Effect of intermittent long-lasting electrical tooth stimulation on pulpal blood flow and immunocompetent cells: a hemodynamic and immunohistochemical study in young rat molars

Dental nerves: a neglected mediator of pulpitis

As one of the most densely innervated tissues, the dental pulp contains abundant nerve fibres, including sensory, sympathetic and parasympathetic nerve fibres. Studies in animal models and human patients with pulpitis have revealed distinct alterations in protein expression and histological appearance in all types of dental nerve fibres. Various molecules secreted by neurons, such as classical neurotransmitters, neuropeptides and amino acids, not only contribute to the induction, sensitization and maintenance of tooth pain, but also regulate non-neuronal cells, including fibroblasts, odontoblasts, immune cells and vascular endothelial cells. Dental nerves are particularly important for the microcirculatory and immune responses in pulpitis via their release of a variety of functional substances. Further, nerve fibres are found to be involved in dental soft and hard tissue repair. Thus, understanding how dental nerves participate in pulpitis could have important clinical ramifications for endodontic treatment. In this review, the roles of dental nerves in regulating pulpal inflammatory processes are highlighted and their implications for future research on this topic are discussed.

A novel combinatorial therapy with pulp stem cells and granulocyte colony-stimulating factor for total pulp regeneration

Treatment of deep caries with pulpitis is a major challenge in dentistry. Stem cell therapy represents a potential strategy to regenerate the dentin-pulp complex, enabling conservation and restoration of teeth. The objective of this study was to assess the efficacy and safety of pulp stem cell transplantation as a prelude for the impending clinical trials. Clinical-grade pulp stem cells were isolated and expanded according to good manufacturing practice conditions. The absence of contamination, abnormalities/aberrations in karyotype, and tumor formation after transplantation in an immunodeficient mouse ensured excellent quality control. After autologous transplantation of pulp stem cells with granulocyte-colony stimulating factor (G-CSF) in a dog pulpectomized tooth, regenerated pulp tissue including vasculature and innervation completely filled in the root canal, and regenerated dentin was formed in the coronal part and prevented microleakage up to day 180. Transplantation of pulp stem cells with G-CSF yielded a significantly larger amount of regenerated dentin-pulp complex compared with transplantation of G-CSF or stem cells alone. Also noteworthy was the reduction in the number of inflammatory cells and apoptotic cells and the significant increase in neurite outgrowth compared with results without G-CSF. The transplanted stem cells expressed angiogenic/neurotrophic factors. It is significant that G-CSF together with conditioned medium of pulp stem cells stimulated cell migration and neurite outgrowth, prevented cell death, and promoted immunosuppression in vitro. Furthermore, there was no evidence of toxicity or adverse events. In conclusion, the combinatorial trophic effects of pulp stem cells and G-CSF are of immediate utility for pulp/dentin regeneration, demonstrating the prerequisites of safety and efficacy critical for clinical applications.

Localization of substance P-induced upregulated interleukin-8 expression in human dental pulp explants

AIM

To localize ex vivo expression of interleukin-8 (IL-8) induced by substance P (SP) in human dental pulps.

METHODOLOGY

Intact caries-free, freshly extracted third molars (n = 20) were collected from patients (15-25 years old). The teeth were split and pulpal tissue was obtained and stored in Dulbecco's modified Eagle medium. Human dental pulp tissue explants were stimulated with SP. Expression of IL-8 in pulp explants was detected and localized by immunohistochemistry.

RESULTS

Moderated IL-8 immunoreactivities were detected mainly in the cell-rich zone in pulp tissues 12 h after tumour necrosis factor alpha (TNF-alpha) stimulation (positive controls), whereas only weak IL-8 expression was observed in tissues stimulated with SP at the same time interval. These data did not differ from those in negative controls. Increased IL-8 expression in pulp explants after 24 h of SP stimulation was noted compared with negative controls and located in fibroblast-like cells, blood vessel-associated cells and extracellular matrix in the central zone and cell-rich zone of pulp explants. Tissues stimulated with TNF-alpha for 24 h (positive controls) revealed weak IL-8 immunoreactivities with altered cell morphology.

CONCLUSIONS

Substance P induces IL-8 expression and was located in fibroblast-like pulp cells, blood vessel-associated cells and extracellular matrix of human dental explants. These data support the hypothesis that neuropeptide (SP) coordinates the modulation of pulpal inflammation via up-regulating chemokine IL-8.

An overview of the dental pulp: its functions and responses to injury

The dental pulp is a unique tissue and its importance in the long-term prognosis of the tooth is often ignored by clinicians. It is unique in that it resides in a rigid chamber which provides strong mechanical support and protection from the microbial rich oral environment. If this rigid shell loses its structural integrity, the pulp is under the threat of the adverse stimuli from the mouth, such as caries, cracks, fractures and open restoration margins, all of which provide pathways for micro-organisms and their toxins to enter the pulp. The pulp initially responds to irritation by becoming inflamed and, if left untreated, this will progress to pulp necrosis and infection. The inflammation will also spread to the surrounding alveolar bone and cause periapical pathosis. The magnitude of pulp-related problems should not be underestimated since their most serious consequence is oral sepsis, which can be life threatening, and hence correct diagnosis and management are essential. Clinicians must have a thorough understanding of the physiological and pathological features of the dental pulp as well as the biological consequences of treatment interventions.

Immunoglobulin producing cells in the rat dental pulp after unilateral sympathectomy

Recent studies show that sympathetic nerves participate in immunomodulation. We investigated the effects of unilateral sympathectomy on recruitment of cells expressing kappa and lambda (kappa and lambda) light chains in the rat dental pulp. Superior cervical ganglion was removed in experimental rats (n=10) while control rats (n=8) received sham surgery. Following perfusion 18 days later, mandibular jaws were processed for immunohistochemistry and electron microscopy. Sympathectomy results in recruitment of cells expressing kappa and lambda light chains into the dental pulp (P=0.005). Electron microscopy revealed these cells to be mainly plasma cells and Mott cells. We conclude that neural imbalance caused by unilateral sympathectomy recruits immunoglobulin producing cells in the dental pulp. Our results are in agreement with a model of immune regulation in which the sympathetic nervous system exerts a tonic regulatory effect over lymphocyte proliferation and migration.

Effect of electrical tooth stimulation on blood flow and immunocompetent cells in rat dental pulp after sympathectomy

Previous experiments show that nerves have effect on the emigration of immunocompetent cells during acute neurogenic inflammation. The present study aims to determine whether the sympathetic or sensory nerves are responsible for emigration of CD43+ and I-A antigen-expressing cells in the dental pulp after electrical tooth stimulation. Wistar rats were used. Experimental rats (n = 6) had the right superior cervical ganglion removed (SCGx), whereas control rats (n = 6) had sham surgery. Fourteen days later, electrical stimulation of the right maxillary 1st molar was performed in both groups for 20-25 s every 5th min for a total period of 4 h. Changes in pulpal blood flow (PBF) were recorded with a laser Doppler flowmeter. All rats were transcardiacally perfused and processed for immunohistochemistry using antibodies against neuropeptides and immune cells. Intermittent electrical stimulation consistently increased PBF and depleted sympathetic and sensory neuropeptides in the dental pulp. The increase in PBF gradually decreased and approached control values at the end of the 4 h stimulation period. A significant increase in the number of I-A antigen-expressing dendritic cells was found in both the SCGx (P < 0.001) and control rats (P < 0.007). In contrast, tooth stimulation did not increase the number of CD43+ cells in the SCGx rats compared to the unstimulated contralateral control molar. Significantly more CD43+ PMN cells (P < 0.01) were found in the control rats after stimulation. It is concluded that stimulation of sympathetic nerves causes recruitment of CD43+ PMN cells, whereas stimulation of sensory nerves causes emigration of I-A antigen-expressing dendritic cells in the dental pulp.

Vascular and cellular responses to pro-inflammatory stimuli in rat dental pulp

Dental pulp reactivity to various pro-inflammatory stimuli was independently evaluated in rats in terms of a vascular permeability increase and leukocyte recruitment. Substance P, calcitonin-gene related peptide (CGRP) and prostaglandin E(2) (in the picomol range) were applied to the exposed pulp from anesthetised animals and the plasma extravasation measured by the Evans blue content in the tissue following 10 min of administration. Leukocyte recruitment was evaluated morphometrically by counting the cell number present in serial sections of 1:3 4 microm pulp tissue 6 h after bacterial endotoxin (LPS; 0.06-1.2 microg/site) administration. Increase in pulp vascular permeability and cellular recruitment due to the injection of mentioned mediators in the skin or LPS in the peritoneal cavity were used as positive controls. Increase in vascular permeability in the pulp occurred in the same dose-range as observed in the skin, being CGRP the most active substance in both cases. However, it was necessary a higher dose of LPS (1.2 microg) to induce a similar cell recruitment in the pulp as that observed in the rat peritoneal cavity (0.3 microg). These data indicate that dental pulp reactivity presents the same pattern of increase in vascular permeability to other tissues in the rat, being CGRP the most potent mediator in this respect. In addition, they suggest the presence of CGRP receptors in the dental pulp. However, an adequate leukocyte recruitment response to bacterial endotoxin was not mounted, suggesting a deficiency in adhesion molecules in blood vessels in the rat dental pulp.

Role of substance P and calcitonin gene-related peptide in the regulation of interleukin-8 and monocyte chemotactic protein-1 expression in human dental pulp

AIM

To determine whether leucocyte infiltration during neurogenic inflammation in the pulp is regulated by neuropeptides via inducing the release of proinflammatory chemokines interleukin-8 (IL-8) and monocyte chemotactic protein-1 (MCP-1) from human dental pulp.

METHODOLOGY

Cultured primary pulp cells and pulp tissue explants were stimulated with substance P (SP) and/or calcitonin gene-related peptide (CGRP). IL-8 or MCP-1, secreted from cultured cells or produced in pulp explants, was analysed by enzyme-linked immunosorbent assay.

RESULTS

Substance P induced IL-8 secretion from cultured pulp cells (approximately threefold increase over control, P < 0.05) and from pulp tissue explants (two- to three fold). SP only minimally to moderately induced MCP-1 (approximately two fold) in cultured pulp cells. While MCP-1 induction in cultured pulp cells was detected after 24 h of SP stimulation, no induction was observed in pulp tissue. CGRP did not induce IL-8, but moderately increased MCP-1 production (approximately three fold) in cultured pulp cells. There was no synergistic induction of MCP-1 by SP plus CGRP stimulation of pulp cells.

CONCLUSIONS

Substance P is a stronger inducer of IL-8 production in dental pulp than CGRP. IL-8 is more strongly induced than MCP-1 by SP, suggesting a more important role for IL-8 than MCP-1 in leucocyte infiltration during neurogenic inflammation in dental pulp.

Effects of sympathectomy on experimentally induced pulpal inflammation and periapical lesions in rats

The role of sympathetic nerves in bone physiology is largely unknown. Recent studies have shown a correlation between sympathectomy and bone remodeling. The present experiments were aimed to study the effects of unilateral sympathectomy on bilateral experimentally induced pulpitis and periapical lesions in the rat maxilla and mandible. Adult male Sprague-Dawley rats were used. Experimental rats (n=11) had the right superior cervical ganglion surgically removed (SCGx) and control rats (n=5) had sham surgery. Pulpal inflammation and periapical bone lesions in the maxilla and mandible were created 14 days later in both experimental and control rats by exposing the dental pulp in the first and second molars and leaving them open to the oral microflora. The rats were perfused 20 days thereafter and the jaws processed for immunohistochemistry with neuropeptide Y (NPY) and ED1 as primary antibodies. Sympathectomy resulted in an almost complete loss of NPY-immunoreactive (IR) fibers in the right SCGx jaws. In the non-sympathectomized (non-SCGx) left side and in the control rats, sprouting of NPY-IR fiber was observed in the inflamed pulp tissue adjacent to reparative dentin formation and in the apical periodontal ligament of the partially necrotic first molars. Significantly more ED1-IR osteoclasts were found in the resorptive lacunae lining the periphery of the periapical lesions on the SCGx side compared with the non-SCGx side (P<0.04) and the controls (P<0.03). The size of the periapical lesions were larger on the SCGx side compared with the non-SCGx side (P<0.03) in the mandible, but not in the maxilla. We conclude that inflammation causes sprouting of NPY-IR nerve fibers and that unilateral removal of the SCG increases both the area of the periapical lesions and the number of osteoclasts in the inflamed region.

Dental neuroplasticity, neuro-pulpal interactions, and nerve regeneration

This review covers current information about the ability of dental nerves to regenerate and the role of tooth pulp in recruitment of regenerating nerve fibers. In addition, the participation of dental nerves in pulpal injury responses and healing is discussed, especially concerning pulp regeneration and reinnervation after tooth replantation. The complex innervation of teeth is highly asymmetric and guided towards specific microenvironments along blood vessels or in the crown pulp and dentin. Pulpal products such as nerve growth factor are distributed in the same asymmetric gradients as the dentinal sensory innervation, suggesting regulation and recruitment of those nerve fibers by those specific factors. The nerve fibers have important effects on pulpal blood flow and inflammation, while their sprouting and cytochemical changes after tooth injury are in response to altered pulpal cytochemistry. Thus, their pattern and neuropeptide intensity are indicators of pulp status, while their local actions continually affect that status. When denervated teeth are injured, either by pulp exposure on the occlusal surface or by replantation, they have more pulpal necrosis than occurs for innervated teeth. However, small pulp exposures on the side of denervated crowns or larger lesions in germ-free animals can heal well, showing the value of postoperative protection from occlusal trauma or from infection. Current ideas about dental neuroplasticity, neuro-pulpal interactions, and nerve regeneration are related to the overall topics of tooth biomimetics and pulp/dentin regeneration.

NK1, NK2, NK3 and CGRP1 receptors identified in rat oral soft tissues, and in bone and dental hard tissue cells

The distribution of the tachykinin receptors neurokinin-1 (NK1), neurokinin-2 (NK2) and neurokinin-3 (NK3), and the calcitonin gene-related peptide-1 (CGRP1) receptor were examined in rat teeth and tooth-supporting tissues by immunohistochemical methods and light and confocal microscopy. Western blot analysis was performed to identify the NK1- and the CGRP1-receptor proteins in the dental pulp. The results showed that odontoblasts and ameloblasts, cementoblasts and cementocytes, osteoblasts and osteocytes are all supported with the tachykinin receptors NK1 and NK2, but a distinct, graded cellular labeling pattern was demonstrated. The ameloblasts were also positive for CGRP1 receptor. Blood vessels in oral tissues expressed the tachykinin receptors NK1, NK2 and NK3, and the CGRP1 receptor. Both gingival and Malassez epithelium were abundantly supplied by NK2 receptor. Pulpal and periodontal fibroblasts demonstrated NK1 and NK2 receptors. Western blot analysis identified both the NK1- and the CGRP1-receptor proteins in the dental pulp. These results clearly indicate that the neuropeptides substance P, neurokinin A, neurokinin B and CGRP, released from sensory axons upon stimulation, directly modulate the function of the different types of bone and dental hard tissue cells, and regulate functions of blood vessels, fibroblasts and epithelial cells in oral tissues.

Immunohistochemical evidence for ATP receptors in human dental pulp

Evidence is accumulating which supports a role for ATP in the initiation of pain by acting on P2X receptors, in particular P2X3, expressed on nociceptive afferent nerve terminals. To investigate whether this receptor plays a role in dental pain, we studied the presence and distribution of P2X3 receptors in human dental pulp, and their co-localization with other neural markers. Pulps were removed from extracted third molars and immunohistochemically stained with an antibody against P2X3 receptors. P2X3 immunoreactive (-ir) nerve fibers were detected in the main body of the pulp, in the sub-odontoblastic plexus of Raschkow, and within the odontoblastic area. Co-localization of the P2X3-ir neurons with neurofilament protein (NF) showed that the majority of the fibers were positive for both NF and P2X3. Double labeling with isolectin B4 (IB4) showed that all P2X3-ir neurons also bind IB4. We conclude that P2X3 receptors are present on both myelinated and unmyelinated nerve fibers in human dental pulp and may play a role in dental pain mechanisms.

Factors influencing pulpal response to cavity restorations

OBJECTIVES

The purposes of this retrospective work were: (1) to determine the relative importance of bacteria on cavity walls, remaining dentin thickness and post-operative time on pulpal inflammation after cavity restoration; (2) to compare the respective influences of bacterial microleakage and the restorative material itself on pulp reaction severity.

METHODS

317 class V cavities, in human bicuspids scheduled for extraction for orthodontic reasons were used for this study. Nine different materials were included. The severity of the pulpal reaction was ranked on hematoxylin/eosin stained sections according to FDI standards. The further parameters recorded were: (1) the presence or absence of bacteria on the cavity walls was noted on Brown and Brenn stained sections; (2) the remaining dentin thickness was measured and the teeth classified into three groups (< 500, 500-1000, > 1000 microns); and (3) the post-operative delay before extraction was recorded and classified as short time (< 5 weeks) or long time (> 5 weeks). Three two-way analyses of variance (ANOVA) followed by Kruskall and Wallis tests evaluated the influence of the three parameters on pulpal reaction severity. The third ANOVA also compared pulpal reactions under the different materials when the teeth were pooled, on bacteria free teeth and on bacteria contaminated teeth.

RESULTS

The first ANOVA ranked by decreasing order of importance: the presence of bacteria (p < 0.0001), the remaining dentin thickness (p = 0.02) and the post-operative delay (p = 0.04). The second ANOVA showed no difference among the restorative materials when bacteria were present on the cavity walls.

SIGNIFICANCE

The presence of bacteria on the cavity walls is the main factor influencing pulpal reaction under restorative materials, but does not account for 100% of the cases.

Dental injury models: experimental tools for understanding neuroinflammatory interactions and polymodal nociceptor functions

Recent research has shown that peripheral mechanisms of pain are much more complex than previously thought, and they differ for acutely injured normal tissues compared with chronic inflammation or neuropathic (nerve injury) pain. The purpose of the present review is to describe uses of dental injury models as experimental tools for understanding the normal functions of polymodal nociceptive nerves in healthy tissues, their neuroinflammatory interactions, and their roles in healing. A brief review of normal dental innervation and its interactions with healthy pulp tissue will be presented first, as a framework for understanding the changes that occur after injury. Then, the different types of dental injury that allow gradation of the extent of tissue damage will be described, along with the degree and duration of inflammation, the types of reactions in the trigeminal ganglion and brainstem, and the type of healing. The dental injury models have some unique features compared with neuroinflammation paradigms that affect other peripheral tissues such as skin, viscera, and joints. Peripheral inflammation models can all be contrasted to nerve injury studies that produce a different kind of neuroplasticity and neuropathic pain. Each of these models provides different insights about the normal and pathologic functions of peripheral nerve fibers and their effects on tissue homeostasis, inflammation, and wound healing. The physical confinement of dental pulp and its innervation within the tooth, the high incidence of polymodal A-delta and C-fibers in pulp and dentin, and the somatotopic organization of the trigeminal ganglion provide some special advantages for experimental design when dental injury models are used for the study of neuroinflammatory interactions.

Effects of alternating and direct electrical current application on the odontoblastic layer in human teeth: an in vitro study

AIM

The aim of this study was to investigate the influence of a low intensity alternating current on the odontoblasts and odontoblast layer and compare this with the effects of a direct current.

METHODOLOGY

Teeth extracted for orthodontic reasons were immersed in physiological saline stabilized with thymol crystals. Within 1 h of extraction, an alternating or direct current was applied on the crown in the direction of the apex of the tooth for 120-360 s. The current doses were 12, 30, 60, 600, 1800, 3600, 7200, 24,000 and 144,000 microC. The teeth were fixed in Bouin or Baker fluids, the pulps removed, dehydrated and immersed in paraffin, then sectioned, stained with haematoxylin and eosin, and studied under a light microscope.

RESULTS

Neither direct nor alternating current, similar to that applied in electrical caries diagnosis caused histological changes in the odontoblasts.

CONCLUSIONS

There was no difference between direct and low intensity alternating current in the response of the odontoblast.

Expression of calcitonin gene-related peptide-1 receptor mRNA in human tooth pulp and trigeminal ganglion

Numerous nerve fibres containing calcitonin gene-related peptide (CGRP) were found by immunocytochemistry in human molar pulp. These nerves were often seen around small blood vessels and as free endings without vascular contact. In the trigeminal ganglion a large number of CGRP-immunoreactive nerve-cell bodies, mostly of small to medium size, was encountered. Reverse transcriptase-polymerase chain reaction, using specific sense and antisense primers, detected mRNA expression of the human CGRP1 receptor in the pulp tissue and the trigeminal ganglion. Thus, both CGRP-containing nerve fibres and CGRP1 receptor mRNA are present in human tooth pulp, where they may be involved in the regulation of vascular tone and other local reactions to injury.