This document provides information about pain and its relation to periodontics. It begins with definitions of pain, including the International Association for the Study of Pain's definition. It then discusses the historical understanding of pain, classifications of pain, and theories of pain mechanisms. The document outlines the nervous system components involved in pain perception and pathways. It discusses assessment of pain and specific types of periodontal and gingival pain, including their characteristics and diagnostic criteria. Overall, the document provides a comprehensive overview of the physiology and experience of pain as it relates to periodontal conditions and treatments.

1. Pain and its relation to Periodontics
PAIN

2.  Introduction
 Definition
 Historical note
 Classification of pain
 Nervous system
 Theories of pain
CONTENTS :
 Pain pathway
 Assessment of pain
 Periodontal pain
 Gingival pain
 Management of pain
 Conclusion

3. Introduction :
 Pain is a sensory experience of special clinical significance to
dentists.
 Pain is the commonest symptom which dentist are called upon to
treat.
 Pain is intensely subjective experience and is therefore difficult to
describe.

4. First it is unpleasant experience and secondly it is evoked by a
stimulus which is actually or potentially damaging to living tissues.
Although it is unpleasant , pain serve as a protective function by
making us aware of actual or impending damage to the body.
Apart from its obvious applied value, study of physiology of pain
has taught us a lot about diagnosis and treatment plan in general.

5. Definition:
• Pain is an unpleasant sensory and emotional experience associated with
actual or potential tissue damage or described in terms of such damage
(Mersky 1986).
(International Association for Study of Pain)
• 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

6. Historical note :
 The word pain is derived from ‘poine’ meaning penalty or payment, which
certain religious segments have translated it s synonyms for punishment.
 Homer thought that pain was result of arrows shot by god
 Aristotle was the first to distinguish five physical senses considering “pain
as passion of soul”
 Plato described pain as emotional experience more than a localized body
disturbance
 John Bonica- father of pain

7. CLASSIFICATION OF PAIN

8. CLASSIFICATION OF PAIN :
According
to
Duration
Acute Chronic
Textbook of ORAL MEDICINE,
2nd edition, Anil Govind Ghom

9. CLASSIFICATION OF PAIN :
According
to
pain intensity
Mild Moderate Severe
Textbook of ORAL MEDICINE,
2nd edition, Anil Govind Ghom

10. CLASSIFICATION OF PAIN :
According
to
Onset
Spontaneous Induced Trigerred
Textbook of ORAL MEDICINE,
2nd edition, Anil Govind Ghom

11. CLASSIFICATION OF PAIN :
According
to
Type
Nocioceptive Neuropathic Inflammatory
Textbook of ORAL MEDICINE,
2nd edition, Anil Govind Ghom

12. CLASSIFICATION OF PAIN :
According
to
Site of Pain
expression
Primary Heterotrophic
Textbook of ORAL MEDICINE,
2nd edition, Anil Govind Ghom

13. According to temporal relation and duration
Intermitent
Continuous
Protracted
Intractable
Reccurent
Remission
Periodic
Textbook of ORAL MEDICINE,
2nd edition, Anil Govind Ghom

14. According to pain location
Localized
Diffused
Radiating
Migrating
Lancinating
Enlarging
Spreading
CLASSIFICATION OF PAIN :
Textbook of ORAL MEDICINE, 2nd edition, Anil Govind Ghom

15. According to qualities of pain
Steady
Pricking
Paroxymal
Stinging
Bright
Burning
Dull
CLASSIFICATION OF PAIN :
Throbbing
Itching
Aching
Textbook of ORAL MEDICINE, 2nd edition, Anil Govind Ghom

16. NERVOUS SYSTEM

17. NERVOUS
SYSTEM
CNS
BRAIN
SPINAL
CORD
PNS
AUTONOMIC
NERVOUS
SYSTEM
SYMPATHETIC
NERVOUS
SYSTEM
PARA SYMPATHETIC
NERVOUS
SYSTEM
SOMATIC
NERVOUS
SYSTEM

18. PARTS OF NEURON

19. CLASSIFICATION OF NEURONS
BASED ON NUMBER OF MYELIN SHEATH
1) Myelinated
2) Non myelinated
3) Partially myelinated

20. CLASSIFICATION OF NEURONS
BASED ON NUMBER OF SENSATION

21. CLASSIFICATION OF NEURONS
BASED ON FUNCTION
1) Afferent neuron
2) Efferent neuron

22. THEORIES OF PAIN

23. THEORIES OF PAIN MECHANISM
(A) Specificity theory:
 1644, Descartes advocated the concept specific cutaneous receptors pain,
touch, cold, pressure and heat.
 He proposed that free nerve endings gave rise to pain sensation in brain.
 This theory is concerned primarily with the sensory discrimination aspects
of pain, its quality, location on skin, intensity and duration.

24. B) 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.

25. C) Gate Control Theory
 Melzack & Wall 1965
 Combined the strengths of previous theories and added some of its own.
 multidimensionality of the pain experience.
 The term “gate” only refers to the relative amount of inhibition
or facilitation that modulates the activity of the transmission cells carrying
information about noxious stimuli.

26.  Activity in large fibers tends to inhibit transmission (close the gate)
 Small fiber activity tends to facilitate transmission (open the gate).
 Thus the theory recognizes receptor specificity and mechanisms of
convergence, summation and inhibition.

27. D) Central Summation Theory (Livingstone)
It proposed that the intense stimulation resulting from the nerve and
tissue damage activates fibers that project to internuncial neuron
pools within the spinal cord creating abnormal reverberating
circuits with self- activating neurons.
E) Intensive Theory (Erb,1874)
Rather, the number of impulses in neurons determines the
intensity of a stimulus.

28. PAIN PATHWAYS

29. The Trigeminal system
• Sensory input from face and
mouth carried by 5th cranial
nerve.
• The cell bodies of Trigeminal
afferent neurons located in the
large gasserian ganglion.

31. Trigeminal nuclei
The sensory trigeminal nerve nuclei
1. The mesencephalic nucleus
- proprioception
2. The chief sensory nucleus (or "pontine
nucleus" or "primary nucleus") – touch
3. The spinal trigeminal nucleus
– pain & temperature.

32. SENSORY RECEPTORS
 At distal terminals of afferent nerves are
specialized sensory receptors that
respond to physical or chemical stimuli.
 When they are adequately stimulated,
impulse is generated in primary afferent
neuron which is carried centrally to CNS
They are classified as:
 Exteroceptors
 Proprioceptors
 Interoceptors

33. Exteroceptors
Merkels corpuscles
Meissner’s corpuscles
Ruffini’s corpuscles
Krause’s corpuscles
Free nerve endings
Proprioceptors
Muscle spindles
Golgi tendon organs
Pacinian corpuscles
Periodontal mechano receptors
Free nerve endings
Interoceptors
Pacinian corpuscles
Free nerve endings

34. Free nerve ending showing tree-like ramifications near the root
apex.
A Ruffini-like nerve ending near the root apex.
An coiled nerve ending in mid periodontal ligament region.
A spindle-shaped nerve terminal
RECEPTORS OF PDL
Takeiyasu et al.,1990

35. NOCICEPTORS
 Sensory receptors for pain, nociceptors, are naked nerve endings
that terminate in the skin and most other tissues of the body.
 This ‘noxious’ information is transduced by the receptors into an
electrical signal and transmitted from the periphery to the central
nervous system along axons.
Jacobs et al.,1994

36.  These receptors are generally classified according to the type to
which they respond:
1. Mechanosensitive pain receptors respond to mechanical damage.
2. Thermosensitive pain receptors respond to respond to temperature
extremes.
3. Chemosensitive pain receptors respond to chemicals that occur
with damaged tissues
Jacobs et al.,1994

37. Chemical pain mediators
 Nociceptors activated by
 Bradykinin
 Histamine
 Serotonin
 Increased potassium
concentration
 Proteolytic enzymes
 Acetlycholine
 Prostaglandins
 Substance P
 Interleukins
 Leukotrienes
Jacobs et al.,1994

38. First order neuron :
Each sensory receptor attached to first
order neuron which carries impulses to
CNS.
A delta fibres and c fibers terminate on
dorsal horn of spinal cord .
First order neurons ends here.
Tip of the dorsal horn is called Substantia
Gelatinosa Rolandi.

39. General classification :
Type A :
Alpha fibers – 13 to 20 µm diameter – 70 to 120 m/s
Beta fibers – 6 to 13 µm diameter – 40 to 70 m/s
Gamma fibers – 3 to 8 µm diameter – 15 to 40 m/s
Delta fibers – 1 to 5 µm diameter – 5to 15 m/s
Type c :
0.5 to 1 µm diameter – 0.5 to 2 m/s
Erlanger and gasser

40. Carried by A delta fibers
Sharp pricking sensation
Early localized
Occurs first
Carried by C fibers
Dull aching , burning
Poorly localized
Occurs second , persistent for
longer time
Slow painFast pain
Zoterman., 1978

41. Second order neuron
From SGR second order neurons arise
and cross to the opposite and form
spinothalamic tract and end in thalamus.
From thalamus third order neurons
arise to end in sensory cortex in parietal
lobe. Some decending fibers from brain
terminate an SGR.
Third order neuron

42. Tandon et al.,2003

43. Tandon et al.,2003

44. Assessment of pain

45. Assessment of pain
METHOD OF PAIN ASSESSMENT
Comprehensive history intake
 Medical history
 Physical history
 Family history
Physical exam
Questioning on characteristic of pain – onset, duration, location,
quality, severity & intensity
Evaluation of psychological status, functional status, behavior status.

46. Pain assessment tools
 Pain may be accompanied by physiologic signs and symptoms and
there are no reliable objective markers of pain
 The severity of pain can be assessed by rating scales &
multidimensional scales.
Provide a simple way to classify the intensity of pain and should be
selected based
Williamson et al .,2005

47. RATING SCALES
SIMPLE DESCRIPTIVE PAIN INTENSITY SCALE
NO PAIN MILD
PAIN
MODERATE
PAIN
SEVERE
PAIN
VERY
SEVERE
PAIN
WORST
POSSIBLE
PAIN
NUMERIC SCALE
Williamson et al .,2005

48. VISUAL ANALOG SCALE (VAS)
FACES SCALE
Collins et al .,1997

49. VERBAL RATING SCALE
PAIN THERMOMETER
Williamson et al .,2005

50. Periodontal pain
International Classification of Orofacial Pain, version 1.0 BETA
Orofacial pain associated with disorders of dentoalveolar and associated structures
Maria Pigg, Sweden (Chair); Alan Law, USA; Donald Nixdorf, USA; Tara Renton,
UK; Yair Sharav, Israel

51. PERIODONTAL PAIN
 Dental pain caused by a disorder involving the periodontium, meaning
the periodontal ligament and the adjacent alveolar (periradicular) bone
tissue.
 Localized deep throbbing pain
 Inflammation around PDL
 Mobility
 Localized bleeding
 Presence of pocket

52. Periodontal pain attributed to chronic periodontitis
 Periodontal pain due to chronic
periodontitis may present in association
with increased tooth mobility is typically
mild.
 The intensity may be mild to severe.
 The pain can be reproduced by percussion
or by applying pressure to the tooth.
 Most cases of chronic periodontitis are not
painful, but may become painful on
inflammatory exacerbation.

53. Periodontal pain attributed to hyperocclusion
or -articulation
 Sensitization of periodontal nociceptors and an inflammatory
response due to the excessive loading of the tooth.

54. The patient may report that the tooth feels elevated..
The pain can be reproduced by percussion or by applying pressure
to the tooth.
The tooth may have increased mobility, and if so, radiographic
examination may show widening of the periodontal space.
Diagnostic criteria
Periodontal pain has developed in close temporal relation to a
change in occlusal conditions involving the painful tooth
Mechanical provocation reproduces the pain

55. Postoperative periodontal pain
 The pain is typically mild to moderate and may co-occur with
clinically observable swelling and occasionally pus formation.

56. Diagnostic criteria
 Periodontal pain has developed in close temporal relation to a surgical
intervention involving the periodontium.
If physiologic (primary) healing occurs normally, the pain duration is
typically short (1–2 weeks).
Prolonged pain due to secondary healing and/or postoperative infection
is occasionally observed but usually does not exceed 3 months.

57. Periodontal pain due to accidental dental
trauma
 The characteristics and severity of pain, depends on the nature and
severity of the traumatic injury.

58. Diagnostic criteria
Periodontal pain + The history reveals a recent accidental trauma affecting
the tooth.
 The tooth has been diagnosed with a traumatic injury based on clinical
and/or radiographic observations
a. concussion , b. subluxation, c. lateral luxation
d. intrusion , e. extrusion , f. avulsion, g. root fracture

59. Periodontal pain attributed to pulpal
inflammation
 The periodontal inflammation is centered to the
periapical region.
 The pulp is vital and thus the tooth typically responds
to pulp vitality testing.
 The tooth is often tender to percussion.
 Clinical findings may include deep caries,
deep/defective restoration, or external cervical root
resorption.

60. Periodontal pain attributed to Endo-perio lesion

61.  Periodontal pain due to combined endodontic and periodontal lesion
may be symptom free.
 If present, the pain is typically moderate to severe,.
 Although localized, the pain frequently refers to other orofacial sites
on the same side, especially if the pain is severe.
 The pain can be reproduced by percussion or by applying pressure
on the tooth and/or the adjacent periapical vestibular region.

62. Periodontal pain attributed to Necrotizing
Ulcerative Periodontitis
 Periodontal pain due to necrotizing
ulcerative periodontitis is typically severe.
 Pain is provoked by physical stimuli
applied to the affected tooth or surrounding
tissue.
 Pain also occurs spontaneously.
 Clinically, necrotic soft tissue lesions and
loss of attachment can be observed.

63. Periodontal pain attributed to periodontal abscess
 Pain due to this is acute condition is usually severe.
 Although localized, the pain frequently refers to other orofacial sites
on the same side, especially if the pain is severe.
 The pain can be reproduced by percussion or by applying pressure
on the tooth and/or the adjacent periapical vestibular region.
 Imaging shows evidence of marginal and periradicular bone
resorption, which may or may not include the periapical region.

64. Periodontal pain attributed to peri implantitis
 Periodontal pain due to
inflammation surrounding a dental
implant is most frequently
painless, but if pain occurs it is
typically moderate to severe.
Diagnostic criteria
 Periodontal pain that it involves an implant and not a natural tooth,
Clinical and/or radiographic evidence of a peri-implant infection

65. Gingival pain

66. Gingival pain
Diagnostic criteria
 Pain is localized to the site of the gingiva, but may refer to other
ipsilateral orofacial locations
Clinical, laboratory, imaging evidence of a lesion or disease of the
gingival tissues, known to be able to cause pain
1. Pain has developed in temporal relation to the onset or appearance of
the lesion
2. Familiar pain is exacerbated by manipulation of the affected gingival
tissue

67. Gingival pain attributed to gingivitis (gingival
inflammation)
Diagnostic criteria
The pain fulfills criteria for Gingival pain
The patient has been diagnosed with
gingival inflammation based on the clinical
observation of inflammation signs in the
gingiva (i.e. tumor, dolor, rubor, and calor)

68. Gingival pain attributed to pericoronitis
Diagnostic criteria
Severe radiating pain
Inability of closure of mouth
Tissue distal to molar is painful to touch

69. Gingival pain associated with trauma
 Traumatic injury of gingival tissues causes acute inflammation and
can be painful to a varying degree.
 The pain may be mild to severe and is exacerbated by mechanical
provocation of the gingiva.
 Spontaneous pain can occur.

70. Gingival pain associated with viral infections
 Viral infections of the gingival tissues include HSV, VZV, HPV,
CMV, Coxsackievirus and HIV infection.
Diagnostic criteria
The infected gingival tissues may often be ulcerated and painful to
touch.
Severe local pain is often associated with eating or drinking acidic
or hot or cold foods or drinks, which may cause the individual to be
unable to eat or drink and become dehydrated.

71. Gingival pain associated with autoimmunity
 Several dermatological immune-mediated vesiculo-ulcerative
lesions conditions may present with oral mucosal involvement,
either concurrent with the skin pathology, as the initial presentation
or sometimes as the only clinical presentation

72. Diagnostic criteria
The pain fulfills criteria for Gingival pain
The pain may be mild to severe and is exacerbated by mechanical
provocation of the gingiva.
Spontaneous pain can occur.

73. Gingival pain associated with allergic reaction
 The pain may be mild to severe and is exacerbated by mechanical
provocation of the gingiva.
 Spontaneous pain can occur
Diagnostic criteria
 The pain fulfills criteria for Gingival pain
Lesions may present with non-specific tissue oedema, erythema,
cracking, ulceration, hyperkeratotic white plaques or mucosal
desquamation

74. Gingival pain associated with malignant lesions
 Gingival pain related to a
malignant disease can be
painful to a varying degree.
 The pain may be mild to
severe and is exacerbated by
mechanical provocation of the
gingiva. Spontaneous pain can
occur.

75. Diagnostic criteria
Oral squamous cell carcinoma (OSCC) is the most common,
frequently presenting as ulceration with clinical induration, fixation to
the underlying tissues, rolled exophytic margins, and pain and/or
numbness

76. Gingival pain associated with trigeminal neuralgia
Diagnostic criteria
 The pain fulfills criteria for Gingival pain
Trigger points of trigeminal neuralgia may be located in the gingiva,
and
Light touch will elicit the typical intense paroxysmal pain attacks
affecting the whole dermatome corresponding to the affected nerve
branch.
The diffuse deep pain, “pre-trigeminal neuralgia pain”, that sometimes
precedes the onset of characteristic paroxysmal pain.

77. Management of pain

78. Control of Pain
Methods:
1) Removing the cause
2) Blocking the pathway of painful impulses e.g. Local anaesthetics
3) Raising the pain threshold e.g. aspirin and other pharmacological agents.
4) Preventing pain reaction by cortical depression e.g. general anaesthesia
5) Using psychosomatic methods e.g. hypnosis, faith healing

79. Management of Pain:
Special emphasis of pain management
Management of pain should primarily encompass two essential elements
Pain perception control Pain reaction control
1.Removing the cause
2.Blocking the path way
of painful impulses
• Analgesics
1.Preventing pain reaction
by cortical depression.
2.Using psychosomatic methods.
Ex: Conscious sedation.
Behavior management

80. Paracetamol = 500 to 1000 mg every 4 to
6 hours
Ibuprofen = 400 to 600 mg every 6 hours
650 mg of paracetamol + 30 mg of
codeine every 12 hours
325 mg of paracetamol + 37 mg of
tramadol every 12 hours
Ketorolac – 10 mg – selective COX-2
inhibitor every 12 hours
Analgesics
Hargreavas.,2005

81. Midazolam
Flumazenil
Propofol
Ketamine
Nitrous oxide
Temazepam
Diazepam
Trialzolam
Concious sedation
Katherine et al., 2008

82. Visual Reality Distraction
 Furman et al., 2009 Uses
virtual reality distraction for
pain control during scaling and
root planing procedures

83. Local Anesthesia
 Most commonly used to control pain
 Local anesthesia forms the backbone of pain control techniques in
dentistry and local anesthetics are the safest and most effective
drugs in all of medicine for the prevention and management of pain

84. Painless Periodontal Probing
 Uses of intrapocket anesthetic gel during periodontal probing.
 20% benzocaine gel showed favaroble anesthetic efficacy compared
to 2% lidocaine gel in reducing pain on periodontal probing .
Arunkumar et al , 2017

85. Computer-controlled Local Anesthetic
Delivery Systems [CCLAD]
 It is essential to deliver local
anesthetic solution at a
constant rate and slower
speed to avoid causing
discomfort to the patient.

86. Jet Injectors
 Jet injection technology is based on the
principle of using a mechanical energy
source to create a pressure sufficient to
push a liquid medication through a very
small orifice, that it can penetrate into the
subcutaneous tissues without a needle.
 Advantages are painless injection, less
tissue damage, faster injection and faster
rate of drug absorption into the tissues.

87. Vibrotactile Devices

88.  These devices work on the principle of ‘gate control’ theory thereby
reduces pain.
 It acts based on the fact that the vibration message is carried to brain
through insulated nerves and pain message through smaller
uninsulated nerves.
 The insulated nerves overrule the smaller uninsulated nerves.
 The devices are: vibraject, dental vibe, accupal.

89. Dentipatch (Intraoral lignocaine patch)
 Dentipatch contains 10-20%
lidocaine, which is placed on dried
mucosa for 15 minutes.
 Hersh et al (1996) studied the
efficacy of this patch and
recommended it for use in achieving
topical anesthesia for injections in
both maxilla and mandible.

90. Conclusion

91. Conclusion
Every day patient seeks care for the reduction or elimination of pain.
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.

92. References

93.  Tandon OP, Malhotra V, Tandon S, D'silva I. Neurophysiology of pain: insight to
orofacial pain. Indian journal of physiology and pharmacology. 2003 Jul;47:247-69.
 Jacobs R, van Steenberghe D. Role of periodontal ligament receptors in the tactile
function of teeth: a review. Journal of periodontal research. 1994 May;29(3):153-67.
 Chintala K, Kumar SP, Murthy KR. Comparative evaluation of effectiveness of intra-
pocket anesthetic gel and injected local anesthesia during scaling and root planing–A
split-mouth clinical trial. Indian Journal of Dental Research. 2017 May 1;28(3):281.
References :

94.  Okeson JP. Bell's orofacial pains: the clinical management of orofacial pain. Chicago,
Ill, USA: Quintessence Publishing Company; 2005 Jan 1.
 Treede RD, Rief W, Barke A, Aziz Q, Bennett MI, Benoliel R, Cohen M, Evers S,
Finnerup NB, First MB, Giamberardino MA. Chronic pain as a symptom or a disease:
the IASP Classification of Chronic Pain for the: International Classification of
Diseases:(: ICD-11:). Pain. 2019 Jan 1;160(1):19-27.
 Kumar KH, Elavarasi P. Definition of pain and classification of pain disorders.
Journal of Advanced Clinical and Research Insights. 2016 May 1;3(3):87-90.
 Renton T, Durham J, Aggarwal VR. The classification and differential diagnosis of
orofacial pain. Expert review of neurotherapeutics. 2012 May 1;12(5):569-76.

95.  Baume RM, Croog SH, Nalbandian J. Pain perception, coping strategies, and stress
management among periodontal patients with repeated surgeries. Perceptual and
motor skills. 1995 Feb;80(1):307-19.
 Furman E, Jasinevicius TR, Bissada NF, Victoroff KZ, Skillicorn R, Buchner M.
Virtual reality distraction for pain control during periodontal scaling and root planing
procedures. The Journal of the American Dental Association. 2009 Dec
1;140(12):1508-16.
 Hargreaves K, Abbott PV. Drugs for pain management in dentistry. Australian dental
journal. 2005 Dec;50:S14-22.
 Li A, Montaño Z, Chen VJ, Gold JI. Virtual reality and pain management: current
trends and future directions. Pain management. 2011 Mar;1(2):147-57.

96.  McCormack HM, David JD, Sheather S. Clinical applications of visual analogue scales:
a critical review. Psychological medicine. 1988 Nov;18(4):1007-19.
 Maeda T, Kannari K, Sato O, Iwanaga T. Nerve terminals in human periodontal ligament
as demonstrated by immunohistochemistry for neurofilament protein (NFP) and S-100
protein. Archives of histology and cytology. 1990;53(3):259-65.
 Perry DA, Gansky SA, Loomer PM. Effectiveness of a transmucosal lidocaine delivery
system for local anaesthesia during scaling and root planing. Journal of clinical
periodontology. 2005 Jun;32(6):590-4.
 Textbook of oral medicine, 2nd edition Anil Govind Ghom