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LEARNING OBJECTIVES

LEARNING OBJECTIVES . The participant will be exposed to the concept of pain, including definition, types of pain, physiology of pain and ultimately a discussion of opioid and nonopioid therapy with indications and contraindications

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LEARNING OBJECTIVES

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  1. LEARNING OBJECTIVES • The participant will be exposed to the concept of pain, including definition, types of pain, physiology of pain and ultimately a discussion of opioid and nonopioid therapy with indications and contraindications • Additionally, the health care provider will be exposed to usage concepts of antiinfectives for head and neck infections

  2. LEARNING OBJECTIVES • The lecture participant will be exposed to the concept of local anesthesia for pain relief, with a discussion of types of anesthetics, maximum dosages, drug interactions and selected techniques

  3. PAIN

  4. PAIN • INTERNATIONAL ASSOCIATION for the STUDY OF PAIN: “Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”

  5. PAIN EXPERIENCE • Involves the psychologic (past experiences, cultural behaviors and emotional state) and • Physiologic aspects(involves the transduction,transmission and modulation of pain) • The experience of pain is linked to emotional,behavioral, and cognitive phenomena

  6. PAIN---An abstract and relative concept perceived by the patient.Described in various ways by various people

  7. --PSYCHOLOGIST--learned behavior

  8. --PHILOSOPHER—a moralizing force

  9. --SOCIOLOGIST—expression of cultural norms

  10. --PHYSICIAN--A symptom to be decodedfor the diagnosis and treatment of organic disease

  11. --ATTORNEY—basis for litigation

  12. --CHARLIE BROWN—where it hurts

  13. AXIS I (PHYSICAL CONDITIONS) • Cutaneous and mucogingival pains • Mucosal pains of the pharynx, nose, and paranasal sinuses • Pains of the musculoskel. structures of the mouth/face • Pains of the visceral structures of mouth/face • Pains of the neural structures of mouth/face

  14. AXIS II (PSYCHOLOGIC CONDITIONS) • Anxiety disorders • Mood disorders • Somatoform disorders • Other conditions, such as psychologic factors affecting a medical condition PSYCHOLOGIC INTENSIFICATION OF PAIN

  15. SENSORY NEURONS • Divided into 3 types: 1) General Somatic Afferent with receptors involved in sensations of pain, touch, and temperature ; 2) Special Somatic Afferent with receptors in muscles,tendons and joints; 3) General Visceral Afferent receptors which sense fullness and discomfort.

  16. NOCICEPTORS:1-5MM DIAMETER NERVE FIBERS.

  17. A-DELTA: Responsible for temperature and fast or first pain. Is myelinated Conduction velocity is 12-45 m/sec C-FIBERS: Responsible for slow or second pain, and temperature. Is unmyelinated Conduction velocity is 0.2-2.0 m/sec PAIN FIBERS(PERIPHERAL NERVE FIBERS)

  18. THE TRIGEMINAL SYSTEM • Sensory input from the face and mouth is carried by V. • Cell bodies of the trigeminal afferent neurons are located in the gasserian ganglion • Impulses carried by V enter directly into brainstem(pons) and synapse in the trigeminal spinal tract nucleus

  19. CIRCUITRY OF SENSATION • Somatosensory input from the periphery is transmitted into the CNS via dermatomal organization to the dorsal root ganglion or if head and neck- the Trigeminal ganglion • Have 2 parallel pathways to the cortex: the discriminative pathway and the slower anterolateral pathway with its 2 subdivisions

  20. PERIPHERAL AND CENTRAL SENSITIZATION • Neurotransmission involves both excitatory and inhibitory pathways and a balance hopefully exists • Peripherally, receptors can respond to nociceptive stimuli (nociceptive neurons), but some of these neurons are silent but with continued stimulation can recruit wide dynamic range neurons and undergo sensitization from exposure to prostaglandins,bradykinin, serotonin,cytokines etc.

  21. CENTRAL NOCICEPTORS • The peripheral neurons, A- delta and C fibers, have a counterpart centrally • These receptors are referred to as AMPA and NMDA. The NMDA receptors are responsible for chronic pain syndromes after continued stimulation

  22. Discriminative pathway for joint movement, proprioception, and delicate touch and is rapid.

  23. ANTEROLATERAL PATHWAY

  24. CORTEX-THE HOMUNCULUS 1955

  25. PAIN:TRANSDUCTION,TRANSMISSION, MODULATION AND PERCEPTION

  26. MECHANISM OF ACUTE PAIN

  27. MECHANISM OF ACUTE PAIN

  28. PAIN • Simplisticly, can be categorized as acute (brief-duration) or chronic (long-lasting) • Was thought of as a symptom and not a diagnosis. Now with molecular biology advances, the plasticity of the brain is seen, whereby physiologic changes are induced by chronic pain. • Is difficult to grade pain objectively

  29. WORLD HEALTH ORGANIZATION • Caregivers in primary, secondary, and tertiary care settings are being asked to consider pain as the 5th vital sign • Want assessment of the patient’s pain level on a scale of 0-10 on a regular basis when assessing other vital signs • STANDARD RI.1.2.9 PATIENTS HAVE THE RIGHT TO APPROPRIATE ASSESSMENT AND MANAGEMENT OF PAIN

  30. PAIN • The fifth vital sign • Blood pressure • Pulse • Temperature • Respirations • Pain 1997 – JCAHO began working to create standards for pain assessment and treatment

  31. PAIN is the most common symptomatic reason to seek medical consultation THE PATIENT IS THE ONLY PERSON WHO CAN DESCRIBE THE INTENSITY AND CHARACTER OF PAIN

  32. EPIDEMIOPLOGY OF PAIN • Orofacial pain is one of the most common types of pain. • Odontalgia is the most prevalent form of orofacial pain • Occurs in nearly 12%-14% of the population, which corresponds to about 20 million people in the U.S.

  33. GOAL OF PAIN THERAPY • Should be to reduce peripheral sensitization, thereby decreasing central stimulation and amplification • Acute pain is often exacerbated by anxiety and secondary reflex musculoskeletal spasms • Acute pain should be aggressively managed • The origins of chronic pain may be neurogenic, nociceptive, psychiatric, or idiopathic

  34. GENERAL TREATMENT PRINCIPLES • Effective treatment considers the cause, duration, and intensity of pain and matches the appropriate intervention to the situation • The goal of therapy is to eliminate or reduce the pain to the lowest tolerable intensity and prevent it from recurring • Patients need monitoring for efficacy and untoward side effects

  35. COMMON CAUSES OF ANALGESIC FAILURE

  36. ANALGESIC SELECTION • Requires an analgesic regimen that is highly effective, predictable. • Has minimal side effects • Is intrinsically safe • Can be easily managed away from a hospital or surgicenter • OPIOD VS NONOPIOID ANALGESIA

  37. NONOPIODS • Includes the classes of NSAIDs, APAP and tramadol • NSAIDs demostrate good analgesic effect for mild to moderate orofacial pain. These drugs are recommended for the initial management of orofacial pain and when an inflammatory or musculoskeletal component is suspected

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