Future Trends in Pain Control, Consultations, and Intro to Prescription Writing

Lecture given 10/16/2025

electronic dental anesthesia

transcutaneous electrical nerve stimulation (TENS)

eutectic mixture of local anesthetics (EMLA)

5% cream containing 25mg lidocaine per gram and 25mg of prilocaine per gram

applied to the skin 1 hour prior to the anticipated procedure, covered with an occlusal dressing

who is EMLA useful for?

peds patients, when performing venipuncture, vaccination, suture removal, ect

if used for peds patients, you need to review age and body weight

who should EMLA not be used for?

neonates with a gestational age less than 37 weeks

no infants under the age of 12 months who are receiving treatment with methemoglobin inducing agents

onpharma

designed for precision buffering of local anesthetics which provides rapid onset of analgesia and less injection pain

sterile, nonpyrogenic, solution of sodium bicarbonate in water for injection

added to lidocaine with epi as a neutralizing agent immediately prior to administration

oraVerse (phentolamine mesylate)

indicated for the reversal of soft-tissue anesthesia and the functional deficits resulting from an intraoral submucosal injection of a local anesthetic containing a vasoconstrictor

should be administered following the dental procedure using the same location and technique (infiltration or block) employed for the administration of the local anesthetic

who is oraVerse not recommended for?

children less than 3 years of age or weighing less than 15 kg

exparel

encapsulated bupivicaine that is released over time

local anesthetic that produces postsurgical anesthesia in patients 6yr and older (infiltration)

10 or 20 ml single use vial

what is dosing of exparel related to?

size of surgical site, volume to cover

what is the max dose of exparel that can be given?

one 20ml vial

4mg/kg, up to maximum of 226mg

how should exparel be administered?

inject into soft tissue site using a 25 gauge needle, slowly with frequent aspiration

use a series of injections, as it does not diffuse through tissues

if a patient is undergoing extraction of 4 impacted 3rd molars, where and how much exparel should be used?

for max sites: 1-2ml infiltrated into each surgical site on the buccal aspect of teeth #1 and #16

mandibular sites: 3-4ml infiltrated into each surgical site

what are important factors to consider when administering exparel?

wait 20 min to administer exparel after administering other non-bupivicaine based LA otherwise there can be an immediate release of bupivicaine from exparel

formulations of bupivacaine other than exparel should not be administered within 96 hours following administration of exparel

how should exparel be stored and handled?

refrigerated, should not be frozen or exposed to high temps

open viles should be used within 4 hours

which patients should not receive exparel?

patients with hepatic disease

what are common adverse reactions of exparel?

nausea, constipation, vomiting

kovanaze

intranasal local anesthetic

tetracaine (LA) and oxymetazline (vasoconstrictor)

used primarily in the realm of ENT procedures but patients noted that their upper teeth felt numb

what teeth are anesthetized with kovanase?

pulpal anesthesia from 1st premolar to 1st premolar, may obtain up to the 2nd premolar

who is kovanaze not recommended for?

peds patients under 3 or children weighing less than 40kg

what is the dosage of kovanaze?

2 sprays (0.2ml per spray), 4-5 minutes apart

adults over 18 may receive 1 additional spray if adequate anesthesia has not been achieved 10 minutes after the second spray

afib

a quivering or irregular heartbeat or arrhythmia, can lead to blood clots/stroke/heart failure

coumadin

an anticoagulant, which reduces the formation of blood clots

what questions should you ask of pts dr if they are on coumadin?

latest PT/INR 

any recent change in coumadin dosage, is patient medically optimized to undergo procedure

prothrombin time (PT)

used to evaluate the extrinsic pathway and common pathway of coagulation

internation normalized ratio (INR)

is <3.0 when using coumadin, usually safe to extract 1-2 teeth

what questions should you ask of pt dr when they have diabetes mellitus and hypertension?

latest HbA1c, present insulin/medication regime, is the pateint medically optimized to undergo procedure

what should you do if a patient tells you they have a ‘liver problem’ and bleed for a long time after getting a cut?

bleeding problems- request lab work

metabolism of certain medications is through the liver, so is the patient medically optimized to undergo this procedure

when writing a prescription, what needs to be included?

doctor’s name, address, phone number, patients name/date, patient’s address and age

drug name/dosage size, number of tablets, direction on how the drug is to be taken

doctor signature, state license number, DEA number

prn

as needed

bid

twice a day

tid

three times a day

qid

four times a day

hs

before bedtime

nonopioid analgesics

NSAIDs, acetaminophen (APAP)

opioid analgesics

hydrocodone, oxycodone, meperidine, propxyphene, tramadol

motrin

produces anti-inflammatory, analgesic, and antipyretic effects by inhibiting prostaglandin

what is the max daily dose for motrin?

not to exceed 3.2g in 24 hrs

what are possible adverse reactions to motrin?

HA, dizziness, fluid retention, edema, peptic ulceration, heartburn, acute renal failure, prolonged bleeding time, elevated liver enzymes, bronchospasm

what are some drug interactions that are possible with motrin?

antihypertensives- may decrease effectiveness

ASA/corticosteriods- increased risk of adverse GI reactions

may increase the plasma levels or effects of several medications and can decrease the clearance of others and thus increased toxicity

acetaminophen

produce analgesia by blocking generation of pain impulses, probably inhibiting prostaglandin synthesis in the CNS or the synthesis or action of other substances that that sensitize pain receptors to mechanical or chemical stimulation

thought to relieve fever by central action in the hypothalamic heat regulating center

effective nonopioid analgesic with antipyretic activity but little anti-inflammatory activity

APAP may function by inactivating the COX enzymes responsible for the final catalytic reaction

potential liver toxicity with excessive dosing (daily dose of 4000mg)

what is the recommended dosage of acetaminophen for an adult?

mild pain or fever- 325-650mg PO every 4 to 6 hours or 1g PO 3 times a day as needed

opioid analgesics

produce analgesia but can also cause sedation, euphoria, cough suppression, constipation, miosis, and respiratory depression

in managing acute pain, dental practitioners generally select a fully agonist with minimal first pass metabolism

to improve analgesic response the selected orally administered analgesic will include a nonopioid as a component of the fomulation to provide added analgesia

what is a comparative oral dosing of oxydocone to hydrocodone to codeine to tramadol?

5mg oxydocone to 10mg hydrocodone to 65mg codeine to 75mg tramadol

amoxicillin

an aminopenicillin that inhibits cell wall synthesis during bacterial multiplication

how can bacteria resist amoxicillin

producing penicillinases (enzymes that hydrolyze amoxicillin)

what is a recommended dosage of amoxicillin?

250-500mg PO every 8 hours