Lesions of the mid-spinal trigeminal complex are effective in producing perioral thermal hypoalgesia

Peripheral Purinergic Modulation in Pediatric Orofacial Inflammatory Pain Affects Brainstem Nitroxidergic System: A Translational Research

Physiology of orofacial pain pathways embraces primary afferent neurons, pathologic changes in the trigeminal ganglion, brainstem nociceptive neurons, and higher brain function regulating orofacial nociception. The goal of this study was to investigate the nitroxidergic system alteration at brainstem level (spinal trigeminal nucleus), and the role of peripheral P2 purinergic receptors in an experimental mouse model of pediatric inflammatory orofacial pain, to increase knowledge and supply information concerning orofacial pain in children and adolescents, like pediatric dentists and pathologists, as well as oro-maxillo-facial surgeons, may be asked to participate in the treatment of these patients. The experimental animals were treated subcutaneously in the perioral region with pyridoxalphosphate-6-azophenyl-2′,4′-disulphonic acid (PPADS), a P2 receptor antagonist, 30 minutes before formalin injection. The pain-related behavior and the nitroxidergic system alterations in the spinal trigeminal nucleus using immunohistochemistry and western blotting analysis have been evaluated. The local administration of PPADS decreased the face-rubbing activity and the expression of both neuronal and inducible nitric oxide (NO) synthase isoforms in the spinal trigeminal nucleus. These results underline a relationship between orofacial inflammatory pain and nitroxidergic system in the spinal trigeminal nucleus and suggest a role of peripheral P2 receptors in trigeminal pain transmission influencing NO production at central level. In this way, orofacial pain physiology should be elucidated and applied to clinical practice in the future.

Peripheral purinergic receptor modulation influences the trigeminal ganglia nitroxidergic system in an experimental murine model of inflammatory orofacial pain

ATP plays an important role as an endogenous pain mediator generating and/or modulating pain signaling from the periphery to the central nervous system. The aim of this study was to analyze the role of peripheral purinergic receptors in modulation of the nitroxidergic system at a trigeminal ganglia level by monitoring changes in nitric oxide synthase isoforms. We also evaluated Fos-positive neurons in brainstem (spinal trigeminal nucleus) and pain-related behavior. We found that local administration of the P2 purinergic receptor antagonist pyridoxalphosphate-6-azophenyl-2',4'-disulphonic acid (PPADS) decreased face-rubbing activity, nitric oxide synthase isoform expression in trigeminal ganglia, and Fos expression in spinal trigeminal nucleus after subcutaneous injection of formalin. These results suggest a role for peripheral P2 purinergic receptors in orofacial pain transmission through modulation of the nitroxidergic system. .

Expression of transient receptor potential ankyrin 1 (TRPA1) in the rat trigeminal sensory afferents and spinal dorsal horn

Transient receptor potential ankyrin 1 (TRPA1), responding to noxious cold and pungent compounds, is implicated in the mediation of nociception, but little is known about the processing of the TRPA1-mediated nociceptive information within the trigeminal sensory nuclei (TSN) and the spinal dorsal horn (DH). To address this issue, we characterized the TRPA1-positive (+) neurons in the trigeminal ganglion (TG) and investigated the distribution of TRPA1(+) afferent fibers and their synaptic connectivity within the rat TSN and DH by using light and electron microscopic immunohistochemistry. In the TG, TRPA1 was expressed in unmyelinated and small myelinated axons and also occasionally in large myelinated axons. Many TRPA1(+) neurons costained for the marker for peptidergic neurons substance P (26.8%) or the marker for nonpeptidergic neurons IB4 (44.5%). In the CNS, small numbers of axons and terminals were immunopositive for TRPA1 throughout the rostral TSN, in contrast to the dense network of positive fibers and terminals in the superficial laminae of the trigeminal caudal nucleus (Vc) and DH. The TRPA1(+) terminals contained clear round vesicles, were presynaptic to one or two dendrites, and rarely participated in axoaxonic contacts, suggesting involvement in relatively simple synaptic circuitry with a small degree of synaptic divergence and little presynaptic modulation. Immunoreactivity for TRPA1 was also occasionally observed in postsynaptic dendrites. These results suggest that TRPA1-dependent orofacial and spinal nociceptive input is processed mainly in the superficial laminae of the Vc and DH in a specific manner and may be processed differently between the rostral TSN and Vc.

Differential activation of the human trigeminal nuclear complex by noxious and non-noxious orofacial stimulation

There is good evidence from animal studies for segregation in the processing of non-nociceptive and nociceptive information within the trigeminal brainstem sensory nuclear complex. However, it remains unknown whether a similar segregation occurs in humans, and a recent tract tracing study suggests that this segregation may not exist. We used functional magnetic resonance imaging (fMRI) to define and compare activity patterns of the trigeminal brainstem nuclear complex during non-noxious and noxious cutaneous and non-noxious and noxious muscle orofacial stimulation in humans. We found that during cutaneous pain, signal intensity increased within the entire rostrocaudal extent of the spinal trigeminal nucleus (SpV), encompassing the ipsilateral oralis (SpVo), interpolaris (SpVi) and caudalis (SpVc) subdivisions. In contrast, muscle pain did not activate SpVi, but instead activated a discrete region of the ipsilateral SpVo and SpVc. Further, muscle noxious stimulation activated a region of the ipsilateral lateral pons in the region of the trigeminal principal sensory nucleus (Vp). Innocuous orofacial stimulation (lip brushing) also evoked a significant increase in signal intensity in the ipsilateral Vp; however, non-noxious muscle stimulation showed no increase in signal in this area. The data reveal that orofacial cutaneous and muscle nociceptive information and innocuous cutaneous stimulation are differentially represented within the trigeminal nuclear complex. It is well established that cutaneous and muscle noxious stimuli evoke different perceptual, behavioural and cardiovascular changes. We speculate that the differential activation evoked by cutaneous and muscle noxious stimuli within the trigeminal sensory complex may contribute to the neural basis for these differences.

Central sensitization induced in thalamic nociceptive neurons by tooth pulp stimulation is dependent on the functional integrity of trigeminal brainstem subnucleus caudalis but not subnucleus oralis

We have previously demonstrated that application of the inflammatory irritant mustard oil (MO) to the rat molar tooth pulp induces central sensitization in nociceptive neurons within the contralateral ventroposterior medial (VPM) nucleus and posterior nuclear group (PO) of the thalamus as well as brainstem subnucleus caudalis (Vc) and subnucleus oralis (Vo). Since Vc and Vo are important relays of pulp afferent input to thalamus, the aim of this study was to test if local application of the synaptic blocker CoCl2 to Vc or Vo influences the pulp-induced thalamic central sensitization. The activity of 32 nociceptive-specific (NS) neurons within the rat VPM and immediately adjacent PO was recorded. Spontaneous activity, mechanoreceptive field (RF), mechanical activation threshold and evoked responses to graded mechanical stimuli were assessed before and after MO application to the pulp. MO application evoked immediate but short-lasting neuronal discharges in 21 of the 32 NS neurons tested, as well as central sensitization reflected in significant and long-lasting (> 60 min) RF expansion, decrease in activation threshold, and increase in graded pinch-evoked responses in all 32 NS neurons. CoCl2 applied to the ipsilateral Vc significantly attenuated these pulp-induced changes for 20 min or more. In contrast, CoCl2 applied to the ipsilateral Vo did not reverse this MO-induced central sensitization. Isotonic saline applied to Vc or Vo was also ineffective. These findings indicate that central sensitization induced in nociceptive neurons within VPM and PO by noxious stimulation of the tooth pulp is dependent upon the functional integrity of Vc but not Vo.

Synaptic organization of tooth pulp afferent terminals in the rat trigeminal sensory nuclei

Previous studies provide evidence that a structure/function correlation exists in the distinct zones of the trigeminal sensory nuclei. To evaluate this relationship, we examined the ultrastructure of afferent terminals from the tooth pulp in the rat trigeminal sensory nuclei: the principalis (Vp), the dorsomedial part of oral nucleus (Vdm), and the superficial layers of caudalis (Vc), by using transganglionic transport of wheat germ agglutinin conjugated to horseradish peroxidase (WGA-HRP). A total of 93 labeled boutons were serially sectioned, in which some sections were incubated with gamma-aminobutyric acid (GABA) antiserum. Almost all labeled boutons formed asymmetric contact with nonprimary dendrites, in which more than half of labeled boutons in the Vc made synapses with their spines. The labeled boutons could be divided into two types on the basis of numbers of dense-cored vesicles (DCVs) in a boutons: S-type and DCV-type. Almost all labeled boutons in the Vp and Vdm were S-type, whereas two types were distributed evenly in the Vc. In contrast to DCV-type boutons, the S-type was frequently postsynaptic to unlabeled axon terminals containing a mixture of round, oval, and flattened vesicles (p-endings) and forming symmetrical synapses. Most p-endings examined were immunoreactive to GABA. The frequency of axoaxonic contacts was higher for labeled boutons in the Vp than in the Vdm and Vc. These results suggest that the three structures of trigeminal sensory nuclei serve distinct functions in nociceptive processing.

Central sensitization of nociceptive neurons in trigeminal subnucleus oralis depends on integrity of subnucleus caudalis

Our recent studies have shown that application to the tooth pulp of the inflammatory irritant mustard oil (MO) produces a prolonged (>40 min) "central sensitization" reflected in neuroplastic changes in the mechanoreceptive field (RF) and response properties of nociceptive brain stem neurons in subnuclei oralis (Vo) and caudalis (Vc) of the trigeminal spinal tract nucleus. In view of the previously demonstrated ascending modulatory influence of Vc on Vo, our aim was to determine whether the Vo neuroplastic changes induced by MO application to the tooth pulp depend on an ascending influence from Vc. In chloralose/urethan-anesthetized rats, MO application to the pulp produced significant increases in Vo nociceptive neuronal orofacial RF size and responses to mechanical noxious stimuli that lasted as long as 40-60 min. These changes were not affected by vehicle (saline) microinjected into Vc at 20 min after MO application, but 0.3 microl of a 5 mM CoCl(2) solution microinjected into the ipsilateral Vc produced a reversible blockade of the MO-induced Vo neuroplastic changes. A similar volume and concentration of CoCl(2) solution injected into subnucleus interpolaris of the trigeminal spinal tract nucleus did not affect the MO-induced neuroplastic changes in Vo. These findings indicate that inflammatory pulp-induced central sensitization in Vo is dependent on the functional integrity of Vc.

Neuroplasticity Induced by Tooth Pulp Stimulation in Trigeminal Subnucleus Oralis Involves NMDA Receptor Mechanisms

We have recently demonstrated that application of the mustard oil (MO), a small-fiber excitant and inflammatory irritant, to the rat maxillary molar tooth pulp induces significant increases in jaw muscle electromyographic (EMG) activity and neuroplastic changes in trigeminal (V) subnucleus caudalis. Since subnucleus oralis (Vo) as well as caudalis receives projections from molar pulp afferents and is also an integral brain stem relay of afferent input from orofacial structures, we tested whether MO application to the exposed pulp induces neuroplastic changes in oralis neurons and whether microinjection of MK-801, a noncompetitive NMDA antagonist, into the Vo influences the pulp/MO-induced neuroplastic changes in chloralose/urethan-anesthetized rats. Single neuronal activity was recorded in Vo, and neurons classified as low-threshold mechanoreceptive (LTM), wide dynamic range (WDR), nociceptive-specific (NS), deep (D), or skin/mucosa and deep (S + D). The spontaneous activity, mechanoreceptive field (RF) size, mechanical threshold, and response to suprathreshold mechanical stimuli applied to the neuronal RF were assessed prior to and throughout a 40- to 60-min period after MO application to the maxillary molar pulp. In animals pretreated with saline microinjection (0.3 μl) into the Vo, MO application to the pulp produced a significant increase in spontaneous activity, expansion of the pinch or deep RF, decrease in the mechanical threshold, and increase in response to suprathreshold mechanical stimuli of the nociceptive (WDR, NS, and S + D) neurons except for those nociceptive neurons having their RF only in the intraoral region. The pulpal application of MO did not produce any significant neuroplastic changes in LTM neurons. Furthermore, in animals pretreated with MK-801 microinjection (3 μg/0.3 μl) into the Vo, MO application to the pulp did not produce any significant changes in the RF and response properties of nociceptive neurons. In other animals pretreated with saline (0.3 μl) or MK-801 (3 μg/0.3 μl) microinjected into the Vo, mineral oil application to the pulp did not produce any significant changes in RF and response properties of nociceptive neurons. These findings indicate that the application of MO to the tooth pulp can induce significant neuroplastic changes in oralis nociceptive neurons and that central NMDA receptor mechanisms may be involved in these neuroplastic changes.

Effects of lesions in the trigeminal oralis and caudalis subnuclei on different orofacial nociceptive responses in the rat

Behavioural responses to two different orofacial noxious stimulations were analysed following lesion of spinal trigeminal subnucleus oralis (Sp5O) in the rat. Lesions were obtained by intranuclear microinjections of quinolinic acid (0.4 microliter of 60 nmol/microliter solution). The control groups received microinjection of saline. Noxious stimulation was a subcutaneous injection of formalin into the upper lip or electrical stimulation of the tooth pulp. The measured behavioural responses were duration of rubbing induced by the formalin injection and thresholds of the jaw-opening reflex (JOR), head rotation (HR) and face rubbing (FR) evoked by the pulp stimulation. In addition, formalin injection was also performed in two groups of rats that had received intranuclear injection of quinolinic acid or saline into rostral subnucleus caudalis (Sp5C). Rubbing duration was not significantly modified by the lesion of Sp5O, whereas a significant decrease occurred after the lesion of rostral Sp5C. After the lesion of Sp5O, an increase in the threshold of JOR was observed whereas the thresholds of HR and FR were not significantly modified. These results suggest that Sp5O is not necessary for the processing and relay of nociceptive inputs triggered by intense stimulations of oral and perioral areas. However further experiments are needed to reconcile these results with the relevant data obtained from cell recording experiments which indicate the existence, in Sp5O, of neuronal activities related to the sensory discriminative aspect of intense nociception.

Caudal portions of the spinal trigeminal complex are necessary for autonomic responses and display Fos-like immunoreactivity after corneal stimulation in the cat

Corneal input to the spinal trigeminal nucleus (Vsp) was assessed by examining Fos-like immunoreactivity (Fos-LI) after chemical irritant stimulation by mustard oil in chloralose-anesthetized cats. The distribution of Fos-LI within the ipsilateral Vsp was bimodal: a dominant group of cells within the superficial laminae at caudal levels of subnucleus caudalis and a second group of cells within the ventrolateral pole of Vsp at obex levels and within the adjacent interstitial islands. Few Fos-positive cells were seen within the Vsp rostral to the mid-portion of subnucleus interpolaris or within the contralateral Vsp. To assess the involvement of caudal portions of the Vsp in mediating the adrenal and autonomic responses to corneal stimulation, mustard oil was applied before and after lidocaine blockade of the Vsp at obex levels in a second group of cats. Corneal stimulation alone increased significantly (P < 0.001) the adrenal secretion of catecholamines, adrenal blood flow, mean arterial pressure and heart rate. With the exception of heart rate, the adrenal and autonomic responses to mustard oil were greatly attenuated or abolished by lidocaine blockade of the ipsilateral Vsp at the level of the obex, a region that displayed a high number of Fos-positive cells after corneal stimulation. These results indicate that neurons within the Vsp at or more caudal than the level of the obex process chemical irritant input from the cornea and are necessary for corneal-evoked changes in adrenal and autonomic function.

Microinjections of glutamate within trigeminal subnucleus interpolaris alters adrenal and autonomic function in the cat

The influence of rostral portions of the trigeminal sensory complex on adrenal and autonomic function was assessed by microinjections of L-glutamate (500 or 5 mM, 100 nl) directed at subnucleus interpolaris (Vi) or at the nucleus principalis/subnucleus oralis level (Vp/Vo) in chloralose-anesthetized cats. Microinjections of glutamate (500 mM) within Vi evoked prompt (by +1 min) dose-related increases in the adrenal secretion of epinephrine (+11.4 +/- 2.5 ng/min, P < 0.001), adrenal blood flow (+0.19 +/- 0.06 ml/min, P < 0.05), mean arterial pressure (+6.6 +/- 3.0 mmHg, P < 0.025) and heart rate (+8.0 +/- 2.7 beats/min, P < 0.01, n = 16). Microinjections of lower doses of L-glutamate (5 mM, n = 7) within Vi had no effect. Microinjections of 500 mM glutamate within VP/Vo (n = 15) or within the spinal trigeminal tract (n = 13) had no consistent effect on adrenal or autonomic function. Plasma concentrations of ACTH were not altered significantly by glutamate regardless of dose or of the site of injection. The results suggest that local release of glutamate within Vi, but not within Vp/Vo, influences adrenal and autonomic function. Together with previous results obtained after injections of glutamate within subnucleus caudalis, these data indicate that glutaminergic input to both Vi and to more caudal portions of the spinal trigeminal nucleus contribute to the control of autonomic function such as that which often accompanies trigeminal nociception.

Physiological properties and morphological characteristics of cutaneous and mucosal mechanical nociceptive neurons with A-delta peripheral axons in the trigeminal ganglia of crotaline snakes

Primary A-delta nociceptive neurons in the trigeminal ganglia of immobilized crotaline snakes were examined by intrasomal recording and injection of horseradish peroxidase in vivo. Thirty-four neurons supplying the oral mucosa or facial skin were identified as A-delta nociceptive neurons which responded exclusively to noxious mechanical stimuli and had a peripheral conduction velocity ranging from 2.6 to 15.4 m/s. These neurons were subdivided into a fast-conducting type (FC-type) and a slowly conducting type (SC-type). Neurons of both types had a receptive field limited to a single spot which responded to pin prick stimulus with a threshold of more than 5 g. The FC-type neurons had a narrow spike followed by a shorter after-hyperpolarization. In contrast, SC-type neurons exhibited a broad spike with a hump on the falling phase and a longer after-hyperpolarization. The diameters of the stem, central and peripheral axons of the FC-type neurons were significantly thicker than those of the SC-type neurons, but there was no statistical difference in the soma size of the two types. Central axons of both types of neurons were thinner than their stem and peripheral axons. Dichotomizing fibers of peripheral axons were observed within the ganglion on 3 neurons. Central axons of the FC-type neurons terminated ipsilaterally in the nucleus principalis, the subnucleus oralis, interpolaris and caudalis and the interstitial nucleus, whereas those of the SC-type neurons generally projected only to the caudal half of the subnucleus interpolaris, subnucleus caudalis and interstitial nucleus ipsilaterally. The present data showed for the first time the physiological and morphological heterogeneity of the primary trigeminal A-delta nociceptive neurons and revealed that the trigeminal nucleus principalis and all the subdivisions of the trigeminal descending nucleus are involved in nociception as relay nuclei, but the subnucleus caudalis and the caudal half subnucleus interpolaris are the essential relay sites of the primary nociceptive afferents supplying the oral mucosa and facial skin. The interstitial nucleus also appears to play an important role in orofacial nociception.

Stimulation of craniofacial muscle afferents induces prolonged facilitatory effects in trigeminal nociceptive brain-stem neurones

Stimulation of small-diameter afferents supplying deep tissues has been shown to increase the excitability of spinal cord neurones responding to cutaneous afferent inputs. This facilitation has been implicated as integral central mechanisms of deep pain that may contribute to the tenderness and spread and/or referral of pain following injury of deep tissues. In view of the recent documentation of deep craniofacial afferent inputs, as well as cutaneous afferent inputs to the trigeminal (V) spinal tract nucleus, we wished to determine the effects of deep inputs excited by the small-fibre irritant mustard oil on trigeminal nociceptive neurones. The extracellular activity of single brain-stem neurones was recorded in subnuclei caudalis and oralis of the V spinal tract nucleus of anaesthetized rats. The neurones were classified as low-threshold mechanosensitive (LTM), wide dynamic range (WDR) and nociceptive specific (NS) on the basis of their cutaneous mechanoreceptive field properties and their responses evoked by electrical stimulation of their cutaneous afferent inputs. Injection of 5% mustard oil (2-5 microliters) into the deep masseter muscle produced a facilitatory effect in 12 of 27 nociceptive neurones tested in caudalis and in 5 of 12 nociceptive neurones in oralis. This effect was reflected in an expansion of the cutaneous mechanoreceptive field, an increase in spontaneous activity or an increase in responsivity to electrical stimulation of cutaneous afferent inputs to the neurones. The facilitation was reversible and typically became apparent within 3-5 min of the injection, reached its peak at 5-10 min, and lasted for 20-30 min.(ABSTRACT TRUNCATED AT 250 WORDS)

Synaptic substrates for enkephalinergic and serotoninergic interactions with dental primary afferent terminals in trigeminal subnucleus interpolaris: an immunocytochemical study using peroxidase and colloidal gold

Pain processing in the trigeminal complex has been thought to reside primarily in the spinal subnucleus caudalis (Vc). However, trigeminal tractotomies eliminating primary afferent input to Vc and severance of secondary trigemino-thalamic fibers from Vc do not disturb pain perception from the central face and oral cavity. Furthermore, large numbers of neurons that are highly responsive to noxious stimuli and suppressed by inputs from the periaqueductal gray and raphe complex have been identified in subnuclei interpolaris (Vi) and oralis (Vo). Therefore, the purpose of this study was to assess the distribution and spatial arrangements of nociceptive modulatory transmitters with nociceptive afferents and trigemino-thalamic relay cells in the rostral portion of the spinal trigeminal nuclear complex. The dental pulp contains predominantly nociceptors that project to all three subdivisions of the trigeminal spinal complex. These projections were visualized by anterograde transganglionic transport of horseradish peroxidase or by degeneration following administration of toxic ricin to the pulp chambers. The spatial arrangements of dental primary afferents with enkephalinergic (ENK) and serotoninergic (5HT) inputs was then assessed by employing avidin-biotin peroxidase and protein-A colloidal gold double-labeling immunocytochemistry. Trigemino-thalamic relay cells were also labeled by retrograde transport of HRP after stereotaxic injections into the ventrobasal thalamus. ENK and 5HT immunoreactivity was found in the ventrolateral quadrant and lateral margin of Vi, together with the adjacent interstitial nucleus (IN). This activity extended from the caudal pole of Vi and the periobex region, where it was most dense, rostrally to a position approximately 2.9 mm from the Obex. Neither ENK nor 5HT immunoreactivity was observed in Vo. Primary dental afferents projected into the ventromedial quadrant of rostral Vi and were found in the ventrolateral quadrant and dorsal aspect of the subnucleus farther caudally. They appeared as simple boutons with single contacts or as larger, sometimes scalloped terminals that formed multiple contacts. Postsynaptic elements were usually small dendritic profiles, although relay cell somata rarely received primary afferent inputs. Many primary afferents entered areas of synaptic clustering and contacted enkephalinergic dendrites, some of which were also postsynaptic to serotoninergic synapses. Alternatively, primary afferents contacted unlabeled processes that were also postsynaptic to the enkephalinergic element to form a triad arrangement. The least common occurrence was axo-axonic contacts in which enkephalinergic synapses were presynaptic to primary afferents. Both enkephalinergic and serotoninergic synaptic categories displayed round vesicles and generally formed asymmetric junctions.(ABSTRACT TRUNCATED AT 400 WORDS)

The rostral part of the trigeminal sensory complex is involved in orofacial nociception

Single units responsive to noxious mechanical stimulation of orofacial receptive fields were recorded within the ventrobasal complex of the rat thalamus. The induced activities were compared before and after deafferentation of the subnucleus caudalis by a trigeminal tractotomy performed at the obex level. The receptive fields activated by noxious stimulation were classified as 'oral' when included in the oral, perioral or paranasal areas, and as 'facial' when included in facial regions distant from the oral cavity. After tractotomy, the unit responses to noxious stimulation of an oral field remained unchanged in 8 cases, decreased in 3 cases, and were suppressed in 4 cases. For units responding to noxious stimulation of a facial field, the responses were suppressed in 8 cases, decreased in two cases and remained unchanged in two other cases. So it appears that the rostral part of the trigeminal sensory complex (1) receives nociceptive afferents mainly from the oral and perioral areas and (2) is a relay in ascending pathways which convey painful sensations.

The neurobiology of facial and dental pain: present knowledge, future directions

This review outlines recent research which has identified critical neural elements and mechanisms concerned with the transmission of sensory information related to oral-facial pain, and which has also revealed some of the pathways and processes by which pain transmission can be modulated. The review highlights recent advances in neurobiological research that have contributed to our understanding of pain, how acute and chronic pain conditions can develop, and how pain can be controlled therapeutically. Each section of the review also identifies gaps in knowledge that still exist as well as research approaches that might be taken to clarify even further the mechanisms underlying acute and chronic oral-facial pain. The properties of the sense organs responding to a noxious oral-facial stimulus are first considered. This section is followed by a review of the sensory pathways and mechanisms by which the sensory information is relayed in nociceptive neurones in the brainstem and then transmitted to local reflex centers and to higher brain centers involved in the various aspects of the pain experience--namely, the sensory-discriminative, affective (emotional), cognitive, and motivational dimensions of pain. Reflex and behavioral responses to noxious oral-facial stimuli are also considered. The next section provides an extensive review of how these responses and the activity of the nociceptive neurones are modulated by higher brain center influences and by stimulation of, or alterations (e.g., by trauma) to, other sensory inputs to the brain. The neurochemical processes, involved in these modulatory mechanisms are also considered, with special emphasis on the role of neuropeptides and other neurochemicals recently shown to be involved in pain transmission and its control. The final section deals with recent findings of peripheral and central neural mechanisms underlying pain from the dental pulp.