Bite - In

Systemic oral medication is a part and parcel of routine dentistry. Of course the range of prescriptions used by a dentist is limited. One of the most common prescription for a dentist is an antiinflammaotry pain killer.Dr. A.Kumarswamy takes a look at the NSAIDS available for the dentist.

NSAIDS IN DENTISTRY

Dental treatment and pain always go hand-in-hand. Over a long time ever, since mankind surfaced on Earth 'Tooth' has been an integral part of the human body albeit facing extinction (read extraction}before the actual end of life. Pain encountered in dental practice has been managed with the help of pharmacological agents. The principal among these agents are Non-steroidal anti-inflammatory drugs (NSAIDS) which by virtue of their analgesics and anti-inflammatory activity are extremely useful. This review examines the role of non-inflammatory drugs(NSAIDs)in the management of dental pain.

Types of dental pain and its management :-

Pain relation to a tooth or a segment of teeth can be of various kinds viz: pain related to the maxillo -facial musculature periodontal tissues and to the tooth per se. The intensity and nature of pain in reference to the onset; duration and progress has to be ascertained before a diagnosis can be made. This assumes even greater importance when the clinician has to prescribe an anti-inflammatory drug to control pain.

The "periodontal" origin pain is normally of moderate type and is diffused; very rarely building up to acute shooting type. It is accompanied by inflammation so the relief would be brought about by treating the aetiology and by an intake of an anti-inflammatory- analgesic along with an antibiotic. Pain emanciation from a carious tooth resulting in periapical infection is normally moderate to acute depending upon the status of inflammation i.e. pulpits with or without a periapical infection. Here again relief is sought by treating the level of involvement i.e. by pulpotomy, pulpectomy or a Root Canal treatment. All along the need for an anti-inflammatory analgesic is warranted.

The more severe type of pain associated with the oral cavity could be traumainduced which can be either dental or dentoalveolar, arising out of the fracture of the jaw bones in which case the treatment involves the management the fracture and medication as needed. Invariably an analgesic would be the treatment of choice.

Pain in dental practice takes a different hue especially if one were to analyse the psychological factor. Fear of the 'unknown' dimension is so high in patients with the dental pain because of the lace of awareness about the treatment aspect in dentistry. This fear anxiety clubbed with the actual aetiology alters the pain threshold and forces the patient to seek instant relief form pain and thus drives him to the first-aid box at home or to the retail chemist.

The over-the -counter [OTC] pain reliever[for him, atleast] is invariably an NSAID like Ibuprofen or a combination with paracetamol The next stop he makes is with his family physician and here the choice again could be a single entity or a fixed-dose NSAID combination like the above combined with a3 day regimen of antibiotic.

If the crisis of pain is tided over the patient invariably does not seek further help and in the bargain allows the aetiology to gain further strength. It is only when there is another episode of similar nature that he goes to the dentist directly or on referral of his family physician. The dentist now gets an opportunity to examine the patient and the concerned site specifically to arrive at a diagnosis and draw up a treatment plan.

The first step towards gaining the confidence of the patient is to control the pain and this can be achieved by prescribing an anti-inflammatory/analgesic like an NSAID along with chair side emergency measure as the case may warrant. Let us now discuss the choice of NSAIDs and the various pros and cons.

NSAIDs in the management of dental pain:

In my opinion the type of NSAID most preferred to tackle dental pain should be ibuprofen because ample literature suggests its potency in combating inflammation and thereby reducing it to relieve pain. Added to this is the vast majority of clinical success (not to mention this authors experience of over 2 decades) obtained with this drug in relieving dental pain. Ibuprofen exhibits an analgesic effect by inhibiting of prostaglandin biosynthesis. The drug has been reported to have an onset of analgesic action renging between 15 to 30 minutes. In dentistry, the requirement of combination of drugs is of a different kind and the combination may be the of an NSAID and an antibiotic because the dental pain could invariably be an infection leading to inflammation and pain.

There may also be a requirement of a muscle relaxant with an analgesic since the pain could be because of a muscular spasm leading to the lack of opening of the mouth because of post therapeutic tismus of a cellulitis. The use of lbuprofen in pain from dental origin only. Ibuprofen and paracetamol have a similar mode of action and they also a same site of i.e. receptor site on the enzyme cyclo-oxygenase Moreover both have been reported to exhibit comparable doseresponse characteristics. In a number of studies has been shown to have a better overall efficacy compared to paracetamol alone and better than the combination of ibuprofen + paracetamol. In view of the above, it is superfluous to prescribe a fixed dose combination of Ibuprofen and paracetamol .

Definite success is realised in a combination of Ibuprofen along with a muscle relaxant like diazepam, carisoprodol and chlorzoxazone in cases of trismus and post-operative inflammation like after a third molar surgical disimpaction or a periodontal flap surgery or any maxillo-facial surgery.

Since the need for pain control dentistry to the intervention of a clinician it is more often than not that relief is brought about by a simple intake of around 400 to 600 mg three times daily of lbuprofen for 2 to 3 days along with clinical intervention by a registered dental practitioner.

All necessary precautions should be exercised in the medically compromised patients especially diabetics; those with respiratory problems; immune-suppressed individuals and in such cases the clearance from the family physician is mandatory. Patients with acid-peptic are also in the red list so an alternative to NSAIDs may be considered.

CONCLUSION

Pain from dental origin is always clubbed with a high level of anxiety. The pain relief is best accomplished by the intake of a single entity NSAID and not necessarily with a fixed-dose analgesic combination. More importantly, the clinical intervention would ensure the total management of pain and invariably a potent of analgesic may be necessary.

Ibuprofen (400 to 600 mg three time a day) for 2 to 3 days is adequate and does not challenge the pain threshold. It is well tolerated in the recommended doses. Moreover, being a non-opioid, the patient does not get addicted to it. It is important that in dental pain the patient gets treated by the dentist rether than fimding his way repeatedly to the chemist or to the family physician for the same problem.