Contemporary
Pain Control in Endodontics
One
of the hottest topics in local anesthesia pain control is TTX-Sodium
Resistant Channels. The goal of local anesthetics is to
block sodium diffusion through the neuron cell membrane. Prior
opinion held that an increase in local pH, caused by inflammation,
resulted in inadequate anesthesia. Difficulties with clinical
anesthesia, may actually be caused by a change or an increase
in Sodium Resistant Channels. The so called TTX Resistant Channels. Sodium
Resistant Channels may be distant from the site of injection
(dorsal horn of the spinal cord and 1st and 2nd order neurons),
therefore local pH is not really a factor. Research is
on-going to identify specific TTX Resistant Channels that will
lead to specifically designed local anesthetics for patients
in severe pain. The current recommendation for TTX Resistant
Channel management is Mepivacaine (3% Carbocaine). TTX Resistant
Channels are less resistant to Lidocaine. So, try Mepivacaine
(3% Carbocaine) as your first anesthetic for patients presenting
in pain.
Some interesting facts from current research:
* NSAID/acetaminophen
combinations are very useful for dental pain when each alone
is inadequate. Try alternating acetaminophen 650-1000 mg every
three hours with ibuprofen 600 mg every three hours. In
other words, the patient is taking one of the two drugs every
three hours not to exceed the maximum daily dose for each drug.
One study reported that this regimen was more effective than
Vicodin.
* In
order for Codeine to be effective as an analgesic, the Codeine
has to be demethylated by the liver into morphine. Approximately
14% of Caucasians lack demethylating cytochrome mechanisms, so
Codeine is not an effective pain medication. How many of
your patients have claimed that Tylenol #3 doesn’t work
for pain control?
* Consider
the use of “fast acting NSAIDs” before administering
local anesthetics. ADVIL Liquigels combined with a first injection
with Mepivacaine (3% Carbocaine) is an excellent combination.
* Increasing
the dose of local anesthetics in blocks exposes a greater length
of the inferior alveolar nerve to the increased likelihood of
a conduction blockade. In this case “more is better” (but
not to the point of overdose).
* A
recent published review reported that naproxen (Aleve, Naprosyn,
Anaprox) is cardioprotective. Naproxen inhibits thromboxane
production by 95% and inhibits platelet aggregation by 88% suggesting
that naproxen has cardioprotective effects similar to aspirin.
Three studies reported that 275 mg of naproxen every 8-12 hours
decreases the incidence of myocardial infarction.
* Reduced
anxiety leads to reduced post-op pain. Memory of pain can be
predicted by the patient’s anxiety at the time of treatment.
Controlling you patient’s anxiety before treatment with
medication or just TLC is important to their post-op pain perception. Keeping
the patient out of pain for as long as possible after the procedure
reduces the “memory of pain”. Administer Marcaine
at the end of the procedure for longer lasting anesthesia and
more effective pain control.
Hargreaves KM, Keiser K. Local anesthetic
failure in endodontics: Mechanisms and management. Endo Topics
2002;1:26-39.
ESCONDIDO
ENDODONTICS 488 EAST VALLEY PARKWAY SUITE 307 ESCONDIDO, CA 92025
(760) 739-1400
FAX (760) 739-1100 www.escoendo.com
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