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In part 1, nonnarcotic drugs against pain for dental pain are discussed. Dentists use these medications to relieve mild to moderate oral pain. This article describes the narcotic medications. For moderate to severe dental pain, medications are typical:

•Tramadol (Ultram), 50 mg every 6 hours as needed for pain.

• Tramadol with acetaminophen (Ultracet, containing 37.5 mg of tramadol hydrochloride and 325 mg of acetaminophen), a table every 6 hours as needed for pain.

• Acetaminophen (Tylenol # 4, containing 60 mg of codeine phosphate and 300 mg of acetaminophen), a table every 4-6 hours as needed for pain.

For pain, opioid combinations are advised. For example, one Vicodin ES (10 mg 750 mg hydrocodone and acetaminophen) may 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 side effects opioidlike varies.

Although opioids as a class are effective for relieving dental pain, some commonly used formulas show poor efficacy for dental pain. Other drugs with fewer serious side effects can have similar results. For example, codeine alone has not been found as effective as other analgesics (acetaminophen and NSAIDs) for relief of dental pain. Oxycodone, hydrocodone and propoxyphene are about as effective as codeine. Dihydrocodeine, penta-and zocine meperidine show no advantages over codeine orally and may even be less effective. Their effectiveness in combination (combining opiods with acetaminophen and NSADs) is better than 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 the effect of tramadol is not mainly through narcotic mechanism. Tramadol, a nonscheduled drug. Serious side effects generally associated with opioids, such as dependence, sedation, respiratory depression and constipation, are less often with this medication. Tramadol has a low rate of abuse, about one per 100,000 persons. The side effects commonly seen with tramadol include nausea, dizziness, drowsiness and fatigue.

Tramadol in the absence of sedation is particularly important for the day of dental surgery. Tramadol does not have the same side effects as traditional NSAIDs or opioids. Side effects are usually 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 and post-dental pain killer. They also show that tramadol has a dose-response. For example, in one study they reviewed, tramadol 200 mg was more effective than 100 mg after third molar extraction. Unlike aspirin and acetaminophen with codeine, a pain that lasts for about four hours, tramadol provides analgesia for five to six hours after dental surgery.

Benzodiazepines are increasingly being used to reduce patient anxiety. Their sedative, “the reduction of anxiety” and “memory” properties, with their mild respiratory depression, are particularly useful for reducing the “view” of dental pain. By reducing the fear of dental treatment, the patient becomes less sensitive to painful stimuli.

Midazolam: Midazolam has the ability to decrease postoperative anxiety. It provides surgical amnesia (memory blockage) that lasts approximately 25 minutes. A multidrug combination of fentanyl, midazolam and metho-hexital (commonly used in intraveous sedation for wisdom teeth removal) gives better pain control but produced deeper sedation.

Treatment of anxiety related to dental procedures is most useful for children. Extreme preoperative apprehension May need more anesthesia and lead to postoperative negative effects. Oral midazolam has been shown significantly to the amnesia of the child when it is given10 minutes before surgery. Recent clinical trials of oral tramadol mixed with midazolam provides effective pain relief during and after surgery for children.

Diazepam: Diazepam is another useful benzodiazepine that treats oral pain associated with muscle spasms. However, its use is limited by the long-term sedation, the potential for abuse and dependence potential. Diazepam May have additive effects with other central nervous system depressants. Combinations of benzodiazepines and opioids are used widely for conscious sedation but are associated with significant risks. These combinations May be used under adequate cardiopulmonary monitoring.

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