2. Dental indications for analgesic use

antipyretic analgesics were discovered: acetaminophen and aspirin (formulated in 1895 by Frederick Bayer and Felix Hoffman) and phenazon, which still make up about 50% of the market of antipyretic analgesics worldwide [1]. Opiates such as morphine, which are derived from the opium poppy, were also used for thousands of years. Later on codeine, as a naturally methylated morphine, was isolated in France in 1830 by Jean-Pierre Robiquet. In 1937, German scientists Max Bockmuhl and Gustav Ehrhart synthesized

Pain is a subjective symptom signaling a requirement to act urgently and is usually associated with other subjective feelings such as anxiety, anger and discomfort. The expression of nature and intensity of pain is a subject of different patient-related characteristics. There are several patient factors having an impact in the patient's interpretation of pain, such as gender, age, physiological factors and drug abuse history, neuropathic and other disease and psychological

Dental pain (toothache or odontalgia) is a common subjective complaint of dental patients following the different interventional procedures and dental diseases. Dental pain presents one of the most common causes (approximately 12%) of patients seeking emergency treatment

Odontogenic pain is a complex cascade process initiated from dental tissue damage and accompanied with heterogeneous neuronal stimuli as a consequence of neurovascular,

The development of new analgesics is a very dynamic process and nowadays clinicians have a greater range of agents in order to select the most efficient and safe analgesic therapy. Taking into consideration the period 1960–2009, 59 analgesics have been introduced and their use still

Analgesics are considered one of the most important drugs groups in dental practice considering the prescription rate, clinical efficacy, cost-effectiveness and safety profile of this drug group. According to this level of importance in dental clinical practice, there are different approaches to develop treatment algorithm and guidelines for dental pain treatment in order to rationalize the use of analgesics. The rationalization of analgesics use is an ongoing challenge, since some analgesics are over-the-counter (OTC) drugs and can be taken without

The management of dental pain in clinical practice is a complex part of dental care and requires high-level knowledge of analgesic pharmacology and implementing the standards of

There is a valuable evidence for significant relationship between nonrational use of analgesics and diminution of drug therapy, increased adverse drug reactions and socioeconomic conse-

Nevertheless, prescription of analgesic drugs for dental indications is often accompanied with challenges, which diminish the treatment success and increase the potential risk for serious

methadone [2].

profile of individual humans [3].

112 Pain Relief - From Analgesics to Alternative Therapies

remains important [6].

medical prescription.

rational use.

quences [7, 8].

adverse effects.

in dental healthcare in the United States [4].

neuroinflammation and morphologic reactions [5].

Odontogenic pain due to periapical and pulpal disease is considered as the most frequent in dental health settings [15] and it is a warning sign and subjective perception of altered pulpodentinal tissue and periapical tissue. These two can be distinguished one from the other and this perception has an impact on the appropriate selection of analgesic drugs.

According to the course of clinical manifestation of the dental pain, it can be classified as acute or chronic and/or with and without malignant disease. Acute pain lasts from several hours to a number of days, while chronic pain can be present for several months and, if primary dental care is not applied, pain can last for years.

Acute pain is usually a reflection symptom of several clinical conditions such as dental trauma, inflammatory conditions of dental tissue and other related tissue structures, including the temporomandibular and masticatory muscle damages. There are several painful dental conditions indicating the analgesic use.

The characteristic of odontogenic pain is so-called referred pain, which means that the damage located in one part of dental tissue can be projected to another dental tissue. Dental referred pain is a complex clinical phenomenon, which requires a highly experienced dentist to diagnose and locate the primary source of pain [16].

The majority of clinical indications of analgesic prescriptions relate to the treatment of acute and chronic dental pain and adjunctive intraoperative and postoperative pain. Moreover, in dental practice associated procedures such as dental extractions require the use of pain reliever therapy [17].

In addition to the understanding of primary mechanism of pain, the dental clinician needs to quantify the perceived intensity of pain. These are preconditions to develop an effective strategy for the selection of efficacious and safe analgesic treatment. According to anticipated pain intensity, the dental pain can be mild, moderate and severe. This classification of dental pain intensity is crucial in the selection procedure of analgesic therapy for satisfactory relief of pain. In patients with mild dental pain, the first lines of analgesics are the nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs can be prescribed in over-the-counter doses and in some cases in combination with other analgesics such as paracetamol [18].

The drug of choice from NSAIDs group for the treatment of mild odontogenic pain is ibuprofen 200 mg or naproxen 200–225 mg individual dose. In patients with persistent mild dental pain, the combination of ibuprofen or naproxen with paracetamol is more effective than individual NSAID agents. Where NSAIDs are contraindicated, the appropriate choice is 500–1000 mg of paracetamol.

Acetyl salicylic acid is not the drug of choice for treatment of dental pain due to its interference with platelet aggregation and patients with heart disease receiving this drug should be treated with precautions.

In patients with moderate dental pain, the analgesic of choice is a NSAID used in pharmacological full doses. NSAIDs can be individually administered or in combination with aniline derivatives, such as mefenamic acid and meclofenamic acid. In some patients where NSAIDs are not effective in combination with paracetamol, a weak opioid analgesic can be considered. The individual dose of ibuprofen is 400 mg, while that of the naproxen is 500–550 mg. In patients where pain is not controlled effectively, the addition of full dose of paracetamol is recommended. If pain is still present, the addition of weak opioid agents in full doses is advised, i.e., codeine 30 mg, hydrocodone 5 mg [19].

In patients with severe dental pain, the pharmacological treatment consists usually of combinations of strong opioid analgesics with high doses of NSAID agents, with or without aniline derivatives. In such patients, treatment of pain should be under close supervision of the dental doctor due to a higher probability of adverse drug reactions. The first choice of drug is hydrocodone 10 mg, oxycodone 5 mg, codeine 60 mg, or tramadol 50–75 mg. Due to high potential of abuse, tramadol is not the drug of choice for the treatment of severe odontogenic pain. In patients with unsatisfactory level of pain control, the combination of full dose opioid agents and NSAIDs is recommended [20].

### 2.1. Factors influencing the analgesic selection

The characteristic of odontogenic pain is so-called referred pain, which means that the damage located in one part of dental tissue can be projected to another dental tissue. Dental referred pain is a complex clinical phenomenon, which requires a highly experienced dentist to diag-

The majority of clinical indications of analgesic prescriptions relate to the treatment of acute and chronic dental pain and adjunctive intraoperative and postoperative pain. Moreover, in dental practice associated procedures such as dental extractions require the use of pain reliever

In addition to the understanding of primary mechanism of pain, the dental clinician needs to quantify the perceived intensity of pain. These are preconditions to develop an effective strategy for the selection of efficacious and safe analgesic treatment. According to anticipated pain intensity, the dental pain can be mild, moderate and severe. This classification of dental pain intensity is crucial in the selection procedure of analgesic therapy for satisfactory relief of pain. In patients with mild dental pain, the first lines of analgesics are the nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs can be prescribed in over-the-counter doses and in some cases in combination with other analgesics such as

The drug of choice from NSAIDs group for the treatment of mild odontogenic pain is ibuprofen 200 mg or naproxen 200–225 mg individual dose. In patients with persistent mild dental pain, the combination of ibuprofen or naproxen with paracetamol is more effective than individual NSAID agents. Where NSAIDs are contraindicated, the appropriate choice is

Acetyl salicylic acid is not the drug of choice for treatment of dental pain due to its interference with platelet aggregation and patients with heart disease receiving this drug should be treated

In patients with moderate dental pain, the analgesic of choice is a NSAID used in pharmacological full doses. NSAIDs can be individually administered or in combination with aniline derivatives, such as mefenamic acid and meclofenamic acid. In some patients where NSAIDs are not effective in combination with paracetamol, a weak opioid analgesic can be considered. The individual dose of ibuprofen is 400 mg, while that of the naproxen is 500–550 mg. In patients where pain is not controlled effectively, the addition of full dose of paracetamol is recommended. If pain is still present, the addition of weak opioid agents in full doses is

In patients with severe dental pain, the pharmacological treatment consists usually of combinations of strong opioid analgesics with high doses of NSAID agents, with or without aniline derivatives. In such patients, treatment of pain should be under close supervision of the dental doctor due to a higher probability of adverse drug reactions. The first choice of drug is hydrocodone 10 mg, oxycodone 5 mg, codeine 60 mg, or tramadol 50–75 mg. Due to high potential of abuse, tramadol is not the drug of choice for the treatment of severe odontogenic pain. In patients with unsatisfactory level of pain control, the combination of full dose opioid

nose and locate the primary source of pain [16].

114 Pain Relief - From Analgesics to Alternative Therapies

therapy [17].

paracetamol [18].

with precautions.

500–1000 mg of paracetamol.

advised, i.e., codeine 30 mg, hydrocodone 5 mg [19].

agents and NSAIDs is recommended [20].

There are several factors that play a crucial role in the selection of analgesic drugs in dental pain treatment including:


Experienced dental clinicians select a safe and effective analgesic therapy using individual drugs or different analgesic combinations to treat dental pain based on individual conditions. This selection in dental practice is not always simple due to numerous confounding factors related to the mechanism and clinical manifestation of pain [21].
