Acute dental pain I: pulpal and dentinal pain

Abstract

The present article, a review aiming to update the reader on cur-rent knowledge on pulpal and dentinal pain, is the first in a series of articles on the theme " Pain and pain management". The specialized anatomy of the pulp-dentin complex and the dense, predominantly nociceptive pulpal innervation from the trigeminal nerve explain the variety of pain sensations from this organ. Brief, sharp pain is typical of A-fiber-mediated pain, while long-lasting, dull/aching pain indicates C-fiber involvement. A-fibers react to cold or mechanical stimuli, such as cold drinks or toothbrushing, while C-fibers are mainly activated by inflamma-tory mediators. Thus, lingering pain suggests presence of irrever-sible pulpal inflammation. During pulpitis, structural changes of the pulpal nerves (spro-uting) occur and neuropeptide release triggers an immune re-sponse; neurogenic inflammation. Pain sensations during pulpi-tis can range from hypersensitivity to thermal stimuli to severe throbbing, aching pain that can be referred and often difficult to localize making diagnosis a challenging situation for the clinici-an. Surface biofilm amplifies hypersensitivity of exposed dentin surfaces because irritants reach the pulp through open dentin tubules, producing inflammation. Removing the biofilm reduces dentin hypersensitivity but supple-mental treatment aiming to reduce dentin permeability, is often necessary. Caries removal and filling therapy is ade-quate during reversible pulpitis if the pulp has maintained its ability to distance itself from the bacterial assault by producing reparative dentin. However, endodontic the-rapy is necessary when pulpitis has reached an irreversible stage.