Acute experimental dental pain: a technique for evaluating pain modulating procedures

Beep tones attenuate pain following Pavlovian conditioning of an endogenous pain control mechanism

Heterotopic noxious counter-stimulation (HNCS) is commonly used to study endogenous pain control systems. The resulting pain inhibition is primarily based on spinal cord-brainstem loops. Recently, functional imaging studies have shown that limbic structures like the anterior cingulate cortex and amygdala are also implicated. Since these structures are involved in learning processes, it is possible that the HNCS-induced pain inhibition may depend on specific cues from the environment that have been associated with pain reduction through associative learning. We investigated the influence of Pavlovian conditioning on HNCS-induced pain inhibition in 32 healthy subjects by using a differential conditioning paradigm in which two different acoustic stimuli were either repeatedly paired or unpaired with HNCS. Series of noxious electrical pulse trains delivered to the non-dominant foot served as test stimuli. Diffuse noxious inhibitory control (DNIC)-like effects were induced by concurrent application of tonic HNCS (immersion of the contralateral hand in ice water). Subjective pain intensity and pain unpleasantness ratings and electromyographic recordings of the facial corrugator muscle and the nocifensive RIII flexion reflex were used to measure changes in pain sensitivity. HNCS induced significant pain and reflex inhibitions. In the post-conditioning phase, only the paired auditory cue was able to significantly reduce pain perceptions and corrugator muscle activity. No conditioned effect could be observed in RIII reflex responses. Our results indicate that the functional state of endogenous pain control systems may depend on associative learning processes that, like in the present study, may lead to an attenuation of pain perception. Similar albeit opposite conditioning of pain control mechanisms may significantly be involved in the exacerbation and chronification of pain states.

Analgesic efficacy of non-steroidal anti-inflammatory drugs in experimental pain in humans

1. The aim of this study was to establish a simple and reliable experimental pain model that could distinguish the analgesic effects of non-steroidal anti-inflammatory drug (NSAID) treatment from placebo in human volunteers. 2. The reproducibility and reliability over time of subject pain ratings was compared using cutaneous electrical stimuli applied to either the thenar eminence or the ear lobe at varying intensities and modes. Subjects were asked to respond firstly, when the stimulus became clearly sharp and painful ('first pain') and secondly, when the sensation became deep and burning and no further increase in stimulus intensity could be tolerated ('second pain'). 3. Constant voltage stimuli were found to be more reproducible than constant current stimuli. Both phasic (intermittent) and tonic (continuous) stimulation modalities produced 'first' and 'second pain' sensations. The latter sensation was more reproducible, and was perceived as a burning pain which is akin to clinical pain. 4. Analgesics from the NSAID class were found to attenuate reliably only 'second pain' sensations. The analgesic effects of ibuprofen (ibuprofen vs placebo: 0.12 +/- 0.09 vs 0.02 +/- 0.07 volt h(-1), P = 0.03; 95% confidence interval for differences (CI): 0.03-0.18) and diflunisal (diflunisal vs placebo: 0.29 +/- 0.40 vs 0.005 +/- 0.27 volt h(-1), P = 0.0001; CI: 0.168-0.407), respectively, could be distinguished from placebo.

Pain and tooth pulp evoked potentials

The purpose of this study was to verify whether the late components (N 140) of TPEPs were a reliable index of pain intensity. In the group with acute pain, except for higher amplitudes of the second negative wave, the plateau phenomenon has been noted. Analgesic and placebo effects indicated that the method used offers more objective than subjective components, because the real value of amplitudes is about 10% of control values for analgesic and between 60 and 70% for placebo. Shorter latency periods were observed in all parts of evoked potentials in the patients suffering from trigeminal neuralgia, as occurrence of a greater number of waves; while amplitudes on the affected side were significantly higher than on the healthy side.

Tooth pulp evoked potentials (TPEPs) in multiple sclerosis patients

The purpose of this study was to determine possible changes of the tooth pulp evoked potentials in patients with multiple sclerosis, and to compare these with other types of evoked potentials, in the same patients. The results showed TPEP changes in all multiple sclerosis patients. In 12 patients the changes were observed on both sides, while in 6 on one side only. It is interesting to note that the second negative wave was characterized by two peaks. The first peak possessed latency of approximately 125 ms that was significantly shorter than in the control group. The second peak appeared after about 195 ms. The significant prolonged latency of the second negative wave was observed in 100% of TPEPs, 95% VEPs and 72% AEPs. In only one case the changes were observed in TPEPs, while VEPs and AEPs were normal. It could be concluded that TPEPs, as well as other types of evoked potentials, are a sensitive indicator of the demyelination process.

Tooth pulp-evoked potentials in the monkey: cortical surface and intracortical distribution

The distribution of tooth pulp-evoked potentials (TPEPs) was characterized in the primary motor (MI), primary somatosensory (SI) and secondary somatosensory (SII) cortices of the monkey. Bipolar electrical tooth pulp stimulation elicited TPEP components P23 and N44 over SI, P26 and N72 over MI, and P72, N161, P280, N420, P561 and N662 over SII. Muscular artifacts and extradental input did not affect the TPEP as demonstrated by experiments using a neuromuscular blocking agent and removal of the pulp, respectively. The short latency TPEPs recorded over SI and MI were evoked by low stimulus intensities and activation of A beta nerve fibers, whereas the long latency TPEPs recorded over SII required higher stimulus intensities and the additional recruitment of A delta nerve fibers. Intracortical recordings revealed polarity reversals of components P23 and N44 in area 3b, P26 and N72 in area 4, and P72, N161, P280, N420, P561 and N662 in the upper bank of the lateral sulcus (SII). Evidence presented in this study suggests that TPEPs recorded from SI and MI relate to non-nociceptive mechanisms while TPEPs recorded from SII relate to nociceptive mechanisms.

Physiological properties of intradental mechanoreceptors

A major role of tooth receptors in signaling overt or impending tissue damage (nociception) has been previously established by substantial evidence from mechanical, thermal and chemical stimulation of exposed dentin. We report evidence showing that some intradental receptors in canine teeth of the cat detect mechanical transients applied to intact enamel. This new finding suggests that dental innervation may play an important non-nociceptive role in oral function such as detecting tooth contact during mastication and swallowing.

Reflex and cortical responses to dental stimuli

Tooth pulp stimulation may evoke reflex responses in the orbicularis oculi, temporal, masseter and retronuchal muscles, which may to a varying degree contaminate the cortical evoked responses. The use of repetitive stimulation reduces the amplitude of the cortical responses but avoids the onset of the majority of the muscle reflexes. The appearance of a silent period in the temporal muscle is hard to avoid and it alters the signal recorded from S1 for the first 60-70 msec. In the center-posterior leads, more protected from the EMG signal of the temporal muscle, a first negative deflection is recorded at 43 msec in 60% of subjects.