Final exam Flashcards
What statement is true of sex differences in sensitivity to pain
Females have higher sensitivity to pain compared to males, with overlap between sexes
What is a reason why peripheral sensitivity decreases in aging?
-Reduced NaV1.8 levels in DRG
[also:
- Reduced density of primary afferent fibers
- Reduced TRPV1 protein in DRG and peripheral nerves
- Neuronal loss in superficial spinal dorsal horn
- Loss of myelin in ascending pathways
- Neuronal death and loss of dendritic arborization in the cerebral cortex (This will affect many functions.]
Which is true of studies of opiate effects and sex in animals vs. in humans?
Females were ____ sensitive to opioids in animals but the opposite was seen in humans
Females were LESS sensitive to opioids in animals but the opposite was seen in humans
Which is true regarding menstruation and pain during ovulation?
There was increase in pain during ovulation by ____
There was increase in pain during ovulation by WOMEN WHO WERE NOT ON ORAL CONTRACEPTIVES
Relationship between age and migraine (recall says TMD/migraine, but Dr Greenspan’s lecture says nothing about TMD and age)
prevalence increased until middle age (~40), and then decreased
Relationship between psychological state and chronic pain can be described as…
Psychological stress can manifest as a result of chronic pain but can cause pain to persist
Which is true of literature review of sex differences in pain?
women are more sensitive to pain in just over half (56%) of analyses
A condition that mostly affects middle aged women (?)
TMD
hormones and pain variation:
____ increases response to pain, while ____ counteracts it
ESTROGEN increases response to pain, while PROGESTERONE counteracts it
Which is true of the study discussed in class about the effects of Nalbuphine (kappa opioid agonist)?
Women ALWAYS show more pain reduction than men
Which of the following clinical pain condition are more prevalent in women of childbearing years?
TMD
Which of the following are more prevalent in women?
TMD, Fibromyalgia, and IBS
What did the study on brain scans show about individual differences in pain?
- S1, ACC, and PFC were more activated in the high-sensitivity subjects
- no difference in thalamic activation.
A maladaptive response to pain that can prolong and increase chronic pain is _____
A maladaptive response to pain that can prolong and increase chronic pain is CATASTROPHIZING
[also:
- perceived helplessness
- low self-efficacy]
True of painful mucosal conditions:
- systemic disease can manifest as painful oral ulcers
- not all present with oral lesions- neuropathy and burning mouth
- is commonly associated with peripheral sensitization
- Ulceration further increase the cytokines to cause hyperalgesia
Two-point discrimination: sensitivity of oral mucosa (high to low)
Tongue tip Finger tip Lip Soft palate Alveolar ridge
Tactile sensation: sensitivity of oral mucosa (high to low)
Perinasal skin Tongue tip Lip Finger tip Palate
Detection of vibration: sensitivity of oral mucosa (high to low)
Face skin
Lower lip
Forefinger
Warmth and heat pain: sensitivity of oral mucosa (high to low)
Infraorbital skin
Side of nose = Tongue tip
Palate
Buccal mucosa
Cool and cold pain: sensitivity of oral mucosa (high to low)
Intraoral tissues = Extraoral tissues
True about burning mouth syndrome:
- prolonged alteration of taste
- most common in women
- found in multiple oral sites
What type of primary afferents transmit visceral pain?
A-delta and C fibers
True of visceral primary afferents:
- carry both sensory for autonomic functions and pain
- high central arborization
True about referred pain from viscera
- visceral-somatic convergence causes referred pain of primary afferents onto dorsal horn neurons
- central sensitization contributes to referred hyperalgesia
- visceral pain does increase referred pain
Patient swallows endodontic file which pokes stomach wall. Which is true?
- Patient may complain about pain on abdominal skin
- If patient has IBS there could be an increase in pain response
- If patient has inflammation of stomach mucosa there will be an increased pain response
What is found at high level in serum in times of severe pain?
Endothelins
Additional info:
- class of vasoactive peptides
- tumors can express high levels of endothelin
- correlation b/w severity of pain and serum endothelin levels
- can directly activate nociceptors
What is the similarity between the mechanisms of action of Taxanes & Vinca Alkaloids?
Disruption of microtubule function
–> act as mitotic inhibitors
Additional info:
- Taxanes - prevent de-polymerization of microtubules
- Vinca alkaloids (e.g. Vincristine) - stabilize tubulin, thus inhibiting tubulin polymerization into microtubules
What does NGF modulate?
- NGF modulates trafficking of sodium channels
- NGF directly activates nociceptors through cell surface TrkA receptors, and modulates the expression/function of a wide variety of molecules (e.g. Substance P, CGRP, receptors including TRP channels)
Release of _____ by osteoclasts and tumor cells causes pain in bones.
______ induce osteoclast apoptosis.
protons; bisphosphonates
What are directly released by tumor cells that cause pain at peripheral nerve endings?
Prostaglandins
Mechanism of action of taxanes?
prevent de-polymerization of microtubules
Mechanism of action of Vinca alkaloids?
stabilize tubulin, thus preventing its polymerization into microtubules
What complication of opioids does not go away with prolonged use?
constipation
What are the primary afferents affected when you lose propioception AND have tingling and numbness from cancer?
A-alpha and A-beta fibers
large diameter myelinated
A burning / shooting / stabbing / lancinating pain would usually characterize which type of cancer pain?
neuropathic pain
Which fibers are involved in making and maintaining tumor pain?
A-delta and C fibers
List the pro-inflammatory cytokines
from Glia lecture:
IL-1-beta
IL-6
TNF-alpha
According to glia lecture, list the anti-pain cytokines
IL-10
What are treatment options if pharmacological means are unsuccessful for treating Orofacial neuropathic pain (trigeminal neuropathic pain)?
Conservative treatments:
- nerve blocking with local anesthetics
- biofeedback
Surgery:
- microvascular decompression (MVD)
- Radiofrequency rhizotomy
- Gamma knife radiosurgery
- Retrogasserian rhizotomy
- suboccipital craniotomy
- glycerol rhizotomy
______ are the most abundant cell in the human brain and spinal cord, help with maintenance functions and maintenance of the blood–brain barrier.
astrocytes
______ supply insulation in the form of myelin to the axons of the central nervous system
oligodendrocytes
_____ fulfill the role of the immune system in the central nervous system since antibodies are generally not able to cross the blood-brain barrier. They form about one-fifth of the total glial cells and scavenge the CNS for damaged neurons, plaques, and infectious agents.
Microglia
_______ are the simple squamous cells forming the linings of the ventricles of the brain and the central canal of the spinal cord; capable of contributing to the production of cerebrospinal fluid (CSF)
Ependymal
Chemical marker for astrocytes
Glial Cell Fibrillary Acidic Protein
GFAP
Upon activation, microglia increase expression of ____
CD11b (OX-42)
Which statement about glial mechanisms of neuropathic pain is FALSE?
Increase in glial glutamate transporters
Main chemical signaling pathways from neurons to glia
glutamate / Glu receptors
ATP / P2X or P2Y receptors
chemokines / chemokine receptors
(e.g. fractalkine / Cx3CR1)
Trigeminal neuralgia:
- age: 90% of cases in patients _____
- gender: more common in _____
- location: almost always _____
- age: 90% of cases in patients over 40 yo
- gender: more common in females
- location: almost always unilateral (more often Right side)
Glial cells & neuropathic pain:
Inhibition of _____ activation blocks or attenuates INITIATION of neuropathic pain
microglia
Glial cells & neuropathic pain:
Inhibition of _____ activation blocks or attenuates MAINTENANCE of neuropathic pain
astrocyte
Glial cells & neuropathic pain:
Neutralization of ______ reduces neuropathic pain behaviors
pro-inflammatory cytokines or chemokines
Which is/are symptoms of neuropathic pain: A. mechanical / cold allodynia B. hyperalgesia C. lancinating pain D. numbness / tingling
all of the above
From Glial cell lecture:
• Mostly no tissue damage
• Sensory aberrations co-occur with the pain.
• The location of the pain does not match the source of the pain
• The nature of the pain is frequently strange (e.g. crawling ants, or a red hot poke that is rubbed in the flesh).
• The location of the pain tends to expand over time
• Poor response to classic analgesic.
Which is NOT included as a part of neuropathic pain?
nociceptive pain
Characteristics of muscle pain:
- aching
- cramping
- poorly localized
_____ is a disease or condition that coexists with a primary disease but also stands on its own as a specific disease
a comorbidity
A 70 year old man gets pain in legs when walking down the stairs. Pain is relieved when he rests for a few minutes. This is consistent with….
Peripheral Artery/Vascular Disease
Axis I grouping for TMD
group I - muscle disorders
group II - disc displacements
group III - joint disorders (arthralgia, osteoarthritis)
Characteristics of muscles of mastication in TMD patients:
- Increased myalgia by function (e.g. mastication)
- Pain upon muscle palpation
- Restricted mouth opening (kinesiophobia)
- Pain referral
Aside from pain, if a patient experiences paresthesia, vibratory sensations and proprioceptive deficits, which fibers are most likely affected?
A-alpha and A-beta
Muscle pain disorders that exhibit a prominent sex difference:
- TMD
- Fibromyalgia
- Chronic fatigue syndrome
Muscle pain disorders that DO NOT exhibit a sex difference:
Intermittent claudication (peripheral artery disease)
Diagnostic criteria of fibromyalgia:
- Widespread pain in all four quadrantS of the body for a minimum of 3 months
- Tenderness or pain in at least 11 of the 18 specified tender points when pressure is applied.
Diagnostic criteria for TMD, Axis II
- pain severity
- psychological status
- pain-related disability
What TMD Axis I group would a patient with a lot of mastication muscle soreness and limited movement of cervical spine and limited jaw opening but no disc derangement be placed in?
TMD1
Patient that had sore muscle with tender bands and when you pinched an area it led to flexor reflex and pain in another muscle–what do they likely have?
Myofascial pain
Features of myofascial pain snydrome
The pain centers around sensitive points in your muscles called trigger points.
The trigger points can be painful when touched.
The pain can spread throughout the affected muscle. Normal pain sensitivity outside the trigger point.
Peripheral mechanisms probable.
Picture with eroded condyle in radiograph, and describes cervical muscle pain plus limited range of mouth opening. What class of TMD does this describe?
TMD I & III
Group III muscle primary afferent neurons are analogous to what cutaneous primary afferent neurons?
A-delta fibers
Chronic TMD Drugs
- Tricyclic antidepressants
- SNRIs
What are anticonvulsants used to treat?
Trigeminal neuropathic pain
Which is a COX 2 inhibitor?
Celecoxib (COX-2 inhibitor)
Blocking COX 2 could cause what?
Cardiovascular complications → blocking COX 2 PGI2
Hydrocodone-acetaminophen (Vicodin) is described as
- DEA Class 2 drug
- Drug with potential for abuse
Which best describes the approach for treating chronic pain?
Treatment is multidisciplinary
Patient on anticoagulants and has GERD. Which analgesic should you prescribe?
Acetaminophen
When it comes to opioids a dentist should:
- First choice should be NSAIDs
- Conduct medical history for potential drug interactions and substance abuse
- Follow and continually review CDC and State licensing board’s recommendations for safe opioid prescribing
- Register with drug monitoring program
Which type of headache results from overuse of analgesics and headache medication?
Medicine overuse headache (such as ibuprofen)
Patient drinks a lot, what medication should they avoid?
acetaminophen
Acetaminophen (Tylenol) is classified as…
Antipyretic (Reduce fever) and analgesic (reduce pain)
[NOT anti-inflammatory]
What is a good drug for someone with chronic pain and feels depressed
duloxetine (Cymbalta)
What is a good polydrug combination?
Nortriptyline and gabapentin
Major side effect of gabapentin and pregabalin that patients complain about
dizziness / ataxia
[effect from anticonvulsants / anti-seizure]
What does tramadol do
mu opioid and SNRI
Patient likes to party, but gets headaches. What would be an adverse effect of taking Acetaminophen
liver toxicity
If kid is getting tooth extracted and will have inflammation and no bleeding, what should he take for pain?
Motrin (IBUPROFEN)
What is the best functional goal of pain management w/ a patient w/ chronic pain
get pain managed enough so that patient can sleep through the night
Man with renal failure, which opioids should he use?
Methadone & fentanyl
Which antidepressant is approved by FDA to treat musculoskeletal pain and neuropathic pain?
duloxetine
Which drug combination is an example of rational polypharmacy?
Morphine and gabapentin
The maximum allowed dosage of ibuprofen is ____ (grams / day)
3.2
90% of all headaches are _____
primary headaches
_______ - headache is a symptom of a disease, related to head or neck
Examples:
Secondary headache
Examples: meningitis brain trauma brain tumor medication overuse headache
3 types of primary headaches:
- Migraine
- Tension-type headache
- Trigeminal autonomic cephalalgias
Most prevalent and disabling of all neurological
diseases
Migraine
Chronic migraine criteria
- Headache on ≥15 days/month for >3 months
- On at least 8 days/month, has the features of migraine headache
- relieved by a triptan or ergot derivative
transmitters involved in migraine
calcitonin gene-related peptide (CGRP)
vasoactive intestinal peptide (VIP)
pituitary adenylate cyclase-activating peptide (PACAP)
prostaglandins E2 (PGE2) & I2 (PGI2)
The most common form of primary headache
tension-type headache (lifetime prevalence of 30-78%
Features of tension-type headache
- Characterized by pericranial tenderness that is exacerbated during headache
- NOT aggravated by routine physical activity
- NO nausea / vomiting
- NO more than 1 of photophobia / phonophobia
Treatments for tension-type headache:
- NSAIDS–COX inhibitors (e.g. naproxen)
- NOT triptans
- for patients with pericranial tenderness:
- tricyclics (amitriptyline, Nortriptyline)
Trigeminal autonomic cephalalgias include:
- cluster headache
- paroxysmal hemicranias
- short-lasting unilateral neuralgiform headache attacks (SUNA)
Cluster headache features:
- affects ___% of population
- gender: predominantly affects ____
- mean age of onset: ____
- affects 0.1% of population
- gender: predominantly affects men
- mean age of onset: 20s
Features of trigeminal autonomic cephalalgias
- unilateral headache
- lateralized, prominent cranial parasympathetic autonomic features
- involve prominent hypothalamic activation
NOT a characteristic of aura: A. general weakness B. Vertigo C. Nausea D. Altered vision
C. Nausea
diagnostic for paroxysmal hemicrania
Prevented absolutely by therapeutic doses of INDOMETHACIN
Moderate or severe unilateral head pain, with orbital, supraorbital, temporal and/or other trigeminal distribution, lasting 1-600 s and occurring as single stabs, series of stabs, or in a saw-tooth pattern
SUNA
treatment of cluster headache
- 100% oxygen
- intranasal lidocaine
- sumatriptan
treatment of paroxysmal hemicrania
-indomethacin (also confirms diagnosis)
treatment of short-lasting unilateral neuralgiform headaches
- lamotrigine
- topiramate
- gabapentin
Which is FALSE about chronic migraine? A. Pain Relief from Acetaminophen B. Greater than 15 days a month for 3 months C. Can present with aura D. At least 8 days of migraine symptoms
A.
Chronic migraine can only be treated with triptans and ergot derivatives
Pain presents as unilateral in ocular area with autonomic symptoms. He is a middle aged smoker. Type of headache?
Cluster headache
Which is an example of a secondary headache
a. Medication overuse headache (MOH)
b. Cluster headache
c. Tension headache
A.
Pain presents as a band around head and is not worsened by exercise–what type of headache?
Tension type headache
What are triptans effective in treating?
episodic migraine headache and cluster headache
T/F:
Ibuprofen is effective in treating migraines
FALSE
T/F:
- Episodic tension headaches can be associated with mild nausea.
- Chronic tension headaches can be associated with mild nausea
False; true
Which best describes the approach to chronic pain management?
multidisciplinary approach
