this presentation concentrates on the pain killers and thier brief mechanism of action

2. Presented by
Dr Guru Ram Tej. K
I yr Post Graduate
Dept Of Periodontics

3. 








Introduction
Pain/ Algesia
Analgesics
Classification
Opoid analgesics
Non opoid analgesics
NSAIDs
Contra indications
Analgesics used in periodontics

5. The Sumerians wrote of demons and tooth
worms causing tooth decay. People would
pray to gods such as Shamash, Anu or Ea to
cure them of their painful oral afflictions

6. 
“An unpleasant sensory and emotional
experience associated with actual or potential
tissue damage, or described in terms of such
damage.”

7. 1.
2.
Pain perception
Reception to pain

8. SUBSTANCES RELEASED
 SUBSTANCE-P
 SERATONIN
 HISTAMIINE
 BRADYKININ-prostaglandins to act

9. 
SOMATIC NOCIRECEPTORS

VISCERAL NOCICEPTORS

10. 
Trigeminal nerve
Semilunar ganglion (g.g)
Sensory root
Pons
Sensory root
Ascending fibres
Tactile sensibility
Descending fibres
Pain and Temperature

11. Each end organ has its pathway into CNS
The pain pathway consists of
First
order neurons
Second
Third
order neurons
order neurons

12. 
Cells of posterior nerve root ganglia

A- delta fibres- marginal cells in posterior
gray horn

C- fibres- Substantia gelatinosa in posterior
gray horn

13. 
The marginal cells and the cells of Substantia
gelatinosa form the second order neurons

14. 
Neurons of Thalamic nucleus, reticular
formation, tectum and grey matter around
aqueduct of sylvius

These neuron axons reach sensory area of
cerebral cortex

15. 



SPECIFICITY THEORY
 Descartes-1644
 Muller-19th century
 Von frey-1895
PATTERN THEORY
 Gold Scheider-1894
INTENSITY THEORY
GATE CONTROL THEORY

16. • GATE input
• GATE output

17. 
Physical (injury)

Emotional (depression)

Behavioural (focusing on pain)

18. 
Physical (medication)

Emotional (happiness, relaxation)

Behavioural (distraction)

19. 

No one has located the actual gate
mechanism
Still assumes the organic basis

20. International Association Of Somatic Pain(IASP)
 REGION

SYSTEM

TEMPERATURE CHANGE

PATIENT STATEMENT

ETIOLOGY

21. 
Based on duration
Acute and chronic

Based on etiology
Inflammatory, Nociceptive and
Neuropathic pain

Atypical facial pain

Refered pain

22. 
Arising from

Pulp

Peri radicular region

Exposed dentin

Cracked tooth syndrome

23. 
LOCAL ANESTHETICS

ANALGESICS

NSAIDS

OPOIDS

CONSCIOUS SEDATION

24. 

“Analgesics are a class of drugs which
obtunds the perception of pain without
producing unconsciousness”
These act on CNS or the peripheral pain
mechanisms

25. 




Oral
Intramuscular Injection
Intravenous Injection
PCA: patient controlled analgesia
Other routes
Transdermal
Sublingual

26. 
Narcotic (opioid / morphine like analgesics)

Non-narcotic (Non opioid / antipyretic /
aspirin like analgesics or NSAIDs)

27. Opium: oldest types of drugs

Opium is extracted from poppy seeds
(Papaver somniferum)

16th century - Analgesic qualities

By the 19th century considered “as legitimate
as tobacco or tea”

28. 


Agonists: Morphine Pethidine, methadone
and propoxyphene.
Antagonists: Naloxone
Mixed: Butorphanol, nalbuphine, &
buprenorphine.

29. (a)Phenyl piperidine series- pethidine &
fentanyl
(b)Methadone series- methadone &
dextropropoxyphene
(c )Benzomorphan series- Pentazocine
& cyclazocine
(d)Semisynthetic thebaine derivatives:
etorphine & buprenorphine

30. 


Mu
Kappa
Delta

33. 
CHEMICAL NATURE

MECHANISM OF ACTION

MODE OF ACTION

THERAPEUTIC CLASSIFICATION

34. CHEMICAL CLASSIFICATION
 SALICYLATES - Acetyl salicylic acid
(aspirin), sodium salicylate, Mg salicylate, choline
salicylate, Na thio salicylate.
 PROPIONIC ACID DERIVATIVES Ibuprofen, ketoprofen, naproxen, oxaprozin, flurbi
profen
 INDOLE ACETIC ACID -Indomethacin, sulindac,
 SUBSTITUTED ANTHRANILIC ACIDS -Mefenamic
acid, meclofenamate Na
 PYRROLE ALKANOIC ACID ketorolac
 OXICAMS Piroxicam, meloxicam
 DIFLUOROPHENYL DERIVATIVES Diflunisal

35. 



ARYL ACETIC ACID Diclofenac
ACETIC ACID DERIVATIVES Etodolac
NAPHTHYL ACETIC ACID PRODRUGS
Nabumetrone
PARA-AMINO PHENOL DERIVATIVES
Acetaminophen

36. ACCORDING TO MECHANISM OF ACTION

NON-SELECTIVE COX INHIBITORS Diclofenac,
etodolac, indomethacin, ketoprofen, ketorolac,
nabumetone, naproxen, oxaprozin, ibuprofen,
flurbiprofen, diflunisol, sulindac, tenoxicam,
tolmetin

COX-1 INHIBITORS Aspirin, indomethacin,
piroxicam, sulindac

COX-2 SELECTIVE INHIBITORS Celecoxib,
etoricoxib, meloxicam

37. THERAPEUTIC CLASSIFICATION

ANALGESICS Aspirin, paracetamol

ANTI-INFLAMMATORY Indomethacin, naproxen,
ibuorofen

ANTI-COAGULANTS Aspirin

ANTI-PYRETICS Aspirin, paracetamol,
indomethacin, celecoxib, ibuprofen

38. W.H.O CLASSIFICATION in 2001
 A: DRUGS WITH WEAK ANTI-INFLAMMATORY
EFFECT Acetaminophen


B: DRUGS WITH MILD TO MODERATE ANTIINFLAMMATORY EFFECT Propionic acid
derivatives, anthranilic acid derivatives
C: DRUGS WITH MARKED ANTI-INFLAMMATORY
EFFECTS Salicylates, acetic acid
derivatives, oxicams, diclofenac.

39. 




Prostaglandins were first discovered in1930s
by Ulf von Euler
During inflammation, pain, fever, Arachidonic
acid is liberated from phospholipids fraction
of the cell membrane, Arachidonic acid is
then enzymatically converted to
prostaglandin (pgi2) and thromboxane a2 in
presence of enzyme cycloxygenase
Cycloxygenase exists in:
Cox-1 (constitutive)
Cox-2 isoforms (inducible)

42. 
Gastric mucosal damage – peptic ulcer
Nausea, vomiting, blood loss in stools
(haemotochesia)
Epigastric distress
Hypersentivity

Salicylism




43. Diclofenac sodium
Newer analgesic, anti-inflammatory.
Antipyretic

Inhibits prostaglandin synthesis,

short lasting antiplatelet action

Neutrophil – production of superoxide
dismutase inhibits chemotaxis

44. 
Piroxicam

Meloxicam

Tenoxicam

45. Ibuprofen
 Prostaglandin synthesis inhibition
 Anti inflammatory
 Anti pyretic

Dosage – 400mg every 6th hourly

46. 


Nausea, dyspepsia, heartburn, vomiting and
abdominal pain
Gastric ulceration and bleeding can occur in
patients using Ibuprofen for prolonged period
of up to one year
Drug interactions- thiazides and lithium

47. 
Ketorolac
 COX 2 inhibition
 Free radical scavenging property
 Inhibition of TNF- alpha
Contra-indications:
Patients on anticoagulants

Uses:
 Post –operative pain, acute musculoskeletal
disorders.

48. 

Indomethacin
prostaglandin synthetase
epileptics and pregnant women
Sulindac

49. 
MEFANAMIC ACID
Low efficacy
Plasma half life 2-4 hrs

50. 
Paracetamol: (acetaminophen)

52. Drug
Preparations
Route
Usual Adult
Dose (Mg)
Pentazocine
30 mg/ml
Lactate (Talwin)
Intramuscular,
Subcutaneous,
Intravenous
30
Pentazocine Hcl
50 mg tablets
Oral
50 to 100
Meperidine Hcl
25, 50, 75 and
100 mg / ml
Intramuscular,
Subcutaneous
50 to 100
50 and 100 mg tablets
Oral
50 to 100
Morphine Sulfate 8, 10, 15 and 30 mg / Subcutaneous
ml
10 to 15
Control Of Pain And Infection, Dent. Clin.
North Am. 17 : 417-427, 1973.

53. 
Pearlman et al in 1997- IBUPROFEN

D W Paquette et al in 1997- KETOPROFEN

J M Thomason et al in 1997- ASPIRIN

A B Pablos et al in 2008- MELOXICAM & DS

C Alen Yen et al in 2008-CELECOXIB

Khalid Al-Hezaimi et al in 2011- KETOROLAC
TROMETHACINE

54. 
Eli E Machtei et al in 2011

55. 






Essentials of medical pharmacology- KD Tripathi
Lippincots illustrated rewiew pharmacology
Pharmacology – padmaja uday Kumar
JSSN U30S-6979
Enantiospecific inhibition of ligature-induced periodontitis in beagles with
topical (S)-ketoprofen: D.W.Paquette J,P.Fioretlini, C Martusceili R,J.
Oringer, T H. Howell, J R. McCullough,D.S.Reasner and R. C williams: J
Clin periodontol 1997: 24: 521-528.
The analgesic efficacy of ibuprofen in periodontal surgery: A multicentre
study: B. Pearlman, S. Boyatzis, C. Daly, R. Evans, J. Gouvoussis, J.
Highfield, S. Kitchings, V. Liew, S. Parsons, P. Serb, P. Tseng, C. Wallis:
Australian Dental Journal 1997;42:5.
Aspirin-induced post-gingivectomy haemorrhage: a timely reminder,
Thoniason JM, Seymour RA, Murphy P, Brigkam KM, Jones P: Aspirininduced post-gingivectomv haetnorrhage: a timely reminder, J Clin
Periodontol 1997; 24: 136-138

56. 



Effect of Meloxicam and diclofenac sodium on peri implant bone healing
in rats: AB Pablos, satunino AR, B Konig, Cristiane F, Vera C de Arujo and
Patricia R Cury: J periodontol 2008; 79; 300-306.
The effect of a selective cycloxygenase-2 inhibitor (Celecoxib) on chronic
periodontitis: C Alen Yen, Petros D Damoulis, Paul C Stark, Patricia L
Hibberd, Medha Singh and Anthena S Papas. J Periodontol 2008; 79: 104113.
Evaluation of novel adhesive film containing ketorolac for post surgery and
pain control: a safety and efficacy study: Khalid Al-Hezaimi, Mansour AlAskar, Zuied Selamhe, Jia- Hui Fu, Ibrahim A. Alsarra, and Hom Lay
Wang: J periodontol 2011; 82: 963-968
Multiple applications of Flurbiprofen and chlorhexidine chips in patients
with chronic periodontitis: a randomized, double blind, parallel, 2- arms
clinical trial: Eli E Machtei, Ilan Hirsh, Maher Falah, Eyal Shoshani, Avi
Avramoff and Adel Penhasi. J Clin Periodontol 2011; 38: 1037-1043.

57. Thank You….