INTRODUCTION:

Pain management is very important in dentistry and surgical fields. Various analgesics and antibiotics are available in the market for infection control and pain management in case of an abscess and cellulitis. The local anesthesia is the best method of pain control in dentistry during the procedure. Presently various researches are being conducted to reduce pain and make endodontics painless. Now all researches are focused on improving the safety of analgesics, antibiotics, anesthetic agents, anesthetic delivery devices. Newer technologies have been developed which help the dentist in providing pain relief to patients with reduced injection pain and minimal side effects.

Analgesics:

NSAIDs are commonly used analgesics in the field of dentistry. They are used to manage mild to moderate tooth pain. NSAIDs also have anti-inflammatory and antipyretic properties. NSAIDs inhibit cyclooxygenase enzyme; which causes a reduction in prostaglandin formation, which is involved in the propagation of pain. Commonly used NSAIDs are paracetamol, ibuprofen, aceclofenac. Recently Ketorolac has been introduced in the market for the management of severe pain. Studies have shown Ketorolac to be much more effective than ibuprofen. Available in the market as 10mg dispersible tablets. Useful in cases of acute pain due to periapical abscess and cases of trauma.^1,2Opioids like Tramadol are also widely used nowadays for the management of severe pain.

Recommended Dosage: Paracetamol 500 mg bid for 5 days.

Ibuprofen 400 mg bid for 5 days.

Ketorolac DT 10 mg bid for 3 days.

Tramadol 50-100 mg bid for 3 days.

Tramadol is centrally acting opioid analgesic which is highly effective in managing acute pain. It is a non-selective pure agonist which has a high affinity for μ-receptor. After oral administration more than 90% of tramadol is absorbed. Dose need to be decided carefully depending on the ae and health of the patient.

Tramadol is contraindicated in following conditions:

- in hypersensitivity to tramadol hydrochloride or any of its components.

- in acute intoxication with alcohol or opioids.

- in patients who are intoxicated with hypnotics and analgesics.

- in patients who are receiving MAO inhibitors.

- in patients with epilepsy.

- for use in narcotic withdrawal treatment.

Warning and precautions before use:

Tramadol should be used with caution in opioid-dependent patients, patients with head injury. Special precaution need to be taken care in patients with altered level of consciousness or rise in intracranial pressure.

This drug is not available in Indian market without prescription from a doctor because of liability of drug abuse.

Antibiotics:

Antibiotics are considered as the mainstay for the management of endodontic infections with swelling and pus discharge. Routinely it is prescribed to patients with co-morbidities to reduce the risk of infection during root canal treatment. The recent guidelines suggest the use of antibiotic prophylaxis in the case of patients with Infective endocarditis.

The prophylactic dose includes the use of Amoxicillin 2gm or Clindamycin 600 mg or Azithromycin 500 mg oralone hour before the procedure. Antibiotics should be given carefully in patients with liver or kidney disorders and pregnant patients. Careful administration is very important to achieve the desired results.²

Recommended Dosage: Amoxicillin 500 mg tid for 5 days.

Augmentin 650mg tid for 5 days.

Amoxicillin 500 mg plus metronidazole 400 mg tid mg bid for 3 days

(For anaerobic infections like swelling and abscess).

Anxiolytics:

They are used in highly anxious patients to reduce their fear and anxiety during dental treatment. This makes the patient more calm and composed and increases the efficiency of the endodontist. Benzodiazepines have become the choice of drugs in endodontics. Most popular among all drugs is Diazepam. Various other anxiolytics are available such as Triazolam, Midazolam, Lorazepam.

They have a shorter duration of action and much more safe clinically. Diazepam is given in a dose of 5-10 mg for an adult patient. Careful patient assessment and drug selection is very important to get maximum benefits. These drugs to be avoided in patients with a history of drug abuse.

Local Anesthesia:

Lignocaine Hydrochloride is the most commonly used local anesthetic (LA) agent in Dentistry due to its good efficacy and low toxicity. It is being used for a long time in dental practice and it is being considered as one of the safest local anesthetic agents. But due to high stress and anxiety among dental patients due to sight of a needle and short duration of action it fails to deliver optimal pain control. So nowadays newer agents and devices are bring searched to make dental treatment completely painless.

Newer Anesthetic Agents:

1) Articaine HCl:

Initially known as Cartacaine Hydrochloride in 1969. It was renamed Articaine in1984.It got US FDA approval in April 2000 for 4% Articaine with epinephrine 1:1,00,000 and in 2006 for 4% Articaine with epinephrine 1:2,00,000 .It is Amino amide based with no benzene ring. It is composed of the Thiophene ring. Biotransformation takes place in the liver and plasma. It is well-tolerated, safe, and effective and provides better diffusion through the bone. Provide Adequate infiltration, block, and pulpal anesthesia. Its effect same as Lidocaine.^3,4

2) Centbucridine:

It is a Quinolone derivative which possess intrinsic vasoconstriction and anti-histaminic properties. Effective in a concentration of 0.5% for infiltration and nerve blocks. Various studies had suggested that it is 4-5 times more potent than that of 2% lignocaine.⁵

New Local Anesthetic Delivery Devices:

1) Vibrotactile devices:

Based on the Concept of Gate Theory given by Melzac and Wall (1965).

Simultaneous activation of nerves conducting Non-noxious stimuli leads to the Reduction of Pain. There is a stimulation of Larger diameter fibers (Pressure or Vibration application) which inhibit transmission of pain carrying smaller diameter fibers. Both fibers transmit through the same gate patients do not experience pain. Resulting in increased patient comfort.^6,7 These devices are Vibrajet, Dental vibe, Accupal.

2) Single Tooth Anesthesia/CompuDent (Wand):

Computer controlled delivery system which provides real-time visual and audio feedback. Minimal Exit pressure and tissue resistance are experienced during LA administration resulting in minimal pain during injection and increase patient comfort. Preprogrammed to control the flow of local anesthetic solutions. Used for PDL injections.^8,9 A new version of this device is available in the market known as Comfort Control Syringe System which is much more sophisticated and reliable. This consists of five pre-programs to deliver local anesthesia for different areas.

3) Jet Injections:

High pressure push the local anesthetic solution through a small orifice which results in penetration into soft oral mucosa without a needle. Mainly used for palatal anesthesia. Examples are Syrijet and Injex.^10,11

4) Intraosseous injections

These devices are used to deposit local anesthesia directly into the cancellous bone with the help of a perforator and needle.Different types are the Stabident system, X-Tip system, Intra flow system.^12,13,14

5) Newer Safety Dental Syringes:

To avoid needle stick injuries newer types of syringes are launched in the market. This includes Ultra Safety Plus XL Syringe, Ultra Safety Plus XL Syringe, HypoSafety Syringe. ^15,16

Agent for Reversing Local Anesthesia effect:

The most popular agent available in the market is Phentolamine Mesylate ( Example: Ora Verse). Approved by FDA in 2008. It is a non-selective alpha-adrenergic blocker. It reverses the effect of epinephrine by causing vasodilation. Equal volume as local anesthesia needs to be administered. The technique for administration is the same as local anesthesia.^17,18,19

Kovacaine Mist Spray:

Combination of 3% Tetracaine + 0.05% Oxymetazoline. Developed as a Nasal spray to provide anesthesia (Needleless). It can be used for Anesthesia of maxillary teeth (15 – 25 minutes). Presently under clinical trial.^20,21,22

FUTURE TRENDS:

To avoid injections which reduce patient anxiety and increase comfort. It also reduces the risk of needle stick injury and contamination. ^23,24,25

Includes:

a) Bio-adhesive anesthetic patch

b) Nasal spray (Kovacaine Mist)

CONCLUSION:

Recent advancements in the field of analgesics, antibiotics, local anesthesia, and delivery devices will make dentistry more comfortable and painless. Thorough knowledge and awareness among clinicians will enable them to provide painless treatment to patients. The latest Kovacaine Mist spray is under clinical trial and holds a promising future in dentistry.

REFERENCES:

1. Paul A Moore, Elliot V Hersh, Sean G Boynes – Update Of Dental Local Anaesthesia. Dental Clinics Of North America 2010 Oct;54(4). doi.org/10.1016/j.cden.2010.07.001.

2. Dym H, Ogle OE. Technological advances in dentistry and oral surgery. Preface. Dent Clin North Am. 2011 Jul;55(3):xiii-xiv. doi: 10.1016/j.cden.2011.04.001.

3. Weaver JM. Articaine, a new local anesthetic for American dentists: will it supersede lidocaine? Anesth Prog. 1999 Fall;46(4):111-2. PMID: 11692350; PMCID: PMC2149003.

4. Malamed SF, Gagnon S, Leblanc D. Articaine hydrochloride: a study of the safety of a new amide local anesthetic. J Am Dent Assoc. 2001 Feb;132(2):177-85.doi: 10.14219/jada.archive.2001.0152.

5. Sarfaraz Ahmad, Sajid Ali, Intakhab Alam, Sarfaraz Alam, Nawazish Alam, Maksood Ali. Drug Interactions of OTC Analgesics-Aspirin: A Review. Research J. Pharm. and Tech. 8(5): May, 2015; Page 580-586. doi: 10.5958/0974-360X.2015.00097.9

6. M. Ashfaq Ahmed, Ashish. R. Jain, ACU. Varma. Knowledge, Attitude and Practice regarding Antisialogogue drugs in Dental Management. Research J. Pharm. and Tech 2017; 10(10): 3489-3491. doi: 10.5958/0974-360X.2017.00624.2

7. J. Rubika. Role of Diazepam in Dentistry - A Short Review. Research J. Pharm. and Tech. 8(8): August, 2015; Page 1014-1016. doi: 10.5958/0974-360X.2015.00172.9

8. Trophimus Gnanabagyan Jayakaran, Vignesh R, Shankar P. Local Anesthetics in Pediatric Dental Practice. Research J. Pharm. and Tech 2019; 12(8): 4066-4070. doi: 10.5958/0974-360X.2019.00700.5

9. Amanthi Ganapathi, Pradeep. D. An Update on Local Anesthesia for Pediatric Dental Patients. Research J. Pharm. and Tech. 2019; 12(7):3169-3174. doi: 10.5958/0974-360X.2019.00534.1

10. Clark TM, Yagiela JA. Advanced techniques and armamentarium for dental local anesthesia. Dent Clin North Am. 2010 Oct;54(4):757-68. doi: 10.1016/j.cden.2010.06.017.

11. Dabarakis N, Alexander V, Tsirlis AT, Parissis NA, Nikolaos M. Needle-less local anesthesia: Clinical evaluation of the effectiveness of the jet anesthesia Injex in local anesthesia in dentistry. Quintessence Int. 2007;38:E572–6

12. Reader, A. and Nusstein, J. (2002), Local anesthesia for endodontic pain. Endodontic Topics, 3: 14-30. https://doi.org/10.1034/j.1601-1546.2002.30103.x

13. Angelo Z, Polyvios C. Alternative practices of achieving anaesthesia for dental procedures: a review. J Dent Anesth Pain Med. 2018 Apr;18(2):79-88. doi: 10.17245/jdapm.2018.18.2.79.

14. Remmers T, Glickman G, Spears R, He J. The efficacy of IntraFlow intraosseous injection as a primary anesthesia technique. J Endod. 2008 Mar;34(3):280-3. doi: 10.1016/j.joen.2007.12.005.

15. Malamed SF. 5th ed. St Louis: Mosby-Year Book; 2004. Handbook of Local Anesthesia.

16. Cuny E, Fredekind RE, Budenz AW. Dental safety needles' effectiveness: results of a one-year evaluation. J Am Dent Assoc. 2000 Oct;131(10):1443-8. doi: 10.14219/jada.archive.2000.0055.

17. Hersh EV, Moore PA, Papas AS, Goodson JM, Navalta LA, Rogy S, Rutherford B, Yagiela JA; Soft Tissue Anesthesia Recovery Group. Reversal of soft-tissue local anesthesia with phentolamine mesylate in adolescents and adults. J Am Dent Assoc. 2008 Aug;139(8):1080-93. doi: 10.14219/jada.archive.2008.0311.

18. Laviola M, McGavin SK, Freer GA, Plancich G, Woodbury SC, Marinkovich S, Morrison R, Reader A, Rutherford RB, Yagiela JA. Randomized study of phentolamine mesylate for reversal of local anesthesia. J Dent Res. 2008 Jul;87(7):635-9. doi: 10.1177/154405910808700717.

19. Tavares M, Goodson JM, Studen-Pavlovich D, Yagiela JA, Navalta LA, Rogy S, Rutherford B, Gordon S, Papas AS; Soft Tissue Anesthesia Reversal Group. Reversal of soft-tissue local anesthesia with phentolamine mesylate in pediatric patients. J Am Dent Assoc. 2008 Aug;139(8):1095-104. doi: 10.14219/jada.archive.2008.0312. Erratum in: J Am Dent Assoc. 2008 Oct;139(10):1312.

20. Ciancio SG, Hutcheson MC, Ayoub F, Pantera EA Jr, Pantera CT, Garlapo DA, Sobieraj BD, Almubarak SA. Safety and efficacy of a novel nasal spray for maxillary dental anesthesia. J Dent Res. 2013 Jul;92(7 Suppl):43S-8S. doi: 10.1177/0022034513484334. Epub 2013 May 20.

21. MH Dehghan, Varsha M Gaikwad, Baby Dandge. Nasal Absorption of Drugs – Barriers and Solutions. Research J. Pharm. and Tech.2 (4): Oct.-Dec. 2009; Page 634-641.

22. M. Ashfaq Ahmed, Ashish. R. Jain, ACU. Varma. Knowledge, Attitude and Practice regarding Antisialogogue drugs in Dental Management. Research J. Pharm. and Tech 2017; 10(10): 3489-3491. doi: 10.5958/0974-360X.2017.00624.2

23. Awale P, Sonawane D, Dhananjay S, Mhatre D, et al. Research J. Pharm. and Tech. 2013.6(8): 899-901. doi: 10.5958/0974-360X.2020.00530.2

24. Thangavelu K, Kannan R, Kumar NS, Rethish E, Sabitha S, Sayeeganesh N. Significance of localization of mandibular foramen in an inferior alveolar nerve block. J Nat Sci Biol Med. 2012 Jul;3(2):156-60. doi: 10.4103/0976-9668.101896.

25. Hersh EV, Pinto A, Saraghi M, Saleh N, Pulaski L, Gordon SM, Barnes D, Kaplowitz G, Bloom I, Sabti M, Moore PA, Lee S, Meharry M, He DY, Li Y. Double-masked, randomized, placebo-controlled study to evaluate the efficacy and tolerability of intranasal K305 (3% tetracaine plus 0.05% oxymetazoline) in anesthetizing maxillary teeth. J Am Dent Assoc. 2016 Apr;147(4):278-87. doi: 10.1016/j.adaj.2015.12.008.

Received on 08.02.2021 Modified on 28.10.2021

Research J. Pharm. and Tech 2022; 15(11):5349-5352.

DOI: 10.52711/0974-360X.2022.00901