Pain seminar

PAIN
Definition
• Unpleasant emotional experience usually initiated by noxious stimuli and transmitted
over a specialized neural network to the CNS where it is interpreted as such –
MONHEIM
• Latin – poena meaning punishment
• Always subjective
• Indicator of tissue damage and most common reason for patients to seek medical help

Etiology
Caused by various stimuli called Noxious stimuli
 Mechanical – cuts, burns, stab injuries
 Chemical – Prostaglandins, Bradykinin
 Thermal – extreme heat and cold
Receptors
• Nociceptors are sensory receptors that detect signals from damaged tissue or the threat
of damage and indirectly also respond to chemicals released from the damaged tissue.
• Nociceptors are free nerve endings found in the skin, muscle, joints, bone and viscera.
• Nerve endings contain transient receptor potential (TRP) channels that sense and detect
damage. The TRP channels are similar to voltage-gated potassium channels
• Types – high threshold mechanonociceptors, chemical nociceptors, thermal nociceptors
and polymodal nociceptors.
Silent Nociceptors
• In the skin and deep tissues there are additional nociceptors called "silent" or "sleep"
nociceptors.
• These receptors are normally unresponsive to noxious mechanical stimulation, but
become “awakened” (responsive) to mechanical stimulation during inflammation and
after tissue injury
• One possible explanation of the "awakening" phenomenon is that continuous
stimulation from the damaged tissue reduces the threshold of these nociceptors and
causes them to respond. This activation of silent nociceptors may contribute to the
induction of hyperalgesia, central sensitization, and allodynia. Many visceral
nociceptors are silent nociceptors.
Factors activating nociceptors
 Glutamate
 Aspartate
 Prostaglandins
 Bradykinin
 Substance P
Factors inhibiting nociceptors
 Serotonin
 GABA
 Endorphins
 Enkephalins
 Dynorphin
 Pain fibres
A – delta fibres
Myelinated fibres
Fast conduction velocity (5-40 m/s)
Receptive fields are small
More accurate localization of pain
2-5mm in diameter
Carry information from mechanical or mechano thermal- specific nociceptors
C fibres
 Unmyelinated fibres
Slow conduction velocity (0.5-2 m/s)
Receptive fields are large
Diffuse pain; no concrete localization
Mainly associated with chronic pain

Classification of pain
Pain

Duration Pathogenesis Location Cause

Acute Nociceptive Head Burns

Neuropathic Neck Tumours

Chronic

Psycho Odontogenic
somatic Face pain

Referred Other body

pain parts

Acute pain
 Acute pain

Somatic Visceral

Deep Angina pectoris,

Superficial
Eg: fractures, peptic ulcer, renal
Eg: cuts or burns calculi
arthritis

Chronic pain
Chronic pain is prolonged pain lasting for months or longer that arises from tissue
injury, inflammation, nerve damage, tumor growth, lesion or occlusion of blood
vessels.
Peripheral sensitization
• Prolonged exposure of receptors to noxious stimuli along with release of chemical
substances
• Silent nociceptive neurons get stimulated
• A small stimulus like light touch will result in severe pain signals to the brain
Central sensitization
• The outcome of peripheral sensitization results in a greater and more persistent barrage
of nerve impulses firing in the CNS.
• The persistent barrage of nerve impulses results in long-term changes in nerve cell
activity at the level of the spinal cord and higher centers in the brain.
• central sensitization persists after the injury apparently has healed.
Substances released during peripheral sensitization
• Calcitonin gene related peptides
• Substance P
Substances released during central sensitization
• Arachidonic acid derivatives
• Glutamate

Acute Vs Chronic pain

Classification based on pathogenesis
Neuropathic pain
• Neuropathic pain is a sharp, shooting and devastating pain.
• It is a persistent pain that arises from functional changes occurring in the CNS
secondary to peripheral nerve injury. Once the nerve is damaged, the damaged nerve
elicits sustained activation of nociceptors and/or nociceptive afferents.
• The neuropathic pain is due to an abnormal activation of the nociceptive system without
specifically stimulating the nociceptors.
• Neuroplastic changes occurring in the CNS secondary to the afferent barrage are
believed to culminate in CNS neuronal hyperexcitability.
• Many scientists suggest that “sensitization” of the nervous system following injury is a
factor in neuropathic pain. Neuropathic pain can usually be controlled by anti-
inflammatory drugs and opioids. In some cases, such as in diabetics, AIDS, cancer, etc.,
no treatment or relief is available to neuropathic pain.
Mechanism of Neuropathic Pain

Trigeminal Neuralgia
  TN also known as TIC DOULOUREUX, is described as the most excruciating pain
known to humanity. The pain typically involves the lower face and jaw, although
sometimes it affects the area around the nose and above the eye.
• This intense, stabbing, electric shock-like pain is caused by irritation of the trigeminal
nerve, which sends branches to the forehead, cheek and lower jaw. It usually is limited
to one side of the face.
• Attacks of trigeminal neuralgia may be triggered by the following: Touching the skin
lightly, Washing, Shaving, Brushing teeth, Blowing the nose, Encountering a light
breeze.

Psychosomatic Pain
• The sensation of pain can be influenced by emotions, past experiences and suggestions.
The same stimulus can elicit different responses in different subjects under the same
conditions.
• Recently, Positron Emission Tomography (PET) has been used to study pain pathways
and psychosomatic pain centers. For example, volunteers had their hands dipped in hot
water (50° C) while they were conscious. They then dipped their hand again in hot
water (50° C) after a post-hypnotic suggestion that the pain would be either more or
less unpleasant than the first time. The PET scans of their brains showed that activity
in the anterior cingulate cortex changed in accordance with how unpleasant they
expected the pain to be.
• However, the intensity in the primary somatosensory cortex remained constant (i.e., the
emotional component of pain is independent of its sensation).
Referred pain
• Referred pain is a painful sensation at a site other than the injured one.
• The pain is not localized to the site of its cause (visceral organ) but instead is localized
to a distant site.
• axons carry pain information from the viscera enter into the spinal cord by the same
route as the cutaneous pain sensation axons.
• Within the spinal cord there is a convergence of the information on the same
nocineurons. This convergence gives rise to the phenomenon of referred pain
Theories of referred pain
Dermatomal Rule
When pain is referred, it is usually to a structure that developed from the same embryonic
segment or dermatome as the structure in which the pain originates. Radiating pain down the
left arm is the result of a myocardial infarction , or pain originating from the shoulder
(dermatomes 3-5)
Convergence Theory
Inputs from visceral and skin receptors converge on the same spinal cord neuron . It is referred
to skin area because the nociceptors' terminals from the viscera terminate in the spinal cord on
the same neurons that receive input from the skin.
Irritable Focus Theory
Pain impulses from the viscera alone are unable to pass directly from spinal cord neurons to
the brain, but create an "irritable focus". When visceral and skin impulses arrive together, the
information transmitted to higher centers and the brain interprets the pain as being from the
skin
Phantom Limb
Phantom (illusory) Pain Phantom or illusory pain is the experience of pain without any signals
from nociceptors. It occurs in a subject with previous injuries such as amputation in which the
dorsal roots are literally absent from the cord.
Even though no sensory signals can enter the cord, the subject often feels extreme pain in the
denervated parts of the body. For example, an amputee will often apparently feel pain in a part
of his body that has been removed.
The phenomenon of phantom limb pain is a common experience after a limb has been
amputated or its sensory roots have been destroyed in which the pain is felt in a part of the
body that no longer exists. Pain from an amputated arm is referred to the viscera as a result of
disruption to the “balance” between different peripheral inputs to the dorsal horn. A complete
break of the spinal cord also often leads to a phantom body pain below the level of the break.
The source of phantom pain is complex and not well understood.
It has been suggested that there may be abnormal discharges:
1) from the remaining cut ends of nerves which grow into nodules called neuromas,
2) from overactive spinal neurons,
3) from abnormal flow of signals through the somatosensory cortex, or
4) from burst-firing neurons in the thalamus.

Terminologies related to pain

 Hyperalgesia
 Hyperalgesia is an increased painful sensation in response to additional noxious
stimuli.
 Explanation for hyperalgesia is that the threshold for pain in the area
surrounding an inflamed or injured site is lowered.
 Allodynia
 Allodynia is pain resulting from a stimulus that does not normally produce pain.
Eg: light touch to sunburned skin produces pain because nociceptors in the skin
have been sensitized as a result of reducing the threshold of the silent
nociceptors.
 When peripheral neurons are damaged, structural changes occur and the
damaged neurons reroute and make connection also to sensory receptors
 Congenital analgesia
 Some people lack the sense of pain. They do not respond to painful or any
noxious stimuli.
  It may be caused by conditions that lead to increased production of endorphins
in the brain. This disorder can also be caused due to aberrations in the voltage-
gated sodium channel SCN9A
Anatomy of the spinal cord

• Tracts that serve to join brain to the spinal cord

• Ascending – lateral spinothalamic tract, spinocerebellar tract, spinotectal tract,
spinoreticular tract
• Descending – corticospinal tract, coticobulbar tract
Pathways of pain conduction
First order neurons
 Cell body is located in the dorsal root ganglion.
 Pseudounipolar neurons
 The Axon (central process) passes to the spinal cord through the dorsal root of spinal
nerve
 Synapses with second-order neurons in the cord and medulla oblongata
Second order neurons
 Has cell body in the spinal cord or medulla oblongata
 Two types
 •Nociceptorspecific primarily in LAMINA I
 •Wide Dynamic Range(WDR) neurons primarily in LAMINA V
 Axon decussate & Terminate on 3rd order neuron

Third order neurons

Located in the thalamus and send fibers to somatosensory areas 1 and 2 in the postcentral gyrus
of the parietal cortex
• Perception and discrete localization of pain take place in this cortical areas.
Physiology of pain
TRANSDUCTION
• During this stage, noxious stimuli trigger the release of mediators of inflammation that
sensitize nociceptors. Noxious or painful stimulation also causes movement of ions
across cell membranes, which excites nociceptors.
TRANSMISSION
• Includes 3 segments.
• 1.pain impulse travels from the peripheral nerve fibers to the spinal cord.
• 2. Transmission from the spinal cord via spinothalamic tracts, to the brain stem and
thalamus.
• 3. Involves transmission of signals between thalamus to the somatic sensory cortex
where pain perception occurs.
MODULATION
• Occurs when neurons in the thalamus and brain stem send signals down to the dorsal
horn of the spinal cord. These descending fibers release substances such as endogenous
opoids, serotonin, and norepinephrine which can inhibit the ascending noxious(painful)
impulses in the dorsal horn.
PERCEPTION
• Is when the client becomes conscious of the pain. Pain perception is the sum of complex
activities in the Central Nervous System that may shape the character and intensity of
pain perceived and ascribe meaning to the pain.

Lateral spinothalamic tract

Pain from face

Theories of pain transmission

Specificity theory – Descartes (1667) & Muler (1840)
One of the earliest pain theory.
• Proposed by Descartes in seventeenth century (1664) and Muler(1840).
• Distinct pain receptors-free nerve endings in the tissue which transmit the sensation
to specific areas in the brain
• Pain is purely an afferent sensory experience. It is considered to be a specific modality
Pattern theory – Goldschneider (1896)
 Proposed by Goldschneider in 1896 and expanded by Weddell and Sinclair in 1947
  Pattern of stimulation of nerve endings determines whether the brain would interpret
stimuli as pain. Pain receptors share endings or pathways with other sensory modalities
but different patterns of activity of the same neurons can be used to signal and
differentiate between painful and non – painful stimuli.
 Eg. Light touch applied to skin would produce the sensation of touch and intense
pressure would produce pain through high frequency firing of the same receptor.
Neuromatrix theory – melzack
 This theory was put forward by MELZACK
 This theory explains the role of brain in pain as well as the multiple dimensions and
determinants of pain
 This theory states that the brain contains a widely distributed neural network called the
body self Neuromatrix that contains somatosensory, limbic, & Thalamocortical
components.
 The body self Neuromatrix involves multiple input sources such as : Somatosensory
inputs , Other impulses/ inputs affecting the interpretation of the situation, Various
components of stress regulation systems and Intrinsic neural inhibitory modulatory
circuits
Gate control theory – melzack & wall 1965

Diagnosis of pain
PAIN ASSESSMENT
Pain History
• O – Onset
• P – Provoking / Palliating factors
• Q – Quality / Quantity
• R – Radiation
 • S – Severity
• T – Timing
Unidimensional approaches
Verbal rating scale
Visual analogue scale
FACES rating scale
Multidimensional approaches
McGill pain questionnaire
Neuropathic pain questionnaire
Brief pain inventory
Verbal rating scale
Response is noted as
None
mild
moderate
severe
Advantage - short, easy to express and understand especially in elderly
Disadvantage - lack of reproducibility

Visual Analogue Scale

10 cm horizontal line is present
the distance from no pain to the patient mark indicates the severity of pain numerically
Advantage - simple, efficient , valid, and minimally intrusive
Disadvantage - more time consuming than others & some difficulty in understanding in elderly
FACES rating scale – Wong & Baker

Advantages
when the communication with the patient is difficult as with the pediatric and patients with
speech and hearing impairment
Disadvantage
Cannot be used in children below 2 years of age and in patients with motor and cognitive
disabilities
McGill Pain Questionnaire
Defines pain in 3 major dimensions by 20 set of descriptive words divided as-
a. 10 sets describes sensory- discriminative (nociceptive pathway)
b. 5 sets describe motivational –affective (reticular and limbic structure)
c. 1 set describe cognitive evaluative
d. 4 sets describe miscellaneous dimensions.
Advantage
Helps in diagnosis as choice of descriptive words that characterize the pain
It correlates well with pain syndromes.
Disadvantage
high level of anxiety and psychological disturbances can obscure the MPQ
discriminative capacity.
Brief Pain Inventory
Measures both the intensity of pain (sensory dimension) and its interference with the
patient life(reactive dimension)
Advantage
Valid for cancer pain and various pain syndromes
Shows good sensitivity to T/t.
Helps in comparing international trials with different culture and population

Neuropathic Pain Questionnaire

The NPQ is a self questionnaire consisting of 12 items :
10 related to sensations or sensory responses
2 related to affect
Each item is scored on a scale of 0(no pain ) to 100(worst possible pain)
Management of pain
• Non pharmacological methods
• Pharmacological Methods
• Surgical methods
Non Pharmacological methods
• Application of superficial heat
• Cryotherapy
• TENS
• PENS
• Acupuncture
• Acupressure
• Placebo therapy
Application of superficial heat
Heat can produce heating effects at a depth limited to between 1 cm and 2 cm.
It has been found to be helpful in diminishing pain and decreasing local muscle spasm.
Superficial heat, such as the hydrocollator pack, should be used as an adjunct to
pharmacological methods.
It is most often used during the acute phases of treatment when the reduction of pain and
inflammation are the primary goals.
 Hydrocollator pack for heat application

Cryotherapy
Cryotherapy can be achieved through the use of ice, ice packs, or continuously via adjustable
cuffs attached to cold water dispensers.
Intramuscular temperatures can be reduced by between 3 °C and 7 °C, which functions to
reduce local metabolism, inflammation, and pain.
Cryotherapy works by decreasing nerve conduction velocity, termed cold-induced neuropraxia,
along pain fibers with a reduction of the muscle spindle activity responsible for mediating local
muscle tone.
It is usually most effective in the acute phase of treatment, though it can be used by patients
after their physical therapy

Cryotherapy
Transcutaneous electrical nerve stimulation (TENS)
During TENS procedures, a small battery-operated device is worn by the patient and electrodes
are typically placed on the surface of the skin, over the area where the pain is felt.
Low level electrical current is then applied for usually about thirty minutes, several times
throughout the day.

TENS Apparatus
Percutaneous electrical nerve stimulation (PENS)
The PENS procedure is similar in concept to TENS.
The main difference is that instead of using the surface electrodes seen in TENS devices, PENS
uses needle probes as electrodes that are inserted through the skin. These needle probes are
typically placed next to the nerve causing painful neuropathy symptoms and then stimulated.
PENS can be used in people who do not get sufficient pain relief from TENS

PENS Apparatus
Acupuncture
Traditional Chinese acupuncture involves the insertion of extremely fine needles into the skin
at specific "acupoints."
This may relieve pain by releasing endorphins, the body's natural pain- killing chemicals, and
by affecting the part of the brain that governs serotonin, a brain chemical involved with mood.
Acupuncture is generally quite safe, and the complication rate appears to be quite low.
However improper use of the technique can result in serious complications such as oculomotor
nerve injury, hematomas, hemorrhage and sepsis.
Acupuncture in dentistry
It is used to treat
• Odontogenic pain
• TMJ pain
• Atypical facial pain
• Xerostomia
• Neuralgia
• Parasthesia
Acupressure
Acupressure points (also called potent points) are places on the skin that are especially
sensitive to bioelectrical impulses in the body and conduct those impulses readily.
Stimulating these points with pressure, needles, or heat triggers the release of
endorphins, which are the neurochemicals that relieve pain.
As a result, pain is blocked and the flow of blood and oxygen to the affected area is
increased. This causes the muscles to relax and promotes healing.
Because acupressure inhibits the pain signals sent to the brain through a mild, fairly
painless stimulation, it has been described as closing the "gates" of the pain-signaling
system, preventing painful sensations from passing through the spinal cord to the brain.
Besides relieving pain, acupressure can help rebalance the body by dissolving tensions
and stresses that keep it from functioning smoothly and that inhibit the immune system.
Acupressure enables the body to adapt to environmental changes and resist illness.
Pharmacological management of pain – WHO pain ladder

Step 1 – non opioid analgesics – NSAID’s

Mechanism of action of NSAID’s

Common NSAID’s used in dentistry

• Aceclofenac 100mg, paracetamol 325mg – Zerodol P
• Ibuprofen 400mg, paracetamol 500mg – Imol, Combiflam
• Caffeine 25mg, ibuprofen 400mg, paracetamol 325mg – Imol Plus
• Ketorolac 10mg – Ketorol
• Aceclofenac 100mg, Paracetamol 325mg, Serratiopeptidase 10mg- Acecloren,
Acekem-SP
• Diclofenac Potassium, Serratiopeptidase- Acfast d, Aldase D (50mg)
• Diclofenac Sodium, Serratiopeptidase- Actimol S, Alnec -S
• Diclofenac Potassium, Chymotrypsin- Alfapsin-D, Alzibit-D

Step 2 – opioid analgesics

Mechanism of action of opioid analgesics
Surgical management of pain
Cordotomy - In the thoracic region , the spinal cord opposite to the side of pain is partially cut
to interrupt the spinothalamic tract

Thalamotomy - Involves cauterization of specific pain areas in the intra thalamic nuclei in the
thalamus, which often relieves suffering type of pain.

Sympathectomy - Involves 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.
Used to treat trigeminal neuralgia.

Pre Frontal lobotomy - Surgical process involving division of one or more nerve tracts that
connects the thalamus to the prefrontal and frontal lobes of the cerebral cortex.

References
1. Text book of medical physiology – Sembulingam
2. Text book of physiology – AK Jain
3. Text book of Oral surgery – Neelima Anil Malik
4. Text book of Oral Medicine – Burkitts
Questions Unanswered:
1. Balanced analgesia
2. Patient controlled analgesia
3. Factors affecting pain
4. Expansion of OLDCART – pain diagnosis