The Management of Pre and Post Operative Pain
As dentists we are commonly faced with fearful patients. They anticipate and expect a painful experience during or after their treatment. They tend to procrastinate to the point where they are presenting with pain and a high level of anxiety, only perpetuating their status. These situations are a challenge to the practioner. It is important to effectively manage the preoperative and post-operative pain in all of our patients to help alleviate these situations. This can be a great practice buildwould like to review the most common drugs used for controlling pain and discuss a protocol that you may apply in your practice for the management of preoperative and postoperative pain.
There are many classes of drugs that can be used in order to manage the pain induced from various dental procedures. The model that has been most effective in studying the effects of these analgesics is the post extraction pain experienced after third molar surgery. The attributes of the oral surgery model of third molar post extraction pain are so consistent and reliable that the United States Food and Drug Administration considers it as one of the most sensitive assays for the evaluation of analgesia.(1) All of these drugs have been studied according to this model and can effectively be applied to various other situations.
The first class of drugs is the non-opioid analgesics; this includes the NSAIDs and acetaminophen. The NSAIDs are a non-opioid analgesic possessing analgesic, anti-inflammatory, and antipyretic effects. The efficacy of the NSAIDs in reducing postoperative hyper-algesia has been hypothesized to result from their ability to inhibit prostaglandin synthesis at the site of tissue damage. This class of drug is the most effective in the reduction of pain that is inflammatory in origin. One of the greatest limitations of this drug class is its “ceiling effect” associated with their analgesic properties. Increasing the dose above the ceiling dose does not offer any additional analgesia. Regardless of the degree of pain the source is always inflammatory in origin. For this reason the NSAIDs are the drug of choice when used appropriately.(2)
Acetaminophen is another non-opioid analgesic, containing analgesic and antipyretic effects. It does not possess anti-inflammatory properties. The analgesia is thought to occur via mechanisms mediated primarily within the CNS. This is drug can be substituted in situations where there are contraindications to the use of NSAIDs.(3) The limiting factor is the maximum allowable daily dose.
The second class of drugs is the opioid analgesics. The analgesic properties of the opioids are well appreciated through- out time. They are indicated in situations when the pain is not relieved with the use of NSAIDs or acetaminophen. The analgesic properties of opioids are attributed to the activation of opioid receptors expressed on the membrane of neurons in the central and peripheral nervous system. The opioid analgesia is very effective. However, the limiting factor is their unwanted side effects. Although they do not have a ceiling dose for analgesia, as the dose is increased the risk of undesirable side effects such, as nausea and vomiting and mental cloudiness are markedly greater. These drugs are usually combined with acetaminophen or NSAIDs in various formulations in order to decrease the necessary dose. An important point to understand is that even though oxycodone and hydrocodone are much more potent (10-12 times greater potency than codeine) the formulation of these two synthetic opioids in most combination analgesics such as percocet and vicodin results in an opioid dose equipotent to 60mg of codeine.(1)
When prescribing, it is important to remember that pain is subjective and can present in various forms and can also have various sources both central and peripheral. Therefore, we must tailor our regimen to the patients’ individual needs. We must have a good appreciation of the properties and limitations of the drugs that we use in order to maximize their effectiveness. The most effective pain control strategies must result in adequate pain control with minimal undesirable side effects. It’s how we use the drugs not what drug we use.
The non-opioid analgesics (NSAIDs, acetaminophen) are considered to be effective in the management of mild pain. This is very unfortunate since these drugs have characteristics that make them very effective in the treatment of patients with moderate to severe pain. According to the third molar model, the period of maximum pain intensity is the first 12 hours after the procedure.(4,5) This is a very important point to keep in mind when establishing a pain management regimen for the patient.
The administration of 400mg of ibuprofen 30 minutes before the initiation of surgery has been proven to delay the onset of postoperative pain and decrease its severity.(5,6) In addition, when you are working on the mandibular teeth, and prior to completion of the procedure, administering a bupivicaine block will keep the patient numb during the acute phase of the pain cycle. You must instruct the patient to take the ibuprofen (400 – 800mg) around the clock for the first 48 hours and as needed for pain (PRN) thereafter. The most common mistake made by patients is that they wait until the onset of pain before taking their medication. At this stage they have missed the opportune time to manage their pain and they must now reach for the opioid for pain relief. This still may not be as effective.
In situations where the pain is not relieved with the opioid alone the patient can combine it with the NSAID following the recommended frequency. If the pain is not relieved following this protocol it is prudent to have the patient return to your office for further evaluation.
It is imperative that we not loose control over the inflammatory cycle and plan ahead to prevent the breakthrough pain that becomes very difficult to manage. We must keep in mind that pain is subjective and every patient’s response will be different. Following the protocol will minimize the use of the opioids and their unwanted side effects and allow the patient a preferred method of pain management.