly reduced pain (by 50%) after 3rd
molar extraction within 15 minutes after administration. It had
high level of patient acceptance and was well tolerated.
CONCLUSION
The rapid onset of analgesia and long duration of action
shown by Stadol NS in this study, as well as its ease of
administration and high level of patient acceptance, suggest
that this drug would be an excellent primary choice for the
management of pain after 3rd molar extraction and oral surgery
in general.


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Control Pain Anxiety Dental Procedures

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