11/30: Orofacial Pain

Question 1

What is the most prevalent pain in the facial region?

Answer 1

Toothache (odontalgia)

Question 2

What is included in odontogenic?

Answer 2

Pulpal
Periodontal

Question 3

What is included in non-odontogenic?

Answer 3

Sinus/nasal
Myofascial
Neurovascular
Neuropathic
Cardiogenic (rare)
Systemic (rare)
Idiopathic

Question 4

What is the prevalence of temporomandibular disorders?

Answer 4

Females more often than males
Younger adults and older adults
Progression is uncommon

Question 5

Why do we feel pain?

Answer 5

Instills protective behavior but if unabated, pain can be harmful

Question 6

What are the principles of pain?

Answer 6

• 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.

Question 7

Why do we experience pain?

Answer 7

• 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)

Question 8

Nociception is not pain until…

Answer 8

it reaches and is processed
by higher centers (supraspinal structures)

Question 9

What are the non-opioid inhibitory neurotransmitters?

Answer 9

Serotonin
Noradrenaline
GABA
Glycine

Question 10

What is influenced by psychological factors?

Answer 10

Supraspinal

Question 11

Where do supraspinal neurons come from?

Answer 11

The cortex and medulla

Question 12

Describe the supraspinal medulla

Answer 12

Periaqueductal gray and restroventral medulla

Question 13

Modulation is….

Answer 13

Always happening

Question 14

What aspects are included in supraspinal modulation?

Answer 14

Psychological
Emotional
Placebo

Question 15

What aspects are included in spinal modulation?

Answer 15

Neurotransmitters
Neuropeptides
Interneurons
Endogenous opioids
Central sensitization

Question 16

What aspects are included in peripoheral modulation?

Answer 16

Peripheral sensitization
Inflammatory mediators
Intense/repetitive/prolonged noxious stimulus

Question 17

Pain modulation is a dynamic process which means?

Answer 17

Can occur at multiple levels of the ascending and descending pathways

Question 18

When do neuronal sensitization arise?

Answer 18

When neurotransmitters are left to linger in the synapse
- due to failure in diffusion, enzymatic destruction, reuptake

Question 19

What kind of effects do neuronal sensitization prolong?

Answer 19

Effect on the post-synaptic neuron

Question 20

What does neuronal sensitization allow?

Answer 20

Subthreshold input to recruit a response

Question 21

In neuronal sensitization, the normal input creates an increased…

Answer 21

responsiveness of nociceptive neurons

Question 22

In neuronal sensitization, the subthreshold input creates a recruitement of a response

Answer 22

Subthreshold input

Question 23

What kind of sensitization has Nociceptive neurons at periphery of receptive field?

Answer 23

Peripheral sensitization

Question 24

What is an increased pain experience in response to a painful stimulus?

Answer 24

Hyperalgesia

Question 25

What are Nociceptive neurons in the central nervous system?

Answer 25

Central sensitization

Question 26

What does an Increased responsiveness to normal/subthreshold afferent input?

Answer 26

Primary and secondary hyperalgesia
Allodynia

Question 27

What is Pain resulting from a
stimulus that does not
normally provoke pain?

Answer 27

Allodynia

Question 28

What is the revised gate control theory?

Answer 28

• 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

Question 29

What is diffuse noxious inhibitor control?

Answer 29

The threshold for nociception can be raised when another
noxious stimulus is provoked in another area

Question 30

Describe a placebo effect

Answer 30

Psychological

Question 31

What does a palcebo effect lead to?

Answer 31

Release of endogenous analgesic substances

Question 32

What are the different ways to categorize different pains?

Answer 32

• Neurophysiology
• Structures involved
• Timing

Question 33

What is Pain resulting from damage or threatened
damage to non-neural tissue?

Answer 33

Nociceptive pain

Question 34

What is Pain resulting from the presence of a lesion or disease of the somatosensory nervous system?

Answer 34

Neuropathic pain

Question 35

What is Pain that arises from altered nociception?

Answer 35

Nociplastic pain

Question 36

What is Pain with close temporal relationship to a stimulus, injury, or disease?

Answer 36

Acute pain

Question 37

Describe chronic pain

Answer 37

• 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

Question 38

What are the most common psychosocial disorders?

Answer 38

Anxiety
Major depression
Personality disorders
Pain distress

Question 39

What are coping mechanisms for psychosocial disorders?

Answer 39

• Internal locus of control
• Perceived control
• Catastrophic thinking
• Hypervigilance
• Fear avoidance

Question 40

What are pain assessments?

Answer 40

• Pain intensity
• Pain distress
• Pain-related interference
  Functional limitation, disability
• Oral Habits

Question 41

What is pain when the Source is central but perceived peripherally?

Answer 41

Central pain
Example: Brain tumor (brain does not have nociceptors)

Question 42

What is pain when it follows same nerve distribution as primary source?

Answer 42

Projected pain
* Dermatome or motor distribution
* Hyperalgesia may be present
* Example: Post-herpetic neuralgia

Question 43

What is pain when its different nerve than primary source and is spontaneous (non-provoked)?

Answer 43

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

Question 44

What kind of intents are used when determining what type of treatment goal is appropriate and achievable?

Answer 44

1. Curative intent
2. 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

Question 45

What is the main class of drugs used to reduce pain?

Answer 45

Opioids
ex: codeine, oxycodone, morphine, hydromorphone, meperidine

Question 46

How long should a patient be treated before being re-evaluated?

Answer 46

10-14 days

Question 47

What are the 3 types of heterotropic pain?

Answer 47

1. Central pain
2. Projected pain
3. referred pain

Question 48

What is heterotopic pain?

Answer 48

Site ≠ source
- treat site of pain, ineffective

Question 49

What is homotopic pain?

Answer 49

Site = source
- treat site of pain, effective