Pain and Pain Pathways

Anjali Savita
MDS I
Dept of Conservative Dentistry and
Endodontics
“I don’t accept the maxim ‘there is no gain
without pain’, physical or emotional. I believe it
is possible to develop and grow with joy rather
than grief; however when pain comes my way, I
try to get the most growth out of it”
- Alexa Mclaughlin
Contents
Introduction Theories of pain
Definition Pain pathway of
History
Maxillofacial Region
Dental pain
Incidence
References
Related Terms
Characteristics of pain
Classification of pain
Pain receptors
Pathway of pain sensation
Introduction
Pain is the commonest symptom which physician are
called upon to treat.
Pain is an intensely subjective experience, and is
therefore difficult to describe.
 Physiology of pain has taught us a lot about neural
function in general.
It has two universal features. First, its an unpleasant
experience. Second, it is evoked by a stimulus which is
actually or potentially damaging to living tissue.
That is why, although it is unpleasant, pain serves a
protective function by making us aware of actual or
impeding damage to the body.
Like all sensory experiences, pain has two components, the
first component is awareness of painful stimulus and second
one is emotional impact(or effect) evoked by experience.
While the awareness is localized to the area stimulated,
experience involve the whole being.
That is why when a finger is hurt, the whole person suffers.
Definition of Pain
Pain is “an unpleasant sensory and emotional experience
associated with actual or potential tissue damage, or described
in terms of such damage”.
- International association for the study of Pain.

“An unpleasant emotional experience usually initiated by

noxious stimulus and transmitted over a specialized neural
network to the CNS where it is interpreted such as.”
- Monheim’s textbook of local anaesthesia
History
Derived from Latin word “poena” meaning punishment from
God.
Homer thought pain is due to arrows shot by God.
Aristotle who was first to distinguish five physical senses
considered pain to “ the passion of the soul” that somehow
resulted from intensification of other sensory experience.
Plato contented, pain and pleasure arose from within the
body.
Bible makes reference to pain not only in relationship to
injury and illness but also an anguish of the soul.
Incidence of Pain
According to Cohen- it was found that 21.8% of adult in the united states
experiences orofacial pain symptoms within 6 months of study.
The most common pain was toothache, which was estimated to have
occurred in 12.3% of the population.
Dental pain is highly prevalent among children, the association being most
apparent in lower socioeconomic groups with reduced access to care.
The prevalence of dental pain was 35% among all pain.
Dental pain has been associated with many factors, such as low
socioeconomic status, high levels of dental caries and restricted access to
dental services.
Related Terms
Allodynia
Hyperalgesia and hypoalgesia
Hyperpathia
Causalgia
Neuralgia
Characteristic of Pain
Threshold and Intensity
 If the intensity of the stimulus is below the threshold(sub
threshold) pain is not felt. As the intensity increases more
and more, pain is felt more and more according to
Weber- Fechner’s Law.
 As per this law magnitude of sensation felt is directly
proportional to log of intensity of stimulus
Adaptation
 Pain receptors show no adaptation, so the pain continues as
long as receptors are stimulated.
Localization of pain
 Pain sensation is somewhat poorly localized, however
superficial pain is comparatively better localized than deep pain.
Influence of the rate of damage on intensity of pain
 If rate of damage(tissue injury) is high, intensity of pain is also
high.
Classification of Pain
Based on source/ location/ referral & duration
Pain
Acute / Traumatic
Chronic pain
pain

Malignant
Non- malignant
Visceral Somatic pain /cancer
benign pain
pain

Musculo-
Superficial Deep Neuropathic
skeletal
ACUTE PAIN
Acute has a sudden onset, usually subsides quickly and is characterized by sharp,
localized sensations with an identifiable cause.
Lasts > 30 days and occurs after muscle strains and tissue injury such as trauma or
surgery.
A poorly treated pain can cause psychological stress and compromise the immune
system due to the release of endogenous corticosteroids
Acute pain is usually characterized by increased autonomic nervous system activity
resulting in psychological symptoms such as anxiety
 Tachypnoea

 Tachycardia with hypertension

 Pallor

 Diaphoresis

 Pupil dilation
VISCERAL PAIN
Visceral pain is a type of nociceptive pain that comes from the
internal organs.
Unlike somatic pain it is harder to pinpoint, described as general
aching or squeezing pain
It is caused by the activation of pain receptors in the chest,
abdomen, or pelvic areas.
In cancer patients pain is caused by tumor infiltration,
constipation, radiation & chemotherapy.
SUPERFICIAL PAIN DEEP SOMATIC PAIN

It is also known as It originates in deep body

cutaneous pain. structures such as
It arises from superficial
periosteum, muscles,
tendons, joints & blood
structures such as skin &
vessels
subcutaneous tissues.
Strong pressure, ischemia,
It is a sharp, bright pain
tissue damage act as stimuli
with a burning quality and
for brain damage
may be abrupt or slow in
onset. Radiation of pain from
original site of injury occur.
CHRONIC PAIN
Chronic pain is defined as pain lasting longer than 3 to 6
months.
It begins when pain persists after the initial injury has
healed.
It is persistent or episodic pain of duration or intensity
that adversely affects the function and well being of the
patient.
It may be nociceptive, inflammatory, neuropathic or
functional in origin.
CHRONIC MALIGNANT PAIN CHRONIC NONCANCER PAIN
It occurs in 60-90 % of patients Pain may last for many years
with cancer. and is considered progressive in
nature.
Pain can be related to the tumor
or cancer therapy or may be May be nociceptive, neuropathic
idiosyncratic. or mixed in nature.
Pain may also be found at the
metastasized regions and
treatment interventions may
activate peripheral nociceptors.
Pain can be somatic/visceral
NEUROPTHIC PAIN
 Neuropathic pain is a result of an injury or malfunction of the
nervous system.
It is described as
 Aching
 Throbbing
 Burning
 Shooting
 Tenderness/ sensitivity of skin
• Acute hemorrhagic neuralgia
Peripheral •
•
Diabetes
HIV
Pain • Chemotherapeutic agents

• Central stroke pain

Central • Trigeminal neuralgia
Pain
MUSCULOSKELETAL PAIN
This a type of chronic non cancer pain occurring due to
musculoskeletal disorders such as
Rheumatoid arthritis
Osteoarthritis
Fibromyalgia
Peripheral neuropathies
BASED ON TRANSMISSION

FAST PAIN SLOW PAIN

 Felt about 0.1 sec after a  Usually begins after 1 sec or
painful stimulus is applied. more and may range from
 It is described as sharp pain, seconds to minutes.
pricking pain, acute & electric  Described as slow, burning,
pain aching, throbbing, nauseous
 Fast sharp pain is not felt in pain and chronic pain
most deeper tissues of the  Associated with tissue
body. destruction.
 Due to activation of Aδ fibres  Due to activation of C fibres
OTHER TYPES OF PAIN
REFERRED PAIN BREAKTHROUGH PAIN
Pain that originate due to Pain is intermittent, transitory.
irritation of a visceral organ and
Usually lasts from minutes to
felt not in organ but in some other
somatic structure as well which hours and can interfere with
has innervated by the same neural functioning.
segment. E.g. Neuropathic pain, Lower
Usually applies to pain that back pain
originates from the viscera
 E.g. The pain associated with MI
commonly is referred to the left
shoulder arm, neck & chest.
Practical clinical classification of cranio facial pain
General Classification Origin of Pain Quality of Pain

Extra cranial Structure Craniofacial region varies

Referred pain from remote Distant organs and Aching and pressing
pathologic sites structures

Intracranial pathosis Brain and related varies

structures
Varies

Neurovascular Blood vessels Throbbing, Pulsing,

Pounding
General Classification Origin of Pain Quality of Pain

Neuropathic Sensory nervous Shooting, sharp,

system burning pain

Causalgic Sympathatic nervous Burning

system

Muscular Muscles Deep aching, tight

OROFACIAL PAIN CLASSIFICATION (OKESON)
AXIS I (physical conditions)
 Somatic pain  Visceral pain

Superficial Somatic pain • Pulpal pain

• Cutaneous pain • Vascular pain

• Mucogingival • Neurovascular pain

Deep Somatic Pain • Visceral mucosal pain

• Muscle pain • Glandular, ocular, auricular pain

• TMJ pain
• Osseous pain
• Periodontal pain
AXIS II (psychologic conditions)
 Mood disorders
 Anxiety disorders
 Somatoform disorders
 Other conditions
• Psychologic factors affecting a medical condition
Pain Receptors
NOCICEPTORS or PAIN RECEPTORS are sensory receptors that
are activated by noxious insults to peripheral tissues.
The receptive endings of the peripheral pain fibres are free
nerve endings.
These receptive endings are widely distributed in the
 Skin
 Dental pulp
 Periosteum
 Meninges
 SILENT
UNIMODAL POLYMODAL NOCICEPTORS
NOCICEPTORS NOCICEPTORS These receptors
 These  These receptors
activated at the
receptors time of
are sensitive to inflammation
respond several varieties
exclusively to only.
of noxious stimuli Upto 40% of C
one modality
i.e. either  These do not have fibers and 30% of
noxious a specialized and Aδ fibers are
chemical or simple nerve silent
heat stimuli. endings in the nociceptors.
periphery.
NERVE FIBRES INVOLVED IN PAIN TRANSMISSION
A FIBRES C FIBRES
A – BETA A – DELTA
FIBRES FIBRES
 Small & unmyelinated
 Large  Small  Very slow conducting
 Myelinated  Lightly  Respond to all types
 Fast
Myelinated of noxious stimuli
conducting  Slow  Transmit prolonged
 Low
conducting dull pain
stimulation  Respond to  Require high intensity
threshold heat, pressure, stimuli to trigger a
cooling & response
 Respond to
chemicals
light touch
 Sharp sensation
of pain
SENSITIZATION OF
SUBSTANCES EXITING NOCICEPTORS
STIMULATION OF
NCs HISTAMINE NOCICEPTORS BRADYKININ PGE2
POTASSIUM ATP
PGI2

ACTIVATION OF NOCICEPTORS BY INTERACTING WITH OTHER DISCHARGE OF PAIN

CHEMICAL MEDIATORS RELEASING SUBSTANCES
PGI2 BY NOCICEPTORS
SUBSTANCE – P
LTs
GLUTAMATE

NEURO TRANSMITTER S INVOLVED IN PAIN

PATHWAYS OF PAIN SENSATION
The pathways of pain sensation are as follows
Pathway from skin & deeper tissues
Pathway from face – pain sensation is carried by trigeminal
nerve
Pathway from viscera – pain sensation from thoracic &
abdominal viscera are transmitted by sympathetic nerves & from
oesophagus, trachea & pharynx by glossopharyngeal nerves
Pathway from pelvic region – conveyed by sacral
parasympathetic nerves
PATHWAY FROM SKIN & DEEPER TISSUES
FIRST
These are the cells in the posterior nerve root ganglia, receive impulses from pain receptors through dendrites
These impulses are transmitted through the axons to spinal cord
FIRST ORDER Impulses are transmitted by Aδ fibre or C fibres
NEURONS

The neurons of marginal nucleus & substantia gelatinosa form the II order neurons
Fibres from these neurons ascend in the form of the lateral spinothalamic tract
Fibres of fast pain arise from neurons of the marginal nucleus
SECOND ORDER The fibres of slow pain arise from neurons of substantia gelatinosa
NEURONS

The neurons of pain pathway are the neurons in Thalamic nucleus, reticular formation, tectum, gray matter
around the aqueduct of sylvius
THIRD ORDER Axons from these neurons reach the sensory area of cerebral cortex or hypothalamus
NEURONS
PAIN PATHWAYS
ASCENDING PAIN PATHWAY
DESCENDING INHIBITORY PAIN PATHWAY
Pain pathway of Maxillofacial region
5TH cranial nerve or trigeminal nerve is the principle
sensory nerve of head region.
Any stimulation in the area of trigeminal nerve is first
received by both myelinated and unmyelinated fibers,
and conducted as an impulse along afferent fibers of
ophthalmic, maxillary and mandibular branches into
semilunar and gasserian ganglion.
Pain impulse descend from the pons by spinal tract
fibers of trigeminal nerve through the medulla
MECHANISMS OF PAIN
Pain sensation involves a series of complex interactions
between peripheral nerves & CNS.
Pain sensation is modulated by excitatory and inhibitory
NTs released in response to stimuli.
Sensation of pain is composed of 4 basic processes
 Transduction
 Transmission
 Modulation
 Perception
TRANSDUCTION
Activation of nociceptor
 Intense thermal and mechanical stimuli, noxious chemicals,
noxious cold
 Stimulation of inflammatory mediators
Damaged tissue release bradykinin, potassium, histamine,
serotonin and arachidonic acid.
Arachidonic acid produce prostaglandins and leukotrienes.
TRANSMISSON
Process by which peripheral nociceptive information is
relayed to CNS.
First order neuron synapses with the secondary order neuron
from where impulse is carried to higher structures of brain.
Repeated or intense C fibre activation brings specific changes
on N-methyl-D-aspartate receptors resulting in central
sensitization, thus, response of second order neurons increases
as well as size of the receptive field also increases.
MODULATION
 It is the mechanism by which transmission of impulse to the brain is
either inhibited or excitated.
Endogenous opioid peptides are naturally occurring paindampening
neurotransmitters and neuromodulators employed in suppression and
modulation of pain because they are present in large quantities in areas
of brain associated with these activities.
PERCEPTION
It is the subjective experience of pain. It is the sum of complex activities
in CNS that may shape the character and intensity of pain perceived and
ascribe meaning to pain.
PAIN THEORIES
Pain theories are proposed to offer the possible physiologic
mechanisms involved in pain. They are as follows
 Specificity theory
 Pattern theory
 Neuro-matrix theory
 Gate control theory
SPECIFICITY THEORY
Proposed by Johannes Muller in 1842.
According to this theory pain is a specific modality
equivalent to vision and hearing.
This theory states pain as separate modality evoked by
specific receptors(free nerve endings) that transmit
information to pain centers or regions in the forebrain
where pain is experienced.
PATTERN THEORY
Proposed by Goldscheider in 1894.
According to this theory pain sensation depends on Spatio-
temporal pattern of nerve impulse reaching the brain.
According to Woddell (1962) warmth, cold and pain are words
used to describe reproducible spatio temporal pattern or codes
of neural activity evoked from skin by changes in environment.
The precise pattern of nerve impulse entering the CNS will be
different for different regions, and will vary for person to person
because of normal anatomical variations.
NEUROMATRIX THEORY
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.
According to this theory 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
 Intrinsic neural inhibitory modulatory circuits
GATE CONTROL MECHANISM
Proposed by MELZACK & WALL IN 1965.
According to this theory, the pain stimuli transmitted by
afferent pain fibres are blocked by GATE MECHANISM
located at the posterior gray horn of the spinal cord
If the gate is open pain is felt, and if the gate is closed pain
is suppressed
Impulses in A – δ & C – fibres can be blocked by
modulated by A – β activity that can selectively block
impulses from being transmitted to the transmission cells
in the spinal cord and then to CNS resulting in no pain
ROLE OF BRAIN IN GATE CONTROL MECHANISM

Pain signals reach the

Gates in spinal cord are Signals are processed in
thalamus through lateral
open thalamus
spinothalamic tract

Signals are sent from Signal are sent to

cortex back to spinal sensory cortex &
Minimizing the cord and the gate is perception of pain
severity & extent of closed by releasing pain occurs in cortex
pain relievers such as opioid
peptides
Tooth pulp pain
Exposure of dentinal tubules causes toothache &
other non noxious sensation.
Both Aδ & C fibers respond to stimuli in dentine
Transmission of stimuli across dentin, mediated by
movement of fluid in dentinal tubules.
Fibers terminate at medullary dorsal horn & synapse
and also at trigeminal sensory nucleus
From trigeminal nucleus send to thalamus & sensory cortex.
Pulpal innervation are capable of regenerating &
reinnervating
Conclusion
Anxiety is determinant for pain during dental care & pain
is related to local anesthetic procedures. There are
evidences that dentists attitude are determinants for pain.
References
Essential of oral physiology- Robert M Bradley

Textbook of medical physiology- Guyton & Hall

Essential of medical physiology- K.Sembulingam & Prema Sembulingam.

Textbook of human physiology- S Chand

Determinants of painful experience during dental treatment- Ruth Suzanne et al

Rev.Dor 2012;13(4)
Case report study on Brown sequard syndrome- Ponachi et al Neurology Asia
2007;12;65-67
Anatomy, physiology & pharmacology of pain- Ryan Moffat, Colin P.Rae anesthesia
& intensive care medicine; 2010;12(1)