INTRODUCTION By creation man is a fighter.

He has been fighting against all the odds of nature since the time of creation. Thats what, theory of survival of fittest states. Pain being always remained the greatest energy of mankind since the time of evaluation. Pain is always being a driving which made the man to explore the field of medicine. This fight against pain will be continued till the point of immortality. Pain is a malady that crosses almost every medical discipline. n dentistry, pain is the most common motivation that brings the patients to the dentist and for those whose are anxious about dental visit, fear of pain is also a primary cause for avoidance of routine dental care. Pain may be defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. !arious cultural, cognitive, emotional and motivational differences alter or modulate the intensity of a patients response to noxious stimuli.

DEFINITION: "n unpleasant sensory and emotional experience associated with actual or potential tissue damage described in terms of such damage. # $ubcommittee on taxonomy of international association for study of pain

HISTORY

"round %&&& yrs ago the world believed that pain exists outside the body %nd century ".'. (alen noted that pain is recogni)ed in brain "ristotle believed in heart as the centre of sensation "ccording to Plato pain and pleasure arise within the body *eonardo da !inci pinpointed the sensation of pain to the nerve of touch. +,th century - with the development of neurology specific pathways associated with sensations were identified .reud gave the concept of psychosomatic nature of pain

BASICS

'ivisions of /ervous system 0entral /ervous $ystem Peripheral /ervous $ystem "utonomic /ervous $ystem $ympathetic Parasympathetic

Central Nervous System

ncludes brain and spinal cord Brain 0erebral hemisphere 0erebellum 1idbrain Pons 1edulla

Spinal Cor

Protected by vertebral column 0ervical - 2 Thoracic# +% *umbar - 3 $acral - 3 0occyx #+

Spinal !or ar!"ite!ture

(ray matter and white matter

Autonomi! nervous system

$ynonyms nvoluntary nervous system (eneral visceral efferent system

.unctions Haemostasis 1etabolic activity "/$ is represented in both P/$ and 0/$ somatic and visceral afferent act as input arm (eneral visceral efferent as output channel

Sympat"eti! system

4nergy utili)ation activities 5 fright, flight and fight6 . Thoracic#lumbar system outflow5T+7*%6 /eurotransmitter - epinephrine and noreinepinephrine

#arasympat"eti! system

0onservation and restoration of energy 0raniosacral system

# #

"ssociated cranial nerves 8,2,, 9 +& . $pinal nerves $%7$:

/eurotransmitter 7 acetylcholine

#erip"eral Nervous System

ncludes spinal and cranial nerves and branches Peripheral ganglion

STRUCTURE OF NEURON 0omponents 0ell body ; contains spherical nucleus 5karyon6 giving of one or more processes . "n axon is often called nerve fiber 0ellbody and dendrites form the receptor and the axon is the conducting )one

protoplasmic processes 'endrites "xons

#HY$O%ENIC CONSIDERATIONS

Phylum - 5(reek word means race 6 Primary or main division of the plant or animal kingdom. (rouping organisms which have common ancestors. 0omponents of human brain $pinal cord or medulla 5 functional in reptiles 6 1ammalian brain < limbic system 5 pain and pleasure center = functional in humans6 0erebral cortex

#ain re!eptors

nput to the nervous system provided by sensory reception that detects sensory stimuli i.e. touch, sound, light, pain etc . 'etection mechanism - by virtue of different sensitivities. "ll pain receptors are free nerve endings 5nociceptors6 'eep tissues are not supplied by free nerve endings . Pain receptors show non adapting nature .

Nerve impulse transmission me!"anism

0ell membrane of body has powerful electrogenic pumps 5/a#> pumps6 1ore ?ve charge on external compared to internal surface 5 @1P #,&m!6. "ctivation stage# potential becomes less -ve i.e. #2&m! to #3&m! . ncreased /a permeability nactivation stage 5after +&,&&&th second6 /a channel closed > channel opens

SYNA#SES

(reek word - connection or Aunction They are Aunctions where the axons or some other portion of presynaptic cell terminates on dendrites or axons of postsynaptic cell "natomically synapses are knob like structures . Bithin knobs there are !esicles 5 neurotransmitters are stored 6 1itochondria 5 provide "TP 6 $ynaptic clefts 5%&& C 6 $ynapses 0hemical 4lectrical 0hemical synapses - by neurotransmitters 4lectrical synapses -acc. to Burnett et al. 5+,,D 6 synapses in which the synaptic clefts are obliterated behave electrically . "cc. to >at) 5+,2:6 if electrical impulses cross the gap they can crossover to adA. fibers which compromises the system . .reEuency of occurrence of electrical synapses is unknown .

Neurotransmitters

/eurochemicals that transmit impulses across the synaptic cleft :& different types of chemicals .

neurotransmitt

ers

$mall molecule rapid acting

*arge molecule slow acting

0lass + # ach

0lass % - amines

0lass 8 - amino acids

Hypothalamic

Pituitary peptide

Peptide of gut

NER&E FIBERS

4ach sensory receptor is attached to +st order neuron . +st order neurons have varying thickness !elocity of impulse transmission varies with diameter of axon . *argest diameter fibers - " fibers 5F,G,H,I6 ntermediate diameter - B fibers $mallest diameter fibers - 0 fibers

A' vs( C Fi)er

pain , low threshold *ocation - periphery of the pulp Produce initial momentary sharp pain $timulation by dentine hypersensitivity . 0 fibers - unmyelinated , small diameter, not specific for pain, high threshold *ocation - core of pulp Produce continuous, constant or throbbing pain. $timulation by tissue inflammation and damage.

ASCENDIN% SENSORY TRACTS

"ll the sensory information from the sensory segments of the body enter the spinal cord through the dorsal root of spinal nerves . The two maAor sensory pathways involved are 'orsal root column 5 medial limeniscal system6 Touch, vibration, pressure, position sensations "nterolateral system Pain , thermal, itch , sexual sensations

Dual transmission o* pain

Tracts involved /eo#spinothalamic tract

Fast+ s"arp pain, A' *i)ers Paleo#spinothalamic tract $low pain 50 fibers 6

'ue to double system of pain innervation a sudden onset of painful stimuli often gives double pain sensation = fast followed by slow pain .

NEO. S#INOTHA$A/IC TRACT

'orsal root of s.nerve7 +st order neuron terminate 5 lamina + 6 7 %nd order neuron crosses to opp. $ide of cord 7 brain through antero#lateral column Termination @eticular area !entro# basal complex 5 thalamus6 Posterior nuclear group of thalamus .rom here to somatic sensory cortex . /eurotransmitter# glutamate

#A$EO. S#INOTHA$A/IC TRACT

'orsal root of spinal nerve 7 +st order neuron terminates in laminae %nd and 8rd 7 most signals pass through one or more small fibers before entering lamina 3 through J 7 brain through anterolateral pathway .

Termination

Bidely in brain stem Knly +<+& to L to thalamus Tectal area of mesencephalon PeriaEueductal grey region .rom brain stem 7 intralaminar and central lateral nuclei 5 thalamus6 7 hypothalamus and basal ganglion /eurotransmitter - P substance

TRANS/ISSION OF TRI%E/INA$ NER&E IN CNS

$ensory root of trigeminal nerve enters the brain , its fibers pass through 8 sensory nuclei 1esencephalic nucleus @eceives fibers carrying proprioceptive impulses of tongue, facial and orbital muscles , periodontal membrane 1any fibers form all the three divisions dichotomise to form ascending and descending branches . Principle nucleus receives impulses mediating touch and pressure sensation from ascending branch . $pinal nucleus is divided into three )ones 'escending fibers terminate in spinal nucleus The rostrally located par oralis receives tactile input from cutaneous area of head, mouth, lip and nose . ntermedially located par interpolaris receive input from forehead, cheek, angle of Aaw, tooth pulp . 0ordally located par caudalis receive modalities of touch, pain and temperature form anterior part of head .

Se!on ary pat"0ays

%nd order neuron of trigeminal system form three secondary pathways .ibers from principle sensory nucleus form trigeminal limeniscus which travels with medial limeniscus , together they go to ventro # posterior nucleus 5 thalamus 6 Krigin is from spinal trigeminal nucleus analogues with neo-spinothalamic tract . This neo# trigeminal thalamic tact Aoins the trigeminal leminiscus and medial leminiscus and converge into ventro - posterior thalamic nucleus . Krigin is from spinal trigeminal nucleus analogous to spino#reticulo#thalamic pathway. This tract receives mechano and thermo receptive information and convey it to intra#laminar nucleus of the thalamus .

RE#RESENTATION INTO CORTE1

$tructure of mouth and face , including teeth are represented at cortex for touch and pressure in post#central gyrus5 primary somatic sensory area6 $pinal nuclei also receive connecting fibers from facio#glossopharyngeal and vagus nerve .

#AIN DUE TO #U$#A$ DISEASES

M "fter many investigations it is concluded that there is no correlation between a patients experience of pain , clinical condition and histological appearance of pulp 5 $elt)er et al +,D8 = 1umford +,2& = "dam et al +,2: 6 #ulp e2posure M M M M M M M M Pain is freEuently experienced Pain lasts for + second . Patient not only feels pain but sees lightening and hears it . @eason - numerous nerve endings are subAected to intense stimuli . 4arly state of disturbed pulpal circulation with increased vascularity . @eversible Pain depends on nature of stimuli nitial inflammation 7 acute condition 7 chronic condition

Hyperal3asia

A!ute pulpitis M M M M M .irst stage involves dilation of capillaries .low is directly proportional to :th power of radius 5 poiseuilles law 6 ncreased dilation 7 increased permeability 7 increased pressure ncreased pressure inversely affects the walls of veins hence stasis occurs Three forms of pain +. $harp, lasts for a relatively short time %. $pontaneous pain5 without external stimuli6 because of chemical changes in pulp . 8. paroxysmal pain in short sharp Aabs occuring spontaneously $o!ali4ation o* pain M M Poor locali)ation because of anatomical convergence of pulpal nerves in trigeminal nuclei and subseEuent convergence at higher level . 'ental pulp does not have individual representation in the human brain .

Se5uelae o* a!ute pulpitis M M Periapical disease 0hronic pulpitis - !irulence of microorganisms decreases - "pical foramen has not fully formed - hence better drainage. C"roni! pulpitis M Types - Kpen 5 less painful due to increased drainage6 - 0losed M M /ot sensitive to thermal changes Pain is not an important feature of chronic pulpitis unless acute exacerbation occurs #ulp 3an3rene M M M M M Pulp is badly damaged and is associated with gas producing micro organisms Pain occurs spontaneously 'ull ache lasts for hours or even days *eads to greater thermal expansion of gas which exacerbates pain 0o#efficient of thermal expansion of gas &.&&8D2<N0 at constant pressure at 82N0 5 Beast +,2% 6

#ulp ne!rosis M M M M 'eath of pulp without micro organisms being necessarily present . Pulp dies slowly, losing fluid and becoming dry 5in some cases pulp disappears6 /o pressure so pain is not there $ymptomless

ENDODONTIC #AIN /ANA%E/ENT

'ivided into 8 sections - Pain during treatment - Pain following instrumentation - Pain following obturation

#ain mana3ement urin3 treatment M M "ssociated with problem of anesthesia 'ivided into anatomic variation - Technical error Anatomi! variation M M M M Bide flaring mandible *ong ramus in superior inferior direction Bulky musculature or excessive adipose tissue 4dentulous patient

INFERIOR A$&EO$AR NER&E B$OC6 FAI$URE

M M M M O failure rate is observed The mandible, hard and soft tissues are supplied by plexus of nerves This plexus with its many communications may allow sensations even if primary trunk is blocked . 1ain nerve in this plexus is inferior dental nerve but lingual, buccal, mylohyoid nerve and sensory fibres from cervical plexus in retromolar area may also innervate the teeth . Te!"ni!al errors M M M M Technical errors are result of misplacement of needle at the time of inAection 'eep penetration in parotid gland $uperficial penetration - absence of sign Penetration superior to occlusal level - absence of sign

$udden agitation or hyperactivity - intravascular inAection

Solutions M M M M (ow#gates nerve block ntroduced by 'r. (eorge (ow#(ates 5+,286 True mandibular nerve block as it provides sensory anesthesia to entire distribution of 8rd branch of trigeminal nerve . "dvantage - single inAection for anesthesia M increased success rate 5,3#,,O6 - .ewer post inAection complications 'isadvantage - *onger time of onset - *ingual and lower lip discomfort to patient &A7IRANI 8 A6INOSI C$OSED /OUTH /ANDIBU$AR B$OC6 M M ntroduced by 'r. Poseph "kinosi in +,22 0losed mouth approach to mandibular anesthesia

In i!ations - *imited mandibular opening - 1ultiple procedures on mandibular teeth nability to visuali)e landmarks for "/B

Supplemental Anest"esia M M M M $upplemental inAection approach followed if +st standard inAection is ineffective Qseful to repeat standard inAection only if the patient is not exhibiting classical signs of soft and hard tissue anesthesia .or postero#superior maxillary block palatal infiltration provides profound anesthesia .or mandibular molars use lingual infiltration and intra#ligamental inAection .

HOT TOOTH M M Periodontal ligament inAection techniEue of choice if the primary inAection is unsuccessful $upplemental inAections for the hot tooth are in following order of preference +. ntra#ligamental inAection %. ntra#septal inAection 8. ntra#pulpal inAection Sta)i ent system M M M M " new intra#bony inAection Beveled steel wire mounted in slow speed Handpiece used to perforate cortical plate adAacent to root in Euestion /eedle of similar diameter and length inserted into tiny opening Before perforation +st inAect into attached gingiva

/ANA%E/ENT OF #AIN FO$$O9IN% INSTRU/ENTATION

M 0auses - some hypotheses proposed - *ocal adaptation syndrome - Periapical pressure changes - 1icrobial flora changes mmunological factor - Psychological factor Non vital toot" ,ne!roti! pulpM M M "pical radiolucency Pain with swelling can sometime arise as result of instrumenting an asymptomatic, non vital 5necrotic6 pulp 0ohen referred to this situation as phoenix abscess

Fa!tors M .ollowing factors, studied by TorabinaAad et al were evaluated +. "ge - :&#:3 yrs. %. $ex - females more 8. "nterior and posterior teeth - no difference :. 1ost problematic - mandibular incisor and bicuspids 3. *east problematic - maxillary molars D. Patient with allergy - increase incidence 2. Presence of systemic disease - no difference J. $i)e of radiolucency - inversely proportional ,. Presence of sinus tract - less problematic +&. $ystemic medication - analgesics more effective than antibiotics . &ital toot" M 0auses - hyper occlusion - Kvermedication - Kver instrumentation

nadeEuate pulp removal

- .racture of temporary dressing #revention M "void apical extrusion of infected debris - 0rown down instrumentation - @otary instrumentation - .reEuent irrigation M 4limination of all micro organisms - 0omplete chemo# mechanical preparation in one visit M ntracanal medication Prophylactic /$" 's - Therapeutic blood level of /$" 's should be attained if possible prior to initial endo visit . deally % oral doses should be given

/ana3ement M M .or immediate relief of pain administer local anesthesia .ollow up with the criteria mentioned - 0heck occlusion - @emove temporary fillings M M M reinstrument to appropriate working length .reEuent irrigation $earch for additional canal5s6

/ANA%E/ENT OF ENDODONTIC #AIN FO$$O9IN% OBTURATION M ncidence of acute pain or swelling subseEuent to completion of endodontic treatment is extremely low. Post endodontic pain is usually mild, transient and managed with an appropriate analgesic. Causes M M M M M M M Kverfilling or over extension 4xtra short fill Hyper occlusion 1issed canal 0racked or split tooth Pain full episodes are usually caused by the pressure inherent in the insertion of root canal filling material. "nother reason can be chemical irritation from ingredients of root canal cements or paste. "s a rule, these effects are short lived and last only for %: - :J hours. M "nother possible cause is fracture of crown or root

/ana3ement M M M M M M M M .or immediate relief of pain administered local anasthesia "fter that following should be consider 0heck occlusion /$" '$ an antibiotics 5$welling6 @e treatment Trephination "pical surgery 4xtraction

/ana3ement M M M M "ttempt to establish drainage through canal 5if no drainage# apical trephination6 "pply corticosteroids and antibiotics 0heck for swelling 5consider antibiotics6 Prescribe analgesics

CONC$USION Pain has always challenged mankind by being on undesirable sensation and man will always find never techniEue to reduce its agony. " clinician is always challenged with patient vague description of his painful condition. Hence adeEuate knowledge of pain will have his analytic skill and leading to better understanding of patient conditions and effective treatment delivery. "s Hilton states Every pain has its distinct significance and pregnant if we will but carefully search for it.

Re*eren!e:
:( $elt)er $amuel, Pain 0ontrol in dentistry diagnosis and management ;( 1umford P.1, Krofacial pain, aetiology, diagnosis and treatment <( (uyton 0. "rthur. Text book of medical physiology 2 th etd. =( Bell 4. Belden Krofacial pains classification diagnosis and management :th etd. >( P.1. 1umford, P. Kf dent res= 3&= p 3&D. etd.

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CONTENTS

INTRODUCTION HISTORY DEFINITION BASIC TER/INO$O%Y #HY$O%ENIC CONSIDERATION #AIN

RECE#TORS

NER&E I/#U$SE TRANS/ISSION /ECHANIS/ BASIC #HYSIO$O%Y OF SYNA#SE NEUROTRANS/ITTERS FIBERS AND TRACTS IN&O$&ED IN #AIN #ATH9AY THRESHO$D OF #AIN C$INICA$ CONSIDERATIONS
O O

#AIN IN ENDODONTICS #AIN CONTRO$ /ETHODS

CONC$USION REFERENCES