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

Pulp nerves
  

Sensory fibers A & C fibers 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 to 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 wellwelllocalized

Neurotransmitters in dental pulp

  

Calcitonin gene-related peptide (CGRP) geneSubstance 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 antibradykinin 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 12-

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 pain  

Histamine Bradykinin Serotonin

Pain relieving drugs



Aspirin inhibitor of cyclo-oxygenase cycloinhibition of PG synthesis Root canal medicaments

Phenol, p-Chlorophenol, cresol, thymol, guaiacol p 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 to dental pulp



In small damaged areas / odontoblastic layer damage is slight

Reparative dentine may seal off small damaged areas
 

Blocks re-innervation reInnervation of adjacent areas is increased

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

Pulpitis


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

More severe stimuli / larger lesions irreversible pulpitis

 

CGRP-mediated growth of nerve fibers outside CGRPinflammation 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 CGRPnecrosis 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