dr. Ken Wirastuti, MKes, Sp.S Bagian Ilmu Penyakit Saraf Fakultas Kedokteran-Universitas Islam Sultan Agung
dr. Ken Wirastuti, MKes, Sp.SBagian Ilmu Penyakit SarafFakultas Kedokteran-Universitas Islam Sultan Agung
Definition
The pain sensation produced in some parts of the body is felt in other structures away from the place of development. This is called referred pain.
The deep pain and some visceral pain are referred to other areas.
MECHANISM OF REFERRED PAIN Dermatomal rule: Pain is referred to a structure,
which is developed from the same dermatome from which the pain producing structure is developed.
A dermatome includes all the structures or parts of the body which are innervated by afferent nerve fibers of one dorsal root. For example, the heart and inner aspect of left arm originate from the same dermatome. So, the pain in heart is referred to left arm.
A dermatome is an area of the skin supplied by nerve fibers originating from a single dorsal nerve root. The dermatomes are named according to the spinal nerve which supplies them.
Myotomes - Relationship between the spinal nerve & muscleDermatomes - Relationship between the spinal nerve & skin
Site and Source of Pain
Site: The location of the pain.
Source: The origin of the pain.
Pains in which the site and source
are in the same location.
Primary Pain
Heterotopic Pain
Pains in which the site and source
are not in the same location.
Heterotopic Pain
Pain felt in an area other than its true site of origin (associated with deep, somatic pain). Projected pain: perceived in the anatomic
distribution of the same nerve that mediates the primary pain (painful adjacent teeth).
Referred pain: felt in an area innervated by a different nerve from the one that mediates the primary pain (teeth in opposing arch, face, head, neck). Does not cross the midline. Convergence of afferent neurons.
EXAMPLES OF REFERRED PAIN Cardiac pain is felt at the inner part of left arm
and left shoulder. Pain in ovary is referred to umbilicus. Pain from testis is felt in abdomen. Pain in diaphragm is referred in right
shoulder. Pain in gallbladder is referred to epigastric
region. Renal pain is referred to loin.
Nonodontogenic Toothaches
Most toothaches will be of odontogenic origin.
However, if there is no identifiable cause or source (e.g. caries) for the pain,
or
the history and clinical findings are inconsistent with odontogenic pain,
then
a nonodontogenic source should be considered.
Cardiac Toothache
Angina pectoris or acute myocardial infarction, refer pain to the shoulder, arm, the jaw and to the teeth.
Associated with chest pain, but occasionally, it is not
Tooth ache increases with exercises and decreased with medication specific for the heart (nitroglycerin)
Treatment is directed to the underlying heartproblem, after dental evaluation.
Toothache of Cardiac OriginToothache of Cardiac Origin
OriginOrigin Myocardial ischemia with regional referral of Myocardial ischemia with regional referral of pain.pain.
Clinical Clinical CharacteristiCharacteristicscs
Periodic dull pressure of aching in the mandible Periodic dull pressure of aching in the mandible or teeth; may accompany pain in chest or arm; or teeth; may accompany pain in chest or arm; history of angina; pain precipitated by exercise, history of angina; pain precipitated by exercise, stress, or physical activity.stress, or physical activity.
Local Local AnestheticsAnesthetics
Anesthesia of teeth not effective.Anesthesia of teeth not effective.
TreatmentTreatmentRefer to medical physicianRefer to medical physician
Toothache of Myofascial Origin
OriginOriginReferral of pain from myofascial trigger points in Referral of pain from myofascial trigger points in muscles of mastication – primarily masseter, muscles of mastication – primarily masseter, temporalis, anterior digastric.temporalis, anterior digastric.
Clinical Clinical CharacteristiCharacteristicscs
Nonpulsatile; constant, aching; variable and Nonpulsatile; constant, aching; variable and cyclic; pain increases with stress and use of cyclic; pain increases with stress and use of offending muscles.offending muscles.
Local Local AnestheticsAnesthetics
Anesthetic block of tooth does not alter pain; Anesthetic block of tooth does not alter pain; anesthetic injection of trigger point relieves anesthetic injection of trigger point relieves pain.pain.
TreatmentTreatment Treatment and elimination of trigger points by Treatment and elimination of trigger points by spray and stretch, injection, or physical therapy.spray and stretch, injection, or physical therapy.
Toothache of Maxillary Sinus/Nasal Mucosa Origin
OriginOrigin Infection of the maxillary sinus or inflammation Infection of the maxillary sinus or inflammation of nasal mucosa.of nasal mucosa.
Clinical Clinical CharacteristiCharacteristicscs
Constant dull ache or pressure; sensitivity to Constant dull ache or pressure; sensitivity to cold, percussion, chewing; pain in multiple cold, percussion, chewing; pain in multiple teeth; pain increased by bending body forward; teeth; pain increased by bending body forward; sinus tender to palpation; Water’s may show air-sinus tender to palpation; Water’s may show air-fluid level.fluid level.
Local Local AnesthesiaAnesthesia
Topical anesthesia of nasal mucosa relieves Topical anesthesia of nasal mucosa relieves pain in anterior teeth; infiltration anesthesia of pain in anterior teeth; infiltration anesthesia of posterior teeth relieves pain.posterior teeth relieves pain.
TreatmentTreatment Antibiotics, antihistamine with a decongestant, Antibiotics, antihistamine with a decongestant, analgesic.analgesic.
Toothache of Neuropathic Origin (Trigeminal Neuralgia)
OriginOriginAbnormal function of nerves that innervate Abnormal function of nerves that innervate teeth (mandibular and maxillary branch of the teeth (mandibular and maxillary branch of the trigeminal nerves).trigeminal nerves).
Clinical Clinical CharacteristiCharacteristicscs
Unilateral, severe, paroxysmal bursts of electric-Unilateral, severe, paroxysmal bursts of electric-like shocks stimulated by minor superficial like shocks stimulated by minor superficial provocation; may be felt in teeth; asymptomatic provocation; may be felt in teeth; asymptomatic between episodes.between episodes.
Local Local AnestheticsAnesthetics
Topical anesthetic of mucosal or skin “trigger” Topical anesthetic of mucosal or skin “trigger” blocks pain; anesthetic block of nerve root blocks pain; anesthetic block of nerve root blocks pain.blocks pain.
TreatmentTreatment Referral to neurologist or neurosurgeon.Referral to neurologist or neurosurgeon.
Toothache of Neuropathic Origin Toothache of Neuropathic Origin [Atypical Odontalgia [Atypical Odontalgia (Phantom Pain)(Phantom Pain)]]
OriginOrigin Not definitely known; most probably a Not definitely known; most probably a deafferentation pain after trauma.deafferentation pain after trauma.
Clinical Clinical CharacteristiCharacteristicscs
Constant pain with no obvious pathology; Constant pain with no obvious pathology; burning, aching pain in molar/premolar area burning, aching pain in molar/premolar area longer than 4 months; local provocation not longer than 4 months; local provocation not reliably effect pain.reliably effect pain.
Local Local AnestheticsAnesthetics
Equivocal responseEquivocal response
TreatmentTreatment Tricyclic antidepressants, gabapentinTricyclic antidepressants, gabapentin
Toothache of Neurovascular Origin Toothache of Neurovascular Origin (Tooth migraine)(Tooth migraine)
OriginOrigin Neurogenic inflamation in the trigeminovascular Neurogenic inflamation in the trigeminovascular systemsystem
Clinical Clinical CharacteristiCharacteristicscs
Maxillay canines/premolars; no dental cause; Maxillay canines/premolars; no dental cause; throbbing, episodic, persistent, recurrent pain; throbbing, episodic, persistent, recurrent pain; dental treatment may provide temporary relief; dental treatment may provide temporary relief; may become widespread.may become widespread.
Local Local AnestheticsAnesthetics
Effects are unpredictable.Effects are unpredictable.
TreatmentTreatment Same as for migraine headache; triptans, Same as for migraine headache; triptans, NSAIDs, beta blockers, ergotamines.NSAIDs, beta blockers, ergotamines.
Toothache of Psychogenic OriginToothache of Psychogenic Origin
OriginOrigin Psychogenic origin.Psychogenic origin.
Clinical Clinical CharacteristiCharacteristicscs
Bizarre behavior; history of psychiatric Bizarre behavior; history of psychiatric treatment; migratory pain in multiple teeth, treatment; migratory pain in multiple teeth, frequently bilateral; unexpected or frequently bilateral; unexpected or inappropriate response to treatment.inappropriate response to treatment.
Local Local AnestheticsAnesthetics
Equivocal effects.Equivocal effects.
TreatmentTreatmentRefer to psychiatrist.Refer to psychiatrist.
Reffered Pain
Constant deep pain input can alter the
central processing of nociception.
Referred pain arises from central excitatory
effects.
(central sensitization)
The Clinical Characteristics of Referred Pain
1. Referred pain most commonly occurs in
other divisions of the same nerve that
mediates the pain.a. vertical laminated pattern
b. does not cross the midline (in the trigeminal)
2. If another nerve is affected, it is usually
cephalad to the nerve that mediates the pain.
Diagnostic Rules for Identifying Referred Pain
1. Local provocation of the site of pain does not
increase the pain.
2. Local provocation of the source of pain increases
the pain not only at the source but also the site.
3. Local anesthesia at the site of pain does not
decrease the pain.
4. Local anesthesia at the source of pain decreases
the pain not only at the source but also at the site.