NYERI JARINGAN KERAS

OROMAKSILOFASIAL

Kenali dan bagaimana

mengatasi pasca operasi gigi

Mohammad Gazali, drg, Sp.BM (K)., MARS

 PENDAHULUAN
• Nyeri (International Association for the Study of Pain)
adalah pengalaman sensori dan emosi yang tidak
menyenangkan dimana berhubungan dengan kerusakan
jaringan atau potensial terjadi kerusakan jaringan.
• Nyeri adalah pengalaman kompleks yang terdiri dari
sensasi tertentu dan reaksi yang ditimbulkan sensasi
tersebut
• Nyeri adalah pengalaman menyusahkan yang terkait
dengan kerusakan jaringan aktual atau yang bersifat
potensial dengan komponen sensorik, emosional, kognitif,
dan sosial

• Anne-Priscille Trouvin, Serge Perrot. Best Practice & Research Clinical Rheumatology. New concepts of pain. Journal Elsevierhealth. 2019. P: 2.
• Becker, Daniel E. "Pain management: Part 1: Managing acute and postoperative dental pain." Anesthesia progress 57.2 (2010): 67-79.
• Williams, Amanda C. de C., and Kenneth D. Craig. "Updating the definition of pain." Pain 157.11 (2016): 2420-2423.
PENDAHULUAN

70,4% kunjungan pasien ke dokter gigi disebabkan oleh dentai pain

Nyeri post ekstraksi yang dirasakan pasien sebesar 81.8%
Nyeri yang tidak diobati memiliki dampak besar pada kualitas hidup
dan dapat memiliki konsekuensi secara fisik, psikologis, sosial, dan
ekonomi
Di Amerika total biaya tahunan perawatan kesehatan karena nyeri
berkisar dari $ 560 miliar hingga $ 635 miliar
Pain management and assessment telah menarik banyak perhatian
karena prevalensi dan perawatannya yang rendah
 PENDAHULUAN

Wilgers, M. R. "Pain management." (2018).

 3-D’S’ PRINCIPLE TO MANAGE PAIN IN DENTAL PRACTICE.

Papirus

dental treatment

drugs.

Hargreaves, K., and P. V. Abbott. "Drugs for pain management in dentistry." Australian dental journal 50 (2005): S14-S22.
 PERSENTASE PASIEN DENGAN NYERI AKUT

Goranka Prpić-Mehičić et al. Odontogenic Pain. Rad 507. Medical Sciences, 34(2010):43-54
 PERSENTASE PASIEN DENGAN NYERI KRONIS

Goranka Prpić-Mehičić et al. Odontogenic Pain. Rad 507. Medical Sciences, 34(2010):43-54
 HUBUNGAN NYERI TMJ DAN NYERI KEPALA

Romero-Reyes, Marcela, and James M. Uyanik. "Orofacial pain management: current perspectives." Journal of pain research 7 (2014): 99.
 AKIBAT DENTAL PAIN

Constante HM et al. Socio-demographic and behavioural inequalities in the impact of dental pain among adults: a population-based study. Community Dent Oral Epidemiol 2012;
40: 498–506
 OROFACIAL
PAIN

Lund, James P., et al. Orofacial Pain: From Basic Science to Clinical Management. 2001.
 CLASSIFICATION OF PAIN

Acute Pain Chronic Pain

Pain lasting <30 days1 Pain lasting >3 months1

Sudden onset Persists although the original cause is not clearly
Severe in intensity present2
Pain plus anxiety May be the result of inadequately treated acute pain2

Arises as a result of tissue injury that May recur due to the presence of noxious
stimulates nociceptors and generally stimuli or repeated exacerbation of injury1
disappears when the injury heals1 Affects lifestyle, attitudes, and behavior2

Treatment includes NSAIDs (mainstay of Treatment includes acetaminophen,

therapy), opioids, and local anesthetic NSAIDs, selective COX-2 inhibitors,
analgesics3 opioids3

WHO guidelines on the pharmacological treatment of persisting pain in children with mental illnesses. 2012; 2Thomas MA. Oschner J 2003;5:15-21;
 CLASSIFICATION OF PAIN

Nyeri nosiseptif Nyeri Neuropatik

Tissue injury Nerve injury

Visceral Pain Neuropathic Pain

Somatic Pain Due to organs lesion. Central: Post stroke, spinals injury,
Due to lesion at skin, ex: appendicitis, kidney Multiple Sclerosis
muscle, joint & bone. stone, myocardial Peripheral: post-herpetic neuralgia,
ex: OA, RA, Gout, AS infarction nephropathy diabetic

localized unlocalized burning sensation

WHO guidelines on the pharmacological treatment of persisting pain in children with mental illnesses. 2012; 2Thomas MA. Oschner J 2003;5:15-21;
 SEL SARAF

Stanley F. Malamed, DDS.Handbook of Local Anesthesia. 7thed. 2020. P: 4

 PAIN PATHWAY

Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049.
 FISIOLOGI NYERI
PERSEPSI

Terdapat empat proses tersendiri:

1. Transduksi
2. Transmisi
3. Modulasi
4. Persepsi. TRANSDUKSI
MODULASI

TRANSMISI

Stanley F. Malamed, DDS.Handbook of Local Anesthesia. 7thed. 2020. P: 4

Guidelines for the management of acute pain in emergency situations. EUSEM. 2020.
 PATOFISIOLOGI NYERI

Stanley F. Malamed, DDS.Handbook of Local Anesthesia. 7thed. 2020. P: 4

Guidelines for the management of acute pain in emergency situations. EUSEM. 2020.
 SKEMA PULPA SEHAT DAN INFLAMASI

DENTAL PAIN

Add Text
Simple
PowerPoint

Dan-Krister Rechenberg et al. Biological Markers for Pulpal Inflammation: A Systematic Review. PLOS ONE November 29, 2016
 PERIPHERAL SENSITIZATION

Decosterd, Isabelle, and Clifford J. Woolf. "Spared nerve injury: an animal model of persistent peripheral neuropathic pain." Pain 87.2 (2000): 149-158.
 CENTRAL SENSITIZATION

Welty-Wolf, Karen E., et al. "Coagulation and inflammation in acute lung injury." Thrombosis and haemostasis 88.07 (2002): 17-25.
PATHOGENESIS OF POSTOPERATIVE PAIN

•Tissue damage Nociceptive

surgery •Inflamed tissue input
CONSEQUENCES OF POST OPERATIVE PAIN
Physiological Physiological/emotional
disturbances disturbances

• Sympathetic overactivity • Fear

• Anxiety
• Tachycardia, hypertension • Apprehension
• Increased cardiac work
• Increased oxygen consumption, etc

Suffering
• Respiratory dysfunction
• GIT dysfunction  ileus
• Renal suppression  oligouria Pain behavior
• Immunosuppression
(chronic pain)
• thromboembolic

Increases morbidity
and mortality
 VITAL SIGN POST OPERATIVE

Pulse Blood Pressure

Temperature Respiratory Rate

American Pain Society (APS) has redefined PAIN as the 5th vital sign
 PAIN EXAMINATION

Relieving and
Timing (onset, Location and
Quality and aggravating factors
duration, and radiation (within
severity. (effect of hot, cold
periodicity) nerve distribution).
sweet foods, etsc)

Associated factors Other pain conditions Impact of pain (sleep,

(headaches, migraines, mood, concentration,
(taste, salivary flow,
chronic widespread fatigue, beliefs, and
clenching, bruxing quality of life)
pain, and fibromyalgia)
habits, etc)

J. M. Zakrzewska et al. Differential diagnosis of facial pain and guidelines for Management. British Journal of Anaesthesia 111 (1): 95–104 (2013)
 PAIN EXAMINATION
• Tongue
• Buccal mucosa
• Floor of the mouth
• Hard palate
• Teeth and periodontal tissues
• Tonsils
• Temporomandibular joints
• Airway
• Ears
• Salivary glands
• Lymph nodes
J. M. Zakrzewska et al. Differential diagnosis of facial pain and guidelines for Management. British Journal of Anaesthesia 111 (1): 95–104 (2013)
 PAIN EXAMINATION

Pulp Percussion
Probing
sensitivity test test

Radiographic
Mobility test Palpation
examination
 PENILAIAN NYERI

Wong Baker faces

pain rating scale

Numeric Rating Scale

VAS

Eko Arisetijono, Maclhusil Husna, Badrul Munir, Dessika Rahmawati . Counting Neurology Education 4 Vertigo dan Nyeri. 2015. Hal: 5
Pain Management Guideline. Best Practice Committee of the Health Care Association of New Jersey. 2006. p: 16.
 FLACC

Eko Arisetijono, Maclhusil Husna, Badrul Munir, Dessika Rahmawati . Counting Neurology Education 4 Vertigo dan Nyeri. 2015. Hal: 5
Pain Management Guideline. Best Practice Committee of the Health Care Association of New Jersey. 2006. p: 16.
TATALAKSANA NYERI
 CYCLOOXYGENASE PATHWAYS

Korbecki, Jan, et al. "Cyclooxygenase pathways." Acta Biochimica Polonica 61.4 (2014).
 TUJUAN TATALAKSANA NYERI

Prevention and Goals for pain management

control of pain that Goals should be:
facilitates function
and quality of life
• Specific
• Measurable
• Patient centered
may include the patient
expressing:
• Adequate pain relief
• Minimal side effects from
the analgesic regimen
• Maintenance or
improvement in functional
status
• Satisfaction with
pain management

UW Health – University of Wisconsin Hospital & Clinics, Madison, WI. Establishing Pain Relief Goals. Accessed November 2018.
 GOALS PAIN MANAGEMENT

Acute pain treatment goals

• Facilitate recovery from the Chronic pain treatment goals
underlying injury, surgery • Restore function
or disease • Decrease pain
• Control and reduction of • Correct the secondary
pain to acceptable level consequences of pain
• Minimize pharmacologic
side effects
Goals often differ for
• Prevent chronic pain
acute and chronic pain

UW Health – University of Wisconsin Hospital & Clinics, Madison, WI. Establishing Pain Relief Goals. November 2018.
PAIN MANAGEMENT
Pain management

Pharmacological1 Non-pharmacological2

Inflammatory pain Neuropathic pain Psychological Complementary

 Paracetamol  Anticonvulsants  Provide pre-operative  Massage

 NSAIDs (carbamazepine information  Aromatherapy
(diclofenac) and gabapentin)  Cognitive methods  Reflex zone
 Opioids  Tricyclic  Relaxation therapy
 Corticosteroids antidepressants  Distraction  Acupuncture
 SNRIs  Guided imagery  Shiatsu
 Corticosteroids  Humor  Therapeutic touch
 Opioids  Hypnosis  TENS
 Music
 Biofeedback

NSAIDs, non-steroidal anti-inflammatory drugs; SNRIs, serotonin and norepinephrine reuptake inhibitors; TENS, transcutaneous electrical nerve stimulation. Accessed June 15, 2015
 NON-FARMAKOLOGIS TERAPHY

Psyhological: Complementary:
• Provide preoperative • Massage
• Cognitive methods • Aromatherapy
• Relaxation • Reflex zone
• Distraction • Therapy
• Humor • Acupunture
• Hypnosis • Shiatsu
• Music • Therapeutic touch

Pain Management Guideline. Best Practice Committee of the Health Care Association of New Jersey. 2006. p: 6.
Eko Arisetijono, Maclhusil Husna, Badrul Munir, Dessika Rahmawati . Counting Neurology Education 4 Vertigo dan Nyeri. 2015. Hal: 5
 Farmakologis Teraphy
(WHO Pain ladder)

Step 2:

WHO Pain Ladder with Pain Management Guidelines _Jan 7_2011 Adapted from a CarePartners/ ET NOW form with permission 2010.
Eko Arisetijono, Maclhusil Husna, Badrul Munir, Dessika Rahmawati . Counting Neurology Education 4 Vertigo dan Nyeri. 2015. Hal: 3-4
PAIN MANAGEMENT
 MULTIMODAL ANALGESIA
Opioid

Systemic
Epidural
Subarach

Ketamin, Tramadol

Cox-2, Cox-3 Local anasthetic

Epidural
Subarachnoid
Peripheral nerve block
LA
COX-1
COX-2

Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049.
 KEUNTUNGAN MULTIMODAL ANALGESIA

Opioids •Reduced doses of each anal

gesic
•Improved pain relief due to
synergistic or
Potentiation additive effects
•May reduce severity of
NSAID (Cox1 & Cox2) side effects of each drug
Acetaminophen,
nerve block

Kehlet H et al. Anesth Analog. 1993;77:1048-1056.

MULTIMODAL ANALGESIA
 TATA LAKSANA NYERI

PASCA BEDAH DAN TINDAKAN PENCABUTAN GIGI

 RECOMMENDATION OF DENTAL PAIN MANAGEMENT

Mainly using NSAID,

Evidenced based, but
acetaminophen and
flexible opioid

Around the clock 48 hours is

recommended in post-
extraction, odontectomy, etc , if
needed. Which means the drugs
are remain administered within
48 hours although the pain is not
occur

Weinberg M, Fine J. Oral Analgesics for Acute Dental Pain. Dentistry Today. 2002 June.
Burgess J, Meyers A. Post Procedural Pain Management. In Pain Management in Dentistry. Medscape. 2012 Feb.
 NSAID Mechanism Of Action & Its side Effect

Reference: Cooper et al., 2019

 DICLOFENAC PROFILE

• Selektivitas inhibisi COX2

diklofenak tergolong pada
preferentially Cox-2

• Selektivitas ini membuat

diklofenak menjadi salah satu
NSAID yang memiliki resiko
efek samping gastrointestinal
lebih kecil dibanding NSAID
lain

Referensi: Warner and Mitchell, 2004

 DICLOFENAC PROFILE

Diclofenac Trusted in
many countries and thus
became the NSAID with
the highest use in 2011

Reference: McGettigan and Henry, 2013

 PROFIL DIKLOFENAK
• Diklofenak tersedia dalam 2 garam, natrium
dan kalium
• Kalium diklofenak lebih larut air dan memiliki
laju disolusi serta absorpsi lebih cepat dari
natrium diklofenak
• Hal ini menyebabkan kalium diklofenak
memiliki onset of action lebih cepat dari
natrium dikofenak, lebih baik untuk nyeri akut

Referensi: Ahmad et al., 2009; Chuasuwan et al., 2009

 SAFETY OF DICLOFENAC

The safety profile of

NSAIDs depends on the
COX1 and COX2 selectivity
of each drug

Reference: Antman Elliott M. et al., 2007

 DICLOFENAC-K WAS MORE EFFECTIVE THAN PARACETAMOL
THAN IBUPROFEN
For postoperative analgesia in adults who are having teeth extracted and deep cavities prepared under local anesthesia

A summary of the number of patients who requested rescue analgesics in paracetamol, ibuprofen,
and diclofenac potassium groups postoperatively

Reference: Giath Gazal & Khalid H. Al-Samadani., 2017

Reference: Hofele et al., 2006
Reference: Akbulut et al., 2014
Reference: Diener et al., 2006
 CATAFLAM EFEKTIF DALAM MENGURANGI NYERI PASKA
OPERASI GIGI
CATAFLAM® tablet mempertahankan peredaan nyeri yang signifikan lebih dari 8 jam

Reference: Hofele et al., 2006

 CATAFLAM FAST EFEKTIF MEREDAKAN NYERI PASKA OPERASI
GIGI
CATAFLAM FAST ® sachet menurunkan 80% nyeri paska operasi gigi dalam waktu 2 jam

Reference: Hofele et al., 2006

 CATAFLAM LEBIH EFEKTIF MEREDAKAN INFLAMASI
DIBANDINGKAN DENGAN NATRIUM NAPROXEN DAN ETODOLAC
CATAFLAM® tablet secara signifikan lebih efektif dalam mengurangi inflamasi paska operasi gigi dibandingkan naproxen sodium dan
etodolac

Reference: Akbulut et al., 2014

Terima Kasih