Chapter 1: Pain Flashcards by arcie cola

______ is one of the most commonly experienced symptoms in dentistry and, as such, is a major concern to the dentist. It is often spoken of as a ______, since it is usually manifested when an environmental change occurs that causes ______ to ______.

Pain, protective mechanism, injury, responsive tissue

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Historically, the pain of ______ has been a constant tormentor since human beings arrived on earth. ______ and ______ that depict early humans suffering dental pain attest to its historical significance.

dental ills, Primitive paintings, carvings

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Although everyone has experienced pain and described it as ______, ______, ______, ______, ______, or ______, the actual pain experience ______ greatly as a result of ______. The involvement of these emotions may be the reason why the word pain has not been defined in a manner ______, despite its long history.

sharp, burning, aching, cramping, dull, throbbing, varies, human emotions, agreeable to all

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Nerve conduction

Basic to the understanding of pain, as well as its elimination through the use of local anesthetics, is the understanding of ______, the self-propagated passage of an electrical current along nerve fibers.

nerve conduction

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Nerve conduction

The conduction of an impulse by a nerve depends on the ______ that exists across the ______.

electrical potential, nerve membrane

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Nerve conduction

Although an ______ exists across the membrane of most cells in the body, the ______, being ______, possesses the ability of transmitting or conducting ______ along its length. The phenomenon is brought about by the flow of ______ across the membrane during the transition of the nerve from the ______ to the ______ state.

electrical potential, nerve cell, excitable, impulses, current, resting, active

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Nerve conduction

The ______ is a thin elastic covering composed of a layer of ______ between two layers of ______. Although the exact ______ of the membrane is in doubt, it is thought that the ______ contains many ______ through which ______ can diffuse under the proper circumstances.

nerve cell membrane, lipid, protein, molecular structure, membrane, minute pores, ions

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Nerve conduction

Normally, electrolytic solutions containing an ______ (of approximately ______ mEq) of ______ and ______ are present on both sides of the ______.

equal concentration, 155, anions, cations, cell membrane

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Resting state

When the nerve is at rest, the greater number of ______ are present inside the cell membrane, whereas an equal number of ______ are gathered outside the membrane. Thus ______ ions are concentrated inside, while ______ and ______ ions are concentrated outside the membrane. The difference in respective ion concentrations across the nerve membrane creates a ______ between the ______ and the ______. The membrane potential can develop by the creation of an ______. This can be accomplished by (1) ______ and (2) ______.

anions (-), cations (+), potassium, sodium, chloride, potential electrical difference, inside negative, outside positive, ionic imbalance

an active diffusion of ions through the membrane
a diffusion of ions across the membrane because of a gradient difference

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Resting state

The electrochemical gradient between the inside of the nerve membrane and the outside is approximately = ______ to ______ mv, which indicates that the inside of the membrane becomes ______ to ______ mv more ______ than the outside (Fig. 1-1). Thus the unstimulated nerve or the nerve at rest is said to have a ______, during which time the membrane is ______ with the inside electrically ______ relative to the outside. The ______ is thus a potential source of energy.

-70, -90, 70, 90, negative, resting potential, polarized, negative, polarized membrane

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Resting state

The ______ of the nerve is assumed to result from and be maintained by the relative permeability of the cell membrane to ______ and its relative impermeability to ______ ions. Although the nerve membrane is freely ______ to potassium, this ion remains within the ______. Positively charged ______ ions are retained by the electrostatic attraction of the negatively charged ______. ______, on the other hand, remains outside the nerve membrane as a result of the opposing ______ forcing ______ migration. No ______ diffuses into the nerve membrane. The maintenance of the resting potential is mainly a result of an active mechanism known as the “______,” which moves the sodium from the area of ______ concentration inside the nerve to that of ______ concentration outside. Because of the greater concentration ______ (______ mEq) and the lesser concentration ______ the nerve (______ mEq), the ______ tends to diffuse back across the membrane into the nerve as it is being pumped out. This pumping action controls the concentration of ______ of both sides of the membrane and thus maintains it in a ______ state. Both the concentration and the electrostatic gradients for sodium favor its ______ movement. It is the relative ______ of the nerve membrane during the resting state that prevents a massive influx of this ion. ______ of the membrane will continue as long as the nerve remains undisturbed.

resting potential, potassium, sodium, permeable, axioplasm, potassium, nerve membrane, Chloride, electrostatic influence, outward, chloride, sodium pump, lesser, greater, outside, 142, inside, 10, sodium, sodium, polarized, inward, impermeability, Polarization

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Depolarization

When a stimulus of sufficient intensity to create an impulse is applied to the ______, the membrane is activated by an alteration in its permeability that permits ______ to ______ its rate of diffusion through the ______ into the ______. It appears that initiation of changes in membrane permeability to sodium occurs as a result of displacement of ______ ions from a ______. The marked increase in the diffusion of ______ into the cell is followed by the passage of ______ out of the cell. This action is said to abolish the ______ and ______ the membrane. It has been stated that the term ______ is inaccurate, since a reversal of polarity actually occurs, with the outside becoming ______ relative to the ______, resulting in a potential (______) of about ______ that of the resting potential.

nerve, sodium, increase, membrane, nerve cell, calcium, phospholipid-binding site, sodium, potassium, resting potential, depolarize, depolarized, negative, inside, reversal potential, twice

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Depolarization

As the nerve cell is stimulated, there is a rapid (______ to ______ msec) passage of ______ into the cell and slower (______ to ______ msec) passage of ______ out of it. The alteration in the permeability of the cell membrane that is initiated after an adequate stimulus is applied is believed to be the result of the liberation of a transmitter substance, ______, at the site of stimulation.

0.1, 0.2, sodium, 1, 2, potassium, acetylcholine

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Depolarization

The passage of the impulse or the speed of the action potential is the result of a continuing stimulation or ______, with each area generating its own potential by the alteration of the permeability of the membrane to the ______ passage of sodium followed by the ______ passage of potassium. In the larger myelinated nerves, the stimulation takes place only at the ______, with the impulse conducted along the nerve fiber from node to node by its own energy source. The “______” of the impulse from node to node through the surrounding interstitial tissue is called ______, which explains the greater rate of ______ at which impulses are conducted by myelinated nerves. ______ occurs rapidly after the passage of an impulse from node to node so that actually only a small portion of the nerve fiber is depolarized at any one time.

chain reaction, inward, outward, nodes of Ranvier, jumping, saltatory conduction, speed, Repolarization

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Repolarization

Following depolarization, the permeability of the nerve membrane again ______, while the high permeability to ______ is restored. ______ moves freely out of the cell, thereby restoring the original ______ and ______. Movement of both sodium ions into the cell during depolarization and potassium out of the cell during repolarization are ______ (nonenergy requiring) actions since each ion moves along its ______ (for example. from an area of high concentration toward one of low concentration).

decreases, potassium, Potassium, electrochemical equilibrium, resting potential, passive, concentration gradient

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Repolarization

The energy driven “______” then actively transports sodium out of the nerve membrane against its concentration gradient while simultaneously transporting ______ inward to reestablish the resting state. ______ provides the energy source for the sodium pump.

sodium pump, potassium, Adenosine triphosphate (ATP)

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Repolarization

The return of the resting potential occurs within ______ to ______ msec after initial stimulation. During this ______ to ______ msec interval, the membrane has a ______ and cannot be stimulated. The nerve is then in an ______. When the normal ionic distribution pattern begins to return, the nerve can be stimulated, but only by a ______ than usual stimulus. The nerve is then said to be in the ______.

3, 4, 3, 4, reverse potential, absolute refractory period, greater, relative refractory period

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Repolarization

When the pre-impulse concentration gradients of ______ inside the nerve and of ______ outside are reached following the ______, the membrane is said to be normally ______ and will react to a stimulus of normal intensity. However, during the ______ or the ______, a certain minimal stimulus is necessary to provoke a sufficient ionic interchange to create an ______. Once an impulse has been initiated within a particular nerve fiber, the amplitude of electrical change as well as the speed of nerve conduction remains ______ regardless of the quality or intensity of stimulus applied, which explains the ______. At times this principle may seem unfounded, particularly when an exceptionally noxious stimulus is applied to a nerve that may produce a much greater reaction. This ______ response stresses the multifiber composition of the nerve; whereas the ______ stimulus affects only a few fibers, the more ______ or ______ stimulus excites more or even all of the nerve fibers.

potassium, sodium, relative refractory period, polarized, relative refractory period, normal polarized state, impulse, constant, all-or-none law of nerve action, greater, weaker, noxious, stronger

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PAIN THEORIES:

• Specificity theory
• Pattern theory
• Gate control theory

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PAIN THEORIES

______
• This classical description was provided by ______ in ______ when he conceived of the pain system as a straight-through channel from the ______ to the ______. The concept changed little until the nineteenth century when ______ postulated the ______ only by way of the ______. In the late nineteenth century, ______ developed the concept of specific cutaneous receptors for the mediation of touch, heat, cold, and pain. ______ were implicated as pain receptors. A pain “______” was thought to exist within the brain, which was responsible for all overt manifestations of the unpleasant experience. The ______ was responsible for the development of several surgical approaches to the management of chronic pain by cutting straight-through tracts.

Specificity theory, Descartes, 1644, skin, brain, Muller, theory of information transmission, sensory nerves, Von Frey, Free nerve endings, center, specificity theory

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PAIN THEORIES

______
• In ______, ______ was the first to propose that ______ and ______ are the critical determinants of pain. The theory suggested that particular patterns of nerve impulses that evoke pain are produced by the summation of ______ within the ______ of the ______. Pain results when the ______ of the cells exceeds a critical level. For example, touch plus pressure plus heat might add ip in such a manner that pain was the modality experienced.

Pattern theory, 1894, Goldscheider, stimulus intensity, central summation, sensory input, dorsal horn, spinal column, total output

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PAIN THEORIES

______
• Proposed by ______ and ______ in ______ and recently reevaluated, is presently receiving considerable attention. Certainly, all aspects are neither clearly understood nor agreed on by all investigators. Future research and developments will surely play a significant role in solving its mysteries.

Gate control theory, Melzack, Wail, 1965

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PAIN THEORIES

Gate control theory
• Briefly stated, the gate control theory postulates the following:

Information about the presence of injury is transmitted to the central nervous system by small peripheral nerves.
Cells in the spinal cord or nucleus of the fifth cranial nerve, which are excited by these injury signals, are also facilitated or inhibited by other large peripheral nerves that also carry information about innocuous events (for example, temperature or pressure).
Descending control systems originating in the brain modulate the excitability of cells that transmit information about injury.

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PAIN THEORIES

Gate control theory
• Therefore, the brain receives messages about injury by way of the gate control system, which is influenced by (1) ______, (2) ______, and (3) ______.

injury signals, other types of afferent impulses, descending control

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Peripheral nerves Pain impulses are believed to be conducted into the ______ by two types of nerve fibers, which are classified by the ______ and ______ at which they conduct the impulse. The ______ fibers, relatively large myelinated fibers from ______ to ______ micra in diameter, conduct the fast or first pain (sharp, localized) at a rate of up to ______ meters per second. (The ______ fibers, which are up to ______ micra in diameter, conduct impulses at a rate of ______ to ______ meters per second. They are confined to the ______ fibers. No such fibers are found in ______; therefore, they have no ______ function.) The ______ fibers, small unmyelinated nerve fibers from ______ to ______ micron in diameter, conduct the slow or second pain at a rate of ______ to ______ meters per second.

central nervous system, size, speed, A delta (ô), 3, 20, 100, B, 3, 3, 14, preganglionic autonomic, dorsal roots, afferent, C, .05, 1, 0.5, 2

Peripheral nerves A nerve fiber that forms an ______ nerve is a separate pathway by which impulses are transmitted into the ______. Each pathway is a separate unit unto itself, and a gathering of thousands of units constitutes an ______. These single units that form a nerve trunk may be stimulated individually or in varying numbers until all the individual fibers are affected.

afferent, central nervous system, afferent nerve trunk

Substantia gelatinosa Facilitation and inhibition occur within the ______ of the ______ and the ______ of the ______. The dorsal horn can be divided into ______ lamina based on ______ of ______. The ______, consisting of laminae ______ and ______, is of particular interest since it represents a unique system that appears to have modulating effects on input. Many large afferent nerve fibers also terminate in this area.

dorsal horn, spinal cord, nucleus, fifth cranial nerve, six, synaptic connections, afferent neurons, substantia gelatinosa, Il, III

Substantia gelatinosa The ______ proposes that large-diameter fiber input has the ability to modulate synaptic transmission of ______ fibers within the ______. ______ fibers transmit impulses at a greater rate of speed than do ______ fibers. ______ fibers transmit signals that are initiated by pressure, vibration, and temperature; ______ fibers transmit noxious or painful sensations.

gate control theory, small-diameter, dorsal horn, Large-diameter, small-diameter, Large-diameter, small-diameter

Substantia gelatinosa Intentional stimulation of the ______ results in inhibition of synaptic transmission within the ______; ______ fibers. In other words, activation of the ______ inhibits small fiber synaptic transmission, which closes the gate to central progression of the impulse carried by small fibers. ______ and ______ are believed to produce their analgesic effects in this manner. Both acupuncture ard TENS stimulate ______ input by the application of ______ stimuli. After a brief time (about ______ minutes), sufficient inhibition will have occurred within the ______ to prevent painful impulses traveling over the ______ fibers from being transmitted to the ______, the second order neuron that transmits the impulse to higher nervous system centers.

large-fiber system, smaller, pain-producing, large fiber system, Acupuncture, transcutaneous electrical nerve stimulation (TENS), large fiber, non-noxious, 20, dorsal horn, small, T cell

Substantia gelatinosa Modulation, either ______ or ______, that occurs within the ______ determines ______ patterns before they influence the ______. When ______ stimulation exceeds a certain critical level, the action system is activated. Recent evidence has shown that certain neurons of ______ fulfill the role of the ______.

facilitation, inhibition, substantia gelatinosa, afferent, T cell, T cell, lamina V, T cell

Activation of the action system In contrast to a pain center proposed by the specificity theory, the ______ postulates the existence of an ______. The action subserve emotion—______, ______, ______ analysis and affect, and several ______ mechanisms (Fig. 1-3). The action system is intimately involved with ______ as well as ______ areas, including the ______, the ______, the ______, and the ______.

gate control theory, action system, attention, memory, spatiotemporal, motor, cortical, subcortical, limbic system, thalamus, hypothalamus, reticular activating system

Sensory-discriminative system Assuming that modulation of peripheral input within the dorsal horn allows activation of the ______, the impulse then ascends to ______ nervous system levels.

T cell, higher

Sensory-discriminative system Under ordinary conditions, a ______ stimulus can quickly be localized in time and place. ______ pathways ascending in the ______ and ______ are so organized that this ______ information is rapidly transmitted. The ______ is topographically organized so that cells responding to stimulation from a small area of the body are clustered together and are physically adjacent to the neurons that receive input from contiguous areas of the body. This system allows identification of ______ and its ______.

noxious, Somatosensory, dorsal columns, dorsolateral spinal cord, spatiotemporal, dorsal column nucleus, pain duration, exact location

Sensory-discriminative system A ______ input into the ______ and ______ thalamic nuclei is from ______ spinothalamic tract input by means of fibers that ascend in the ______--the classic pain pathway. These rapidly conducting neurons form an alternate pathway for discriminative somatosensory functions and do not respond primarily to noxious stimuli.

secondary, posterolateral, ventral posterolateral, direct, ventrolateral spinal cord

Motivational-affective system The ______ consists of fibers of the ______ system that synapse in the ______ formation of the ______, where neurons form a complex network with extensive connections to ascending and descending systems. In addition to acting as a relay station for nociceptive impulses, the ______ regulates vasomotor and autonomic functions.

paleospinothalamic system, ventrolateral, reticular, brain stem, reticular formation

Motivational-affective system This complex system may provide the neural pathways for the ______ component of pain— the suffering aspects often associated with painful experiences. In addition to interactions with the ______ and the ______, the system projects to the ______; where it may interact with ______ impulses that ultimately aid in the modulation of impulse transmission within the substantia gelatinosa and possibly other spinal cord sites.

aversive-motivational, limbic system, hypothalamus, periaqueductal gray matter, descending

Motivational-affective system When pain does not evoke its usual responses (fear, anxiety, suffering), the individual's ability to tolerate pain will be markedly ______ even when the ability to perceive it is unaltered. Many drugs, particularly the ______, can alter the aversive-motivational aspects of the pain experience. That is, these agents reduce fear and anxiety and can eliminate the suffering aspects associated with pain. Indifference toward ______ stimulation is produced in this manner. Even though impulses from the periphery continue to bombard higher nervous system centers in an un-impeded fashion, the individual gains a tremendous ability to tolerate them. Patients may state that the pain sensation has not diminished in intensity, but that they are no longer bothered by it because of the indifference created by drugs. Clinical experience has borne out this phenomenon repeatedly.

enhanced, narcotic analgesics, noxious

Activation of motor mechanisms Motor mechanisms that are responsible for many of the overt reactions to pain are interrelated with ______ analysis and affective aspects of the painful experience. Once integrated and modulated within the ______, the impulse triggers a sequence of responses characterized in the individual by (1) ______, (2) ______, (3) ______, (4) ______, (5) ______, (6) ______, (7) ______, and (8) ______. Facial grimacing, clenching the teeth, crying, and other outward manifestations of the experience may occur. Changes in vital signs, mediated primarily through the ______ and ______, accompany activation of motor mechanisms. ______ nervous system function is generally enhanced as well.

spatiotemporal, central nervous system 1. startle response 2. flexion reflex 3. postural readjustment 4. vocalization 5. orientation of the head and eyes to examine the damaged area 6. evocation of past experience in similar situations 7. prediction of the consequence of the stimulation 8. many other patterns of behavior aimed at diminishing the sensory and affective components of the entire experience hypothalamus, medulla, Sympathetic

Activation of motor mechanisms The experience described rather simply by the term pain is actually a very complex phenomenon. The idea of a ______, as postulated in the ______, responsible for all overt manifestations of the unpleasant experience has been replaced by the more encompassing global concept of an ______. The system is not only responsible for identification, appreciation, recognition. and reaction to the unpleasant impulses arriving from the periphery, but it is also intimately involved with ______ of impulse transmission at ______ (or ______) levels.

pain center, specificity theory, action system, modulation, spinal cord, trigeminal nucleus

Descending control An important aspect of the gate control theory is the ability of ______ located within the brain to either ______ or ______ neural transmission at ______. Both laboratory data and human studies have confirmed the existence of such a control mechanism. In the decerebrate animal, a powerful tonically active ______ within the ______ and the ______ projects to the ______. Another system descends indirectly from the ______ of the ______ to the ______. Stimulation of this area produces profound ______ in humans and animals.

nervous system centers, facilitate, inhibit, first synaptic levels, inhibitory system, pons, medulla, dorsal horn, periaqueductal gray matter, midbrain, substantia gelatinosa, analgesia

Descending control The ______ may also be activated by pharmacological or psychological factors. It has long been recognized that "______" may alter an individual's ability to tolerate pain. As early as the first World War, ______ noted that battle casualties tolerated their injuries more easily than civilians at home suffering similar traumas. He suggested that to the soldier the injury represented a degree of good news in that it meant his withdrawal from combat. On the other hand the civilian saw his injury as a troublesome inconvenience that would only encumber him.

descending system, mind set, Beecher

Descending control More recently, medical and dental professionals have come to realize that fear, anxiety, and apprehension only serve to ______ an individual's painful experience. Conversely, elimination of these aspects either by pharmacological or psychological methods greatly ______ a person's ability to tolerate noxious stimuli most probably by activating ______ control mechanisms.

heighten, increases, descending

BIOCHEMICAL MEDIATORS OF PAIN Recent research involving pain mechanisms has led to the discovery of chemical entities that have the ability to ______, ______, or ______ pain. These findings are significant because they provide a better understanding of the sequence of events involved in the pain experience. Their discovery has already allowed for the development and clinical introduction of pharmacological agents with new and varied mechanisms of action for pain control. Many more agents and technigues of pain control are certain to be developed as a result of these findings.

augment, produce, eliminate

BIOCHEMICAL MEDIATORS OF PAIN One must realize that the study of ______ of pain is just beginning and that agreement regarding specific functions is lacking. Nevertheless, a brief review of the most popular concepts involving these mediators is helpful. The role of chemical mediators in the ______, ______, ______, and ______ of a painful impulse from the pulp of the tooth will be discussed.

biochemical mediators, initiation, transmission, modulation, modification

The dental pulp The sensitivity of ______ has long been recognized as a clinical entity; however, the exact mechanism for initiation and transmission of painful impulses from this seemingly inert structure has remained a mystery until recently.

dentin

The dental pulp In the last century, three theories explained the phenomenon:

1. Dentinal sensitivity is a result of direct stimulation of sensory nerve endings in the dentin. 2. Odontoblasts are sensory cells. 3. Dentinal sensitivity is a result of mechanical stimulation of free nerve endings in the pulp caused by rapid fluid flow in the dentinal tubules when the dentin is stimulated.

The dental pulp In the last century, three theories explained the phenomenon Dentinal sensitivity is a result of ______ stimulation of ______ in the ______. There is no doubt that nerves exist in the ______ part of the dentin, although several physiological studies indicate that the nerves are located only in the most ______ portion of the dentin and none are present in the ______. However, clinical experience has shown that the most sensitive area of the tissue is near the ______, the area furthest from the nerves. Therefore, it seems that a mechanism must exist whereby stimuli are transferred through the dentin to the area where nerves have been demonstrated.

direct, sensory nerve endings, dentin, mineralized, pulpal, periphery, dentinoenamel junction

The dental pulp In the last century, three theories explained the phenomenon Odontoblasts are ______. Through their processes in the ______, odontoblasts receive and transfer stimuli to ______ in the ______. This theory had substantial support until ______ studies failed to show the presence of odontoblastic processes in the ______ dentin.

sensory cells, dentinal tubules, nerve endings, pulp, scanning electron microscopic, peripheral

The dental pulp In the last century, three theories explained the phenomenon Dentinal sensitivity is a result of ______ stimulation of ______ in the ______ caused by ______ in the ______ when the dentin is stimulated (Fig. 1-4). (From the days of the specificity theory, ______ have generally been accepted to be the pain-specific receptor regardless of their location on the body.) If this ______ is to explain dentinal sensitivity, it is necessary to show that all stimuli that cause pain, the only sense experienced by the dental pulp, also cause fluid to flow in the dentina! tubules. Indeed, results of studies have demonstrated that the application of pain-provoking stimuli such as air blasts, dry heat, and hypertonic solutions causes rapid movement of fluid into or out of the dentinal tubule. It has also been shown that the critical factor in the degree of pain noted is the rate of change of fluid flow and not the maximum flow rate produced. Though not yet universally accepted, the ______ does explain how an impulse may be initiated by environmental change without direct contact with the receptor being made.

mechanical, free nerve endings, pulp, rapid fluid flow, dentinal tubules, free nerve endings, hydrodynamic theory, hydrodynamic theory

PAIN RECEPTORS Many investigators have shown that various chemicals consistently produce pain following injection or application. Among these "______" or pain-producing substances are ______, ______, ______, ______, ______, ______, and ______. The peptide ______ is very potent and elicits the kind of pain that mimicked the clinically experienced sensation.

algesic, hypertonic saline, potassium chloride, acetylcholine, 5-hydroxytryptamine, histamine, bradykinin, substance P, bradykinin

PAIN RECEPTORS These findings led to the conclusion that sensory nerve endings that mediate pain (______) are actually ______. It is currently believed that there are both ______ and ______ nociceptors. It has also been demonstrated that there is considerable specificity of the chemoreceptors on a nociceptive fiber. Different algesic agents may act independently of each other. The chemical transmitters in nociceptive, thin, myelinated or nonmyelinated fibers may include ______ and ______.

nociceptors, chemoreceptors, mechanoreceptive, chemoreceptive, substance P, glutamate

PAIN RECEPTORS Criteria that must be met for a substance to be classified as a chemical pain mediator include:

1. General accessibility and activation as a consequence of injury, infection, or mechanical tissue damage. 2. Suppression of mediator formation resulting in prevention of pain fiber activation. 3. Easy formation from labile precursors, release from sensitive storage sites, and short half-life. 4. Pain caused by exogenous application onto nociceptors.

PAIN RECEPTORS All criteria are met within the dental pulp by the peptide, ______. In other areas of the body, other chemicals are significant, with ______ being one of the most active.

substance P, bradykinin

PAIN RECEPTORS Soon after cell injury, the ______ (______, ______, and ______) are released. In addition to pain, they cause ______ and ______. They are mediators of inflammation and are important in the induction of inflammatory pain. ______, ______, and ______ are the main sources of the amines. Other cells appear to release ______ on deformation of the ceil membrane. A complex cascade of biochemical reaction is necessary for its formation. The ______ system acts as the activator (Fig. 1-5).

vasoactive amines, 5-hydroxytryptamine, histamine, bradykinin, peremia, swelling, Basophils, platelets, mast cells, bradykinin, blood-clotting

PAIN RECEPTORS Cellular injury leads to the formation of ______, a protease, that liberates kinins from their precursors. Degradation of ______ by ______ and ______ occurs rapidly. Because of their potency, the kinins are strongly implicated in inflammatory pain. No known ______ exist.

kallikrein, bradykinin, plasma, lymph kininases, kinin antagonists

PAIN RECEPTORS Bradykinin also releases ______, which form a complex group of fatty acids. They are not stored within cells but are generated from ______ precursors in the cell membrane in response to noxious stimuli (Fig. 1-6). ______ themselves do not cause pain except in very high doses. The main contribution of ______ is to sensitize the nociceptors to the effects of ______, thereby accentuating its action.

prostaglandins, phospholipid, Prostaglandins, prostaglandins, bradykinin

PAIN RECEPTORS Drugs such as ______, ______, and other minor analgesic agents block the ______ reaction by inactivating the enzyme, thereby preventing the biosynthesis of ______. The principal site of action of aspirin-like drugs is probably at the ______ level since central (at brain center levels) administration does not produce analgesia.

aspirin, indomethacin, cyclooxygenase, prostaglandin, nociceptor

PAIN RECEPTORS The anti-inflammatory effects of ______ are the basis of their efficacy in the treatment of inflammatory pain. These steroids reduce the availability of ______ precursors by means of synthesis of a protein or peptide that blocks ______ activity.

glucocorticoids, prostaglandin, phospholipase A2

SYNAPTIC TRANSMISSION Strong evidence exists that ______ is also an excitatory transmitter within the nociceptive system at the ______ level. The chemical is present in abundance within the ______ of the spinal column as well as the nucleus of the ______. However, excitation induced by ______ is slower than that induced by natural stimulation or by ______, another likely transmitter candidate. ______ may act as a ______ of neural excitability rather than as a ______.

substance P, first afferent synaptic, dorsal horn, trigeminal nerve, substance P, glutamate, Substance P, modulator, neurotransmitter

OPIATE RECEPTORS In 1969, ______ reported the discovery of a group of cells within the ______ and ______ gray matter of the brain that, when stimulated electrically, produced profound analgesia equal to large doses of ______. Results of subsequent studies showed that electrically induced analgesia was ______ by the narcotic antagonist, ______. These findings sparked numerous studies that determined that many endogenous morphine-like chemicals, collectively called ______ (meaning morphine within), are released following exposure to stress and noxious stimuli. Receptors for these endogenous as well as synthetic or naturally occurring narcotics are located at several levels along the pain pathway. ______ are located in abundance in the ______ of the spinal cord, ______, ______, and areas of importance for the regulation of mood and behavior such as the ______ and ______. Areas of the ______ involved in neuroendocrine regulation also contain high receptor levels. Outside the central nervous system, receptors are abundant in the ______. The biochemical substrait for all actions of narcotics, including analgesia, euphoria or dysphoria, and constipation, has been identified.

Reynolds, periventricular, periaqueductal, morphine, reversible, naloxone endorphins, Opoid receptors, dorsal horn, medullary raphe nuclei, periaqueductal gray matter, locus ceruleus, striatum, hypothalamus, small intestine

OPIATE RECEPTORS The endorphins show a distribution within the ______ that corresponds to the distribution of ______. Thus, the ______ system is intimately involved with an endorphin-mediated antinociceptive system. Apparently, exposure to noxious stimuli activates a sequence of events that tends to produce both analgesia and indifference to the expemence.

central nervous system, opoid receptors, nociceptive

OPIATE RECEPTORS Both ______ and ______ produce analgesia at a central nervous system level through actions on ______ receptors. In addition, activation of these receptors activates a descending control mechanism mediated by ______. This system, in turn, modulates pain within the ______ and the ______ of the spinal cord by provoking the release of endorphins at those sites. Therefore, analgesia may be produced by ______ to noxious stimuli at the first synaptic level. Closure may be accomplished pharmacologically by the action of ______ as described or by the intrathecal administration of these agents. Their direct action on the ______ is the production only of analgesia through their attachment to receptors located in the dorsal horn. No other sensory modality is affected to a significant degree.

endorphins, narcotics, periaqueductal, 5-hydroxytryptamine, trigeminal nucleus, dorsal horn, closing the gate, narcotics, spinal cord

OPIATE RECEPTORS The gate may also be closed by techniques such as ______ and ______. These modalities elevate the ______ through the release of ______, a fact that can be demonstrated by reversal of analgesia by ______.

suggestion, hypnosis, pain threshold, endorphins, naloxone

OPIATE RECEPTORS Another pharmacological approach to the production of analgesia by activation of the descending central control mechanism is through the administration of drugs that "______" about threatening experiences. It is well documented that fear, anxiety, and apprehension over a pending procedure ______ the individual's ability to tolerate noxious stimuli. Administration of agents such as ______ eliminate or substantially decrease these factors, thereby "______." The net effect of the indifference produced permits activation of the central process so that the gate is closed and the ability to tolerate noxious stimuli is ______.

change the patient's mind, decrease, psychosedatives, changing the patient's mind, increased

NEUROHORMONES Many of the chemicals that are neurotransmitters in the analgesic system also play a role as ______ in pain control; that is, their release from a particular site is followed by ______ to another area of the body to produce their effects.

neurohormones, vascular circulation

NEUROHORMONES Following exposure to stress, a large polypeptide, ______, is released by the ______ and is the precurser for both ______ and ______, a 91 amino acid peptide. ______, in turn, serves as the precurser for most endorphins, including ______, ______, and ______. These neurohormones produce a wide variety of effects, including analgesia, euphoria, catatonia, hallucinations, and improvement of symptoms of schizophrenia.

pro-opiocortin, pituitary gland, adrenal cortico-tropic hormone (ACTH), B-lipotropin, B-lipotropin, B-endorphin, metenkephalin, leuenkephalin

THE DUAL NATURE OF PAIN Regardless of the theory of pain to which one adheres, all popular theories ascribe to the ______. The first aspect, ______, is the physioanatomical process whereby an ______ is generated, following application of an adequate ______, and is transmitted to the ______. This aspect of pain is remarkably similar in all healthy individuals and varies little from day to day. Stimulus intensity as well as the duration for which it must be applied are relatively ______, as is the rate of impulse conduction for particular nerve types.

dual nature of pain, pain perception, impulse, stimulus, central nervous system, uniform

THE DUAL NATURE OF PAIN Impulses that involve nociception travel over a specialized neural network that has ______ peculiar to it.

chemical neurotransmitters

THE DUAL NATURE OF PAIN The second aspect of pain, ______, is a psychophysiological process that represents the individual's overt manifestation of the unpleasant perceptual process that just occurred. This aspect of pain embraces extremely complex neuroanatomical and psychological factors involving the ______, ______, ______, and ______. These complex factors determine how the individual will react to the unpleasant experience and are analagous to the events triggered and occurring within the action system described in the gate control theory. Unlike pain perception, ______ varies markedly from one individual to another and from day to day in the same individual. The pain reaction threshold is commonly interpreted as being ______ to pain reaction. A patient who is hyporeactive is considered to have a ______ pain threshold and a patient who has a ______ threshold hyperreacts in response to noxious stimulis.

pain reaction, cortex, limbic system, hypothalamus, thalamus, pain reaction, inversely proportional, high, low

THE DUAL NATURE OF PAIN If pain is to be controlled, both aspects of its nature must be considered. For example, the use of only ______ for the control of operative dental pain in apprehensive patients may be inadequate. Because of apprehension and anxiety, these individuals may subconsciously misinterpret non-noxious stimuli. Central integrating systems may operate in such a manner that ordinary non-noxious stimuli is considered painful.

regional analgesia

THE DUAL NATURE OF PAIN In many instances, the control of pain perception by the use of ______ must be coupled with the use of various ______ and ______ drugs for the control of pain reaction.

local anesthetics, analgesic, psychotic

THE DUAL NATURE OF PAIN These variations of pain reaction ______ or ______ the pain threshold. The following factors have a definite bearing on an individual's pain reaction thresholds. In all probability, these factors are related to the ability of ______ impulses from the brain to modulate ______ patterns before they influence the ______ and are therefore responsible for variations in the pain reaction threshold.

raise, lower, descending, afferent, T cells

Emotional states The pain threshold of individuals depends to a great degree on their attitude toward the procedure, the operator, and the surroundings. As a rule, patients who are emotionally unstable will have ______ pain reaction thresholds. It has also been observed that patients who are greatly concerned or have problems not necessarily related to the dental procedure at hand tend to have a ______ pain reaction threshold. Research has shown that although emotionally unstable individuals have a pain perception within the range of stable individuals, their pain reaction is greatly ______.

low, low, increased

Fatigue Of significant importance to the patient's pain threshold is fatigue. It has been proved that patients who are well rested and who have had a good night's sleep previous to an unpleasant experience will have a much ______ pain reaction threshold than an individual who is tired.

higher

Age Older individuals tend to tolerate pain and thus have a ______ pain reaction threshold than younger individuals or children. Perhaps their philosophy of living or the realization that unpleasant experiences are a part of life may account for this fact. In cases of extreme age or senility, pain perception itself may be affected.

higher

Racial and nationality characteristics It has been said that racial characteristics are reflected in the pain threshold. My experiences have been confined mostly to the Caucasian and Negro races, and ______ or ______ variation in the pain reaction threshold of the two races was found.

little, no

Racial and nationality characteristics Nationality groups offer a different picture, and it has been my experience that ______ and ______ are more emotional and thus have ______ pain reaction thresholds than ______ or ______. It is uncertain whether these two latter groups, if reared in warmer climates, would tend to have a ______ pain reaction threshold. However, evidence seems to point in that direction.

Latin Americans, Southern Europeans, lower, North Americans, Northern Europeans, lower

Sex It is generally considered that men have a ______ pain reaction threshold than women. This may be a reflection of man's desire to maintain his feeling of superiority, which is exhibited in his predetermined effort to tolerate pain.

higher

Fear and apprehension In most cases the pain reaction threshold is ______ as fear and apprehension increase. Individuals who are extremely fearful or apprehensive of a procedure tend to magnify within their own minds their unpleasant experience. These patients become ______ and will magnify the pain out of all proportion to the original stimulus. It is essential, therefore, that the operator secure the patient's confidence. As noted previously, psychological as well as pharmacological methods are available to help control fear and apprehension in the dental office. Either method will augment the patient's central descending control mechanism, thereby increasing the patient's ability to tolerate noxious stimulation.

lowered, hyperreactive

PAIN PATHWAYS The ______ cranial nerve, or ______ nerve, is the principal sensory nerve of the head region. Any stimulus in the area of the trigeminal nerve is first received by both ______ and ______ fibers and conducted as an impulse along the afferent fibers of the ______, ______, and ______ branches into the ______ or ______ ganglion. From the ganglion, the impulse is mediated by the ______ of the nerve into the ______. Here the sensory root either ends directly in the ______ or bifurcates into ______ and ______ fibers. The ______ fiber conveys general tactile sensibility, whereas the ______ fiber conveys pain and temperature. Thus the pain impulse descends from the ______ by the ______ of the ______, through the ______, down to about the level of the ______, where the tract terminates. The ______, ______, and ______ branches terminate in the ______ in that order.

fifth, trigeminal, myelinated, nonmyelinated, ophthalmic, maxillary, mandibular, semilunar, gasserian, sensory root, pons, main sensory nucleus, ascending, descending, ascending, descending, pons, spinal tract fibers, trigeminal nerve, medulla, second cervical segment, mandibular, maxillary, ophthalmic, nucleus

PAIN PATHWAYS Axons of the secondary neurons emerge from the ______, cross the midline, and ascend to join with fibers of the ______ nucleus to form the ______ or ______, of the ______ nerve. These tracts continue upward and terminate in the ______ of the ______. Some fibers of the ______ cause a general stimulation of the reticular formation that ______ the patient's awareness of and reaction to pain.

spinal nucleus, mesencephalic, trigeminal lemniscus, spinothalamic tracts, fifth, posteroventral nucleus, thalamus, lateral spinothalamic tract, increases

PAIN PATHWAYS The pain impulse, on reaching the ______ of the ______, is mediated by ______ neurons that project from the ______ to the ______ of the ______.

posteroventral nucleus, thalamus, secondary connecting, posteroventral thalamus, posterocentral convolutions, cerebral cortex

PAIN PATHWAYS Although each end organ has its own pathway into the central nervous system, it should be understood that it is not entirely an anatomical continuity but a ______ one as well. The physiological continuity is effected by ______, which implies a relationship between two neurons without actual anatomical union.

physiological, synaptic transmission

PAIN PATHWAYS ______ occurs when the appropriate chemical neurotransmitter is liberated by the presynaptic nerve ending on nerve stimulation. The transmitter traverses the distance between the nerve fibers and initiates ______ in the ______. In this manner a chemical mediator transmits the electrical potential from ______ to ______ neurons.

Synaptic transmission, depolarization, postsynaptic nerve fiber, presynaptic, postsynaptic

PAIN PATHWAYS Although the ______ cranial nerve is the main sensory nerve of the head, the ______, ______, and ______ cranial nerves and the ______ and ______ cervical nerves play a minor part in the mediation of pain from this area.

fifth, seventh, ninth, tenth, second, third

DEFINITION OF PAIN Undoubtedly, no simple definition of the word pain will be acceptable to all nor is any current definition likely to be an enduring one. Rapid developments and discoveries in the field of pain research will mandate periodic updating and redefinition. Arbitrarily one may define pain as:

an unpleasant emotional experience usually initiated by a noxious stimulus and transmitted over a specialized neural network to the central nervous system where it is interpreted as such.

DEFINITION OF PAIN Examination of the proposed definition reveals the inclusion of several well-documented facts Pain is not a ______ as is hearing, vision, and the like and cannot be dealt with as such. Rather, pain is an ______ experience as attested to by the complex interactions involving the action system. Fear, anxiety, past experience, and suffering are all components of the unpleasant episode. This aspect was unwittingly realized centuries ago when ______ was determined to be "______" for pain. Not only did opium produce definite analgesic effects, but it also eliminated fear, anxiety, and suffering.

pure sense, emotional, opium, God's own medicine

DEFINITION OF PAIN Examination of the proposed definition reveals the inclusion of several well-documented facts The experience is usually created by a ______, but this is not always the case. In some pain syndromes no stimulus can be found, and in other instances only stimuli that is generally felt to be non-noxious may be identified. Mild trauma, for example, may result in the formation and release of chemical entities that sensitize nerve endings. Subsequent application of non-noxious stimuli may generate a ______ than normal response resulting in the production of pain.

noxious stimulus, greater

DEFINITION OF PAIN Examination of the proposed definition reveals the inclusion of several well-documented facts Though not all ramifications are known at this time, a specialized neural network with ______ peculiar to the system has been isolated and identified. Several algesic mediators have been postulated.

synaptic neurotransmitters

DEFINITION OF PAIN Examination of the proposed definition reveals the inclusion of several well-documented facts Central processing mechanisms must identify and interpret the unpleasant experience as being painful. Results of studies in which electrical ablation of ______ system centers occurs demonstrate that ______ and ______ may be separated from each other. In these studies the individuals were able to perceive pain in an undiminished fashion yet were rendered totally indifferent to the experience and were no longer able to identify it as pain. ______ have been shown to produce similar effects through receptors located within the ______ system.

limbic, pain perception, pain reaction, Narcotics, limbic

CONTROL OF PAIN One of the most important aspects of the practice of dentistry is the ______ or ______ of pain. In the past, pain has been so closely associated with dentistry that the words pain and dentistry have become almost synonymous. Research at the ______ has proved that more patients stay away from dental offices from fear of pain than from all other reasons combined. This should no longer be a fact, since pain can be controlled or eliminated in all phases of dental practice. Pain in many instances is considered a necessary element of everyday living because it is a warning of trouble. In the practice of dentistry, we do not consider pain as a warning signal but as an evil to be conquered.

control, elimination, University of Pittsburgh

METHODS OF PAIN CONTROL Following are methods of pain control:

1. Removing the cause. 2. Blocking the pathway of painful impulses. 3. Raising the pain threshold. 4. Preventing pain reaction by cortical depression. 5. Using psychosomatic methods. The first two methods affect pain perception, the last two affect pain reaction, and the third may affect both aspects.

METHODS OF PAIN CONTROL Removing the cause Removing the cause would, of course, be the ______ method of controlling pain. If this could be accomplished, the environmental change in tissue would be eliminated; consequently, ______ would not be excited and no ______ would be initiated. It is imperative that any removal leave no permanent environmental change in tissues, since this condition would then be able to create the impulse, even though the original causative factors had been eliminated. This method of pain control clearly affects ______.

desirable, free nerve endings, impulses, pain perception

METHODS OF PAIN CONTROL Blocking the pathway of painful impulses The most widely used method in dentistry for controlling pain is ______. By this method a suitable drug, possessing local ______ properties, is injected into the tissues in proximity to the nerve or nerves involved. The local anesthetic solution prevents ______ of the nerve fibers at the area of absorption, thus preventing those particular fibers from conducting any impulses centrally beyond that point. As long as the solution is present in the nerve in sufficient concentration to prevent ______, the block will be in effect. The theories and mode of action of local anesthetics are discussed in detail in Chapters 3 and 5. It is obvious that this method of pain control is possible by interfering with ______.

blocking the pathway of painful impulses, analgesic, depolarization, depolarization, pain perception

METHODS OF PAIN CONTROL Raising the pain threshold In recent years the dentist has become more aware of and has shown a greater appreciation for this method of pain control. ______ depends on the pharmacological action of drugs possessing analgesic properties. These drugs raise the pain threshold ______ and therefore interfere with ______. In this method of pain control the cause of the original stimulus may still be present. The neuroanatomical pathways are intact and able to conduct impulses. In other words, ______ is unaffected; but pain reaction is ______ and thus the pain reaction threshold is ______. It should be clearly understood that the pain threshold can be raised to limited degrees only, depending on the specific drugs used. It is physiologically impossible to eliminate all pain of the most severe nature by raising the pain threshold alone. To further clarify the preceding statement, the presence of more noxious stimuli creating severe pain necessitates blocking the pathway of the impulse or completely depressing pain reaction by the use of a ______.

Raising the pain threshold, centrally, pain reaction, pain perception, decreased, raised, general anesthetic

METHODS OF PAIN CONTROL Raising the pain threshold Various drugs possess analgesic properties in varying degrees, and thus some are more effective in raising the ______ than others. Certain drugs such as ______ (______) are effectively only in the relief of mild discomfort. On the other hand, the ______, although not pure analgesics (because they also possess hypnotic properties) are effective against more severe pain because they are able to raise the pain threshold to a greater degree. All drugs used to raise the pain threshold have optimal doses. To increase the dosage beyond this limit does not further increase the analgesic effectiveness of the drug without producing undesirable or dangerous results. For example, 10 grains of aspirin may be the effective maximum dosage; increasing the dosage cannot further raise the pain threshold. ______ also has a maximal effective dosage; any increase beyond this may ______ pain reaction by producing sleep or severe central nervous system depression, rather than by raising the pain threshold alone. As described previously, certain agents have the ability, through actions on cortical and subcortical centers, to change the patient's mind. Fear, anxiety, and apprehension are reduced, and augmentation of the descending control mechanism occurs because of this action. By modulating painful input at ______ levels, perception of pain is reduced.

pain threshold, aspirin, acetylsalicylic acid, narcotics, Morphine, decrease, first synaptic

METHODS OF PAIN CONTROL Preventing pain reaction by cortical depression Eliminating pain by cortical depression is within the scope of ______ and the ______. Here, the anesthetic agent of choice, by its increasing depression of the central nervous system, prevents any conscious reaction to a painful stimulus. In those cases in which the cerebral cortex is depressed only to the point that the inhibitions are suppressed, the patient may become hyperreactive to a painful stimulus. Therefore any stimulation should be avoided in these instances. General anesthesia does not fall within the realm of the general practitioner and requires special postgraduate training and experience.

general anesthesia, general anesthetic agents

METHODS OF PAIN CONTROL Using psychosomatic methods All too often the ______ approach to the elimination or the control of pain is sadly neglected in dental practice. By no other method can so much be gained with so little ill effect on the patient. This method affects both ______ and ______ and depends for its effectiveness on putting the patient in the proper frame of mind. It is amazing what can be accomplished without the use of drugs when the patient's faith and confidence are gained.

psychosomatic, pain perception, pain reaction

METHODS OF PAIN CONTROL Using psychosomatic methods One of the most important factors in this approach is ______ and ______ toward the patient. This factor necessitates keeping the patient well informed about the procedure and what might be expected. It is a well-known physiological axiom that the ______ system dislikes surprises and, in many instances, reacts violently toward them. The patient should be made to understand by a kind, considerate approach the extent of the discomfort that may be expected. Also, patients should be assured that any unpleasant sensory experience can be adequately controlled by the knowledge and methods at hand and that these would be used if any question of discomfort were to arise. Patients like to believe that their comfort is of prime consideration to the dentist. Once they are secure in this feeling, they will tend to tolerate unpleasant sensations to a greater degree. In this manner, ______ is depressed and the ______ is inversely raised. The patient's ______ control mechanism aids in the control of pain perception when nonpharmacological methods are used to alter the patient's frame of mind.

honesty, sincerity, nervous, pain reaction, pain threshold, central

PSYCHOGENIC PAIN ______ may be defined as that unpleasant sensation that has no organic basis. It is any pain that originates wholly within the mind and is fixed on some portion of the anatomy. In many cases the pain is a symptom of a deep underlying neurosis of which the patient himself may be unaware.

Psychogenic pain

PSYCHOGENIC PAIN The dentist should be careful about establishing the diagnosis of ______. All methods and means of locating a possible organic source of pain should be exhausted before the psychogenic cause is contemplated. Dentists must fully understand the innervation of the ______ and ______ area so that they may determine if the described pain follows the anatomy of the ______. The patient's pain must not follow an authentic anatomic pattern before it can be accepted as psychogenic.

psychogenic pain, head, neck, peripheral innervation

PSYCHOGENIC PAIN The subject of psychogenic pain and its control presents a difficult and sometimes embarrassing situation for the dentist. It is my opinion that no one practitioner should feel free or sufficiently confident to establish a diagnosis of pain from ______ origin. At least one other dentist, oral surgeon, or physician should be called in consultation. If it is the opinion of all concerned that psychogenic pain may be the true diagnosis, the patient should be advised to see a competent ______. Just how to go about advising a patient to see a psychiatrist may in itself be a difficult problem. It may be a good plan to consult a physician about the best means for making such a suggestion to the patient.

psychogenic, psychiatrist

PSYCHOGENIC PAIN No drastic steps should be taken to alleviate the patient's pain if there is any possibility that it may be ______. It is far more advantageous for dentists to take only temporary measures until they are absolutely certain of the diagnosis. It is not uncommon for a patient to demand the removal of a normal tooth, only to appear at a later date focusing his or her attention on and complaining of pain in another area.

psychogenic

PSYCHOGENIC PAIN The dentist should not fail to understand that although the pain may be psychogenic, it can be very ______ to the patient. Even after dentists believe that there is a possibility that the pain is psychogenic, they should be ______ toward the patient, take temporary measures for its relief, and contemplate how the patient may best be handled from a medical and psychiatric point of view. By no means should the patient be bluntly told, "You're just imagining you have pain; it's all in your mind." Practitioners should be careful that they are not misled by referred pain. ______ is that pain experienced at a site some distance from the site of injury. In these cases, finding no organic reason for the pain in the immediate area, the dentist should not hastily conclude that the pain is psychogenic.

real, sympathetic, Referred pain

PSYCHOGENIC PAIN In many instances it is difficult to explain ______. This, however, should not cause the dentist to discard its possibility. It may occur as the result of convergence of ______ at the level of the ______ as well as in the ______. As previously stated in this chapter, each nerve fiber constitutes its own pathway from the ______ into the ______. It is not possible for a stimulus to pass from one nerve to another, and any thought that nerves anastomose is erroneous. However, it is necessary that the dentist consider the possibility of ______ before concluding that the pain is psychogenic.

referred pain, impulses, thalamus, spinal cord, periphery, central nervous system, referred pain

Before any attempt is made to control or eliminate pain by any method, the patient should receive the benefit of a ______ as careful as possible. No treatment should be prescribed on a "______" basis, since pain is a symptom and should not be treated without a plan. Every effort should be made to locate the source of the pain and to treat the pathologic condition rather than the discomfort alone.

diagnosis, per chance

During the examination and history taking the type of pain should be noted, since pains originating from different sources have varying characteristics, such as the following:

1. Neurogenic pain 2. Vascular pain 3. Muscle pain

During the examination and history taking the type of pain should be noted, since pains originating from different sources have varying characteristics, such as the following • ______ - Sharp, burning, and intense

Neurogenic pain

During the examination and history taking the type of pain should be noted, since pains originating from different sources have varying characteristics, such as the following • ______ - Diffuse

Vascular pain

Muscle pain

Chapter 1: Pain Flashcards

(114 cards)