PULPAL & DENTAL PAIN

Oral physiology

Dent 207

Dental pulp
Specialized connective tissue Contained within the tooth Enclosed by dentine Continuous with the periodontal ligament through: Apical foramen
Narrow only allows for passage of the neurovascular bundle

Small volume
Total volume in all teeth is 0.40 ml

Pulpodentine complex
Functions of pulp & dentine are interlinked Functions of the pulp
Maintain dentinal health by supplying nutrients Provide a pathway for sensory impulses from dentine Initiate & govern repair of dentine in injury

Odontoblasts
The layer of specialized cells immediately adjacent to dentine Have processes that penetrate dentine for varying distances Responsible for formation of dentine Involved in sensory perception of dentine

Components of pulpal tissue

Fibers
Collagen
Confers rigidity Maintains 3D spatial relationship of cells, blood vessels & nerves

Elastin in blood vessel walls

Cells
Odontoblasts Fibroblasts Undifferentiated mesenchymal cells Macrophages, histocytes & lymphocytes

Amorphous matrix
Support

Nerves & blood vessels

Pulp nerves
Sensory fibers A & C fibers Types of nerve terminals near blood vessels
Large fibers
Contain small vesicles (resemble cholinergic endings)

Medium fibers
Numerous small dense-cored vesicles Found in pulp horns & pulp chamber

Small fibers
Numerous large dense vesicles (purinergic or peptidergic endings)

Plexus of Raschkow (subodontoblastic plexus)

Individual axons divide into many branches in the plexus

Pulp nerves during tooth formation

Fibers near base of dental papilla At cap stage
Fibers form a plexus - to dental follicle to dental papilla

At bell stage unmyelinated At eruption - number of fibers & their average size increase transition towards myelination Continues to increase for a few years after eruption Dentine is laid down pulp reduced in size nerve plexus decrease in size Ageing pulp
Decrease in number of axons entering pulp Reduction in myelinated fiber size Raschkows shows little change

Pulp nerves in primary teeth

Number of axons is less than that in permanent Except primary canine Number of axons decrease with resorption until the tooth is shed

Neurotrophic substances
Nerve growth factors evidence
Promote survival of neural crest cells in trigeminal ganglion Produced in the maxillary process to maintain survival of nerve axons No role in directing spread of fibers Act on nearby nerves govern late invasion of pulp tissue by nerve fibers Allow permanent teeth to recruit their nerve supply from branches of axons previously supplying deciduous teeth Odontoblastic factors promote extension of new nerve fibers into the subodontoblastic layer & dentine in reimplanted teeth

Functions of A fibers
Myelinated Diameter: 1 4 m Rapidly conducting (>2 m/s) Mediate sharp, piercing pain sensations Responsible for dentinal sensitivity Respond to any stimuli causing fluid movement in dentinal tubules
Drilling, drying & application of osmotic solutions

Functions of C fibers
Unmyelinated Diameter: < 0.5 m Slowly conducting (< 2 m/s) Polymodal: activated by
Thermal Mechanical Chemical stimuli histamine & bradykinen

Mediate dull, longer standing & less well-localized

Neurotransmitters in dental pulp

Calcitonin gene-related peptide (CGRP) Substance P Neurokinin A

Autonomic nerve supply in the pulp

Sympathetic Parasympathetic

Sympathetic
Majority of autonomic Some are cholinergic
Removal of superior cervical ganglion some decrease in cholinesterase staining in the pulp

In mouse
in pulp horn 1/3 in pulp chamber Rest in root canal

Functions
Control pulp blood flow Regulation of odontogenesis Afferent transmission of impulses associated with pain sensation

Evidences of functions
Anatomical: near blood vessels & odontoblasts Sympathectomy vasodilatation & changed in dentine apposition

Parasympathetic
Majority are cholinergic
Resection of inferior alveolar nerve
Abolish cholinesterase staining Increased rate f tooth eruption (increased intrapulpal pressure)

Nociceptive response substance P

Pulp reacts initially to stimulating dentine
Electrically Mechanically Chemically

C fibers stimulated Retrograde impulse in C branches Release of substance P at terminals

Vasodilatation tissue edema Release of histamine increase capillary permeability & fluid extravasation

Nociceptive response - bradykinin

Noxious stimulation of the pulp Bradykinin formation
Contribute to vasodilatation May stimulate release of encephalins from pulpal cells

Encephalins anti-inflammatory inhibit bradykinin release protective ve feedback mechanism

Nociceptive responce ecosanoid group

Are metabolites of arachidonic aid
Prostaglandins Leucotrienes

PG I2 produced by endothelial cells

Inhibit platelet aggregation Vasodilator

Thromboxane A2 produced by platelets & fibroblasts

Stimulate platelet aggregation

In the pulp
PG I2, PG F2 , PG E2 Thromboxane A2 Leucotrience 12-HETE, LTC4

Nociceptive response prostaglandins

Bacterial/mechanical/chemical irritation Increase in prostaglandin F2 & E2 (found in high conc. In inflamed pulp)
Vasodilatation Increase pain-producing properties of
Histamine Bradykinin Serotonin

Pain relieving drugs

Aspirin inhibitor of cyclo-oxygenase inhibition of PG synthesis Root canal medicaments
Phenol, p-Chlorophenol, cresol, thymol, guaiacol Inhibit synthesis of PG & leucotrienes Have antibacterial activity

Eugenol more effective than phenols in inhibition of prostaglandin synthesis

Pulpitis & pulp necrosis

Injury to dentine (cavity prep.)
Nerve fibers & odontoblastic processes pulled by hydrodynamic force Separated from pulpal tissue Damaging nerve fibers & killing of odontoblasts Pain in dentine

Small injury
In small damaged areas / odontoblastic layer damage is slight
Reparative dentine may seal off small damaged areas
Blocks re-innervation Innervation of adjacent areas is increased

CGRP from reactive axons promote growth of new fibers When the lesion heals - new fibers disappear

Pulpitis
Cavity reaches the pulp
Odontoblastic layer destroyed Inflammation occurs locally In small lesions, dentine bridge forms inflammation resolves & pulp heals (reversible pulpitis)
Inflammation area demarcated by fibrous tissue

More severe stimuli / larger lesions irreversible pulpitis

Severe inflammation -inflammation area demarcated by fibrous tissue Lack of pain at a later stage of pulpitis

CGRP-mediated growth of nerve fibers outside inflammation area

Hypersensitivity in early pulpitis Difficulty in achieving anesthesia a tooth with an inflamed pulp

Pulp necrosis
More severe pulpal exposure
Irreversible pulpitis - necrosis occurs Necrosis area demarcated by fibrous tissue CGRP-mediated growth of nerve fibers outside necrosis area

Lesion extends to root apex

Nerve growth in periapical tissue New fibers appear to be involved in pain sensation

Pain of dental origin

Exposed dentine sensitivity - pain
Dental caries or cavity prep. Cemental layer wears away

Any sensation through dentine pain Heat / cold may be perceived as separate sensations? Most sensitive areas in dentine as at
EDJ Exposed dentine in cervical root areas

Nerve fibers to dentine are limited to coronal dentine Nerve fibers numerous under cusps Nerve fibers extend for a short distance within dentine Odontoblastic processes vary in extension through dentine
Function as receptors

Three theories of dentinal hypersensitivity

Odontoblastic processes as receptors
Odontoblasts are neural crest in origin

Nerve fibers extend through dentine

Direct stimulation Deformation of odontoblasts by fluid movement promotes potassium release action potential in neighboring nerve fibers

Hydrodynamic theory
Movement of fluids through dentinal tubules inward & outward Distortion of nerve endings in Raschkows plexus

Referred pain
Sensation of pain resulting from a deep organ peripherally in areas derived from the same somite
Pain of cardiac origin may be perceived in the arm

Convergence of somatic & visceral sensory impulses at one or more of 3 levels

Prespinal Spinal Supraspinal

Referred orofacial pain

In trigeminal, levels are
Prepontine Pontomedullary Suprapontine

No convergence within brain Pain within the oral cavity is referred

Within the distribution of the specific divisions of the trigeminal nerve Doesnt cross midline except in ramifications of nerve terminals (incisor region)

Migrainous headache may be due to dental conditions

Not referred pain Because it is vascular in origin