pathway of pain
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‘PATHWAY OF PAIN’
ORAL BIOLOGY PRESENTATION
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PRESENTED BY:
DR.TEHRIM NASEER
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‘PAIN’
An unpleasant sensory and emotional experience which we primarily associate with tissue damage or describe in terms of such damage, or both.
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‘NOCICEPTION’
The detection of tissue damage by specialized transducers connected to A-delta and C-fibers.
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CHARACTERISTICS OF PRIMARY
AFFERENT FIBRESA-DELTA FIBER:
• Myelinated
• Diameter fine 2 - 5 μm
• 12 - 30 m/sec. conduction velocity
• Terminated at I and V layer
• Fast pain, rapid, pricking and well localized
• Neurotransmitter - Glutamate
• 20% pain conduction
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CHARACTERISTICS OF PRIMARY
AFFERENT FIBRESC-FIBER:
• Non-Myelinated
• Diameter less than 2 films
• -0.5 to 2 m/s conduction velocity
• Terminate in I and n layers
• Slow, diffuse, dull, aching
• Neurotransmitter - P-Substance
• 80% of pain conduction
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CLASSIFICATION OF PAIN NOCICEPTION
• Proportionate to the stimulation of the nociceptor.
• When acute•Physiologic pain•Serves a protective function•Normal pain
• when chronic•Pathologic pain
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‘CLASSIFICATION OF PAIN’
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NEUROPATHIC PAIN:
• Sustained by aberrant processes in PNS or CNS
• Disproportionate to the stimulation of nociceptor
• Serves no protective function
• Pathologic pain
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MIXED PAIN:
• Nociceptive components
• Neuropathic components
• Examples:• Failed low-back-surgery syndrome• Complex regional pain syndrome
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IDIOPATHIC PAIN:
• No underlying lesion found yet, despite investigation
• Pain disproportionate to the degree of clinically discernible tissue injury
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‘NORMAL CENTRAL PAIN
MECHANISMS’
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Ascending Tracts Descending Tracts
CORTEX
MIDBRAIN
PONS
MEDULLA
SPINAL CORD
THALAMUS
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‘ASCENDING AND DESCENDING PAIN
PATHWAYS’
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‘PAIN INHIBITORY AND PAIN
FACILITATORY MECHANISMS
WITHIN DORSAL HORN’
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MECHANISM
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Neuronal circuitry within the dorsal horn.Primary afferent neuron axons synapse onto spinothalmic neurons and onto inhibitory and excitatory neurons.
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‘FACIAL PAIN’
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CAUSES OF FACIAL PAIN
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CAUSES OF FACIAL PAIN
Facial pain can be caused by anything, from an infection to nerve damage in the face.
Common causes for facial pain include:
• oral infections
• ulcers (open sores)
• abscess (collection of pus under the surface tissue in the mouth, for example)
• skin abscess (collection of pus under the skin)
• headache
• facial injury
• toothache
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More serious causes for facial pain include:
• herpes zoster (shingles)
• migraine
• sinusitis (sinus infection)
• nerve disorder
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CHRONIC OROFACIAL PAIN
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TRIGEMINAL NEURALGIA
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TRIGEMINAL NEURALGIA
• Tic douloureux / fothergill’s neuralgia
• Paroxysms of fleeting ,excruciating u/l facial pain, usually lasting less than a minute.
• Usually V2/V3 , rarely V1
• MC – adv age, women , rt side
• Stimulation of trigger zone – pain
• Pain – by activities like talking, chewing, brushing teeth, exposure to cold, by wind on face
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• Trigeminal / gasserian / semilunar ganglion
• Situated just beside pons in a shallow depression in petrous apex – meckel’s cave
• Sensory root enters the pons course dorsomedially & terminate within brainstem: Nucleus of spinal tract of Vth N
Main/Principal sensory nucleus
Mesencephalic nucleus
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• Fibres – pain & temp – enter spinal tract of trigeminal & descend to various levels depending on their somatotropic origin, then synapse in adjacent nucleus of spinal tract.
• The axons of second order neurons cross midline, aggregate as trigeminothalamic tract & ascend to VPM
• From VPM , fibres project through thalamic radiations to sensory cortex in post central gyrus
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• B/L Weakness of muscles of mastication with inability to close the mouth ( dangling jaw ) – motor neuron ds, neuromuscular transmission disorder, myopathy
Clinical examination
motor functions
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Clinical examination
SENSORY FUNCTIONS
• Pain, touch, heat, cold – tested on face & mucous membranes
• Each of the 3 divisions of Vth.N is tested individually and compared with the opposite side.
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Stimulate Direct corneal reflex
Consensual corneal reflex
Complete VthN lesion
Involved eye Absent Absent
Opposite eye Normal Normal
Complete VIIthN lesion
Involved eye Absent Normal
Opposite eye Normal Absent
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Second-Order Neuron; Some times is called a
transmission neuron since it transfer the
impulse on to higher center .
The synapse of the primary afferent and
second-order neuron occurs in the dorsal
horn of the spinal cord .
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Afferent (Sensory) Somatic Nerves
• – Trigeminal Nerve
• – Facial Nerve
• – Glossopharyngeal Nerve
• – Vagus Nerve
• – Cervical Spinal Nerves
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Efferent (Motor) Somatic Nerves
– Occulomotor, and abducent Nerves
– Trigeminal Nerve
– Facial Nerve
– Glossopharyngeal nerve
– Vagus nerve
– Accessory Nerve
– Hypoglossal Nerve
– Cervical Spinal Nerves
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TYPES OF PAIN• Myofascial Pain
• Myositis
• Myospasm and Dystonia
• Protective Muscle Splinting
• Contracture
• Neoplasia
• Fibromyalgia
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LEISIONS AND DISORDERS OF
NERVES
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Supranuclear lesions
• Lesions affecting corticobular pathway -Contralateral trigeminal motor paresis (deviation of jaw away from the lesion)
• B/L UMN lesions ( pseudobulbar palsy ) – trigeminal motor paresis , exaggerated jaw jerk.Mastication markedly impaired.
• Thalamic lesions – anaesthesia of c/l face
• Parietal lesions – depression of c/l corneal reflex
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NUCLEAR LEISIONS
• Motor , sensory nuclei – primary/met . tumours
AV malformations
demyelinating ds
infarction/h’age
syringobulbia
that affect pons, medulla and upper cervical cord.
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Lesions affecting preganglionic
trigeminal nerve roots• Tumour ( meningioma, schwannoma, metastasis,
nasopharyngeal ca )
• Infection ( granulomatous, infectious , carcinomatous meningitis )
• Trauma
• Aneurysm
Char i/p facial pain, parasthesias, numbness, sensory loss, corneal reflex depressed, trigeminal motor paresis.
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HERPES ZOSTER
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Lesions affecting peripheral
branches of VthCranial
Nerve• Ophthalmic div : in middle cranial fossa , at
temporal bone apex, lat wall of cavernous sinus, sup.orbital fissure, distally in face
• Maxillary div : lower lateral wall of cavernous sinus, at foramen rotundum, in pterygopalatine fossa, in floor of orbit, at infraorbital foramen, in face
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Raeder’s paratrigeminal
syndrome• U/l oculosympathetic paresis – miosis ,
ptosis (without facial anhydrosis)
• Evidence of trigeminal involvement on same side.
• d/t lesions in middle cranial fossa ( b/w trigeminal ganglion & int.carotid.a, near petrous apex)
• Lesions of gasserain ganglion – tumour, aneurysm, trauma, infection
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Lesions affecting Gasserian
ganglion• Lesions of middle cranial fossa ( tumour, herpes zoster, sarcoidosis,
syphilis, tuberculosis, arachnoiditis, trauma, abscess )
• Pain – severe & paroxysmal
• Hemifacial / selective div of Vth CN
( esp V2,V3 )
Parasthesias , numbness may also occur
Sensory loss depends on div involved
u/l pterygoid & masseter paresis may occur.
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‘VISCERAL PAIN’
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VISCERAL PAIN PATHWAY
Pain - Aδ and fibersTravel with autonomic
afferent
Spinal cord(Dorsal Horn)
Lat. spinothalmic tract
Thalamus
Somatosensory Cortex
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‘REFERENCES’• Guyton and Hall textbook of Medical Physiology
• http://science.howstuffworks.com/life/inside-the-mind/human-brain/pain3.htm
• http://www.docstoc.com/docs/
• http://www.google.fr/imgres
• www.ksums.net
• www.authorstream.com
• http://www.docstoc.com/docs/70291468/Pain-Terminology-and-Pain-Pathways
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