Aims & Objectives Dental Pain

Aim - To introduce theories of pain and pulpal sensitivity Objectives - By the end of the lecture you should be able to:
Outline the embryology of the dental pulp Describe the theories of dentinal sensitivity with reference to anatomy of the pulp See the relevance of the hydrodynamic theory to operative dentistry Suggest what modifies perception of pain Determine which nerves are being stimulated causing dental pain

Pain
an unpleasant and emotional experience associated with actual or potential tissue damage or described in terms of such damage

Presentation of pain
Can you see it? Organic damage Psychological damage Interaction of these

Trauma
Concentration: Expectation/ Anxiety

(eg. hot/cold, physical)

Misdirection: Focussed activity/Hypnosis TENS

Increasing factors

Pain

Reducing factors

Where does the dental pulp come from?

Layers
Ectoderm Mesoderm Endoderm

Neural Tube

Gut

The dentine-pulp complex

Theories of dentinal sensitivity

Innervation of tubules Synaptic junction with odontoblast Hydrodynamic theory

Theory 1 Nerve fibrils are in the tubules

Theories of dentinal sensitivity

Innervation of tubules Synaptic junction with odontoblast Hydrodynamic theory

Theories of dentinal sensitivity

Innervation of tubules Synaptic junction with odontoblast Hydrodynamic theory

Theory 2 Anastamosis with odontoblast

Hydrodynamic theory
Gysi 1900 Brnnstrm et al 1967 Cold outward flow: aspiration & less shearing forces Hot inward flow

Alfred E Gysi

1865-1957

Theory 3 Fluid movement in tubules

Nerves
A- A- myelinated C (0.2-1.0m) respond to mediators of inflammation)

Mechanism of dentinal fluid flow

Fluid outflow
Increased by inflammation/neuropeptides Decreased by Albumin, globulins, fibrinogen

Fluid flow and pain

18.1 pLs-1mm-2
Normal physiological flow

1.0-1.5 nLs-1mm-2
Threshold for pain sensation (50x normal)

Sensation from the pulp

Few proprioceptive fibres body finds it difficult to localise Hot/cold/tingle Pain or no pain

Fluid flow in teeth

Poiseuille-Hagen equation

Pulpal Pressure
Increased in inflammation
V= volume P= pulpal pressure r = tubule radius l = tubule length = viscosity of fluid

V=

P r4 8 l

Decreased with local containing adrenaline

Pashley (1989) Scanning Microsc 3 161-176

Tubule morphology

Fluid flow in teeth

Tubule radius 0.8 - 2.5m (EDJ - pulp) (anatomical. Functional diameter 5-10%) Pulpal pressure 15cm H2O - 36cm H2O (low-high) Fluid viscosity Decreases from pulp to EDJ

enamel

0.8m

3m

Pulp

Michelich et al (1978) J Dent Res 57 1019-1024 Gerzina and Hume (1995) J Dent Res 74 369-373

Cavity dentine depth

If we assume viscosity and pulpal pressure remain constant relative to fluid flow at EDJ :
Radius increases Length of tubule x16 x0.5

Cavity dentine depth

If we assume viscosity and pulpal pressure remain constant relative to fluid flow at EDJ:
Radius increases Length of tubule x256 x0.25

Fluid flow increases

x32

Fluid flow increases

x1024

Tubules
Density varies between and within teeth 75,000 mm-2 coronally 30,000 mm-2 mid-root Surface area of dentine made up of tubules 1% at EDJ 22% at pulp
Schellenberg et al (1992) J Endod 18 104-109 Pashley (1989) Scanning Microsc 3 161-176