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
 Aδ & 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
• Raschkow’s 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 Aδ fibers
• Myelinated
• Diameter: 1 – 4 µm
• 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 µm
 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
• ½ 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 F2α , PG E2
• Thromboxane A2
• Leucotrience 12-HETE, LTC4
Nociceptive response – prostaglandins
 Bacterial/mechanical/chemical irritation –
 Increase in prostaglandin F & E (found in high
2α 2

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 Raschkow’s 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
• Doesn’t 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