By :Dr. Mustafa Kareem

B.D.S

Unpleasant sensory &emotional experienceassociated with actualor potential tissuedamage or describedin terms of suchdamage.”

• Specialized receptors = free nerve endings

• Stimulation– Mechanical damage

– Extreme temperature

– Chemical irritation

• Two types of neurons– A-delta: first pain, sharp

– C: second pain, dull

Four distinct processes Transduction

Transmission

Modulation

Perception

Origin of pain

1) Nociceptive pain Result of mechanical, thermal or

chemical

Subdivided into• Somatic

• Visceral

2) Neuropathic pain– PNS

– CNS

Duration of pain

1. Chronic

2. Acute

Other types of pain

1. Projected pain

2. Referred pain

3. Phantom pain

• Phantom pain:– Pain coming from a body part that's no longer

exist

– Used to be considered a psychological problem, but now is recognized as real sensations originate in the spinal cord & brain

• Projected Pain:– Pain felt at peripheral ends of nerve, while

stimulus occurred along the course of that nerve.

– Example: pain in TMJ sensed as pain in ear

• Referred pain:– Pain felt in an area distant from that in which

the causative pathology is located

– Example: angina pectoris sensed as pain over the left side of the mandible / pain in lower teeth felt in upper teeth

‡Pain and anxiety are two sides of the samecoin.

Pain can cause a person to be anxious, and an anxiouspatient is likely to experience more pain than a patientwho is not anxious.Therefore interventions that modulate anxiety reducepain. Defining anxious patient and do the necessary toreduce its anxiety is a mean part of pain management

‡Even the most experienced clinician isoften unsure how to interpret apatient’s response to dental treatment. Is itreally pain, or is the patient justjumpy? Is it painful or merely unpleasant?Why is this particular patient soupset?

The dentist may ask certain questions as part of the routine preoperative patient history or during the patient interview

Patient interview questionsIf you had to go the dentist tomorrow, how would you feel about it?When you are waiting in the dentist’s office for your turn in the chair, how do you feel?When you are in the dentist’s chair waiting he or she get’s the drill ready to begin working on your teeth, how do you feel?

When investigating acute dental pain, the history should focus on the pain's:•Location•�type•frequency and duration •Onset•exacerbation and remission (for example the response to heat or cold)•Severity•area of radiation.•Current Medications•History of Allergies •Associated pathology and•referred pain should also be considered.

‡Information regarding a patient’smedications not only provides insightregarding medical status but also may alertthe dentist to possible drug interactions.Careful attention should be paid to anyprescribed medications the patient is takingcurrently or has taken withinthe past month.

‡Patients may label any adverse drugexperience as an allergic reaction.‡Any report of allergy should be furtherquestioned to clarify that signs andsymptoms were consistent withhypersensitivity reactions (i.e., rash,pruritus, urticaria, airway compromise).

‡TongueBuccal mucosa �Floor of the mouth�Hard palateTeeth and periodontal tissuesTonsils �Temporomandibular joints �Airway �Ears �Salivary glands �Lymph nodes.

The following structures need to be

examined carefully in order to be sure that

the pain is of dental origin:

There are several simple tests that may assistin diagnosis of dental pain.

Dry ice, or an ordinary icestick (made in a plastic orglass tube), is placed on thecervical third (neck region) ofthe tooth crown. A responseto the stimulus indicates thatthe pulpal tissue is capableof transmitting nerveimpulses. No response mayindicate pulp necrosis.

Pulp sensitivity test

Using an instrument handle, the tooth istapped in the longitudinal axis. A painfulresponse suggests possible periapicalinflammation

Placing a fine, blunt probegently into the gingivalsulcus surrounding thetooth enables the healthof the gingival tissues tobe assessed. Bleedingand/or sulcus depthsgreater than 3-4 mmindicate gum disease

Percussion test

Probing

Holding a tooth firmly on the buccal andlingual sides between the two instrumenthandles enables mobility to be assessed. Allteeth have a small amount of mobility (<0.5mm), but visible movement suggests loss ofbone support around the root of the tooth.

Careful palpation around the area of concernmay reveal tenderness and the type andextent of swelling

Mobility test

Palpation

If it is possible to obtain a screening radiograph, such as anorthopantomograph (OPG), this may assist in the diagnosis andlocalisation of the cause of the pain. The radiograph shouldshow clearly the apical and periapical structures of teeth andassociated tissues. The relationship of the maxillary molars andpremolars to the floor of the maxillary sinus can be examined,and radiographs may reveal recurrent caries or periapicalradiolucencies associated with an established infection.

Radiographic examination

Teeth and supporting Tissue Disease

Disease of the Jaw

Oral mucosal diseases

Pain in the edentulous patient

Pain triggered by mastication

Referred pain

Neurological diseases

The pulp is capable of a full recovery if the irritating factors subsided or removed

Signs and symptoms:- The pain is moderate to sharp.The pain is of short duration.The pain does not occur without stimulation.No mobility or sensitivity to percussion.Change in the body position do not affect thenature or duration of the pain.The pain is easily to be localized.

The pulp will not recover. The pulp tissue will exhibit a wide spectrum of acute and chronic inflammatory changes.

Signs and symptoms:-Sharp sever pain on thermal stimulation.The pain is continuous after the stimuli isremoved .The pain may be spontaneous or continous.The pain may be exacerbated when thepatient lies down.The pain increases in intensity as a throbbingpressure that can keep the patient awake atnight .The pain is difficult to be localized.No mobility or sensitivity to percussion.

Pain from acute periapical periodontitis should bereadily identifiable as there is precisely localisedtenderness of the tooth in its socket. Radiographs are oflittle value in the early stages but useful after sufficientdestruction shows itself as loss of definition of theperiapical lamina dura.

Acute maxillary sinusitis can rarely cause similartenderness of a group of teeth, particularly uppermolars

The tooth is tenderin its socket,It is vital and thereis deep localisedpocketing.

Acute ulcerative gingivitis usually causes soreness, butwhen it extends deeply and rapidly, destroying theunderlying bone, there may be severe aching pain. Insuch cases the diagnosis is usually obvious clinically.HIV-associated periodontitis presents a somewhatsimilar picture and is acutely painful.

Ulcer generally cause soreness rather

than pain , but deep ulceration may causesever pain.

Carcinoma in particular causes sever

pain once nerve fibers become involved.

Herpes zoster causes sever pain ,

sometime indistinguishable from toothache, (because of involvement of cervical ganglia.

The important feature of these conditions is that, aswell as the history and clinical presentation, theprovisional diagnosis depends on the radiographicfindings.

Fractures and osteomylitis should berecognizable by radiograph.

The differentiation of infected cyst from a malignanttumor is difficult and the diagnosis depends on biopsyand histological examination.

Painful jaw diseases : Fractures Osteomyelitis Infected cysts Malignant neoplasm

These conditions differ from most othersbecause dental causes can be excluded. Thechief difficulty is to decide whether the painis due to the dentures themselves, or tosome condition of the mucosa or jaws onwhich a denture is pressing.

The common dental cause for pain on mastication isapical Periodontitis.

Diseases of teeth and supporting tissuesPain dysfunction syndromeDiseases of the temporomandibular jointTemporal arteritisTrigeminal neuralgia (rarely)Salivary calculi

The least common cause of pain during eating isorganic disease of the temporomandibular joint.

Diseases of the maxillary antrumAcute sinusitisCarcinoma, particularly when it involves theantral floor

Diseases of salivary glandsAcute parotitisSalivary calculiSjogren's syndromeMalignant neoplasms

Diseases of the earsOtitis mediaNeoplasms in this region

Myocardial infarction

Clinical Presentation

• Affects elderly (5th-7th decade)

• Almost always unilateral

• Usually one branch is involved

• Paroxysmal pain – seconds to < 2 min

• Distributed along 5th cranial nerve

• Pain provoked by touching, smiling, eatingor cold air and teeth brushing.

• Asymptomatic between attacks

• Trigger points

Investigations:• Always exclude dental origin (cracked

tooth)• Full cranial nerve assessment• Refer to neurologist if:

– patient <50y – Bilateral presentation– Associated neurological signs or cranial

nerve defect

Suspect multiple sclerosis

Cause:• Demyelination & hyper-excitability of

the nerve induced by vascular pressure• 2% of cases associated with posterior

fossa tumor

Surgical

• for refractory cases

• Simple peripheral cryotherapy or openintracranial procedure

• If these fail , micro vascular decompressionof the trigeminal ganglion may be required.

Medical

• Anticonvulsant– Carbamazepine (100mgX2) up to 1000 mg/day

– Gabapentin

• Start with small initial dose

• Side effects includes drowsiness , dryness ofthe mouth , diarrhea and nausea.

• Similar to Trigeminal Neuralgia

• Less common & less severe

• The pain felt in the base of the tongue andfauces on one side. It may also radiatedeeply into the ear.

• Unilateral pain precipitated by swallowing ,chewing , and coughing.– Pharynx

– Soft palate

– Base of tongue

– Ear

– Mastoid

• Treatment as for TN

TreatmentUnfortunately, postherpetic neuralgia is remarkablyresistant to treatment. Nerve or root section areineffective and the response to drugs of any type.Application of transcutaneous electrical stimulation tothe affected area by the patient himself is sometimeseffective.

– Anticonvulsants (Gabapentin)

– TCAs

– Antiviral in combination with TCA

All patients with HZ infection should be vigorouslytreated with acyclovir to reduce risk of PHN

The pain is more variable in character and severity thantrigeminal neuralgia. It is typically persistent rather thanparoxysmal.

Affect elderly & immunocompromised patientsThe diagnosis is straightforward if there is a history of facial zoster or if scars from the rash are present.

A minority of patients with multiple sclerosis have painindistinguishable from trigeminal neuralgia.

younger persons (under 50) are typically affected.

In about 30%, pain, unlike trigeminal neuralgia, may bepersistent and lack trigger zones, or may spread beyond thetrigeminal area

Disturbances of sensation are distributed according to thesites of lesions in the brain.

The lip may be affected and symptoms may range fromparaesthesia to extreme hypersensitivity, whereby the patientwill literally jump or scream with pain if the lip is touched.

The diagnosis usually depends on the presence of multipledeficits, particularly defects of vision, weakness of the limbs,and sensory losses.

Carbamazepine is sometimes effective for trigeminalneuralgia-like pain, otherwise surgical treatment as fortrigeminal neuralgia may be required.

Migrainous neuralgia is caused by vascular changes at thebase of the skull and may occasionally be mistaken fortrigeminal neuralgia. It is rarely seen in dental practice.

Migrainous neuralgia has many features in common withclassical migraine (hemicrania) and is due to oedema anddilatation of the wall of the internal carotid and probably alsothe external carotid arteries.

Cluster headache mainly affects men, usually young adultsbut up to the age of 50.

Attacks may be precipitated by alcohol or vasodilators, orcome on spontaneously one to three times a day.

Attacks sometimes recur at precisely the same time eachday or may disturb sleep.

Pain is localized to the region of the orbit, or maxilla. Theduration is 0.5-2 hours.

Cluster headache may respond to simple analgesics or toergotamine.

Ergotamine should be given an hour before the expected

attack and is most effective by subcutaneous. Alternatively,ergotamine powder can be inhaled from a spinhaler.

Treatment should preferably be stopped for one day each

week to see whether there has been spontaneous remission.

The eye may become suffused and water, the nostrils may beblocked, the skin over the cheek may become red and theremay be sweating on that side.

Paraesthesia of the lip can cause by Osteomyelitis orFracture of the jaw

Prolonged anaesthesia or paraesthesia of the lip canoccasionally follow inferior dental blocks.

The inferior dental nerve may be compressed by a neoplasmor a tumour may infiltrate the nerve sheath.

The mental foramen can become exposed by excessiveresorption of mandibular bone in an edentulous patient

Tetany is the result of hypocalcaemic states and causesheightened neuromuscular excitability together disorders ofsensation