PARASYMPATHETIC

NERVOUS SYSTEM

Guided by:
Dr.Vishesh Yadav, Reader

PRESENTED By:
Bhargavi Sood
Pg 1st year
 i c Central Peripheral
om
at nervous nervous
An al ns
o system system
i si
iv
D Cranial
Brain Nerves
(12)
Spinal
Spinal
Nerves
chord
(31)
 Autonomic
Functio nervous
nal system
division Efferent

Somatic
Peripheral System
nervous
system
Afferent
 Cell Body: bulbous, non-process portion of
a neuron. Also known as Some. Collectively
form the grey matter and nuclei in CNS and
ganglia in PNS

Axon Terminal

Dendrites: These are extensions Axons: these are single elongated

that arise from cell body and process, and conduct the impulses
carry impulses towards it. away from the cell body. They form
the white matter in CNS and Nerves
in peripheral nervous system.
 Functional division of
Neurons
• Spinal or
Primary sensory Motor neuron
or 1st neuron Uppe
order seen in
neuron
dorsal root
r
ganglion moto • Motor area of
• Seen in grey r brain
Sensory
Seconda
ry or 2nd
matter of Lowe
neur
spinal cord
Neuron order
neuron and
onr • Present in cranial
brainstem moto nerve nuclei, and
r anterior horn of
Tertiary neur spinal chord.
• Seen in
or 3rd
on
order thalamus
neuron
Parasympathetic neurons

• Preganglionic neurons arise from motor nuclei of

Cranial Nerve III, VII, IX and X. also arise from S2-S4
segments and are myelinated.
• Postganglionic neuronsThe ratio of
are present in the wall or
preganglionic
close to wall of viscera. These are: not myelinated.
postganglionic
• Also known as “cranio-sacral outflow”
neurons is 1:3
Sympathetic neurons

• Preganglionic neurons arise from Lateral horn of T1-

L2 segments.
• Postganglionic neurons form the sympathetic trunk
• Also known as “thoraco-lumber outflow”
AUTONOMIC NERVOUS SYSTEM
• Autonomic nervous system or Visceral
nervous system act as control system that
functions below the level of consciousness.
• Controls involuntary or visceral bodily
functions One of the most
Cardiovascular striking feature of
Respiratory ANS is its rapidity
and intensity with
Digestive which it can
Urinary change visceral
 Reproductive function function.
Key role of bodily response in stress.
The organization of the ANS is on the basis of the reflex
arc and it has an afferent limb, efferent limb, and a
central integrating system.

The afferent limb transmits information from the periphery to the

central nervous system (CNS). The transmissions from these receptors
are conducted along neural pathways into the spinal cord via the
dorsal root ganglion or to the brain stem via cranial nerves.

The efferent limb is made up of preganglionic and post-ganglionic

fibres and an autonomic ganglion. The efferent limb is further
subdivided based on its anatomic and physiological differences into
sympathetic and parasympathetic components.

Simple reflexes are completed within the organ system involved. More
complex reflexes are regulated by higher autonomic centers present in
the CNS, mainly the hypothalamus and the brain stem.
 EMBRYOLOGY
• The peripheral nervous system derives from neural crest cells. The neural crest is
divided axially into the cranial, vagal, truncal, and lumbosacral neural crest cells.
Truncal neural crest cells contribute to the dorsal root of the spinal cord and the
sympathetic ganglia. The parasympathetic innervation of the heart forms from the
vagal neural crest. The majority of the parasympathetic nervous system, including
all of the ganglia of the head, has been shown to arise from glial cells, rather than
neural crest cells.
• The Enteric Nervous System originates from the vagal neural crest with cells that
migrate in a rostral-to-caudal pattern through the intestinal wall, forming a
network of glia and neurons of various subtypes. Cells of the ENS complete their
migration by four to seven weeks of development and express all varieties of ENS
neurotransmitters by gestational week 24. However, mature gut motility is not
realized until at least late gestation to shortly after birth.
 AUTONOMIC NERVOUS SYSTEM

SYMPATHETIC NERVOUS
SYSTEM
 Allows body to function
under stress
 FLIGHT OR FIGHT
 Primes body for intense
PARASYMPATHETIC NERVOUS
skeletal muscle activity SYSTEM
Maintenance function
 Rest and Digest
Counters Sympathetic
system
Parasympathetic nerves leave CNS though the motor nuclei of cranial nerves III, VII,
IX and X and additional fibres leave through S2-S4 segments.
About 75% of fibres leave though the VAGUS NERVE, supplying the entire thorax
and abdomen. Giving of parasympathetic supply to heart, lungs esophagus, stomach,
small intestine, proximal half of colon, gall bladder, Pancreas, kidney and upper part
of ureter

Parasympath
 Parasympathetic fibres leaving though third cranial nerve – Occulomotor nerve
goes to pupillary sphincter and ciliary muscles of eye.
etic nervous
system
 Parasympathetic fibres leaving through the VII cranial nerve- Facial Nerve, supply
the Nasal, Lacrimal and Submandibular gland.

 Parasympathetic fibres leaving through XI cranial nerve – Glossopharyengeal nerve

supply the parotid gland.

Parasympathetic fibres from sacral segment are in pelvic nerves and pass through
the Spinal Nerve sacral plexus, which passes on each side of spinal chord at S2-S3
level. It supplies the descending colon, rectum, urinary bladder, lower portion of
ureter, and also the external genetilia.
• Both sympathetic and parasympathetic nerves secrete either
Acetyl-choline or Nor-Epinephrine as neurotransmitters. Hence
they are called as cholinergic or adrenergic nerves
respectively.
• The preganglionic fibres of both sympathetic and
parasympathetic fibres are cholinergic.
• The post-ganglion fibres of Parasympathetic are mostly
cholinergic.
• The post-ganglionic fibres of Sympathetic are mostly
adrenergic, with few being cholinergic.
Mechanism of Transmission:
The parasympathetic nerve fibres nerve endings are similar to the neuro-
muscular junction. They have cholinergic endings.

The parasympathetic nerves when passing near the effector organs show
a bulbous enlargements known as Varicosities.

The Terminal ending and the Varicosities show multiple vesicle which
produce and stores the neuro transmitter – acetyl-choline.

There are abundant mitochondria's present in the nerve ending, which

give a continuous supply of ATP, to energize the formation of Acetyl-
Choline.
 Generation of
action potential,
which spread to the Neuro-humoral
terminal endings Transport
After the
transmission of
impulses, the Acetyl
choline splits into Increase
Acetate ion and permeability to
choline with the help calcium ions.
of
Acetylcholinesterase
Choline
that is to
is bound Acetyl choline is formed
transported
collagen and in the terminal endings,
back into the
glycosamines The acetylAcetyl
cholineCo-A Acetyl
terminal act on the choline
nerve endings cholinergic+receptors
choline
The vesicles rupture In presence
of effector nerve or of Choline
and the the organs. Thus acetyl
a post-transferase.
neurotransmitter is synaptic impulse is
released at the nerve gernerated.
endings
 Receptor on Effector organ:
The neurotransmitter bind with receptor
present on effector cell.
The receptor is present outside the cell
membrane on a protein molecule, which
penetrates the cell membrane.
When neurotransmitter binds to receptor,
there are conformational changes in
protein.
By activating or inactivating an enzyme
The neurotransmitters can act by altering
secondary messenger enzymes.
These enzymes are usually bound to the receptor
protein, which is present intracellularly.
Eg: Nor-epinephrine increases the activity of cAMP,
which in turn can initiate many different
intracellular reactions.
By Change In Cell Membrane
Permeability
 The receptor when binding to
the protein molecule bring
some changes in cell
permeability.
 Like Na+ or Ca++ channels
are frequently opened, which
results in influx of these ions
and efflux of K+ions thus
depolarizing and exciting the
cell. (EPSP)
 Other times, Cl- channels are
open which results in influx of
cholrine ions which inhibit the
cell as there is increased hyper
negativity in cell. (IPSP)
• Cholinergic nerves has two kinds of receptor :- Muscarinic
Receptor

:- Nicotinic Receptor

• All effector cells stimulated by postganglionic cholinergic nerves (

both parasympathetic and sympathetic ) has Muscarinic
Receptors.

• In autonomic ganglia, where preganglionic and post ganglionic

nerves synapse, Nicotinic receptors are present ( both
parasympathetic and sympathetic).

• Both Sympathetic and Parasympathetic may cause excitatory

 PARASYMPATHETIC
GANGLIA
 Cranial Parasympathetic
ganglia
 Otic ganglia
 Submandibular
PREGANGLIONIC ganglia POSTGANGLIONIC
FIBRES  Pterygopalatine FIBRES
ganglia
 Ciliary ganglia
Myelinated fibres Non- Myelinated
 Cardiac plexus
Long fibres. fibres
 Pulmonary plexus
Slow conducting B Short fibres
 Myenteric plexus
fibres Slower conducting
 Mucosal plexus
C fibres.
 Hypogastric plexus.
 CRANIAL PARASYMPATHETIC
GANGLION.

• The parasympathetic nerves exit the brain though the CN III, VII, IX, X
and from spinal chord through the segments S2-S4.
• While the CN X supply thorax and abdomen, the parasympathetic fibres
arising from CN III, VII, IX relay into peripheral ganglions and supply head
and neck region.
• There are four parasympathetic ganglions, present on the course of
efferent fibres:
 Ciliary Ganglion
 Otic Ganglion
 Pterygopalatine ganglion
 Submandibular Ganglion
 CILIARY GANGLION
 Placed in the course of oculomotor
nerve.
 Present near the apex of the orbit
between the optic nerve and the tendon
of lateral rectus
 Has three roots : Parasympathetic root
: Sensory Root
: Sympathetic Root

The preganglionic
parasympathetic root arises
from the motor nucleus of CN
III- Edinger-Westphal Nucleus
and relay into oculomotor
nerve.
The preganglionic
fibres synapse the post-ganglionic fibres
with pass through the short
postganglionic ciliary nerve, and supply the
fibres in ganglion. sphincter pupillae and the
ciliary muscles.
 PUPILLARY LIGHT REFLEX

• Parasympathetic nerves supplies the

pupillary sphincter and hence controls
the light reflex of eye also known as
Pupillary light reflex.
• Pupillary light reflex means that when
light is shone into the eye the pupils
contract.
• The light falling on retina carry
impulses through the optic nerve to
pretectal nucleus.
• From here the impulse pass on to the
Edinger-Westphal nucleus which relays
in the parasympathetic nerve, which
results in contraction of pupils.
 ACCOMODATION OF LENS

• To focus on the nearby objects the lens accommodate to

give the best visual acuity.

• The lens is usually flattened, but when focusing on a

nearby object the lens becomes more concave by
contraction of ciliary muscles. This mechanism occurs by
stimulation of Parasympathetic System.

• The motor signals from the ciliary muscles are

transmitted to pretectal area, which again passes the
impulse to nuclei of third cranial nerve, which through
parasympathetic nerve, causes contraction of ciliary
muscle.
 PTERYGO-PALATINE GANGLION
The facial nerve arising
from the Lacrimatory
Nucleus carries the
parasympathetic fibres.
The facial nerve enter
From the  It is the largest parasympathetic ganglion,
the geniculate
pterygopalatine suspended by 2 roots of maxillary nerve.
ganglion and gives of
ganglion, the  Functionally related to CN- VII
a branch – Greater
parasympathetic  Has three roots- Sensory, sympathetic,
Petrosal Nerve which
fibres relay in the Parasympathetic roots
carry the
maxillary nerve, from
parasympathetic
maxillary nerve it
fibres
relays into zygomatic
branch.
The greater petrosal
nerve acts as pre- Then the parasympathetic fibres
ganglionic relay into the zygomatico-
parasympathetic fibres temporal branch of zygomatic
and relay into the nerve, and continues to supply
Pterygopalatine to the lacrimal gland, where it
ganglion. relays finally into the lacrimal
 SUBMANDIBULAR GANGLION

 The submandibular ganglion is present

superficial to the Hyoglossus muscle, in the
submandibular region.
 Functionally apart of VII cranial nerve.
 Topographically part of Lingual nerve- br. Of
Mandibular Nerve Post-ganglionic fibres
arise from the
Submandibular
The It continues as nervus ganglion.
parasympathetic intermedius and as Submandibular gland
secretomotor chorda tympani either receives direct
supply originates in branch later on. The supply or along the
the superior chorda tympani duct.
salivatory branch joins the Sublingual gland,
nucleus lingual nerve, and receives parasym.
of the facial nerve Supply from lingual
form the pre-
 OTIC GANGLION
 Otic ganglion lies deep to trunk of
mandibular nerve, in the Infratemporal
fossa, just distal to Foramen Ovale.
 Functionally related to IX-
Glossopharyngeal
 Topographically related to V –
Mandibular nerve

The post ganglionic fibres

The parasympathetic fibres arise of parasympathetic, to
from the inferior salivatory nucleus parotid is supplied by
the pre-ganglionic fibres
of CN- IX; Glossopharyngeal nerve. Auriculo-temporal Nerve.
pass as tympanic nerve and
Lesser petrosal nerve. ( Mandibular nerve)
 The nasal, lacrimal, salivary, and
many gastrointestinal glands are strongly
stimulated by the
parasympathetic nervous system, usually
resulting in copious
quantities of watery secretion.
 The glands of the alimentary
tract most strongly stimulated by the
parasympathetics are
those of the upper tract, especially those of
the mouth and
stomach.
 EFFECT ON OTHER STRUCTURES :
ON HEART:
 Parasympathetic fibres originate in
 Activation of parasympathetic system
dorsal nucleus of vagus, and descend
causes:
into thorax into the vagus nerve.
 Decrease in heart rate
 Pre-ganglionic fibres synapse with
 Decrease in force of contraction of
post-ganglionic fibres in the cardiac
heart
plexus.
 Contraction of coronary arteries.
 Post-ganglionic fibres innervate the
Sini-atrial & Atrio-ventricular nodes.
Also the coronary arteries

On LUNGS:
 Parasympathetic fibres originate in the
dorsal
Activation
nucleus
of parasympathetic
of vagus. system
 The preganglioniccauses:
fibres synapse with
 Broncho-constriction
post ganglionic fibres in pulmonary
plexus.  Vasodilation
 the
 Increase
post ganglionic
in glandular
fibressecretion
form a
network around the bronchi, and blood
vessel.
 EFFECT ON ARTERIAL PRESSURE

Arterial pressure is controlled by two factors:

 Propulsion of blood by heart
 Resistance at peripheral blood vessels.
Moderate parasympathetic stimulation causes decrease in rate
and force of contraction of heart.
But virtually has no effect on peripheral vascular resistance.
But a very strong vagal parasympathetic stimulation can stop
the heart for a few seconds and can cause temporary loss of all
or most arterial pressure.
 On GASTRO-INTESTINAL TRACT:
 The parasympathetic preganglionic
fibres enter the abdomen, with right
 Activation
and of parasympathetic
left vagal trunks.
 The GIT has system
its owncauses:
INTRA-MURAL
Plexus.ThePromote peristalsis
Auerbach and Messiner
plexus. These act as
 Relaxation ofpost-ganglionic
sphincter
fibres.
 Increased glandular activity.
 The post ganglionic fibres innervate
the smooth muscles and glands upto
transverse colon.

Remaining portion of GIT:

 Preganglionic parasympathetic fibres
arise from Grey matter, of spinal chord
at S2-S4 level.
 The fibres pass through Pelvic
Splanchic Nerve plexus.
 The postganglionic fibres are supplied
by Intramural plexus to smooth
muscles and glands.
 AUTONOMIC REFLEXS

Cardiovascular Reflexes
The carotid sinus, located in the bifurcation of the common carotid artery,
and the aortic arch serve as baroreceptors. As the blood pressure rises,
nerve endings situated in the walls of these vessels are stimulated.
The combined effect of stimulation of the parasympathetic action on the
heart and inhibition of the sympathetic action on the heart and peripheral
blood vessels reduces the rate and force of contraction of the heart and
reduces the peripheral resistance of the blood vessels. Consequently,
theblood pressure falls.
Gastrointestinal Autonomic Reflexes.
The uppermost part of the gastrointestinal tract and the rectum are
controlled principally by autonomic reflexes. For instance, the smell of
appetizing food or the presence of food in the
mouth initiates signals from the nose and mouth to the vagal,
glossopharyngeal, and salivatory nuclei of the brain stem.
These in turn transmit signals through the parasympathetic nerves to the
secretory glands of the mouth and stomach, causing secretion of digestive
juices sometimes even before
food enters the mouth.
 MUSCARINIC RECEPTORS
 They are postganglionic
receptors.
 They are G-protein coupled
receptor.
 Selectively stimulated by
Muscarin and blocked by
Atropine.
 Seen in Autonomic effector
cells:
 Heart
 GIT
 Blood Vessel
There are mainly five types of receptors- M1,  Eye
M2,M3, M4, M5.  Smooth Muscle
 M1- neuronal receptor- Autonomic nervous  Respiratory system
system  Urinary tract
 M2- cardiac muscarinic receptor  Sweat glands
 M3- Visceral smooth muscle
 NICOTINIC RECEPTORS
 Ligand gated cation
channels.
 Activated by Nicotine and
blocked by Tubocuraine
and hexamethonium.
 seen on skeletal muscles
and ganglionic cells,
adrenal medulla.
There are two main type of receptor: Nm, Nn:
 Nm: skeletal muscle
 Nn: ganglionic cells of both sympathetic and
parasympathetic nervous system, Adrenal
medullary cells and spinal cord.
 CHOLINERGIC AGONIST ANTICHOLINESTERASE
Act by interacting with Cholinergic Act by increasing the acetyl choline
receptors. at these sites
CHOLINE Reversible:
ESTERS  Carbamate
 Acetyl  Physostigmine
choline  Neostigmine
 Methacholin CHOLINERGIC
ALKALOIDS DRUGS –
 Pyridostigmin Irreversible:
e e  Organophospha
PARASYMPATHOMIMETIC
Mucarine  Acridine
 Bethanecoli te
 Pilocarpine  Tacrine  Dyflos
ne  Arecoline  Echothiopha
te
 Carbamate
 Carbaryl

Anti-cholinesterase inhibit the enzyme Cholinesterase thus

preventing hydrolysis of Ach. The carbamates and
phosphates act on the ester site of the enzyme
Cholinesterase thus making it unavailable to act on Ach.
 MUSCARINIC RECEPTORS:
1. Heart- decreased rate of
impulse generation and force of
contraction. Can also result in
Bradycardia or even cardiac
arrest. NICOTINIC RECEPTOR
2. Blood Vessel- all blood vessels 1. Autonomic ganglia- both
are dilated, though only blood sympathetic and CENTRAL NERVOUS
vessel of skin, neck and salivary parasympathetic are SYSTEM
gland has cholinergic activated. It is manifested at  There are
innervation. There is decrease in high dose. muscarinic
B.P and flushing of flush area of 2. Skeletal muscle- receptors in CNS.
face. It is mediated by  Iontophoretic  I.V Ach does not
Endothelial release factor – application- cross the blood-
Nitrous oxide. contraction of muscle brain barrier.
3. Smooth Muscle- contraction of endplate  Direct injection
smooth muscles, tone and  Intraarterial Injection- produces arousal
peristalsis increased, voiding of twitching and followed by
urine, bronchospasm. fasiculation depression.
4. Glands- increased secretion of  I.V- no effect –
gland [ increase in sweating, hydrolysis of Ach.
salivation, lacrimation, trachea-
bronchial and gastric secretion].
5. Eye- contraction of Iris- Miosis
Ganglia:
 It stimulates the ganglia primarily through muscarinic The actions of Anti-
receptors. cholinesterase are
 High dose cause persistent depolarization of nicotinic similar to Ach. Relative
receptor cause transmission blockade. intensities of action
CVS:
 If it acts directly on Muscarinic receptor of heart- bradycardia,
hypotension
 If it acts on Medullary centre- stimulation followed by
depression
 Ganglionic blockade- bradycardia.
Skeletal Muscle:
 Ach released is not immediately destroyed, rebinds to the receptor, and
spreads over a larger area- twitching and fasicluations
 In high dose persistant depolarization occurs – blockade of Nero-muscular
system, resulting in weakness and paralysis.
CNS:
 Lipophillic agents cross the blood brain barrier, has a generalized alerting
response, improve cognitive function in Alzehimer patients.
 High dose- cause excitement, mental confusion, disorientation, tremor,
convulsions and death.
• USES:
• As Miotic: increased tone of ciliary muscle, decrease in intra
ocular pressure, used in open angle glaucoma.
Pilocarpine is used- rapid and short acting.
• Myasthenia Gravis: Auto immune disorder, antibodies are
formed against the Nicotinic receptor- at skeletal muscle.
Weakness and fatigability on repeated activity.
Neostigmine is given- allow Ach to accumulate and act directly
over a larger area.
• Alzheimer's disease.
 This term is restricted to those drugs which
block the action of Ach, on Autonomic
Effectors.
those which block the nicotinic receptor are
known as Ganglion blocker/ Neuromuscular
blockers.

SYNTHETIC
 Mydriatics – Tropicamide
Natural Semi-Synthetic
ANTI-CHOLINERGIC DRUGS -
 Antisecretory-
 Atropine  Antispasmodic –
Homatropin
PARASYMPATHOLYTIC Glycopyrolate
 Hyoscine  Ipratropium  Vasicoselective-
 Scopolamine bromide Oxybutynin
 Antiparkinsonian-
Procyclidin
• Has stimulant action
• Stimulate medullary centre ( vagal, respiratory and vasomotor
centres)
• Block cholinergic overactivity ( tremor is prevented in
Parkinsons)
• Anti-motion sickness properties.
CVS:
• Heart: Tachycardia dur to blockade of M2 receptor, higher the
existing vagal tone, higher is tachycardia.
• Blood Pressure: No marked effect on BP.

SMOOTH MUSCLE:
• Relaxation of smooth muscle occurs
• Tone and amplitude of contraction decreases, peristalsis is not
completely supressed as it is influenced by a number of factors like-
Enteric plexus and Non-Cholinergic transmitters.
• Bronchodilation occurs and reduced airway resistance.

GLANDULAR SECRETIONS:
Decreased salivation, sweating, lacrimation
tracheobronchial secretion

BODY TEMPERATURE:
Increase in body temperature at higher doses occur due to
inhibition of sweating as well as stimulation of
temperature regulating centre.
USES:
1. ANTI-SECRETORY:
• used for per-anaesthetic medication.
• previously used in treatment of peptic ulcer.
2. ANTI-SPASMODIC:
• Intestinal or renal colic – but NSAIDS and opioid provide better relief.
3. BRONCHIAL ASTHMA/ ASTHMATIC BRONCHITIS/ COPD: Ipratropium
bromide
4. MYDRIATIC AND CYCLOPLEGIC:
5. As CARDIAC VAGOLYTIC:
• Counteracting sinus bradycardia and partial heart block in patient with vagal tone.
6. CENTRAL ACTION:
• Mild case of Parkinson’s
• Motion Sickness
DRUGS ACTING ON AUTONOMIC
GANGLIA
Ach is primary neurotransmitter in both
sympathetic and parasympathetic
It also has Muscarinic, Adrenergic, autonomic ganglia.
dopaminergic peptidergic neuro
transmitters.
Autonomic ganglia is not merely one
transmitter but a complex system.

GANGLIONIC STIMULANT NICOTINE GANGLIONIC BLOCKERS


• Primary
Selectivealkaloid in tobacco. • Competitive
Nicotine ( low dose) Hexamethosoni
 Agonist of Nn and Nm.
Lobeline um
Dimethyl
 phenyl and
Sympathetic piperazine
Parasympathetic ganglia are stimulated in low doses.
• Persistant
• Non-selective
 Higher doses cause Nicotine ( large
persistent depolarization and ganglionic blockade.
Acetylcholine dose )
Pilocarpine
APPLIED
ASPECTS
1.INJURY TO PARASYMPATHETIC SYSTEM:
I. Damage to OCCULOMOTOR NERVE – in head injuries or due to
compression of nerve because of aneurysm, causes dilatation of pupil
and loss of visual light reflex.

II. Damage to FACIAL NERVE- in skull fracture involving temporal bone

causes impaired lacrimation in addition to paralysis of facial muscle.

III. Damage to GLOSSOPHARYNGEAL & VAGUS NERVE – stab/ bullet

injury to neck, causes loss of taste sensation and effect on various
visceral organs.

IV. Damage to SACRAL NERVES- spinal chord or corda equina injuries

causes disruption of bladder, rectal, sexual functions.
2. DISEASE INVOLVING PARASYMPATHETIC SYSTEM / ANS:
I. Diabetes Mellitus: it can cause diabetic autonomic neuropathy, and affect
the autonomic system. There is impaired autonomic control of CVS known as
Cardio-vascular Autonomic Neuropathy and causing life threatening
complications like arrhythmias, silent myocardial ischemia and sudden death.

II. Argyll-Robertson pupil: Associated with neurosyphilis, that involve the

parasympathetic fibres that run from pretectal nucleus to the Edinger-
Westphal nucleus. Pupil is fixed and do not react to light reflex. But
accommodation reflex is intact as the connection between the
parasympathetic nuclei and the constrictor pupillae muscle of the iris are
intact.

III. Adie Tonic Pupil Syndrome: decreased or absent light reflex, with slow or
delayed accomodation reflex. Disorder of parasympathetic innervation to the
IV. Frey Syndrome: Following penetrating wound around the parotid gland.
During healing the postganglionic parasympathetic fibres traveling in
auriculotemporal nerve grow out and join the greater auricular nerve which
supply the sweat gland of the face hence salivation manifests as sweating.
V. Crocodile Tears: Injury to facial nerve. During regeneration the
parasympathetic fibres that are supposed to innervate the submandibular
and sublingual gland are diverted to lacrimal glands hence reflex
lacrimation occurs on salivation.
VI. Hirschsprung Disease: It is a congenital condition where there is failure
of development of myenteric plexus in distal part of colon. The involved
part lacks the parasympathetic fibres, thus peristalsis is absent. There is
blockage and distended colon.
VII.Guillian Barre Syndrome: Rare disorder where the immune system
attacks the nerve. It causes breathing difficulties, fluctuation of blood
pressure, cardiac arrythmia and loss of bowel and bladder control.
VIII.Anticholinesterase
poisoning: SLUD
Syndrome
( increased salivation
lacrimation, urination and
defection).
Bradycardia/ Tachycardia
Muscular fasciculation,
respiratory paralysis.
Death due to respiratory
failure.
Treatment:- airway
maintenance , terminating
further exposure, atropine is
given.
IX. Disease By Botulinum Toxin: very small amount of botulinum toxin
bind to nerve plasma membrane irreversibly and prevent release of Ach. It
cause Atropine like syndrome with muscle weakness.

X. Disease By Black Widow Spider: brief release of Ach, followed by

blockade.

XI. Parkinson Disease: Parkinson's disease is a progressive nervous

system disorder that affects movement. There is impaired motor function.
Along with these there are cardio-vascular dysfunction ( chronotropic
insufficiency, decreased heart rate ) and gastric dysfunction tha are dur
involvement of parasympathetic neurons.

XII.Cholinergic Dysautonomia: impaired lacrimation, salivation, loss of

pupillary constriction, decreased gastrointestinal motility and atony of
bladder. Decreased sweating ( due to impaired sympathetic function-
 • Dental Considerations
Cholinergic drugs have limited use in dental practice. Pilocarpine
is an agonist at muscarinic receptors and can also be used to
promote salivation for the treatment of xerostomia in patients
with radiation induced salivary dysfunction. Pilocarpine is
marketed for this indication as Salagen in 10-mg tablets
administered 3 times daily. 
More selective cholinergic drugs like Cevimeline (Evoxac) is a
cholinergic agonist having greater selectivity for the M3 receptor
and is given for xerostomia at dosages of 30 mg 3 times daily.
Anticholinergic drugs may also be used as antisialagogues to
improve conditions during tedious dental procedures.
Scopolamine is very effective in this regard, but its sedative
and psychotomimetic effects may be troubling at times,
especially in geriatric patients.
Glycopyrrolate (Robinul) is a quaternary, water-soluble
compound, which limits its distribution to brain. As an
antisialagogue, it is preferred over atropine and scopolamine,
because it effectively inhibits salivation while producing less
change in heart rate and no CNS influences.
In cases where intravenous access is not in place, it is effective
following sublingual injection, but onset may require up to 5
minutes. It is also available in tablets for oral administration.
TOBACCO CESSATION: Use of tobacco is the leading cause of
cancer in the Indian population. Majority of tobacco users wish to
quit the habit but cannot as Nicotine dependency.
The main measure is counselling and motivation, but this can be
supplemented with pharmacotherapy. It reduces the craving by
satisfying the reward centre, and by suppressing the withdrawal
symptoms. This is done by Nicotinic replacement therapy.
NICOTINE TRANSDERMAL NULIFE- 1,2,4 mg
Patch applied to chest/upper For those smoking more
NICOTINE CHEWING GUM
arm/abdomen. It ameliorates than 20 cigarettes/day –
As alternative to transdermal,
symptoms of Nicotine start with 4mg, kept for 30
number of gum pieces can be
withdrawal. minutes when urge is felt.
adjusted according to need
But only partially supresses After few days tapered to
felt.
the symptoms as peak is not 2mg and 1 mg.
reached. Not more than 15 a day.
• CONCLUSION:
The knowledge of the autonomic nervous system gives us a
better understanding of the involuntary functions of the body.
Though it finds multiple uses in medicine it has a limited
application in dentistry. It can work towards providing relief in
radiation induced dry mouth, and for tobacco cessation in
patients, to prevent future advent of cancer.
 REFERENCES
B.D Chaurasia’s Human Anatomy- 6th edition
Snell’s Clinical Neuroanatomy- 7th edition
Gyton and Hall textbook of Physiology- 12th Edition
Essentials of Medical Pharmacology- K.D Tripathi- 7th edition
Waxenbaum JA, Varacallo M. Anatomy, autonomic nervous system.
InStatPearls [Internet] 2019 Mar 9. StatPearls Publishing.
Becker DE. Basic and clinical pharmacology of autonomic drugs.
Anesthesia progress. 2012 Dec;59(4):159-69.