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Rivaroxaban is one of the new oral anticoagulants (NOACs). It has many potential advantages in comparison with Vitamin K Antagonists (VKA). It has a predictable anticoagulant effect and does not theoretically require biological monitoring. It is also characterized by less food and drug interactions. However, due to major risks associated with over- and under-dosage, its optimal use in patients should be carefully followed by health care professionals. The aim of this article is to provide recommendations for pharmacists on the practical use of Xarelto in its different approved indications. This document is adapted from the practical user guide of rivaroxaban which was developed by an independent group of Belgian experts in the field of thrombosis and haemostasis.

First, the fundamentals of impulse transmission and pain perception are revised. The role of the primary afferent nociceptors is explained. Dental pain is described as a form of acute pain and the mechanism of nociception is fundamental. Peripheral and central sensitization can evolve. The second part covers the pharmacological aspects. Local anesthetics reduce impulse transmission by interfering with the mechanism of normal depolarisation. Binding to specific receptors located at the nerve membrane, more specifically on the sodium channel, results in decreased or eliminated permeability to sodium ions and leads to interruption of nerve conduction. The different types of local anesthetics used in dentistry are discussed in more detail with respect to their physico-chemical characteristics and analgetic properties. The importance of factors such as lipophilicity, degree of protein binding and dissociation constant pKa are explained together with the clinical implications of pH and possible toxic effects. Failure of local anesthesia can be the result of problems with the administration of the product or can have a pharmacological basis. Injection of the anesthetic should take place in amounts large enough, with suitable volume and as close as possible to the nerve. When infection and inflammation are present, the intravascular resorption of the anesthetic will accelerate and the lowered pH influences diffusion negatively. Repetitive administration can induce the phenomenon of tachyfylaxis (decreased anesthetic effect).

The surgical stress can be defined as a complex array of neuroendocrine, haemodynamic, metabolic and inflammatory changes following surgical injury. These responses, when excessive, may contribute to increased postoperative morbidity and mortality. Thus a major endpoint of general anaesthesia is to protect the patient against the noxious stress response components. The different classes of anaesthetic or associated drugs are reviewed in this respect: sedative/hypnotics (barbiturates, etomidate, propofol, benzodiazepines), opioids, alpha-2 adrenergic agonists (clonidine), non-steroidal antiinflammatory drugs, intravenous local anaesthetics. Central and peripheral sensitization phenomenons--ie the sympathoadrenal response to surgery--might likely be efficiently attenuated by preemptive analgesia, and/or well-designed computer-guided total intravenous anaesthesia. 119 references complete this review.