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Acute dental pain I: pulpal and dentinal pain

ABSTRACT

Oversigtsartikel Dato: 03.02.2016

Den specialiserede anatomi i pulpa-dentin-organet samt den rige pulpale innervation fra trigeminusnerven forklarer de forskellige typer af smertefølelser i en tand. En kort skarp smerte er typisk for en A-(nerve) fibermedieret smerte, imens en langvarig, bankende smerte indikerer C-(nerve) fiberaktivitet. A-fibre reagerer på termiske eller mekaniske stimuli, såsom kolde drikke eller tandbørstning, imens C-fibre hovedsagelig aktiveres ved inflammatoriske mediatorer. Således vil en dvælende smerte indikere en irreversibel pulpal inflammation. Ved pulpitis vil der opstå strukturelle ændringer i de pulpale nerver, der samtidig frigiver neuropeptider, som udløser et immunrespons: neurogen inflammation. Smertefornemmelser under pulpitis kan variere fra hypersensibilitet overfor termiske stimuli til svære dunkende og uudholdelige smerter. Smerterne kan være meddelte og ofte vanskelige at lokalisere, hvorfor diagnostik af inflammation i pulpa er en klinisk udfordring. En biofilm forstærker hypersensitivitet af eksponerede dentinoverflader, fordi de mikrobielle irritamenter kan nå pulpa gennem åbne dentintubuli, hvorved der fremkaldes inflammation. Fjernelse af biofilm reducerer isninger i tænderne, men supplerende behandling er ofte nødvendigt med det formål at opnå en reduktion af dentinens permeabilitet. Cariesekskavering samt fyldningsterapi er en tilstrækkelig behandling ved en klinisk bedømt reversibel pulpitis, hvorimod endodontisk behandling er nødvendigt, når pulpitis har nået et irreversibelt stadium.

The specialized anatomy of the pulp-dentin complex and the dense, predominantly nociceptive pulpal innervation from the trigeminal nerve explains the variety of pain sensations from this organ. Brief, sharp pain is typical of A-fibre-mediated pain, while long-lasting, dull/aching pain indicates C-fibre involvement. A-fibres react to cold or mechanical stimuli, such as cold drinks or toothbrushing, whereas C-fibres are mainly activated by inflammatory mediators. Thus, lingering pain suggests presence of irreversible pulpal inflammation. During pulpitis, structural changes of the pulpal nerves (sprouting) occur and neuropeptide release triggers an immune response; neurogenic inflammation. Pain sensations during pulpitis can range from hypersensitivity to thermal stimuli to severe throbbing. There might also be aching pain, possibly referred and often difficult to localize. Thus, diagnosis is challenging for the clinician. 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 supplemental treatment, aiming to reduce dentin permeability, is often necessary. Caries removal and filling therapy are adequate measures during reversible pulpitis if the pulp has maintained its ability to distance itself from the bacterial assault by producing reparative dentin. However, endodontic therapy is necessary when pulpitis has reached an irreversible stage.