9. Challenges of dental pain management

indication that dosage choice is an important factor regarding its related combinations

Naproxen is indicated in toothache and its pain relief efficacy is comparable with ibuprofen. It is comparable with etodolac, but less effective in swelling when compared with diclofenac when they were used in oral surgical procedures, including postoperative third molar surgery or orthodontic pain [96–98]. Diclofenac is used in moderate to severe pain following third molar extraction and it could be used in an intravenous form in risk population groups such as the elderly and renal insufficiency, postoperative anticoagulation which uses ketorolac as the only choice for the moderate to severe acute pain. Very similar effects were shown when transdermal diclofenac patches were used compared to oral administration

Due to safety concerns COX-2 selective inhibitors have been introduced as a safe alternative in dentistry practice with superior analgesic and inflammatory conditions in periodontal diseases and after oral surgery procedures. Etoricoxib and celecoxib groups were shown to be comparable to ibuprofen on its efficacy in the dental pulpal pain or postoperative pain relief, third

Their use is favorable in patients with upper-GI-complications, in the aspirin user for cardiovascular comorbidities, or those allergic to aspirin and perioperative settings due to their lack of properties over blood clotting. But they are limited to be used in such short periods including postoperative periods due to their cost effectiveness compared to other NSAIDs. Also, their long-term uses in the painful temporo mandibular joint disorders and chronic orofacial pain in the patients without cardiovascular risk factors could be considered as

NSAIDs display major interactions when used alongside anticoagulant and antiplatelet effects of warfarin and clopidrogel, which results in enhancement of their effects and increased risk of bleeding. In this situation acetaminophen is an appropriate choice at the lowest possible dose, in short-term treatment only. Ibuprofen use in patients taking cardioprotective aspirin does not interfere with its antiplatelet activity, even though there are studies that demonstrate reduced cardioprotective benefits and increase gastrointestinal risk, in contrast to diclofenac or acetaminophen which did not influence effects of aspirin on platelet function [86]. Moreover, patients taking daily aspirin for cardiovascular disease prevention should avoid chronic use of ibuprofen and FDA recommends taking ibuprofen in intervals of more than 8 h before or more than 30 min after the immediate release of aspirin to reduce potential interaction in platelet function [40]. Concurrent use of NSAIDs with warfarin or corticosteroid may increase gastrointestinal risk. They also increase the risk of gastrointestinal ulceration in concomitant use with biphosphonates. Effects of antidiabetic sulfonylureas are increased with

molar surgery but superior toacetaminophene [101–103].

8. Significant drug interactions of analgesics

another therapeutic option [41, 104].

128 Pain Relief - From Analgesics to Alternative Therapies

coadministration of NSAIDs.

[93–95].

[99, 100].

Safe and effective dental pain management strategy requires an understanding of several factors. Pain is perceived differently by individual patients, depending on their biogenetic profile, gender, age, sociocultural attitudes, comedical and psychiatric conditions and several other factors [110]. Due to ethical consideration there are limited scientific data for drug efficacy in dental pain management and this is why it is important to challenge the work of clinicians in daily clinical practice. Dental clinicians assign a comprehensive practice that involves the pharmacological, biological and psychosocial aspects of pain management in order to ensure effective low risk pain treatment. Therefore, they need to implement and coordinate the extrapolated evidence base, knowledge, personal clinical experience and close monitoring of patients to achieve the effective balance of pain treatment in dental patients [11]. In general more attention should be paid by dental practitioners to reducing opioid drug abuse and monitoring of prescription and nonprescription uses of analgesics, improvement of drug choice alone or in combination, new analgesic alternatives and adjustment in course of treatment according to clinical needs. Also, individualization of therapy and dosage needs to be done carefully in the risk groups mentioned above, coupled with the need for adequate monitoring of drug interactions.
