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3. Oral Surgery > Analgesia > Flashcards

Analgesia Flashcards

1
Q

When is it best for a pt to start analgesics?

A

before LA wears off - get ahead of the pain

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2
Q

What drugs can we prescribe?

AAAAABBC

A

Aciclovir

Amoxicillin

Artificial saliva gel

Aspirin

azithromycin

beclometasone

benzydamine

carbamazepine

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3
Q

What is aciclovir?

A

Used to treat herpes simplex infection

can prescribe oral suspension or tablets

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4
Q

What is amoxicillin?

A

Antibiotic used for bacterial infections

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5
Q

What is azithromycin?

A

Antibiotic

good for pts allergic to penicillin

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6
Q

What is beclometasone used for?

A

Oral ulcers

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7
Q

What is carbamazepine used for?

A

relieves nerve pain - trigeminal neuralgia

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8
Q

What are the types of analgesics we can discuss with out pts?

A

Aspirin

Ibuprofen

Diclofenac

Paracetemol

Duhydrocodeine

Carbamazepine

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9
Q

What is pain?

A

unpleasant sensory and emotional experience associated with actual and potential tissue damage

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10
Q

What do trauma and infection lead to?

A

breakdown of membrane phospholipids which produce arachidonic acid which can then be broken down to prostoglandins

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11
Q

What can arachidonic acid be broken down to?

A

Prostoglandins

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12
Q

What are prostaglandins?

A

Group of lipids made at sites of tissue damage or infection that are involved ind ealing with injury and illness. - they control inflammation, blood flow, formation of clots and induction of labour

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13
Q

What do prostaglandins do?

A

Sensitise tissues to other inflammatory products such as leukotrienes which result in pain

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14
Q

What are leukotrienes?

A

lipid mediators that play role in acute and chronic inflammation and allergic diseases

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15
Q

What happens if prostaglandin production decreases?

A

This will moderate and pain will decrease

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16
Q

What is aspirin?

A

NSAD

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17
Q

What is NSAID effective at treating?

A

Dental and TMJ pain

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18
Q

What is diff between aspirin and paracetamol?

A

It has superior anti-inflammatory properties compared to paracetamol

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19
Q

What are the properties of aspirin? 5

A

Analgesic

anti-pyretic

anti-inflammatory

anti-plt

metabolic properties

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20
Q

Describe analgesic action of aspirin

A

Analgesic action is exerted both peripherally and centrally

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21
Q

What is the mechanism of action of aspirin?

A

Asprin REDUCES PRODUCTION OF PROSTAGLANDINS

It inhibits COX1 and COX2

COX 1 Inhibition results in inhibition of PLT aggregation for 7-10 days (life span of plt)

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22
Q

What does inhibition of COX1 do?

A

Inhibits PLT aggregation for life span of PLT (7-10 DAYS) whichh prevents production of pain causing prostaglandins and stops conversion of arachidonic acid to thromboxane A2 which induces PLT aggregation resulting in clots and harmful embolisms

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23
Q

What does COX1 inhibition stop conversion of?

A

Arachidonic acid –> thromboxane a2 which induces aggrigation of PLTs and can lead to clots

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24
Q

What is the issue with COX1 inhibition?

A

causes reduced plt aggregation which predisposes to damage of gastric mucosa

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25
Q

How can NSAIDs cause damage to gastroduodenal mucosa?

A

topical irritant effect on epithelium

impairment on barrier properties of mucosa

suppression of gastric PG synthesis

reduction of gastric mucosal blood flow

interfere with repair of superficial injury

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26
Q

What are some side effects/adverse reactions of aspirin?

A

GIT problems

hypersensitivity

overdose

aspirin burns

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27
Q

What GIT problems can aspirin cause?

A

can affect lining of stomach

this is because prostoglandins will inhibit gastric acid secretion and increase blood flow through the gastric mucosa and help producition of mucin by cells and aspirin reduces production of PGs

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28
Q

Why must care be taken in pts with GIT problems?

A

ulcers - aspirin interferes with stomaches ability to protect itself from damaging acids - promote ulcers by disrupting mucous that coats stomach lining

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29
Q

How does aspirin promote ulcers?

A

iNTERFERES with stomaches ability to protect itself from damaging acids - disrupts mucous that coats stomach lining

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30
Q

What do most pts taking aspirin suffer?

A

Some blood loss from the GIT but asymptomatic and not detectable

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31
Q

What are some allergic reactions to aspirin?

A

Minor rashes

itching

swelling

sob (care with asthmatics unless taken before)

asthma type attacks

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32
Q

What can overdose of aspirin cause?

A

Tinnitus

metabolic acidosis - can kill

coma

hyperventilation

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33
Q

What can aspirin do to mucosa?

A

Can cause mucosal burns

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34
Q

Why can aspirin cause mucosal burns?

A

effects of salicylic acid - aspirin shouldn’t be applied directly to mucosa as has NO TOPICLA EFFECT AND WILL CAUSE CHEMICAL BURNS IF APPLIED OT MUCOSA

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35
Q

What will pts sometimes do with aspirin if significant tooth pain?

A

may hold aspirin beside sore tooth however zero topical action and will result in chemical burn

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36
Q

Who shouldn’t be taking aspirin?

A

pts with:

  • peptic ulcers
  • epigastric pain
  • bleeding disorders
  • anticoagulants
  • pregnancy and BF
  • Steroid pts
  • Renal and hepatic impairment pts

children under 16

asthma

allergy to other NSAIDs

taking there NSAIDs

elderly

G6PD deficiency

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37
Q

Why should pt with peptic ulcer not take aspirin?

A

can result in perf

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38
Q

Why should pt not take aspirin if epigastric pain?

A

may have undx ulcer

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39
Q

Why should pts not take aspirin if on other anticoaugs?

A

Double the effect of blood thinners

aspirin enhances warfarin

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40
Q

What interaction do aspirin and warfarin have?

A

aspirin displaces warfarin from binding sites on plasma proteins increasing free warfarin in blood so enhances its effect (majority of warfarin normally bound and inactive so if released then active increasing bleeding tendency)

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41
Q

Why should pregnant pts avoid aspirin?

A

Especially in 3rd trimester

can cause impairment of plt fuction which can increase risk of haemorrhage and jaundice in baby and prolong/delay labour

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42
Q

Why should pts on steroids avoid aspirin?

A

25% on long term steroids develop PUD so dont wanna risk perf

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43
Q

Where isa aspirin metabolised?

A

liver and excereted in kidney

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44
Q

Why is aspirin contraindicated in kidney impairment pts?

A

Excretion may be reduced or delayed resulting in drug being in body for longer - pt may need reduced dose or lease with team

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45
Q

Why is aspirin not used in chidlren 16 and under?

A

Can cause reyes syndrome

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46
Q

What is reyes syndrome?

A

Very rare disorder that can cause serious liver and brain damage if not tx quickly can lead to brain damage or death

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47
Q

When should aspirin be avoided in adoscelents?

A

if fever or viral infection

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48
Q

How does reyes syndrome work?

A

fatty degenerative process occurs in liver and kidney and profound swelling in brain (can die due to encephalopathy)

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49
Q

What is link between aspirin and asthma pts?

A

not contraindication but if not used before then best not to

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50
Q

What does taking a combo of NSAIDs increase?

A

Risk of side effects

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51
Q

Why are elderly more susceptible to drug induced side effects?

A

Smaller

smaller circulating BV

On other meds - poly pharmacy

have other med issues

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52
Q

What is aspirin complete contraindication in?

A

children and young people under 16

breastfeeding pts

previous or active pud

haemophilia

hypersensitivity to aspirin or any other nsaid

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53
Q

What dose of aspirin can pts take?

A

300mg 2 tablets 4x daily (every 4 hours) after food

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54
Q

What is max dose of aspirin?

A

4g

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55
Q

How many tablets can be taken of aspirin in one dose?

A

900mg - 3 tablets

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56
Q

What can’t be prescribed following extraction or minor surgery?

A

Aspirin

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57
Q

What is the thrombotic prophylaxis dose of aspirin?

A

75mg daily

after ischameic event - 150-300mg aspirin

58
Q

If pt has active or previous PUD and paracetamol isn’t enough and aspirin can’t be prescribed what can pt take?

A

Pt can be prescribed NSAID and PPI such as lansoprazole or omeprazole

59
Q

What does of lansoprazole should be taken if we prescribe PUD pt aspirin?

A

15mg capsules
5 capsules
1 daily

60
Q

What dose of omeprazole should be taken if we prescribe PUD pt aspirin?

A

20mg capsules
5 capsules
1 day

61
Q

What is ibuprofen?

A

NSAID OTC that has similar effect to aspirin however less effect on PLTs

62
Q

How does ibuprofen work?

A

Ibuprofen (IBP) is one of the most commonly available over-the-counter pharmaceuticals in the world. The anti-inflammatory and analgesic properties of IBP are thought to arise from inhibition of COX-2 rather than COX-1

63
Q

What are the properties of aspirin?

A

anti inflammatory

anti-pyretic

analgesic

64
Q

Why is ibuprofen better than aspirin?

A

Less effect on PLTS

lower risk of gastric mucosa irritation

65
Q

What can ibuprofen be used for?

A

MILD TO MOD ODONTOGENIC PAIN, POST OP OR INFLAM PAIN

66
Q

What is 5 day regime for ibuprofen

?

A

5 days

400mg tablet 1x 4x a day after food

67
Q

What is max dose of ibuprofen?

A

2.4g

68
Q

groups we are cautious when prescribing ibuprofen

A

previous or active pud

elderly

preg

BF

Renal cardiac or hepatic impairment

asthma

allergy to nsaids

on other nsaids

systemic steroids long term use

69
Q

What are some side effects of ibuprofen?

A

GIT discomfort

occasional bleeding and ulceration

headache

dizzy

depression

nervousness

insomnia

vertigo

tinnitus

70
Q

What can ibuprofen interact with?

A

ACE inhibitors

antibiotics

anticoags

anti depresants

corticosteroids

beta blockers

ca channel blockers

71
Q

What are signs of ibuprofen overdose?

A

Nausea

vomiting

tinnitus (more serious toxicity is v uncommon)

72
Q

How to reverse ibuprofen overdose?

A

activated charcoal if more than 400mg/kg within the hour

73
Q

What form do we use to write a prescription in Scotland?

A

GP14

74
Q

What do NSAIDs inhibit?

A

• COX and so reduce production of prostaglandins which sensitise tissues to other inflammatory mediators that result in pain

75
Q

What does ibuprofen and aspirin predominantly inhibit?

A

inhibit COX-1 (ASPIRIN 150X MORE EFFECTIVE AT INHIBITING COX1) – The amount of aspirin required to have sufficient anti-inflammatory effects by inhibition of COX2 will cause gastric damage due to amount of COX-1 inhibition

76
Q

What does COX 1 do?

A

allows PLT aggregation (produces prostaglandins that activate PLTs)
 COX-1 is the cyclo-oxygenase predominantly responsible for catalysing the reaction that produces prostaglandins associated with:
• Platelet aggregation
• Protection of the gastric mucosa

77
Q

What does COX 2 do?

A

catalyses the conversion of arachidonic acid to prostaglandins.

COX-2 is the enzyme responsible for the generation of most of the inflammatory prostaglandins (although in some situations COX-1 is also involved)

78
Q

What are actions of prostaglandins dependent on?

A

o The pathological situation
o Whether they are formed by COX1 or COX2
o Whether they are formed in excessive amounts

79
Q

Summary of how NSAIDs work

A

NSAIDs inhibit cyclo-oxygenases and so reduce prostaglandins (which sensitise the tissues to other inflammatory mediators resulting in pain).

80
Q

What do ibuprofen and aspirin predonomiantly inhibit?

A

COX 1

81
Q

what is action of cox1?

A

allows pLT aggregation

82
Q

What is cox2 action?

A

COX-2 is the enzyme responsible for the generation of most of the inflammatory prostaglandins (although in some situations COX-1 is also involved)

83
Q

What is idea behind cox2 selective inhibitors?

A

cox2 predominantly responsible for analgesic action and is we dont target cox1 then less gastric irritation

84
Q

What is Celebrex?

A

selective cox2 inhibitor

85
Q

What is celebrex?

A

Useful anti-inflammatory actions and fewer GIT damaging actions compared with non-selective NSAIDs
as cox 2 is selectively inhibited sparing cox1 inhibition which can lead to gastric irritation

86
Q

Why may selective cox2 inhibitors be too simplex of a view?

A

evidence that cox generated PGs can lead to gastric mucusal integrate and dcmic repair

however do have a lower risk of serious upper GIT side effects compared to non selective NSAIDs

87
Q

What does BNF recommend for dental and orofacial pain?

A

COX 2 selective should only be chosen in pts at high risk of gastric or duodenal ulceration (history of peptic ulcer)

88
Q

Who might tolerate highly selective cox2 inhibitors?

A

clotting disorder pts as dont have effect on plt aggregation

89
Q

What is contraindicated in pts with active PUD?

A

ALL NSAIDS

90
Q

What is paracetemol?

A

simple analgesic without anti-inflammatory activity

91
Q

What are the properties of paracetamol?

A

analgesic

antipyretic

no anti-inflammatory action

no effects on bleeding time

doesn’t interact with warfarin

less irritating to git

suitable for kids

92
Q

What does the metabolism of arachidonic acid by cox generate?

A

Hydroperoxides which exert a positive feedback to stimulate cox activity - this produces prostaglandins which sensitise tissues to other inflammatory mediators that result in pain

93
Q

How does paracetamol work?

A

the metabolism of arachidonic acid by cox generates hydroperoxides which have a positive feedback effect producing cox adcitivty resulting in prostaglandins which sensitise other tissues to inflammatory mediators resulting in pain

paracetamol blocks this positive feedback mechanism and indirectly inhibits COX

94
Q

What does paracetamol indirectly inhibit?

A

COX by blocking the positive feedback action of hydroperoxides resulting in analgesia and antipyretic action

95
Q

Where is the main site of action for paracetamol?

A

Reduction of prostaglandins in the pain pathways of the CNS such as the thalamus

96
Q

Why does paracetamol have little to no gastric mucosal effect?

A

not much effect on peripheral prostaglandins

97
Q

paracetamol cautions when prescribing?

A

hepatic impairement

renal impairment

alcohol dependence

98
Q

What are the rare side effects of paracetamol?

A

rashes

blood distorders

liver damage

99
Q

What is the interactions of paracetamol with other drugs?

A

prolonged use can enhance effects potentially of anticoagulant effects of the coumarins such as warfarin

cytotoxics

lipid regulating drugs

100
Q

What is the appropriate regime for mild to moderate Odontogenic pain with paracetamol?

A

5 day regime

500mg-1g up to 4 times a day

101
Q

what is max dose of paracetamol?

A

4g

102
Q

What can overdose of paracetamol cause?

A

hepatic damage that doesn’t become apparent till 4-6 days

103
Q

How much paracetamol required for overdose?

A

10-15g in 24hrs

104
Q

What should we warn pts when taking paracetamol?

A

Dont exceed maximum dose!! take as we have advised

dont take any other paracetamol containing drugs at same time such as lemsip or cocodamol

105
Q

How many tablets needed for paracetamol OD?

A

10-15G

20-30 TABLETS

150MG/LG

106
Q

what can paracetamol overdose lead to?

A

severe hepatocellular necrosis

less freq renal tubular necrosis

107
Q

What dose can those aged 1-18 take?

A

500mg x 4 day

108
Q

What are symptoms of overdose?

A

anorexia

nausea

vomiting

usually settles within 24hrs but if beyond then abdo paint nd can indicate development of hepatic necrosis

liver damage 3-4 days after ingestion and can lead to jaundice, haemorrhage, renal failure, encephalopathy, death

109
Q

What is an opioid analgesic we can prescribe?

A

dihydrocodeine

110
Q

What does opiod analgesia do?

A

it acts in the spinal cord (ind oral horn pathways associated with paelo-spinothalamic pathways)

causes central regulation of pain in periaqueductal grey matter, nucleus rectularis paragigantocellularis, raphe magnus nculeus

111
Q

how do opioid analgesics product their effects?

A

via specific receptors closely associated with neuronal pathways that transmit pain to cns

112
Q

What does BNF state about opioid analgesics?

A

Relatively ineffective in dental pain

113
Q

Wha is the problem with opioid analgesia?

A

Dependence

tolerance

effects on SM

114
Q

What is the issue with opioid analgesics and dependence?

A

Withdrawl of drug will lead to psychological cravings and pt will also be physically ill

115
Q

What is tolerance with opioid analgesia?

A

this is where at achieve same therupatic affects the dose needs to be progressively increased

116
Q

What effects can opioid analgesia have on the SM?

A

constipation

urinary and bile retention

117
Q

What do opiod analgesics depress?

A

pain centre

reps centres

higher centres

cough centres

vasomotor

118
Q

What can opioid analgesia often stimulate?

A

vomiting centre - limits its value id dental pain

119
Q

What are some side effects of opioid analgesia?

A

dry mouth

sweating

headahce

tacky

palpatations

hypothermia

hallucianations

mood changes

reduced libido

120
Q

What are some cautions with opioid analgesia?

A

dependance

elderly

hypotension

asthma

hypothyroidism

pregnancy

renal impairment

121
Q

What is opioid analgesics contraindicated?

A

in acute alcoholism

acute respiratory depression

raised icp/head injury

122
Q

What is codeine?

A

Codeine is an opiate and prodrug of Morphine used to treat pain, coughing, and diarrhea

1/12thy potency of morphine

taken orally

123
Q

What is codeine usually in combo with?

A

NSAID or paracetamol

124
Q

What is dihydrocodeine?

A

dihydrocodeine belongs to a group of medicines called opiates. It works in the central nervous system and the brain to block pain signals to the rest of the body.

125
Q

How can dihydrocodeine be taken?

A

SC OR IM - controlled

ORALL - not controlled

126
Q

What is dose of dihydrocodeine we can prescribe?

A

30mg every 4-6 hours

we can only prescribe oral

127
Q

What are some general opioid side effects?

A

nausea

vomiting

constipation

drowsiness

128
Q

What does dihydrocodeine have serious interactions with?

A

antidepressants (Maois)

dopaminergics

129
Q

What are general opioid cautions?

A 
	Hypotension 
	Hypothyroidism 
	Asthma 
	Pregnancy/BF
	Renal/Hepatic disease
	Elderly/children
130
Q

When should opioid analgesics never be prescribed?

A

o NEVER PRESCRIBE IN RAISED INTERCRANIAL PRESSURE/SUSPECTED HEAD INJURY

131
Q

Why are opioid analgesics little use for dental pain?

A

due to side effects of nausea and vomiting it is often little value for dental pain

132
Q

What is naloxone?

A

Used when opioid OD iff coma or bradypnoea

133
Q

What is another category of pain meds beside NSAIDs and opioids?

A

neuropathic and functional pain such as

TRIGEMINAL NEURALGIA

POST HERPETIC NEUALGIA

FUCNTIONAL - TMJ OR ATYPICAL PAIN

134
Q

What is the drug we can prescribe for neuropathic or functional pain?

A

carbamazepine

135
Q

What can we prescribe for trigemnial neuralgia?

A

carbamazepine

136
Q

What other drugs can be used for trigemnial neuralgia that aren’t on dental list?

A

Gabapentin

Phenytoin

137
Q

What are the clinical features of trigemental neuralgia?

A

severe pain spasms - electric shock pain

unilateral normally

trigger spot

periods of remission

recurrences of greater severity

138
Q

What does of carbamazepine do we prescribe for trigeminal neurgalia

A

100 or 200mg tablets once or twice daily but we can gradually increase to 200mg 3-4 times a day up to 1.6g

139
Q

Side effects of carbamazepine?

A

diziness

ataxia

drowsiness

leucopenia and other blood disorders

monitor ps blod

140
Q

when is carbamazepine contraindicated?

A 
o	AV conduction abnormalities (unless paced)
o	History of bone marrow depression 
o	Porphyria 
o	Hepatic/renal/Cardiac disease
o	Skin reactions 
o	History of haematological rxns to other drugs 
o	Glaucoma 
o	Pregnancy/BF
o	Avoid abrupt withdrawal
141
Q

What are 5 drugs we must always be aware of?

A

aspirin iburpofen diclofenac

paracetamol

dihydrocodeine

carbamazepine

3. Oral Surgery (9 decks)

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