Analgesic prescription practice for pulpal pain— An institution-based retrospective study

Cinthura C1, Dhanraj Ganapathy*2, Arvina Rajasekar3 1Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai 600077, Tamil Nadu, India 2Department of Prosthodontics, Saveetha Dental College and Hospitals, Saveetha Institute of medical and technical sciences, Saveetha University, Chennai 600077, Tamil Nadu, India 3Department of Periodontology, Saveetha Dental College and Hospitals, Saveetha Institute of medical and technical sciences, Saveetha University, Chennai 600077, Tamil Nadu, India


INTRODUCTION
Patients visit dental institutions and private clinics complaining of swelling or pain, and often this pain is usually of odontogenic origin like extensive dental caries with or without pulpal involvement. Although most conditions are treated by conservative management, adjuncts like antibiotics or analgesics are indicated (Keiser and Hargreaves, 2002). Natural products like Aloe Vera also have good medicinal properties (Subasree et al., 2016). (Gupta et al., 2010;Ashok et al., 2014;Venu-gopalan et al., 2014) Pain is a complex sensation, and odontogenic pain is considered as a multi factorial experience that involves sensory responses with cognitive and emotional aspects (Sessle, 1986;Ashok and Suvitha, 2016;Ganapathy, 2016). Postoperative pain of mild intensity can rarely occur if the endodontic or conservative treatment had suitable standards (Cunningham and Mullaney, 1992;Kaushik and Kaushik, 2012). (Selvan and Ganapathy, 2016;Vijayalakshmi and Ganapathy, 2016) Drugs that relieve pain selectively by acting in the central nervous system or pain mechanism while the patient is conscious are called Analgesics. (Ajay et al., 2017;Jyothi et al., 2017) They are divided into two groups, namely Nonopioids or NSAIDs and Opioid analgesics (Becker and Phero, 2005). NSAIDs inhibit cyclooxygenase activity which leads to inhibition of prostaglandin and thromboxane synthesis. On the contrary, opioids have been misused and pose a well-recognised public health issue (Weekes, 2016). Recently lasers are being employed to reduce pulpal in lammation and pain (Metin et al., 2018). Culturing to know the de inite root cause for the pain is seldom done in routine practice.
Therefore, prescriptions are based on presumption from previously determined clinical, epidemiological data (Roda et al., 2007). Appropriateness of various analgesic compounds for the management of endodontic pain has been investigated, but insuf icient literature is available regarding the dose and the type of analgesic needed for different clinical scenarios to help in reducing pulpal pain (Dionne et al., 1983;Rousseau et al., 2002).
The necessity for larger sample study and methodologically sound trials to act as evidence was discussed in a Cochrane review (Fedorowicz et al., 2013).  Painful conditions can impact or affect the success rate of vari-ous restorative and prosthetic treatments. (Ranganathan et al., 2017) Management of pain is a crucial factor before undertaking prosthetic treatments (Basha et al., 2018;Kannan and Venugopalan, 2018;Duraisamy et al., 2019).

MATERIALS AND METHODS
A retrospective study was carried out by accessing the data of the Department of Endodontics of Saveetha Dental College and Hospital, Chennai, India using the colleges' patient management software from June 2019 to March 2020. Institutional ethical committee clearance was obtained for data retrieval and usage as needed for the study (SDC/SIHEC/2020/DIASDATA/0619-0320).

Figure 3: Bar graph depicting the association between type of clinic and the analgesics prescribed.
Patients who were prescribed analgesics for pulpal pain -pretreatment purpose, pulp capping, pain management, endodontic emergencies and multivisit RCTs were identi ied. Incomplete records and double entries were excluded from the study. For each patient, details about the type of analgesic prescribed, age, gender and clinic type (UG/PG) were collected.

Statistical analysis
Following the collection of data by non-probability sampling. Data were subjected to statistical analysis. Microsoft Excel 2016 data spreadsheet was used to collect data and later exported to the Statistical package for social science for Windows (SPSS version 20.0, IL, Chicago, USA). The distribution percentages were obtained, following which associations were assessed using Chi-Square tests.

RESULTS AND DISCUSSION
The inal data set consisted of 7989 patients who had analgesics prescribed to them for various reasons associated with pulpal pain. Table 1 represents the age groups associated with the highest prevalence of analgesics prescribed for pulpal pain to be within the range of 35-55 years (48.5%) and the least among the age group above 75 years (0.3%). Figure 1 presents a distribution of gender among patients who were prescribed analgesics for pulpal pain showing male predominance (52.3%). Figure 2 presents a graph representing the distribution of clinic type in which the patients were prescribed analgesics for pulpal pain showing UG clinics as the predominant type (85.57%). Table 2 depicts the distribution of Analgesics among patients with the complaint of pulpal pain showing commonly prescribed as Paracetamol (72.9%), followed by Paracetamol and Aceclofenac (10.9%), Aceclofenac (10.8%) whereas tramadol, paracetamol and ketorolac combinations were the least prescribed (0.1%). Figure 3 represents the association between the type of clinic and analgesics prescribed to the patient showing a signi icant trend (p=0.000). Blue depicts the Postgraduate (PG) clinics, and red depicts the Undergraduate (UG) clinics.
The data for this study was based on residents of Chennai seeking treatment at Saveetha dental college, Chennai. There is a dearth in the literature about studies assessing the association between analgesics prescribed and experience of the dentist in the given region. There was no sorting process, and all of the data available was included to avoid sampling bias. This study gives importance to the prevalence of use of analgesics for pulpal pain and its association with the clinic type or experience of the dentists.
In the present study (Table 1), patients between 35-55 years (48.5 %) were a higher number in visiting the dental clinics with complaints of pulpal pain and the least were patients above 75 years (0.3%). This was coherent with a study conducted by Gómez and García's, which concluded that patients above 40 years of age were those diagnosed with pulpal pathologies (Porcegué and Sánchez, 2006). This suggested that they had higher chances to visit dental clinics more often. The reduced incidence above the age of 75 years may be due to ageing that causes rapid loss of teeth and therefore reduced their need to visit a dentist.
Male predominance (52.3%) was observed among patients with pulpal pain (Figure 1). This result was consistent with a study conducted by Parejo Madén et al., showing higher rates of root canal treatments among the males (Maden et al., 2009). In a study by Appukuttan et al., he reported that more females suffered from a dental phobia in an India population (Appukuttan et al., 2015), which could be a reason for their lesser visits.
In the present study (Table 2), paracetamol was the commonly prescribed drug, and analgesics like ketorolac, diclofenac and aceclofenac were least prescribed than paracetamol. This was contradictory to the study by Maslamani M et al. in Kuwait, which showed higher use for diclofenac and ibuprofen (Maslamani and Sedeqi, 2018). Another study by Sarkar C et al. also showed higher use of ibuprofen (Sarkar et al., 2004). The difference in preference may be due to a change in geographical location and availability of the drug. Paracetamol is ineffective in its anti-in lammatory properties. It can also be toxic for patients with depleted glycogen stores and liver dysfunction, which may be the reason for its reduced use in the contradictory studies (Mittal et al., 2012). Opioids aren't prescribed in the study, and this can be because they lead to tolerance and dependence in the long term (Goodman et al., 1996).
Undergraduates prescribed more analgesics than postgraduates (Figures 2 and 3), and they mostly prescribed paracetamol (66.03%). In a study by Jayadev M, it was established that experienced dentists often prescribe analgesics only when the patient also had an elevated temperature, or only after a proper evaluation when compared to newer dentists (Jayadev et al., 2014). Another study in Nigeria, the respondents were those with less than ive years of experience, and they often prescribed paracetamol, and only a few knew about the adverse effects of this drug (Azodo and Umoh, 2013). In another study by Ravi Kumar Konagala et al. (Konagala et al., 2019), lesser experienced dentists prescribed more pretreatment medications. The aforementioned reasons are a few that explain the higher number of analgesic prescriptions given to the patients treated in the undergraduate clinics compared to the postgraduates.

CONCLUSIONS
Within the limitations of this study, it is observed that paracetamol has been the most prescribed drug despite its side effects. The male population was prescribed more analgesics than females, especially patients within the age range of 35 to 55 years. The undergraduate students prescribed analgesics frequently to their patients, and there exists a statistically signi icant association between the type of clinic and the analgesics prescribed. Extensive research has to be done to study the use of analgesics in clinical practice to build a guide which can be followed universally.