W11: Analgesia and Anaesthesia

Question 1

Pain serves as a protective funciton and yeilds a learning oppitunity (conditioning).
Provide the definition of pain according to the International Association for the Study of Pain

Answer 1

An unpleasant sensory and emotional experience associated with or resempling that associated with, actual or potential tissue damage

Question 2

Explain the biopsycho social model of pain

Answer 2

What influences pain…

Question 3

Why do we need to manage it in dentistry?

Answer 3

The only surgery mainly undertaken on Conscious patients
* Makes treatment possible
* Reduces stress for patient and staff
* Prevents development of dental anxiety (and missed appointments), thus promoting regular preventative attendance.
* Practice-builder
* Early management prevents hyperalgesia during recovery

Failure to control pain is currently the most common cause for litigation

Question 4

Amount of stimulus to provoke pain is the same for everyone, but the response depends on…?

Answer 4

• Culture
• Personal history
• Sleep
• Personality
• Emotions e.g anxiety may reduce tolerance or increase pain ex. battle
• Cognition: Voluntary control is possible, Knowledge about what to expect, Relaxation techniques

Question 5

How can you measure Pain?

Answer 5

Question 6

Describe the catagories for the types of Pain ie. classification of orofacial pain

TEST

Answer 6

Dental pain tends to be inflammatory in nature and acute Chronic = neurological (transmission/nerve affected) or sensitisation (change within brain)

Question 7

Answer 7

Question 8

List and describe the 3 types of pain

N’s…

TEST

Answer 8

Question 9

Compare the three types of pain, specifically referring to origin of stimulus, localisation to site of stimulus, description and examples of each

Answer 9

Examples:
* Nociceptive- Periapical abscess & Dentine sensitivity
* Neuropathic- Trigeminal neuralgia & Phantom limb pain
* Nociplastic- Irritable Bowel syndrome & Low back pain

Question 10

Describe the link between the physiology of pain and analgesics to manage the pain

Answer 10

• Sensory function - Nerve selectively detects the relevant stimulus (i.e. nociceptors are stimulated by anything that might cause damage… Stimulus needs to be intense enough to potentially cause tissue damage - so normally high threshold)
• BUT sensitivity/selectivity can be influences (e.g. with inflammation or mood ect.)
• The brain interprets the nociceptive signal as pain

Question 11

List some pain management strategies

Answer 11

A continuum from purely psychological to purely pharmacological (usually a combination)
* Explaining honestly and preparing the patient for what might happen – reduces anxiety
* Empathy
* Distraction - music, chatting, D.A ect.
* Hypnosis
* Acupuncture
* Cognitive Behavioural techniques (by psycologist)
* Biofeedback (e.g. progressive muscle relaxation)
* Effective LA
* Sedation
* GA
* Effective analgesics perioperatively with clear (written) advice
* Availability for patient contact

Question 12

Describe the three key stimulators of Nociceptors

Answer 12

Question 13

Describe Sensitization briefly (include 2 causes)

Answer 13

Causes:
* Peripheral (mediators such as prostaglandins and bradykinin)
* Central (progressively increasing amplitude of synaptic potentials – known as “wind-up”)

Question 14

Compare the two types of altered sensitivity

Answer 14

• Hyperalgesia - ↑pain with mild stimulus
• Allodynia – pain with non-noxious stimulus

Question 15

Compare Anaesthesia and Analgesia

Answer 15

Analgesia can be Pre- Peri- or Post- & is often associated with Inflammation- so we need to know about inflammation, its role and how we can target it to manage pain

Question 16

List and describe three inflammatory mediators that contribute to pain

Answer 16

Question 17

Describe where some typical analgesics (lidocaine, capsacin, NSAIDS, Opiods, Tricyclic antidepressents, SNRI’s, gabapentin, NMDA blockers) act.

Answer 17

Question 18

Give examples of, and describe how non-steroidal anti-inflammatories, Opioid analgesics and Aniline analgesic work.

TEST

Answer 18

Avoid opioid analgesics - rarely effective for inflammatory pain (besides 3rd molar surgery).

Question 19

Describe the MOA and uses of NSAIDS

TEST

Answer 19

• Reduction of prostaglandin synthesis with significant duration of action.
• Most widely used for dental pain (e.g. Ibuprofen) and more effective that paracetamol or opioids, due to predominant role of inflammation in dental pain
• Analgesic effects are limited and are less effective in severe or chronic pain

Question 20

Describe the MOA and uses of Paracetamol

TEST

Answer 20

• Useful for mild to moderate pain where inflammation is not primary cause.
• Mechanism complex and not fully understood but CNS effect (believed that a metabolite acts on receptors in the brain and alsoterminals of C-fibres in the spinal dorsal horn, which modulates nociceptive transmission)
• Weak inhibitor of prostaglandins - mild anti-inflam
• Antipyretic (similar efficacy to Ibuprofen)
• Better tolerated than NSAIDs, so safer alternative for a mild analgesic)

Question 21

List some potential problems with oral analgesics such as NSAID’s and paracetamol

Answer 21

Question 22

Describe the MOA and uses of Opiods

Answer 22

Question 23

List the potential problems with Opiods

Answer 23

Question 24

List the symptoms, cause and treatment for Trigeminal neuralgia

Answer 24

Question 25

Describe where each drug sits on the WHO three step ladder for pain relief

Answer 25

Question 26

List some influences on pain

Answer 26

Question 27

List some factors that could affect/influence Local Anaesthetic duration/effectiveness

Answer 27

Question 28

List the techniques for improving LA acceptability

Answer 28