Review Article
Neuropeptides in Dental Pulp: The Silent Protagonists
Javier Caviedes-Bucheli, DDS, MSc, Hugo Roberto Muñoz, DDS, MSc,
María Mercedes Azuero-Holguín, DDS, and Esteban Ulate, DDS
Abstract
Dental pulp is a soft mesenchymal tissue densely in-
nervated by afferent (sensory) fibers, sympathetic fi-
bers, and parasympathetic fibers. This complexity in
pulp innervation has motivated numerous investiga-
tions regarding how these 3 major neuronal systems
regulate pulp physiology and pathology. Most of this
research is focused on neuropeptides and their role in
regulating pulpal blood flow and the development of
neurogenic inflammation. These neuropeptides include
substance P, calcitonin gene-related peptide, neuroki-
nin A, neuropeptide Y, and vasoactive intestinal
polypeptide among others. The purpose of this article is
to review recent advances in neuropeptide research on
dental pulp, including their role in pulp physiology, their
release in response to common dental procedures, and
their plasticity in response to extensive pulp and dentin
injuries. Special attention will be given to neuropeptide
interactions with pulp and immune cells via receptors,
including studies regarding receptor identification,
characterization, mechanisms of action, and their ef-
fects in the development of neurogenic inflammation
leading to pulp necrosis. Their role in the growth and
expansion of periapical lesions will also be discussed.
Because centrally released neuropeptides are involved
in the development of dental pain, the pain mecha-
nisms of the pulpodentin complex and the effectiveness
of present and future pharmacologic therapies for the
control of dental pain will be reviewed, including re-
ceptor antagonists currently under research. Finally,
potential clinical therapies will be proposed, particu-
larly aimed to manipulate neuropeptide expression or
blocking their receptors, to modulate a variety of bio-
logic mechanisms, which preliminary results have
shown optimistic results. (J Endod 2008;34:773–788)
Key Words
CGRP, dental pulp, neurogenic inflammation, neu-
ropeptides, NKA, NPY, Substance P, VIP
From the Endodontics Department, School of Dentistry,
Pontificia Universidad Javeriana, Bogotá, Colombia.
Address requests for reprints to Javier Caviedes-Bucheli,
DDS, MSc, School of Dentistry, Pontificia Universidad Javeri-
ana, Cra 7 No. 40-62 Building 26, Bogotá, Colombia. E-mail
address: javiercaviedes@cable.net.co.
0099-2399/$0 - see front matter
Copyright © 2008 American Association of Endodontists.
doi:10.1016/j.joen.2008.03.010
JOE — Volume 34, Number 7, July 2008
T he involvement of afferent neuron fibers in regulating peripheral inflammatory
processes has been widely reported in the medical literature. It has been demon-
strated more than a century ago that stimulation of these fibers leads to vasodilation and
the subsequent edema (1). The term neurogenic inflammation has been developed to
describe the component of inflammation caused by an appropriate stimulus applied to
peripheral neurons, resulting in the release of neuropeptides that alter multiple pro-
cesses including vascular permeability and vasodilation at the site of injury (2, 3). Since
the initial observations that stimulation of sensory neurons produces vasodilation,
plasma extravasation, and hypersensitivity, great progress has been made in under-
standing the etiology of neurogenic inflammation. Studies have focused extensively on
the role of the neuropeptides, including substance P (SP), calcitonin gene-related
peptide (CGRP), neurokinin A (NKA), neuropeptide Y (NPY), and vasoactive intestinal
polypeptide (VIP) (4 –7).
Neuropeptides are defined as peptide neurotransmitters or neuromodulators.
This implies that they are synthesized and released from neurons and trigger biologic
effects by activating receptors located on the plasma membrane on target cells (8).
Neuropeptides typically consist of polypeptide chains of 3–100 amino acids and up to
50 times larger than classic neurotransmitters (eg, acetylcholine), but they are smaller
than many other proteins and have a less complex 3-dimensional structure. Neuropep-
tides represent the largest class of neurotransmitters/neuromodulators and are highly
conserved through evolution (9). Neuropeptides are structurally more complex and
often possess multiple recognition sites for receptor binding compared with smaller
classic neurotransmitters, but they also exhibit slower rates of diffusion and slower
kinetics in binding to their receptors (10). Neuropeptides are widely distributed
throughout the entire human body and are present in every branch of the nervous
system from the central nervous system (CNS) to the peripheral nervous system (PNS),
including both autonomic and somatosensory neurons (11–13). They have multiple
and variable functions, because they could act as neurotransmitters, growth factors,
hormones, and immune system signaling molecules. This is why it is generally accepted
that the nervous system contributes to the pathophysiology of peripheral inflammation,
and a neurogenic component has been implicated in many inflammatory diseases,
including oral diseases such as periodontitis and pulpitis (14).
This review article provides an overview of neuropeptides, detailing their role and
interactions with other inflammatory factors, which ultimately lead to neurogenic in-
flammation. The biologic effects of SP, NKA, CGRP, NPY, and VIP are described, and
evidence of their involvement in the localized inflammatory process that occurs in
pulpitis and periapical pathology is discussed. A summary of neuropeptide origin,
localization, receptors, and biologic effects is presented in Table 1.
Neuropeptides and Their Receptors in Dental Pulp
Tachykinins (SP and NKA)
SP was the first neuropeptide to be identified in dental tissues (15). Thereafter,
immunohistochemical studies subsequently confirmed the relative abundance of SP-
positive immunoreactive nerve fibers within the tooth pulp and dentin of several species,
including human (16). In the central pulp, SP fibers traverse in close proximity to blood
vessels. In the periphery, many SP fibers are directly associated with small blood vessels
(Fig. 1). However, some SP fibers have no obvious association with blood vessels, and
indeed not all blood vessels are accompanied by these fibers. SP fibers are also observed
at the subodontoblast layer where they branch toward predentin, with some SP fibers
penetrating into the dentin (17). The trigeminal origin of SP-expressing intradental
Neuropeptides in Dental Pulp 773
774
TABLE 1. Summary of Pulpal Neuropeptides, Receptors, and Their Functions
Cell
Neuropeptide Origin Localization Stimulus for release Cell expressing the receptor Biologic effect
receptor
Review Article

Substance P Trigeminal C and A! ● Thermal (23–25) NK1 ● Mast cells (31) ● Vasodilation (93)
ganglion fibers ● Mechanical (23–25) ● Macrophages (31) ● Plasma extravasation (94 )

Caviedes-Bucheli et al.
● Chemical (23–25) ● Mesenchymal cells (31) ● Immune system stimulator (98,
● Electrical (23–25) ● Odontoblasts (32–33) 99)
● Caries (121) ● Fibroblasts (31) ● Chemotaxis (99)
● Capsaicin (26, 27) ● Lymphocyte T (31) ● Enhances macrophages activity
● Inflammation ● Lymphocyte B (31) (98, 99)
mediators (28, 29) ● Hard tissue formation (113,
● Bradykinin (28, 29) 114 )
● Prostaglandins (28, ● Tissue reparation (113, 114 )
29) ● Mitogen for lymphocyte T (102,
103)
Neurokinin A Trigeminal C and A! ● Thermal (23–25) NK2 ● Mast cells ● Vasodilation (93)
ganglion fibers ● Mechanical (23–25) ● Macrophages (31) ● Plasma extravasation (94 )
● Chemical (23–25) ● Mesenchymal cells (31) ● Chemotaxis (99)
● Electrical (23–25) ● Lymphocyte T (31) ● Pain (135)
● Caries (121) ● Lymphocyte B (31)
● Capsaicin (26, 27)
● Inflammation
mediators (28, 29)
● Bradykinin (28, 29)
● Prostaglandins (28,
29)
Calcitonin Trigeminal C and A! ● Thermal (23–25) CGRP1, ● Mast cells (39) ● Vasodilation (93)
gene- ganglion fibers ● Mechanical (23–25) CGRP2 ● Macrophages (39) ● Plasma extravasation (94 )
related ● Chemical (23–25) ● Mesenchymal cells (32) ● Chemotaxis (99)
peptide ● Electrical (23–25) ● Fibroblasts (32) ● Lymphocyte T suppressor (104 )
● Caries (121) ● Ameloblasts (32) ● Hard tissue formation (113–
● Capsaicin ● Lymphocyte T (39) 115)
(26,27,30) ● Lymphocyte B (39) ● Repair process (113–115)
● Inflammation ● Mitogen for odontoblasts (115)
mediators (28, 29) ● Pain (135)
● Bradykinin (28, 29) ● Resorption control (152, 153)
● Prostaglandins (28,
29)
Neuropeptide Superior Sympathetic ● Stress (55) Y receptor ● Smooth muscle cells ● Vasoconstriction (77)
Y cervical fibers ● Electrical (56) (78,79) ● Pain (83)
ganglion ● Thermal (53) ● Sensory neurons (51) ● Repair process (53)
● Caries (53) ● Mesenchymal cells (51)
Vasoactive Parasympathetic Parasympathetic ● Not well VPAC1, ● Osteoblasts (63) ● Vasodilation (90)
intestinal Ganglia fibers elucidated VPAC2 ● Osteoclasts (63) ● Immunomodulator (137)
peptide ● Cytokines (61) ● Mast cells (64 ) ● Regulates inflammation (138)
● Lipopolysaccharides ● Macrophages (64 )
(61) ● Lymphocyte T (64 )
● Nitric oxide (60) ● Lymphocyte B (64 )

JOE — Volume 34, Number 7, July 2008


Figure 1. Photomicrograph showing the anatomic relationship between pulpal
nerves and blood vessels in coronal tooth. Double labeling for biotintylated Ulex
europaeus agglutinin I lectin (UEIL, a specific marker of human vascular
endothelium, blue) and SP-containing fibers (green) showing a perivascular
plexus of SP-labeled fibers. (Reprinted from Rodd and Boissonade (170) with
permission of Blackwell Publishing.)
nerves has been well-established by denervation studies in which nerve
transection leads to loss of detectable SP (18). NKA originating from the
trigeminal nerve has also been detected in oral tissues including dental
pulp (Fig. 2) (19 –22).
SP is released by neurons on various types of noxious stimuli.
Examples of the appropriate type of stimuli are noxious thermal, me-
chanical, and chemical stimulation of the pulpodentin complex (23–
25). Moreover, the electrical stimulation of thin, unmyelinated afferent
C fibers or the administration of capsaicin has been found to result in the
release of SP (26, 27). In many fibers, SP is coexpressed with CGRP and
NKA in the same terminal endings, and in general the same stimuli that
release SP will also evoke release of NKA and CGRP, including thermal,
mechanical, and chemical stimulation, with substances such as capsa-
icin and inflammatory mediators such as bradykinin and prostaglandins
(Fig. 3) (28 –30).
Because neuropeptides cannot cross cell membranes, target cells
must express the appropriate receptor on their plasma membrane, and
the receptor must have a binding site on the extracellular surface of the
cell. These receptors perform 2 basic functions, binding the natural
agonist when it is present in the extracellular environment and gener-
ating intracellular signals that regulate various functions within the cell.
There are 3 types of tachykinin receptors, NK1, NK2, and NK3, exhibiting
preferences for SP, NKA, and NKB, respectively. NK1 receptors are ex-
pressed on most inflammatory cells, such as mast cells and macro-
phages, and on other connective-tissue cells (31). Recent studies have
shown the presence of NK1, NK2, and NK3 receptors in rat oral soft
tissues and in bone and dental hard tissue cells (32). NK1 receptors
have also been found in the mature dental pulp of rats (33). A clinical
study used a radioreceptor analysis to compare SP receptor expression
in teeth having a clinical diagnosis of acute irreversible pulpitis with
teeth with healthy pulps and teeth with induced inflammation. The re-
sults demonstrated that SP receptor expression in human pulps is sig-
nificantly greater during clinical inflammatory phenomena (34).
CGRP
CGRP-immunoreactive cells constitute 40%–50% of dorsal root
ganglia neurons (35). Primary afferent neurons containing CGRP orig-
inating from the trigeminal ganglion terminate in the spinal trigeminal
nucleus. CGRP-positive sensory neurons primarily exhibit relatively
slow conduction velocities (unmyelinated C and small myelinated A!
fibers); only 10%–15% of CGRP-positive cells were identified having
faster conduction velocities in the range of the heavily myelinated A"/#
JOE — Volume 34, Number 7, July 2008
Review Article
neurons (36). Multiple studies have demonstrated that trigeminal af-
ferent neurons expressing CGRP innervate dental pulp (37– 40). Im-
munohistochemical sections have demonstrated CGRP-immunoreactive
neurons branching extensively in the coronal pulp near the pulp horn
tip and entering into dentin for up to 0.1 mm (Fig. 4) (23). CGRP has
also been detected in gingival crevicular fluid (41).
The pharmacologic characteristics of CGRP receptors have been
studied in a variety of tissues. The existence of high-affinity binding sites
for CGRP has been reported in the brain, as well as in various peripheral
organs such as heart, liver, spleen, skeletal muscle, lung, and the dental
pulp (42– 44). There are 2 known types of CGRP receptors, CGRP1 and
CGRP2, which have been identified on the basis of pharmacologic re-
sponses to selective agonists and antagonists and subsequently identi-
fied by molecular methods. Interestingly, CGRP1 receptor could not be
identified on odontoblasts in the mature rat molar, suggesting that its
presence is associated mainly with blood vessels (32). Calcitonin-re-
ceptor–like receptor (CRLR) is an important component of the CGRP1
receptor complex. CRLR mRNA protein has been identified in human
dental pulp and trigeminal neurons by reverse transcriptase–polymer-
ase chain reaction (RT-PCR) (45). Another study with immunohisto-
chemical methods showed an extensive labeling of ameloblasts indica-
tive of CGRP1 receptor taking part in the regulation of ameloblast
function and formation of enamel (32). CRLR mRNA protein has also
been shown in human osteoblasts and rat osteogenic sarcoma cell lines
in vitro (46). Moreover, it has been reported that CGRP stimulates cyclic
adenosine monophosphate in osteoblast cell lines and inhibits bone
resorption in vitro, confirming the presence of CGRP receptor in bone
tissue that signals via cyclic adenosine monophosphate synthesis (47,
48). A radioreceptor analysis for comparing CGRP receptor expression
in human pulp tissue samples collected from teeth having a clinical
diagnosis of acute irreversible pulpitis, healthy pulps, and teeth with
induced inflammation demonstrated that CGRP receptor expression in
human pulps is significantly greater during clinical inflammatory phe-
nomena (44).
NPY
The expression of NPY in human dental pulp was first reported in
1984 by Uddman (49). Several immunohistochemical studies have
demonstrated the presence of NPY in human dental pulp from sympa-
thetic nerves originating in the superior cervical ganglion (50 –52).
NPY fibers have been observed accompanying blood vessels and char-
acteristically encircle them (Fig. 5). They were also observed in the
subodontoblastic plexus and also as free nerves in the odontoblastic
Figure 2. Immunofluorescence microphotograph of NKA-containing nerve fi-
bers in feline dental pulp. NKA-containing nerve fibers with varicosities in net-
work arrangement at the wall of large blood vessel. Some NKA-containing nerve
fibers are not associated with the blood vessel (arrowhead), and not all blood
vessels are associated with NKA-containing nerve fibers (asterisk). (Reprinted
from Wakisaka et al (171) with permission of Springer Science and Business
Media.)
Neuropeptides in Dental Pulp 775
Review Article

Figure 3. Different stimuli that trigger neuropeptide release and their role in neurogenic inflammation. VIP is released from parasympathetic fibers stimulated by nitric
oxide (NO), lipopolysaccharides (LPS), and cytokines, generating vasodilation and exerting immunomodulatory effects on different immune cells by binding on VPAC
receptors. Tachykinins (substance P, neurokinin A and B) are released from C and A! sensory fibers stimulated by thermal, mechanical, or chemical irritants. Several
inflammatory mediators, such as bradykinin (BK) and prostaglandins (PG), as well as LPS and capsaicin also result in release of tachykinins, generating vasodilation
and activation of some immune cells by binding to NK receptors. NPY is released from sympathetic fibers stimulated by caries, stress, and/or electrical, thermal, and
mechanical irritation, generating vasoconstriction and consequently reducing fluid tissue pressure. It also inhibits neuronal activity in normal conditions. CGRP is
generally co-released with SP and NKA after stimulation of the same neurons. CGRP generates vasodilation and participates in repairing processes by inducing dentin
formation and modulating the action of some immune cells.

layer projecting toward the dentin, particularly in the pulp horn areas
(Fig. 6) (53). In sympathetic neurons, NPY is co-stored with norepi-
nephrine and is released together with it on sympathetic nerve activation
(54). Physiologically, NPY is released on stress, physical exercise, myo-
cardial ischemia, and life-threatening situations (55). In pulp tissue,
electrical stimulation of sympathetic nerve fibers causes constriction of
pulpal blood vessels and lowers the tissue fluid pressure (56). These
effects might be attributed to NPY and norepinephrine release. Caries
and thermal/mechanical irritants of the pulpodentin complex have also
shown to stimulate NPY release (Fig. 3) (53). Although expression of
NPY has been demonstrated in animal and human dental pulp (22, 38,
49), the presence of its receptor has not yet been determined.
VIP
VIP is expressed predominately in parasympathetic neurons. Al-
though there are some controversies regarding parasympathetic inner-
vation of the dental pulp, VIP is expressed in dental pulp neurons (57).
VIP fibers travel along the large blood vessels and show a network-like
arrangement adjacent to the blood vessel wall. They also traverse along
small blood vessels [38]. However, some VIP fibers are observed in no
obvious association with a blood vessel, and not all blood vessels are
associated with VIP fibers (Fig. 7). At the subodontoblast layer, there are
very few VIP fibers (Fig 8) (58). VIP has also been found expressed in
periradicular lesions (59).

776 Caviedes-Bucheli et al. JOE — Volume 34, Number 7, July 2008


Figure 4. Double-exposure photomicrograph showing a great proportion of
CGRP-immunolabeled fibers (yellow) in the pulp horn of an intact permanent
molar. (Reprinted from Rodd and Boissonade (52) with permission of
Elsevier.)
The precise stimuli that trigger VIP release from parasympathetic
neurons during inflammatory reactions have not yet been elucidated.
Nitric oxide is one possible candidate because it has been demonstrated
to induce VIP release from enteric ganglia (60). Moreover, immune
cells are capable of expressing VIP, and consequently, stimulators of
immune cells such as lipopolysaccharides, cytokines, concanavalin A,
or T-cell receptor antibodies act as inducers of VIP release (Fig. 3)
(61). However, it appears that noxious stimulation of dental pulp does
not influence VIP release, because its expression remained unchanged
during inflammatory phenomena (22). VIP has shown potent immuno-
modulator properties, which might account for variable VIP release
according to stage of periradicular lesions (59).
VIP receptors are called VPAC1 and VPAC2 (previously VIPR1 and
VIPR2) (62) and are expressed in osteoclasts and osteoblasts (63).
Furthermore, VPAC1 and VPAC2 had been identified in other immune
cells such as macrophages, mast cells, B and T lymphocytes (64),
suggesting that VIP plays an important role as endogenous modulator of
Figure 5. Confocal laser-scanning immunofluorescent photomicrograph show-
ing a nerve fiber immunoreactive with NPY, characteristically encircling a blood
vessel in the pulp of a noncarious tooth. (Reprinted from El Karim et al (53)
with permission of Blackwell Publishing.)
JOE — Volume 34, Number 7, July 2008
Review Article
Figure 6. Photomicrograph showing the anatomic relationship between pulpal
nerves and blood vessels in coronal tooth. Triple labeling for protein gene
product (PGP, red), UEIL (blue), and NPY (yellow/green) in the pulp horn
region showing some NPY-immunoreactive fibers closely associated with a
small blood vessel. (Reprinted from Rodd and Boissonade (170) with permis-
sion of Blackwell Publishing.)
immune response (65). A recent study used radioreceptor analysis for
evaluating whether VIP receptors were present in chronic periapical
lesions and to determine whether differences in its expression were
found according to the size of the lesions. Results showed that VIP
receptors are expressed in chronic periapical lesions, and its levels are
inversely proportional to the lesion sizes, suggesting that VIP could have
an important role in regulating the inflammatory phenomenon in the
development of periapical lesions via cellular receptors (66).
Biologic Functions of Neuropeptides
Dental Pulp and Neurogenic Inflammation
Neuropeptides and their receptors are widely distributed through-
out the body, and many are coreleased with classic neurotransmitters.
The functions of neuropeptides are multiple and diverse, because they
participate in paracrine, endocrine, and neurocrine (“neurotransmit-
ter”) forms of communication (10). Two dynamic changes occur to
peptidergic afferent neurons during inflammation. First, there is a
sprouting of afferent fibers as based by both anatomic and receptor field
studies (23, 67). Second, local increases in inflammatory mediators
trigger neuropeptide release, leading to neurogenic inflammation, in-
cluding vasodilation, plasma extravasation, and recruitment/regulation
Figure 7. Photomicrograph showing the anatomic relationship between pulpal
nerves and blood vessels in coronal tooth. Triple labeling for protein gene
product (PGP, red), UEIL (blue), and VIP-immunoreactive fibers (yellow)
showing perivascular PGP-labeled nerve fibers but an absence of vascular-
related VIP-expressing fibers. (Reprinted from Rodd and Boissonade (170)
with permission of Blackwell Publishing.)
Neuropeptides in Dental Pulp 777
Review Article
Figure 8. Double-exposure photomicrograph showing moderate VIP expres-
sion in the subodontoblastic nerve plexus of an intact permanent tooth; od,
odontoblast layer. (Reprinted from Rodd and Boissonade (52) with permission
of Elsevier.)
of immune cells such as macrophages, mast cells, and lymphocytes.
These cells have been identified to express functional neuropeptide
receptors on their cell membrane and thus becoming able to respond to
their biologic signal (68).
Dental pulp is a soft, mesenchymal tissue enclosed by rigid min-
eralized dentin, situating it in a low compliance environment that limits
its ability to increase its volume during inflammation (69). Extensive
research has been conducted on the physiology of pulp tissue. Many of
these important physiologic effects are mediated or regulated by neu-
ropeptides. Dental pulp is among the most densely innervated tissues in
the body. Thus, neural agents are an important signal for neurogenic
inflammation, for stimulation and repair, and for regulating homeo-
static functions of the pulp (67). The nerve fibers in pulp are compo-
nents of a larger peripheral nervous system that includes afferent (sen-
sory) fibers originating from the trigeminal ganglion and sympathetic
fibers originating from the cervical sympathetic ganglia (70, 71). There
are still controversies regarding the parasympathetic innervation of the
human pulp (72).
The Role of Innervation and Neuropeptide Release in the
Control of Pulpal Blood Flow
Immunohistochemical observations have demonstrated that pulp
innervation is closely related to the microvasculature. Consequently,
many studies have evaluated the role of neuropeptides in regulating
blood flow and plasma extravasation (73–75). Hemodynamic regula-
tion in the dental pulp has several important functions. It serves to
provide optimal nutrition to pulpal cells, supports the removal of me-
tabolites and waste products from the tissue, and acts to maintain a
pulpal blood pressure in harmony with pulpal tissue pressure (76).
Activation of the sympathetic nervous system reduces pulpal blood
flow via local release of neurotransmitters in the pulp, including nor-
epinephrine, NPY, and adenosine triphosphate, which constrict vessels
expressing the correspondent receptor (77). Functional studies have
shown that sympathetic vasoconstriction in the pulp is mediated mainly
by "-adrenergic receptors located on the vascular smooth muscle cells
of arterioles and venules (78, 79). The distribution of sympathetic fibers
is highest in blood vessels in the pulp horns near the odontoblastic
region and is lowest in the apical region. They terminate as free nerve
endings in pulp and innervate predominantly the arterioles, although
other vessels also receive some innervation (80). The presence of NPY
in sympathetic terminals in dental pulp also contributes to vasoconstric-
tion, as demonstrated after appropriate "-adrenoreceptor blockade,
particularly during high-frequency stimulation of the sympathetic sup-
ply. Moreover, after ablation of the superior cervical ganglion, NPY-
containing axons disappear from the pulp (81, 82).
778 Caviedes-Bucheli et al.
Sympathetic modulation also influences pain transmission. It has
been demonstrated that sympathetic vasoconstriction in the cat dental
pulp strongly inhibits the excitability of intradental sensory nerves (83).
The A-type fibers rapidly lose their normal sensitivity during pulpal
ischemia (84). A heat stimulus, which normally excites sensory nerves
in the pulp, was shown to be ineffective during a period of sympathetic
activation. This could lead to fluctuations in pulpal pain intensity by
stress-induced sympathetic vasoconstriction. Therefore, some patients
with pulpal pain might experience a relief of their symptoms on the way
to the dentist (76). However, under certain pathologic conditions, the
increased activity in sympathetic nerves and release of norepinephrine
might directly activate certain sensory nerve endings. For that reason,
"-adrenoreceptors present on sensory nerve endings might stimulate
pain transmission when activated by norepinephrine and might contrib-
ute to fluctuations in pain symptoms from inflamed pulps (85).
It also has been demonstrated that sympathetic vasoconstriction in
the pulp is prone to inhibition after local tissue irritation such as deep
cavity preparation and thermal variations. These stimuli might eliminate
the vasoconstrictor response to sympathetic activation for several hours
(86). Intra-arterial infusions of histamine, bradykinin, SP, and acetyl-
choline also neutralize sympathetic vasoconstriction (87).
Many of the functions of the sympathetic neurons are opposed by
activation of parasympathetic neurons. Although the occurrence of
parasympathetic vasodilation in the dental pulp is still questioned; some
studies have shown that acetylcholine applied locally on dog pulps pro-
vokes an increase in pulpal blood flow (88). Furthermore, acetylcho-
line receptors have been found in porcine dental pulp (89). However,
the presence of specific receptors and agonist effects is not indisputable
evidence of a parasympathetic influence on the pulp (76). VIP immu-
noreactivity is a marker for parasympathetic postganglionic neurons.
VIP-containing nerve fibers have been found in dental pulp (57). In
addition, intra-arterial injection of synthetic VIP causes vasodilation in
the cat pulp (90), and denervation experiments demonstrated that VIP
in the pulp of cats does not originate from sensory or sympathetic nerves
(91). A radioimmunoassay study quantified the expression of VIP in
healthy and inflamed human dental pulp. However, no significant dif-
ferences were found in VIP expression during inflammatory phenome-
non (22). This finding would support a weak influence of parasympa-
thetic nerves on pulpal blood flow.
The control of pulpal blood flow also involves peptidergic afferent
nerves from the trigeminal ganglion. Although these neurons are clas-
sified as sensory, because of the high content of neuropeptides, these
fibers cause vasodilation and inhibit sympathetic vasoconstriction in
response to painful stimulation of the tooth. Neuropeptides released
from these fibers include SP, NKA, and CGRP (50). Studies indicate that
these sensory-derived neuropeptides terminate primarily near blood
vessels, although some free nerve endings are also observed. Both SP
and CGRP are released from terminals of pulpal nociceptors consisting
of unmyelinated C fibers and thinly myelinated A-delta fibers (92). Other
studies have demonstrated the appropriate receptors for these neu-
ropeptides are found in dental pulp (34, 44). SP and CGRP are potent
vasodilators in the dental pulp, whereas NKA has a much smaller effect
on pulpal blood flow (93). On activation of sensory nerves, either by
brief antidromic electrical stimulation of the inferior alveolar nerve or
by direct simulation on the tooth crown, neuropeptides are released,
inducing a long-lasting blood flow increase and increased vascular per-
meability in the pulp (94). The initial component of the vasodilator
response is mediated by SP, whereas the continued long-lasting rise in
blood flow is dependent on CGRP (95). After exerting their effects,
neuropeptides are rapidly degraded by enzymes in the pulp tissue (96).
Other clinically relevant stimuli, such as drilling, probing of exposed
dentin, application of ultrasound, or percussion of teeth, also cause
JOE — Volume 34, Number 7, July 2008

Figure 9. Vascular changes in dental pulp due to neuropeptide interactions.
Hemodynamic regulation after pulpodentin complex irritation is controlled by
neuropeptides. NPY generates vasoconstriction and a reduction in pulpal blood
flow (PBF) by binding to "-receptors in blood vessels. VIP, CGRP, SP, and NKA
generate vasodilation and increase PBF. CGRP, SP, and NKA exert a long-lasting
control of PBF, whereas VIP regulation of PBF is weak compared with other
neuropeptides.
vasodilation in the pulp, which is mediated by intradental sensory nerves
(97). Figure 9 summarizes the vascular changes in dental pulp as a
result of neuropeptide interactions.
Interaction Between Nerve Fibers and Cellular Population of
the Dental Pulp
Increased production and release of neuropeptides play an im-
portant role in initiating and propagating pulpal inflammation, because
they have the ability to interact with immunocompetent cells. In general,
SP acts as an immunostimulatory agent, because it can enhance the
chemotaxis and phagocytosis of macrophages (98, 99). Production by
macrophages of arachidonic acid metabolites and cytokines is also
increased by SP (100, 101). Furthermore, SP also stimulates the mito-
genic responses and cytokine production of T lymphocytes (102, 103).
In contrast, CGRP often produces immunosuppression, because it in-
hibits mitogen-induced T-lymphocyte proliferation, blocks H2O2 pro-
duction in macrophages, and reduces antigen presentation of class II
antigen-expressing cells (104 –106). CGRP also inhibits the induction
of delayed-type hypersensitivity (107).
It has been demonstrated that SP and CGRP interact with mast cells,
inducing the release of histamine and thereby causing elevated vascular
permeability and increased blood pressure in tissue (108). In the rat
molar pulp, SP and CGRP were shown to be present in close proximity
to macrophages and class II antigen-positive cells, an association that
was more prevalent in the odontoblastic layer than in the central pulp
(109).
Neuropeptides alter the release of other inflammatory mediators.
SP induces interleukin-8 secretion from human dental pulp cells (110)
and enhances expression of lipopolysaccharide-induced inflammatory
factors in dental pulp cells (111). SP and CGRP also regulate the mono-
cyte chemotactic protein-1 expression in human dental pulp (112).
These neuropeptide interactions with inflammatory cells in the pulp
lead to an increased expression of cyclooxygenase 2 and interleukin-10
mRNA levels in pulp tissue (108). The addition of SP to rat pulpal cell
cultures increased the proliferation of concanavalin-A–stimulated T
lymphocytes, whereas CGRP decreased it (109).
Neuropeptides also potentiate chemotaxis, phagocytosis, lympho-
cyte proliferation, interleukin-2 production, and the expression of ad-
hesion molecules in immunocompetent cells (108). In addition to these
vasodilator and immunomodulatory effects, SP and CGRP exert stimu-
latory effects on the growth of pulpal cells such as fibroblasts and odon-
toblast-like cells (113, 114). CGRP also increases the expression of
bone morphogenetic protein-2 transcripts in human pulp cells, leading
to odontoblast-like cell differentiation and thus inducing dentin regen-
JOE — Volume 34, Number 7, July 2008
Review Article
eration and lowering dentin permeability (115). These interactions
between neuropeptides and pulpal cells suggest that they also play an
important role in pulp repairing process. Fig. 10 summarizes the inter-
actions between neuropeptides and different cell population of the den-
tal pulp.
It is interesting to notice that nerve fibers have their cell body
located far away from the pulp (trigeminal ganglion for sensory neurons
and cervical sympathetic ganglia for sympathetic fibers). This implies
that retrograde axonal transport is required for transport of tissue fac-
tors to the cell body, and conversely, anterograde transport is necessary
to send back neuropeptides, receptors, or ion channels (116). This
axonal transport signaling to and from the cell body requires at least
several hours and can take up to several days. Consequently, the dis-
tinction between very rapid signals via action potentials that travel along
nerve membranes and the much slower chemical signals carried by
axonal transport is important for the understanding of the functions of
sensory nerves in teeth, their interactions with pulp, and their responses
to injury (69).
Neuronal Response to Injury of the Pulpodentin Complex
The diversity of nerve-pulp interactive systems and the high density
of sensory innervation in teeth indicate a dominant role for dental in-
nervation in pulpal biology and the response to dental injury. Thus, if the
sensory innervation is removed before injury, the pulp is less able to
defend itself, to trigger neurogenic inflammation, or to heal after pulpal
exposure (117, 118). Injury to the pulpodentin complex produces nu-
merous neuronal responses. It is important to realize that these noci-
ceptive peptidergic neurons not only signal the occurrence of tissue
damage by triggering an afferent barrage back to the CNS but also
regulate the peripheral response to tissue damage by the release of
neuropeptides into the dental pulp tissues (119, 120). Moreover, this
system undergoes dramatic changes after tissue injury. For example, the
expression of SP in the dental pulp was found to be significantly in-
creased with the progression of caries (Fig. 11). Indeed, SP expression
was significantly greater in grossly carious painful specimens than in
asymptomatic teeth. These data suggest that the expression of SP within
pulpal nerves undergoes dynamic changes after caries, which might
have clinical significance in terms of inflammation and pain experience
(121).
The dental sensory fibers also react to tooth injury by extensive
anatomic and cytochemical changes in their preterminal branches and
endings. Pioneering studies in CGRP physiology by Taylor et al (122)
have shown sprouting of CGRP-immunoreactive fibers in response to
dentin injury in rat molars and in the presence of inflammation. In rat
models of dental injury, there is an initial depletion of neuropeptides
that are released into the pulp tissue followed by increased neuropep-
tide content and sprouting of the terminal fibers within 1 day after injury
(117, 123). Superficial injuries to dentin, such as shallow cavity prep-
aration, shallow scaling of cervical dentin, or even a strong orthodontic
force, cause a transient change in pulp. There is an extensive sprouting
of neuropeptide-rich nerve fiber endings near the injury that return to
normal within a few days to a few weeks (Fig. 12). These changes are
correlated with the local production of nerve growth factor by fibro-
blasts near the injury site (124).
A study used radioimmunoassay for determining the effect of cavity
preparation (without pulp exposure) on SP expression in healthy hu-
man dental pulp. The results revealed SP expression in all samples,
showing a significantly greater expression in pulp from teeth where
cavity preparation had been performed compared with control values,
suggesting that SP is released during common dental procedures and its
expression might have an important clinical significance in terms of
experiencing inflammation and pain (25).
Neuropeptides in Dental Pulp 779
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Caviedes-Bucheli et al.
JOE — Volume 34, Number 7, July 2008

Figure 10. Interactions between neuropeptides and different cell population of the dental pulp. Neuropeptides initiate and spread neurogenic inflammation. SP generates immunostimulatory effects by enhancing macrophage
phagocytosis, chemotaxis, and cytokine release. In other immunocompetent cells, SP induces the release of prostaglandin E2 (PGE2), interleukin-1 (IL-1), IL-2, IL-6, IL-8, and tumor necrosis factor (TNF). SP also regulates
the expression of monocyte chemotatic protein-1 (MCP-1), as well as the mitogenic activity and cytokine release of T lymphocyte (LT) and promotes neutrophil (PMN) chemotaxis. Both SP and CGRP induce histamine release
from mast cells. CGRP inhibits mitogen-induced T-lymphocyte proliferation, blocks hydrogen peroxide (H2O2) production in macrophages, and reduces antigen presentation of class II antigen-expressing cells (MHC-II).
CGRP exerts stimulatory effects on the growth of fibroblasts and odontoblast-like cells by increasing the expression of bone morphogenetic protein-2 (BMP-2), therefore inducing dentin regeneration and lowering dentin
permeability.

Figure 11. Double-exposure photomicrograph of a nerve trunk in the mid-
coronal region of an intact permanent tooth (A) showing minimal SP expres-
sion. A marked increase in SP expression is observed within the nerve trunk of
a grossly carious specimen (B). (Reprinted from Rodd and Boissonade (52)
with permission of Elsevier.)
Deep dentinal cavity, small pulp exposures, or heat stimulation of
long duration and high intensity provokes leukocyte invasion and local
vascular responses. There is also an extensive sprouting of nerve fibers
containing CGRP and SP, and it continues as long as the inflammation
process stills active. After resolution of the inflammatory response and
tissue repair, the fiber sprouting decreases, and neuropeptide levels
return to normal (125). When large pulpal exposure or damage occurs,
local repair is not always possible; consequently, irreversible pulpitis is
established, accompanied by a large and intense sprouting of sensory
fibers in the vital pulp remaining near the lesion. However, nerve
sprouting and healing are low at the site of healing (126).
There is strong evidence that SP, CGRP, and NKA expression sig-
nificantly increases in the pulp when acute irreversible pulpitis or me-
chanical pulp exposure occurs (21, 22, 127, 128). Another study used
drilled rat molar dentin and determined injury-related changes in the
levels of immunoreactivity of both SP and CGRP. Pulpal exposures
caused a massive 90% decrease in SP levels and a moderate 55% de-
crease in CGRP levels, consistent with substantial neuropeptide release.
Cavity preparation without exposure caused 80%–90% reduction in
neuropeptide levels, whereas acid etching of the dentin caused a 40%
decrease (28). According to the previous findings, it seems that pulpal
neuropeptides undergo dynamic injury-specific and peptide-specific
responses after trauma (Fig. 13).
Another study assessed NPY levels and confirmed the distribution
of NPY fibers by immunocytochemistry in carious and noncarious adult
human pulp tissue. Results showed changes in the levels and distribu-
tion of NPY in human dental pulp during the caries process, with sig-
nificantly greater levels of NPY in carious teeth compared with healthy
teeth (Fig. 14), even in mild/moderate caries, suggesting that NPY could
have a modulatory role in pulpal inflammation and in reparative dentin
formation (53).
JOE — Volume 34, Number 7, July 2008
Review Article
It has been demonstrated that dental injuries also provoked
changes in the trigeminal ganglion. Another rat model study showed that
in normal trigeminal ganglion, some perivascular nerves displayed NPY-
like immunoreactivity, but there were no immunoreactive ganglionic
cells. However, after dental injury such as pulp exposure, NPY-like
immunoreactive cells appeared in the ganglion, indicating a change in
the primary sensory neurons of the ganglion (129).
A recent study used a radioimmunoassay to evaluate the SP expres-
sion during induced inflammation of rat pulp tissue after capsaicin
injection into the inferior dental nerve. The results showed that the
infiltration of capsaicin on the inferior dental nerve provoked a signif-
icant reduction in pulpal SP expression (even lower than normal SP
basal levels), although mechanical pulp exposures were carried out to
induce an inflammatory response in dental pulp. The greatest SP ex-
pression was found in mechanically exposed pulps with no capsaicin
pretreatment. However, it could not be determined whether capsaicin
infiltration of inferior dental nerve caused any structural damage to
nerve endings in pulp (130). These findings suggest that sensory nerves
play a role in the modulation of extracellular matrix production and
secondary dentinogenesis, which are key elements in the healing of the
pulp, because they are able to control neurogenic inflammation and
have immunomodulatory properties.
As can be concluded from all of the above, dental pulp inflamma-
tion is a complex process involving a wide variety of nervous and vas-
cular reactions, which are key components of the neurogenic inflam-
mation that could lead to pulp necrosis (131). Fig. 15 illustrates the
neuronal response to injuries of the pulpodentin complex, such as
caries, cavity preparation, or orthodontic forces.
Role of Neuropeptides in Pain Mechanisms of Pulpodentin
Complex
There are 3 major steps to the perception of odontogenic pain:
detection, processing, and perception. Detection is a primary function
of peripheral sensory nociceptive neurons (eg, A-delta and C fibers),
which are stimulated by either noxious physical stimuli or the release of
inflammatory mediators that act on receptors located in terminal end-
ings, sensitizing or depolarizing these nerve fibers (132). In the in-
flamed dental pulp, it is generally accepted that nociceptive afferent
nerve fibers detect the presence of inflammatory mediators via recep-
tors that are synthesized in the neuron’s cell body located in the trigem-
inal ganglia and then transported to the periphery. However, recent
evidence has demonstrated that mRNA transcripts are transported to
peripheral terminals, suggesting that peptide synthesis could occur di-
rectly in the peripheral terminals (133). When the mediator reaches a
concentration in the inflamed tissue sufficient to activate the receptor,
the nociceptive fiber could become activated (ie, triggering an afferent
barrage to the central nervous system) or sensitized. A sensitized fiber
displays spontaneous depolarization, reduced threshold for depolariza-
tion, and increased afterdischarges to suprathreshold stimuli (132).
Besides activation and sensitization, the peripheral afferent sen-
sory neurons respond to neurotrophins such as nerve growth factor by
increasing the synthesis of SP and CGRP and the subsequent sprouting of
terminal fibers in the inflamed tissue (117). Similar increases in neu-
ropeptides have been shown in human pulp infected by caries (121).
Sprouting causes an increase in the density of innervation of the in-
flamed tissue, contributing to increased pain sensitivity in chronic pul-
pal inflammation (117).
Once activated, the A-delta and C fibers transmit nociceptive sig-
nals to the trigeminal nuclear complex, where they end primarily in the
outer layer of the medullary dorsal horn. The processing of pain takes
place in this site (134). These sensory fibers transmit information by
releasing glutamate and neuropeptides, SP or CGRP. These excitatory
Neuropeptides in Dental Pulp 781
Review Article

Figure 13. Response mechanism to neuropeptide stimulation. Local trauma

generates pulp inflammation, which induces nerve sprouting. This leads to an
increased neuropeptide release, which regulates vascular changes and immune
response, resulting in a perpetuation of inflammatory process (if trauma con-
tinues) or a repair process (if the irritant is adequately removed).

molecules activate their receptors located on postsynaptic projection

neurons that transmit the nociceptive signal to the thalamus (135).
From the thalamus, additional neurons relay this information to the
cerebral cortex where perception of pain occurs. Fig. 16 illustrates the
pain pathway from dental pulp to thalamus and cerebral cortex.
It is interesting to notice that under certain inflammatory condi-
tions, A-beta fibers (normally innocuous mechanoreceptors) begin to
express SP and develop new central terminations in the dorsal spinal
cord. These changes might explain some pain conditions that present an
exquisite mechanical allodynia (136). One endodontic example of ex-
quisite mechanical allodynia is the patient presenting with an acute
apical abscess, where even gentle touching evokes pain. However, it is
not yet known whether these transformed A-beta fibers contribute to the
pain of acute apical abscess. In addition to these peripheral mecha-
nisms, central sensitization might also occur from a barrage of impulses
from C nociceptors, resulting in the central release of glutamate and SP.
This leads to activation of central receptor for both molecules. In this
situation, stimulation of the A-beta fibers would also produce a pain
response, constituting a central mechanism of allodynia (132).

Neuropeptides and the Development and Healing of Periapical

Lesions
Neuropeptides have been associated with the development of
chronic periapical lesions as a result of the dense innervation of this
tissue. VIP could participate in the growth and maturation processes of
the lesion, because it has been associated with bone resorption and
regulating osteoclastic functions (63). The presence of VIP in periapical
lesion has been reported, and its levels are inversely related to lesion
size. Given the functions of this neuropeptide in other tissues, it has been
hypothesized that VIP participates in regulating the growth of periapical
lesions (59). Results from another study showed that VIP receptors are
expressed in chronic periapical lesions, and its levels are also inversely
proportional to the lesion sizes, suggesting that VIP could have an im-
portant role in regulating the inflammatory phenomenon in the devel-
opment of periapical lesions via cellular receptors (66).

Figure 12. Immunohistochemical sections of a matched pair of first maxillary

rat molars. In the control tooth (A), numerous CGRP-immunoreactive fibers are
observed near the pulp horn tip and extended along the pulp dentin border to
the cervical line (dashes). The injured tooth (B) was drilled at the cervical
region 4 days earlier; numerous CGRP-immunoreactive fibers have sprouted
below the injury and have extended into previously sparsely innervated cervical
regions along the pulp dentin border. (Reprinted from Taylor et al (122) with
permission of Elsevier.)

782 Caviedes-Bucheli et al. JOE — Volume 34, Number 7, July 2008


Figure 14. Double-exposure photomicrograph of (A) an intact molar showing
minimal NPY expression near the pulp horn (ph) and (B) a grossly carious
molar showing numerous NPY-labeled fibers in the pulp horn. (Reprinted from
Rodd and Boissonade (52) with permission of Elsevier.)
It has been suggested that both osteoblasts and osteoclasts are
equipped with VIP receptors and that this neuropeptide might regulate
bone resorption. Osteoclast cell culture studies have demonstrated that
the presence of greater concentrations of VIP leads to a decrease in their
ability to form lacunae of osseous resorption, causing rapid cytoplas-
matic contraction and reduced cell mobility (63). VIP-induced oste-
oclast inhibition is transitory and similar to that caused by calcitonin;
however, late osteoclast resorption is made more efficient in the pres-
ence of osteoblast stromal cells and is mediated by cyclic adenosine
monophosphate (137).
High proportions of macrophages have been reported in periapi-
cal lesions. It has been demonstrated that macrophages have an impor-
tant function in periapical lesion development and also perpetuating
chronic inflammatory reactions by activating humoral and cellular im-
munologic responses (138). VIP exerts an effect on macrophages,
blocking the production of tumor necrosis factor–", interleukin-6 and
Figure 15. Neuronal response to injuries of the pulpodentin complex, such as
caries, cavity preparation, or orthodontic forces. The effect of orthodontic
forces and local trauma (eg, caries/cavity preparation) generates anatomic
alterations in the distribution of nerve fibers (sprouts), leading to an increased
neuropeptide expression and therefore increased pain sensitivity due to periph-
eral sensitization.
JOE — Volume 34, Number 7, July 2008
Review Article
Figure 16. Pain pathway from dental pulp to thalamus and cerebral cortex. Pain
pathway involves 3 steps: detection, processing, and perception. Detection of
noxious injury occurs via primary afferent nociceptors that travel to the trigem-
inal ganglion and to the medullary dorsal horn (specifically in the oral and
caudal subnecleus), where processing occurs. The output from the medullary
dorsal horn is conveyed across a synapse to a wide-dynamic range (WDR)
projection neuron that travels to the thalamus along the trigeminothalamic tract.
The sensory fibers can directly activate the WDR neuron or indirectly activate it
via contacts onto excitatory interneurons. Perception occurs primarily in the
cerebral cortex.
!12, when they are stimulated by lipopolysaccharides, consequently
reducing inflammation (139, 140). These findings suggest that VIP
could have a role in controlling growth of periapical lesions.
Lymphocyte subpopulations are also present in periapical lesions
(141). Lymphocyte apoptosis is recognized as being the major element
in controlling the immune response because it constitutes a peripheral
tolerance maintenance mechanism and limits the progress of an im-
mune response (142). VIP participates in T-lymphocyte apoptosis, pro-
tecting CD4 and stimulating CD8 apoptosis (143). Previous studies have
shown that there are more CD4 lymphocytes in relation to CD8 during
the initial stage of a periapical lesion and that this proportion becomes
inverted during later stages when lesions become stable (144). The
distribution of SP in immune cells localized in periradicular granulo-
mas has also been reported (145). SP was expressed cytoplasmically in
macrophages in both acute and chronic inflammatory lesions. Plasma
cells were SP-positive in both acute and chronic lesions. Endothelial
cells were SP-positive in some granulation tissues, and neutrophils were
found to be SP-negative in some acute lesions; although SP has been
shown to be the cause of initiation of neutrophil migration into the
inflammation site (146, 147). SP has been shown to elevate intercellular
adhesion molecule 1 and vascular cell adhesion molecule 1 expression
on human endothelial cells. It also has been demonstrated that endo-
thelial cells that previously came across an antigen begin to express SP
and increase the vascular permeability and the expression of adhesion
molecules (148 –150). In another study, SP and NKA have activated B
lymphocytes for antibody isotype switching (151).
Neuropeptides are also involved in the healing process of periapi-
cal lesions. CGRP has been shown to be highly distributed in bone via
nerve fibers closely related with blood vessels (152). In experimentally
induced rat periapical lesions it has been shown that the number of
bone resorbing osteoclasts began to decrease when the density of CGRP-
immunoreactive nerve fibers reached their peak, suggesting a possible
role for CGRP in inhibiting bone resorption (153, 154). This CGRP-
induced reduction of bone resorbing has been related to the inhibition
of osteoclast motility (155). Experimental studies support the involve-
ment of CGRP in bone remodeling (156, 157). Receptors for CGRP have
been found in osteoblasts, and it has been demonstrated that these cells
are able to express CGRP endogenously (60). All this evidence supports
the nervous system’s influence over bone metabolism (158).
In accordance with the previous data, the inflammatory and heal-
ing events that occur within periradicular lesions seem to be neurogen-
Neuropeptides in Dental Pulp 783
Review Article

Figure 17. Role of neuropeptides in growth and healing of periapical lesions. VIP expression in periapical lesions is inversely proportional to lesion size. VIP blocks
the production of tumor necrosis factor (TNF), interleukin-2 (IL-2), and IL-6 by macrophages and stimulates lymphocyte (CD8) apoptosis. Increased VIP
concentrations reduce osteoclast activity, thus inhibiting bone resorption. On the other hand, osteoblasts possess VIP receptors. SP is expressed by macrophages and
stimulates neutrophil (PMN) migration by enhancing vascular permeability. CGRP also inhibits bone resorption by reducing osteoclast motility.

ically controlled by neuropeptide effects on immunocompetent cell
population of the periapical tissue. Fig. 17 summarizes the role of neu-
ropeptides in growth and healing of periapical lesions.
Neuropeptide Antagonists: Current Perspectives
Evidence from animal and clinical studies suggests that neuropep-
tide antagonists binding to peptide receptors could be useful for the
treatment of disease states associated with high levels of neuropeptides.
Because neuropeptides have been implied in the pain mechanism of the
pulpodentin complex and other tissues, the use of neuropeptide antag-
onists is likely to constitute prototypes for future class of analgesic
drugs.
Early clinical results in dental pain studies are promising (159).
The administration of receptor antagonists to glutamate and SP in par-
ticular, and to CGRP to a lesser extent, reduces hyperalgesia or noci-
ceptive transmission in animal studies (160). Evidence to date strongly
implicates antagonists to the glutamate N-methyl-D-aspartate receptor
as being particularly effective in reducing hyperalgesia, as well as an-
tagonists of NK1 receptor in animal studies. However, results from hu-
man clinical trials have been equivocal, and few studies have shown
antagonists to have significant effects on dental pain (161, 162).
Potential Clinical Therapies for the Control of
Neuropeptide Release
Current evidence suggests that neuropeptides could be mobilized
by peripheral electric stimulation to benefit human health. Brain func-
tions are regulated by chemical messengers that include neurotransmit-
ters and neuropeptides. It has been shown that acupuncture or electri-
cal stimulation in specific frequencies applied to certain body sites can
facilitate the release of specific neuropeptides in the CNS, eliciting pro-
found physiologic effects and even activating self-healing mechanisms
(163). Further research on the conditions controlling this neurobio-
logic reaction could have theoretical and clinical implications. It would
be ideal to cure diseases by noninvasive measures that activate self-
healing mechanisms, without using drugs or surgical operations. Evi-
dence demonstrates that it is possible to facilitate the release of certain
neuropeptides in the CNS by means of peripheral electrical stimulation.
The clinical efficacy of this technique to reduce postoperative pain
(164), lower-back pain (165), and diabetic neuropathic pain (166)
holds exciting promise for the future of odontogenic pain control.
How to activate a self-healing mechanism in the pulp when it is
surrounded by dentin has been a topic of controversy for years. The
concept of using the porosity of dentin as an avenue for drug delivery to
the pulp was suggested by Pashley (167) in 1990. The problems in-
volved with this approach have also been discussed, such as the possi-
bility that the therapeutic agent binds to dentin (168). However, under
the proper conditions, it is conceivable that dentinal tubules might
provide a route of administration of many drugs, including growth fac-
tors and neuropeptides, to elicit a response in the pulp. For example,
the ability of osteogenic protein-1 (OP-1) to promote reparative dentin
formation after topical application to dentin in cavities prepared on
monkey’s teeth (169) has been demonstrated.
Research performed up to date has led to a number of therapies,
pharmacologic or not, that alleviate symptoms in a number of diseases

784 Caviedes-Bucheli et al. JOE — Volume 34, Number 7, July 2008


associated with neurogenic inflammation. However, there is still a long
way to go in discovering unique endogenous substances that act directly
on sensory neurons and novel transduction cascades that regulate ex-
citability of sensory neurons.
Conclusion
It is clear that mechanisms of pulpal pathophysiology are complex
and include actions of multiple neuropeptides. The low compliance
environment in which the dental pulp is allocated enhances the com-
plexity of its pathophysiology, explaining the unique responses of pulp
tissue to pathologies like caries and periodontal diseases, as well as to
additional injuries provoked by dental treatment such as mechanical
and chemical irritation from cavity preparation and dental materials
that could lead to neurogenic inflammation and consequently pulp ne-
crosis and periapical disease. The vast evidence regarding neuropeptide
interactions with normal pulp and inflammatory cells via receptors de-
mands further research regarding potentially novel therapeutic ap-
proaches for the management of inflammatory disorders such as pul-
pitis and other pain conditions of the orofacial structures. The use of
antagonists and enzymes that modulate neuropeptide release are highly
relevant targets for the development of new drugs.
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