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Pain and pain pathways

CONTENTS
Introduction History Levels of pain processing Neural pathways of pain Theories of pain Types of pain Measurment of pain Management of pain Studies References

The most fundamental and primitive sensation Pain impairs the lives of millions of people In 1984 Bonica reported that 1/3 of the worlds population suffers from pain of some etiology We dentists are concerned with teo of the most common pains:
1st Acute orofacial pain arising from teeth and associated structures 2nd Chronic orofacial pain , which is belived to account for 40% of all chronic pain problems

Responsibility of the dentist:


To identify the cause To treat ( by dental or multidiciplinary approach)

History
Root : from greek word Poin derived from latin Poena Dorlands Medical dictionary defined pain as A more or less localised sensation of discomfort ,distress or agony, resulting from stimulation of specialised nerve endings. It serves as a protective mechanism in so far as it induces the suferer to remove or withdraw from the source

An unplesant sensation associated with acute


or potential tissue damage and mediated by spefic nerve fibers to the brain wheere its conscious appreation may be modified by various factors Pressure to seek aid for pain increases when patient is under greater than usual stress Degerr of pain is not related to amount of injury. . . . . . But on attention given by patient

Levels of pain processing


Nociception Pain Suffering Pain behaviour

Pain is presently recognised as an experience rather than a sensation

Neural pathways of pain


Feilds has noted that subjective experience of pain arises from 4 distinct processes Transduction
Noxius stimuli electric activity in sensory neuron

Transmission
1st order neurons: sensory organ 2nd order neurons: spinal chord 3rd order; interaction spinal chord thalamus

Modulation Perception

Fibers carrying pain impuls:


A delta fibers:
Myelinated Mechanical stimulus

C fibers
Unmylinated Chemical and thermal stimuli

Theories of pain
Intensity theory
When sensation is beyond a level

Speficity theory
Spefic nociceptors + center in brain

Pattern theory
Nan specialised receptors; excitation thresholds, adaptation ranges,distribution of branches

Protopathic and epicritic theory


Primitive system + advanced system

Gate control theory


1965, Melzack and Wall Activity in several interacting neural pathways
Cells in substantia gelatinosa

Gate control system modulates efferent paterns before they influnce T cells Central control trigger activates areas in brain influnces modulating prop of GCS

Dorsal column fibers that project towards the brain

First central transmission (T) cells in spinal chord

Activates neural mechanism for perception - Threashold

Orofacial pain classification:


Axis I (Physical conditions) I. Somatic pain Superficial somatic pain
Cutananeous pain Mucogingival pain
Temporomandibularjoint pain Ligamentous pain Retrodiscal pain Capsular pain Arthritic pain Osseous /periosteal pain Soft connective tissue pain Periodontal dental pain Visceral pain Pulpal dental pain Vascular pain Neurovascular pain Visceral mucosal pain Glandular, ocular, auricular pain

Deep somatic pain


Musculoskeletal pain Muscle pain Protective co contraction Local muscle soreness Myofacial pain Myospasm Centrally mediated myalgia

II Neuropathic pain Episodic neuropathic pains


Paroxysmal neuralgia pain Trideminal neuralgia Glossopharyngeal neuralgia Geniculate neuralgia Superior laryngeal neuralgia Nervus intermidus Occipital neuralgia Neurovascular pain

Centrally mediated pain Burning mouth disorder Atypical odontalgia Postherpetic neuralgia Metabolic polyneuropathies Diabetic neuropathy Hypothyroid neuropathy Alcholic neuropathy Nutritional neuropathy

Continuous neuropathic pain


Peripherally mediated pain Entrapment neuropathy Deafferentiation pain Traumatic neuroma pain Neuritic pain Peripheral neuritis Herpes zoster

Axis II (psychologic conditions) Mood disorders Anxiety disorders Somatoform disorders Other conditions

Measurment of pain
Pain perception threashold (PPT) Severe Pain Threashold (SPT) Variability Scales for measurment
Category scale Rupee analog scale Numeric rating scale Visual analog scale

Visual analog scale:

Pain score

No pain 0- no pain 1 Probabaly no pin 2 Mild discomfort 3 Mild pain or discomfort 4 Mild to moderate pain 5 Moderate pain

10 cms

Worst possible pain

6 Increased moderate pain 7 moderate to severe pain 8 Severe pain 9 Severe to excruciating pain 10 Worst possible pain

Management of pain
Therupatic modalities: Pharmacologic therapy 1) Analgesic agents 2) Anesthetic agents 3) Anti inflamatory agents 4) Muscle relaxants 5) Antidepressants 6) Anti anxity agents 7) Vasoactive agents 8) Non epinephrine blockers 9) Antimicrobial agents 10) Antiviral agents

11) Antihistamine agents 12) Anticonvulsants 13) Neurolytic agents 14) Uricisuric agents 15) Dietary considerations Physical therapy 1) Modalities Sensory stimulation Ultrasonic Electrogalvanic stimulation Deep heat 2) Manual techniques Massage Spray and streach technique Exercise Physical activity Psychologic therapy 1) Counclling 2) Behaviour modification * Stress releiving training * Relaxation training * Physical self regulation

Analgesic agents:
Shouldnt eliminate pain. . . . But make it tolerable
Non narcotic analgesics: - 4 basic actions - Inhibition of COX
- PGs induce hyperalgesia

PG E2 formation

- Temperature in fever
- Inhibits PGE2 formation in hypothalamus

- Prolongs bleeding time


- Synthesis of platelet aggregator factor TXA2

- No tolerance, physical dependence - Have celing effect - Toxicity: gastric mucosal damage, bleeding, Renal blood flow, aggrevates Asthma &anaphylactoid reactions Eg: Asprin, Iboprofen, Ketoprofen (short t1/2) Nabumetone, naproxen (long t1/2) Acetaminophen (adv)

Most commonly used for acute dental pain Mild-moderate pain + inflamation : Paracetamol + low dose Iboprofen Post extraction pain : Ketorolac/ diclofenac / nimesulide/ asprin Gastric intolerance to NSAIDs: Celecoxib/ Raficoxib/ Paracetamol With history of asthma; anaphylaxis to NSAIDs: Nimesulide Children: only Paracetamol/ Asprin/ Ibuprofen(asprin in viral infections: Reyes syn) Pregnancy: paracetamol is safest; 2nd choice low dose asprin

Asprin dose: 300-500 mg TDS/QID


ASSPRIN, DISPRIN 350 mg tabS

Paracetamol: 500mg-1g TDS


CROCIN 500mg; 1g, METACIN,PARACIN 500mg tabs; CROCIN PAIN RELIF: paracetamol 650mg+ Caffine 50mg tabs

Diclofenac 50 mg TDS
VOVERAN, DICLONAC, MOVONAC 50 mg entric coated tabs

Celecoxib 100-200 mg BD
CELACT, REVIBRA 100mg 200mg caps

Narcotic analgesics - Act through CNS receptors. . . . . Induce peripheral analgesia - Depress nociceptor neurons - Have inhibitory influnce on release of substance P - Tolerance should be noted - May cause constipation, physical dependence, addiction, Acute morphine poisoning (R naloxone) - Should be given on strict time schedule - Used only for severe acute pain, chronic cancer pain - Eg ; morphine, codine, Pentazocine, Tramadol

Anesthetic agents : - For diagnostic and therupatic Topical anesthesia - Solutions / spraya / lozenges - Alovera juice inflamatory pain - Analgesic balms : Balsam of peru, eugenol, guaiacol . - Use
- Eg: Xylocaine 4% topical solution

- Topical LA mixed with other medication


- Eg: Peripheral neuropathy: lignocain + amitriptyline + Carbamazepine (Tegretol)

Injectable LA Low potency short duration: Procaine Intermediate Potency and duration: Lignocaine Prilocaine High potency, long duration : Tetracaine Bupivacaine Ropivacaine Mechanism of action: Reduces Na entry during AP depolarization dosent reach threashold no AP Rate of rise of action potential Lignocaine2% + adrenalin :commonly used pulpal anesthesia obtained in 2-3 mins; lasts for 40-60 mins Soft tissue anesthesia 2-3 hrs Analgesia may not be acheived in very sensitive teeth, marked inflamation Lignocaine10% spray: for impressions Bupivacaine 2% + adr 1: 200000 High lipid soluble- low bone penetration anesthesia in >5 mins lasts for <2 hrs. soft tissue anesthesia 8 hrs

Anti Inflamatory agents By inhibiting PGs Devar reported that locally applied steroid rapidly and eeffectively arrested pain Corticosteroids potent; but immune system Uses: reccurent oral ulcers; Phemphigus;erosive lichenplanus; pain from exposed dental pulp; Hydrocortisone may be injected into TMJ to relive refractory pain and stifness
Contraindicated in systemic fungal and herpes infections

Muscle relaxants - in myogenous pain - Potential agents (succinyl choline, methocarbamol) restricted to hospitalised pts
Anti depressants - In Chronic pain with depression - Tricyclic anti depressants action: availability of 5HT, norepinephrine, dopamine in CSF - Eg: low dose of amitryptaline before sleep on prolonged use reduces chronic pain ( nt acute pain) - Amitryptaline : post herpetic neuralgia - Newer antidepresants SSRIs eg: fluoxetine, venloflaxine

Antianxity agents
Reduces modulating effect of pain and apprehension Major tranquilizer : Phenothiazine Minor tranquilizers: Diazepam,Meprobamate Have muscle relaxant action also Potential for drug tollerance,dependence When used for analgesia best prescribed for limited period Clonazepam
Has analgesic effect in certain neuropathic pains Effective in burning mouth syndrome

Vasoactive agents:
In neurovascular pain Somatostatin has inhibitory action on substance P B adrenergic blockers are proven effective in phantom limb pain, migrane adrenergic blocking drugs( eg: ergotamine tartarate) : stimulating effect on b.v
Used in cluster headache

Caffine has enhancing effect on its action

Norepinephrine blockers:
Block reuptake of norepinephrine Block stellate ganglion : control of sympathetically maintained pains of orofacial region Guanethidine commonly used Also effective in rheumatoid arthritis

Antimicrobial agents
Reduce pain by resolving Intrinsic analgesic effect
Pain Long term therapy - only if infection present

Antiviral agents
Effective in primirary infection of HSV, HZV Eg Acyclovir, Famcyclovir
Famcyclovir effectively reduces all symptoms Drug of choice even in immunocompromised, HIV

Anti histamine agents


In allergic reactions and neurovascular pain Also has some analgesic effect Antihistamine + acetaminophen greater analgesia than acetaminophen alone

Anticonvulsants
Useful in neuropathic pain Eg: Carbamazepine- primary mediator in inflamatory pain Neuropathic pain also treated by: Gabapentin; oxycarbamazepine; Topiramate

Neurolytic agents
Treat pain by destroying neves Deafferentiation pain: Pain caused by destroying nerves Eg: 95% ethyl alchol (may not prevent regeneration of peripheral axons) Glecerol injected into retro gasserian spc for treating trigeminal neuralgia
It demyleanetes neurons responsible for trigeminal neuralgia

Uricosuric agents:
Used in hyperurecemia causing TMJ pain Colchicine: subsides acute attacks of gout and relives pain Probenicide: for for chronic gout arthritis
Acts by inhibiting reuptake of urates by kidney

Gout can involve TMJ

Dietary supplementation of L-tryptophan : elevated pain tollerence Tryptophan competes with other amino acids for passage across BBB 2% plasma tryptophan Tryptophan hydroxylase Vit B6 . Tryptophan Brady et al: 10 chronic pain patients included in study obtained pain relif by taking 4g of L tryptophan per day and consuming low-protein, low-fat, high carbohydrate diet for 8 weeks CNS seratonergic neurons are actively involved in nociceptive response Seltzer et al: reduction in clinical pain and elevated pain tolerance among randomly selected patients suferring from chronic maxillofacial pain as a result of 4 weeks tryptophan supplement therapy

Dietary considerations:

Physical therapy
Sensory stimulation Cutaneous
Trans cutaneous Percutaneous

Cutaneous stimulation Effect occurs by stimulation of thick mylinated afferents ; A- neurons chiefly Many forms of cutaneous stimulation effectively attenuate pain
Rubbing skin Superficial massage
With alchol, menthol

Counter irrigation Muster plaster Mixture of aconite + iodine : stimulation of nociceptive fibers : analgesic effect

Vapocoolant therapy
Useful in reliving myofacial trigger point pain Interrmittancy is esseential Act By stimulating cutaneous nociceptors and thicker A fibers Eg: ethyl chloride spray

Alternative applications of heat & cold for brief periods


Eg : moist heat application over painful areas. When heat isnt effective ice may be tried Infra red heat Warm saline moutwashes for pain relif after chord insertion for gingival retraction

Mechanical vibrations
Reported to give complete pain relif in 1/3 of patients with dental pain

Hydrotherpy
Especially in neck & back pain of muscle origin
Effect of warm saline mouth washes on reduction of pain after packing chord for gingival retraction ;J of Mashhad dentistry 2007

Transcutaneous stimulation
Low intensity current of high frequency Mild tingling vibration 50 70% pain relif Action is immediate , restricted to segment

Acupuncture
By stimulating endogenous antinociceptive system Electro acupuncture: low intensity, high frequency current Acupoints Stimulates muscle nociceptors anti nociceptive system Induction period: 15-20 mins. Effect segmental or generalised Acupoint of oral cavity: inte orbital bridge + Ho Ku point

Per cutaneous stimulation:


By electrodes that penetrate skin: Subcutaneous nerve stimulation
Prolonged analgesia, no tollerance Lawrence :
electric stimulation of perriosteum by insulated needles 9 122 V at 100-300 Hz for 45 mins Reported it was better than EA &TENS for chronic pain

Ultrasound
tissue temperrature at interrface
blood flow, seperates collagen fibers

Has better effect on deeper tissueskin Phonophoresis: ultrasound used to administer drugs through
Eg 10% hydrocortisone cream + Ultrasound

EGS:
Uses electric stimulation to cause muscle contracture
Repeated involuntary contraction+ relaxation of muscles

Help in breaking up myospasm and increasing blood flow to muscles Reported to yield good results in MPDS

Deep heat therapy


Phisiotherapy in form of penetrating heat Especially useful inflamatory pain In form of ultrasound and diathermy In myospasm and myofacial trigger point pain

Manual techniques: Massage:


Gentle massage Deep massage preceeded by 10 15 mins deep moist heat effective in releiving trigger point pain and relaxing muscles

Spray and streach technique


Muscle is streaxhed short of pain Vapocoolant is applied in parallel sprays in one direction travelling towards refrence area Procedure After 3 sweeps muscle is rewarmed After treatment moist heat applied and range of movement exercise done

Exercise
Forceful contraction of anagonist muscle causes reflex relaxation of agonist Used for treating masticatory muscle spasm
For mucle to maintain normal resting length occational stimulation of receptors is necessary

Studies
A study to determine prevelence of joint diseases in 2 forms of myofacial pain( with limited mouth opening and without) showed that patients with myofacial pain and limited mouth opening often had joint diseases that were not detected with clinical examination Study on modulation of myofacial pain by reproductive harmones showed that pain levels were constant when harmone levels were constant wheras they varied with harmone levels in nonusers Posture corrections when given along with cognitive behaviour intervention were seen to treat myofacial pain better

Maping of pressure pain threasholds (ppt) in edentulous mucosa showed that ppt from ant post alveolus but decreased from ant palate to post palate. Ppt reduced from ridge crest to buccal vestibule Another study conducted in 1993 showed that intraoral appliance (IA) was more effective than BF/SM in treating TMJ disorders with pain and depression but after 6 mnts IA group significantly relapsed wheras BF/SM maintained and continued improvement Neeraj Madan, ijdr, 2001 :Denture wearing patients with pain in oral musculature &tmj could be attributed to improperly recorded vertical jaw relations

O.gabbert 2005 : case report of pt who developed neuropathic pain after implant placement: underwent multiple RCTs, extraction, long term opoid therapy . Finally CT,MRI showed perforation of mandibular cannal by implant.

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