Pain in dentistry

Pain in dentistry

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  PAIN in Dentistry theories pathways, types diagnosis Dr.AASHNA DHINGRA
 Postgraduate student (II year) Dept. of Public Health Dentistry
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  INTRODUCTION Pain is avital function of the nervous system, in providing the body with a warning of potential or actual injury.
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  DEFINITION “ an unpleasantsensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage ” International Association for the study of Pain (IASP) Monheim “ an unpleasant emotional experience usually stimulated by a noxious stimulus and transmitted over a specialized neural network to the CNS where it is interpreted as such.”
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  HISTORY Greek word ‘poin’- meaning penalty Latin word ‘poena’ - punishment from god. Aristotle- first to distinguish the 5 physical senses. Considered pain to be the ‘passion of the soul’.
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  HISTORICAL Theories Hippocrates -imbalance in vital fluids. 1664-Rene descartes - disturbance in nerve fibers that reaches the brain. 1955 - G. Wedell - proposed that all skin fiber endings (with the exception of those innervating hair cells) are identical, and that pain is produced by intense stimulation of these fibers. 20th century - “Gate Control Theory”- Ronald Melzack and Patrick Wall. proposed that both thin (pain) and large diameter (touch, pressure, vibration) nerve fibers carry information from the site of injury to two destinations in the dorsal horn of the spinal cord, 
 and that the more large fiber activity relative to thin fiber activity at the inhibitory cell, the less pain is felt.
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  Changing Concepts ofPain During recent years concept of pain has evolved. It is now recognized as being an experience than just a sensation. Cognitive - which represents a subject’s ability to comprehend and evaluate the significance of experience. Emotional - represents the feelings that are generated. Motivational - which has to do with the drive to eliminate pain.
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  3 Dimensions ofPain In 1968 Ronald Melzack and Kenneth Casey described pain in terms of its three dimensions: "sensory-discriminative" (sense of the intensity, location, quality and duration of the pain), "affective-motivational" (unpleasantness and urge to escape the unpleasantness), and "cognitive-evaluative" (cognitions such as appraisal, cultural values, distraction and hypnotic suggestion)
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  Concept Today.. “intensive theory” thata pain signal can be generated by intense enough stimulation of any sensory receptor. At the peripheral end of the nociceptor, noxious stimuli generate currents that, above a given threshold, send signals along the nerve fiber to the spinal cord. The "specificity" (whether it responds to thermal, chemical or mechanical features of its environment) of a nociceptor is determined by which ion channels it expresses at its peripheral end. Wilhelm Erb’s
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  Noxious stimulus leadsto electrical activities in the sensory nerve endings. Neural events that carry the nociceptive input into the CNS for processing. Ability of CNS to control the pain transmitting neurons. Nociceptive inputs reaches the cortex where perception occurs which immediately initiates a complex interaction in the neurons between higher centers of the brain. NEUROPHYSIOLOGY OF PAIN
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  THEORIES OF PAIN 1.INTENSITY THEORY 2. SPECIFICITY THEORY 3. PATTERN THEORY 4. CHEMICAL THEORY 5. LINDHAL’S BIOCHEMICAL THEORY 6. GATE CONTROL THEORY
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  INTENSITY THEORY Erb -1874 Pain is a non specific sensation and is stimulated only by high intensity stimulation. Not Accepted - trigeminal neurlagia, pt. can suffer pain by merely gentle touch of trigger zone.
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  SPECIFICITY THEORY Von Frey- 1895 Body has a separate sensory system for perceiving pain. Meissner corpuscles - touch Ruffini end organs - warmth Krausse end bulbs - cold Nociceptors - pain (eg: C fibers) Not Accepted - does not account for wide range of physiological factors that affect our perception of pain.
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  PATTERN THEORY Goldscheider 1920 Proposedthat pain is generated by non specific receptor. Assumed that all peripheral nerve fibre endings are alike and that pattern for pain is produces by more intense stimulation than for other sensations. Nerve impulse entering CNS is diff. for diff. persons depending on anatomic variation.
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  CHEMICAL THEORY Balance betweenthese two groups of chemical messengers determines the pain outcome.
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  LINDHAL’s BIOCHEMICAL THEORY Acc.to this, alteration in the local pH in the vicinity of nerve is the cause for pain. Eg: Pain of abscess (due to acidic environment) - can be reduced by increasing alkalinity of the area. ACIDITY - Causes pain ALKALINITY - Reduces pain
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  GATE CONTROL THEORY RonaldMelzack and Patrick Wall 1965 Small fibers relay impulses to the cells of substantial gelatinous Large fibers relay impulses - marginal cells of posterior grey horn Large fibers had ability to modulate synaptic transmission of small fibers within the dorsal horn Large fiber creates a hypothetical gate that can open or close the system to pain stimulation
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  INNERVATION OF THEHEAD Somatic and visceral sensory innervation : Trigeminal Nerve (V), partly by glossopharyngeal (IX), and vagus (X). Voluntary Motor Innervation : 
 Occulomotor (III)
 Trochlear (IV) 
 Abducent (VI)
 Facial Nerve (VII) - muscles of expression
 Motor branch of Trigeminal (Vm) - Muscles of mastication
 Glossopharygeal (IX) - swallowing Autonomic Motor Innervation :
 entire sympathetic supply to smooth muscles is from Superior Cervical Sympathetic Ganglion.
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  OROFACIAL PAIN
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  Pain due tolocal causes A. Pathological changes in teeth and jaws B. TMJ and associated muscles of mastication C. Nose and paranasal diseases D. Oral mucosal diseases E. Lymph node diseases F. Salivary gland disease G. Diseases of blood vessels Pain along nerve trunk and central pathways A. Trigeminal neuralgia and glossopharyngeal neuralgia B. Migraine C. Atypical facial palsy Referred pain from other organs A. Cervical spondalities B. Angina pectoris C. Oropharygeal diseases ETIOLOGICAL CLASSIFICATION
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  1. Experimental Noxious stimulicauses mild uncomfortable or painful sensation. 2. Transient
 Short duration Severe Self limiting 3. Acute Pathological Pain
 Sharp, fast, pricking Occurs very rapidly
 Carried by large diameter A𝛿 fibers.
 Usually alleviated with professional help 4. Chronic Pathological Pain Burning, aching
 Gradually decreases
 Non myelinated C fibers
 Persistent pain that may last for months to years
 Little apparent cause
 Pain often increases over time Based on onset, duration and quality of pain
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  2. NON-INFLAMMATORY PAIN
 Poorlyunderstood, psychic and chronic. 1. INFLAMMATORY PAIN
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  Primary afferent fibers SensoryReceptors Related to tooth
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  OROFACIAL PAIN PATHWAY Somaticinputs from the face and oral structures do not enter the spinal cord by way of spinal nerves. Instead, sensory input from the face and mouth is carried by way of the fifth cranial nerve, the trigeminal nerve.
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  BASIC
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  Primary somatosensory OROFACIAL PAIN PATHWAY
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  • Visceral incharacter and is of threshold type. • Responds to all types of noxious stimuli but to ordinary masticatory function. • Non-localisable • A basic clinical feature is that it does not remain the same indefinitely. • Generally it resolves, becomes chronic or proceeds to PDL structures. DENTAL PAIN OF PULPAL ORIGIN
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  • Deep somaticpain of musculoskeletal type. • More localized than pulpal pain. • Intimately related to biomechanical function (masticatory) • Receptors of PDL are capable of precise localization. • Characterised by discomfort during biting - Under occlusal pressure - tooth feels sore or elongated. DENTAL PAIN OF PDL ORIGIN
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  DIAGNOSIS OF PAIN
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  1. The chief complaint- Location of pain Onset of pain - Associated factors
 Progression Characteristics of Pain
 - Quality of pain
 - Behavior of pain Intensity Flow of the pain Aggravating and Alleviating factors Past consultation and treatments Relationships to other complaints 2. Past Medical History 3. Psychological Assessment
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  LOCATION • Indicates whetherthe pain is intraoral/extra oral • Diffused or localized . • Precise or vague • If referred pain is present then it indicates the extent ONSET • Pt should relate when the signs of present complaint were first perceived • The origin and mode of onset is important to determine the chronicity of pain. A long continued pain with insidious onset indicates chronic nature of the disease, whereas a recent onset of pain with sudden impact indicates acute nature of disease.
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  TYPE OF PAIN –Vague pain: It is a mild continuous pain, e.g. periodontal pain – Burning pain: Pain usually occurs with the burning sensation, e.g. reflex oesophagitis. – Throbbing pain: Type of pressured throbbing sensation is felt, e.g. in abscesses. – Stabbing pain: Sudden, severe, sharp and short-lived pain, e.g. acute pulpal pain. – Shooting pain: Pain increases in severity in a short period, e.g. trigeminal neuralgia.
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  INTENSITY OF PAIN Indicatesthe tissue damage and to some extent reflects the EXTENT of damage FEAR of dental procedures - exaggerate perceived symptoms - causing an inconsistency b/w the symptoms & pulpal pathosis. DURATION OF PAIN In terms of days/months/years. The clinician asks ‘how long the pain lasts’? Pain can be intermittant or continuous. A continuous pain is the one which persists for a longer duration. An intermittent pain is the one which occurs after short intervals of time.
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  AFFECTING FACTORS Affecting Factors-aggravating,relieving or altering the symptoms Postural Changes Maxillary sinus involvement :HEADACHE/jaw pain accentuated by jogging, bending over, blowing of nose The pain of cracked tooth syndrome occurs when the patient relieves the occlusal pressure over the tooth.
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  TOOLS TO MEASUREDEGREE OF PAIN OR DISCOMFORT Non verbal self-report technique Age and measure of pain intensity Visual analog scale Pain thermometer scale Color selection Heart rate in response to pain stimuli
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  Age Self- report measures Behavior Measures Physiologic measures Birth-3years Not available Of primary importance Of secondary importance 3-6 years Specialized, developmentally appropriate scales available Primary if self- report not available. Of secondary importance. >6 years Of primary importance Of secondary importance Of secondary importance. Age and measure of pain intensity
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  Visual Analogue Scale Unidimensionalmeasure of pain intensity. used mostly in research studies.
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  Pain Thermometer Scale
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  Color selection Tool
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  PUBLIC HEALTH PERSPECTIVE ONDENTAL PAIN Complete knowledge of dental pain paves a way for evidence based oral health care.
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  The order ofbirth of the child, being the middle child and youngest son, and a history of dental pain (OR: 84.477, 95%CI:33.076-215.759) were found to be indicators of perceived impact on OHRQoL among preschool children.
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  CONCLUSION: Dental painis related to dental caries experience and activity and to socioeconomic and psychosocial factors, showing the need for further attention to these conditions. From 592 participants, 33.44% have reported dental pain as reason for their most recent dental appointment. After statistical analysis, dental pain was associated with low income (p = 0.04), higher number of people living in the same home (p < 0.01), low frequency of daily tooth brushing (p = 0.01), long interval between dental appointments (p < 0.001), longer time elapsed since last dental appointment (p < 0.001), dental anxiety (p < 0.01), consumption of cariogenic food (p = 0.03), high dental caries experience (p < 0.01) and with the presence of untreated dental caries (p < 0.001).
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  REFERENCES Textbook of OrofacialPain and Headache - Yair Sharav and Rafael Benoliel A practical manual of Public Health Dentistry - by CM Maurya Serpell M. (2006) Anatomy, physiology and pharmacology of pain. Surgery 24 (10): 350-353
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  PAIN MANAGEMENT in DENTALOFFICE PREVIOUSLY : theories pathways mechanism diagnosis Various Orofacial Pains Non pharmacological Pharmacological
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  NON-INTERVENTIONAL
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  The 1st stepof Psychological comfort is attempt to call the patient by his first name Gaining confidence of the patient - 
 proper instruments applied with skill. Explain the procedure in simple words and not medical terms. Show and not just explain. Meet the Patient..
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  Pain and anxiety Enhancingcontrol and information - Tell show do approach Ask permission before adjusting chair positions, or before giving injections. Modifying attention and Using Distraction - background music. Relaxation Paced Breathing Biofeedback : pulse meter to monitor heart rate. Desensitization : (Cognitive behavioral psychology)- for long standing dental fears. Pt. is taught relaxation and paced breathing. Then each stimuli is presented in order. Therapeutic recommendations : difficult patient.
 attempt to establish a rapport, then institute prevention-oriented procedure 1st. 
 Analgesics and antibiotics to alleviate pain.
 Referral of overanxious pt. to mental health practitioners for prescribing sedating drugs.
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  Non Pharmacological Interventions BedRest Distraction Therapeutic modalities TENS Superficial heat Ultrasound Cryotherapy Acupuncture Exercise Hypnosis BED REST : beneficial to allow for reduction of muscle spasm brought on by upright activity. DISTRACTION : diversion of one’s attention from pain to something else. TENS (Transcutaneous Electrical Nerve Stimulation) - the local stimulation of sore sites and strong neurologic sites in the region of pain, followed by stretching of the stiff muscle. For Chronic pain conditions, not in acute pain.
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  SUPERFICIAL HEAT :upto a depth of 1-2cm. Diminishes pain and decreases local muscle spasm. ULTRASOUND : Deep heating modality. Not indicated in acute inflammatory conditions. CRYOTHERAPY : reduction of i/m temp. to 3°-7°C by application of cold. (eg: ice) Works by decreasing the nerve conduction velocity along pain fibers. Applied over a region for 15-20min and 3-4times/day. Acute phase of treatment. Bed Rest Distraction Therapeutic modalities TENS Superficial heat Ultrasound Cryotherapy Acupuncture Exercise Hypnosis
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  ACUPUNCTURE : Most commonform of strong counter stimulation. Chronic pain Local needling in sore site and strong neurologic site in the region 30min of low frequency electrical stimulation i.e. 2-3Hz is added by clipping the stimulator directly to the inserted needle. Bed Rest Distraction Therapeutic modalities TENS Superficial heat Ultrasound Cryotherapy Acupuncture Exercise Hypnosis HYPNOSIS : Application of techniques of attention modification, paced breathing and muscle relaxation.
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  Acute Orofacial pain •Caries • Broken restoration • Sensitivity • Abrasion • Gingival • Periodontal Intensity - 6-10 on VAS.
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  Acute Orofacial pain
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  T/T of Dentinalpain • Removal of carious lesion. • Replace existing fractured restorations. • Desensitizing toothpastes. (SnF2 & potassium nitrate) • Tubule blocking agents - resins, GIC, Ca or silica cont. materials. Acute Orofacial pain T/T of Pulpal pain • Extirpation of pulp or Extraction of Tooth. • Analgesics : Acetaminophen (PCM) • Systemic penicillin (Amoxicillin)
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  T/T of Periodontalpain • Recover quickly with local treatment. • Grinding (selective) of tooth to relieve pain. • Irrigation and curettage of pockets. • Antibiotics : Amoxicillin, clindamycin, erythromycin stearate). Acute Orofacial pain T/T of Gingival pain • Correction of faulty contacts between restorations. • Irrigation of debris with saline or antibacterial agent (chlorhexidine) • ANUG : swabbing with ChX, or hydrogen peroxide.
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  T/T of Mucosalpain • Aphthous lesion - topical corticosteroids and tetracycline
 Topical Diclofenac • Acute Herpetic Gingivostomatitis - mild bicarbonate rinse or saline solution.
 Antiviral agents (acyclovir) Acute Orofacial pain T/T of Pain from Salivary gland • Surgical or Endoscopic approaches to remove the block. • In acute bacterial infections - antibiotic therapy.
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  TMJ and Masticatory myofascialpain • Causes: bruxism, occlusal derrangements, • Regional unilateral pain • localise around the ear • Triggers - aggravated during jaw function. • Asso. signs - dizziness, soreness of neck, trismus. Intensity - 0-3 on VAS.
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  Treatment aims inTMJ and Masticatory myofascial pain AIMS THERAPIES Reduce pain Analgesics, tricyclic antidepressants, rest Restore function Physiotherapy, trigger injection, Vapocoolant spray Increase bite comfort Occlusal appliances Reduce psychological stress Information, counseling, cognitive behavioral therapy
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  Vapocoolant spray (ethyl chloride) Oralsplints Occlusal adjustments Pharmacological Simple Analgesics • Nsaids (COX-2): 
 Ibuprofen (400mg TDS)
 Etodolac (1200 mg daily) • Amitriptyline 10-30mg/day • Clonazepam (BZD) • Cyclobenzaprine TMJ Surgery • TMJ Arthrocentesis • TMJ Arthrosocpy • Condylotomy • Arthrotomy
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  Neuropathic Orofacial Pain TRIGEMINALNEURALGIA - U/L - Quality: paroxysmal, sharp, shooting/stabbing - Trigger areas - QoL is much reduced (depressed, anxious) TREATMENT Pharmacological:
 DOC- Carbamezapine (10mg/ ml)
 Baclofen 80mg/day Phenytoin (add on) Intracapsular injections - triamcinolone or dexamethsone TREATMENT Surgical:
 Peripheral procedures- Cryotherapy of peripheral branches Central Procedures - Percutaneous trigeminal rhizotomy - Microvascular decompression -Gamma knife
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  Pharmacological Non-narcotic analgesics Narcotic analgesics Adjuvantanalgesics
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  1986
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  Non-Narcotic NSAIDS - have antipyretic,anti- platelet, anti- inflammatory actions. Prevent the formation of PGs and LTs by inhibitory action on COX (cyclo- oxygenase).
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  Opioids/Narcotic Analgesic Act bydepressing nociceptive neurons while stimulating non-nociceptive cells. Elevates threshold for pain. Alters emotional reaction to pain Specific receptors in CNS Useful in severe acute pain and chronic cancer pain. Contraindicated in chronic orofacial pain.
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  Topical agents Anesthetic agents Givessoothing palliative relief of inflammatory pain. Useful in controlling pain from exposed/ulcerative tissue, exposed dentin and acute alveolitis.
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  Injectable LA LA arealkaloid bases - combine with acids to form water soluble salts. Blockade of sodium channels and thus failure of pain to achieve threshold potential.
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  Vasoactive agents Neurovascular painmay be influenced by alpha adrenergenic blocking action of ergotamine tartrate, which causes stimulating effect on smooth muscles of peripheral and cranial vessels. It is available with or without addition of caffeine. Caffeine enhances vaso- constricting effect
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  Non epinephrine blockers Guanethineand reserpine appears to block the uptake of nonepinephrine by sensitized axons used in treatment of orofacial pain by blocking satellite ganglion These are commonly used in rheumatoid arthritis
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  Muscle Relaxants Used tocontrol myogenous pain Anticholinergics-
 Succinyl Choline
 Methocarbamol For TMJ disorders: Cyclobenzaprine, started at lower dosages (5–10 mg) and taken 1–2 hours before bedtime.
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  Antidepressants Tricyclic antidepressants -increase availability of serotonin in CSF. 
 Amitriptyline 10mg before sleep. MAO inhibitors - increases serotonin by inhibiting its breakdown.
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  Anticonvulsives PHENYTOIN - trigeminalneuralgia, Glossopharyngeal neuralgia. A/E - Gingival hyperplasia.
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  DIET L tryptophan -dietary supplement Increased activity of serotonin - associated with analgesia and enhanced drug potency. 1. L tryptophan 4 grams of per day 2. Low protein, low fat, high carbohydrate 3. Vitamin B-6 10-25 mg/day
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  Create a comprehensivepopulation health-level strategy for pain prevention, treatment, management and research. Accepting the population-based, public health nature of pain prevention and control confronts pain medicine with a major challenge. Necessity - understand the experience of pain, its prevention, and control. CONCLUSION
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  REFERENCES