Pulp Biology

Joyce Chia-Yi Chen, DDS

Division of Endodontics, School of Dental and Oral Surgery Columbia University

Topics
Embryology

of the dental

pulp Pulpodentin complex Pulp tissue Pulp reaction to caries and dental procedures

Embryology of the dental pulp

Early Development of Pulp

Pulp originates from ectomesenchymal cells of the dental papilla. Differentiation of odontoblasts is accomplished through an interaction among mesenchymal cells, dental epithelium, basement membrane, and proteins present in extracelluar compartment. Cells of inner enamel epithelium are important and essential participants in this differentiation process.

Early Development of Pulp

Formation of dentin by odontoblasts begins with deposition of unmineralized matrix at the cusp tip and progresses cervically. Deposition is rhythmic and regular, averaging about 4.5 m per day, and follows the crown shape that has been predetermined by the proliferative pattern of inner enamel epithelium.

Early Development of Pulp

During crown formation, growth and organization of the pulp vasculature occur. Unmylinated sensory nerves and autonomic nerves grow into pulpal tissue. Myelinated sensory nerve ingrowth is slower to develop and mature.

Root Formation

In the cervical region of the crown, the junction between the inner and outer enamel epithelia is known as the cervical loop. From this region, root formation begins, initiated as apical proliferation of the two fused epithelial structures (Hertwigs epitelial root sheath). After the first dentin has formed, the underlying basement membrane breaks up, and the innermost root sheath cells secrete a hyaline-like material over the newly formed dentin.

Root Formation

Fragmentation of Hertwigs epithelial root sheath also allows cells of the investing follicle to pass through and contact the newly formed dentin surface. Here the cells differentiate into cementoblasts and initiate cementum formation. Portions of the fragmented root sheath persist in the periodontium in close proximity to the root after root development epithelial cell rests of Malassez.

Pulp tissue

light micrograph of mature coronal pulp

Something about the Pulp

normal mandibular first molar at 50 days of postnatal life. (Reprinted from DSouza et al with permission)

A soft tissue of mesenchymal origin with specialized cells, the odontoblasts, arranged peripherally in direct contact with dentin matrix.
In many ways similar to other connective tissues of the body, including nerves, vascular tissue, connective tissue fibers, ground substance, interstitial fluid, fibroblasts, antigen-presenting cells..etc.

Unlike most tissue the pulp lacks a true collateral system and is dependent on the relatively few arteriols entering through the root foramina. Within a low-compliance environment that limits its ability to increase in volume during episodes of vasodilation and increased tissue pressure.

Careful regulation of blood flow is critically important to the vitality of the pulp.

Pulp tissue

Cells in the pulp Odontoblasts Fibroblasts Undifferentiated mesenchymal cells Immunocompetent cells

Odontoblasts
They belong to the unique group of specialized cells, like the nerve cells, that normally last the entire life of the teeth. If destroyed by trauma, inflammation or other means, replacement odontoblasts may be differentiated from undifferentiated cells in the dental pulp under favorable conditions.

The Odontoblast Porcess

Devoid of the typical organelles associated with protein synthesis Its ultrastructure demonstrates microtubules, microfilaments, granules and vesicles. The full length of odontoblast process is in the pulpal 0.1mm to 1mm of the dentin.

Undifferentiated Cells
Depending on the stimulus they may give rise to fibroblasts and odontoblasts. These precursor cells are found in the cell-rich zone adjacent to the odontoblast layer and in the pulp core associated with blood vessels.

Fibroblasts
The most common cell type in the pulp. Producing collagen and ground substance and eliminate collagen during the process of remodeling. Present throughout the pulp but tend to concentrate in the cell-rich zone.

Immunocompetent Cells
Antigen-presenting dendritic cells are present in the odontoblast layer, and macrophae-like cells are found centrally in the pulp. A small number of recirculating T cells are identifiable whereas B cells are extremely rare or undetectable. Plasma cells are absent in the normal pulp.

Extracellular matrix
Type I collagen is the predominant collagen in dentin, whereas both type I and type III collagen are found in pulp. The overall collagen content becomes more apparent with age because it is organized more as bundles.

Extracellular matrix
Pulp ground substance is composed principally of glycosaminoglycans, glycoproteins, and water. A sol-gel that supports cells and acts as medium for transport of nutrients and metabolites. The interstitial fluid is similar in composition to plasma except for less plasma proteins, favoring capillary absorption.

Blood supply in the pulp

Arterioles and venules enter and leave the dental pulp through the apical foramen. They branch and end up in a dense capillary network which is particularly predominant in the subodontoblastic region.

Blood supply in the pulp

All capillaries in the subodontoblastic layer are normally not functional at the same time. They may be filled quickly and an almost instant local or general hyperemia may be established during pulp irritation.

Blood supply in the pulp

The presence of lymphatics in the dental pulp was once a debate. However, studies have confirmed their existence. The lymphatic vessels are composed of an endothelium with opening in the walls, which permit passage of interstitial tissue fluid and remove inflammatory exudates.

Pulp tissue pressure

Compared to most other tissues, the pulpal tissue pressure seems high, 520 mmHg. The significance of a relatively high tissue pressure in a low compliance environment may be linked to a neurogenic defense mechanism that helps to protect the pulp against entry of harmful agents via exposed dentinal tubules

Innervations of the pulp

V2 and V3 of the trigeminal nerve provide the principal sensory innervation to the pulp of maxillary and mandibular teeth. Pulp also receives sympathetic innervation from T1 and T2 via the superior cervical ganglion. They causes pulpal vasoconstriction through activating alpha receptors.

Innervations of the pulp

Myelinated A- and non-myelinated Cfibers are somatic afferent nerves which carry sensory pain impulses. Stimulation of A- fibers results in fast, sharp, and relatively localized pain. Stimulation of C fibers produces pain that is slower in onset and duller and more diffuse.

Innervations of the pulp

The sensory nerve fibers, which are responsible for tooth sensation, also have a profound impact on pulpal circulation through releasing neropeptides. Release of neuropeptides from pulpal nerve endings may in fact be the earliest reaction to pulp inflammation.

Pulp-dentin organ

Developmentally, Pulp and dentin develop from the dental papilla during the bell stage of the enamel organ.

Structurally, pulpal elements such as odontoblast processes and neuronal terminals extend into the dentin

In functional aspect, 1) pulp is capable of elaborating dentin both physiologically and in response to external stimuli 2) pulp carries nerves that give dentin its sensitivity 3) encapsulation in dentin creates a low-compliance environment that influences the defense potential of the pulp

Although the dentin and pulp are basically different, they remain anatomically and functionally closely integrated throughout the life of the tooth. Thus, the two tissues are often referred to as the pulpodentincomplex.

All

procedures performed in dentin are in essence treatment of both dentin and pulp.

cavity preparation on the cervical root of a rat molar

Dentin Hypersensitivity

Pain elicited by scraping or cutting of dentin or by application of cold or hypertonic solutions.

Theories of Dentin Hypersensitivity

Direct Innervation of dentin - the nerves are present only in the inner third of the dentin - nerves are absent in root dentin - application of pain-producing and pain-relieving substances to dentin fails to elicit a nervous response.

Theories of Dentin Hypersensitivity

Odontoblasts as Receptors the odontoblast process extended only partway through dentin the odontoblast membrane potential is too low to permit transduction

Theories of Dentin Hypersensitivity

Hydrodynamic theory Brannstrom and Astrom, 1972 rapid movement of fluid in the dentinal tubules results in distortion of nerve endings in the plexus of Raschkow.

Dentin Hypersensitivity

Agents that block exposed dentinal tubules Pashley discovered that oxalate salts are effective agents to block dentinal tubules. Potassium oxalate solution forms a microcrystal consisting of calcium oxalate.

Dentin Hypersensitivity

Agents that reduce intradental nerve excitability Sodium, lithium, and aluminum compunds have little effects on reducing sensory nerve activity Potassium compounds were most effective ingredients for sensory nerve activity reduction.

Dental Caries
Affected

dentin & Infected dentin

Diagrammatic illustration of Newbruns six zones

Pulpal reaction to Caries and Dental Procedures

Pulpal Reaction to Dental Caries

A decrease in the dentin permeability dentin sclerosis dentinal tubules become partially or completely filled with apatite and whitlockite crystals

Pulpal Reaction to Dental Caries

The formation of tertiary dentin Reactionary dentin is defined as a tertiary dentin matrix secreted by surviving postmitotic odontoblast cells Reparative dentin is defined as a tertiary dentin matrix secreted by a new generation of odontoblst-like cells in response to an appropiate stimulus after the death of the original odontoblasts.

Pulpal Reaction to Dental Caries

Effects of local anesthetics on the pulp

Both infiltration and mandibular block injections cause a significant decrease in pulpal blood flow. With the ligamental injection, pulpal blood flow ceases completely for about 30 minutes when 2% lidocaine with 1: 100,000 epi. is used.

Effects of local anesthetics on the pulp

Irreversible pulpal injury is particularly apt to occur when dental procedures such as full crown preparations are performed immediately following a ligamental injection. the release and accumulation of vasoactive agents, such as substance P, during tooth preparation

Cavity and Crown preparation

It was found in a retrospective study that 11% of over 1000 restored teeth followed for a long period of time showed pulp necrosis During the preparation of a tooth and the placement of a restoration there are many steps during which pulpal damage can occur.

Frictional Heat
Blushing of teeth during or after cavity or crown preparation has been attributed to frictional heat. It represents vascular stasis in the subodontoblastic capillary plexus blood flow. A dark purplish color indicates thrombosis, and is associated with a poor prognosis.

Frictional Heat
The greatest potential for damage was within a 1- to 2- mm radius of the dentin being cut. It is imperative to utilize sufficient water cooling, well-centered burs and minimal pressure to avoid frictional heat.

Desication of dentin
When the surface of freshly cut dentin is dried with a jet of air, there is a rapid outward movement of fluid through the dentinal tubules. Fluid movement results in stimulation of the sensory nerve of the pulp and drawing odontoblasts up into the tubules. Do not overdry the cavity preparation

Remaining dentin thickness

Odontoblast cell numbers were unaffected by cavity preparation as close as 0.5mm to the pulp. Deeper cutting (less than 0.3mm from the pulp) resulted in direct odontoblast injury and cell death. It has been shown in vitro that 1mm of remaining dentin reduces the effect of a toxic material to 10% of the original level and a 2mm dentin thickness basically prevents any pulpal insult by a toxic material.

Restorative Materials

Properties of materials that produce pulp injury Acidity Absorption of water during setting Heat generated during setting Poor marginal adaptation resulting in bacterial contamination

Restorative Materials

The pulpal reaction to dental materials is mainly transitory and a manifest inflammation only occurs after bacteria or their byproducts have been able to reach the pulp. Studies have shown that when bacterial contamination can be prevented, favorable pulpal responses are seen, even to materials with established track records of being harmful to the pulp, such as silicate cement and acrylic resin

Zinc Oxide-Eugenol
Eugenol is known to be toxic, and it is capable of producing thrombosis of blood vessels when applied directly to pulp tissue. It also has anesthetic properties through blocking the transmission of action potentials in nerve fibers. Because eugenol injures cells, some authorities suggest ZOE should not used in very deep cavity preparations where there is a risk of pulp exposure.

Zinc Phosphate Cement

When a liner was omitted, severe pulpal reactions occurred in teeth where deep class V cavities were restored with zinc phosphate cement. It is likely that irritation to the pulp was due primarily to marginal leakage rather than acidity.

Zinc Polycarboxylate Cements

It is well tolerated by the pulp, being roughly equivalent to ZOE cements. This may be due to its ability to adapt well to dentin.

Composite Resins
The bond strength is less in the deep portion of a cavity compared to superficial dentin, due to a decreased area of intertubular collagen which is necessary for the formation of a hybrid layer. It is still advisable today to use a base material in the deepest part of a cavity.

Glass-Ionomer Cement
In vivo tests demonstrated only minimal pulp reactions when modified glass ionomers was evaluated in nonhuman usage models. A in vivo study of direct capping under proper hemorrhage control showed pulp healing and dentin bridge formation.

Dental Amalgam
It is well known that insertion of amalgam restorations may result in postoperative thermal sensitivity. Such sensitivity results from expansion or contraction of fluid that occupies the gap between the amalgam and the cavity wall. The use of a cavity varnish or base is recommended.

Conclusion

Knowledge of pulpal biology is essential for the development of a rational approach to treatment of pulp and associated tissues.

References
1. Mjor, I. & Heyeraas, K.(1998) Pulp-dentin and Periodontal Anatomy and Phsiology.In Essential Endodontology, (eds D. Orstavik and T.R. Pitt Ford), pp 9-4 , Blackwell Science, U.K. 2. Hasselgren, G.(1998) Treatment of the exposed dentin-pulp complex.In Essential Endodontology, (eds D. Orstavik and T.R. Pitt Ford), pp192-210, Blackwell Science, U.K. 3. Pashely, D.(2002) Pulpodentin Complex.In Seltzer and Benders Dental Pulp, (eds D. Hargreaves and Goodis), pp 63-93, Quintessence Publishing, IL 4. Okiji, T.(2002) Pulp as a connective tissue.In Seltzer and Benders Dental Pulp, (eds D. Hargreaves and Goodis), pp 95150, Quintessence Publishing, IL 5. Torneck,C.& Torabinejad, M.(1996) Biology of the dental pulp and periradicular tissues In Priciples and Practice of Endodontics, (eds Walton and Torabinejad), pp 6-28, W.B. Saunders Company, Penn.