dr. Ken Wirastuti, MKes, Sp.SBagian Ilmu Penyakit Saraf
Fakultas Kedokteran-Universitas Islam Sultan Agung
Definisi Nyeri
“…Pengalaman sensorik dan emosional yang tidak menyenangkan yang berkaitan dengan
kerusakan jaringan potensial atau aktual.
International Association for Study of Pain (IASP)
Rasa nyeri : persepsi subyektif respons
individual-sangat bervariasi stimulus sama intensitas nyeri dpt
berbeda Nyeri : seringkali merupakan keluhan
utama yg membawa pasien ke dokter Nyeri terutama yg sedang /berat/akut
seringkali disertai anxiety ↑ TD, berdebar,↑ kortisol plasma, kontraksi otot
Incidence 15-20% nyeri akut karena tindakan operasi atau
trauma Nyeri kronik persistent: 25-30% Penyebab disabilityas pada usia<45 tahun Nyeri wajah/rahang: 20 juta
Beban finansial• Managemen yang tidak adekwat• Hilangnya hari-hari kerja
Konsekuensi: Mengakibatkan penderitaan bagi penderita Disfungsi fisik / psikososial Immunosuppression
Epidemiologi Nyeri
Lima Dimensi Nyeri
1. Sensory = mengenali nyeri Pattern, area, intensity, nature (PAIN)
2. Affective = respon emosional Marah, takut, depressii, cemas Mengganggu kualtas hidup (QOL)
3. Behavioral = perilaku yang tampak atau dalam mengendalikan nyeri facial expression, posturing, ADLs
4. Cognitive = beliefs, sikap, memori, dan arti nyeri
Strategi menghadapi nyeri Menentukan tujuan/harapan pasien
5. Sociocultural = demografi, dukungan, peran sosial, budaya
usia, jenis kelamin, pendidikan Keluarga bisa berperan sebagai
penjaga/pelindung
Klasifikasi Nyeri
Pathophysiology
Duration
Nociceptive
Non Nociceptive
Acute: < 3 months
Chronic: > 3months - < 6 months
Somatic
Visceral
Neurophathic
Psychogenic
Classification of Orofacial Pain
Orofacial pain:Intracranial/vascular pain
Neurovascular pain (primary headache)Secondary headache related to disease/substances
Neurogenic/neuropathic painParoxysmal pain disordersContinuous pain disorders
Extracranial pain disordersEye, ear, nose, and throat
Intraoral pain disordersTeeth and periodontal tissuesMucogingival tissuesToungeSalivary glands
Musculoskeletal pain disordersCervical disordersTemporomandibular disorders
American Academy of Orofacial Pain (AAOP), 1996
Urgent dental problems most often involve acute orofacial pain and may originate from:
► Teeth► Periodontium► Mucosa► Muscle► Bone► Blood vessels
► Lymph nodes► Paranasal sinuses► Salivary glands► TMJ’s
Acute Orofacial Pain
SOMATIC NEUROPATHIC
SUPERFICIALDEEP
VISCERAL MUSCULOSKELETAL
PulpBlood Vessel
GlandsVisceral Mucosa
Ears
Periodontal LigamentsJoints
MusclesBone
TOOTHACHE PAIN
Toothache of odontogentic origin can be visceral (pupal) or musculoskeletal (periapical or periodontal).
When the pulp is exposed to a noxious stimulus, there is a reactive inflammatory response.
The resulting edema is unable to expand because of the surrounding inflexible cementum → ↑ tissue pressure and ↓ blood flow that causes damaging effects to the pulp.
Primary Odontogenic Pain
Odontogenic toothache arises from
pulpal tissue
or
periapical tissue
with general characteristics that indicate the tissue of origin.
Characteristics of Pulpal & Periapical Pain
Pupal PainPupal Pain(Deep, Somatic,
Visceral)
Periapical PainPeriapical Pain(Deep, somatic, Musculoskeletal)
Masticatory functionMasticatory function(Biomechanical (Biomechanical stimulation)stimulation)
NotNot stimulated by stimulated by biting, chewing, or biting, chewing, or percussionpercussion
Stimulated by biting, Stimulated by biting, chewing, or chewing, or percussionpercussion
LocalizationLocalization Frequently difficult Frequently difficult to localize to localize specifically specifically
Usually can localize Usually can localize preciselyprecisely
SequenceSequence Usually precedes Usually precedes periapical painperiapical pain
Usually follows Usually follows pulpal pain pulpal pain (unless (unless periodontitis, periodontitis, hyperocclusion, hyperocclusion, bruxism)bruxism)
Classification of Toothaches of Odontogenic Origin
► Pulpal disease Reversible pulpitis (brief, stimulated pain) Irreversible pulpitis (prolonged, stimulated or spontaneous pain) Necrotic pulp (prolonged or spontaneous pain, no response to pulp
testing, sensitive to percussion)
► Periapical disease Acute apical periodontitis (sensitivity to percussion) Acute apical abscess (sensitivity to percussion, swelling, pus) Chronic apical periodontitis (often asymptomatic, periapical
radiolucency)
► Heterotopic pain Projected pain (pain in adjacent teeth) Referred pain (pain in teeth in opposing arch)
Type FunctionAvg.
(m)Avg. C.V.
(m/s)A Primary muscle-spindle afferent, motor
to skeletal muscles15 70-120
A Cutaneous touch and pressure afferents 8 30-70A Motor to muscle spindles 5 15-30A Cultaneous temperature and pain
afferents<3 12-30
B Sympathetic pre-ganglionic 3 3-15C Cutaneous pain afferents, sympathetic
post-ganglionic(unmyelinated)1.0 0.5-2
Classification of nerve fibres
Reseptor: alat penerima rangsang Rangsang yang bersifat nyeri disebut noxious Reseptor nyeri disebut nosiseptor berupa
ujung-ujung saraf bebas Terutama serabut C and Aδ Serabut C tidak bermyelin dan diaktivasi oleh
stimuli kimia, termal, dan mekanik Serabut Aδ bermyelin dan kecepatan
hantarnya 25 X lebih cepat dari pada serabut C; diaktivasi oleh stimuli mekanik dan termal.
Struktur Somatic banyak mengandung serabut Aδ dan serabut C vs struktur visceral terutama mengandung serabut C
Aktivasi serabut Aδ first pain: menimbulkan sensasi nyeri yg cepat, tajam , terlokalisasi
Aktivasi serabut C second pain:sensasi nyeri yg lama, nyeri tumpul, terbakar, intense, menyebar
Examples• Peripheral• Post-herpetic neuralgia• Trigeminal neuralgia• Diabetic peripheral neuropathy• Post-surgical neuropathy• Post-traumatic neuropathy• Central• Post-stroke pain• Common descriptors2
• Burning • Electrical• Sudden, intense
• Hypersensitivity to touch or cold
Examples
Somatic tissue (bone, joint, muscle, skin, connective tissue
• Aching, Throbbing• Well localized
Visceral tissue• Arises from
internal organs Poorly localized
Common descriptors2
• Aching• Sharp• Throbbing
Examples • Low back pain with
radiculopathy• Cervical
radiculopathy• Cancer pain• Carpal tunnel
syndrome
Mixed PainPain with
neuropathic and nociceptive components
Neuropathic PainPain initiated or caused by a
primary lesion or dysfunction in the nervous system (either peripheral or
central nervous system)1
Nociceptive PainPain caused by injury to
body tissues (musculoskeletal,
cutaneous or visceral)2
1. International Association for the Study of Pain. IASP Pain Terminology.2. Raja et al. in Wall PD, Melzack R (Eds). Textbook of pain. 4th Ed. 1999.;11-57
Nociceptive vs Neuropathic Pain
Differences Between Nociceptive and Neuropathic Pain
Acute vs Chronic Pain
Characteristic Acute Pain Chronic Pain
Cause Generally known Often unknown
Duration of pain Short, well-characterized
Persists after healing, 3 months
Treatmentapproach
Resolution of underlying cause, usually self-limited
Underlying cause and pain disorder; outcome is often pain control, not cure
Differences between Acute and Chronic Pain
Karakteristik nyeri akut dan kronis
Effects of acute pain:
Neuroendocrine response to stressIncreased metabolic rate Increased cardiac outputImpaired insulin responseIncreased retention of fluidsIncreased risk for physiologic disordersDecreased deep breathing and mobility
Effects Chronic Pain:
Suppressed immune function Resultant increased tumour growth Depression and lack of motivation Anger Fatigue
Substances that stimulate the norciceptors:
Bradykinin: a powerful vasodilator that increases capillary permeability and constricts smooth muscle. Plays a role in chemistry of pain at site of injury.
Histamin Postaglandins: hormone-like
substances that send additional pain stimuli to CNS
Serotonin Substance P: believed to act as a
stimulant at pain receptor sites and may influence inflammatory response
Transduction Transmission Perception Modulation
27
Perception
Modulation
Transduction
Transmission
Mechanism of action
Bagaimana mekanisme nyeri nosiseptif?
Stimulasi• sebagian besar jaringan dan organ diinervasi
reseptor khusus nyeri nociceptor -> yang berhubungan dengan saraf aferen primer dan berujung di spinal cord.
• Jika suatu stimuli (kimiawi, mekanik, panas) datang diubah menjadi impuls saraf pada saraf aferen primer ditransmisikan sepanjang saraf aferen ke spinal cord ke SSP.
Transmisi dan persepsi nyeri Transmisi nyeri terjadi melalui serabut saraf aferen (serabut
nociceptor), yang terdiri dari dua macam: serabut A-δ (A-δ fiber)peka thd nyeri tajam, panasfirst pain serabut C (C fiber)peka thd nyeri tumpul dan lama second pain
contoh : nyeri cedera, nyeri inflamasi Mediator inflamasi dapat meningkatkan sensitivitas nociceptor ambang rasa nyeri turunnyeri
Contoh: prostaglandin, leukotrien, bradikininpada nyeri inflamasi substance P, CGRP (calcitonin gene-related peptide)pada nyeri
neurogenik Persepsi nyeri
Setelah sampai di otaknyeri dirasakan secara sadar menimbulkan respon: Aduuh ..!!
• Nyeri yg ditimbulkan oleh stimulus yg sama sangat berbeda pada situasi
dan individu berbeda• Atlet fraktur berat hanya merasakan
nyeri ringan • Saat perang prajurit tidak/ kurang merasakan nyeri akibat injury• Sugestiefek analgetik (Efek plasebo)
Modulasi Nyeri
Jalur nyeri ascending:tr. spinotalamikus kontralateral yg menujuke talamus kontraleteral , melalui medulla, pons dan midbrain bagian lateral Dari talamus axon diproyeksikan ke cortex:somatosensory: lokasi,intensitas.cingulate gyrus dan lobus frontalis : berhub.dg afektif atau respons emosional takut
Neuroanatomy Orofacial Pain
12
3
45
C2C3
12
34
5
Pain
IntNACHNE5HT
Thalamus
T-C-BG
snC
Nociceptive / Fatigue Barrages Neurogenic Inflammation
second orderneuron
MSN
C2
C3
C4
thirdorderneuron
Problem KliniK Orofacial pain:
Prevalensi meningkat Akut kronis Problem Aktifitas fisik Problem psikologi: depresi, cemas. Gangguan tidur Ketergantugan obat Penggunaan bermacam-macam obat ES obat. Costly Quality of Life Problem sosial