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

The Sympathetic Nervous System in Dental Implantology

The sympathetic nervous system plays a vital role in various regulatory mechanisms. These include the well-known fight-or-flight response but also, for example, the processing of external stressors. In addition to many other tissues, the sympathetic nervous system influences bone metabolism. This effect could be highly relevant concerning osseointegration, which is responsible for the long-term success of dental implants. Accordingly, this review aims to summarize the current literature on this topic and to reveal future research perspectives. One in vitro study showed differences in mRNA expression of adrenoceptors cultured on implant surfaces. In vivo, sympathectomy impaired osseointegration in mice, while electrical stimulation of the sympathetic nerves promoted it. As expected, the beta-blocker propranolol improves histological implant parameters and micro-CT measurements. Overall, the present data are considered heterogeneous. However, the available publications reveal the potential for future research and development in dental implantology, which helps to introduce new therapeutic strategies and identify risk factors for dental implant failure.

The use of electrodermal activity in pulpal diagnosis and dental pain assessment

AIMS

To explore whether electrodermal activity (EDA) can serve as a complementary tool for pulpal diagnosis (Aim 1) and an objective metric to assess dental pain before and after local anaesthesia (Aim 2).

METHODOLOGY

A total of 53 subjects (189 teeth) and 14 subjects (14 teeth) were recruited for Aim 1 and Aim 2, respectively. We recorded EDA using commercially available devices, PowerLab and Galvanic Skin Response (GSR) Amplifier, in conjunction with cold and electric pulp testing (EPT). Participants rated their level of sensation on a 0-10 visual analogue scale (VAS) after each test. We recorded EPT-stimulated EDA activity before and after the administration of local anaesthesia for participants who required root canal treatment (RCT) due to painful pulpitis. The raw data were converted to the time-varying index of sympathetic activity (TVSymp), a sensitive and specific parameter of EDA. Statistical analysis was performed using Python 3.6 and its Scikit-post hoc library.

RESULTS

Electrodermal activity was upregulated by the stimuli of cold and EPT testing in the normal pulp. TVSymp signals were significantly increased in vital pulp compared to necrotic pulp by both cold test and EPT. Teeth that exhibited intensive sensitivity to cold with or without lingering pain had increased peak numbers of TVSymp than teeth with mild sensation to cold. Pre- and post-anaesthesia EDA activity and VAS scores were recorded in patients with painful pulpitis. Post-anaesthesia EDA signals were significantly lower compared to pre-anaesthesia levels. Approximately 71% of patients (10 of 14 patients) experienced no pain during treatment and reported VAS score of 0 or 1. The majority of patients (10 of 14) showed a reduction of TVSymp after the administration of anaesthesia. Two of three patients who experienced increased pain during RCT (post-treatment VAS > pre-treatment VAS) exhibited increased post-anaesthesia TVSymp.

CONCLUSIONS

Our data show promising results for using EDA in pulpal diagnosis and for assessing dental pain. Whilst our testing was limited to subjects who had adequate communication skills, our future goal is to be able to use this technology to aid in the endodontic diagnosis of patients who have limited communication ability.

Neural Regulations in Tooth Development and Tooth-Periodontium Complex Homeostasis: A Literature Review

The tooth-periodontium complex and its nerves have active reciprocal regulation during development and homeostasis. These effects are predominantly mediated by a range of molecules secreted from either the nervous system or the tooth-periodontium complex. Different strategies mimicking tooth development or physiological reparation have been applied to tooth regeneration studies, where the application of these nerve- or tooth-derived molecules has been proven effective. However, to date, basic studies in this field leave many vacancies to be filled. This literature review summarizes the recent advances in the basic studies on neural responses and regulation during tooth-periodontium development and homeostasis and points out some research gaps to instruct future studies. Deepening our understanding of the underlying mechanisms of tooth development and diseases will provide more clues for tooth regeneration.

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.

The influence of adrenergic blockade in rats with apical periodontitis under chronic stress conditions

OBJECTIVE

To investigate the influence of chronic stress and adrenergic blockade in a rat model of apical periodontitis.

METHODS

Thirty-two Wistar rats were submitted to an animal model of periapical lesion and randomly divided into 4 groups (n = 8): no stress (NS); stress + saline solution (SS); stress + β-adrenergic blocker (Sβ); stress + α-adrenergic blocker (Sα). The SS, Sβ and Sα groups were submitted to an animal model of chronic stress for 28 days and received daily injections of saline solution, propranolol (β adrenergic blocker) and phentolamine (α adrenergic blocker), respectively. After 28 days the animals were euthanized and the following analyses were carried out: a) serum corticosterone levels through Radioimmunoassay; b) measurement of serum levels of IL-1B, IL-6, IL-10 and IL-17 by enzyme-linked immunosorbent assay (ELISA); c) volume of periapical bone resorption by micro-computed tomography; d) histomorphometric analysis by staining with hematoxylin and eosin; e) expression of β-AR, α-AR, receptor activator of nuclear factor kappa-B ligand (RANKL) and osteoprotegerin (OPG) by immunohistochemistry; f) tartrate-resistant acid phosphatase (TRAP) staining; g) ex-vivo cytokine release followed by the stimulation with LPS in superfusion system, by ELISA.

RESULTS

SS group displayed significantly higher corticosterone levels than NS group (non-stressed). Higher IL-1β serum level was observed in the NS group (p < .05); compared to all stressed groups. Other cytokines were present in similar amounts in the serum of all groups. All groups presented similar periapical lesions. All groups presented moderate inflammatory infiltrate, without statistically significant differences between them. No differences were observed regarding β-AR, α-AR, Rank-L and OPG expression. The number of TRAP-positive cells was significantly decreased in the groups that received daily injections of adrenergic blockers. The IL-1β release followed LPS stimulation was significantly suppressed when the superfusion media contained propranolol (p < .05). Perfusion containing phentolamine induced a greater release of IL-10. TGF-β was significantly suppressed by phentolamine perfusion in the NS group (p < .05).

CONCLUSIONS

Chronic stress can significantly change the inflammatory cytokines release. Rank-L/OPG system and periapical lesion volume were not affected following the current method applied. The administration of adrenergic blockers was not able to modulate the inflammatory response but presented effectivity in reducing the number of osteoclasts in the periapical region.

Neurogenic inflammation in periimplant and periodontal disease: A case-control split-mouth study

OBJECTIVE

Although the regulatory effects of substance-P (SP), neurokinin-A (NKA), calcitonin gene-linked peptide (CGRP) and neuropeptide-Y (NPY) on periodontal inflammatory responses have been described, the effects of these neuropeptides on healthy and diseased periimplant tissues are not clearly defined.

MATERIALS AND METHODS

Thirty-nine implants loaded at least for 12 months with their symmetrically matching teeth were evaluated and compared by a split-mouth study design. Six study groups were created in this regard as follows: group 1 (healthy periodontal tissues), group 2 (healthy periimplant tissues), group 3 (gingivitis), group 4 (periimplant mucositis), group 5 (periodontitis) and group 6 (periimplantitis). Clinical examinations included Silness-Löe plaque index, Löe-Silness gingival index, bleeding on probing, probing pocket depth and clinical attachment level measurements. Gingival crevicular fluid and periimplant sulcular fluid samples were collected, and the concentrations of neuropeptides were determined by enzyme-linked immunosorbent assay. Their levels and correlations were investigated together with the clinical parameters.

RESULTS

Neuropeptide levels were different in the teeth and implant groups according to the periodontal status (p < 0.001). SP and NKA levels were increased, whereas CGRP and NPY levels were decreased in the diseased states. There were no differences between the neuropeptide levels of matching teeth and implants (groups 1-2, groups 3-4 and groups 5-6; p > 0.05).

CONCLUSION

Our study demonstrated the presence of local neuropeptides in healthy and diseased periimplant tissues. The neurogenic inflammatory responses were also found to be similar in both periimplant and periodontal tissues.

Contribution of capsaicin-sensitive innervation to the continuous eruption of the rat mandibular incisors

A major component of tooth innervation is made of capsaicin-sensitive primary afferents (CSPA). These fibers play a key role in tooth pain and inflammation; little is known, however, about the role of CSPA in tooth eruption. The aim of this study was to examine the role of the capsaicin-sensitive afferents in the process of eruption of intact rat incisors. CSPA fibers in several rat groups, were subjected to one of the following experimental procedures: systemic chemical ablation, systemic ablation followed by chemical sympathectomy and localized activation. The observed effects on incisor eruption were compared to those made on controls. The total amount of eruption in control/naïve rats, measured over a total period of 144 h, was 3.18 ± 0.07 mm and decreased to 2.43 ± 0.08 mm (n = 7; p < 0.001) following systemic ablation of CSPA. Further decrease to 2.24 ± 0.08 mm (n = 7; p < 0.001) was noticed when chemical sympathectomy was added to CSPA ablation. The average rate of eruption was 1.7 ± 0.25 mm following CSPA activation, compared to an average of 0.8 ± 0.07 mm for controls (n = 7; p < 0.001). Capsaicin sensitive fibers play an important role in tooth homeostasis, and intact neural supply is required for tooth growth under normal conditions.

Modulation of Dental Inflammation by the Sympathetic Nervous System

Recent findings have indicated that immune responses are subjected to modulation by the sympathetic nervous system (SNS). Moreover, the findings show that the SNS inhibits the production of pro-inflammatory cytokines, while stimulating the production of anti-inflammatory cytokines. The present review is an attempt to summarize the current results on how the SNS affects inflammation in dental tissues. In dental tissues, it has been found that the SNS is significant for recruitment of inflammatory cells such as CD 43+ granulocytes. Sympathetic nerves appear to have an inhibitory effect on osteoclasts, odontoclasts, and on IL-1α production. The SNS stimulates reparative dentin production, since reparative dentin formation was reduced after sympathectomy. Sprouting of sympathetic nerve fibers occurs in chronically inflamed dental pulp, and neural imbalance caused by unilateral sympathectomy recruits immunoglobulin-producing cells to the dental pulp. In conclusion, this article presents evidence in support of interactions between the sympathetic nervous system and dental inflammation.

Sympathetic Regulation of Tertiary Dentinogenesis via Beta-2 Adrenergic Receptor on Rat Odontoblasts

INTRODUCTION

Beta-2 adrenergic receptor has been found within the osteoblast membrane meditating bone remodeling. Propranolol is a sympatholytic beta antagonist commonly used as long-term medication for the management of many common diseases such as hypertension. This study was performed to verify the presence of this receptor on odontoblasts in rats and, if present, to investigate its possible association with tertiary dentinogenesis.

METHODS

Twenty male Sprague-Dawley rats (9 weeks old) were randomly assigned to 4 groups: CP0.8 group, cavity preparation + propranolol treatment (0.8 mg/day, n = 5); CP4 group, cavity preparation + propranolol treatment (4.0 mg/day, n = 7); CON group, cavity preparation + saline treatment (0.2 mL/day, n = 5); and NT group, no treatment (n = 3). Cavity preparation was performed on the mesial aspect of the maxillary first molars bilaterally. After 2 weeks, the tertiary dentinogenesis (CP0.8, CP4, and CON) was examined by hematoxylin-eosin staining, and the localization of beta-2 adrenergic receptor (NT) was examined by immunohistochemistry.

RESULTS

The beta-2 adrenergic receptor immunoreactivity was observed in the odontoblastic layer in normal rat molar dental pulp. The tertiary dentinogenesis beneath the prepared cavity was significantly higher in the rats receiving 2-week systemic administration of propranolol than in those without the propranolol treatment. The higher-dose treatment of propranolol (P < .001) presented more effective up-regulation of tertiary dentinogenesis than the lower-dose treatment (P < .01).

CONCLUSIONS

These results indicate that the sympathetic nervous system decreases tertiary dentin formation via beta-2 adrenergic receptors located on rat odontoblasts. It suggests that adrenergic beta antagonist is expected to use in the treatment of inducing tertiary dentin formation to protect dental pulp.

Cervical sympathectomy causes alveolar bone loss in an experimental rat model

BACKGROUND AND OBJECTIVE

Periodontal disease, a pathological destructive inflammatory condition, is characterized by alveolar bone loss. Recent studies have suggested a correlation between the sympathetic nervous system and bone remodeling. To confirm the importance of the sympathetic nervous system in bone resorption, we investigated the effects of superior cervical ganglionectomy and oral challenge with Porphyromonas gingivalis on alveolar bone loss in rats.

MATERIAL AND METHODS

Rats were divided into three groups: group A underwent a sham operation as the control group; group B underwent superior cervical ganglionectomy; and group C underwent a sham operation and oral challenge with P. gingivalis. Horizontal alveolar bone loss was evaluated by measuring the distance between the cemento-enamel junction and the alveolar bone crest. Cytokine gene expression in the gingival tissues was assessed using reverse transcription-polymerase chain reaction analyses. The furcation areas of the mandibular molars were examined histologically.

RESULTS

Both superior cervical ganglionectomy and oral challenge with P. gingivalis resulted in accelerated alveolar bone loss. Gingival tissues in the superior cervical ganglionectomy group showed increased expression of the cytokines interleukin-1 alpha, tumor necrosis factor-alpha and interleukin-6. The density of neuropeptide Y-immunoreactive fibers was decreased following superior cervical ganglionectomy. Osteoclasts were observed in the superior cervical ganglionectomy and P. gingivalis-challenged groups.

CONCLUSION

Both superior cervical ganglionectomy and oral challenge with P. gingivalis induced alveolar bone loss. These results provide new information on the occurrence of alveolar bone loss, in that both oral challenge with P. gingivalis and superior cervical ganglionectomy are important accelerating factors for alveolar bone loss. Thus, we suggest that the sympathetic nervous system is linked with the prevention of alveolar bone loss.

Neuropeptide Y (NPY) and NPY Y1 receptor in periodontal health and disease

OBJECTIVES

Neuropeptide Y (NPY) coordinates inflammation and bone metabolism which are central to the pathogenesis of periodontitis. The present study was designed to determine whether NPY was quantifiable in human gingival crevicular fluid (GCF) and to test the null hypothesis that GCF levels of NPY were the same in periodontal health and disease. A subsidiary aim was to determine the potential functionality of released NPY by detecting the presence of NPY Y1 receptors in gingival tissue.

DESIGN

The periodontitis group consisted of 20 subjects (10 females and 10 males) mean age 41.4 (S.D. 9.6 years). The control group comprised 20 subjects (10 females and 10 males) mean age 37.4 (S.D. 11.7 years). NPY levels in GCF were measured in periodontal health and disease by radioimmunoassay. NPY Y1 receptor expression in gingival tissue was determined by Western blotting of membrane protein extracts from healthy and inflamed gum.

RESULTS

Healthy sites from control subjects had significantly higher levels of NPY than diseased sites from periodontitis subjects. NPY Y1 receptor protein was detected in both healthy and inflamed gingival tissue by Western blotting.

CONCLUSIONS

The significantly elevated levels of NPY in GCF from healthy compared with periodontitis sites suggests a tonic role for NPY, the functionality of which is indicated by the presence of NPY Y1 receptors in local gingival tissue.

Sympathectomy alters bone architecture in adult growing rats

Sympathetic nervous system (SNS) fibres and alpha- and beta-receptors are present in bone, indicating that the SNS may participate in bone metabolism. The importance of these observations is controversial because stimulation or inhibition of the SNS has had various effects upon both anabolic and catabolic activity in this tissue. In this study we evaluated the effects of pharmacological sympathectomy, using chronic treatment of maturing male rats with 40 mg of guanethidine/kg i.p., upon various parameters in bone. Double labelling with tetracycline injection was also performed 20 and 2 days before sacrifice. Bone mass, mineral content, density and histomorphometric characteristics in different skeletal regions were determined. Bone metabolic markers included urinary deoxypyridinoline and serum osteocalcin measurements. Guanethidine significantly reduced the accretion of lumbar vertebral bone and of mineral content and density, compared to controls. Femoral bone mineral content and density were also significantly reduced, compared to controls. Histomorphometric analyses indicated these effects were related to a reduction of cortical bone and mineral apposition rate at femoral diaphysials level. Both markers of bone metabolism were reduced in controls as they approached maturity. Guanethidine significantly decreased serum osteocalcin compared to controls, while urinary deoxypyridinoline was unchanged. These data indicate that guanethidine-induced sympathectomy caused a negative balance of bone metabolism, leading to decreased mass by regulating deposition rather than resorption during modeling and remodeling of bone.

Sympathectomy decreases size and invasiveness of tongue cancer in rats

The sympathetic nervous system plays a role in carcinogenesis wherein locally released sympathetic neurotransmitters affect proliferation, angiogenesis, vessel permeability, lymphocyte traffic and cytokine production. The present in vivo study was designed to investigate whether surgical sympathectomy, both unilateral and bilateral, had an effect on tumor growth, interstitial fluid pressure (IFP) and lymphatics in rat tongue cancer. We used 4-nitroquinoline-1-oxide (4-NQO) in drinking water for 19 weeks to induce tongue cancer in 20 Dark Agouti rats. After 11 weeks, one group underwent unilateral sympathectomy and another underwent bilateral sympathectomy, while the third group underwent sham surgery. By 19 weeks, tumors in the bilaterally sympathectomized (BL-SCGx) rats were significantly smaller (P<0.05), more diffuse in appearance and less invasive (P<0.05) compared with the large exophytic tumors in the sham-operated rats. The relative lymphatic area was significantly decreased (P<0.05) in tumors in the BL-SCGx rats compared with the sham group. Interestingly, the tumors in rats that underwent unilateral or bilateral sympathectomy had a significantly lower (P<0.05) IFP than those in sham rats. Lack of tyrosine hydroxylase (TH) immunoreactive nerves and few neuropeptide Y (NPY) positive fibers indicate absence of sympathetic nerve fibers in the bilateral sympathectomized group. The peritumoral lymph vessel area was correlated with the tumor size (P<0.001), depth of invasion (P<0.001), weight of rats (P<0.005) and IFP (P<0.05). In conclusion, the present study presents evidence that deprivation of sympathetic nerves decreases tumor growth in rat tongue, probably caused by decreasing IFP and lymph vessel area.

Caries-induced changes in the expression of pulpal neuropeptide Y

Recent evidence suggests that the sympathetic nervous system may have a role in modulating neurogenic inflammation and bone remodelling. Neuropeptide Y (NPY) is a well-characterized neuropeptide transmitter in the peripheral sympathetic nervous system. NPY is known to be present in human dental pulp; however, quantitative data on NPY levels in pulpal health and disease in an adult population remain to be determined. The aims of the current study were to assess, quantitatively, NPY levels by radioimmunoassay and confirm the distribution of NPY fibres by immunocytochemistry in carious and non-carious adult human pulp tissue. Our results suggest changes in the levels and distribution of NPY in human dental pulp during the caries process, with significantly higher levels of NPY in carious compared with non-carious adult human teeth. Within the carious samples studied, our finding, that NPY levels were significantly elevated in mild/moderate caries, concurs with the hypothesis that NPY could have a modulatory role in pulpal inflammation and in reparative dentine formation.

Tissue interactions in the regulation of axon pathfinding during tooth morphogenesis

Like many other organs, the tooth develops as a result of the epithelial-mesenchymal interactions. In addition, the tooth is a well-defined peripheral target organ for sensory trigeminal nerves, which are required for the function and protection of the teeth. Dental trigeminal axon growth and patterning are tightly linked with advancing tooth morphogenesis and cell differentiation. This review summarizes recent findings on the regulation of dental axon pathfinding, which have provided evidence that the development of tooth trigeminal innervation is controlled by epithelial-mesenchymal interactions. The early dental epithelium possesses the information to instruct tooth nerve supply, and signals mediating these interactions are part of the signaling networks regulating tooth morphogenesis. Tissue interactions, thus, appear to provide a central mechanism of spatiotemporally orchestrating tooth formation and dental axon navigation and patterning.

Unilateral Severe Chronic Periodontitis Associated With Ipsilateral Surgical Resection of Cranial Nerves V, VI, and VII

BACKGROUND

The central and peripheral nervous systems participate in several local physiological and pathological processes. There is experimental evidence that the inflammatory, local immune, and wound healing responses of a tissue can be modulated by its innervation. The aim of this clinical report is to present a case of unilateral severe periodontitis associated with ipsilateral surgical resection of the fifth, sixth, and seventh cranial nerves and to discuss the possible contribution of the nervous system to periodontal pathogenesis.

METHODS

A 39-year-old female patient with a history of a cerebrovascular accident caused by a right pontine arteriovenous malformation and destruction of the right fifth, sixth, and seventh cranial nerves was diagnosed with severe chronic periodontitis affecting only the right maxillary and mandibular quadrants. The patient's oral hygiene was similar for right and left sides of the mouth. Percentages of tooth surfaces carrying dental plaque were 41% and 36% for right and left sides, respectively. Non-surgical and surgical periodontal therapy was performed, and the patient was placed on a regular periodontal maintenance schedule.

RESULTS

Healing following initial periodontal therapy and osseous periodontal surgery occurred without complications. Follow-up clinical findings at 1 year revealed stable periodontal health.

CONCLUSIONS

This case report suggests that periodontal innervation may contribute to the regulation of local processes involved in periodontitis pathogenesis. It also suggests that periodontal therapy can be performed successfully at sites and in patients affected by paralysis.

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.