dr. Ken Wirastuti, MKes, Sp.

S Bagian Ilmu Penyakit Saraf Fakultas 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 & muscle Dermatomes - Relationship between the spinal nerve & skin

Site and Source of Pain

Site: The location of the pain.

Source: The origin of the pain.

Primary Pain
Pains in which the site and source are in the same location.

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 heart problem, after dental evaluation.

Toothache of Cardiac Origin

Origin
Myocardial ischemia with regional referral of pain.

Periodic dull pressure of aching in the mandible or Clinical teeth; may accompany pain in chest or arm; history of Characteristics angina; pain precipitated by exercise, stress, or physical activity.

Local Anesthetics Treatment

Anesthesia of teeth not effective.

Refer to medical physician

Toothache of Myofascial Origin

Origin
Referral of pain from myofascial trigger points in muscles of mastication primarily masseter, temporalis, anterior digastric.

Nonpulsatile; constant, aching; variable and cyclic; Clinical pain increases with stress and use of offending Characteristics muscles.

Local Anesthetics Treatment

Anesthetic block of tooth does not alter pain; anesthetic injection of trigger point relieves pain.

Treatment and elimination of trigger points by spray and stretch, injection, or physical therapy.

Toothache of Maxillary Sinus/Nasal Mucosa Origin

Origin
Infection of the maxillary sinus or inflammation of nasal mucosa.

Constant dull ache or pressure; sensitivity to cold, Clinical percussion, chewing; pain in multiple teeth; pain Characteristics increased by bending body forward; sinus tender to palpation; Waters may show air-fluid level.

Local Anesthesia Treatment

Topical anesthesia of nasal mucosa relieves pain in anterior teeth; infiltration anesthesia of posterior teeth relieves pain. Antibiotics, antihistamine with a decongestant, analgesic.

Toothache of Neuropathic Origin (Trigeminal Neuralgia)

Origin
Abnormal function of nerves that innervate teeth (mandibular and maxillary branch of the trigeminal nerves).

Unilateral, severe, paroxysmal bursts of electric-like Clinical shocks stimulated by minor superficial provocation; Characteristics may be felt in teeth; asymptomatic between episodes.

Local Anesthetics
Treatment

Topical anesthetic of mucosal or skin trigger blocks pain; anesthetic block of nerve root blocks pain. Referral to neurologist or neurosurgeon.

Toothache of Neuropathic Origin [Atypical Odontalgia (Phantom Pain)]

Origin
Not definitely known; most probably a deafferentation pain after trauma.

Constant pain with no obvious pathology; burning, Clinical aching pain in molar/premolar area longer than 4 Characteristics months; local provocation not reliably effect pain.

Local Anesthetics
Treatment

Equivocal response

Tricyclic antidepressants, gabapentin

Toothache of Neurovascular Origin (Tooth migraine)

Origin
Neurogenic inflamation in the trigeminovascular system

Maxillay canines/premolars; no dental cause; Clinical throbbing, episodic, persistent, recurrent pain; dental Characteristics treatment may provide temporary relief; may become widespread.

Local Anesthetics
Treatment

Effects are unpredictable.

Same as for migraine headache; triptans, NSAIDs, beta blockers, ergotamines.

Toothache of Psychogenic Origin

Origin
Psychogenic origin.

Bizarre behavior; history of psychiatric treatment; Clinical migratory pain in multiple teeth, frequently bilateral; Characteristics unexpected or inappropriate response to treatment.

Local Anesthetics Treatment

Equivocal effects.

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.