Minh Nguyen asked: In part 1, nonnarcotic pain medications for dental pain are discussed. Dentists use these medications for relieving mild to moderate oral pain. This article describes the narcotic medications. For moderate to severe dental pain, the typical medications are:
o Tramadol (Ultram), 50mg every 6 hours as needed for pain.
o Tramadol with acetaminophen (Ultracet, containing 37.5 mg tramadol hydrochloride and 325 mg acetaminophen), one table every 6 hours as needed for pain.
o Acetaminophen (Tylenol#4, containing 60 mg Codeine Phosphate and 300 mg Acetaminophen), one table every 4-6 hours as needed for pain.
For severe pain, opioid combinations are advised. For example, one Vicodin ES (10 mg hydrocodone and 750 mg acetaminophen), can be taken every 4-6 hours as needed for pain.
Opioids: Opioids are narcotic agents that act on the central nervous system. Side effects-including nausea, constipation, dizziness, sedation and respiratory depression-are common with opioid therapy. However, the relative risk of opioidlike side effects varies.
Although opioids as a class are effective dental pain reliever, some commonly used formulas show poor efficacy for dental pain. Other drugs with fewer severe side effects can have similar results. For examples, codeine alone has not been found as effective as other common analgesics (acetaminophen and NSAIDs) for relief of dental pain. Oxycodone, hydrocodone and propoxyphene are about as effective as codeine. Dihydrocodeine, penta-zocine and meperidine show no advantages over codeine orally and can even be less effective. Their effectiveness in combination therapy (combining opiods with acetaminophen and NSADs) is better than that in monotherapy.
Tramadol: Tramadol is a synthetic, centrally acting pain reliever. It is indicated for moderate to moderately severe oral pain. Its analgesic action affects both opioid receptor and serotonin uptake. This suggests that tramadol’s effect is not mainly through narcotic mechanism. Tramadol, thus, is a nonscheduled drug. The serious side effects typically associated with opioids-such as dependence, sedation, respiratory depression and constipation-occur less often with this medication. Tramadol also has a low rate of abuse, about one per 100,000 persons. The side effects commonly seen with tramadol include nausea, dizziness, drowsiness and tiredness.
Tramadol’s lack of sedation is particularly important for same-day dental surgery. Tramadol does not have the same side-effects like NSAIDs or traditional opioids. Adverse side effects generally are mild and transient. Importantly, tramadol does not have the ceiling dose effect common to many other analgesics. Recent studies show that tramadol is a good postsurgical and dental pain killer. They also show that tramadol has a dose-response effect. For instance, in one study they reviewed, tramadol 200 mg was more effective than 100 mg after third-molar extraction. Unlike aspirin and acetaminophen with codeine, which have an analgesic duration of about four hours, tramadol provides analgesia for five to six hours after dental surgery.
Benzodiazepines are increasingly being used to decrease patient’s anxiety. Their sedative, “anxiety-reducing” and “forgetful” properties, along with their mild respiratory depression, are especially helpful for lowering the “view” of dental pain. By reducing the dental fear, the patient becomes less sensitive to painful stimuli.
Midazolam: Midazolam has the ability to decrease postoperative anxiety. It provides complete surgical amnesia (memory blockage) that lasts about 25 minutes. A multidrug combination of fentanyl, midazolam and metho-hexital (commonly used in intraveous sedation for wisdom teeth removals) gives better pain control but produced deeper sedation.
Treatment of anxiety related to dental procedures is most worthwhile for children. Extreme preoperative apprehension may need more anesthesia and lead to postoperative negative effects. Oral midazolam has been shown to produce significant amnesia in children when it is given10 minutes before a surgical procedure. Recent clinical trial of oral tramadol mixed with midazolam provides effective pain relief during and after surgical procedures for kids.
Diazepam: Diazepam is another useful benzodiazepine that treats oral pain associated with muscle spasm. However, its use is limited by long-term sedation, abuse potential and dependence potential. Diazepam may have additive side effects with other central nervous system depressants. Combinations of benzodiazepine and opioids are used widely for conscious sedation but are associated with significant risks. These combinations may be safely used only under adequate cardiopulmonary monitoring.
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