CATEGORY AUSTRALASIAN DENTIST 29 One of the most frequent areas of concern in dentistry is how to best use medicines for acute pain management. Dr Geraldine Moses, founding member of DAN and highly experienced clinical pharmacist, is well qualified to address these questions. In the 25 years she has worked with the dental profession, she has found that about 1 in 5 queries are about using medication to manage dental pain, and the most common among these are about how best to use paracetamol and ibuprofen. Questions are of two broad types: general and patient-related. When questions relate to a specific patient, it is necessary to share the patient’s medical and medication history so that their specific issues and current situation are taken into account to tailor the medicines appropriately. General questions are often asked just to update the dental professional’s knowledge. However, a growing concern is the need to resolve conflicting advice, which typically occurs as a result of today’s availability of too much health information! Ready access to resources such as Google, ChatGPT and other forms of AI often leads to information overload and also tempts untrained people to think they are experts. This makes it difficult for both health professionals and consumers to know who to believe. Accessing truly authoritative information from actual experts can resolve this situation. Following is some of the frequently asked questions Geraldine answers about pain management and their brief answers. When should paracetamol and ibuprofen be used on their own and or together? Therapeutic Guidelines Oral and Dental advises that mild to moderate pain can be adequately managed with either paracetamol OR ibuprofen, on their own. The choice between these two drugs depends on whether the pain is inflammatory in nature, in which case a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen is the drug of choice. However, paracetamol will be more appropriate in patients for whom NSAIDs are contraindicated, such as those with heart failure or renal impairment. Moderate to severe dental pain can be adequately managed with paracetamol and ibuprofen taken together. The two drugs should be taken simultaneously, not alternating. The problem with alternating is that you only get the effect of one drug at a time. When taken simultaneously, the two drugs have an additive effect, which produces greater analgesia than either drug alone and lasts longer, i.e. up to 8 hours per dose. Should the two drugs be taken in one tablet or will separate tablets suffice? Clinical trials have shown that giving paracetamol and ibuprofen in one tablet such as ‘Maxigesic’ or ‘Nuromol’ ensures the two drugs start working at the same time. In clinical practice, however, it is common to give the drugs via separate tablets while preserving their efficacy. In many ways, the choice between using combined or separate formulations depends on the patient. Combined formulations are more expensive than separate tablets, but some patients are more inclined to take the medication if they only have to swallow one or two tablets rather than two or four at a time. So, cost and adherence should be considered before prescribing. What is the best dose, one or two tablets of each? The manufacturer’s instructions for ‘Nuromol’ give a dose of just ONE tablet three times a day, whereas the dose of Maxigesic is 1-2 tablets every six hours. The reason for the lower ‘Nuromol’ dose is that the pre-marketing efficacy trials submitted to the TGA showed that TWO tablets containing ibuprofen 200mg and 500mg paracetamol gave only slightly greater pain relief than one tablet, and both doses lasted the same amount of time. So, the TGA arbitrarily decided to recommend just one tablet be the official dose to improve the risk profile while maintaining efficacy. No other regulatory agency in the world has done that. In other countries where ‘Nuromol’ is sold such as New Zealand, the recommended dose is 1-2 tablets 6-8 hourly. Do they need to be taken with food? It is a common misconception that NSAIDs need to be taken with food. In fact, both ibuprofen and paracetamol will have a delayed onset and reduced concentrations if taken on a full stomach. Moreover, there is no evidence that food improves the safety of these drugs. So they are best taken away from food to improve absorption but ultimately can be taken without regard to food, preferably with a glass of water to ensure they are well dissolved. When used as first-line treatment, should they be prescribed with opioids or not? Most guidelines recommend maximising analgesia on the first day of acute pain management, e.g. post-op pain, with the equivalent of 1000mg paracetamol and 400mg ibuprofen 3-4 times a day. But as the pain subsides, the dose can be reduced to a single dose of each, then down to just one drug alone less often… then cease. Following this regimen, opioid analgesics are rarely required. If an opioid is deemed necessary, a low dose of oxycodone can be added to the paracetamol and ibuprofen for a day or two. u For more information on how DAN can assist you and your practice, visit www.dentaladvicenetwork.com.au Helping dental professionals optimise medicines for pain management By Dr Geraldine Moses AM from the Dental Advice Network PROFILE
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