Bhargav Seminar

physiology of pain
Department of Prosthodontics
College of dental sciences and research center
Presented by: BHARGAV TRIVEDI
Contents
Definition
Benefits of pain
Pain receptors
Types of pain
Properties of pain sensation
Pain pathway
Analgesic pathway
Methods of pain control
Pain during prosthodontic treatment
Conclusion
References
Definition
An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” - The International Association for the Study of Pain (IASP)
“
An unpleasant emotional experience usually initiated by noxious stimulus and transmitted over a specialized neural network to the CNS where it is interpreted as such - Monheim
Monheim’s local anesthesia and pain control in dental practice – C Richard Bennett – seventh edition
Definition
BELL
the subject’s conscious perception of
modulated nociceptive impulses that generate
an unpleasant sensory and emotional
experiences associated with actual or potential
tissue damage or described in terms of such
damage.
Bell’s oral and facial pain 7th edition

Benefits of pain
Gives warning signal about the existence of a problem
or threat
Prevents further damage by causing reflex withdrawal
of the body from the source of injury
Forces the person to rest or to minimize the activities
thus enabling the rapid healing of the injured part
Urges the person to take required treatment to prevent
major damage
Sembulingam K, Sembulingam P. Essentials of medical physiology. JP Medical Ltd; 2012 Sep 30.
Acc. To pain
physiology:
Nociceptive
Types of pain neuropathic
Fast pain
Clinical types:
Slow pain
Fast pain
Somatic pain
Slow pain Acc. To source of
Dentistry: Visceral pain
origin: Referred pain
Odontogenic
Superficial Radiating pain
Non
Deep Projected pain
odontogenic
Visceral
indu Khurana I. Medical physiology for undergraduate students-E-book. Elsevier Health Sciences; 2018
Sep 9.
Fast pain or epicritic pain Slow pain
Felt within about 0.1 second Begins after 1 second or more
after a painful stimulus. and then increases slowly
over many sec. or min.
sharp, localized Dull, intense, diffuse, and

sensation unpleasant feeling
Felt mainly in skin. Not felt in It can occur both in the skin
most deeper tissues of the and in almost any deep tissue
body or organ
Caused by mechanical or Caused mainly by

thermal stimuli. chemical stimuli
Transmitted by Aδ fibers Transmitted by C fibers
Velocity 5-15 m/s Velocity 0 to 5 m/s
NT- Glutamate NT- Substance P
Example: Example:
pricking pain, acute slow burning pain, aching pain,
pain, and electric pain,stabbing sensation throbbing pain, nauseous pain,
and chronic pain
Khurana I. Medical physiology for undergraduate students-E-book. Elsevier Health Sciences;

2018 Sep 9.
“Good pain” responsible for flexor “Bad pain ” autonomic symptom along
withdrawal reflex with slow pain pathway
Also known as neo-spinothalamic tract Also known as paleo spinothalamic tract
(lateral spinothalamic tract)
Terminates at sensory cortex Terminates at thalamus
No branching Gives branches
source of origin -- three types of pain
Superficial pain: pain arising from skin
and mucous membrane.
Deep (somatic) pain: pain originating
from somatic structures deep to the skin
are known as deep pain.
 Visceral pain: pain arising from
different internal organs or viscera
Khurana I. Medical physiology for undergraduate students-E-book. Elsevier Health Sciences; 2018 Sep
9.
According to pain physiology:
Nociceptive:
represents the normal response to noxious insult
or injury of tissue such as skin, muscles, visceral
organs, joints, tendons or bones.
Neuropathic:
Pain initiated or caused by a primary lesion or
disease in the somatosensory nervous system.
Pain in dentistry
Odontogenic pain Non odontogenic pain
Presence of etiologic factors for an No apparent factors for odontogenic pain.
odontogenic origin.(e.g (e.g. trigeminal
Caries,Trauma,Fracture, Leakage of neuralgia ,temporomandibular disorders)
restorations,)
Pain reduction by local anesthetic No consistent relief of pain by local

anesthetic
Unilateral and localized pain Bilateral pain or multiple painful teeth
Sensitivity on temperature,percussion and Increased pain associated with palpation
digital pressure of trigger point or muscles,emotion
stress,physical exercise etc
Rajendran R. Shafer's textbook of oral pathology. Elsevier India; 2009.

Clinical types of pain
In clinical practice, pain sensations can be
classified as:
Somatic pain,
Visceral pain,
Referred pain,
Radiating pain and
Projected pain
9.
Somatic pain:
Somatic pain, as the name indicates, arises from
the tissues of the body other than viscera.
Superficial somatic pain : arises from the skin
and superficial tissues.
Deep somatic pain: arises from the muscles,
joints, bones and fascia.
9.
Clinical conditions associated with somatic pain
Injuries, which can be in the form of mechanical
trauma, chemical injuries and thermal injuries.
Tissue ischaemia: Blockage of the blood flow to
the tissues causes severe pain.
Inflammation of the tissues caused by bacteria,
virus and other organisms.
Muscle spasm: due to spasm of blood vessels
9.
Visceral pain
Features:
Poorly localized, because pain receptors in
viscera are comparatively few.
Autonomic symptoms in the form of nausea,
vomiting, profuse sweating and lowering of
blood pressure
Reflex contraction of skeletal muscle of
abdominal wall is a common association
9.
Common causes :
Inflammation of the viscera, e.g. appendicitis,
cholecystitis, pancreatitis, etc
Overdistension of hollow viscera, e.g. intestinal
distension in intestinal obstruction
Chemical stimuli: Damaging substances may leak
from gastrointestinal tract into the peritoneal cavity
Spasm of hollow viscus: Pain is caused due to
mechanical stimulation of pain endings and
ischaemia.
Ischaemia: as occurs in tractions on mesentery. Pain
is due to acidic metabolic end products
9.
Referred pain:
It is that pain which originates due to irritation of
a visceral organ and is felt not in the organ but in
some other somatic structure (usually skin)
supplied by the same neural segment.
9.
Characteristic features :
Heart pain is referred to
the inner aspect of left arm.
Diaphragmatic pain to the

tip of the shoulder
Ureteric pain to the testes

in male and the inner aspect
of the thigh in female.
Gall bladder pain referred
to epigastric region.
Pain from the maxillary
sinus referred to the nearby
tooth.
Sembulingam K, Sembulingam P. Essentials of medical

.
physiology. JP Medical Ltd; 2012 Sep 30.
Theories of referred pain:
Convergence theory:
According to this theory, when the first-order
neurons carrying pain sensation from a somatic
area and a visceral organ converge on a
common second-order neuron ,the brain is
unable to identify the source of pain.
9.
9.
Facilitation theory:
According to this theory, the visceral
irritation is inadequate for producing
pain by itself. However, it facilitates
pain fibers from somatic structures, so
that even minor somatic irritation
produces perceptible pain.
9.
Dermatome rule
Referred pain is always felt over structure that
develops from same embryological segment or
dermatome from which the organ which is source pain
has developed.
Ganong’s review of medical physiology. 26 t h edition

Radiating pain and projected pain:
Sometimes, visceral pain is experienced both
locally and also at a distant point . Pain seems
to spread from the local area to the distant
site.
This is called radiating pain.
Projected pain is the perception of pain at
more distal sites due to damage to a nerve
along its course.
9.
Examples of radiating pain are:
In appendicitis, pain starts in the right iliac fossa
and radiates towards center of abdomen.
Example of projected pain are:
Striking the elbow causes pain to be projected to
the hand
9.
Hyperalgesia
Hyperalgesia refers to an enhanced painful response to a normal
stimulus.
(i) Primary hyperalgesia. In it the noxious stimuli produce more
severe pain than expected. It occurs over an area of tissue damage.
The pain threshold is lowered, so that even non-noxious stimuli
(e.g. touch) produce pain
(ii) Secondary hyperalgesia refers to the occurrence of far more
severe pain than expected in response to noxious stimulus applied
to normal healthy skin. In this condition, there is no lowering of
pain threshold

2018 Sep 9.
Allodynia
Allodynia is pain the arises from stimuli that do not

normally evoke pain e.g.tactile or thermal stimuli becoming
painful, this may be associated with nociceptive pain from
sunburn or tissue injury.
Khurana I. Medical physiology for undergraduate students-E-book. Elsevier Health

Sciences; 2018 Sep 9.
SENSORY THRESHOLD- defined as the lowest level of
stimuli that will cause any sensation-the summation of
large sensory fibers from receptors for touch, temperature
& vibration.
PAIN THRESHOLD -As the stimulus is increased, the

sensation becomes stronger until pain is perceived. This
is pain threshold.
Fairly constant among individuals.

PAIN TOLERANCE /RESPONSE
THRESHOLD
If the intensity of the stimulus is increased above pain

threshold, a level of pain will be reached that the subject
can no longer endure. This is pain tolerance or the
response threshold.
At this point the individual makes an attempt to

withdraw from the stimulus.
Range between the pain threshold and the response

threshold is termed as a person's tolerance to pain.
Ganong’s review of medical physiology. 26 th edition
Processing of pain from the stimulation of primary
afferent nociceptors to the subjective experience of
pain can be divided into 4 steps
1) Transduction
2) Transmission
3) Modulation
4) Perception
(Fields H. Pain,1987)
TRANSDUCTION
Pain is converted to electric energy and this

will travel. this electric energy is called
transduction. This stimulus sends impulse
across peripheral nerve fiber.
Anatomy and Physiology of Pain Mary M. Heinricher, Ph.D.

Pain processing
Anatomy and Physiology of Pain Mary M. Heinricher, Ph.D.

Pain receptors
The pain receptors in the skin and other tissues are all
free nerve endings.
The receptors which mediate pain are called
NOCICEPTORS.
widespread in the superficial layers of the skin as well as in

certain internal tissues, such as the periosteum, the arterial
walls, the joint surfaces, and the falx and tentorium in the
cranial vault.

Types of stimuli that excite pain receptors
Pain can be elicited by multiple types of stimuli.
They are classified as mechanical, thermal, and chemical
pain stimuli.
fast pain is elicited by the mechanical and thermal types of
stimuli slow pain can be elicited by all three types.

Mechanical stimulation due to:
Excessive pressure or tension on
nerves.
E.g.- a blow on the head, pulling of hair
etc. Compression of nerves by tumour.
Thermal stimulation- Raising skin temperature above
45°C or exposure to cold (0°C) is painful.
Chemical stimulation by irritant chemicals such as

histamine, kinins & prostaglandins released from damaged
tissue.

Chemical mediators of pain
Nociceptors Nociceptors
activated sensitized by
Prostaglandins
by Substance P
Interleukins
Bradykinin
Leukotrienes
Histamine
Serotonin
Increased potassium
concentration
Proteolytic enzymes
Acids
Acetlycholine
One chemical that seems to be more painful than
others is bradykinin.
Increase in potassium ion concentration and

proteolytic enzymes that directly attack the nerve
endings and excite pain by making the nerve
membranes more permeable to i ons. •
Variety of substance released during tissue damage to

cells these have a profound effect on the afferent
fibres.

Transient receptor potential channels
• These are family of excitatory channels
• Subfamily :
• 1. vanilloid receptor:
noxious heat (painful heat)
H+ion
capsaicin(vanillin group of compounds)

• Trpv1 reactive to H+ion,capsaicin
• Trpv3 reactive to temp between 35 and 39
degree
• Trpv4 reactive to temp upto 34 degree

• 2. acid sensing ion channels detection
of H+ion
• 3.ankyrin receptor known as
trpa1, pain
• 4.purinergic known as p2x,
p2y for pain pain by trpa1 and p2x
and p2y(by means of atp)

• 5.Menthol receptor: known as trpn3 for
moderate cold also known as CMR-
1 receptor (cmr= cold and menthol
sensitive receptor- 1)

Chemical mediators of pain

TRANSMISSIO
N
the process by which peripheral nociceptive information
is relayed to the central nervous system.
The primary afferent nociceptor synapses with a second

order pain transmission neuron in the dorsal horn of
the spinal cord where a new action potential heads
toward higher brain structures.
THE DUAL PATHWAY FOR TRANSMISSION OF

SIGNALS IN THE CENTRAL NERVOUS SYSTEM
a fast - sharp pathway
a slow - chronic pathway.

GUYTON . Textbook of Medical Physiology. 11 th edition
Sembulingam K, Sembulingam P. Essentials of medical physiology. JP Medical Ltd; 2012
Sep 30.
GUYTON . Textbook of Medical Physiology. 11 t h edition
Dual pain pathway in the cord and brain
stem
THE NEOSPINOTHALAMIC TRACT
THE PALEOSPINOTHALAMIC TRACT

Processing of the fast signals neospinothalamic tract
• A3 fibers transmit fast pain
•Terminate in lamina I (lamina marginalis) of the dorsal

horns of the spinal cord. Excite second-order neurons of the
neospinothalamic tract.

Processing of the fast signals neospinothalamic tract
These give rise to long fibers that cross immediately to

the opposite side of the cord through the anterior
cornmissure
and then turn upwards, passing to the brain in
the anterolateral columns.

Termination of the fast acute pain pathways in the
brain stem and thalamus
Most pass all the way
to the thalamus without
interruption,
terminating in the
ventrobasal.
From these thalamic

areas the signals are
transmitted to other
basal areas of the
brain as well as the
somatosensory cortex.
GUYTON . Textbook of Medical
Physiology. 11 th edition
CAPABILITY OF THE NERVOUS SYSTEM
TO LOCALIZED FAST PAIN IN THE BODY;
Fast pain can be localized much more exactly in different parts

of the body.
However, when only pain receptors are stimulated, without the

simultaneous stimulation of tactile receptor, even fast pain may
be poorly localized.

Processing of slow signals paleospinothalamic
tract
The type C - fibers terminate almost entirely in the
laminae II & III of the dorsal horns( substantia
gelatinosa).
Most of the signals then pass through one or more
additional short fiber neurons evenltually
terminating mainly in Lamina V.

Here the last neuron in the series gives rise to long axons that
join the fibers from the fast pain pathway, passing first
through the anterior commissure to the opposite side of the
cord, then upward to the brain in the anterolateral pathway.

Dual nature of pain
Pain has two components:
Pain perception
Pain reaction

Pain perception Pain reaction
Objective component of pain. Emotional experience to the
perceived injury.
Physio-anatomic process Psycho physiological process and

Impulse is generated after application of involves the cortex, hypothalamus &
adequate stimulus and is transmitted to thalamus.
the CNS.
This aspect of pain is almost similar Varies from individual to individual

in all healthy individuals and varies and also from day to day in the same
little from day to day person.

PAIN PERCEPTION
MRI studies have demonstrated the involvement of the
thalamus & multiple cortical areas in the perception of pain
The center for pain sensation is post central gyrus of

parietal cortex. Fibers reaching the cortex are the
cause of arousal mechanism during sleep.
Khurana I. Medical physiology for undergraduate students-E-book. Elsevier Health Sciences; 2018
Sep 9.
Perception of pain is the phenomenon by which noxious stimuli
reach consciousness.
It involves two components: Nociceptive component, and Affective
(cognition and attention) component.
Nociceptive component of pain perception. Pain perception occurs
at subcortical levels, i.e. in the thalamus and in the reticular
formation of the brain stem. However, somatosensory cortex helps
in exact and meaningful interpretation of quality and localization of
pain. Affective (cognitive and attention) component of pain
perception is the psychological component. It involves the activity
of spinothalamic tracts—limbic system pathway.
Cognitive perceptions are those abilities that recognize,
discriminate, memorize or judge afferent information. It involves
patient’s ability to relate a painful experience to another event, e.g.
pain experienced in a pleasant environment elicits a less intense
response than an experienced in a setting of depression
2018 Sep 9.
THEORIES OF PAIN PERCEPTION
Specificity theory
1908's von Frey
Central Summation theory
Livingstone,1943
Sensory-Interaction theory
Noordenbos 1959
Gate Control Theory
Ron Melzack and Patrick Wall in 1965
Theories of pain: from specificity to gate control Massieh Moayedi1,3 and Karen D. Davis1,2,
SPECIFITY THEORY
1908's von Frey
Body has a separate sensory system for perceiving
pain just as it does for hearing and vision
They Considered pain as an independent sensation,

which respond to damage and send signal to the
target centre in brain.
Free nerve endings are pain receptors. according to
specificity theory says referred pain
require convergence of noxious input from
different sites on neurons responding
MAJOR DEFICITES OF SPECIFFITY THEORY:
Inability to explain some of the characteristics of clinical
pain.
Hyperalgesic areas of skin following peripheral injury;
cannot explain all pathologic pains produced by mild non-
noxious stimuli.
The specificity theory also does not explain referred pain

that can be triggered by mild innocuous stimulation of
normal skin.
Also does not explain pain produced by mild stimulation

of trigger zones in trigeminal neuralgia.
GATE CONTROL THEORY
Ron Melzack and Patrick Wall in 1965
Substanitia geletinosa in dorsal horn in spinal cord act as

gate and allows only one sensation to travel through it.
If A beta is stimulated it closes gate and doesn’t allow A delta
and c fibers to pass signals.
If A delta and c fibers are stimulated it closes gate for A beta.
Dorsal horn act as the gate and allows only sensation from
larger fibers to be carried. A beta carrying sensation will
inhibit A delta when it arrives(accupunture).
Cells which transmit signal from spinal cord to
brain are called T-cells.
These cells can inhibit or allow communication into
CNS .
When pain sensation is produced- other afferent
particular the touch fibers reaching the posterior
column also gets activated.
Dorsal column sends collaterals to substantia
geletinosa in dorsal grey horn.
Thus signals pass through collaterals of substantia
geletinosa in dorsal grey horn.
It is here the sensation inhibit release of substance
p which thus reduce pain.
e.g. large fibres can inhibit transmission from
small fibres from communicating to brain, in
this way large fibres create a hypothetical
gate that opens and closes to pain
stimulation.
The greater the level of pain the less

adequate the gate in blocking the
communication.
Final response - depend on the net result of the initial input
from all 3 systems
1) Large diameter fibers
2) Small diameter fibers
3) Central Control
Thin fibres activity impedes the inhibitory cells (allow

the transmission cell to transmit signal)
Large diameter fibre activity excites the inhibitory cell

(inhibiting transmission cell activity)
More the large fibre activity (touch, pressure) relative to thin

fibre activity at inhibitory cells, less pain is felt.
MODULATION
Refers to mechanisms by which the transmission of noxious
information to the brain is reduced.
THE PAIN SUPPRESSION (ANALGESIA) SYSTEM

IN
THE BRAIN AND SPINAL CORD:
The degree to which each person reacts to pain varies
tremendous!y.
This results partly from the capability of the brain itself to control
the degree of input of pain signals to nervous system by activating
of a pain control system called an analgesia system
(descending inhibitory systems)
2018 Sep 9.
Pain and Disability: Clinical, Behavioral, and Public Policy Perspectives (1987)
Pain suppression systems in CNS
1.Spinal pain suppression system
Gate control hypothesis
2. Supraspinal pain suppression system
a. Descending serotonergic and opioid inhibitory system
b. Descending purinergic inhibitory system
c. Descending adrenergic inhibitory system
3. Acetylcholine

2018 Sep 9.
a. Descending serotonergic and opioid inhibitory
system
It is the most important supraspinal pain inhibitory system.
(i) Raphe magnus nucleus (RMN). It is a thin midline
nucleus located in the lower pons and upper medulla.
Its neurons receive innervation from the PAG reticular
formation, hypothalamus and frontal cortex. The
serotonergic neurons of the RMN project down the
dorsolateral column to influence the neurons in dorsal
horn of spinal cord, which are excited by primary
nociceptive afferents. The serotonergic fibres exert
their effect by post-synaptic inhibition.
2018 Sep 9.
(ii)Periaqueductal grey area in the mid brain. It
inhibits pain by stimulating the RMN . Neurons of
PAG have opioid receptors on their surface
membranes. When opioid receptors are stimulated
by exogenously administered opioid compounds
(analgesics) or by endogenous opioid
neurotransmitters (endorphins and enkephalins)
found in the brain, the pain suppression circuitry is
activated and this leads to reduced pain perception.
Khurana I. Medical physiology for undergraduate students-E-book. Elsevier Health Sciences; 2018
Sep 9.
(iii) Hypothalamus and frontal cortex also
play a role in pain suppression
Neurons descending from the hypothalamus and
frontal cortex stimulate both the above described
brain stem centres of pain inhibition, i.e. PAG as well
as RMN
(i) When limbic system is stimulated. Limbic system is
the seat of emotions. Fibres from the limbic system
supply the PAG. This explains why a soldier wounded
in the battlefield may feel no pain during the heat of
battle
(ii) Autofeedback. When the spinothalamic tract
(STT) is stimulated, the collaterals from STT stimulate
the descending inhibitory pathway
2018 Sep 9.
2. Descending purinergic inhibitory system:
comprising specifically of adenosine, has been
recognized.
Role of adenosine on pain suppression
(a)Effective attenuation of neuropathic pain
following low dose infusion of adenosine.
3. Descending noradrenergic inhibitory system:
Fibres of this system originate from the locus
coeruleus and medullary reticular formation and
descend in dorsolateral fasciculus (stress may
activate this descending inhibitory mechanism).

2018 Sep 9.
QUANTIFYING THE PAIN
EXPERIENCE VISUAL ANALOG
SCALES
A line. that represents continuum of a particular
experience, such as pain
The most common form used for pain is a 10cm line,
whether horizontal or vertical, with perpendicular
stops at the ends.
Numbers should not be used along the line
No pain Worst pain imaginable

NUMERICAL RATING SCALE
,c mcCaffery,M.,Beebe,A,et al.(1989)
scored O to 10
• involve asking for estimates of pain using numbers representing

increasing pain severity.
require numeracy, the ability to think and express oneself in

quantitative terms, and verbal communication skills.
O·10 Numeric Pain Intensity Scale

•
0 1 2 3 4 5 6 7 8 9 10
No M oderate Worst
pain pain possibl
e
pain
Measurement of Pain
McGILL PAIN QUESTIONARE
Developed at McGill University by Melzeck and Torgerson 1971
ve bal pain scale that uses a vast array of words commonly used to describe pain
These qualitative sensory descriptors are invaluable in providing key clues to possible
diagnosis. Similarly, patients use different words to describe the affective component of
their pain.
Melzeck and Torgerson set about categorizing many of these verbal descriptors into
classes and subclasses designed to describe aspects of pain experience.
Section:3
Quality of pain: categories 1 through 20
change of Pain with time : category 3
How strong is your pain: category 6
The McGill Pain Questionnaire

Pain transmission through Dentin
Theories of dentinal hypersensitivity:
Hydrodynamic theory
Direct Neural Stimulation
Transduction Theory
Orban’s oral histology & embryology – 11th edition

Hydrodynamic theory

Direct stimulation theory
direct stimulation of sensory nerve
stimuli reach the nerve ending in the inner

dentin
Painful response
Dentinal hypersensitivity
Transduction theory
Membrane of odontoblast process is excited by the stimulus and the
impulse is conduct to the nerve ending in the inner dentin.

Methods of pain control
1) Removing the cause
2) Blocking the pathway of painful impulses
3) Raising the pain threshold
4) Preventing pain reaction by cortical depression
5) Using psycosomatic method

1. Removing cause :
Stop continuous excitation of
nociceptor
no impulse generated.
2. Blocking the pathway of painful impulses :
Suitable drug possessing local analgesic
properties injected into tissue in proximity to
involved nerves.
Widely used in dentistry by using LA.
3) Raising the pain threshold:
By using drugs.
Raised pain threshold centrally therefore
interfere with pain reaction.
Pain perception is unaffected.
Depends upon analgesics effect of drug.eg.
Aspirin – mild analgesic effect
Opioids – more effect.
4. Preventing pain reaction by cortical
suppression:
by GA and its agent.
cause CNS depression that prevents any
conscious reaction to a painful stimuli.
5. Using psychosomatic methods:
Affect both pain perception and reaction.
Without drug. Depend of its effectiveness on
putting patient in proper frame of mind.
Goals of pain management
To relieve suffering.

 Increase functional capacity.
 Improve quality of life.
Pain Control Stratergy
Analgesics
A drug that selectively relives pain by acting in
CNS or on peripheral pain mechanism ,without
significantly altering consciousness.
It relieves pain as a symptoms without effecting
its cause.
Analgesics can be divided into two groups :
a) opioids/narcotics /morphine like analgesics
B)non opioid /non narcotics /aspirin like
/antipyretic or anti-inflammatory analgesics
Opioids
It is strong analgesics.
Pain relievers that act on the CNS.
They become habit forming if used over long periods
Dull, poorly localized visceral pain is relieved better

than sharply defined somatic pain.
Pain perception and reaction both are altered.

It inhibit the release of substance P and even
affects the limbic system.
Used in dentistry : when NSAID’S like

analgesics are not effective.
NSAIDS
Weaker analgesics, do not suppress CNS.
Act primarily on peripheral pain mechanism.
M/A :- By inhibiting PG synthesis and blocks

this sensitization of pain mechanism.
It relieves inflammatory, tissue related injury,

connective tissue and integumental pain but
ineffective in several visceral and ischemic pain.
TENS
Constant sub threshold impulses in larger nerve near the site of injury
are transmitted.
So they block out input from smaller nerves.
So it prevents painful stimulus.
Okeson JP. Management of temporomandibular disorders and occlusion-E-book. Elsevier Health

Sciences; 2014 Jul 21.
Intermittent painful stimulation
Due to higher concentration of nociceptors and
low electrical impedence there is stimulation of
pain at a distant site.
But endorphins morphins, beta endorphins
appear to be release in CSF which reduces the
pain.
E.g. Runners high
Okeson JP. Management of temporomandibular disorders and occlusion-E-book. Elsevier Health

Psychological modulation system
This mechanism is not well understood but
psychological state of patient positive or
negative affects patient a lot.
E.g. Patients who devote more amount of
attention to their pain suffers more than the
patient who are reluctant towards their pain.
Okeson JP. Management of temporomandibular disorders and occlusion-E-book. Elsevier

Health Sciences; 2014 Jul 21.
WHO Analgesic Ladder
Pain in prosthodontics treatment
Complete
denture Removable Fixed partial
partial denture denture
Over extended denture Improper adjustment of clasp Dentinal Hypersensitivity

Sharp edges High points Over heating while crown prep
Exostosis and bony spicules Over extended denture Gingival retraction
Increased VDO High points
Premature occlusal contacts
Whenever restoring a tooth or teeth with Complete denture,
Removable partial denture, cast partial denture, fixed partial denture or
implant there must not be any premature contact.
Occlusion must be in harmony with the masticatory system
TMJ DISORDERS
Temporomandibular disorders – Limitation of opening,

episodes of joint locking, pain with mandibular
dysfunction, facial pain and headache.
Management
Physical therapy
Pharmacotherapy - analgesics, nonsteroidal anti-inflammatory
drugs (NSAIDs), local anesthetics, oral and injectable
cortico steroids and muscle relaxants.
NSAIDS - Commonly used NSAIDs include ibuprofen
and naproxen, celecoxicb
TMJ injections - Intracapsular injection of
corticosteroids significantly reduces TMJ pain.
Muscle relaxants – It can be prescribed for acute
muscle tension associated with TMJ disorders.
A commonly used and effective muscle relaxant is
cyclobenzaprine, started at lower dosages (5–10 mg)
and taken 1–2 hours before bedtime
Antidepressants:
Tricyclic antidepressants like amitriptyline and
nortriptyline. They have anti-nociceptive effects.
Occlusal appliance therapy:
acrylic devices / thermoplastic sheets that are
used for the purpose of equally distributing jaw
parafunctional forces.
reduces the forces placed on the masticatory
muscles, and protects the occlusal surfaces of the
teeth
Conclusion
Pain is multidimensional experience involving both
sensation evoked by a noxious stimulus but also the
reaction to it.
The sensation of pain therefore depends in part on the

patients past experience, personality and level of
anxiety.
So before any attempt is made to control or eliminate

pain by any method, the patient should receive the
benefit of a diagnosis as careful as possible.
References
Khurana I. Medical physiology for undergraduate
students-E-book. Elsevier Health Sciences; 2018 Sep
9.
Sembulingam K, Sembulingam P. Essentials of
medical physiology. JP Medical Ltd; 2012 Sep 30.
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Anatomy and Physiology of Pain Mary M.

Heinricher, Ph.D.

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physiology of pain

Bell’s oral and facial pain 7th edition

sharp, localized Dull, intense, diffuse, and

Caused by mechanical or Caused mainly by

Khurana I. Medical physiology for undergraduate students-E-book. Elsevier Health Sciences;

Pain reduction by local anesthetic No consistent relief of pain by local

Rajendran R. Shafer's textbook of oral pathology. Elsevier India; 2009.

Diaphragmatic pain to the

Ureteric pain to the testes

Sembulingam K, Sembulingam P. Essentials of medical

Ganong’s review of medical physiology. 26 t h edition

Khurana I. Medical physiology for undergraduate students-E-book. Elsevier Health Sciences;

Allodynia is pain the arises from stimuli that do not

Khurana I. Medical physiology for undergraduate students-E-book. Elsevier Health

PAIN THRESHOLD -As the stimulus is increased, the

Fairly constant among individuals.

If the intensity of the stimulus is increased above pain

At this point the individual makes an attempt to

Range between the pain threshold and the response

Pain is converted to electric energy and this

Anatomy and Physiology of Pain Mary M. Heinricher, Ph.D.

Anatomy and Physiology of Pain Mary M. Heinricher, Ph.D.

widespread in the superficial layers of the skin as well as in

Ganong’s review of medical physiology. 26 th edition

fast pain is elicited by the mechanical and thermal types of

stimuli slow pain can be elicited by all three types.

Ganong’s review of medical physiology. 26 th edition

Chemical stimulation by irritant chemicals such as

Ganong’s review of medical physiology. 26 th edition

Increase in potassium ion concentration and

Variety of substance released during tissue damage to

Ganong’s review of medical physiology. 26 t h edition

Ganong’s review of medical physiology. 26 th edition

Ganong’s review of medical physiology. 26 t h edition

Ganong’s review of medical physiology. 26 th edition

Ganong’s review of medical physiology. 26 t h edition

Ganong’s review of medical physiology. 26 th edition

The primary afferent nociceptor synapses with a second

THE DUAL PATHWAY FOR TRANSMISSION OF

a fast - sharp pathway

a slow - chronic pathway.

THE PALEOSPINOTHALAMIC TRACT

GUYTON . Textbook of Medical Physiology. 11 th edition

• A3 fibers transmit fast pain

•Terminate in lamina I (lamina marginalis) of the dorsal

GUYTON . Textbook of Medical Physiology. 11 th edition

These give rise to long fibers that cross immediately to

GUYTON . Textbook of Medical Physiology. 11 t h edition

From these thalamic

Fast pain can be localized much more exactly in different parts

However, when only pain receptors are stimulated, without the

GUYTON . Textbook of Medical Physiology. 11 th edition

GUYTON . Textbook of Medical Physiology. 11 t h edition

GUYTON . Textbook of Medical Physiology. 11 t h edition

Ganong’s review of medical physiology. 26 th edition

Physio-anatomic process Psycho physiological process and

This aspect of pain is almost similar Varies from individual to individual

Ganong’s review of medical physiology. 26 t h edition

The center for pain sensation is post central gyrus of

They Considered pain as an independent sensation,

The specificity theory also does not explain referred pain

Also does not explain pain produced by mild stimulation

Substanitia geletinosa in dorsal horn in spinal cord act as