1. PRESENTED BY,
LALITHADEVI.P
BDS - CRRI
VDCW

2. INTRODUCTION
• Pain is one of the most common reasons for
patients to seek medical attention and one of the
most prevalent medical complaints
• 9 out of 10 Americans aged 18 or older suffer
pain at least once a month, and 42% experience
it every day.
• Consequently, physicians and other practitioners
need education to assist in developing the skills
needed to evaluate and manage patients with
pain.

3. PAIN - DEFINITION
• The International Association for the Study
of Pain (IASP) defines pain as “an
unpleasant sensory and emotional
experience which we primarily associate
with tissue damage or describe in terms of
such damage, or both.”
• Father of pain - Bonica

4. Three Hierarchical Levels of Pain
• Sensory-Discriminative Component
(location, intensity, quality)
• Motivation-Affective Component
(depression, anxiety)
• Cognitive-Evaluation Component
(thoughts concerning the cause and
significance of the pain )

5. Types of pain
• Nociceptive,
• Neuropathic,
• Psychogenic,
• Mixed, or idiopathic.

6. PATHOPHYSIOLOGY OF PAIN
Descartes in 17th century described PAIN PATHWAY

7. Pain messages are two-way traffic. Inhibitory effects are
achieved through the descending pathways, which reach from
the conscious brain down to the gates in the subconscious
brain and the spinal cord.
The reason for this is that the gates are places where the flow
of pain messages can be controlled or influenced (Wells &
Nown 1998).
By sending responses back to the periphery, the brain can
ordered the release of chemicals that have analgesic effects,
which can reduces or inhibit pain sensation.
Pain generally starts with a physical event; a cut, burn, tear, or
bump (Catalano, 1987).

8. Nociceptive Pain and Its Mechanisms
• nociceptive pain occur as a result of the
normal activation of the sensory system by
noxious stimuli
• a process that involves transduction,
transmission, modulation and perception.

9. Tissue injury
(activates)
primary afferent neurons called nocicep-tors, (with
A-delta and C-fibers)
These fibers have specific receptors for noxious
me-chanical, chemical or thermal stimuli.
Transduction – depolarization of peripheral nerve
Transmission occur proximally along the spinal
cord to higher centres

10. Neuropathic pain and its mechanism
• Neuropathic pain is the label applied to
pain syndromes inferred to result from
direct injury or dysfunction of the
peripheral or central nervous system.
• It is frequently described in terms that
warrant the descriptor “dysesthetic:” an
uncomfortable, unfamiliar sensation such
as burning, shock-like or tingling.

11. Injury to a peripheral nerve axon
abnormal nerve morphology.
damaged axon may grow multiple nerve sprouts, -form neuromas.
These generate spontaneous activity
These areas of increased sensitivity are associated with a change
in sodium receptor concentration, and other molecular
processes
sites of demyelination or nerve fiber injury
associated with tenderness and the appearance of Tinel’s sign

12. 5
1
2 4
3

13. Psychological and “Idiopathic” Pain
Mechanisms
• When reasonable inferences about the
sustaining pathophysiology of a pain syndrome
cannot be made, and there is no positive
evidence that the
• etiology is psychiatric, it is best to label the pain
as “idiopathic.”
• The experience of persistent pain appears to
induce disturbances in mood ,impaired coping,
and other processes, which in turn, appear to
worsen pain and pain-related distress.

14. • Other patients have premorbid or
comorbid psychosocial concerns or
psychiatric disorders that are best
understood as evolving in parallel to the
pain.
• patients with personality disorders,
substance use disorders, or mood
disorders often are best served by primary
treatment for the psychiatric problem

15. Initial Pain Assessment
Guidelines
• Obtain a detailed history, including
• an assessment of the pain characteristics,
• impact of the pain on multiple domains (physical,
psychosocial, role functioning, work, etc.),
• related concerns and comorbidities (other
symptoms, psychiatric disorders including
substance use disorder, etc.),
• prior work-up and working diagnosis,
• prior therapies

16. • Conduct a physical examination, emphasizing
the neurological and musculoskeletal
examination
• Obtain and review past medical records and
diagnostic studies
• Develop a formulation including 1) working
diagnoses for the pain etiology, pain syndrome
and inferred pathophysiology, and 2) plan of
care including need for additional diagnostic
studies and initial treatments for the pain and
related concerns

17. TYPES OF PAIN BY NATURE
Pain perception
Pain reaction
THEORIES OF PAIN
Specific theory
Pattern theory
Gate control theory

18. GATE CONTROL THEORY

20. Critical Elements of the Pain History
• Characteristics of the pain
• Prior evaluation of the pain
• Prior treatments for the pain
• Patient’s perception of impact of the pain on multiple
domains
• Physical functioning
• Mood and psychological well being
• Social, familial, and marital well being
• Role functioning, including work, social, family
• Sleep, energy level
• Comprehensive medication history

21. PAIN CHARACTERISTICS

22. Characteristics Potential Elements
Temporal Acute, recurrent or persistent, Onset and
duration, Course and daily variation,
including breakthrough pain
Intensity(verbal rating or 0-10 numeric Pain “on average” last day or week
scale) Pain “at its worst” last day or week
Pain “at its least” last day or week
Pain “right now”
Topography Focal or multifocal
Focal or referred, and specific radiation
Superficial or deep
Quality Any descriptor (e.g., aching, throbbing,
stabbing or burning)
Familiar or unfamiliar
Exacerbating / relieving factors

23. PAIN CHARACTERISTICS
Characteristics Acute Pain Persistent Pain
Temporal features Recent onset and expected to Remote, often ill-defined onset;
last duration unknown
•
no longer than days or weeks
Differences Between Acute and Persistent Pain
Intensity Variable Variable
Associated affect Anxiety may be prominent when Irritability or depression
pain is severe or cause is
unknown; sometimes irritability
Associated pain- related Pain behaviors (e.g., moaning, May or may not give any
behaviors rubbing, splinting) may be indication of pain; specific
prominent when pain is severe behaviors (e.g., assuming a
comfortable position) may
occur
Associated features May have signs of sympathetic May or may not have
hyperactivity when pain is vegetative signs
severe such as: lassitude, anorexia,
(e.g., tachycardia, weight loss, insomnia, loss of
hypertension, sweating, libido; these signs may be
mydriasis) difficult to distinguish from other
disease-related effects.

24. PAIN MANAGEMENT

25. Pharmacologic approaches to pain
management
WHO 3-Step Ladder
Step 3, Severe Pain_______
Morphine
Hydromorphone
Methadone
Levorphanol
Fentanyl
Step 2, Moderate Pain_______ Oxycodone
Acet or ASA + + Nonopioid analgesics
Codeine + Adjuvants
Hydrocodone
Oxycodone
Dihydrocodeine
Tramadol
+ Adjuvants
Step 1, Mild Pain_______
Aspirin (ASA)
Acetaminophen (Acet)
Nonsteroidal anti-inflammatory drugs
(NSAIDs)
+ Adjuvants

26. Control of dental pain
Three phases
Pain control before treatment
Pain control during a treatment
Pain control after a treatment

27. 1) Before treatment
• Find out the cause of pain and eliminate it
PULPAL PAIN
• Deep caries
• Thermal changes without protective base
• High points in restoration
• Traumatic injuries

28. Managed by,
1) Deep caries excavation and use of cements
2) Pulp capping procedures in deep cavities
3) Protective base should be given in cases of metal
restorations
4) Before sending the patient after restorative treatment,
check for highpoints
5) Attent to traumatic injuries and do the needful
6) Find the causes of referred pain and treat the cause

29. 2)During the treatment
Use high speed instruments with
• H2O coolants witch will reduce heat and pain
• Small bur size, as the size of bur increases, heat
dissipation increases
• Continuous cutting- increased heat generation
• Minimal pressure while cutting or with sharp instruments
• Condensation pressure, 4-5 pounds
• Burnishing and carving to be done after initial setting of
material
• Polishing should be done in wet medium

30. Causes of pain after 24 hours of
treatment
• High speed cutting without coolant
 Remove restoration and place temporarily sedative
dressing and wait till the pain stops and then proceed for
permanent restoration
• High points
 Reduce them
• Deep cavity restored with amalgam without a base
 Remove the restoration and place base, varnish
• **If pain persist then do pharmacological treatment

31. Methods of pain control
A. Local or regional anaesthesia
1. Topical anaesthesia
2. Local infiltration
3. Field block anaesthesia
4. Nerve block
5. Intraligamentary
6. Crestal anaesthetic technique(CAT)

32. B. Electronic anaesthesia
• Trans cutaneous electronic nerve
stimulation (TENS)
• Based upon gate control theory

33. C. Audio analgesia
• White noise
• Principle- stimulus distraction

34. D. Inhalational anaesthesia
• Conscious sedation
• N2O + O2

35. E. Hypnosis
F. Accupuncture

36. • “Adjuvants” refers either to medications
that are coadministered to manage an
adverse
• effect of an opioid, or to so-called adjuvant
analgesics that are added to enhance
• analgesia.

37. REFERENCES
• EPEC Project, 1999 Module 4: Pain
Management,
• MJA - Volume 185 Number 2 -17 July 2006
• ARTICLE – AMA :Module 1 Pain Management :
• Pathophysiology of Pain and Pain Assessment
• mja.com.au | The Medical Journal of Australia
• Operative Endodontics – Neeraj Gupta