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At the end of this lecture, you will be asked if you would like to take this course for continuing education units.
California Continuing Education Credits: 2 units
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Ibuprofen | Acetaminophen | Diflunisal | Naproxen |
Control of postoperative pain following periodontal surgery involves choosing the analgesic regime that is appropriate for each patient. All patients should have an adequate blood level of analgesic agent at the time the local anesthesia is losing its effect. This loss of local anesthetic effect varies according to the type of anesthesia used and the patients individual differences, but is usually is two to three hours after administration of lidocaine. Some patients do not require any additional analgesic beyond this initial dose, but it is necessary to have appropriate pain reduction medications available for all patients after this first dose. In general about half of all patients undergoing periodontal surgery have slight or no postoperative pain compared to 95111f patients reporting significant pain after extraction of impacted third molars.
Patients with a low pain threshold and/or patients who have undergone periodontal surgery that is more extensive in the areas involved, the techniques used or in the time needed, may benefit from using a long acting supplemental local anesthesia such as bupivacaine eg., Marcaine given at the conclusion of the surgery.
It is generally necessary to have sufficient analgesic medication for two to three days post surgery. Pain that is present beyond this time should be regarded as unusual, and the patient needs to be evaluated clinically to see what is causing the pain. Infections, accentuated post operative edema, pressure from sutures and overextended surgical dressing, occlusal trauma due to post surgical tooth extrusion and pulpal inflammation are the common causes of unusual post surgical pain. These need correction by the appropriate procedures rather than simply relying on analgesics.
While there are a wide range of analgesics available, among the most widely used agents are non-steriodal analgesics (NSAIDS) and acetaminophen. In the NSAIDS group, aspirin is no better as an analgesic than the other agents and has significantly more undesirable side effects. The use of opioids is generally not necessary following periodontal surgery. Codeine alone at 60 mg is only slightly better than a placebo and its use with aspirin or acetaminophen in doses of 30 mg to 60 mg. may offer slightly more analgesia than acetaminophen alone or NSAIDS alone, but can cause more severe adverse effects. Also the use of opioids has the risk of the patient becoming tolerant to their therapeutic effect as well as the risks of chemical dependency. More potent opioid analgesic such as meperdine, pentazocine and hydromorphone hydrochloride are generally not indicated for pain following periodontal surgery, but are used parentally for severe pain related to more intensive surgical procedures such as abdominal surgery.
Patients have variability in their susceptibility to the analgesic effect of the various non-steriodal anti-inflammation agents and so when these drugs are used it may be necessary to change to another agent in this group in order to get acceptable analgesia. In order to get peak levels of the analgesic agent at the time the local anesthesia is wearing off, the appropriate time for the patient to take these tablets is based on the pharmacodynamics of each agent. Acetaminophen and ibuprofen work best if given at the end of the surgical procedures, longer acting agents like diflunisal may be more effective given immediately prior to the surgery.
Examples of selected analgesics are outlined below:
The non-steriodal anti-inflammatory agents and acetaminophen have very few side effects or contraindication, particularly when used for short periods of time as suggested after periodontics surgery. The adverse effects of these agents have one-half to one-tenth the frequency reported for long term utilization.
Curtis, J.W., McLain, J.B., Hutchison, R.A., The Incidence and Severity of Complications and Pain following Periodontal Surgery. J. Periodontol 1985;57:597. (Abstract)
Dionne, R. A., Campbell, R. A., Cooper, S.A., Hall D. L., Buckingham, B., Suppression of Postoperative Pain by Preoperative Administration of Ibuprofen in Comparison to Placebo, Acetaminophen and Acetaminophen Plus Codeine. J. Clin Pharmacology 1983;23:37. (Abstract)
Vogel, R. A., Desjardims, P. J., Major, K. V. O., Comparison of Presurgical and Immediate Postsurgical Ibuprofen on Postoperative Periodontal Pain. J. Periodontal 1992; 63:914. (Abstract)
Hass, D. A., Current Concepts in the Use of Analgesics on Dentistry. Oral Health 1993; 14:7. (Abstract)
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