PHYSIOLOGY OF PAIN

Saturday, February 25, 2023 1:51 PM

FACTORS AFFECTING INDIVIDUAL'S PAIN THRESHOLD 2. TRIGEMINAL PATHWAY: is the principal sensory nerve of the
head region.
Age older individual tends to tolerate pain and thus • Noxious stimuli from the face area are transmitted in the nerve
have a higher pain fibers originating from the nerve cells in the trigeminal ganglion as
reaction threshold well as cranial nuclei VII, IX, X.

Racial and Nationality VII FACIAL FACIAL EXPRESSION

characteristics
IX GLOSSOPHARYN TASTE, SENSATION, SWALLOWING
GEAL
Sex it is generally considered that men have a
X VAGUS SWALLOWING, SPEAKING,
higher pain reaction threshold than woman
SENSATION, TASTE
Fear and Apprehension pain reaction threshold is lowered as fear and
apprehension increase

• Nociceptors are unspecialized free unmyelinated nerve endings that

convert (transduce) a variety of stimuli into nerve impulses, which the
brain Interprets to produce the sensation of pain.
• The nerve cell bodies are located in the dorsal root ganglia, (for the
trigeminal nerve in the trigeminal ganglia) and trey send one nerve fiber
branch to the periphery and another into the spinal cord or brainstem.

2 types of nerve fibers:

a. small-diameter (C fibers) unmyelinated The C-fiber nociceptors
nerves that conduct the nerve impulse respond poly modally to:
slowly(2m/sec=7.2 km/h) 1. thermal
2. mechanical
3. chemical CONTROL OF PAIN
• One of the most important aspects of dentistry is the elimination of
pain
b. larger diameter( Aδ fibers/alpha-delta) Aδ-fiber nociceptors
lightly myelinated nerves that conduct nerve respond to METHODS OF PAIN CONTROL
impulses faster (20 m/sec = 72 kmh) 1. mechanical 1. REMOVING THE CAUSES
2. mechanothermal • The desirable method of controlling pain
Ab-fiber nociceptors ○ This method of pain control clearly affects PAIN
produce the sensation PERCEPTION
of: 1. sharp • Removal of the nerve fiber of the tooth which causes the pain
2. fast but not the tooth structure as a whole.
• C-fiber nociceptors produce the sensation of the delayed, dull pain • Not solved always by “extraction”
(applicable to toothache) • i.e., dental caries

Sensation of pain is made up of two categories:
1. epicritic, an initial fast, sharp pain (Aδ-fibers)
2. protopathic, a later slow, dull, long-lasting pain (C fibers)
EPICRITIC
• the precise nature and degree of a stimulus as light touch and moderate
temperature would be appreciated
• relating to or denoting those sensory nerve fibres of the skin that are
capable of fine discrimination of touch or temperature stimuli.
PROTOPATHIC
• There was a fairly rapid return of painful sensation with awareness of
extremes of temperature and diffuse localization
• relating to or denoting those sensory nerve fibres of the skin which are
capable of discriminating only between relatively coarse stimuli, chiefly
heat, cold, and pain
PAIN SENSATIONS COULD ARISE DUE TO:
1) INFLAMMATION OF THE NERVES: e.g., temporal neuritis
2) INJURY TO THE NERVES AND NERVE ENDINGS WITH SCAR
FORMATION e.g., surgical damage or disk prolapse
3) NERVE INVASION BY CANCER: e.g., brachial plexopathy
• common among elderly patient; other
4) INJURY TO THE STRUCTURES IN THE SPINAL CORD,
THALAMUS, OR CORTICAL AREAS THAT PROCESS PAIN
INFORMATION, WHICH CAN LEAD TO INTRACTABLE PAIN:
deafferentation
e.g. spinal trauma
⎯ Spinal cord is a very big trunk of your nerves, therefore if it is injured it
can lead to intractable pain ( described as severe, unbearable;
deafferentation: asymptomatic/ numbness of some part of the
2. BLOCKING THE PATHWAY OF PAINFUL IMPULSES
• The most widely used method in dentistry
• Suitable drugs possessing local analgesic properties is injected
• Block stimulus in the brain
• By administering anesthetic solution
• Administer LA above the apical area of the tooth in order to
block the stimulus/pathway between the pain and the brain
3. RAISING THE PAIN THRESHOLD
• Depends on the pharmacological action of drugs possessing
analgesic properties
• Drugs raise the pain threshold centrally and therefore interfere
with pain reaction without affecting pain perception
• The pain perception is eliminated
• Higher pain threshold→ no pain
• Sensation is dependent on threshold i.e., high threshold→ no
pain/minimal pain is felt by the patient
4. PREVENTING PAIN REACTION BY CORTICAL DEPRESSION
• within the scope of general anesthesia and the general
anesthetic agents
• Use of morphine
• depression of the CNS with anesthetic agent prevents any
conscious reaction to a painful stimulus
• Using general anesthesia, or gas anesthesia
• Produces unconsciousness, the patient is paralyzed, cannot
react to the stimulus
• Addressing the reaction; 2 components of pain: pain reaction &
sensation
• Vital signs indicate the presence of pain; If surgeon only
administered GA and not LA, vital signs will increase→ means
that the brain feels the pain

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 deafferentation
e.g. spinal trauma sensation
⎯ Spinal cord is a very big trunk of your nerves, therefore if it is injured it • Vital signs indicate the presence of pain; If surgeon only
can lead to intractable pain ( described as severe, unbearable; administered GA and not LA, vital signs will increase→ means
deafferentation: asymptomatic/ numbness of some part of the that the brain feels the pain
body/absence of pain, no pain at all) 1. The patient is drugged, so the patient can’t produce reaction
⎯ Due to trauma
5. USING PSYCHOSOMATIC METHOD
5) ABNORMAL ACTIVITY IN THE NERVE CIRCUITS • Depends for its effectiveness on putting the pt in the proper
e.g., phantom pain frame of mind
What are the phantom pains? • Basing on psychology, management of the brain of the patient
• Phantom pain is when you feel pain in a body part that you no longer • EX. Hypnotics/Hypnosis
have. • Using the power of the mind
• If a limb or portion of the body is cut, there’s unexplained pain being felt
by the patient sometimes.
• Applicable to dentition, on teeth after surgical procedure/cutting of the
coronal portion of the pulp

PAIN PATHWAYS

 Spinothalamic pathway/ also referred to as “tract”

 Trigeminal, major nerve routes

1. SPINOTHALAMIC PATHWAY
• The nerve fibers from the dorsal root ganglia enter the spinal cord
through the dorsal root and send branches 1-2 segments up and down
the spinal cord before entering the spinal gray matter, where they make
contacts with the nerve cells in Rexed lamina (marginal zone) and lamina
II (substanti gelatinosa).

• The AO(alpha-delta) fibers innervate the cells in the marginal zone, and
the C fibers innervate mainly the cells in the substantia gelatinosa layer
of the spinal cord.
• These nerve cells, in turn, innervate the cells in the nucleus proprius,
another area of the spinal cord gray matter (Rexed layers IV, V, and VI),
which send nerve fibers across the spinal midline and ascend (in the
anterolateral or ventrolateral part of the spinal white matter) through the
medulla and pons and innervate nerve cells located in specific areas of
the thalamus.

Where is the spinal gray matter?

• From extremities (left/right) which pass through the spine and then enters
to brain for interpretation.
• Spinothalamic→stimulus which comes from below the neck.

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