Endo 6 - Analgesics, Antibiotics, Anesthesia in Endo (Dr. Chen)

Define the following:

A multifactorial noxious experience that involves not only the sensory response but also modification by cognitive, emotional and motivational influences related to past experience?

pain

What type of pain?

- Sharp, stabbing, short duration

acute

What type of pain?

- Dull, aching, long duration

chronic

What is an increased pain sensation or lowered pain threshold?

hyperalgesia

Patient experiences severe/prolonged pain to a cold test that is only mildly painful on the control tooth. What are they experiencing?

hyperalgesia

What type of pain?

A stimulus that is usually painful is even more painful

hyperalgesia

What is pain resulting from a non-noxious stimulus?

allodynia

What type of pain?

A stimulus that is usually NOT painful becomes painful

allodynia

Patient experiences pain on percussion that is not painful on control tooth. What are they experiencing ?

allodynia

What is absence of sensibility to pain, particularly to the relief of pain without loss of consciousness?

analgesia

What are the 3 D's of treating endo pain?

1. Diagnosis

2. Definitive dental treatment

3. Drugs

Which D?

- Pre-op pain control

- Accurate diagnosis

- Anxiety reduction

Diagnosis

Which D?

- Intra-op pain control

- Effective local anesthetic and operative techniques

- Completing the procedure

Definitive dental treatment

Which D?

- Post-op pain control

- Pharmacologic agents

Drugs

When diagnosing odontogenic pain, which principle is most important for identifying the source of the patient's chief complaint?

Reproduce the chief complaint

T/F: Research states that patients are only accurate 60-70% of the time on which tooth associates with pain but 90% accurate when the pain is periapical

True (estimated %s)

What should you do if a diagnosis cannot be made?

Consider referral to specialist

- Only proceed to treatment if there is a clear diagnosis

Odontogenic pain can be caused by what?

inflammation

Define the following:

- Pulpal inflammatory pain due to stimulation of nociceptors on afferent nerve fibers (A-delta and C- fibers) in dental pulp

- Periodontal inflammation

Odontogenic pain

Pulpal inflammation is the release of inflammatory mediators that stimulate receptors on nociceptive afferent nerve fibers. What are the nerve fibers that are stimulated?

A) A-delta

B) B-delta

C) C-fibers

D) A + C

E) all of the above

D) A-delta and C-fibers

T/F: Antibiotics can reduce pain in a patient with irreversible pulpitis

false (DO NOT REDUCE PAIN)

6 types of non-odontogenic pain

1. Musculoskeletal: myofascial pain, TMD

2. Neuropathic: trigeminal neuralgia, herpes infection, atypical odontalgia (phantom tooth pain)

3. Neurovascular: migraine, cluster headache

4. Inflammatory: sinusitis

5. Systemic disorders: cardiac pain, herpesvirus infections, tumors

6. Psychogenic pain: somatic symptom disorder

Inflammatory mediators sensitize nociceptive neurons leading to spontaneous pain and ______ pain threshold (allodynia)

reduce

effective dental tx decreases which 3 tissue level inflammatory mediators

1. Bradykinin "BK”

2. Prostaglandin "PG”

3. Cytokines

In Pak & White's 2011 study, it showed patients reported 90% reduction in pain within ________ of RCT

1 week

Pre-operative pain increases the chances for failing anesthesia by ___ fold!

8

Local anesthesia works by blocking what from entering cells?

sodium

What ion needs to be attached to the LA drug in order to block sodium from entering the cell?

hydrogen

T/F: Hydrogen must be attached to allow the drug to cross the cell membrane

false (cannot cross with hydrogen, reattaches when in cytoplasm)

How do you numb a highly sensitive tooth?

1. Initial LA

   1. Maxilla: buccal + palatal infiltration

   2. Mandible: IAN block and infiltration

2. Supplemental techniques

What are some ways to improve LA in a highly symptomatic patient?

1. Initial IAN block(s) and infiltration

2. Multiple IAN blocks

3. Supplemental anesthetic (intraligamental/PDL, intra-pulpal, intraosseous)

4. Pre-op NSAIDS

Which type of anesthesia technique?

- The needle is wedged between the root and crestal bone with heavy pressure slowly applied for 10-20 seconds

- Need significant resistance to deposition of solution

- Only a small volume is necessary (0.2 mL)

- Onset is immediate and lasts about 10 min

Intra-ligamental/PDL

Which type of anesthesia technique?

- 2 options:

- - Inject into pulp chamber through hole in the roof

- - Inject into each root individually if chamber has already been unroofed

- Wedge the needle into the chamber or canal

- Apply pressure on the syringe handle for 5-10 s

Intra-pulpal

What is CRUCIAL when giving an intra-pulpal injection?

Back pressure (Walton 1997, Rosenberg 1975)

Do the types of anesthetics have any influence on the intra-pulpal effectiveness?

No - even saline works!

(In intrapulpal anesthesia, pain control comes from the pressure of the injection, not the pharmacologic action of the anesthetic so any solution, even saline, is effective as long as adequate back pressure is achieved)

Which type of anesthesia technique?

- Injection of solution directly into cancellous bone spaces around tooth

- Quick onset (30 seconds)

- Avoid mental foramen and IAN area

- Avoid perforating into the maxillary sinus

intraosseous

Do lip numbness and soft tissue anesthesia = pulpal anesthesia?

NO

If treating mandibular tooth, consider _________, check for lip numbness, then perform additional infiltrations

IAN block

For vital cases, how should you always test the tooth before beginning treatment?

Cold test

Opioid or non-opiod?

- NSAIDs

- Acetaminophen

Non-opioid

3 common opioids

1. Codeine

2. Hydrocodone (Vicodin)

3. Oxycodone (Percocet)

4 advantages of non-opioids

1. Can be effective for pain of inflammatory origin

2. Fewer side effects than opioids

3. No addiction potential

4. Readily available (OTC)

For Post-Op instructions, we recommend that patients should take ___ tablets of Ibuprofen (____ mg) every 4-6 hours

2, 400

For Post-Op instructions, we recommend that patients should take ___ tablets of Acetaminophen (____ mg) every 6 hours

2, 650

What is the max amount of Ibuprofen vs. acetaminophen a pt should take post-op per day?

• ibuprofen: 3200 mg

• acetaminophen: 3000 mg

What 3 effects do NSAIDS have? (hint: all As)

1. Anti-inflammatory

2. Analgesic

3. Antipyretic

Aspirin and NSAIDS block which pharmalogical pathway?

Cyclo-oxygenase (COX)

NSAIDS and aspirin target the COX pathway which also blocks what?

prostaglandins → depresses inflammatory response

What pain pathways do NSAIDS work on?

Peripheral pain pathways

Decrease in PG concentration has what 2 effects?

1. Raise threshold for pain-conducting nerves to discharge

2. Reduce fever

What are 3 adverse effects of NSAIDs?

1. Causes reversible effects on platelet aggregation (TXA2) → increase bleeding time

2. Long term use may cause changes in renal + liver functions and may require monitoring

3. GI side effects

What is 1 NSAID contraindication that was emphasized?

Pregnant/nursing women (use acetaminophen)

6 additional contraindications of NSAIDs

1. Cardiovascular disease with fluid retention

2. Coagulopathies

3. Peptic ulcer

4. Ulcerative colitis

5. History of Aspirin hypersensitivity

6. Use caution with some ACE inhibitors, beta blockers, thiazide diuretics, loop diuretics, cyclosporine, hydantoins, lithium, methotrexate, sympathomimetics, anticoagulants

Pre-op ibuprofen blocks the development of hyperalgesia by reducing input from peripheral ____________

nociceptors (Dionne 1986, Hargreaves 1989)

Using NSAID's pre-op can mask testing of vital teeth by what 3 ways?

1. Mask palpation 40%

2. Mask percussion 25%

3. Mask cold 25%

McClanahan & Bowles, 2014)

What drug?

- Analgesic and antipyretic (only WEAK anti-inflammatory action)

- Weak COX inhibitor

- - Decrease PG production → depresses inflammatory response

- Acts primarily on CNS but also has peripheral action

Acetaminophen (Paracetamol/"APAP")

What are 4 acetaminophen contraindications/adverse effects?

1. G6PD-deficient patients

2. Do not use with alcohol

3. Drugs that interfere w/ hepatic P450 enzyme may increase toxic metabolites as acetaminophen is metabolized in the liver

4. Little to no effect on platelets or GI system

how do opioids block pain

blocks CNS mechanisms of pain + hyperalgesia by interfering with pain transmission, integration, and interpretation in cerebral cortex via activation of Mu and/or kappa receptors

7 adverse effect of opioids

1. Nausea

2. Dizziness

3. Drowsiness

4. Constipation

5. Potential for respiratory depression

6. Potential for abuse, tolerance, and addiction

7. Increased CNS depression when taken with alcohol

According to Moore & Hersh (2013), what analgesic regimen provides the greatest postop pain relief after 3rd molar extraction + fewer adverse effects than opioids?

Ibuprofen-APAP combination

T/F routine endo has mild anticipated post-procedural pain

true

T/F surgical endo has severe anticipated post-procedural pain

false, moderate

This is the ADA recommendation for which type of pain?

Ibuprofen 200-400mg every 4-6 hours for 24 hours

A) mild pain

B) mild to moderate pain

C) moderate to severe pain

D) severe pain

A) mild pain

This is the ADA recommendation for which type of pain?

Ibuprofen 400-600mg every 4-6 hours for 24 hours

Then Ibuprofen 400mg as needed every 4-6 hours

A) mild pain

B) mild to moderate pain

C) moderate to severe pain

D) severe pain

B) mild to moderate pain

This is the ADA recommendation for which type of pain?

1. Ibuprofen 400-600mg every 4-6 hours plus acetaminophen 500mg fixed internal every 6 hours for for 24 hours

2. Ibuprofen 400mg and acetaminophen 500mg as needed every 4-6 hours

A) mild pain

B) mild to moderate pain

C) moderate to severe pain

D) severe pain

C) moderate to severe pain

This is the ADA recommendation for which type of pain?

1. Ibuprofen 400-600mg plus acetaminophen 650mg with hydrocodone 10mg fixed interval every 6 hours for 24-48 hours.

2. Ibuprofen 400-600mg plus acetaminophen 500mg as needed every 6 hours

A) mild pain

B) mild to moderate pain

C) moderate to severe pain

D) severe pain

D) severe pain

Codeine is what schedule drug?

III

Codeine can be taken with which non-opioid drug?

Tylenol

Oxycodone is what schedule drug?

II

What is post-op pain that requires an unscheduled visit and treatment?

flare up

What is the biggest indicator of flare ups?

pre-op pain

2 types of antibiotics

1. bactericidal

2. bacteriostatic

Which type of antibiotic?

- Causes microbial cell death

- Interferes with cell wall synthesis

bactericidal

2 common bactericidal antibiotics

1. Penicillins

2. Cephalosporins

Which type of antibiotic?

- Inhibits the growth, reproduction, or pathogenicity of the bacteria

- Depends on the host immune system to eradicate the bacteria

bacteriostatic

2 common bacteriostatic antibiotics

1. Macrolides

2. Tetracycline

Can you give a bactericidal with bacteriostatic antibiotics?

NO

What are 5 targets of antibiotics?

1. Metabolic enzymes

2. Cell wall synthesis

3. Ribosomes

4. Cell membrane

5. DNA synthesis

5 indications for antibiotics in endo

1. Acute apical abscess w/ systemic involvement or in a medically compromised pt

2. Rapidly progressing infections w/ cellulitis or osteomyelitis

3. Persistent infection despite intervention

4. Soft tissue trauma requiring tx

5. Replantation of avulsed teeth

Should you prescribe antibiotics?

•Chronic apical abscess

no

Should you prescribe antibiotics?

•Acute apical abscess without systemic involvement (localized fluctuant swelling)

no

Should you prescribe antibiotics?

•Stand-alone treatment for endodontic pain/infections

no

Should you prescribe antibiotics?

•Irreversible pulpitis

no

When prescribing antibiotics in endo for an active infection, do you want a broad or narrow spectrum?

narrowest possible

What is the drug of choice for early orofacial infections + pregnant pts?

penicillin VK

Which drug rx?

- 500 mg

- Disp: 20 tablets

- Sig: take 1 tab QID for 5 days until finished

Penicillin VK

Does penicillin or amoxicillin have a broader spectrum?

amoxicillin

Where is amoxicillin absorbed?

Rapidly in the gut

What pregnancy class does amoxicillin have?

Class B

What is your "go-to" if a patient needs antibiotics + has no allergies?

amoxicillin

What dose is amoxicillin prescribed at?

500 mg

How many pills are given with an amoxicillin rx?

21 tabs

What is the instructions for an amoxicillin 500 mg rx?

take 1 tab Q8H for 7 days

Which antibiotic?

Amoxicillin + clavulanate potassium

Augmentin

Which antibiotic?

- Bactericidal - cell wall synthesis inhibitor + beta lactamase inhibitor

- For more severe infections

- Expensive! --> cheaper option = 2 Rxs

- Common doses - 500 mg/125 mg or 875 mg/125 mg

Augmentin

Which antibiotic rx?

875 mg/125 mg

Disp: 14 tabs

Sig: take 1 tab TID for 7 days

Augmentin

Which antibiotic?

- Bactericidal - cell wall synthesis inhibitor

- Classified into 5 generations based on spectrum

- Allergic cross reaction possible between penicillin and cephalosporin due to side chain similarity

Cephalosporins

Which antibiotic rx?

Cephalexin (Keflex) 500mg

Disp: 21 capsules

Sig: take 1 tab Q8H for 7 days

Cephalosporins

These are examples of commonly used ________:

- Cephalexin (Keflex) - 1st gen

- Cefuroxime (Ceftin) - 2nd gen

Cephalosporins

T/F:

- True penicillin allergy is much less common than reported.

- Most childhood rashes are delayed, non-IgE reactions often related to viral infections, not a true allergy.

- True penicillin allergy is IgE-mediated, occurs within minutes to hours, and only a small subset of patients truly need to avoid penicillins (and select cephalosporins with similar side chains)

True