This document discusses the relationship between acute and chronic pain. It begins by looking at epidemiological data on chronic pain, finding it affects approximately 30-50% of people. Chronic pain is often neuropathic in nature and can develop after surgery or dental procedures. The document then examines chronic post-surgical pain (CPSP) in detail, outlining its 4-point clinical definition. Risk factors for developing CPSP include the severity of acute postoperative pain, with higher pain levels correlating with greater risk. The most consistent predictor is the level of pain experienced during the acute phase.

1. An Evaluation of the
Relationship Between
Acute and Chronic Pain
Can Acute Pain Become a Chronic
Problem?
Jennifer L. Gibbs MAS, DDS, PhD
New York University Department of Endodontics

2. Acute Dental Pain
Heaivilin et al., JDR 2011

3. Acute Pain
Chronic Pain

4. Acute Pain
Chronic Pain

5. Acute Pain
?
Chronic Pain

6. Pain: An unpleasant
sensory and emotional
experience associated with
actual or potential tissue
damage, or described in
terms of such damage.

7. All Chronic Pain Was
At One Time Acute

8. Chronic Pain: Pain that
persists beyond the healing
phase of an injury

9. Clinical definition of
chronic pain comes
down to.....

11. Pain History

12. Pain History
“The tooth
hurt for about
3 months
before the root
canal”

13. Pain History
“The tooth
hurt for about
3 months
before the root
canal”
“The
pain was so
bad after the
treatment I had
to go back and
get vicodin ”

14. Pain History
“The tooth “The root
hurt for about canal was one of
3 months the most painful
before the root experiences of
canal” my life”
“The
pain was so
bad after the
treatment I had
to go back and
get vicodin ”

15. Pain History
“The tooth “The root
hurt for about canal was one of
3 months the most painful
before the root experiences of
canal” my life”
“The
pain was so
bad after the
treatment I had
to go back and “The pain
get vicodin ” never really
went away”

16. Pain History
“The tooth “The root
hurt for about canal was one of
3 months the most painful
before the root experiences of
canal” my life”
“The
pain was so
bad after the
Pre-Op Pain
treatment I had
to go back and “The pain
get vicodin ” never really
went away”

17. Pain History
“The tooth “The root
hurt for about canal was one of
3 months the most painful
before the root experiences of
canal” my life”
“The
pain was so
bad after the
Pre-Op Pain
treatment I had
to go back and “The pain
get vicodin ” never really
went away”
Post-Op Pain

18. Pain History
“The tooth “The root
hurt for about canal was one of
3 months the most painful
before the root experiences of
canal” my life”
“The
pain was so
bad after the
Pre-Op Pain Intra-Op Pain
treatment I had
to go back and “The pain
get vicodin ” never really
went away”
Post-Op Pain

19. Pain History
“The tooth “The root
hurt for about canal was one of
3 months the most painful
before the root experiences of
canal” my life”
“The
pain was so
bad after the
Pre-Op Pain Intra-Op Pain
treatment I had
to go back and “The pain
get vicodin ” never really
went away”
Post-Op Pain
Chronic Pain?

20. TIMELINE
3 mo 9 mo ?
RCT Completed PG Endo NYU

21. TIMELINE
ONE YEAR!
3 mo 9 mo ?
RCT Completed PG Endo NYU

22. Where we’ll go today

24. Epidemiology/
Risk Factors of
Chronic Pain

25. Epidemiology/ Mechanisms of
Risk Factors of Acute and
Chronic Pain Chronic Pain

26. Epidemiology/ Mechanisms of
Risk Factors of Acute and
Chronic Pain Chronic Pain
Imaging the
Brain in
Chronic Pain

27. Epidemiology/
Risk Factors
of Chronic
Pain
Chronic Pain is
Common

28. Epidemiology/
Risk Factors
of Chronic
Pain

29. Epidemiology/
Risk Factors
of Chronic
Pain
46%
54%

30. Epidemiology/
Risk Factors
of Chronic No Pain
Pain Chronic Pain
46%
54%

31. Epidemiology/
Risk Factors
of Chronic No Pain
Pain Chronic Pain
46%
54%
Elliott et al., Lancet 1999

32. Epidemiology/
Risk Factors
of Chronic No Pain
Pain Chronic Pain
46% 48%
54% 52%
Elliott et al., Lancet 1999

33. Epidemiology/
Risk Factors
of Chronic No Pain
Pain Chronic Pain
46% 48%
54% 52%
Torrance et al., J Pain
Elliott et al., Lancet 1999
2006

34. Epidemiology/
Risk Factors
of Chronic No Pain
Pain Chronic Pain
31%
46% 48%
54% 52%
69%
Torrance et al., J Pain
Elliott et al., Lancet 1999
2006

35. Epidemiology/
Risk Factors
of Chronic No Pain
Pain Chronic Pain
31%
46% 48%
54% 52%
69%
Torrance et al., J Pain Bouhassira et al., Pain
Elliott et al., Lancet 1999
2006 2008

36. Epidemiology/
Risk Factors
of Chronic
Pain
Chronic Pain Can
Often Be Neuropathic

37. Epidemiology/
Risk Factors
of Chronic
Pain
Neuropathic Pain: Pain
arising as a direct
consequence of a lesion
or disease affecting the
somatosensory system.
Image from:georgiapainphysicians.com

38. Epidemiology/
Risk Factors
of Chronic
Pain
Post-Traumatic Neuropathy
Trauma
CRPS
Neuropathic Pain=
Nerve Injury

39. Epidemiology/
Risk Factors
of Chronic
Pain
Post-Traumatic Neuropathy
Trauma
CRPS
Surgery
Neuropathic Pain=
Nerve Injury

40. Epidemiology/
Risk Factors
of Chronic
Pain
Post-Traumatic Neuropathy
Trauma
CRPS
Surgery
Neuropathic Pain=
Nerve Injury

41. Epidemiology/
Risk Factors
of Chronic
Pain
Post-Traumatic Neuropathy
Trauma
CRPS
Surgery Chronic Post-Surgical Pain
Neuropathic Pain=
Nerve Injury

42. Epidemiology/
Risk Factors
of Chronic
Pain
Neuropathic Pain is
not as common

43. Epidemiology/
Risk Factors
of Chronic
Pain

44. Epidemiology/
Risk Factors
of Chronic No Pain
Pain Neuropathic Pain

45. Epidemiology/
Risk Factors
of Chronic No Pain
Pain Neuropathic Pain
8%
92%

46. Epidemiology/
Risk Factors
of Chronic No Pain
Pain Neuropathic Pain
8%
92%
Torrance et al., J Pain
2006

47. Epidemiology/
Risk Factors
of Chronic No Pain
Pain Neuropathic Pain
8% 7%
92% 93%
Torrance et al., J Pain
2006

48. Epidemiology/
Risk Factors
of Chronic No Pain
Pain Neuropathic Pain
8% 7%
92% 93%
Torrance et al., J Pain Bouhassira et al., Pain
2006 2008

49. Epidemiology/
Risk Factors
of Chronic
Pain
Chronic Post-Surgical
Pain

50. Epidemiology/
Risk Factors
of Chronic
4- Point Definition
Pain
of CPSP
Macrae and Davies, IASP Press 1999

51. Epidemiology/
Risk Factors
of Chronic
4- Point Definition
Pain
of CPSP
Pain Developed
After a Surgical
Procedure
Macrae and Davies, IASP Press 1999

52. Epidemiology/
Risk Factors
of Chronic
4- Point Definition
Pain
of CPSP
Pain Developed Pain of at Least
After a Surgical 2 Month
Procedure Duration
Macrae and Davies, IASP Press 1999

53. Epidemiology/
Risk Factors
of Chronic
4- Point Definition
Pain
of CPSP
Pain Developed Pain of at Least
After a Surgical 2 Month
Procedure Duration
Exclude the
Possibility that
Pain is
Continuing From
a Pre-Existing
Problem
Macrae and Davies, IASP Press 1999

54. Epidemiology/
Risk Factors
of Chronic
4- Point Definition
Pain
of CPSP
Pain Developed Pain of at Least
After a Surgical 2 Month
Procedure Duration
Exclude the
Other Causes Possibility that
for the Pain Pain is
Have Been Continuing From
Excluded a Pre-Existing
Problem
Macrae and Davies, IASP Press 1999

55. Epidemiology/
Risk Factors
of Chronic
4- Point Definition
Pain
of CPSP
Pain Developed Pain of at Least
After a Surgical 2 Month
Procedure Duration
Exclude the
Other Causes Possibility that
for the Pain Pain is
Have Been Continuing From
Excluded a Pre-Existing
Problem
Macrae and Davies, IASP Press 1999

56. Epidemiology/
Risk Factors
of Chronic
4- Point Definition
Pain
of CPSP
Pain Developed Pain of at Least
After a Surgical 2 Month
Procedure Duration
Exclude the
Other Causes Possibility that
for the Pain Pain is
Have Been Continuing From
Excluded a Pre-Existing
Problem
Macrae and Davies, IASP Press 1999

57. Epidemiology/
Risk Factors
of Chronic
4- Point Definition
Pain
of CPSP
Pain Developed
After a Surgical
Procedure
p Pain of at Least
2 Month
Duration
Exclude the
Other Causes Possibility that
for the Pain Pain is
Have Been Continuing From
Excluded a Pre-Existing
Problem
Macrae and Davies, IASP Press 1999

58. Epidemiology/
Risk Factors
of Chronic
4- Point Definition
Pain
of CPSP
Pain Developed
After a Surgical
Procedure
p Pain of at Least
2 Month
Duration
p
Exclude the
Other Causes Possibility that
for the Pain Pain is
Have Been Continuing From
Excluded a Pre-Existing
Problem
Macrae and Davies, IASP Press 1999

59. Epidemiology/
Risk Factors
of Chronic
4- Point Definition
Pain
of CPSP
Pain Developed
After a Surgical
Procedure
p Pain of at Least
2 Month
Duration
p
Exclude the
Other Causes
?p
Possibility that
for the Pain Pain is
Have Been Continuing From
Excluded a Pre-Existing
Problem
Macrae and Davies, IASP Press 1999

60. Epidemiology/
Risk Factors
of Chronic
4- Point Definition
Pain
of CPSP
Pain Developed
After a Surgical
Procedure
p Pain of at Least
2 Month
Duration
p
Exclude the
Other Causes
?p ?p
Possibility that
for the Pain Pain is
Have Been Continuing From
Excluded a Pre-Existing
Problem
Macrae and Davies, IASP Press 1999

61. Phantom Tooth Pain
Atypical Odontalgia
Persistent Post-
Treatment Pain

62. Epidemiology/
Risk Factors
of Chronic
Pain
Majority of CPSP
cases have
neuropathic
characteristics

63. Epidemiology/
Risk Factors
of Chronic
Pain
Chronic Pain 1 Year After Surgery
Bandolier, Accessed 4/2012. www. medicine.ox.ac.uk

64. Epidemiology/
Risk Factors
of Chronic
Pain
Kehlet, Jensen, Woolf, Lancet 2006

65. Epidemiology/
Risk Factors
of Chronic
Pain
Kehlet, Jensen, Woolf, Lancet 2006

66. Epidemiology/
Risk Factors
of Chronic
Pain
Ballantyne, et al., IASP Clinical Update, January 2011

67. Epidemiology/
Risk Factors
of Chronic
Pain
Ballantyne, et al., IASP Clinical Update, January 2011

68. Epidemiology/
Risk Factors
of Chronic
Pain
Individual
Predisposition
for CPSP
Bruce, J. et al., Pain 2003

69. Epidemiology/
Risk Factors
of Chronic
Pain
Individual
Predisposition
for CPSP
Bruce, J. et al., Pain 2003

70. Epidemiology/
Risk Factors
of Chronic
Pain
Individual
Predisposition
for CPSP
12%
Bruce, J. et al., Pain 2003

71. Epidemiology/
Risk Factors
of Chronic
Pain
Individual
Predisposition
for CPSP
12%
Bruce, J. et al., Pain 2003

72. Epidemiology/
Risk Factors
of Chronic
Pain
Individual
Predisposition
for CPSP
12%
9%
Bruce, J. et al., Pain 2003

73. Epidemiology/
Risk Factors
of Chronic
Pain
Individual
Predisposition
for CPSP
12%
p=0.12 x 0.09 =0.01 or 1%
9%
Bruce, J. et al., Pain 2003

74. Epidemiology/
Risk Factors
of Chronic
Pain
Individual
Predisposition
for CPSP
12%
p=0.12 x 0.09 =0.01 or 1%
Incidence of Chronic
Pain at Both Sites=
9%
18%
Bruce, J. et al., Pain 2003

75. Epidemiology/
Risk Factors
of Chronic
Pain
What are some of the
risk factors for CPSP?
Patient Surgery
Specific Specific

76. Epidemiology/
Risk Factors Patient
of Chronic
Pain Specific
The most consistent
predictor of CPSP is....

77. Epidemiology/
Risk Factors Patient
of Chronic
Pain Specific
The most consistent
predictor of CPSP is....
pain itself

78. Epidemiology/
Risk Factors Patient
of Chronic
Pain Specific
Severe Pain Mod Pain No Pain
100
75
%
50
25
0
No Pre-Op Pain Pre-Op Pain
Genet J.M et al., IEJ 1986

79. Epidemiology/
Risk Factors Patient
of Chronic
Pain Specific
Females are More at
Risk for CPSP

80. Epidemiology/
Risk Factors Patient
of Chronic
Pain Specific
Persons of Younger
Age are More at Risk
for CPSP

81. Epidemiology/
Risk Factors Patient
of Chronic
Pain Specific
Psychosocial Factors
ANXIETY
CATASTROPHIZING
FEAR

82. Epidemiology/
Risk Factors Patient
of Chronic
Pain Specific
Genetics
COMT
Diatchenko L et al., Human Mol Genetics 2005

83. Epidemiology/
Risk Factors Patient
of Chronic
Pain Specific
COMT
Diatchenko L et al., Human Mol Genetics 2005

84. Epidemiology/
Risk Factors Patient
of Chronic
Pain Specific
COMT
Diatchenko L et al., Human Mol Genetics 2005

85. Epidemiology/
Risk Factors Patient
of Chronic
Pain Specific
COMT
Diatchenko L et al., Human Mol Genetics 2005

86. Epidemiology/
Risk Factors Patient
of Chronic
Pain Specific
Genetics
Dr. Paul Rosenberg- Saturday 1:45

87. Epidemiology/
Risk Factors
of Chronic
Pain
What are some of the
risk factors for CPSP?
Patient Surgery
Specific Specific

88. Epidemiology/
Risk Factors
of Chronic
Surgery
Pain Specific
Longer complicated
surgeries associated
with higher incidence
of chronic pain

89. Epidemiology/
Risk Factors
of Chronic
Surgery
Pain Specific
MASTECTOMY +
RECONSTRUCTION 49%*
MASTECTOMY 31%
BREAST REDUCTION 22%
Wallace MS et al., Pain 1996

90. Epidemiology/
Risk Factors
of Chronic
Surgery
Pain Specific
SURGICAL ENDO 23.8%*
NON-SURGICAL ENDO 10.7%
Polycarpou N. et al., IEJ 2005

91. Epidemiology/
Risk Factors
of Chronic
Surgery
Pain Specific
Minimize Chances of
Nerve Injury By Surgical
Strategy

92. Epidemiology/
Risk Factors
of Chronic
Pain
But Could Teeth Be
Different?

93. Epidemiology/
Risk Factors
of Chronic
Pain
1. The Trigeminal System
2. Use of LA in dental procedures
3. Biologically programmed
denervation
But Could Teeth Be Different?
Bennet G., J Oraf Pain 2004

94. Epidemiology/
Risk Factors
of Chronic
Pain
1. The Trigeminal System
2. Use of LA in dental procedures
Text
3. Biologically programmed
denervation
But Could Teeth Be Different?
Bennet G., J Oraf Pain 2004

95. Epidemiology/
Risk Factors
of Chronic
Pain
1. The Trigeminal System
2. Use of LA in dental procedures
3. Biologically programmed
denervation
But Could Teeth Be Different?
Bennet G., J Oraf Pain 2004

96. Epidemiology/
Risk Factors
of Chronic
Pain
Does CPSP Occur In
Endodontics?
Polycarpou N. et al., IEJ 2005

97. Epidemiology/
Risk Factors
of Chronic
Pain
Does CPSP Occur In
Endodontics?
Polycarpou N. et al., IEJ 2005

98. Epidemiology/
Risk Factors
of Chronic
Pain
Risk Factor OR 95% CI
Pre-op Pain 7.8 (1.7, 35.6)
Chronic Pain 4.5 (1.5, 13.5)
Inter Appt Pain 3.9 (1.4, 10.7)
Gender 4.5 (1.2, 16.4)
Surgery 4.0 (1.0, 14.6)

99. Epidemiology/
Risk Factors
of Chronic
Pain
Does CPSP Occur In
Endodontics?
Nixdorf, DE et al., JOE 2010

100. Epidemiology/
Risk Factors
of Chronic
Pain
Can We Prevent CPSP
with Analgesics?

101. Epidemiology/
Risk Factors
of Chronic
Pain
Katz and Seltzer, Exp Rev
Neurotherapeutics, 2009

102. Epidemiology/
Risk Factors
of Chronic
Pain Conclusions
Chronic Post Surgical Pain (CPSP) can occur
after dental surgeries including RCT.
Management of Pain, Pre-Op, Intra-Op, and
Post-Op to Minimize Risk
Minimize Invasive Procedures to Minimize
Risk

103. Epidemiology/
Risk Factors
of Chronic
Pain In The Future
Inform Our Patients About the Risk Factors for
Chronic Pain After All Dental Procedures (RCT,
EXT, IMPLANT)
Estimate an Individuals Risk for Developing
CPSP
Using Atypical Analgesics (e.g. Gabapentin) in
High Risk Cases
Emphasis on preserving vital pulp when
possible???

104. Epidemiology/ Mechanisms of
Risk Factors of Acute and
Chronic Pain Chronic Pain
Imaging the
Brain in
Chronic Pain

105. Mechanisms
of Acute and
Chronic Pain
Trigeminal (Vth) nerve
(Peripheral)
The Trigeminal System

106. Mechanisms
of Acute and
Chronic Pain
Trigeminal (Vth) nerve
(Peripheral)
Central Sensitization

107. Mechanisms
of Acute and
Chronic Pain
Trigeminal (Vth) nerve
(Peripheral)
Central Sensitization

108. Mechanisms
of Acute and
Chronic Pain
4 Days 3 Weeks
Neuroplasticity
Taylor PE et al., Brain Research, 1988

109. Mechanisms
of Acute and
Chronic Pain
Normal
Inflammation
Neuroplasticity
Rodd HD et al., Arch Oral Biol, 2002

110. Mechanisms
of Acute and
Chronic Pain
Neuroplasticity
Zhang et al., Exp Brain Res, 1995

111. Mechanisms
of Acute and
Chronic Pain
Ectopic Activity
Contributes to spontaneous pain
Occurs in damaged and adjacent undamaged neurons
Nerve!
Injury!

112. Mechanisms
of Acute and
Chronic Pain
Reduced Descending Inhibition
A-Beta Fiber Mediated Mechanical
Allodynia
Glia**

113. Mechanisms
of Acute and
Chronic Pain
Deafferentation
Somatotopic
Reorganization
More Spontaneously
Active Neurons
Increased Receptive
Field Size Hu et al., J Phys, 1986

114. Mechanisms
of Acute and Control
Chronic Pain
Induction of
Glial
Activity 7D Post Pulp Exp
Increased GFAP
Expression After
Pulp Exposure.
Stephenson & Byers Exp Neurol 1995

115. Mechanisms
of Acute and
Chronic Pain Conclusions
Multiple Mechanisms Contribute to
Development of Chronic Pain
In Animal Models Similar Mechanisms of
Pulpal Deafferentation and Other Types of
Nerve Injury
Biologically Pulpal Degeneration or Removal
Has the Potential to Cause Chronic Pain

116. Epidemiology/ Mechanisms of
Risk Factors of Acute and
Chronic Pain Chronic Pain
Imaging the
Brain in
Chronic Pain

117. NO BRAIN…………………NO PAIN
Imaging the
Brain in
Chronic Pain

118. Imaging the
Brain in
Chronic Pain
fMRI

119. Woollett and Maguire: Current Biology, 2011

120. Woollett and Maguire: Current Biology, 2011

121. Woollett and Maguire: Current Biology, 2011

122. Brain Imaging in the
Media

123. Brain Imaging in the
Media

124. Brain Imaging in the
Media

125. Can Brain Imaging
Let Us “See” Pain?

126. The
Pain
Matrix

127. Measuring
Chronic Pain is
More Challenging

128. Watching Chronic
Pain in the Brain
Baliki, MN et al., J Neurosci 2006

129. Changes in Brain
Anatomy with
Chronic Pain
Apkarian AV, et al. J Neurosci 2004

130. Changes in Brain
Anatomy with
Chronic Pain
Apkarian AV, et al. J Neurosci 2004

131. Changes in Brain
Anatomy with
Chronic Pain
Apkarian AV, et al. J Neurosci 2004

132. What is the
Consequence of
Grey Matter
Atrophy?

133. Functional
Consequence of
Cortical Degeneration
Apkarian VA et al., Pain 2004

134. Functional
Consequence of
Cortical Degeneration
Apkarian VA et al., Pain 2004

135. Functional
Consequence of
Cortical Degeneration
Apkarian VA et al., Pain 2004

136. DLPFC Amygdala
S2 cortex insular cortex
Brainstem ACC
Rodriguez-Raecke, et al., J. Neurosci, 2009

137. Every Type of
Chronic Pain is
Different
Apkarian AV, et al., Pain 2011

138. Every Type of
Chronic Pain is
Different
Apkarian AV, et al., Pain 2011

139. Limitations of Brain
Imaging Studies

141. Multiple
Comparisons
Problem

142. Multiple
Small Sample
Comparisons
Sizes
Problem

143. Multiple
Small Sample
Comparisons
Sizes
Problem
Over
Simplification of
Brain Function

144. Multiple
Comparisons
Problem
Bennett C.M et. al., Human Brain Mapping Conference
2009

145. Small
Sample Sizes

146. Over
Simplification
of Brain
Function

147. Over
Simplification
of Brain
Function

148. Brain Imaging:
Conclusions
1. Subjective Experience of
Pain Can Be Objectively
Measured Using Brain
Imaging

149. Brain Imaging:
Conclusions
2. Acute Pain and Chronic
Pain Activate Distinct
Regions of the Brain

150. Brain Imaging:
Conclusions
3. Chronic Pain Causes Long
Term Changes in Brain
Structure That May Relate
to Cognitive Changes

151. Epidemiology/ Mechanisms of
Risk Factors of Acute and
Chronic Pain Chronic Pain
Imaging the
Brain in
Chronic Pain

152. Chronic Pain is a
Disease
Not just a symptom anymore

153. Real knowledge is to
know the extent of one’s
ignorance.
Confucius

155. ★ Avoid damaging nerves

156. ★ Avoid damaging nerves
★ Get patients out of pain asap

157. ★ Avoid damaging nerves
★ Get patients out of pain asap
★ Minimize intraoperative pain
experience

158. ★ Avoid damaging nerves
★ Get patients out of pain asap
★ Minimize intraoperative pain
experience
★ Minimize post-operative pain
★ follow up
★ multi-modal analgesia

159. THANK
YOU !