PAIN &

PAIN PATHWAY

PRESENTED BY
K MAHESHKUMAR
1ST YEAR
PEDODONTIC AND PREVENTIVE DENTISTRY
CONTENTS

 Introduction
 Definitions
 Benefits of pain sensation
 Classification of pain
 Receptors
 Sensory neurons
 Pain pathways
 Pain theories
 Pain in orofacial region
 Pain diagnosis
 Conclusion
 References
INTRODUCTION

The word pain is derived from the Latin word Peone and the Greek word Poine meaning
penalty or punishment

Pain is an intensely subjective experience, and is therefore difficult to describe.

Prevention and management of pain is an important aspect of health care.

DEFINITION

According to The International Association for the Study of Pain (2011) says an “unpleasant
sensory and emotional experience associated with actual or potential tissue damage, or
described in terms of such damage.”

BENEFITS OF PAIN SENSATION

 Pain gives warning signal about the existence of a problem or threat.

 It also creates awareness of injury.
 Pain prevents further damage by causing reflex withdrawal of the body from the
source of injury
 Pain forces the person to rest or to minimize the activities thus enabling rapid healing
of injured part
 Pain urges the person to take required treatment to prevent major damage.

CHARACTERSTICS OF PAIN

1. Threshold and Intensity

according to the Weber-Fechner’s law.

If the intensity of the stimulus is below the threshold (sub- threshold) pain is not felt. As the
intensity increases more and more, pain is felt more and more
2. Adaptation

Pain receptors show no adaptation and so the pain continues as long as receptors continue to
be stimulated.

3.Localization of pain:

Pain sensation is somewhat poorly localized. However superficial pain is comparatively

better localized than deep pain.

4.Influence of the rate of damage on intensity of pain :

If the rate of tissue injury (extent of damage per unit time) is high, intensity of pain is also
high.

CLASSIFICATION OF PAIN

Based on source/ location/ referral & duration

ACUTE PAIN

Acute has a sudden onset, usually subsides quickly and is characterized by sharp, localized
sensations with an identifiable cause.

Felt with in 0.1 second after pain stimulus is applied

Acute pain is usually characterized by increased autonomic nervous system activity resulting
in Psychological symptoms

VISCERAL PAIN

Type of nociceptive pain that comes from the internal organs

Unlike somatic pain it is harder to pinpoint

Caused by the activation of pain receptors in the chest, abdomen, or pelvic areas

SOMATIC PAIN

Nociceptors are involved

Often well localized

Usually described as throbbing or aching

Can be superficial (skin, muscle) or deep (joints,tendons, bones).

Periodontal,alveolar,mucosal example of somatic pain

SUPERFICIAL PAIN

It is also known as cutaneous pain

It arises from superficial structures such as skin & subcutaneous tissues

It is a sharp, bright pain with a burning quality and may be sudden or unexpacted or slow in
onset

DEEP PAIN

It is a sharp, bright pain with a burning quality

It originates in deep body structures such as periosteum, muscles, tendons, joints & blood
vessels

Radiation of pain occur from original site of injury

CHRONIC PAIN

Chronic pain is defined as pain lasting longer than 3 to 6 months

It is persistent or episodic pain of duration or intensity that adversely affects the function and
well being of the patient

It may be nociceptive, inflammatory, neuropathic or functional in origin .

Tempromandibular joint disorder example of the chronic pain contition

NEUROPTHIC PAIN

Neuropathic pain is a result of an injury or malfunction of the nervous system. It is described

as

Aching

Throbbing
Burning

Shooting

Stinging

Tenderness/ sensitivity of skin

MUSCULOSKELETAL PAIN

This a type of chronic non cancer pain occurring due to musculoskeletal disorders such as

Rheumatoid arthritis

Osteoarthritis

Fibromyalgia

Peripheral neuropathies

BASED ON TRANSMISSION

FAST PAIN

Felt about 0.1 sec after a pain stimulus is applied

It is described as sharp pain,pricking pain, acute & electric pain

Fast sharp pain is not felt in most deeper tissues of the body

SLOW PAIN

Usually begins after 1 sec or more and may range from seconds to minutes

Described as slow, burning, aching, throbbing, nauseous pain and chronic pain

Associated with tissue destruction

REFERRED PAIN

Referred pain is the pain that is perceived at a adjacent site to or away from the site of origin..

SITES OF REFERRED PAIN

Referred dental pain

Dental pain occur as a result of extradental causes.

FOR INSTANCES SEVERAL TYPES OF HEADCHE CAN CAUSE PAIN IN THE

TEETH AND JAW

EXAMPLES OF REFERRED PAIN

1. Cardiac pain is felt at inner part of left arm and left shoulder

2. Pain from testis is felt in abdomen

3. Pain in diaphragm is referred to shoulder

4. Pain in gallbladder is referred to epigastric region

RECEPTORS

Pain Receptors (Nociceptors) Are Free Nerve Endings.

They are widespread in the superficial layers of the skin, as well as in oral mucosa, dental
pulp, periosteum, meninges, etc.

exception: Brain

SENSORY RECEPTORS

According to stimulus source

Exteroceptors

Proprioceptors

Interoceptors

According to modality

Nociceptors
Thermoreceptors

Mechanoreceptors

1) Mechanosensitive nociceptors (of Aδ fibers), which are sensitive to intense

mechanical stimulation (such as pinching with pliers) or injury to tissues.

2) Temperature-sensitive (thermosensitive) nociceptors (of Aδ fibers), which are

sensitive to intense heat and cold.

3) Polymodal nociceptors (of C fibers), which are sensitive to noxious stimuli that are
mechanical, thermal, or chemical in nature. Although most nociceptors are sensitive
to one particular type of painful stimulus, some may respond to two or more types

SENSORY NEURONS

First Order

Second Order

Third Order

FIRST ORDER NEURON:

These are the cells in the posterior nerve root ganglia, receive impulses from pain receptors
through dendrites

These impulses are transmitted through the axons to spinal cord

Impulses are transmitted by Aδ fibre or C fibres

SECOND ORDER NEURONS

The neurons of marginal nucleus & substantia gelatinosa form the II order neurons

Fibres from these neurons ascend in the form of the lateral spinothalamic tract

Fibres of fast pain arise from neurons of the marginal nucleus •

The fibres of slow pain arise from neurons of substantia gelatinosa

THIRD ORDER NEURONS

• The neurons of pain pathway are the neurons in Thalamic nucleus, reticular formation,
tectum, gray matter around the aqueduct of sylvius

• Axons from these neurons reach the sensory area of cerebral cortex or hypothalamus

PAIN PATHWAYS

Even though all pain receptors are free nerve endings, these endings use two separate
pathways for transmitting pain signals into the central nervous system.

The two pathways mainly correspond to the two types of pain-

 a fast-sharp pain pathway (Neospinothalamic tract)

 a slow-chronic pain pathway (Paleospinothalamic tract)

ANALGESIC PATHWAY

Analgesic pathway that interferes with pain transmission is often Considered as descending
pain pathway, the ascending pain pathway being the afferent fibers that transmit pain
sensation to the brain
PAIN THEORIES

Pain theories are proposed to offer the possible physiologic mechanisms involved in pain.
They are as follows

 Specificity theory
 Pattern theory
 Gate control theory

SPECIFICITY THEORY

DESCARTES 1664, MULLER 1840

Pain occurs due to stimulation of specific pain receptors (nociceptors) with transmission by
nerves directly to the brain

Pain, Touch, Cold, Pressure and heat.

This theory considers pain as an independent sensation with specialised peripheral sensory
receptors [nociceptors], which respond to damage and send signals through pathways (along
nerve fibres) in the nervous system to target centres in the brain.

PATTERN THEORY:

 Goldschieder 1894

 He proposed that pain results from over stimulation of other primary sensations.

 He proposed that pain resulted when activity exceeded a critical level due to
excessive activation of receptors resulting in convergence and summation of activity.
GATE CONTROL MECHANISM

Proposed by MELZACK & WALL IN 1965 • According to this theory, the pain stimuli
transmitted by afferent pain fibres are blocked by GATE MECHANISM located at the
posterior gray horn of the spinal cord

•If the gate is open pain is felt, and if the gate is closed pain is suppressed
PAIN IN PEDIATRIC DENTISTRY

Odontogenic pain

Odontogenic pain refers to pain initiating from the teeth or their supporting structures, the
mucosa, gingivae, maxilla, mandible or periodontal membrane.

TOOTH PULP PAIN

 Trigeminal Neuralgia

Trigeminal Neuralgia (Tic Douloureux)

chronic pain condition characterized by recurring episodes of extreme, sporadic, sudden

burning or electric shock-like face pain.

pain typically involves the lower face and jaw

 Pericoronitis

Pain commonly arises from the supporting gingivae and mucosa when infection arises from
an erupting tooth (teething or pericoronitis). This is the most common cause for the removal
of third molar teeth (wisdom teeth). The pain may be constant or intermittent, but is often
evoked when biting down with opposing maxillary teeth.

 Apical pain

can be caused by infection spreading through the apical foramen of the tooth into the apical
periodontal region causing inflammation (apical periodontitis) and ultimately a dental abscess
if left untreated

PAIN DIAGNOSIS

Diagnosing a pain complaint consists of these major steps :

 History
 Clinical examination
 Accurately identifying the location of the extractions from which the pain emanates
 Establishing the correct pain category that is represented in the condition under
investigation
Assessment of pain

In the assessment of pain intensity, rating scale techniques are often used. The most
commonly used techniques are:

 Numerical Rating Scale

 Visual Analogue Scale
 Numerical Rating Scale (NRS)
 Visual Analogue Scale

MANAGEMENT OF PAIN GOALS OF THERAPY

To decrease the subjective intensity

To reduce the duration of the pain complaints

To decrease the potential for conversion of acute pain to chronic persistent pain syndromes

To decrease the physiological, psychological, & socioeconomic sequelae associated with

under treatment of pain

PAIN MANAGEMENT IN PEDIATRIC DENTISTRY

Effective pain management involves a combination of pharmacologic, psychologic,

cognitive-behavioral, and physical treatments.

Simple measure for dealing with a child in pain include:

Reassurance, explanation, a calm environment, and gentle handling.
Cold or hot packs.

Oral Analgesics And Pain Medication

Most common pharmacologic therapy for children in pain.

Analgesic treatment should include proper dosing according to: body weight, physiologic
situation, and the medical situation.
Local Anesthetics And Nerve Blocks:
Local anesthetics are used to stop the conduction of pain impulses through the nerves.

Conscious Sedation:
The use of sedatives alone during painful procedures does not provide analgesia, but makes a
child less able to communicate distress.

Hypnosis:
This technique involves helping children to focus away from the feared aspects of a medical
or dental procedure.

Inhibition of pain transmission by tactile sensory signals

Stimulation of large type Aß sensory fibers from the peripheral tactile receptors can depress
the transmission of pain signals from same body area.

Simple methods like rubbing the skin near painful areas is often effective in relieving the
pain.

Liniments are often used.

Acupuncture.

VIBROTACTILE DEVICES

VIBROJECT

Small battery-operated device which is attached to the standard anesthetic syringe, causing
the syringe and needle apparatus to vibrate.

DENTAL VIBE

Cordless, rechargeable, hand held device that delivers soothing, pulsed micro-oscillations at
the site where an injection being administered.

Stimulates the sensory receptors at the injection site, effectively closing the neural pain gate.

Accupal

Cordless device that uses both vibration and pressure to precondition the oral mucosa.

Provides pressure and vibrates the injection site to the needle penetration, which shuts the
“pain gate.”
NON – PHARMACOLOGICAL MANAGEMENT

The non – pharmacological management involves the following approaches

Physiotherapy

Psychological techniques

Stimulation therapies – Acupuncture & Transcutaneous Electrical Nerve Stimulation (TENS)

SURGICAL PROCEDURE FOR THE RELIEF OF PAIN

CORDOTOMY: In the thoracic region , the spinal cord opposite to the side of pain is
partially cut to interrupt the anterolateral Pathway

THALAMOTOMY: Involves cauterization of specific pain areas in the intra thalamic nuclei
in the thalamus, which often relieves suffering type of pain

SYMPATHECTOMY Excision of the segment of the sympathetic nerve or one or more

sympathetic ganglia RHIZOTOMY Surgical removal of spinal nerve roots for the relief of
pain or spastic paralysis

FRONTAL LOBOTOMY Surgical process involving division of one or more nerve tracts in
a lobe of the cerebrum usually frontal lobe NEWER APPROACHES- TNS,
ACUPUNCTURE

CONCLUSION

Pain is bad but not feeling can be worse. Dental pain is multicausative in origin.The dentist
should use multimodalities to treat the patient. Nothing is more satisfying to the clinician than
the successful elimination of pain. The most important part of managing pain is
understanding the problem and cause of pain .It is only through proper diagnosis that
appropriate therapy can be selected.
REFERENCES

Textbook of Medical Physiology 10th edition- Guyton and Hall

Textbook of medical physiology 7th edition- Sembulingam

Essentials of Medical Pharmacology 7th edition- KD Tripathi

Kumar KH, Elavarasi P. Definition of pain and classification of pain disorders. J Adv Clin
Res Insights 2016;3:87-90.

Tandon OP et al Neurophysiology of pain: insight to orofacial pain. Indian J Physiol

Pharmacol 2003; 47 (3) : 247–269

Chapter 7: Pain Tracts and sources. Ann textbook for the neuroscience

Renton T. Dental (odontogenic) pain. v o l . 5 – n o . 1 – m a r c h 2 0 1 1

Gupta R, Mohan V, Mahay P, Yadav PK (2016) Orofacial Pain: A Review. Dentistry 6: 367.
doi:10.4172/2161-1122.1000367