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