Top Banner
dr. Ken Wirastuti, MKes, Sp.S Bagian Ilmu Penyakit Saraf Fakultas Kedokteran-Universitas Islam Sultan Agung
26
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Page 1: Reffered Pain

dr. Ken Wirastuti, MKes, Sp.SBagian Ilmu Penyakit SarafFakultas Kedokteran-Universitas Islam Sultan Agung

Page 2: Reffered Pain

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.

Page 3: Reffered Pain

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.

Page 4: Reffered Pain

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.

Page 5: Reffered Pain

Myotomes - Relationship between the spinal nerve & muscleDermatomes - Relationship between the spinal nerve & skin

Page 6: Reffered Pain

Site and Source of Pain

Site: The location of the pain.

Source: The origin of the pain.

Page 7: Reffered Pain

Pains in which the site and source

are in the same location.

Primary Pain

Page 8: Reffered Pain

Heterotopic Pain

Pains in which the site and source

are not in the same location.

Page 9: Reffered Pain

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.

Page 10: Reffered Pain

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.

Page 11: Reffered Pain

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.

Page 12: Reffered Pain
Page 13: Reffered Pain
Page 14: Reffered Pain

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.

Page 15: Reffered Pain

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

Page 16: Reffered Pain
Page 17: Reffered Pain

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.

Page 18: Reffered Pain

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.

Page 19: Reffered Pain

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.

Page 20: Reffered Pain

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

Page 21: Reffered Pain

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.

Page 22: Reffered Pain

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.

Page 23: Reffered Pain

Reffered Pain

Constant deep pain input can alter the

central processing of nociception.

Referred pain arises from central excitatory

effects.

(central sensitization)

Page 24: Reffered Pain

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.

Page 25: Reffered 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.

Page 26: Reffered Pain