dr. Ken Wirastuti, MKes, Sp.

S
Bagian Ilmu Penyakit Saraf
Fakultas Kedokteran-Universitas Islam Sultan Agung
 Definisi Nyeri
“…Pengalaman sensorik dan emosional yang
tidak menyenangkan yang berkaitan dengan
kerusakan jaringan potensial atau aktual.

International Association for Study of Pain (IASP)

 Rasa nyeri : persepsi subyektif  respons
individual-sangat bervariasi
 stimulus sama  intensitas nyeri dpt
berbeda
 Nyeri : seringkali merupakan keluhan
utama yg membawa pasien ke dokter
 Nyeri terutama yg sedang /berat/akut
seringkali disertai anxiety  ↑ TD,
berdebar,↑ kortisol plasma, kontraksi otot
 Epidemiologi Nyeri
 Incidence
 15-20% nyeri akut karena tindakan operasi atau trauma
 Nyeri kronik persistent: 25-30%
 Penyebab disabilityas pada usia<45 tahun
 Nyeri wajah/rahang: 20 juta
 Beban finansial
• Managemen yang tidak adekwat
• Hilangnya hari-hari kerja
 Konsekuensi:
 Mengakibatkan penderitaan bagi penderita
 Disfungsi fisik / psikososial
 Immunosuppression
Lima Dimensi Nyeri

1. Sensory = mengenali nyeri

 Pattern, area, intensity, nature (PAIN)

2. Affective = respon emosional

 Marah, takut, depressii, cemas
 Mengganggu kualtas hidup (QOL)

3. Behavioral = perilaku yang tampak atau

dalam mengendalikan nyeri
 facial expression, posturing, ADLs
4. Cognitive = beliefs, sikap, memori, dan arti
nyeri
 Strategi menghadapi nyeri
 Menentukan tujuan/harapan pasien

5. Sociocultural = demografi, dukungan,

peran sosial, budaya
 usia, jenis kelamin, pendidikan
 Keluarga bisa berperan sebagai
penjaga/pelindung
 Klasifikasi Nyeri
Somatic
Nociceptive
Pathophysiology Visceral

Neurophathic
Non Nociceptive
Psychogenic

Acute: < 3 months

Duration
Chronic: > 3months - < 6
months
Classification of Orofacial Pain
Orofacial pain:
Intracranial/vascular pain
Neurovascular pain (primary headache)
Secondary headache related to disease/substances
Neurogenic/neuropathic pain
Paroxysmal pain disorders
Continuous pain disorders
Extracranial pain disorders
Eye, ear, nose, and throat
Intraoral pain disorders
Teeth and periodontal tissues
Mucogingival tissues
Tounge
Salivary glands
Musculoskeletal pain disorders
Cervical disorders
Temporomandibular disorders

American Academy of Orofacial Pain (AAOP), 1996

 Urgent dental problems most often
involve acute orofacial pain and may
originate from:

► Teeth ► Lymph nodes

► Periodontium ► Paranasal sinuses

► Mucosa ► Salivary glands

► Muscle ► TMJ’s

► Bone

► Blood vessels
 Acute Orofacial Pain

SOMATIC NEUROPATHIC

SUPERFICIAL
DEEP

VISCERAL MUSCULOSKELETAL
Pulp
Blood Vessel Periodontal Ligaments
Glands Joints
Visceral Mucosa Muscles
Ears Bone
 TOOTHACHE PAIN
Toothache of odontogentic origin can be visceral
(pupal) or musculoskeletal (periapical or
periodontal).
 When the pulp is exposed to a noxious
stimulus, there is a reactive inflammatory
response.

 The resulting edema is unable to expand

because of the surrounding inflexible cementum
→ ↑ tissue pressure and ↓ blood flow that
causes damaging effects to the pulp.
Primary Odontogenic Pain

Odontogenic toothache arises from

pulpal tissue
or
periapical tissue
with general characteristics that indicate
the tissue of origin.
Characteristics of Pulpal & Periapical
Pain
Pupal Pain Periapical Pain
(Deep, Somatic, (Deep, somatic,
Visceral) Musculoskeletal)

Masticatory function
Not stimulated by Stimulated by biting,
(Biomechanical
stimulation)
biting, chewing, or chewing, or percussion
percussion

Localization Frequently difficult to Usually can localize

localize specifically precisely

Usually precedes Usually follows pulpal

Sequence pain (unless periodontitis,
periapical pain
hyperocclusion, bruxism)
Classification of Toothaches of Odontogenic Origin
► Pulpal disease
 Reversible pulpitis (brief, stimulated pain)
 Irreversible pulpitis (prolonged, stimulated or spontaneous pain)
 Necrotic pulp (prolonged or spontaneous pain, no response to pulp
testing, sensitive to percussion)
► Periapical disease
 Acute apical periodontitis (sensitivity to percussion)
 Acute apical abscess (sensitivity to percussion, swelling, pus)
 Chronic apical periodontitis (often asymptomatic, periapical
radiolucency)
► Heterotopic pain
 Projected pain (pain in adjacent teeth)
 Referred pain (pain in teeth in opposing arch)
 Classification of nerve fibres

Avg.  Avg. C.V.

Type Function
(m) (m/s)
A Primary muscle-spindle afferent, motor
15 70-120
to skeletal muscles
A Cutaneous touch and pressure afferents 8 30-70
A Motor to muscle spindles 5 15-30
A Cultaneous temperature and pain
<3 12-30
afferents
B Sympathetic pre-ganglionic 3 3-15
C Cutaneous pain afferents, sympathetic
1.0 0.5-2
post-ganglionic(unmyelinated)
 Reseptor: alat penerima rangsang
 Rangsang yang bersifat nyeri disebut noxious
 Reseptor nyeri disebut nosiseptor  berupa
ujung-ujung saraf bebas
 Terutama serabut C and Aδ
 Serabut C tidak bermyelin dan diaktivasi oleh
stimuli kimia, termal, dan mekanik
 Serabut Aδ bermyelin dan kecepatan
hantarnya 25 X lebih cepat dari pada serabut C;
diaktivasi oleh stimuli mekanik dan termal.
 Struktur Somatic banyak mengandung serabut
Aδ dan serabut C vs struktur visceral terutama
mengandung serabut C
 Aktivasi serabut Aδ  first pain: menimbulkan
sensasi nyeri yg cepat, tajam , terlokalisasi
 Aktivasi serabut C second pain:sensasi nyeri
yg lama, nyeri tumpul, terbakar, intense,
menyebar
 Nociceptive vs Neuropathic Pain

Neuropathic Pain Mixed Pain Nociceptive Pain

Pain initiated or caused by a Pain with Pain caused by injury to
primary lesion or dysfunction neuropathic and body tissues
in the nervous system nociceptive (musculoskeletal,
(either peripheral or components cutaneous or visceral)2
central nervous system)1

Examples Examples Examples

• Peripheral
• Post-herpetic neuralgia • Low back pain with Somatic tissue (bone, joint,
• Trigeminal neuralgia radiculopathy muscle, skin,
• Diabetic peripheral neuropathy • Cervical connective tissue
• Post-surgical neuropathy radiculopathy • Aching, Throbbing
• Post-traumatic neuropathy • Cancer pain • Well localized
• Central • Carpal tunnel Visceral tissue
• Post-stroke pain syndrome • Arises from
• Common descriptors2 internal organs
• Burning Poorly localized
• Electrical
• Sudden, intense Common descriptors2
• Hypersensitivity to touch or cold • Aching
1. International Association for the Study of Pain. IASP Pain Terminology. • Sharp
• Throbbing
2. Raja et al. in Wall PD, Melzack R (Eds). Textbook of pain. 4th Ed. 1999.;11-57
Differences Between Nociceptive and Neuropathic Pain
 Acute vs Chronic Pain

Characteristic Acute Pain Chronic Pain

Cause Generally known Often unknown

Duration of pain Short, Persists after healing,

well-characterized 3 months

Treatment Resolution of Underlying cause and

approach underlying cause, pain disorder; outcome
usually self-limited is often pain control, not
cure
Differences between Acute and Chronic Pain
Karakteristik nyeri akut dan kronis
 Effects of acute pain:

 Neuroendocrine response to stress

 Increased metabolic rate
 Increased cardiac output
 Impaired insulin response
 Increased retention of fluids
 Increased risk for physiologic disorders
 Decreased deep breathing and mobility
 Effects Chronic Pain:

 Suppressed immune function

 Resultant increased tumour growth

 Depression and lack of motivation

 Anger

 Fatigue
 Substances that stimulate the
norciceptors:
 Bradykinin: a powerful vasodilator
that increases capillary permeability
and constricts smooth muscle. Plays
a role in chemistry of pain at site of
injury.
 Histamin
 Postaglandins: hormone-like
substances that send additional pain
stimuli to CNS
 Serotonin
 Substance P: believed to act as a
stimulant at pain receptor sites and
may influence inflammatory response
 Transduction
 Transmission
 Perception
 Modulation
 Mechanism of action
Perception

Modulation

Transmission

Transduction
27
 Bagaimana mekanisme
nyeri nosiseptif?
Stimulasi
• sebagian besar jaringan dan organ diinervasi
reseptor khusus nyeri  nociceptor -> yang
berhubungan dengan saraf aferen primer dan
berujung di spinal cord.
• Jika suatu stimuli (kimiawi, mekanik, panas) datang
 diubah menjadi impuls saraf pada saraf aferen
primer  ditransmisikan sepanjang saraf aferen ke
spinal cord  ke SSP.
 Transmisi dan persepsi nyeri
 Transmisi nyeri terjadi melalui serabut saraf aferen (serabut nociceptor),
yang terdiri dari dua macam:
 serabut A-δ (A-δ fiber)peka thd nyeri tajam, panasfirst pain
 serabut C (C fiber)peka thd nyeri tumpul dan lama second pain
contoh : nyeri cedera, nyeri inflamasi
 Mediator inflamasi dapat meningkatkan sensitivitas nociceptor
ambang rasa nyeri turunnyeri
Contoh:
 prostaglandin, leukotrien, bradikininpada nyeri inflamasi
 substance P, CGRP (calcitonin gene-related peptide)pada nyeri
neurogenik
 Persepsi nyeri
 Setelah sampai di otaknyeri dirasakan secara sadar menimbulkan
respon: Aduuh ..!!
 Modulasi Nyeri

• Nyeri yg ditimbulkan oleh stimulus yg

sama sangat berbeda pada situasi
dan individu berbeda
• Atlet fraktur berat hanya merasakan
nyeri ringan
• Saat perang prajurit tidak/ kurang
merasakan nyeri akibat injury
• Sugestiefek analgetik (Efek plasebo)
Jalur nyeri ascending:
tr. spinotalamikus kontralateral yg menuju
ke talamus kontraleteral , melalui medulla,
pons dan midbrain bagian lateral
Dari talamus axon diproyeksikan ke cortex:
somatosensory: lokasi,intensitas.
cingulate gyrus dan lobus frontalis :
berhub.dg afektif atau respons emosional 
takut
Neuroanatomy Orofacial Pain
 Pain T-C-BG

Thalamus
third
order
neuron
5 C2
4 IntN
ACH
NE
3 MSN 5HT
2
C3
1
1
C2 2
C4
C3 snC 3 second
4 order
neuron

Nociceptive / Fatigue Barrages 5

Neurogenic Inflammation
 Problem KliniK Orofacial pain:
 Prevalensi meningkat
 Akut  kronis
 Problem Aktifitas fisik
 Problem psikologi: depresi, cemas.
 Gangguan tidur
 Ketergantugan obat
 Penggunaan bermacam-macam obat  ES obat.
 Costly
 Quality of Life
 Problem sosial