Pulpal & Dental Pain
Uploaded by
Ali Al-QudsiPulpal & Dental Pain
Uploaded by
Ali Al-QudsiPULPAL & 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
