11/30: Orofacial Pain Flashcards
What is the most prevalent pain in the facial region?
Toothache (odontalgia)
What is included in odontogenic?
Pulpal
Periodontal
What is included in non-odontogenic?
Sinus/nasal
Myofascial
Neurovascular
Neuropathic
Cardiogenic (rare)
Systemic (rare)
Idiopathic
What is the prevalence of temporomandibular disorders?
Females more often than males
Younger adults and older adults
Progression is uncommon
Why do we feel pain?
Instills protective behavior but if unabated, pain can be harmful
What are the principles of pain?
- It is always subjective.
- It may or may not be tied to a stimulus.
- It is always a consequence of an emotional
experience and psychological state.
Why do we experience pain?
- Environmental stimulus (thermal, mechanical, chemical, polymodal)
- Receptor activation
- Generation of action potential
- Transmission through primary afferent to dorsal horn (trigeminal spinal track nucleus)
- Projection from dorsal horn/TSTN to brain for perception and interpretation
- Pain location, intensity, reflexes, and meaning (supraspinal structures)
Nociception is not pain until…
it reaches and is processed
by higher centers (supraspinal structures)
What are the non-opioid inhibitory neurotransmitters?
Serotonin
Noradrenaline
GABA
Glycine
What is influenced by psychological factors?
Supraspinal
Where do supraspinal neurons come from?
The cortex and medulla
Describe the supraspinal medulla
Periaqueductal gray and restroventral medulla
Modulation is….
Always happening
What aspects are included in supraspinal modulation?
Psychological
Emotional
Placebo
What aspects are included in spinal modulation?
Neurotransmitters
Neuropeptides
Interneurons
Endogenous opioids
Central sensitization
What aspects are included in peripoheral modulation?
Peripheral sensitization
Inflammatory mediators
Intense/repetitive/prolonged noxious stimulus
Pain modulation is a dynamic process which means?
Can occur at multiple levels of the ascending and descending pathways
When do neuronal sensitization arise?
When neurotransmitters are left to linger in the synapse
- due to failure in diffusion, enzymatic destruction, reuptake
What kind of effects do neuronal sensitization prolong?
Effect on the post-synaptic neuron
What does neuronal sensitization allow?
Subthreshold input to recruit a response
In neuronal sensitization, the normal input creates an increased…
responsiveness of nociceptive neurons
In neuronal sensitization, the subthreshold input creates a recruitement of a response
Subthreshold input
What kind of sensitization has Nociceptive neurons at periphery of receptive field?
Peripheral sensitization
What is an increased pain experience in response to a painful stimulus?
Hyperalgesia
What are Nociceptive neurons in the central nervous system?
Central sensitization
What does an Increased responsiveness to normal/subthreshold afferent input?
Primary and secondary hyperalgesia
Allodynia
What is Pain resulting from a
stimulus that does not
normally provoke pain?
Allodynia
What is the revised gate control theory?
- Myelinated (fast) non-nociceptive afferent fiber can activate
inhibitory interneurons modulating nociceptive transmission. - Reason you instinctively wave, hold, clench your fingers
when they burn. - Reason why T.E.N.S. helps relieve pain
What is diffuse noxious inhibitor control?
The threshold for nociception can be raised when another
noxious stimulus is provoked in another area
Describe a placebo effect
Psychological
What does a palcebo effect lead to?
Release of endogenous analgesic substances
What are the different ways to categorize different pains?
- Neurophysiology
- Structures involved
- Timing
What is Pain resulting from damage or threatened
damage to non-neural tissue?
Nociceptive pain
What is Pain resulting from the presence of a lesion or disease of the somatosensory nervous system?
Neuropathic pain
What is Pain that arises from altered nociception?
Nociplastic pain
What is Pain with close temporal relationship to a stimulus, injury, or disease?
Acute pain
Describe chronic pain
- Pain that has lasted >3 months.
- Does not typically respond to treatment in a linear dose-dependent fashion.
- Presence of other/multiple ongoing pains is a predictor for transition from acute to chronic.
- More influence of psychosocial factors.
- More difficult to treat
What are the most common psychosocial disorders?
Anxiety
Major depression
Personality disorders
Pain distress
What are coping mechanisms for psychosocial disorders?
- Internal locus of control
- Perceived control
- Catastrophic thinking
- Hypervigilance
- Fear avoidance
What are pain assessments?
- Pain intensity
- Pain distress
- Pain-related interference
Functional limitation, disability - Oral Habits
What is homotopic pain?
Site = source
- treat site of pain, effective
What is heterotopic pain?
Site ≠ source
- treat site of pain, ineffective
What are the 3 types of heterotropic pain?
- Central pain
- Projected pain
- referred pain
What is pain when the Source is central but perceived peripherally?
Central pain
Example: Brain tumor (brain does not have nociceptors)
What is pain when it follows same nerve distribution as primary source?
Projected pain
* Dermatome or motor distribution
* Hyperalgesia may be present
* Example: Post-herpetic neuralgia
What is pain when its different nerve than primary source and is spontaneous (non-provoked)?
Referred pain
* Not aggravated by palpation
* Does not respond to anesthesia at site of pain –must block source of pain
* Does not typically cross midline (only if generated at midline)
* Can refers upward: cervical to trigeminal, mandibular to maxillary
* Example: Mandibular molar affected, but perceived at maxillary molar
Same nerve root
What kind of intents are used when determining what type of treatment goal is appropriate and achievable?
- Curative intent
- Palliative intent
- Limit tissue damage
- Get patient through adaptive phase
- Manage chronic pain
- More aggressive care if palliative care is ineffective to control
symptoms or of there is significantly decreased quality of life
What is the main class of drugs used to reduce pain?
Opioids
ex: codeine, oxycodone, morphine, hydromorphone, meperidine
How long should a patient be treated before being re-evaluated?
10-14 days
