- Pain is a subjective, perception based on physical stimuli, psychological variables and spiritual beliefs.
- *The nature of the response determines the pain experience
- it can result from both the loss of inhibitory control or the activation of excitory modulating neurons
What are pain receptors or nociceptors?
What are the Three types?
- Free nerve ednings present in all tissue except brain tissue.
- Three types
- - specific = respond to intese stimuli only (A8 Fibres)
- - polymodal = responds to diff modes of stimuli e.g. touch and has an increased response to intense stimuli (C Fibres)
- - Silent = recently discovered, normally inactive, activated by chemicals released in the inflammatory response (AB Fibres)
Describe A8 Fibres:
- small in diameter with thin myelin shealth
- transmission of signals at 5-10m.s-1
- usually occurs for a few seconds after stimulus elecits a reflex withdrawal
Describe C Fibres:
- small in diameter and unmyelinated therefore there is a slower conduction than A8 fibres = 1m.s.-1
- polymodal = transmits signals other than pain
- produces reflex activation of models e.g. produces trismus (spazim) of the muscles of mastication following surgial removal of the 8's
Describe Silent AB Fibres:
- in normal circumstances only transmit touch sensations
- they are not sensitive to noxious stimuli unless they are sensitised by inflammatory mediators
- i.e. they are not involved in acute pain transmitters but become them in chronic or when inflammatory mediators are present
Briefly descibe what gate control theory is?
- melzack and wall 1965, 1982
- a gate is located in the doral horn which modulates and balances sensory input
- both peripheral and central factors can potentiate and moderate pain perceptions and cns is essential for pain process and percceptions
Two key neurotransmitters involved in descending inhibition
- serotonin and noradrenaline
- stimulation of nociceptors in one part of the body can supress the perception of pain evoked by a noxious stimulation applied to another area
- non-nocicpetive afferent input - suppresses/ induces inhibition of nociceptive transmissions
What is the endogenous opioid system?
the analgesic effects mediated by the placebo effect, hypnosis and acupcture are in part mediated by this system.
Sources of Acute orofacial pain:
- Dental pulpitis, cracked tooth
- periodontal problems (gingivitis, periodontitis and pericoronitis)
- mucosal ulceration
- traumatic TMJ dysfunction
- maxillary sinusitis, carcinoma
- salivary gland pathology
Source of Chronic orofacial pain:
- TMD/ myofascial pain
- oral neuropathic pain (phantom tooth pain)
- trigeminal neuralgis
- cancer, osteoarthritis, rheumatoid arthritis
- burning mouth/ tongue (glossodynia)
- headaches; tension; migrance, facial migranious neuralgia
Psychological importance of face/ orofacial pain;
- vital importance of mouth/ face
- vital for feeding, communication and public presentation of the self
- damaged face = damaged self
- recent trauma/ face readily rekindles past trauma
Who is the expert in acute and chronic pain?
- acute = dentist is expert
- chronic = patient is the expert and dentist is a facilitator
the apprehensive anticipation of future danger or misfortune accompanied by a feeling of dysphoria or somatic symptoms of tension
What is dental phobia?
extreme irrational reaction to a dental stimulus which causes patients to avoid attending dental care.
Psychological factors affecting the perception of Pain
- anxiety and dpression
- hypervigilance/ attension to pain
- self control over pain
- coping skills
- role of significant others
- situational factors
- cultural factors
What are some tools to help calm fear in paediatric patients?
- dentist talking whilst working
- watching the work in the mirror
- signal to stop work - having some control
- to be told they are a great helper and having positive rewards
- *TELL SHOW DO*
Managing phobic patients
- establish the problem - psychological and behavioural assessment and self report scales
- develop a managment plan
- manage the problem but telling showing and doing, distraction of the patient, positive reinforcements, hypnosis, breathing exercisers, pharmaceutical ideas - e.g. drugs
- the act of wearing or grinding down by friction
- caused by tooth to tooth contact
- slow process
- chewing adn biting surfaces and also mesial and sital surfaces in older patients
- rate of it is modified by abrasion and erosion factors
- wear facets in the enamel, absence of mammelons and flattening of the cusps posteriorally
- e.g. Bruxism
- the abnormal pathological wearing away of tooth structure from a repetitive mechanical process involving forieng objects or substances
- something rubbing against the teeth = tooth brush abrasion creating notch shaped defects near the labial or buccal cervical margin of the tooth
- are found in adult patiens and are related to the biomechanical stresses that are constantly applied to teeth
- teeth undergo great functional stress are subjected to deformation and flexure which leads to fracturing of the tooth structure in the cervical region
- notch at the CEJ
- occurs when teeth are exposed to various chemicals influding acids and other materials that tend to soften tooth structure
- affects enture tooth surface = amalgam restorations look raised
- caused by acids which can derive from intrinsic (Gastroesophageal relux or poor saliva) or extrinsic source (food s and drinks)
- thinning of the enamel - prone to chipping
- dentine dissolves more rapidly
- cover tooth structure in composite resin and determine the cause before treatment.
Define tooth fractures:
- teeth may fracture when subjected to great force of sharp impacts
- can be two types: a break which is classified by where it breaks and what tissues are involved and Displacement in the socket.
Explin the four types of Crown Fractures:
- 1. Enamel Fracture = can round off if sharp but if no hurting aesthetics, no treatment
- 2. Enamel- dentin Fracture = need to repair - shouldnt be any irreversible factors as pulp not involved
- 3. Fracture involving the Pulp = how long has the pulp been exposed? treat pulp f reversible pulpitis
- 4. Root = can repair but depends on how badly its fractured, radiographs are important and the more apical it is, the easier it is to treat!
When you suscept a displacement fracture, what should you do?
- must look at periodontal ligament and pulp to get best result
- put back in within 5 mins - clean first
- keep tooth in milk if cant put back
- primary teeth = dont put back in
What is Concussion and Subluxation?
- damages the pdl but hasnt moved it so tooth is still intact
- pdl may regenerate or ankylose
- do nothing
What is extrusion and lateral luxation?
- pdl is severly damaged
- blood supply of the tooth may be severed so worth following up as pulp can become necrotic - abscess or root resorption
- can be pushed back into place but alveolar bone fracturing can also take place - be aware
- pdl is destroyed, may repair if cells are there
- pushed up into the socket
What is Avulsion
- tooth completely out
- how much time it was out of the mouth is important - the faster the better
- pulp can revitalise but normally dies
Two potential problems with the roots of our teeth after a fracture?
- 1. inflammatory root resorption = inflammation eats away the tooth, removal of pulp and replaement with calcium hydroxide
- 2. Ankylosis = replaced with bone, wille eventually need to be extracted as crown submerges below gingiva and eventually root will resorb and enamle and detine crown will fall out - would need to do a bone graph if it needed surgery for extraction
What are thermal burns and chemical burns?
- thermal burns are from hot foods and drinks that burn the soft tissues
- chemical burns may be seen in the oral cavity in repsonse to the presence of an irritant, caustic or corrosive material e.g. aspirin
What is a traumatic ulcer?
- occurs when tissue is famaged by biting, toothbrush injury, injury from sharp objects i.e. tooth pick or a sharp fractured edge of a tooth eg. denture irritation
- take away the cause and then it will heal
- ulcers often undergo secondary infection and are painful, but they usually heal without problems when the cause has been addressed
What is friction keratosis?
refers to the whitish thickening of keratin on a mucosal surface that occurs when the area is subejcted to constant rubbing - cheeks being chewed constantly - linea alba on buccal mucosa
what is a haematoma?
- blood vessel breaks and seeps into the soft tissues
- "blood blister"
- swollen reddish-blue area
- once formed it can stay there
- cause is from a traumatic episode
What is a mucocele?
- when a minor salivary gland duct is cut due to trauma
- saliva accumulates = lump
- can be deep or superficial
- can be exised but will probably come bakc (sometimes chronic and recurrent)
- bluis in colour and common in lower lip
what is a ranula and what is a sialolithasis?
- major salivary gland duct is cut and is often found in the floor of the mouth
- when calculus forms in the duct of a mjor salivary gland it blocks saliva causing swilling resulting in a ranula.
- patient with complain of pain before during and after meals
- it is possible to remove small calculi by manipulating them out of the duct lumen
What is an amalgam tattoo?
- bluey grey discolouration on soft tissues caused by amalgam becoming trapped in the tissues
- is permanent
a break in the surface epithelium where the connective tissue is exposed
Causes of Ulcerations:
- 1. Traumatic
- - mechanical = acute is where there is pain , yellow base, red margins, heal within 7-10 days and chronic is where there is a yellow base and elevated margins and a biopsy needs to be taken if does not heal within ten days
- - chemical
- - thermal = thins epithelium
- - radiation
- 2. Infective
- - viral e.g. herpes, varicella-zoster, hand foot and mouth
- - bacterial e.g. TB, ANUG
- - fungal
- 3. Immunological
- - recurrent apthus stomatitis - classified by appearance and number of ulcers, how they heal
- 4. Associated with systemic disease
- - behcets disease - oral ulcers on muscoa
- - ulcerative colitis and chrohns disease (bowels)
- 5. Associated with dermatological Diseases
- - pemphigus = result of autoantibodies that react with desmosomal glycoproteins that are presented on the cell surface of the keratinocyte
- - mucuous membrane pemphigus = women in the 60s, lossf attachment between the epithelium and connective tissue
- -Erythema multiforme = yellow central bulla or pale clearing surround by odema and bands of erythma
- - oral lichen planus = chronic immunologic inflammatory mucocutaneous disorder
- 6. Neoplastic
- - squamous cell carcinoma or other malignant neoplasm
- - signs of oral cancers - painless, chronic ulder, with indurated edges and associated with smoking and alcohol
- general term refferring to the proliferation of cells within a tissue beyound that which is seen normally (hyper = growth and plasia = formation)
- = increase in cell number
- response to tissue trauma, lesion is confined and remains localised
- size regresses and proliferation stops after stimulus is removed
increase in the volume of an organ or titssue due to the enlargemenet of its component cells = increase in size
What is reactive (inflammatory) hyperplasia?
- obvious irritants
- broad and raised lesions
- contains dense connective tissue
- pale in colour (decreased blood capillaries)
- surface = smooth or ulcerative
- e.g. palatal papillary hyperplasia (denture papillomatosis) and denture induced irritation
- e.g. linea alba = epithelial hyperplasia and hyperkeratosis
What is fibroma (fibroepithelial polyp)?
- mainly on cheeks (if on gingiva = fibrous epulis
- firm, pink, painless pedunculated or swollen
- may have white keratotic surface
- histologically = granulation tissues with epithelial hyperplasia
What is pyogenic granuloma?
- common on gingiva
- soft, red, pedunculated nodule
- bleeds easy
- over exuberant inflammatory response to injury e.g. plaque or calculus
- treatment = removal of stimuli and excision if required
- histologically = numerous dialated blood vessels and fibrovascular tissue
What is peripheral giant cell granuloma?
- dark red pedunculated or sessile swelling
- highly vascular
- collection of multinucleated osteoclast like giant cells lying in a richly vascular and cellular stroma
What are some gingival hyperplasia or hypertrophy causes?
- plaque accumulation
- systemic factors
range of cellular abnormalities that induces changes in cell size and morphology, increases in mitotic figures, hyperchromatism and alteration in normal cellular orientation and maturation
epithelial dysplasia is usually found in potentially malignant oral lesions as wel as cancer lesions. There is irregular stratification or loss of polarity of the cells in the epithelium, increased mitosis, nuclear hyperchromatism, increase in nuclear-cytoplasmic ratio, polymorphism of cells and abnormal keratinisation
- is an abnormal mass of tissue as a result of abnormal proliferation of cells
- growth persists are the cessation of the stimuli
- can be benign (-oma) or malignant (-carcinoma - epithelial origin, and -sarcoma - mesenchymal origin)
Talk about three benign neoplasias:
1. Papilloma = benign tumor of squamous epithelium, exophytic pedunculated or sessile growth, white or colour of normal mucosa, cauliflower like and needs to be surgically removed
2. haemangioma = benign tumour of vascular tissue, proliferation of capillaries, cavernous (contains large blood vessels), present at birth, on tongue which can lead to macroglossia OR on head and neck areas, blanch on pressure and treatment on surgical removal or injection of sclerosing solution
3. odontome = odontogenic tumour composed of mature enamel, dentine, cementum and pulp. Can be compound (collection of small teeth in anterior region) or complex (mass) and can pose as threat as they can prevent normal eruption of teeth, displace them or cause swelling
What are some features of a malignant neoplasia?
- rapid rate of growth
- margins not defined
- grow with progressive infiltration, invasion and destruction of host tissue
- blood vascularisation is poorly formed
What is metastasis
spreading of cancer from one organ to another
Six capabilities of malgnant cancer cells
- self sufficiency in growth signals
- insensitivity to antigrowth signals
- avoidance of apoptosis (programmed cell death)
- limitless replicative potential
- development of new vascular supplies
- invasion and metastasis
Aetiological factors of Oral squamous cell carcinoma:
- betal quid
- diet and nutrition
- dental factors
What are some features of oral squamous cell carcinomas?
- asymptomatic but mild discomfort is felt
- keratin pearls present in tumor tissue
- significant inflammatory response (lymphocytes, plasma cells and macrophages
- surgery and radiation which can complicate saliva, taste function, caries rate and nutrition
- early detection is the best
what is a basal cell carcinoma?
nonhealing ulcer with characteristic rolled borders
How does nicotine work?
- it binds to receptors of the neurotransmitter acetylchoine which excites the cells in the brain.
- it has complex interactions with reflex nerve loops so it can calm a person but can also increase concentration, learning ability and retention of learned information
- smokers develop physical and psychological dependence along with tolerance - req. greater dosage
what is the fagerstrom test?
- tool used to measure nicotine dependence
- kinda like a survey - times when you smoke, who your with, what mood your in etc.
General Health Effects:
- loss of productivity in the workforce
- cancer - lung mouth pharyn larynx etc.
- cardiovascular disease
- peptic ulcer disease
Smoking and females:
- adversely effects the female reproduction system, lung function, high density lipoprotein and cholesterol levels
Oral Effects of Smoking
- keratosis = white lesions appear on mucosa where the epithelium is thicker (leukoplakia = patches of keratosis)
- external stains from tars = tars get stuck in the enamel lamellae
- increased mature plaque
- reduced resting salivary flow and pH
- impared taste
- hyperpigmentation (smokers melanosis = pigmentation due to irritants ins moke stimulating melanin production in basal layer of epithelium (alveolar mucosa) and hyperkeratosis)
- poor wound healing after survery, implants
- caries (lower oxygen tension and lower salivary rate), periodontitis, ANUG and oral cancer risk increases
- lower redox potential
- less oxygen levels in tissues
Effects on the tongue from Smoking:
black hairy tongue = an overgrowth of filiform papillae due to increased keratin production or decreased keratin desquamation, staining of the papilla = colour depends on source, aesthetics and halitosis concern, elongated filiform papillae in midline of tongue anterior to circumvallate papillae
What is smokers palate:
- nicotine extomatitis
- small dots on opening of minor salivary glands that are occluded.
What is nicotine stomatitis
smokers keratosis and smokers palate
What are some microbes that are present in smokers mouths:
- Tanneranella forsenthysis
- Porphyromonas gingivalis
- Aggregaterbacter actinomycetemcomitans
- Treponema denticola
Effects of smoking on cells
- contents of cigarettes are cytotoxic to cells that are involved in wound healing
- increases platelet adhesiveness, raising risk of microvascular occlusion and tissue ischaemia
- impaired chemotaxis
- impaired phagocytosis of neutrophils or polymorponuclear leukocyte
- impaired production of protective antibodies to periodontal pathogens
- impaired fibroblast function for surgerys and implants - less production of collagen
5 strategies for smoking cessation:
- relevance - help the person identify reasons for quitting
- risks - identify short and long term risks for smoking
- rewards - rewards or benefits to self and loved ones from smoking cessation
- roadblocks - help the person identify barriers to quitting
- repetition - may take more than one time to quit
Benefits of Quitting:
- blood circulation increases (immediately)
- breathing becomes easier (few days)
- lung function improves (2- 3 months)
- risk of coronary heart disease is reduced by 50 per cent (one year)
- risk of stroke decreases and same with cancers and heart disease (5-15 years after)
- Best to quit before age of 50 as their risk of dying in the next 15 years is half that of a person who smokes
- cold turkey
- counselling/ advice
- medications both over the counter and prescription such as Bypropion (zyban) and varenicline (cantix: pfizer) which block nicontine action of acetylcholine receptors - removes pleasure