PULP

o Introduction and definition

o History

o General overview

o Development

o The molecular basis of pulp development:

Linkage molecules

Growth factors

o Anatomy

Pulp chamber
Root canal
Foramina

Acessory canals

o Histology of the pulp

The periphery:
Odontoblast layer
Cell-poor zone
Cell-rich zone

The central pulp or the pulp proper

o Cells of the pulp

Odontoblast
Odontoblast process
Clinical importance
Relationship of structure to function
Fibroblast (pulp cell)
Macrophage

Dendritic cell

Lymphocytes
 Mesenchymal Cell

Mast cell

o Pulp metabolism
Clinical significance of pulp metabolism

o Ground substance
Significance

Degradation of the ground substances

o Fibers of the pulp

Clinical significance

o Innervation of the pulp

Distribution and organization of nerve fibers in the dentin-pulp border
zone of human teeth

o Anatomic relationships between the odontoblasts, their processes, and

the intratubular nerve endings
Clinical significance

o Vascular supply
Hemodynamics

Clinical significance: blood circulation in an inflamed pulp

o Lymphatics

Clinical significance

o Repair

o Pulp calcifications
Pulp stones
Clinical significance
 Diffuse calcifications

o Pulp changes with age

Dimensional

Structural

“regressive” changes

o Pulpal response to inflammation

o Effect of posture on pulpal pain

o Systemic distribution of substances from dentin and pulp

Clinical significance

o The connection with the periradicular region

o Calcific metamorphosis

o Tests for pulp vitality

o The reparative capacity of pulp tissue

o Modern take on classifications of pulp pathology

o Hyperemia

o Pulpitis

o Necrosis

o A note on vital pulp therapy

o Pulp Capping with MTA

 THE MODERN ASPECTS OF PULP: NEWER HORIZONS IN PULP
RESEARCH

 Tissue engineering and pulp regeneration

 Regeneration of the endodontium: microscale technologies

 Dental pulp tissue engineering with stem cells from exfoliated deciduous teeth

 Pulp revascularization as a new treatment option

 The apical papilla: the hidden treasure of pulp regeneration

 Pulp and Parkinson’s disease

 Conclusion
 PULP

INTRODUCTION AND DEFINITION

According to cohen, the pulp is a soft tissue of mesenchymal origin residing

within the pulp chamber and root canals of teeth.
As the principal source of pain within the mouth and as the major site of
attention in endodontic treatment, the pulp warrants direct inspection. By its
very location deep within the tooth, it defies visualization, other than its
appearance as radiolucent lines on radiographs.
It is a pink, coherent soft tissue is noted, obviously dependent on its normal hard
dentin shell for protection and hence, once exposed, extremely sensitive to
contact and to temperature changes.

HISTORY

The history of endodontics begins in the 17th century. Since then, there have
been numerous advances and developments, and research has proceeded
continuously.

Pierre fauchard (1678-1761), considered the founder of modern dentistry,in his

textbook “le chirurgien dentiste” precisely described the dental pulp and
dispelled the legend of the “tooth worm,” which had been considered the cause
of caries and toothaches since the time of the assyrians.

In 1746, pierre fauchard described the removal of pulp tissue.

In 1820, leonard koecker cauterized exposed pulp with a heated instrument and
protected it with lead foil.

In 1836, shearjashub spooner recommended arsenic trioxide for pulp

devitalization.

Also in 1867, magitot suggested the use of an electric current to test pulp vitality.
GENERAL OVERVIEW

The dental pulp is in many ways similar to other connective tissues of the body,
but its special characteristics deserve serious consideration. Even the mature
pulp bears a strong resemblance to embryonic connective tissue; and yet at its
periphery is a layer of highly sophisticated cells, the odontoblasts.
The pulp chamber is tilled with nerves, vascular tissue, fibers, ground substance,
interstitial fluid, odontoblasts, fibroblasts, and other minor cellular components.
Since each of these constituents is relatively incompressible, the total volume of
blood within the pulp chamber cannot be increased, although reciprocal volume
changes can occur between arterioles and venules.
No true arteries or veins enter or leave the pulp, so the circulatory system of the
pulp is actually a microcirculatory system whose largest vascular components are
arterioles and venules. Unlike most tissues, the pulp lacks a true collateral system
and is dependent upon the relatively few arterioles entering through the root
foramina and the occasional arteriole through a lateral canal. Since with age
there is a gradual reduction in the luminal diameters of these foramina, the
vascular system of the pulp decreases progressively.
The pulp is also a rather unique sensory organ. Being encased in a protective
layer of dentin, which in turn is covered with enamel, it might be expected to be
quite unresponsive to stimulation; yet, despite the low thermal conductivity of
dentin, the pulp is undeniably sensitive to thermal stimuli
Following tooth development the pulp retains its ability to form dentin
throughout life. This enables the vital pulp to partially compensate for the loss of
enamel or dentin caused by mechanical trauma or disease. How well it serves this
function depends on many factors, but the potential for regeneration and repair
is as much a reality in the pulp as in other connective tissues of the body.
Because it is the central or innermost tissue of the tooth, it is sometimes called
the endodontium.

Every person normally has 52 pulp organs, 32 in permanent and 20 in the primary
teeth. Each of these organs have a shape that conforms to that of the respective
tooth. The total volume of all the permanent teeth pulp organs is 0.38cc and the
mean volume of a single adult human pulp is 0.02 cc. Molar pulps are three to
four times larger than incisor pulps.
DEVELOPMENT

Embryologic studies have shown that the pulp is derived from the cephalic neural
crest. Neural crest cells arise from the ectoderm along the lateral margins of the
neural plate and migrate extensively. Those that travel down the sides of the
head into the maxilla and mandible contribute to the formation of the tooth
germs.
The dental papilla, from which the mature pulp arises, develops as
ectomesenchymal cells proliferate and condense adjacent to the dental lamina at
the sites where teeth will develop.
During the sixth week of embryonic life, tooth formation begins as a localized
proliferation of ectoderm associated with the maxillary and mandibular
processes. This proliferative activity results in the formation of two horseshoe-
shaped structures, one on each process, that arc termed the primary dental
laminae. Each primary dental lamina splits into a vestibular and a dental lamina.
Numerous studies have indicated that the embryonic development of any tissue
is promoted by interaction with an adjacent tissue.

THE MOLECULAR BASIS OF PULP DEVELOPMENT:

Linkage molecules

The timing and position of epithelia and mesenchyme are thought to reside in the
sequential expression of cell transmembrane linkage molecules such as integrin,
cell surface adhesion molecules (cams), and substrate adhesion molecules cams
mediate morphogenesis through controlled cell proliferation, specific cellcell
adhesion, and migration.
Cells contain membrane proteins called integrins, which are specific receptors
for cams. Laminin is the cam of basement membranes. It contains binding
domains for heparan sulfate, type iv collagen, and cells. Sams carry out cell-
matrix interactions.

Growth factors
Growth factors are polypeptides produced by cells that initiate proliferation,
migration, and differentiation of a variety of cells.
Epidermal growth factor has been shown to play a role in tooth development by
stimulating proliferation of cells in the enamel organ and preodontoblasts. It has
been hypothesized that transforming growth factor-pi (tgf-pj) may regulate
changes in the composition and structure of ecm. A fibroblast growth factor may
also be involved in the determination and differentiation of odontoblasts.
From the onset of tooth formation, a dental basement membrane(dbm) exists
between the inner dental epithelium and the dental mesenchyme. The dbm
consists of a thin basal lamina, which is formed by the epithelial cells, and a layer
of ecm derived from the dental mesenchyme. The basal lamina is composed of an
elastic network composed of type iv collagen, which has binding sites for other
basement membrane constituents
Such as laminin, fibronectin, and heparan sulfate proteoglycans. Laminin binds to
type iv collagen and also to receptors on the surface of preameloblasts and
ameloblasts. The
Dbm also contains mesenchyme-derived type i and type iii collagen, hyaluronate,
heparan sulfate, and chondroitin sulfates.
Odontoblast cell surface proteoglycans function as receptors for matrix
molecules. Signals from components of the matrix influence the migration and
differentiation of odontoblasts.
The composition of the dbm changes during tooth development, and these
alterations appear to modulate the successive steps in odontogenesis. With the
differentiation of odontoblasts, type iii collagen disappears from the predentin
matrix, and fibronectin, which surrounds preodontoblasts, is restricted to the
apical pole of mature odontoblasts.

The initial stage of development of the dental papilla is characterized by

proliferative activity beneath the dental lamina at sites corresponding to the
positions of the prospective primary teeth. Even before the dental lamina begins
to form the enamel Organ, a capillary vascular network develops within the
ectomesenchyme, presumably to support the increased metabolic activity of the
presumptive tooth buds. This primordial vascularization is thought to play a key
role in induction of odontogenesis.
Various stages can be described that leads to the formation of the dentin and the
laying down of th enamel. Its only after the beginning of the dentin formation the
papilla comes to be known as the pulp.

The bud is the initial stage of tooth development, wherein the epithelial cells of
the
Dental lamina proliferate and produce a budlikc projection into the adjacent
ectomesenchyme. The cap stage is reached when the cells of the dental lamina
have proliferated to form a concavity that produces a cap like appearance. The
outer cells of the "cap" are cuboidal and constitute the outer enamel epithelium.
The cells on the inner or concave aspect of the cap are somewhat elongated and
represent the inner
Enamel epithelium. Between the outer and inner epithelia is a network of cells
termed the stellate reticulum because of the branched reticular arrangement of
the cellular elements. The rim of the enamel organ (i.e., where the outer and
inner enamel Epithelia are joined) is termed the cervical loop.
As the cells forming the loop continue to proliferate, there is further invagination
of the enamel organ into the mesenchyme. The organ assumes a bell shape, and
tooth development enters the bell stage.
During the bell stage the ectomesenchyme of the dental papilla becomes partially
enclosed by the invaginating epithelium. Also during this stage the blood vessels
Become established in the dental papilla.

Differentiation of epithelial and mesenchymal cells into ameloblasts and

odontoblasts, respectively, occurs during the bell stage of tooth development.
This differentiation is always more advanced in the apex of the "bell" (the region
where the cusp tip will develop) than in the area of the cervical loop.
From the loop upward toward the apex the cells appear progressively more
differentiated. The preameloblasts differentiate at a faster rate than the
corresponding odontoblasts so that at any given level mature ameloblasts appear
before the odon- toblasts have fully matured. In spite of this difference in rate of
maturation, dentin matrix is formed before enamel matrix.
As the ameloblasts undergo differentiation, changes are taking place across the
basement membrane in the adjacent dental papilla. Prior to differentiation of
odontoblasts, the dental papilla consists of sparsely distributed polymorphic
mesenchymal cells with wide intercellular spaces
With the onset of differentiation a single layer of cells, the presumptive
odontoblasts (preodontoblasts), align themselves along the basement membrane
separating the inner enamel epithelium from the dental papilla. These cells stop
dividing and elongate into short columnar cells with basally situated nuclei.
Several cytoplasmic projections from each of these cells extend toward the basal
lamina. At this stage the preodontoblasts are still relatively undifferentiated.
As the odontoblasts continue to differentiate, they become progressively more
elongated and take on the ultrastructural characteristics of protein-secreting
cells. Production of the first dentin matrix involves the formation, organization,
and maturation of collagen fibrils and proteoglycans.
With the onset of dentinogenesis the dental papilla becomes the dental pulp.
As predentin matrix is formed, the odontoblasts commence to move away
toward the central pulp.
Occasionally during formation of the root sheath a break develops in the
continuity of the sheath, producing a small gap, when this occurs, dentinogenesis
does not take place opposite the defect. The result is a small "accessory" canal
between the dental sac and the pulp. An accessory canal can become established
anywhere along the root, thus creating a periodontalendodontic pathway of
communication and a possible portal
Of entry into the pulp if the periodontal tissues lose their integrity.

Few large myelinated nerves are found in the pulp until the dentin of the crown is
well advanced. At that time nerves reach the odontogenic zone in the pulp horns.
The sympathetic nerves, however follows the blood vessels into dental papilla as
the pulp begins to organize.

A large number of nerves enter the pulp prior to root formation. The plexus of
raschkow is not established until the root formation is complete.

ANATOMY

The living pulp creates and shapes its own locale in the center of the tooth. The
pulp, under normal conditions, tends to form dentin evenly, faciolingually and
[Link] pulp therefore tends to lie in the center of the tooth and shapes
itself to a miniaturization of the tooth.
This residence of the pulp is called the pulp cavity, and one speaks of its two main
parts as the pulp chamber and the root canal
The key word in understanding the gross anatomy of the pulp is “variation.”
Equally evident in any study of the pulp is the reduction in size of the chamber
and canals with age. Such reduction in size thus becomes a new variation.
In addition to changes in pulp size and shape with aging, external stimuli also
exert an effect. Caries, attrition, abrasion, erosion, impact trauma, and clinical
procedures are some of the major irritants that may cause formation of irritation
dentin. The clinician must appreciate the resultant alterations in internal
Anatomy that accompany disease and damage of the pulp and dentin.

Pulp chamber

At the time of eruption, the pulp chamber of a tooth reflects the external form of
the enamel. Anatomy is
Less sharply defined, but the cusp form is present. Often the pulp suggests its
original perimeter (and threatens its future) by leaving a filament of itself, the
pulp horn within the coronal dentin. A specific stimulus such as caries leads to the
formation of irritation dentin on the roof or wall of the chamber adjacent to the
stimulus. Of course, with time, the chamber undergoes steady reduction in size
as secondary, and irritation dentin is produced on all surfaces.

Root canal

An unbroken train of connective tissue passes from the periodontal ligament

through the apical root canal(s) to the pulp chamber. Each root is served by at
least one such pulp corridor. Actually, the root canal is subject to the same pulp-
induced changes as the chamber. Its diameter becomes narrowed, rapidly at first
as the foramen takes shape in the posteruptive months but with increasing
slowness once the apex is defined. The canal diameter tends to decrease slightly
with age; irritants such as periodontal disease may cause further constriction.

According to orban, the shape of the canal,“to a large degree, conforms to the
shape of the root. A few canals are round and tapering, but many are elliptical,
broad and thin.” A curve at the end of the root means almost invariably that the
canal follows this curve.
Meyer stated that “roots that are round and cone-shaped usually contain only
one canal, but roots that are elliptical and have flat or concave surfaces more
frequently have more canals than one”
The foramen can change in shape and location because of functional influences
on the tooth (eg, tongue pressure, occlusal pressure, mesial drift). The pattern
that develops is the reverse of the changes in the alveolar bone around the tooth.
Cementum resorption occurs on the wall of the foramen farthest from the force
and apposition on the wall nearest. The net result is a deviation of the foramen
away from the true apex.

Foramina

The anatomy of the root apex is partially determined by the number and location
of apical blood vessels
Present at the time of formation of the [Link] the tooth is young and just
erupting, the foramen is open. Islands of dentin may appear within the
mainstream of connective tissue when the root sheath has induced them, but
these islands are widely separated. Progressively, the main channel narrows. The
primary vessels and nerves, though never directly threatened with strangulation,
have a restricted passage.
Increments of cementum apposition contribute to this continuous modeling. The
possibilities of vascular branching are so varied at the apex that prediction of the
number of foramina in a given tooth becomes impossible.
It is known that the incidence of multiple foramina is high. The majority of single-
rooted teeth have a single canal that terminates in a single foramen. Less often,
they possess an apical delta, which terminates in a major channel and one or
more collateral exits. Occasionally, the delta has several channels of equal
Magnitude. Root canals of the multirooted teeth, on the other hand, tend to
have a more complex apical [Link] foramina are the rule rather than
the exception. When accessory foramina are found in one root of a multirooted
tooth, the other roots usually have a similar condition. Moreover, because the
individual roots of such teeth often contain two or even three canals, a new
factor is introduced. These canals can merge, but they need not and often do not
merge before making their exit. Indeed, each may leave the root independently.
Branching of the emergent canals within the apical area is a common finding
because the preexisting vessels are linked.
Also, cementum forms in abundance at the root apex. Because of the apposition
of new layers of cementum, in response to eruption, the foramen anatomy is by
no means constant. The center of the foramen tends to deviate increasingly from
the apical center. Also, many root canals have two apical diameters. The minor
diameter at the level of the dentinocemental junction can be as small as one half
that of the major diameter at the external surface of the root. Cementum
deposition tends to produce an apical funnel of increasing divergence.
Contributing to this is secondary dentin formation that narrows the dentinal
orifices of the canal.

According to cohen, stereomicroscopic analysis of some 700 posterior root apices

showed that at least half of the major foramina take eccentric positions that
deviate as far as 2 mm from the apex. Accessory foramina, on average, were
found to be located twice the distance of the major foramina from the vertex.

Acessory canals

Communication of pulp and periodontal ligament is not limited to the apical

region. Accessory canals are found at every level. Many of these tributaries may
get sealed by cementum or dentin, while others remain patent. The majority
appear to be encountered in the apical half of the root. These generally pass
directly from the root canal to the periodontal ligament.
A common area in which accessory canals appear is the furcation area of molar
teeth.
According to hulen and vertucci and anthony, molars frequently presented
openings in the furcation areas. However, the studies did not determine how
many of these represented patent (continuous) accessory canals all the way from
the pulp to the periodontal ligament.

HISTOLOGY OF THE PULP

Classically, the pulp is described as having two defined regions, central and
peripheral. Typically, however, studying sections of pulp under the microscope
reveals that the classic description is not consistent; levels of activity dictate
regional morphology.

The pulp is in intimate contact with the dentin and survives only through the
protection of its hard outer Covering. As the price of this protection, the pulp
contributes a cose [Link] general, the pulp demonstrates homogeneity in
its blend of cells, intercellular substance, fiber elements, vessels, and nerves.
The periphery:
Odontoblast layer
The outermost stratum of cells of the healthy pulp is the odontoblast layer. This
layer is located immediately subjacent to the predentin. Since the odontoblasts
processes are embedded within the dentinal tubules, the odontoblast layer is
composed principally of the cell bodies of odontoblasts. Additionally, capillaries
and nerve fibers maybe found among the odontoblasts.

In the coronal portion of a young pulp the odontoblasts assume a tall columnar
form. The tight packing together of these tall slender cells produces the
appearance of a palisade. The odontoblasts vary in height; consequently, their
nuclei are not all at the same level and are aligned in a staggered array. This often
produces the appearance of a layer three to five cells in thickness. Between
odontoblasts there are small intercellular
Spaces approximately 300 to 400 a in width.
The odontoblast layer in the coronal pulp contains more cells per unit area than
in the radicular pulp. Whereas the odontoblasts of the mature coronal pulp are
usually columnar, those in the midportion of the radicular pulp are more
cuboidal.
Near the apical foramen the odontoblasts appear as a flattened cell layer. Since
there are fewer dentinal tubules per unit area in the root than in the crown of
the tooth, the odontoblast cell bodies are less crowded and are able to spread
out laterally. The cell body of most of the odontoblasts borders on the predentin;
the odontoblast process,
However, passes on through the predentin into the dentin.
Between adjacent odontoblasts there are three types of specialized cell-to-cell
junctions:

Spot desmosomes (macula adherens) located in the apical part of odontoblast cell
bodies mechanically join odontoblasts together.
Numerous gap junctions (nexuses) provide low-resistance pathways through
which electrical excitation can pass between odontoblasts. These junctions are
most numerous during the formation of primary dentin.
Gap junctions and desmosomes have also been observed joining odontoblasts to
the processes of fibroblasts in the subodontoblastic area.
Tight junctions (zonula occludens) are found mainly in the apical part of
odontoblasts in young teeth. These structures consist of linear ridges and grooves
which close off the intercellular space. It appears that tight junctions determine
the permeability of the odontoblasts layer by restricting the passage of
molecules, ions, and fluid.

In addition to odontoblasts, class ii antigen-expressing dendritic cells have been

observed in the odontoblast layer.

Cell-poor zone
Immediately subjacent to the odontoblast layer in the coronal pulp there is often
a narrow zone approximately 40 µm in width that is relatively free of cells.
It is traversed by blood capillaries, unmyelinated nerve fibers, and the slender
cytoplasmic processes of fibroblasts.
The presence or absence of the cell-poor zone depends upon the functional
status of the pulp. It may not be apparent in young pulps rapidly forming dentin
or in older pulps where reparative dentin is being produced.

Cell-rich zone
Usually conspicuous in the subodontoblastic area is a stratum containing a
relatively high proportion of fibroblasts compared with the more central region
of the pulp. It Is much more prominent in the coronal pulp than in the radicular
pulp. Besides fibroblasts, the cell-rich zone may include a variable number of
macrophages and lymphocytes.
The cell-rich zone forms as a result of peripheral migration of cells populating the
central regions of the pulp, commencing at about the time of tooth eruption.
Although cell division within the cell-rich zone is a rare occurrence in normal
pulps, death of odontoblasts causes a great increase in the rate of mitosis.
Since irreversibly injured odontoblasts are replaced by cells that migrate from the
cell-rich zone into the odontoblast layer, this mitotic activity is probably the first
step in the regeneration of the odontoblast layer
The central pulp or the pulp proper

This consists of the cells and the supportive structures.

CELLS OF THE PULP

ODONTOBLAST

Because it is responsible for dentinogenesis both during tooth development and

in the mature tooth, the odontoblast is ihc most characteristic cell of the dentin-
pulp complex. During dentinogenesis the odontoblasts form the dentinal tubules,
and their presence within the tubules makes dentin a living tissue.
These cells produces a matrix composed of collagen fibers and proteoglycans that
is capable of undergoing mineralization. The ultrastructural characteristic of
odontoblasts exhibits a highly ordered rer, a prominent golgi complex, secretory
granules, and numerous mitochondria. In addition, these cells are rich in rna and
their nuclei contain one or more prominent nucleoli. These are the general
characteristics of protein-secreting cells.
Perhaps the most significant differences between odontoblasts, osteoblasts, and
cementoblasts are their morphologic characteristics and the anatomic
relationships between the cells and the structures they produce. Whereas
osteoblasts and cementoblasts are polygonal to cuboidal in form, the fully
developed odontoblast of the coronal pulp is a tall columnar cell.
In bone and cementum the osteoblasts and cementoblasts become entrapped in
the matrix as osteocytes or cementocytes respectively. The odontoblasts, on the
other hand, leave behind cellular processes to form the dentinal tubules.
Lateral branches between the major odontoblast processes interconnect the
processes through canals just as osteocytes and cementocytes are linked
together through the canaliculae in bone and cementum. This provides for
intercellular communication as well as circulation of fluid and metabolites
through the mineralized matrix.

The cell body of the active odontoblast has a large nucleus that may contain up to
four nucleoli. The nucleus is situated at the basal end of the cell and is contained
within a nuclear envelope. A well-developed golgi complex, centrally located in
the supranuclear cytoplasm, consists of an assembly of smooth-walled vesicles
and cisternae. Numerous mitochondria are evenly distributed throughout the cell
body. Rer is particularly prominent, consisting of closely stacked cisternae
forming parallel arrays that are dispersed diffusely within the cytoplasm.
Numerous ribosomes closely associated with the membranes of the cisternae
mark the sites of protein synthesis. Within the lumen of the cisternae,
filamentous material probably representing newly synthesized protein can be
observed.
Apparently the odontoblast synthesizes only type i collagen and an unusual type i
trimer having three alpha chains. In addition to proteoglycans and collagen, the
odontoblast secretes phosphophoryn, a phosphoprotein involved in extracellular
mineralization. This substance is unique to dentin and is not found in any other
mesenchymal cell lines.
Acid phosphatase activity occurs in the golgi complex and in lysosomes located in
the cell body close to the predentin. Some activity extends into the basal portion
of the odontoblasts process. It has been suggested that lysosomal enzymes such
as acid phosphatase may be involved in digesting material that has been
resorbed from the predentin matrix, possibly proteoglycans associated with
[Link] odontoblasts also secretes alkaline phosphatase, an enzyme
that is closely linked to mineralization but whose precise role is yet to be
illuminated. In contrast to the active odontoblast, the resting or inactive
odontoblast has a decreased number of organelles and may become
progressively shorter. These changes can begin with the completion of root
development.

Odontoblast process
Cytoplasmic microtubules extend from the cell body into the odontoblast
process. These straight structures follow a course that is parallel with the long
axis of the cell and impart the impression of rigidity. Although their precise role is
unknown, theories as to their functional significance suggest that they may be
involved in cytoplasmic extension, transport of materials, or simply the provision
of a structural framework.
Microtubules and microfilaments are the principal ultrastructural components of
the odontoblast process and its lateral branches. These structures have a
preferential arrangement parallel with the long axis of the process. The plasma
membrane of the odontoblast process closely approximates the wall of the
dentinal tubule. Localized constrictions in the process occasionally produce
relatively large spaces between the tubule wall and the process. Such spaces may
contain collagen fibrils and fine granular material which presumably represents
ground substance. The peritubular dentin matrix lining the tubule is
circumscribed by an electron-dense limiting membrane.
A space separates the limiting membrane from the plasma membrane of the
odontoblast process. This space is usually narrow except in areas where, as
mentioned previously, the process is constricted. The extent to which the
 odontoblast process extends outward in the dentin has been a matter of
considerable controversy.
It has long been thought that the process is present throughout the full thickness
of dentin.
However, many ultrastructural studies using scanning and transmission electron
Microscopy have described the process as being limited to the inner third of the
dentin.
On the other hand, studies employing scanning electron microscopy have
described the Process in peripheral dentin, often extending to the dej.
It has been shown1 that the lumen of the dentinal tubule is surrounded by an
electron-dense structure, the lamina limitans, which is indistinguishable from the
odontoblast process, and he has suggested that this is what others have
described as being the odontoblast process.
Using antibodies directed against microtubules, investigators have demonstrated
immunoreactivity throughout the dentinal tubule, suggesting that the process
extends throughout the entire thickness of dentin.
The odontoblast is considered to be a fixed postmitotic cell in that once it has
fully differentiated it apparently cannot undergo further cell division. If this is
indeed the case, the lifespan of the odontoblast coincides with the life-span of
the viable pulp.

Clinical importance
Since high-speed drilling can disrupt odontoblasts, it would be of considerable
clinical importance to establish conclusively the extent of the odontoblast
processes in human teeth. With this knowledge the clinician would be in a better
position to estimate the impact of restorative procedures on the underlying
odontoblast layer.

Relationship of structure to function

In experimental animals the intraperitoneal injection of collagen precursors such

as 3h-proline is followed by autoradiographic labeling of the odontoblasts and
predentin matrix.
It is now known that collagen fibrils precipitate from a solution of tropocollagen
and that the aggregation of fibrils occurs on the outer surface of the odontoblast

1
Thomas HF, and Payne RC: The ultrastructurc of dentinal tubules from erupted human premolar teeth, J Dent Res 62:532, 1983
plasma membrane. Fibrils are released into the predentin and increase in
thickness as they approach the calcification front. Whereas fibrils at the base of
the odontoblasts process are approximately 150 a in diameter, fibrils in the
region of the calcification front have attained a diameter of about 500 a.
Similar tracer studies have elucidated the pathway of synthesis, transport, and
secretion of the predentin proteoglycans. The protein moiety of these molecules
is synthesized by the rer of the odontoblast whereas sulfation and addition of the
gag moieties to the protein molecules takes place in the golgi complex. Secretory
vesicles then transport the proteoglycans to the base of the odontoblast process,
where they are secreted into the predentin matrix. Proteoglycans, principally
chondroitin sulfate, accumulate near the calcification front. The role of the
proteoglycans is speculative, but mounting evidence suggests that they act as
inhibitors of calcification by binding calcium. It appears that just before
calcification the proteoglycans are removed, probably by lysosomal enzymes
secreted by the odontoblasts.

FIBROBLAST (PULP CELL)

Fibroblasts of the pulp appear to be tissue-specific cells capable of giving rise to
cells that are committed to differentiation as odontoblasts, given the proper
signal. These cells produce the collagen fibers of the pulp, and since they degrade
collagen, they are also responsible for collagen turnover. Although distributed
throughout the pulp, fibroblasts are particularly abundant in the cell-rich zone.
The early differentiating
Fibroblasts are polygonal and appear to be widely separated and evenly
distributed within the ground substance. Cell-to-cell contacts are established
between the multiplc processes that extend out from each of the cells. Many of
these contacts take the form of gap junctions, which provide for electronic
coupling of one cell to another. Ultrastructurally the organelles of the immature
fibroblasts are generally in a rudimentary stage of development, with an
inconspicuous golgi complex, numerous free ribosomes, and sparse rer.
As they mature, the cells become stellate in form and the golgi complex enlarges,
the rer proliferates, secretory vesicles appear, and the fibroblasts take on the
characteristic appearance of protein-secreting cells. Along the outer surface of
the cell body, collagen fibrils commence to appear. With an increase in the
number of blood vessels, nerves, and fibers there is a relative decrease in the
number of fibroblasts in the pulp.
 These cells do seem to remain in a relatively undifferentiated modality as
compared to fibroblasts of most other connective tissues. This perception has
been fortified by the observation of large numbers of reticulin fibers in the pulp.
reticulin fibers, once believed to be precollagenous in nature and therefore the
product
Of immature cells, have an affinity for silver stains and are similar to the
argyrophilic fibers of the pulp.
However, in a careful review of the subject, baume concluded that because
Of distinct histochemical differences, reticulin fibers, such as those of gingiva and
lymphoid organs, are not present in the pulp. He suggested that these pulpal
fibers be termed argyrophilic collagen fibers. The fibers apparently acquire a gag
sheath, and it is this sheath that is impregnated by silver stains. In the young pulp
the nonargyrophilic collagen libers are sparse, but they progressively increase in
number as the pulpAges.
Many experimental models have been developed to study wound healing in the
pulp, particularly dentinal bridge formation following pulp exposure or
pulpotomy.
One study2 demonstrated that mitotic activity preceding the differentiation of
replacement odontoblasts appears to occur primarily among fibroblasts. Thus, it
appears that pulpal fibroblasts can be regarded as odontoprogenitor cells.

MACROPHAGE
Tissue macrophages, or histiocytes, are monocytes that have left the
bloodstream, entered the tissues, and differentiated into macrophages. These
cells are quite active in endocytosis and phagocytosis. In addition, a proportion of
macrophages participate
In immune responses as accessory cells by processing and presenting antigen to
lymphocytes.
The processed antigen is bound to class ii (la] histocompatibility antigens on the
macrophage where it can in- interact with specific receptors present on
immunocompetent t cells. Such interaction is obligatory for induction of cell-
mediated immunity. Macrophages also produce a large variety of soluble factors
including interleukin-1 and other cytokines.

2
Fitzgerald M, Chiego DJ, and Heys DR: Autoradiographic analysis of odontoblast replacement following pulp exposure in primate leelh,Arch
Oral Biol 35:707, 1990.
 DENDRITIC CELL
Dendritic cells, like macrophages, arc accessory cells of the immune system.
Similar cells arc found in the epidermis and mucous membranes, where they are
called langerhans' cells. Dendritic cells are primarily found in lymphoid tissues,
but they are also widely distributed in connective tissues, including the pulp
These cells are termed antigenpresenting cells and are characterized by, dendritic
cytoplasmic processes and the presence of cell surface class ii antigens.
Like macrophages, they phagocytose and process antigens but are otherwise only
weakly phagocytic. Together with macrophages and lymphocytes, dendritic cells
are believed to participate in immunosurveillance in the pulp.

LYMPHOCYTES
Harm and colleagues reported finding t lymphocytes and b lymphocytes in
normal pulps from human teeth. T8 (suppressor) lymphocytes were the
predominant t-iymphocyte subset present in these pulps.
Lymphocytes have also been observed in the pulps of impacted teeth.

MESENCHYMAL CELL
Some authors hold the view that primordial mesenchymal cells persist in adult
tissues as "undifferentiated" mesenchymal cells. However, during wound healing
well-differentiated fibroblasts undergo rapid serial division to give rise to new
fibroblasts.
Consequently, there is no need to postulate that in (he pulp new mesenchymal
cells arise from cells other than pulpal fibroblasts.

MAST CELL
Mast cells are widely distributed in connective tissues, where they occur in small
groups in relation to blood vessels.
One investigator3 reported the presence of mast cells in inflamed as well as
uninflamed human pulps. This cell has been the subject of considerable attention
because of its dramatic role in inflammatory reactions. The granules of mast cells

3
Farnoush A: Mast cells in human dental pulp, J Endod 10:250,1984.
 contain heparin, an anticoagulant, as well as histamine, an inflammatory
mediator.

PULP METABOLISM

The metabolic activity of the pulp has been studied by measuring the rate of
oxygen consumption and the production of carbon dioxide or lactic acid by pulp
tissue in vitro.
More recent investigations have employed the radiospirometry method.
Because of the relatively sparse cellular composition of the pulp, the rate of
oxygen consumption is low in comparison to that of most other tissues. During
active dentinogenesis, metabolic activity is much higher than following the
completion
Of crown development. As would be anticipated, the greatest metabolic activity
is found in the region of the odontoblasts layer.
In addition to the usual glycolytic pathway, the bovine pulp has the ability to
produce energy through a phosphogluconate (pentose phosphate) shunt type of
carbohydrate metabolism, suggesting that the pulp may be able to function
under varying degrees of ischemia.

Clinical significance of pulp metabolism

The pp shunt could explain how the pulp manages to withstand periods of
vasoconstriction resulting from the use of infiltration anesthesia employing
epincphrinc-containing local anesthetic agents.4

Several commonly used dental materials (e.g., eugenol, zinc oxide-eugenol,

calcium hydroxide, silver amalgam) have been shown to inhibit oxygen
consumption by pulp tissue, indicating that these agents may be capable of
depressing the metabolic
Activity of pulpal cells.5 6

4
Kim S, et al: Effects of local anesthetics on pulpal blood flow in
dogs, J Dent Res 63:650, 1984

5
Fisher AK, et al: Effects of dental drugs and materials on the rate of
oxygen consumption in bovine dental pulp, J Dent Res 36:447,1957

6
Comparative dental material cytotoxicity measured by depression of rat incisor pulp respiration, J Endod 5:48, 1979.
 One study found that application of orthodontic force to human premolars for 3
days Resulted in a 27% reduction in respiratory activity in the pulp. 7

GROUND SUBSTANCE
Ground substance comprises the matrix in which connective tissue cells and
fibers arc embedded. Whereas the fibers and cells of the pulp have recognizable
shapes, the ground substance is described as being amorphous. The cells that
produce connective tissue fibers also synthesize the major constituents of ground
substance.
Ground substance can be thought of as a sol (fluid colloidal system) or a gel that
cannot be easily squeezed out of the connective tissue. In this respect it differs
from tissue fluid that can be removed largely by drainage alone.
Early in embryonic development the ground substance is quite fluid, whereas in
mature connective tissue it tends to be viscous or [Link] may help to limit
the spread of bacteria.
The principal molecular components of interstitial ground substance arc
proteoglycans and glycoproteins. Proteoglycans consist of polysaccharide chains
(gags) linked covalcntly to a protein molecule. In the pulp the principal
proteoglycans include hyaluronic acid, dermatan sulfate, heparan sulfate, and
chondroitin sulfate.
The ability of connective tissue to retain water is ascribed to the gags. The
proteoglycan content of pulp tissue decreases approximately 50% with tooth
eruption.
During active dentinogenesis, chondroitin sulfate is the principal proteoglycan,
particularly in the odontoblastpredentin layer, where it is somehow involved with
mineralization, but with tooth eruption hyaluronic acid and dermatan sulfate
increase and chondroitin sulfate decreases greatly.
Ground substance glycoproteins help form extracellular fibrils or basement
membranes, or serve as adhesive molecules that bond to cell surfaces and other
matrix molecules. In this way they participate in the formation of connective
tissue matrices.
Fibronectin is a major surface glycoprotein that, together with collagen, forms an
integrated fibrillary network that influences adhesion, motility, growth, and
differentiation of cells.

7
Hamersky PA, Weimer AD, and Taintor JF: The effect of orthodontic
force application on the pulpal tissue respiration rate in the human
premolar, Am J Orthod 77:368, 1980
Laminin, an important component of basement membranes, binds to type iv
collagen and cell-surface receptors.
Tenascin is another substrate adhesion glycoprotein. The consistency of a
connective tissue such as the pulp is largely determined by the proteoglycan
components of the
Ground substance. The long gag chains of the proteoglycans molecules form
relatively rigid coils constituting a network that holds water, thus forming a
characteristic gel. Hyaluronic acid in particular has a strong affinity for water and
is a major component of ground substance in tissues with a large fluid content,
such as wharton's jelly.

The water content of the pulp is very high (approximately 90%).

Significance
The ground substance forms a cushion capable of protecting cells and vascular
components of the tooth. This may be ascribed to the high watrer content of the
pulp.

Ground substance also acts as a molecular sieve in that it excludes large proteins
and urea. Cell metabolites, nutrients and wastes pass through the ground
substance between cell and blood vessels. In some ways ground substance can
be
Compared to an ion-exchange resin since the polyanionic charge of the gags bind
cations.

Additionally, osmotic pressures can be altered by excluding osmotically active

molecules. Thus the proteoglycans can regulate the dispersion of interstitial
matrix solutes, colloids, and water and in large measure determine the physical
characteristics of the pulp.

Degradation of the ground substances

Degradation of ground substance can occur in certain inflammatory lesions in

which there is a high concentration of lysosomal enzymes. Proteolytic enzymes,
hyaluronidases, and chondroitin sulfatascs of lysosomal as well as bacterial origin
are examples of the hydrolytic enzymes that can attack components of the
ground substance. The pathways of inflammation and infection are strongly
influenced by the state of polymerization of the ground substance components.

FIBERS OF THE PULP

Two types of structural proteins are found in the pulp: collagen and clastin.
However, elastin fibers are confined to the walls of arterioles and, unlike
collagen, are not a part of the intercellular matrix.
A single collagen molecule, referred to as tropocollagen, consists of three
polypeptide chains, designated as either a-1 or a-2 depending upon their amino
acid composition and sequence. The different combinations and linkages of
chains making up the tropocollagen molecule has allowed collagen to be
classified into a number of types. Type i is found in skin, tendon, bone, dentin,
and pulp. Type ii occurs in cartilage.
Type ill is found in most unmineralized connective tissues. It is a fetal form found
in the dental papilla as well as the mature pulp, in the bovine pulp it comprises
45% of the total pulp collagen during all stages of development. Type iv collagen
is found only in basement membranes.
In collagen synthesis the protein portion of the molecule is formed by the
polyribosomes of the rer of connective tissue cells. The proline and iysine
residues of the polypeptide chains are hydroxylated in the cisternae of the rer,
and the chains are assembled into a triple helix configuration in the smooth
endoplasmic reticulum. The product of this assembly is termed procollagen, and
it has a terminal unit of amino acids known as the telopeptide of the procollagen
molecule. When these molecules reach the golgi complex, they arc glycosylated
and packaged in secretory vesicles. The vesicles are transported to the plasma
membrane and secreted via exocytosis into the extracellular milieu, thus
releasing the procollagen. Here the terminal telopeptide is cleaved by a
hydrolytic enzyme and the tropocollagen molecules begin aggregating to form
collagen fibrils. It is believed that aggregation of tropocollagen is somehow
mediated by the gags. The conversion of soluble collagen into insoluble fibers
occurs as a result of cross-linking of tropocollagen molecules.
The small collagen fibers of the pulp stain black with silver impregnation stains
and are thus referred to as argyrphilic fibers. Collagen fibers in the young pulp
are characteristically small and irregularly oriented.
 The presence of collagen fibers passing from the dentin matrix between
odontoblasts into the dental pulp has been reported in fully erupted teeth. These
fibers are often referred to as von korfffibers.
Larger collagen fiber bundles, more often seen in older pulps, are not argyrophilic
but can be demonstrated with special histochemical methods such as gomori's
trichrome stain or mallory's blue. The highest concentration of these larger fiber
bundles is usually found in the radicular pulp near the apex.

Clinical significance
Torneck8 advises that, during pulpectomy, if the pulp is engaged with a barbed
broach in the region of the apex this generally affords the best opportunity to
remove it intact.

INNERVATION OF THE PULP

The pulp is a sensory organ capable of transmitting information from its sensory
receptors to the central nervous system. Regardless of the nature of the sensory
stimulus (i.e., thermal change, mechanical deformation, injury to the tissues),
All afferent impulses from the pulp result in the sensation of pain. The
innervation of the pulp includes both afferent neurons, which conduct sensory
impulses, and autonomic- fibers, which provide neurogenic modulation of the
microcirculation and perhaps regulate dentinogenesis, too.

In addition to sensory nerves, sympathetic fibers from the superior cervical

ganglion appear with blood vessels at the time the vascular system is established
in the dental papilla.
In the adult tooth sympathetic fibers form plexuses, usually around pulpal
arterioles. Stimulation of these fibers results in constriction of the arterioles and
a decrease in blood flow.
Sympathetic fibers have also been found lying independent of blood vessels in
close association with the region of the odontoblasts.
Both adrenergic and cholinergic fibers have been found in close relation to
odontoblasts. It is thought that autonomic nerve fibers may somehow be
involved in the regulation of dentin formation.

8
Torneck CD: Dentin-pulp complex. In Ten Cate AR: Oral histology; development, structure, and function, ed 2, St. Louis, 1985, Times Mirror
Vlosby College Publishing
Classification of nerve fibers (according to cohen)

Type or fiber function diameter velocity

conduction (hin) (m/s)

An motor, proprioception 12-20 70-120

A-p pressure, touch 5-12 30-70

Ah motor, to muscle 3-6 15-30

spindles

A-δ pain, temperature, 1-5 6-30

touch

B preganglionic <3 3-15

autonomic

C dorsal root pain 0.4-1.0 0.5-2

Sympathetic post ganglionic 0.3-1.3 0.7-2.3

Most of the nerves of the pulp fall into two main categories, a-δ and c with
following characterstics:

Fiber myelination location of terminals pain characteristics stimulation

threshold

A- δ yes principally in region of sharp, pricking relativelylow

pulp-dentin junction

C no probably distributed burning, less bearable relativelyhigh

throughout pulp aching injury
associated
 During the bell stage of tooth development, "pioneer" nerve fibers enter the
dental papilla following the path of blood vessels. While only unmyelinated
fibers arc observed in the dental papilla, a proportion of these libers are probably
a fibers that have not yet become myelinated. Myelinated fibers are the last
major structures to appear in the developing human dental pulp.
The number of nerve fibers gradually increases and some branching occurs as the
fibers near the dentin, but during the bell stage very few fibers enter the
predentin. The sensory nerves of the pulp arise from the trigeminal nerve and
pass into the radicular pulp in bundles via the foramen in close association with
arterioles and venules.
Each of the nerves entering the pulp is invested within a schwann cell, and the a
fibers acquire their myelin sheath from these cells. With the completion of root
development the myelinated fibers appear grouped in bundles in the central
region of the pulp. Most of the unmyelinated c fibers entering the pulp are
located within these fiber bundles;
The remainder are situated toward the periphery of the pulp.

In a study9 on the human premolar, it was found the numberof unmyelinated

axons entering the tooth at the apex reached a maximum number shortly after
tooth eruption. At this stage they observed an average of 1800 unmyelinated
axons and upwards of 400 myelinated axons, although in some teeth fewer than
100 myelinated axons were present. The number of a fibers gradually increased
to upwards of 700 five years
After eruption.

The nerve bundles pass upward through the radicular pulptogether with blood
vessels. Once they reach the coronal pulp, they fan out beneath the cell-rich
zone, branch into smaller bundles and finally ramify into a plexus of single nerve
axons known as the plexus of raschkow.
Full development of this plexus does not occur until the final stages of root
formation. It has been estimated that each fiber entering the pulp sends at least
eight branches to the plexus of raschkow, there is prolific branching of the fibers
in the plexus, producing a tremendous overlap of receptor fields. It is in the
plexus that the a fibers emerge from their myelin sheaths and, while still within

9
Johnsen DC, Harshbarger J, and Rymer HD: Quantitative assessment
of neural development in human premolars, Anat Rec 205:421,
1983.
 schwann cells, branch repeatedly to form the subodontoblastic plexus. Finally,
terminal axons exit from their schwann cell investiture and pass between the
odontoblasts as free nerve endings.

DISTRIBUTION AND ORGANIZATION OF NERVE FIBERS IN THE DENTIN-PULP

BORDER ZONE OF HUMAN TEETH

There are simple fibers that run from the subodontoblastic nerve plexus towards
the odontoblast layer but do not reach the predentin. These fibers terminate in
extracellular spaces in the cell-rich zone, the cell-poor zone, or the odontoblast
layer.

Other fibers extend into the predentin and run straight or spiral through a
dentinal tubule in close association with an odontoblast process. Most of these
intratubular fibers extend into the dentinal tubules for only a few microns, but a
few may penetrate as far as 100 or so microns.

Complex fibers that reach the predentin and branch extensively. The area
covered by a single such terminal complex often reached thousands of square
microns.

ANATOMIC RELATIONSHIPS BETWEEN THE ODONTOBLASTS, THEIR

PROCESSES, AND THE INTRATUBULAR NERVE ENDINGS

These fibers lie in a groove or gutter along the surface of the odontoblast
process. Toward their terminal ends the nerve fibers twist around the process
like a corkscrew. The cell membranes of the odontoblasts process and the nerve
fiber are closely approximated and run closely parallel for the length of their
proximity.
Intratubular nerve endings are most numerous in the area of the pulp horns
where as many as one in four tubules contain fibers. The number of intratubular
fibers decreases in other parts of the dentin, and in root dentin only about one
tubule in ten contains a fiber.
the functional significance of the intratubular fibers is by no means established,
and there is still some question as to whether they are autonomic or sensory
 fibers. It has even been suggested that they may be passively trapped in the
tubules during the final stage of dentin formation.

Note that the pulpal cell odontoblast dies not act like a receptor.

In addition to sensory nerves, sympathetic fibers from the superior cervical

ganglion appear with blood vessels at the time the vascular system is established
in the dental papilla. In the adult tooth sympathetic fibers form plexuses, usually
around pulpal arterioles. When stimulated, these fibers cause constriction of the
arterioles, resulting in a decrease in blood flow.
Sympathetic fibers have also been found lying independent of blood vessels in
the region of the odontoblasts. It is thought that these nerve endings may be
involved in the regulation of dentin formation.
One study reported finding both adrenergic and cholinergic nerve endings among
the odontoblasts10.
Another study showed that a reduction in pulpal blood flow induced by
stimulation of sympathetic fibers leading to the pulp results in depressed
excitability of pulpal a fibers11.
The excitability of c fibers is less affected than that of a fibers by a reduction in
blood flow.
Pulpal nerve fibers contain neuropeptides such as neuropeptide y, calcitonin
gene-related peptide (cgrp), vasoactive intestinal polypeptide (vip), tyrosine
hydroxylase, and substance p . Release of these peptides can be triggered by
such things as tissue injury, complement activation, antigen-antibody reactions,
or antidromic stimulation of the in ferior alveolar nerve. Once released,
vasoactive peptides produce vascular changes that are similar to those evoked
by histamine and bradykinin.

Clinical significance

The electric pulp tester delivers a current sufficient to overcome the resistance of
enamel and dentin and stimulate the a-δ fibers at the pulp-dentin border zone. C
fibers of the pulp do not respond to the conventional pulp tester because
significantly more current is needed to stimulate them.
10
Avery JK, Cox CF, and Chiego DJ Jr: Presence and location of adrenergic nerve endings in the dental pulps of mouse molars, Anat Rec
198:59, 1980.

11
Edwall L, and Scott D Jr: Influence of changes in microcirculation on the excitability of the sensory unit in the tooth of the cat, Ada Physiol
Scand 82:555, 1971.
Bender and others found that in anterior teeth the optimum placement site of
the electrode is the incisal tooth edge, as the response threshold is lowest at the
incisal edge and increases as the electrode is moved toward the cervical region of
the tooth.

Of considerable clinical interest is the evidence that nerve fibers of the pulp are
relatively resistant to necrosis. This is apparently due to the fact that nerve
bundles in general are
More resistant to autolysis. Even in degenerating pulps, the nerve fibers could
still respond to stimulation. It may be that c fibers remain excitable even after
blood flow has been compromised in the diseased pulp, for c fibers are better
able to maintain their functional integrity in the presence of hypoxia. This may
help to explain why instrumentation of the root canals of apparently nonvital
teeth sometimes elicits pain.

VASCULAR SUPPLY

Hemodynamics

Blood from the dental artery enters the tooth via arterioles having diameters of
100 p.m or less. These vessels pass through the apical foramen or foramina in
company with nerve bundles. Smaller vessels may enter the pulp via lateral or
accessory canals. The arterioles course up through the central portion of the
radicular pulp and give off branches that spread laterally toward the odontoblast
layer, beneath which they ramify to form a capillary plexus.
As the arterioles pass into the coronal pulp, they fan out toward the dentin,
diminish in size, and give rise to a capillary network in the subodontoblastic
region. This network provides the odontoblasts with a rich source of metabolites.
Capillary blood flow in the coronal portion of the pulp is nearly twice that in the
root portion. Moreover, blood flow in the region of the pulp horns is greater than
in other Areas of the pulp.
The subodontoblastic capillaries are surrounded by a basement membrane, and
occasionally fenestrations (pores) are observed in their [Link] fenestrations
are thought to provide rapid transport of fluid and metabolites from the
capillaries to the adjacent odontoblasts.
In young teeth, capillaries commonly extend into the odontoblasts layer, thus
assuring an adequate supply of nutrients for the metabolically active
odontoblasts.

Blood passes from the capillary plexus first into postcapillary venules and then
into progressively larger venules. Venules in the pulp have unusually thin walls,
which may facilitate the movement of fluid in or out of the vessel. The muscular
coat of these venules is thin and discontinuous.
The collecting venules become progressively larger as they course to the central
region of the pulp. The largest venules have a diameter that may reach a
maximum of 200 µm; thus they are considerably larger than the arterioles of the
pulp .

Arteriovenous anastomoses (avas) may be present in both the coronal and

radicular portions of the pulp, particularly in the latter. Such vessels provide a
direct communication between arterioles and venules, thus bypassing the
capillary bed. The avas are relatively small venules, having a diameter of
approximately 10 µm. It is hypothesized that the avas play an-important role in
the regulation of the pulp circulation. Theoretically they could provide a
mechanism for shunting blood away from areas of injury where damage to the
microcirculation may result in thrombosis and hemorrhage.

Among the oral tissues, the pulp has the highest volume of blood flow, but it is
substantially lower than blood flow in the major visceral organs. This reflects the
fact that the respiratory rate of pulp cells is relatively low.

Among the oral tissues, the pulp has the highest volume of blood flow, but it is
substantially lower than blood flow in the major visceral organs. This reflects the
fact that the respiratory rate of pulp cells is relatively low.

Activation of a-adrenergic receptors by the administration of epinephrine

containing local anesthetic solutions may result in a marked decrease in pulpal
blood flow.
Clinical significance: blood circulation in an inflamed pulp

A unique feature of the pulp is that it is rigidly encased within dentin. This places
k in a lowcompliance environment, much like the brain and bone marrow. Thus,
pulp tissue has limited ability to expand, so vasodilatation and increased vascular
permeability evoked during an inflammatory reaction result in an increase in
pulpal hydrostatic pressure. Presumably, any sudden rise in intrapulpal pressure
would be distributed equally within the area of pressure increase, including the
blood vessels. Theoretically,
If tissue pressure increases to the point that it equals the intravascular pressure,
the thin-walled venules would be compressed, thereby increasing vascular
resistance and reducing pulpal blood flow. This could explain why injection of
vasodilators such as bradykinin into an artery leading to the pulp results in a
reduction rather than an increase in pulpal blood flow.
However, it is possible that an increase in intrapulpal tissue pressure would
promote absorption of tissue fluid back into the blood and lymphatic vessels,
thus reducing The pressure. In this case blood flow could increase, in spite of a
marked elevation in tissue pressure.

LYMPHATICS
The presence of pulpal lymphatics is disputed. However, lymphatics have been
identified in the pulp at the ultrastructural and histologic levels by the absence of
red blood cells in their lumina, the lack of overlapping of endothelial margins, and
the
Absence of a basal lamina. They arise as lymphatic capillaries in the peripheral
pulp zone
and join other lymph capillaries to form collecting [Link] vessels unite
with progressively larger lymphatic channels that pass through the apex with the
other vasculature. Numerous authors, using both histologic and functional
methods, have described extensive anastomoses between lymph vessels of the
pulp, periodontal
Ligament, and alveolar bone.

The structural identification of lymph capillaries complements the functional

studies of
Walton and langeland who demonstrated that substances placed in the pulp
chamber can be found in regional lymph nodes. The open endothelial margins
and incomplete basal lamina permit entry of large molecules and even bacteria.

Clinical significance

The fact that materials placed on pulps can migrate to lymph node indicates the
possibility of immunologic reactions to substances that enter the pulp.

The lymphatics may collapse as pulp pressure rises, thus inhibiting removal of
irritants and fluid.

The anastomoses of pulpal, periodontal, and alveolar lymphatics may be

important routes for the spread of pulpal inflammation into adjacent tissues
during the removal of irritants and fluid from the pulp.

REPAIR
The inherent healing potential of the dental pulp is well recognized. As in all
other connective tissues, repair of tissue injury commences with debridement by
macrophages followed by proliferation of fibroblasts, capillary buds, and the
formation
Of collagen. Local circulation is of critical importance in wound healing and
repair. An adequate supply of blood is essential to transport inflammatory
elements into the area of pulpal injury and to provide the young fibroblasts with
nutrients from which to synthesize collagen. Unlike most tissues, the pulp has
essentially no collateral circulation; and for this reason it is theoretically more
vulnerable than most other tissues. Thus, in the case of severe injury, healing
would be impaired in teeth with a limited blood supply. It is well recognized that
the highly cellular pulp of a young tooth, with a wide open apical foramen and
rich blood supply, has a much better healing potential than does an older tooth,
with a narrow foramen and a restricted blood supply.

PULP CALCIFICATIONS

Basically, there are two distinct types of pulpal calcifications: formed structures
commonly known as pulp stones (denticles) and tiny crystalline masses generally
termed diffuse (linear) calcifications. Pulp stones seem to be found
 predominantly in the coronal pulp, whereas the calcifications found in radicular
pulp seem to be of the diffuse variety.

Calcifications are common in the dental pulp, with a tendency to increase with
age and irritation. It has been speculated that these calcifications may aggravate
or even incite inflammation of pulp or may elicit pain by pressing on structures;
however, these speculations have not been proved and are improbable. Although
These calcifications are not pathologic, their presence under certain conditions
may be an aid in diagnosis of pulpal disease. Moreover, their bulk and position
may interefere with endodontic treatment.

PULP STONES

These discrete calcific masses appear with frequency in mature [Link] there is
increased incidence with age, they are not uncommon in young teeth.

It has also been demonstrated that their occurrence and size often increase with
external irritation. Pulp stones also may arise spontaneously; their presence has been
identified on radiographs and, on histologic examination, even in impacted teeth.

Interestingly, there appears to be a predisposition for pulp stone formation in certain

individuals, possibly a familial trait.
Pulp stones have been classified as two types, true or false.
True pulp stones are islands of dentin, demonstrating tubules and formative
odontoblasts on their surface. However, serial sectioning has shown that these are not
Islands but peninsulas—extrusions from dentin walls. Therefore, the term “denticle,”
which would imply dentin structure, is a misnomer. The term “pulp stone” is more
correct, particularly because the “false” pulp stone so closely resembles gallstones and
Kidney or ureter stones. Pulp stones, like other types of stones, are formed from clearly
concentric or diffuse layers of calcified tissue on a matrix that seems to consist primarily
of collagen. Their structure may help explain their origin; it has been shown that
potential nidi of pulp stones may occur in the sheaths associated with blood vessels
And nerves. Other potential nidi are calcifications of thrombi in vessels or calcification of
Clumps of necrotic cells. Whatever the nidus, growth is by incremental layering of a
matrix that quickly acquires mineral salts.
Pulp stones are also classified according to location. “free” stones are those that are
islands, “attached” stones are free pulp stones that have become fused with the
continuously growing dentin, and “embedded” stones are formerly attached stones that
have now become surrounded by dentin.

Clinical significance

Pulp stones may be important to the clinician who attempts access preparation or to
negotiate canals. Either free or attached denticles may attain large size and occupy
considerable volume of the coronal pulp. Their presence may alter the internal anatomy
and confuse the operator by obscuring, but not totally blocking, the orifice of the canal.
Attached denticles may deflect or engage the tip of exploring instruments in the canals,
thus preventing their easy passage down the canal.

Pulp stones of sufficient size are readily visible on radiographs, although the majority are
too small to be seen except on histologic examination. The large, discrete masses,
occasionally appearing to nearly fill the chamber are likely to be those of natural
occurrence. The chamber that appears to have a diffuse and obscure outline may
represent a pulp that has been subjected to a persistent irritant and has responded by
forming large numbers of irregular pulp stones. This finding is a diagnostic aid and
indicates a pulp exposed to a persistent chronic irritant.

DIFFUSE CALCIFICATIONS

also known as linear calcifications because of their longitudinal orientation.

They may appear in any area of the pulp but predominate in the radicular region. Their
form is that of tiny calcified spicules, usually aligned close to blood vessels and nerves or
to collagen bundles. Because of their size and dispersion, they are not visible in
radiographs and are seen only on histologic specimens. Like pulp stones, diffuse
calcifications also tend to increase with age and with irritation but otherwise have no
known clinical significance.

PULP CHANGES WITH AGE

Teeth age, not only with the passage of time but also under the stimulus of function and
irritation. Therefore, age is a chronologic occurrence, but even more importantly, an
“aged” tooth may represent a premature response to the abuses of caries, extensive
restorative procedures, and inflicted trauma. Since the pulp reacts to its environment
and is in intimate contact with dentin, it responds to abuses by altering the anatomy of
its internal structures and surrounding hard tissue.

Dimensional
With time and/or injury, the pulp volume decreases by forming additional calcified
tissues on the walls. Ordinarily, with time, formation of dentin continues, with the
greatest increase on the floor of the chamber of posterior teeth and on the incisal of
anterior teeth. In such teeth, the location of the pulp chamber and/or root canals may
be difficult. In anterior teeth, the clinician may have to search cervically to locate a
remnant of the chamber. In molars, dentin formation may have rendered the chamber
almost disk-like; while searching, it is easy to inadvertently pass a bur through the
flattened chamber. If the preparation is continued, the next hemorrhage encountered
will arise from the furcation, not from the chamber. Careful examination of radiographs
to identify chamber size and location, followed by measurements of the
occlusochamber distance, will prevent this mishap. Irritation dentin formation will also
alter internal anatomy. Therefore, when the dentin has been violated by caries or by
attrition, one should expect increased amounts of hard tissue in the underlying
Pulp. Irritation dentin may occasionally be extensive enough to obscure or fill large
areas of the chamber.

Structural
Although exacting quantitative studies have not been published, there is agreement that
the number of cells decreases and the fibrous component increases with aging of the
pulp. The increased fibrosis with time is not from continued formation of collagen
But rather may be attributable to a persistence of connective tissue sheaths in an
increasingly narrowed pulp space.
Bernick observed a decrease in the number of blood vessels and nerves supplying the
aging pulp, noting that many of the arteries demonstrated arteriosclerotic changes
similar to those seen in other tissues. These changes involve decreases in lumen size
with intimal thickening and hyperplasia of elastic fibers in the media. Also common is
calcification of arterioles and precapillaries. Although these structural changes are
described, it is not clear whether the vascular and neural changes alter the function of
The older pulp.
Not only do cells decrease in number, notably fibroblasts and odontoblasts, but the
remaining cells are likely to appear relatively inactive. These ordinarily active cells
demonstrate fewer organelles associated with synthesis and secretion.
“regressive” changes
The term “regressive” is defined as a condition of decreased functional capability or of
returning to a more primitive state. Older pulps have been described as regressive and
as having a decreased ability to combat and recover from injury. This has been surmised
because older pulps have fewer cells, a less extensive vasculature, and increased fibrous
elements. In fact, there have never been experiments proving that aged pulps are more
susceptible to irritants or less able to recover. Until these have been conclusively
demonstrated, the term “regression” is not appropriate, and the dentist should not
assume that pulps in older individuals are less likely to respond favorably than are
younger pulps.

Pulpal response to inflammation

Pulp structures and functions are altered, often radically, by injury and resulting
[Link] a part of the inflammatory response, neutrophilic leukocytes are
Chemotactically attracted to the site. Bacteria or dying pulp cells are phagocytosed,
causing release of potent lysosomal enzymes. These enzymes may attack surrounding
Normal tissue, resulting in additional damage. For instance, by-products of the
hydrolysis of collagen and fibrin may act as kinins, producing vasodilation and increased
vascular permeability. Escaping fluid tends to accumulate in the pulp interstitial space,
but because the space is confined, the pressure within the pulp chamber rises. This
elevated tissue pressure produces profound, deleterious effects on the local
microcirculation. When local tissue pressure exceeds local venous pressure, the local
veins tend to collapse, increasing their resistance; hence blood will flow away from this
area of high tissue pressure as it seeks areas of lower resistance. This process of blood
Diversion can be illustrated by applying slight pressure to the end of a fingernail. As the
pressure increases, the nail bed blanches as blood is squeezed out of the local vessels,
and new blood is prevented from flowing through this area of elevated tissue pressure.
Persistent pressure continues to compromise circulation. The consequences of reduced
local blood flow are minor in normal tissue but disastrous in inflamed tissue because
The compromised circulation allows the accumulation of irritants such as injurious
enzymes, chemotoxic factors, and bacterial toxins.
This event may lead to the development of the “compartment
Syndrome,” a condition in which elevated tissue pressure in a confined space alters
structure and severely depresses function of tissues within that space. Depressed
function often leads to cell death, which, in turn, produces inflammation resulting in
fluid escape and increased pressure within the compartment.
The increased tissue pressure collapses veins, thereby increasing the resistance to blood
flow through capillaries. Blood is then shunted from areas of high tissue pressure to
more “normal” areas. Thus, a vicious cycle is produced in which inflamed regions tend
to become more inflamed because they tend to limit their own local nutrient blood
flow.
This is not to say that the pulp “strangulation” theory is [Link] shown by van hassel,
and more recently by nahri and tönder and kvinnsland,pressures are not readily
transmitted throughout the pulp. Therefore, inflammation and increased pressure in the
Coronal pulp will not collapse veins in the apical region. Pulps physiologically have
multiple compartments throughout. It is as if small volumes of pulp tissue are enclosed
in separate connective tissue sheaths, each of which can contain local elevations in
tissue pressure.
Although no histologic evidence exists to support this notion, these functional
compartments may break down individually to become necrotic and may coalesce
To form microabscesses.
The micropuncture work by tönder and kvinnsland demonstrated that there are highly
localized elevations in interstitial tissue pressure in inflamed pulp. This is thought by
some to be caused by the release of vasoactive neuropeptides such as substance p
And calcitonin gene–related peptide, both found in pulp nerve fibers. During pulpal
inflammation, there is an increase in the number of calcitonin gene–related peptide–
containing nerves in areas previously devoid of nerves. The release of these peptides
seems to promote and sustain inflammation, prompting some to call it neurogenic
inflammation.

EFFECT OF POSTURE ON PULPAL PAIN

Whenever an appendage is elevated above the heart, gravity acts on blood on the
arterial side to reduce the effective pressure and, hence, appendage blood flow. This is
why one’s arm rapidly tires when working overhead. The reduced pressure effect occurs
in structures in the head that, in normal upright posture, are well above the heart.
When the patient lies down, however, the gravitational effect disappears, and there is a
significant increase in pulp blood pressure and corresponding rise in tissue pressure
over and above that caused by endogenous mediators of inflammation. In this position,
an irritated and inflamed pulp becomes more sensitive to many stimuli and may
spontaneously begin to fire a message of pain. This is why patients with pulpitis
frequently call their dentists after lying down at night. In the supine position, a higher
perfusion pressure and, presumably, a higher tissue pressure develop in the patient,
which cause more pulp pain. Patients often discover that they are more comfortable if
they attempt to sleep sitting up, which again emphasizes the effects of gravity on pulp
blood flow.
Another factor contributing to elevated pulp pressure on reclining is the effect of
posture on the activity of the sympathetic nervous system. When a person is upright,
the baroreceptors (the so-called “carotid” sinus), located in the arch of the aorta and
the bifurcation of the carotid arteries, maintain a relatively high degree of sympathetic
stimulation to organs richly innervated by the sympathetic nervous system.

Tönder demonstrated that canine pulps showed large reductions in blood flow when the
baroreceptor system was manipulated. If the human dental pulp is similar, it would
result in slight pulpal vasoconstriction whenever a person is standing or sitting upright.
Lying down would reverse the effect with an increase in blood flow and tissue pressure
in the pulp. Lying down, then, increases pulp blood flow by removing both the effects of
gravity and the effects of baroreceptor nerves, which decrease pulpal vasoconstriction.
Thus, the increase in pain from inflamed pulps at night or the transformation of the pain
from a dull to a throbbing ache has rational physiologic bases.

SYSTEMIC DISTRIBUTION OF SUBSTANCES FROM DENTIN AND PULP

The rate of blood flow in the pulp is moderately high and falls between that of organs of
low perfusion, such as skeletal muscle, and highly perfused organs, such as the brain or
kidney. Since dentinal fluid (the fluid filling the tubules) is in communication with the
vasculature of the pulp, in theory, substances placed directly on pulp or dentin diffuse to
the interstitial fluid and are quickly absorbed into the bloodstream or into the
lymphatics. In vivo evidence indicates that both may occur. Numerous authors have
demonstrated that substances placed onto dentin or into pulp chambers are absorbed
systemically. These substances include radioactive labeled cortisone, tetracycline, lead,
formocresol,glutaraldehyde,and camphorated monochlorophenol.

This direct communication of dentin to systemic circulation was proved by pashley,who

demonstrated
That radioactive iodide and albumin placed on dog dentin rapidly gave measurable
blood levels of the substances.
Systemic absorption of substances following pulp application was shown by myers and
colleagues, who measured the systemic appearance of i from pulpotomy sites in
monkeys both before and after treatment of the pulp stumps with formocresol.
Similar studies have recently been completed using 14c-formaldehyde and 14c-
glutaraldehyde. Barnes and langeland demonstrated that circulating antibodies were
formed against bovine serum albumin and sheep erythrocytes placed on exposed pulps
of monkeys.
Thus, the pulp provides an access route not only to the systemic circulation but also to
the lymphatic system.

Clinical significance

The relationship of teeth to the cardiovascular and lymphatic systems is intimate and
absolute. Clinicians should remember this when performing dental procedures since
their placement of materials on dentin or pulp may result in widespread distribution of
that material or medicament.

THE CONNECTION WITH THE PERIRADICULAR REGION

At the periapex, the connective tissues of root canal, foramen, and periradicular zone
form a tissue continuum that is inseparable. This intimate relationship is confirmed by
the frequency of disease in the pulp, inciting disease beyond the [Link] both the
pulp and periapex are jointly involved, immediate therapy must often focus on the
periradicular region. More commonly, only pulp therapy is necessary. Healing of the
periradicular tissue generally occurs spontaneously, demonstrating its capacity to repair.
During preparation of the pulp space, the cardinal principles of instrumentation and
obturation, aimed at confining everything to the canal space, indicate how necessary it
is to respect the periradicular connective tissue.

CALCIFIC METAMORPHOSIS

Luxation of teeth as a result of trauma may result in calcific metamorphosis, a condition

that can in a matter of months or years lead to partial or complete radiographic
obliteration of the pulp chamber. The cause of radiographic obliteration is excessive
Deposition of mineralized tissue resembling cementum or, occasionally, bone on the
dentin walls. Histologic examination invariably reveals the presence of some soft tissue,
and cells resembling cementoblasts can be observed lining the mineralized tissue.

Clinically, the crowns of teeth affected by calcific metamorphosis may show a yellowish
hue as compared with adjacent normal teeth. This condition usually occurs in teeth with
incomplete root formation. Trauma results in disruption of blood vessels entering the
tooth, thus producing pulpal infarction. The wide periapical foramen allows connective
tissue from the periodontal ligament to proliferate and replace the infarctcd tissue,
bringing with it cementoprogenitor and osteoprogenitor cells capable of differentiating
into either cementoblasts or osteoblasts, or both.

TESTS FOR PULP VITALITY

Thermal tests
Heat tests provide the most reliable information regarding the health or degree of
inflammation of the pulp. Patients frequently complain of pain following changes in
temperature. A necrotic or inflamed pulp responds in a very different manner from a
healthy pulp to thermal stimuli. Healthy pulp is normally sensitive to hot or cold stimuli,
and this sensitivity will disappear shortly after the stimulus is removed. A necrotic or
inflamed pulp, on the other hand, either does not respond or responds in an
exaggerated and prolonged manner.
When performing tests that duplicate the patient’s symptoms and thus reproduce their
pain, one must first have the patient experience the response of a normal pulp before
proceeding to test the suspect tooth or teeth. In other words, one must always begin
from the least suspect tooth, so as to minimize the patient’s natural anxiety. The teeth
must then be dried and isolated with cotton rolls.

Heat test: this is performed by heating a piece of gutta-percha wrapped around the
handle of a spatula or an old instrument with a flame the gutta-percha is heated to the
point at which it is nearly too hot to be touched, but no more than about 65° c. It is
placed on the apical third of the buccal surface, where the enamel is thinnest. Like the
electric test, the heat test assesses dentinal sensitivity and therefore must be performed
where the enamel, a poor conductor of heat and electricity, is thinnest.
The heat test can also be performed using the “touch’n heat” or the “system b” devices with the
specially designed tip.
To perform the heat test on teeth with full gold crowns, one can use a polishing rubber
disk in a rotary handpiece revolving at a low speed, generating frictional heat against
the metal. If the tooth is covered by a ceramic-metal crown, the test is performed at the
lingual cervical area, where there is usually some exposed metal surface.
Another method for performing the heat test in gold-ceramic-covered teeth is to irrigate
the suspect tooth with very hot water, after the tooth has been isolated with the rubber
dam. In this manner, more reproducible results are obtained, and heat is used in
quantities sufficient to penetrate the crown.
The response of a normal pulp to the heat test is evident and immediately recedes after
the removal of the stimulus.
The patient should not feel any pain.
It must not be forgotten that when the heat test is performed to diagnosis pulpitis, one
can produce an extremely strong radiating pain, which is throbbing and prolonged.
Therefore, a means of relieving this pain, such as anesthesia or, more simply, cold water
or an ice cube must be within reach.
Patients with intense pain of pulpal origin may be aware that cold reduces their
discomfort and sometimes bring with them a glass of cold water for relief.

Cold test:
This can be performed by spraying ethyl chloride on the cervical area of a tooth or on a
cotton pellet held in pliers and then placing it at the cervical area of the dried tooth. The
second method is preferable, as ethyl chloride is a highly flammable anesthetic and
potentially dangerous. A better and simpler method is to use sticks of ice, as weine
suggests. They can be produced by filling with water the disposable anesthetic needle
holders and placing them in the freezer compartment of the refrigerator, where they
remain ready for use. When needed, the top of the plastic container is removed, leaving
a stick of ice about 3 cm. Long, which will more than suffice for testing the teeth of an
entire quadrant.
Also for this test, the teeth must be dried and isolated with cotton rolls. While the ice is
applied, the assistant should aspirate the cold water of the melting stick, which, dripping
on the adjacent tooth, could yield a false positive response. If there is concern about not
having a precise response from the patient and the test must be repeated in a more
selective manner, a rubber dam can be used to singly isolate the teeth to be tested and
immerse them in cold water.
The response of a normal pulp to cold stimulus is identical to that to a hot stimulus: the
pulp has no specific receptors, and the neural fibers in the pulp transmit only the
sensation of pain. The patient should not feel pain, but only a moderate sensation,
which recedes immediately after the removal of the stimulus. If the responses to the
thermal tests, hot or cold, deviate from a simple moderate response, for example pain
that is slow to resolve even after withdrawal of the stimulus, very acute pain, or no
response at all, the pulp that has been tested is not healthy, but variably inflamed. The
lack of response may suggest either a necrotic pulp or a false-negative response due for
example to excessive calcification, an immature apex, recent trauma, or patient
premedication.

Electric pulp test

This test is performed with an instrument that can electrically stimulate the neural
elements within the pulp. Consequently, the responses suggest the presence or absence
of such neural fibers, but they will not provide any information about the status of the
blood supply of the pulp, which would be very useful to know and on which alone pulp
vitality depends.
In other words, this test can distinguish whether the pulp is vital or necrotic, but it
provides no information about the type of pulp vitality, whether the pulp is alive and
healthy (i.e., vital) or whether it is viable but diseased. Furthermore, because of the
possibility of false-positive or -negative responses, this test must always be used in
association with other pulp tests or to corroborate what other tests have indicated.

The device is battery operated and thus easily portable from one operatory to another
without requiring an electrical outlet. Once dental contact is made using a conductive
gel (tooth paste), the intensity of the current increases, always starting at zero current;
thus, there is no danger of shocking the patient, which would provoke a sudden and
unexpected pain. The current automatically increases without advancing any manual
rheostat. Even the contact is automatically established, so that it is not necessary to
turn on any switches. The rate of increase of the intensity of the current transmitted to
the tooth can be regulated; thus, if the patient is anxious or if an early response is
expected, one can set the switch to a minimal level. If the patient or the dentist’s hand
moves involuntarily and causes loss of contact between the tip of the instrument and
the tooth for a few seconds, the instrument resets and begins at the level at which the
contact was lost as soon as contact is reestablished. If contact is interrupted for several
seconds, for example in the time required to pass from one tooth to another, the
electric pulp tester automatically resets and starts again from zero.
The instrument’s scale ranges from 0 to 80, and the range in which the teeth generally
respond is around 20 for the incisors and cuspids, 30 for the premolars and 40 for the
molars.
As long as the instrument is functional, it is necessary to establish a physical contact
between the dentist and the patient, for example by touching the cheek with the hand
holding the mirror used as a retractor. Otherwise, the pulp tester will not function. If the
dentist is wearing rubber gloves, the patient must touch the metal portion of the
instrument handle with a hand in order to complete the electric circuit.
The teeth to be tested must be isolated with cotton rolls and dried. Contact between
the tooth and the instrument tip must be established with a conductive gel.

Toothpaste is acceptable, but it is better to use the appropriate gel provided by same
manufacturer or even electrocardiogram gel. Like the other tests discussed above, this
test also must first be performed on teeth known to be healthy, to insure that the
patient understands the response of a normal pulp and thus reduce his or her fear. If
there are doubts about the responses that the patient gives, it is prudent to perform the
test on the contralateral healthy tooth. Since the response is subjective and can vary
slightly from one moment to another, the test must be repeated several times and the
average recorded in the chart.
The patient’s first sensation is a very faint one. It can be described as a slight tingling or
a slight sensation of heat. At a certain point, if the instrument is left in contact with the
tooth, the patient feels a pain that slowly becomes unbearable, but if at the first tingling
the patient raises a hand, the dentist can interrupt the circuit and the patient will feel no
more discomfort. If the dentist is wearing rubber gloves, it is enough for the patient to
release the metal part of the probe to interrupt the circuit and thus the stimulus.
As for the thermal tests, the electric test must also be performed at the point at which
the enamel, a poor conductor of electricity, is thinnest, since the sensitivity of the pulp-
dentinal organ is being tested.
Nonetheless, the instrument tip must be applied at the cervical area, paying attention to
avoid contact of the electrode or conductive paste with the gingival tissue or with any
restoration, since that would cause a false response.

If there is periodontal disease with gingival recession, it can be applied to the exposed
dentin, thereby eliciting a more rapid response.
In the teeth of elderly patients, there are sometimes false negative responses due to
extensive pulp calcification. These teeth are frequently abraded on their occlusal
surfaces, with exposed, sclerotic dentin no longer covered by enamel. In such cases, one
can perform the test by applying the instrument to the abraded surface, in such a way
as to establish direct contact with the dentin, no longer mediated by the enamel.
The electric test of pulp vitality must not be used in patients with pacemakers because
of the potential interference.
The responses that the electric test of pulp vitality provides are usually reliable,
especially if they are obtained with a reliable instrument. Nonetheless, false readings
can sometimes occur. One false-positive response occurs in the case of a necrotic pulp,
a false-negative response in the case of a vital pulp.

Causes of false-positive responses.

1) rather than touching the enamel at the cervical area, the electrode or the conductive
paste touches the gingiva or a large amalgam filling, and the current is transmitted
through the periodontal ligament.
2) the patient is anxious and states that the shock is felt before the current has begun to
flow.
3) liquefaction necrosis: the current is transmitted to the periodontal ligament through
the fluid present in the root canal, but is felt only at the highest range. The patient may
feel some tingling when the intensity of the current reaches about 60, but he feels no in-
crease of the tingling and no pain if the instrument remains in contact until the highest
range is reached. The control test performed on the controlateral vital tooth establishes
this diagnosis easily.
4) the tooth is not dry or well isolated.

Causes of false-negative responses:

1) the patient is premedicated with a large quantity of analgesics, narcotics, alcohol, or

tranquilizers.
2) contact with the enamel is inadequate, either because there is little conductive paste
or because a composite restoration is being touched. In these cases, however, the
electric tester does not even begin to work.
3) the tooth has recently sustained trauma. In this case, the pulp nerve fibers are in
shock and the normal response will not return for 30 to 60 days.
4) the canal is heavily calcified.

5) the batteries are discharged or the device has not been turned on.
6) the tooth is newly erupted and the apex is immature.

7) there is partial necrosis: although the pulp is still partially alive, it may appear totally
necrotic with the electric test.

This last circumstance may give rise to some doubts. How will a multi-rooted tooth with
necrotic pulp in one canal and vital pulp in the others respond to the electric test? The
answer to this question is quite simple if one keeps in mind two very important facts:

a) Diseases of the pulp proceed in a coronal-apical direction, while pathological

processes begin in a pulp horn. From here the pathology that leads to pulp ne-
crosis propagates to the pulp of the chamber and then to the pulp of the root
canal.

B)when the electric pulp test is performed, the pulp of the pulp chamber is actually
being tested.

In this case, if the pulp of one canal is necrotic, all the overlying pulp – i.e., the pulp of
the chamber – has also become necrotic. Consequently, the response of the tooth to
the electric test will be negative and the tooth will therefore be considered to all effects
a necrotic tooth: the opening of the access cavity and the cleaning and shaping of the
necrotic root canal without any need for anesthesia. If, in beginning to treat the other
canals, one discovers that the pulp there is still vital, then and only then does one resort
to anesthesia.
There is only one case in which one can have a positive response to the electric test in a
tooth like the one just described. This is the case in which the pulp cavity has a large
calcification and the roof and floor are merged, so that the chamber is literally divided
into two separate portions: one mesial or mesiobuccal, for example, and one distal or
distopalatal.

In a case such as this the electric pulp test performed on the distobuccal or palatal area
will yield a positive response, while at the mesiobuccal it will give a negative response.
If it is necessary to perform the electric test on a tooth covered by a full crown, it can be
performed with the appropriate mini-tip by placing it between the border of the
prosthesis and the gum. This technique, however, does not always yield precise
responses, since it is inevitable that at least the conductive paste touches both the
metallic border and the gum. Or, if it is still necessary, the electric test can be performed
after the cavity test.

Cavity test

When the responses of the other tests are questionable or when it is not possible to
perform them (e.g., because the teeth are completely covered by full crowns), one
should proceed with this test, which is undoubtedly the most reliable of all and
immediately erases any doubt.
The test is performed by preparing a small cavity on the occlusal surface of the posterior
teeth or on the palatal and/or lingual surfaces of the anterior teeth, using a small round
bur mounted on a high speed handpiece, obviously without anesthesia. In this way,
once the thickness of the prosthetic restoration, and possibly the enamel (if it has been
left) has been removed, the bur will stimulate the dentin and the patient will experience
a sudden but slight pain. This will confirm the vitality of the pulp.
If at this point there is enough space, for further confirmation the other tests, including
the electric test, can be performed through the small opening. If the tests are positive,
the cavity will be filled, just like any class i cavity.
If, instead, the bur continues until it reaches the pulp chamber without the patient
feeling any symptoms, the suspicion that the pulp was necrotic was well founded. The
small opening made to perform the cavity test can then be enlarged and transformed
into an access cavity.
This test is particularly useful when there are lesions of dubious etiology (endodontic vs
periodontal) on teeth with full crowns, as it will be discussed in the chapter on perio-
endo relationships.

Anesthesia test

In the rare situation in which all the tests discussed are inconclusive to establish the
diagnosis, we can make recourse to the use of selective anesthesia. For instance, in the
case in which the patient has diffuse hemifacial pain without any sign indicating one
particular tooth or another, one may anesthetize one hemiarch and check whether after
several minutes the pain resolves. If this occurs, the opposite hemiarch can be excluded.
If, on the other hand, the pain persists, one must perform anesthesia singly on the teeth
of the opposite arch, hoping to finally anesthetize the responsible tooth.
There are disagreements on the area which one should begin to anesthetize.
Weine recommends beginning with the most mesial teeth, since the innervation of the
palatal root of the posterior teeth arrives from the most posterior portions of the
palate, through the greater palatine foramen, adjacent to the second molar. If the
palatal injection were done here, the inflamed pulp of the palatal canal of any tooth an-
terior to the infiltration zone would be anesthetized.
Cohen, on the other hand, states that the anesthesia of maxillary teeth should start with
the most distal.

According to arnaldo castelluci, anesthesia test cannot identify the tooth affected by
pulp pathology, but can only indicate whether a zone is responsible for the pain.

According to simon12 et al. And littner13 et al, to make the anesthesia test more
selective, one can use intraligamental injection, suggest, administering the anesthetic on
the buccal side of each suspect tooth. If this type of anesthesia is performed correctly,
the pain will resolve immediately. Littner et al. Suggest not to perform such anesthesia
in the interproximal zone, where usually the intraligamental anesthesia is recommen-
ded, since doing so one could anesthetize the adjacent tooth as well and the test would
lose selectivity

PULSE OXIMETER

A non-invasive device which determines the pulp oxygenation level of a tooth and the
vitality of a tooth using multiple-wavelength optical plethysmography. A sensor is
shaped to be mounted on a tooth and circuitry for processing a signal from the sensor
and supplied from a photosensitive diode is used. The photosensitive diode in the
sensor detects light scattered from the tooth which was emitted from red, green, and
infrared LEDs. An electrocardiogram (ECG) monitor is provided so as to produce
improved detection reliability by synchronous averaging using the occurrence of the R-
wave of the ECG as a time marker. Using this approach, a threshold-of-detection
criterion can be established based on an average computed over a period to achieve a
desired signal-to-noise ratio.

THE REPARATIVE CAPACITY OF PULP TISSUE

12
SIMON, D.E., JACOBS, T.L., STEVE SENIA, E., WALKER, W.A.: Intraligamentary anesthesia as an aid in endodontic diagnosis. Oral Surg.,
54(1):77, 1982

13
LITTNER, M.M., TAMSE, A., KAFFE, I.: A new technique of selective anesthesia for diagnosing acute pulpitis in the mandible. J.
Endod., 9:116, 1983
Opinions regarding the reparative capacity of pulp tissue are contrasting. Several
maintain that the pulp cannot sustain any insult, while others are convinced that
because it is very resistant any attempt to preserve it is justified.
These are two extreme positions. Neither is correct; rather, the truth lies somewhere in
between.
Histologically, the pulp, apart from the odontoblasts, is a fibrous connective tissue of
mesenchymal origin, has most of the characteristic cells of this tissue, and responds in
an analogous manner to various irritant stimuli. Its responses are thus typical of con-
nective tissue of any other part of the organism: an irritation produces damage, and this
stimulates an inflammatory process whose final end is the “restitutio ad integrum”.
Nonetheless, the responses of the pulp are different from those of the other tissues.
This is due to topographical and anatomical conditions that cannot be modified.
In 1939, gottardi noted that the pulp was enclosed in a mineralized, rigid, and
inextensible theca. Other authors have even said that the pulp is already enclosed
within its own coffin!
The source of its blood supply is at a considerable distance from the large mass of
coronal pulp tissue, and the volume of the pulp is relatively large if compared with the
transverse diameter of its foramen or foramina, except in the case of teeth with an
immature apex. This means that the blood supply of the pulp is abundant.
Unfortunately, however, all the arteries enter the tooth through a relatively restricted
apical opening, and the veins exit through the same foramen.
For this reason, the pulp, having to react to external stimuli and pathological processes,
both inflammatory and infectious, is unfavorably situated. Indeed, when the pulp is in
some way injured at the coronal level, it responds with inflammation and a consequent
increase of vascular permeability and exudation of fluid into the surrounding tissues, as
in other connective tissues. In contrast to the latter, however, the pulp has no room to
expand and swell as it manifests the five pathological signs of inflammation: “rubor,
calor, tumor, dolor, and functio lesa”.
Thus, the pulp draws no advantages from the inflammatory process. On the contrary,
the increased volume of its inflamed tissues and the simultaneous inability to swell, the
compromised efferent circulation and rapid reabsorption of the exudate induce necrosis
of a large number of cells.
Further aggravating the situation, the pulp lacks collateral circulation, since its
circulation is of the terminal type, especially at the coronal level, where there is a
greater amount of tissue.
Moreover, the coronal pulp is the first to sustain insults of any sort and the furthest
from the entrance of the blood supply in the apical foramen.
When the pulp sustains an insult sufficient to create true inflammation, its anatomy
makes it highly susceptible to necrosis and gangrene. Indeed, the pressure caused by
edema is frequently sufficient to interrupt the circulation at the level of the apical
foramen. The stasis of blood flow provokes destruction of this peduncle of soft tissue.
In conclusion, when the pulp is exposed to external pathogenic agents, in particular
bacteria, following an accidental insult or pathological process, it is incapable of reacting
to them. Rather, in spite of opposing them with its reactive and defensive processes, it is
fatally destined to succumb to necrosis.
On the other hand, this does not mean that the pulp dies no matter what! Many studies
have demonstrated the reparative capacity of the pulp tissue.
Nonetheless, one must be very prudent when undertaking so-called “vital pulp
therapies” and must determine very carefully whether the compromise has caused
reversible or irreversible damage in the pulp that one is about to treat.
Many have confirmed that, in the absence of bacterial infection, the most important
parameter to be taken into consideration is the blood supply. If the pulp has an ample
blood supply, its reparative capacity may be considerable.

THE MODERN TAKE ON CLASSIFICATIONS

Several attempts have been made to classify pulp disease. However the absolute lack of
correlation between the intensity of pain and the extent of pulp compromise is a reality
of which one can only take note. On the other hand, what truly interests the dentist is
not so much arriving at the subtle distinction between serous and seropurulent pulpitis,
as making the sometimes difficult decision to treat the tooth endodontically or to at-
tempt preventive measures. Once the need for endodontic intervention has been
established, knowledge of the precise histopathological nature of the pulp tissue has
only academic value, since it will not change the therapy, which in any case is total
extirpation or pulpectomy.

For these reasons, clinicians today adopt a clinical classification based on the symptoms
with which the patient may present and on the signs which the dentist must look for:
HYPEREMIA
The term “hyperemia” is used in reference to a reversible clinical situation characterized
by the onset of a sudden, sharp pain in response to a cold stimulus which resolves
almost immediately once the stimulus has been removed.
In medicine and physiology, hyperemia indicates an increase of the amount of blood in a
certain tissue. However, numerous histological studies have demonstrated that pulps
that are clinically classified as hyperemic are only infrequently found to be histologically
hyperemic.
This latter case may be a situation of dentinal hypersensitivity.
Clinically, dentinal hypersensitivity can be associated with a histologic appearance of
hyperemia; on the other hand, hyperemia can also exist without clinical hypersensitivity.
Furthermore, the clinical and histological situations may coexist, as in the case of
dentinal hypersensitivity with hyperemia.
In conclusion, hyperemia and reversible pulpitis are not diseases, but symptoms.

Clinical symptoms

Clinically, the patient presents with the sudden onset of sharp pain provoked by a cold
stimulus. It lasts only a few moments and resolves immediately after the stimulus is
removed. The pain never occurs spontaneously, but is always provoked; in fact, there is
a strict cause-and-effect relationship.
The cause of the pain could be cold beverages or cold air. The patient may complain of it
after a metallic restoration has been performed or as the first sign of incipient caries. In
the latter case, the pain may also be provoked by sugar containing substances. It may
also occur in response to the curettage or root scaling or after a periodontal procedure
that exposes the root surface. The exposed dentin of the root surface can also be
stimulated by acidic substances, by the bristles of a toothbrush, by flossing, or by a
probe. In these cases, the cementum covering the dentin is missing or has been
removed by curettage or excessively vigorous brushing with the consequent exposure of
the dentinal tubules.
The pain associated with dentinal hypersensitivity is explained by the “hydrodynamic
theory” of Brännström, according to which the back-and-forth movements of fluids
within the dentinal tubules stretch and stimulate the nerve fibers.

When dentin is exposed to a brief air blast, the fluid within the dentinal tubules
evaporates to a depth of 0.1 to 0.3 mm. This leads to the aspiration of odontoblasts and
nerve fibers within the tubule. The nerve fibers are stretched or even disrupted, with
the consequent production of pain.

The physiopathology
It is similar in the case of cold stimulation. The cold causes the fluids within the tubules
to contract, causing the fluids to flow in a centrifugal direction, owing to the pressure
within the pulp. This flow causes the nerve fibers to stretch within the tubules, together
with the odontoblasts.

Diagnosis

The diagnosis is made on the basis of the patient’s symptomatology and the results of
testing.
Since the pain is of pulpal origin and the pulp lacks proprioceptive nerve endings, the
patient cannot localize the diseased tooth and sometimes not even the arch, upper or
lower, but can only say whether it is right or left, as the pain does not cross the midline.

The application of a cold stimulus is an excellent method for identifying the involved
tooth.

Sometimes, the patient may complain of dentinal hypersensitivity to cold beverages,

while stimulation with an ice stick of the cervical area of the suspected tooth does not
provoke an unusual response. In this case, the entire dental surface must be surrounded
by cold, so that the pulp may react. The tooth must therefore be isolated with a thick
dam and then completely immersed in icy water.

Therapy
The best treatment for this sort of symptomatology, as Grossman correctly states, is
prevention. Good oral hygiene to prevent the development of caries, early filling once
the carious cavity has formed, desensitization of the cervical area of the tooth when
there is marked gingival recession, the use of a varnish or cement as a cavity liner prior
to filling, and care in the preparation of the cavity and in finishing the filling are all
preventive measures.
When dentinal hypersensitivity is present, the removal of the noxious stimulus is usually
sufficient. After the resolution of symptoms, it is necessary to recheck the vitality of the
tooth to ascertain that pulp necrosis has not developed in the interval.
PULPITIS

Symptomatology

Pulpitis, an irreversible inflammation of the pulp tissue, is clinically manifested by

spontaneous pain that is exacerbated in particular by hot stimuli, never cold. In fact,
cold very often brings relief to the patient.
Pain produced by heat peaks with some latency, remains at this level even after the
stimulus has been removed, and takes several minutes to hours before it resolves The
inflammation present within the pulp tissue initially causes an exudation with a
consequent increase of the intrapulpal pressure beyond the pain threshold and thus
causes spontaneous pain.
In its early phases, such pain can be described as bothersome or annoying, but quickly
becomes more intense, sharp, diffuse, and referred to another area.
The pain may arise spontaneously if the patient simply assumes the supine position

Diagnosis

As in all other pain of pulpal origin, because there are no proprioceptive nerve endings
in pulp tissue, the patient with pulpitis cannot identify the origin of the pain, which can
radiate to the eye, ear, or other areas, depending on the tooth affected
By causing dilatation of the blood vessels, tissues, and gaseous products of proteolysis,
heat increases the pain. In contrast, cold has a contractile effect on the remaining
functional vascular bed, reducing the intrapulp pressure below the pain threshold of the
pain receptors still present.
Application of heat using the various heat tests described are useful in diagnosis but
they shiuld be done after reassuring the patient and starting with the tooth that’s
normal first.

The electric test is not very helpful. A positive test indicates that the pulp is vital, but
provides no information about its health. The tooth responds normally to palpation and
percussion unless it has been complicated by periodontitis.

Radiographic examination

The radiographic examination may provide information about the presence of

interproximal caries that are not visible on intraoral clinical examination and of caries
underneath an old restoration, close to a pulp horn The periapical zone usually appears
intact. At most, it may present a slight widening of the space of the periodontal
ligament. The presence of early resorption of the bony trabeculae close to the apex is
the exception and certainly not the rule.

The first area affected by the pathogenic injury is usually the pulp horn or, in any case, a
part of the pulp chamber.
All the etiologic agents act at the coronal level. The diseases of the pulp always proceed
in a corono-apical direction. If one imagines the histopathology of clinical pulpitis, one
can find a small abscess collection in the horn. Not infrequently, one notes a noxious
odor at the chamber opening and the exudation of pus, then blood); around the
microabscess, there can be an area of necrosis, then an area with an infiltrate of
polymorphonuclear leukocytes and a hyperemic area with many dilated and bulging
vessels filled with blood. Proceeding corono-apically, one can find a proliferation of
fibroblasts trying to isolate the lesion, and beyond this, within the canals, normal, intact
pulp tissue.

The therapy
Therapy for pulpitis is pulpectomy and endodontic therapy. However, since the patient
with pulpitis presents on an emergency basis, it is unlikely that one will have all the time
that is necessary to perform the entire therapy. It is sufficient to undertake the proper
emergency treatment to discharge the patient without any symptoms.
The treatment varies slightly, depending on whether one is dealing with a single- or
multi-rooted tooth.
In the single-rooted teeth, emergency treatment consists of total extirpation of the pulp
or pulpectomy, following anesthesia.
In the multi-rooted teeth, the recommended emergency treatment is pulpotomy with
Cresatin.
The success of pulpotomy with Cresatin depends on two factors:
1. The correct diagnosis of “pure” pulpitis, that is, without a component of periodontitis
(lack of pain on palpation and percussion).
2. The presence of vital tissue within the root canal (positive response to vitality tests).
If the two circumstances are confirmed, the patient can live with the medicated tooth
for as long as a month without any bother. There is thus plenty of time to plan the
necessary appointments to complete the therapy. It is absolutely mistaken to give in to
the temptation to also remove the pulp of the canals, if there is insufficient time to
complete the cleaning and shaping of these canals.
In case of the situation being complicated by a component of periodontitis, the canals
must be debrided to prevent an acute alveolar abscess.
Whether a “closed” treatment is performed or the tooth is left “open,” in the therapy of
pulpitis, one must not forget to remove the tooth from the occlusion.

NECROSIS

The irreversible inflammation of the pulp that occurs in pulpitis may persist for a certain
period of time, but eventually it causes total necrosis of the pulp tissue. Necrosis, or
death of the pulp tissue, is thus the direct consequence of pulpitis, but it may also arise
immediately after trauma that damages the vascular peduncle.
As a result of an inflammatory process, the pulp tissue continues to disintegrate,
forming a slowly enlarging zone of liquefactive necrosis. The lack of collateral circulation
and the presence of the inextensible walls of dentin aggravate and accelerate the
process that leads to total necrosis of the tissue.
The rapidity of the progression of the liquefactive necrosis varies, depending on
whether the inflammatory fluids can drain, and thus on the rate of increase of in-
trapulpal pressure
Pulpitis in a tooth with a completely closed pulp chamber leads more rapidly to total
necrosis of the entire pulp, with the almost miraculous resolution of all symptoms. In
contrast, pulpitis in a tooth with penetrating caries or, especially, an open pulp chamber
leads to slower destruction, with degeneration of the coronal pulp and the presence of
vital tissue at the radicular level
The progression is again in a coronoapical direction.

Symptomatology

The tooth with a necrotic pulp is completely asymptomatic. The patients may give a
history of pulpitis, from which they may believe they just recovered, or a history of
trauma. Sometimes, the patients may be suspicious only because of the discoloration of
the crown of the tooth. On occasion, the patient’s history is completely unremarkable,
and there is no apparent explanation of the pulp necrosis, which is identified on routine
check-ups or possibly by the development of a mucosal fistula .
Pain associated with pulp necrosis arises from the periapical tissues. The associated
inflammation is the cause of the swelling, mobility, and pain on percussion and
palpation of the tooth.
Radiographic examination

The radiographic findings are normal. A slight widening of the space of the periodontal
ligament may be present

Treatment consists of endodontic therapy, which, in the absence of symptoms, can be

planned normally.

A NOTE ON VITAL PULP THERAPY

On no other subject in dentistry has there been as much written and discussed as the
maintenance of the vitality of an exposed pulp. Everything, including the droppings of
the English sparrow (HUNTER, W.C.: Saving pulp, a queer process. Dent. Items Interest,
p. 352, 1883) , has been tried.
At the beginning of the last century, to avoid extirpation at all costs, any attempt at
maintaining the vitality of the pulp was justified, since there was no way to perform
proper endotontic therapy and the success rate was higher after pulp capping as
compared to pulpectomy and canal treatment.
Today, however, given the abundant research that has been performed, such an
attitude is no longer acceptable. The exposed pulp horn must no longer produce the
same fear that it did almost one hundred years ago.
Herman first introduced the use of calcium hydroxide in such cases, and Teuscher and
Zander first described the formation of the dentin bridge below the treatment
Mitchell and Shankwalker have described the intense calcification that occurs in the
pulp tissue following such treatment. This phenomenon has also been described by
Baume. The quality and quantity of newly-formed dentin is unpredictable
From these and other similar research, it is clear that, independent of the size of the
exposure, pulp capping, when performed in a desperate attempt to maintain the vitality
of a condemned pulp, is not only an unpredictable procedure with an uncertain
prognosis, but it is also dangerous, since it may cause internal resorption, calcific pulp
degeneration, or both.
Weine states that calcium hydroxide is the material of choice in direct pulp capping, but
if such therapy fails and the tooth becomes symptomatic, it may be difficult, if not
impossible, to treat it by traditional endodontics because of severe calcifications in the
root canal, which are frequently associated with internal resorption, as described also
by other authors.
What makes pulpotomy or pulp capping with calcium hydroxide dangerous is that the
pulp tissue is in some way stimulated to become isolated from communication with the
outside and thus form the dentinal bridge without knowing when to stop making these
calcific depositions. The process of apposition, which is known to be associated with
resorption, therefore continues.
the following criteria must be carefully confirmed:
a) the tooth must not be sensitive to heat or cold, nor must there be spontaneous
pain
b) there should be no pain on palpation or percussion
c) there should be no periapical radiographic change
d) marked narrowing of the pulp chamber or root canal should not be present
e) there should be no calcifications in the pulp chamber
f) there should not be the slightest suspicion of bacterial infection, since asepsis is the
most important factor in pulp healing following exposure.30
The indications for direct capping are therefore drastically reduced to the following:
a) the patients should be young and well motivated, so that they will easily return for
check-ups and necessary radiographs
b) the exposure must be in healthy dentin and not below caries, and therefore not in
infected dentin
c) the maintenance of strict intra-operative asepsis is mandatory
d) the pulp chamber must be free of calcifications, which occupy space and reduce
the blood supply to the pulp tissue which must heal.
Finally, Langeland is also clearly opposed to indirect pulp capping, which he calls an
unacceptable procedure. The reasons for its apparent success, as for direct capping or
pulpotomy, are due to the removal of most of the disintegrated tissue, but the
technique is destined to fail because of the presence of bacteria and sometimes a small
zone of pulp necrosis that is left in contact with the capping agent. The success of any
therapy depends on the total removal of all the disintegrated tissue.
In conclusion, the dentist’s efforts to maintain the vitality of a pulp that has been
exposed are not only justified but obligatory in teeth with an immature apex especially if
the exposure is a result of recent trauma. The treatment of choice in such cases is
undoubtedly pulpotomy, which is preferable to direct pulp capping. This therapy should
be considered a provisional therapy, pending maturation of the apex and root. The pulp
must be kept vital, because it must still complete its primary, formative function. Seltzer
and Bender state that, once the development of the root has been completed, the pulp
has no reason to remain there.
Since it represents only a threat because of the calcifications and internal resorption
that may develop, it must be removed, and the tooth must be treated endodontically.
After all, who can inform the pulp to stay vital and inert inside the root canal after the
dentin bridge has been completed and the apical closure has occurred?
On the other hand, pulp exposure in a tooth with a mature apex must be considered an
indication for endodontic treatment, since, as Rebel stated as long ago as 1922, “an
exposed pulp is a lost organ”

Pulp capping with MTA

Recently, Dr. Mahmoud Torabinejad of Loma Linda University, California, has developed
a new cement named Mineral Trioxide Aggregate (MTA; ProRoot MTA, Dentsply Tulsa
Dental) , which appears to have all of the characteristics requested of the ideal cement
to seal pathways of communications between the pulp and the oral cavity (mechanical
and carious pulp exposures), and between the root canal system and the periodontium
(iatrogenic perforations, open apices, resorbed apices, root-end preparations).
MTA is an endodontic cement that is extremely biocompatible, capable of stimulating
healing and osteogenesis, and is hydrophilic. MTA is a powder that consists of fine
trioxides (Tricalcium oxide, Silicate oxide, Bismute oxide) and other hydrophilic particles
(Tricalcium silicate, Tricalcium aluminate, responsible for the chemical and physical
properties of this aggregate), which set in the presence of moisture. Hydration of the
powder results in formation of a colloidal gel with a pH of 12.5, that solidifies to a hard
solid structure in approximately three-four hours. This cement is different from other
materials currently in use because of its biocompatibility, antibacterial properties,
marginal adaptation and sealing properties, and its hydrophilic nature
It shows the absence of cytotoxicity when MTA came in contact with fibroblasts and
osteoblasts, and the formation of dentin bridges when the material was used for direct
pulp capping
sealing ability and biocompatibility of MTA are superior to those of amalgam, Super-EBA
and IRM
The characteristic that distinguishes MTA from other materials used to date in
endodontics is its hydrophilic properties. Materials used to repair perforations, to seal
the retro-preparation in surgical endodontics, to close open apices, or to protect the
pulp in direct pulp capping, are inevitably in contact with blood and other tissue fluids.
Moisture may be an important factor due to its potential effects on the physical pro-
perties and sealing ability of the restorative materials.
As shown by Torabinejad et al, MTA is the only material that is not affected by moisture
or blood contamination: the presence or absence or blood seems not to affect the
sealing ability of the mineral trioxide aggregate. In fact, MTA sets only in the presence of
water.

MTA mechanism of action is similar to that of calcium hydroxide, but in addition, MTA
provides a superior bacteria-tight seal.
For all these reasons MTA is to be preferred to the use of calcium hydroxide.

Operative sequence for pulp capping

After achieving anesthesia and isolation with a rubber dam, the exposed pulp is irrigated
with NaClO to control bleeding. The MTA powder is mixed with sterile water and the
mixture is placed in contact with the exposure using a Dovgan carrier. Compress the
mixture against the exposure site with a moist cotton pellet. Place a moist cotton pellet
over the MTA and fill the rest of the cavity with a temporary filling material. After four
hours, the patient is seen again, the rubber dam is positioned, the temporary filling
material and cotton are removed, and the set of the material is assessed. Then, the
tooth can be restored and the patient is scheduled for regular recalls

THE MODERN ASPECTS OF PULP: NEWER HORIZONS IN

PULP RESEARCH

TISSUE ENGINEERING AND PULP REGENERATION

Tooth regeneration offers new and innovative approaches to common problems

encountered in oral and dental surgery and may eventually provide other alternatives to
orthodontic surgery.

Tissue engineering is a term that describes the application or use of cells, scaffolds, and
growth factors to restore, maintain, or enhance tissue function (langer and vacanti,
1993)
A variety of strategies has been used to repair or supplement tissues of the
periodontum and dental pulp to reduce the likelihood of tooth loss.
Current efforts to reproduce a viable tooth can be broadly categorized as those based
on tissue engineering techniques (scaffold-based) or developmental biology
organogenesis- or germ-tissue-based)

The tissue engineering approach commonly utilizes a cellseeded scaffold to guide and
support tooth formation, while the developmental or “organotype” approach facilitates
development of a tooth from a collection of cells resembling the tooth germ.

REGENERATION OF THE ENDODONTIUM: MICROSCALE

TECHNOLOGIES14

Regenerative endodontics (repair of the dental pulp) is a likely near-term dental

treatment that will bring widespread application of tissue engineering principles to
regenerative dentistry (murray et al., 2007; sloan and smith, 2007; huang, 2008). The
objectives of pulp replacement procedures are to regenerate the pulp-dentin complex,
regenerate damaged coronal dentin, and regenerate resorbed root and cervical or apical
dentin (cotti et al., 2008; gotlieb et al., 2008; huang, 2008). Tissue engineering
approaches may include the use of growth factors for revascularization, as well as stem
cells and scaffolds for pulp tissue regeneration (murray et al., 2007; sloan and smith,
2007; tecles et al., 2008).
Pulp regeneration may be a particularly beneficial treatment for damaged developing
adult teeth (fig. 2), as has been demonstrated experimentally with tooth slices and cells
implanted subcutaneously into a murine model (nor et al., 2001; nor, 2006). Pulp
regeneration may be restricted by the anatomy of the tooth, specifically, the single
point of vascular access at the tooth apex. As a result, microscale technologies that
provide open channels or the ability to guide vascular ingress from the apex through the
pulp may be of particular benefit.

DENTAL PULP TISSUE ENGINEERING WITH STEM CELLS FROM

EXFOLIATED DECIDUOUS TEETH15

Regenerative medicine offers exciting opportunities to replace or restore tissues of

The body after disease and trauma. Tissue engineering approaches aim to fabricate

14
S.A. Hacking: Applications of Microscale
Technologies for Regenerative
Dentistry:J Dent Res 88(5):409-421, 2009
15
Mabel M. Cordeiro Dental Pulp Tissue Engineering with Stem Cells from
Exfoliated Deciduous Teeth, JOE — Volume 34, Number 8, August 2008
New replacement body tissues, and such approaches commonly involve seeding of cells
At various stages of differentiation within scaffolds, which can then be implanted.
The complexity of architecture and function of many tissues, however, provides
significant
Challenges to engineering replacement tissues resembling their physiologic
counterparts.
Use of stem cells, either of embryonic or postnatal derivation, for tissue engineering
Is attractive because it offers greater scope for cell fate to try and mimic
Physiologic tissue architecture. However, ethical constraints associated with use of
Embryonic stem cells (escs) and limitations of readily accessible sources of autologous
Postnatal stem cells with multipotentiality pose significant challenges for use of stem
Cells in tissue engineering. Furthermore, the requirement for good vascularization of
Any tissue construct is of paramount importance to its vitality.
The discovery of stem cells in the pulp of permanent teeth and also in deciduous
Teeth ( raised the intriguing possibility of using dental pulp stem cells for tissue
Engineering the dental pulp stem cells have been shown to be capable of
Self-renewal and multilineage differentiation . These stem cells can be isolated from
Patients with relatively minimal morbidity, especially when they are retrieved
noninvasively from the pulps of exfoliated deciduous teeth . The first successful attempt
to engineer complex whole tooth structures used single-cell suspensions dissociated
from porcine third molar tooth buds and suggested the existence of dental pulp stem
cells in this tissue . Others have successfully used a similar approach for the
bioengineering of organs for regenerative therapies . The concept of using stem cells for
dental tissue engineering was explored by sharpe and young .
They and others demonstrated that it is possible to engineer murine teeth by using
adult stem cells of nondental or dental origin . Recently, mesenchymal stem cells
isolated from the root apical papilla of human teeth were shown to be capable of
mediating tooth regeneration with recovery of tooth strength and appearance .
Stem cells from human exfoliated deciduous teeth (shed) have become an attractive
Alternative for dental tissue engineering . The use of shed might bring advantages for
tissue engineering over the use of stem cells from adult human teeth as follows:
Shed were reported to have higher proliferation rate and increase cell population
doublings as compared with stem cells from permanent teeth . This might facilitate the
expansion of these cells in vitro before replantation.
Shed cells are retrieved from a tissue that is “disposable” and readily accessible in young
patients, ie, exfoliated deciduous teeth dental pulp tissue engineering with stem cells
could be ideally suited for young patients who have suffered pulp necrosis in immature
permanent incisors as consequence of trauma. Such treatment could potentially allow
for the completion of vertical and lateral root development and perhaps improve the
long-term outcome of these teeth.
The fact that these patients are in mixed dentition, and therefore their deciduous
molars are at various degrees of exfoliation, makes shed a timely and opportune stem
cell source for the engineering of dental pulps in immature permanent teeth.

Although the concept of engineering whole tooth structures offers exciting potential,
Significant clinical challenges still remain, and engineering or regeneration of
Component tissues of the tooth might be a more realistic shorter-term goal. In
particular, engineering of dental pulp, which is the formative and supportive organ for
dentin, the major mineralized tissue of the tooth, would provide immense clinical
benefits.
Key considerations in development of a strategy for pulp tissue engineering include
choice of scaffold and cells, which show potentiality to differentiate into the various cell
populations characteristic of the pulp, especially the dentin-secreting odontoblasts and
the cells of the vasculature to provide vitality to the tissue. Polymers, such as
polyglycolic acid (pga), have been previously found to act as suitable matrices
For seeding of dental pulp fibroblasts, allowing their proliferation and development of a
tissue with similar cellularity to normal pulp pga was a more conducive scaffold for
dental pulp cell proliferation than a hydrogel and an alginate other scaffolds, including a
spongeous collagen, a porous ceramic, and a fibrous titanium mesh, can support the
attachment, growth, and differentiation of dental pulp stem cells in vitro, and when
such constructs were implanted in vivo, the cells organized into a well-vascularized
tissue that expressed dentin sialophosphoprotein, a marker of dentin . However, limited
extracellular matrix mineralization was observed only with the ceramic scaffold
Engineering of human blood vessels in immunodeficient mice on the basis of seeding of
human dermal microvascular endothelial cells (hdmec) in porous biodegradable
scaffolds and subcutaneous transplantation in severe combined immunodeficient mice
(scid) offers an attractive methodologic approach for pulp tissue engineering. The
opportunity to engineer pulp tissue with the required high degree of vascularity and
anastomosis of the engineered blood vessels with the host vasculature should provide
good tissue vitality and enhanced prognosis for the tissue constructs.
PULP REVASCULARIZATION AS A NEW TREATMENT OPTION16 17

The rationale
Revascularization is the procedure to reestablish the vitality in a nonvital tooth to allow
repair and regeneration of tissues. The rationale of revascularization is that if a sterile
tissue matrix is provided in which new cells can grow, pulp vitality can be reestablished.
Revascularization protocols are derived from the observations of reimplanted and
autotransplanted teeth in experimental animals in which necrotic pulp, if free of
infection, provided a matrix into which the cells from the periapical tissues could grow
and reestablish pulp vascularity, slowly replacing the necrotic tissue. In immature,
infected, nonvital teeth, infection control is achieved with minimal instrumentation,
depending more on aggressive, copious irrigation with sodium hypochlorite.

The study:
Endodontic treatment options for immature, nonvital teeth conventionally include
surgical endodontics, apexification with calcium hydroxide, or single visit mineral
trioxide aggregate plug. A new treatment option of revascularization has recently been
introduced. It involves disinfecting the root canal system, providing a matrix of blood
clot into which cells could grow, and sealing of the coronal access. The present pilot
clinical study was undertaken to evaluate the efficacy of revascularization in 14 cases of
infected, immature teeth. Endodontic treatment was initiated, and after infection
control, revascularization was performed. The access cavity was sealed with glass
ionomer cement.
The cases were followed up at regular intervals of 3 months; the range in follow-up was
0.5–3.5 years. The outcomes were as follows. Radiographic resolution of periradicular
radiolucencies was judged to be good to excellent in 93% (13 of 14) of the cases. In the
majority of cases, a narrowing of the wide apical opening was evident.
In 3 cases, thickening of apical dentinal walls and increased root length were observed.
The striking finding was complete resolution of clinical signs and symptoms and
appreciable healing of periapical lesions in 78% (11 of 14) of cases. Thickening of lateral

16
Naseem Shah Efficacy of Revascularization to Induce
Apexification/Apexogensis in Infected, Nonvital,
Immature Teeth: A Pilot Clinical Study (J Endod 2008;34:919–925)

17
Elisabetta Cotti:Regenerative Treatment of an Immature, Traumatized
Tooth With Apical Periodontitis: Report of a Case (J Endod 2008;34:611– 616)
dentinal walls was evident in 57% (8/14) of cases, and increased root length was
observed in 71% (10/14) of cases. None of the cases presented with pain, reinfection, or
radiographic enlargement of preexisting apical pathology. This pilot study documented a
favorable outcome of revascularization procedures conducted in immature nonvital,
infected permanent teeth

Mechanism of revascularization

It is possible that a few vital pulp cells remain at the apical end of the root canal . These
cells might proliferate into the newly formed matrix and differentiate into odontoblasts
under the organizing influence of cells of hertwig’s epithelial root sheath, which are
quite resistant to destruction, even in the presence of inflammation . The newly formed
odontoblasts can lay down atubular dentin at the apical end, causing apexogenesis
(elongation of root), as well as on lateral aspects of dentinal walls of the root canal,
reinforcing and strengthening the root.
Another possible mechanism of continued root development could be due to
multipotent dental pulp stem cells, which are present in permanent teeth and might be
present in abundance in immature teeth. These cells from the apical end might be
seeded onto the existing dentinal walls and might differentiate into odontoblasts and
deposit tertiary or atubular dentin.
The third possible mechanism could be attributed to the presence of stem cells in the
periodontal ligament , which can proliferate, grow into the apical end and within the
root canal, and deposit hard
Tissue both at the apical end and on the lateral root walls. The evidence in support of
this hypothesis is presented by documentation of cementum and sharpey’s fibers in the
newly formed tissues.
The fourth possible mechanism of root development could be attributed to stem cells
from the apical papilla or the bone marrow. Instrumentation beyond the confines of the
root canal to induce bleeding
Can also transplant mesenchymal stem cells from the bone into the canal lumen. These
cells have extensive proliferating capacity. Transplantation studies have shown that
human stem cells from bone narrow can form bone or dentin in vivo.
Another possible mechanism could be that the blood clot itself, being a rich source of
growth factors, could play an important role in regeneration. These include platelet-
derived growth factor, vascular endothelial growth factor (vegf), platelet-derived
epithelial growth factor, and tissue growth factor and could stimulate differentiation,
growth, and maturation of fibroblasts, odontoblasts, cementoblasts, etc
From the immature, undifferentiated mesenchymal cells in the newly formed tissue
matrix. Expression of vegf in immature and mature permanent teeth has been
documented.
It can be completed in a single visit. It is also very cost-effective, because the number of
visits is reduced, and no additional material (such as tcp, mta) is required. Obturation of
the canal is not required unlike in calcium hydroxide– induced apexification, with its
inherent danger of splitting the root during lateral condensation. However, the biggest
advantage is that of achieving continued root development (root lengthening) and
strengthening of the root as a result of reinforcement of lateral dentinal walls
With deposition of new dentin/hard tissue.
There are only a few limitations of revascularization. Long-term clinical results are as yet
not available. It is possible that the entire canal might be calcified, compromising
esthetics and potentially increasing the difficulty in future endodontic procedures if
required. In case post and core are the final restorative treatment plan,
revascularization is not the right treatment option because the vital tissue in apical two
thirds of the canal cannot be violated for post placement.

THE APICAL PAPILLA: THE HIDDEN TREASURE OF PULP

REGENERATION18 19

A number of recent clinical case reports have revealed the possibilities that many teeth
that traditionally would receive apexification may be treated for apexogenesis. A call for
a paradigm shift and new protocol for the clinical management of these cases has been
made by the authors. A recent scientific finding, which may explain in part why
apexogenesis can occur in these infected immature permanent teeth, is the discovery
and isolation of a new population of mesenchymal stem cells (mscs) residing in the
apical papilla of incompletely developed teeth. These cells are termed stem cells from
the apical papilla (scap), and they differentiate into odontoblast-like cells forming dentin
when implanted into the subcutaneous space of immunocompromised mice using
hydroxyapatite/tricalcium phosphate (ha/tcp) as a carrier vehicle. Although scap show
similar characteristics to dental pulp stem cells (dpscs) that were discovered earlier they
also behave differently in a number of aspects that were assessed by histologic,
18
George T.-J. Huang: The Hidden Treasure in Apical Papilla: The Potential Role
in Pulp/Dentin Regeneration and BioRoot Engineering:
(J Endod 2008;34:645– 651)

19
Wataru Sonoyama: Characterization of the Apical Papilla and Its Residing Stem Cells
from Human Immature Permanent Teeth: A Pilot Study: (J Endod 2008;34:166 –171)
immunohistochemical, cellular, and molecular analyses. Evidence is accumulating to
support the hypothesis that scap appear to be the source of primary odontoblasts that
are responsible for the formation of root dentin, whereas dpscs are likely the source of
replacement odontoblasts. Conservation of these stem cells when treating immature
teeth may allow continuous formation of the root to its completion.
Little, if any, information on the human apical papilla is available in the literature. In
developing teeth, root formation starts as the epithelial cells from the cervical loop
proliferate apically and influence the differentiation of odontoblasts from
undifferentiated mesenchymal cells and cementoblasts from follicle mesenchyme. This
apically extending two-layered epithelial wall (merging of the inner and outer enamel
epithelium) forms hertwig’s epithelial root sheath (hers), which is responsible for
determining the shape of the root(s) and forms cementum through epithelial-
mesenchymal transition. It has been known that dental papilla contributes to tooth
formation and eventually converts to pulp tissue. Because the root continues to develop
after the bell stage, the location of the dental papilla becomes apical to the pulp tissue.
The histologic features at the junction of the pulp and the apical papilla have not been
well described.

DENTAL PULP & PARKINSON’S DISEASE

A study in may 1 issue of European Journal of Neuroscience shows dental pulp provides
great support for nerve cells lost in parkinson’s disease & could be transplanted directly
into the affected parts of the brain.
Using dental pulp has other advantages besides its availability, Norsat said. The cells
produce a most of beneficial “neurotrophic” factors.
These neurotrophic factors are like –
- glial cell lined neurotrophic factor
- nerve growth factor
- brain derived neurotrophic factor
They have the potential to promote the survival of brain neurons lost in parkinson’s
disease.
This disease is characterized by tremors of the hands, arms or legs, rigidity of the body
and difficulity balancing for such activities like standing or walking. Parkinson’s affect
nerve cells in the part of the brain called the basal ganglia, which is responsible for
control of voluntary movement.
 Norrat’s study involved evaluating the potential of tooth cells for the
development of a cell-based therapy for Parkinson’s disease and injecting tooth cells
into the specific part of the brain with the tooth cells providing neurotrophic support for
dying nerve cells and replacing dead cells. Neurotrophic factors play a key role in the
functioning of the nervous system.
Researchers extract a tooth and draw cells from its center, than culture them in a
petridish to increase the number of the cells. The mixture then contain neuronal
precussor cells and cells that produce beneficial neurotrophic factors.
Nosrat emphasizes that there is much work to be done before human patients
might find relief from Parkinson’s symptoms as a result of this therapy.

CONCLUSION

The pulp lies at the centre of the tooth and also the centre of endodontics. Our focus
may have shifted over the years from merely diagnosing to later treating and now
regenerating this unique tissue, but the fact remains unchanged that the basic
understanding of the pulp has been and shall forever be the mainstay of this speciality.
 REFERENCES

Thomas HF, and Payne RC: The ultrastructurc of dentinal tubules from erupted human
premolar teeth, J Dent Res 62:532, 1983

2
Fitzgerald M, Chiego DJ, and Heys DR: Autoradiographic analysis of odontoblast
replacement following pulp exposure in primate leelh,Arch Oral Biol 35:707, 1990.

3
Farnoush A: Mast cells in human dental pulp, J Endod 10:250,1984.

4
Kim S, et al: Effects of local anesthetics on pulpal blood flow in
dogs, J Dent Res 63:650, 1984
5
Fisher AK, et al: Effects of dental drugs and materials on the rate of
oxygen consumption in bovine dental pulp, J Dent Res 36:447,1957
6
Comparative dental material cytotoxicity measured by depression of rat incisor pulp
respiration, J Endod 5:48, 1979.
7
Hamersky PA, Weimer AD, and Taintor JF: The effect of orthodontic
force application on the pulpal tissue respiration rate in the human
8
Torneck CD: Dentin-pulp complex. In Ten Cate AR: Oral histology; development,
structure, and function, ed 2, St. Louis, 1985, Times Mirror Vlosby College Publishing

9
Johnsen DC, Harshbarger J, and Rymer HD: Quantitative assessment
of neural development in human premolars, Anat Rec 205:421,
1983.

10
Avery JK, Cox CF, and Chiego DJ Jr: Presence and location of adrenergic nerve endings in
the dental pulps of mouse molars, Anat Rec 198:59, 1980.

11
Edwall L, and Scott D Jr: Influence of changes in microcirculation on the excitability of
the sensory unit in the tooth of the cat, Ada Physiol Scand 82:555, 1971.

12
SIMON, D.E., JACOBS, T.L., STEVE SENIA, E., WALKER, W.A.: Intraligamentary
anesthesia as an aid in endodontic diagnosis. Oral Surg., 54(1):77, 1982

13LITTNER, M.M., TAMSE, A., KAFFE, I.: A new technique of selective anesthesia for
diagnosing acute pulpitis in the mandible. J. Endod., 9:116, 1983

14
S.A. Hacking: Applications of Microscale
Technologies for Regenerative
Dentistry:J Dent Res 88(5):409-421, 2009

15
. Mabel M. Cordeiro Dental Pulp Tissue Engineering with Stem Cells from
Exfoliated Deciduous Teeth, JOE — Volume 34, Number 8, August 2008

16.
Naseem Shah Efficacy of Revascularization to Induce
Apexification/Apexogensis in Infected, Nonvital,
Immature Teeth: A Pilot Clinical Study (J Endod 2008;34:919–925)
17
Elisabetta Cotti:Regenerative Treatment of an Immature, Traumatized
Tooth With Apical Periodontitis: Report of a Case (J Endod 2008;34:611– 616)

18
George T.-J. Huang: The Hidden Treasure in Apical Papilla: The Potential Role
in Pulp/Dentin Regeneration and BioRoot Engineering:
(J Endod 2008;34:645– 651)
19
Wataru Sonoyama: Characterization of the Apical Papilla and Its Residing Stem Cells
from Human Immature Permanent Teeth: A Pilot Study: (J Endod 2008;34:166 –171)
20
. Ingle John I. and Bakland Leif: Endodontics 5th edition: 2002 BC Decker Inc Hamilton •
London

21
. Cohen and Burns: Pathways of the Pulp 6th edition: Mosby elsiever

22
. Arnaldo Castellucci: Endodontics volume I: Il Tridente

ABSTRACTS OF CITED REFERENCE ARTICLES

1. The ultrastructure of dentinal tubules from erupted human premolar teeth

H.f. thomas

Department of oral biology, school of dental medicine, university of connecticut health center,
farmington, connecticut 06032

R.c. payne

Department of pediatric dentistry, university of texas health science center, san antonio, texas
78284

Different regions of crown dentin from erupted human premolars were examined
ultrastructurally to determine the contents of the dentinal tubules. Odontoblast processes were
limited to inner dentin, and nerve fibers were not observed in any tubules examined.

Journal of dental research, vol. 62, no. 5, 532-536 (1983)

2. Autoradiographic analysis of odontoblast replacement following pulp exposure in primate
teeth

,1
m. Fitzgerald , d.j. chiego jr2 and d.r. heys1

Abstract
Cell migration and replication associated with odontoblast replacement occurring soon after
pulp exposure in primate teeth were studied. Class 5 cavity preparations resulting in pulp
exposures were restored with a calcium hydroxide-containing capping agent and amalgam.
Eighty-four and 96 h after this the animals were injected with 0.5 μci/g body wt tritiated
thymidine (sp. Act. 6.7 ci/mm). Teeth were extracted 6, 8, 10 and 12 days after treatment. The
number of labelled cells as well as the number of grains per labelled cell were counted for
odontoblast-like, fibroblast-like and perivascular cells in three 60 × 260 μm zones. These zones
represented the odontoblast and cell-free (zone 1), cell-rich (zone 2) and deep pulp (zone 3)
areas of normal pulp tissue. Ten sections centred around the mid-point of the exposure were
counted for each tooth. Matrix formation and labelled odontoblast-like cells were observed at
the interface between the capping agent and the pulp as early as day 8. Other significant
findings were: (1) an increase in labelled odontoblast-like cells in zone 1 over time, suggesting a
continual influx of differentiating cells; (2) an increase in labelled cells in zone 1 over time with a
concurrent decrease in zone 3, suggesting that the influx of cells in zone 1 was from the deeper
pulp; and (3) differences in grain counts between zones, treatment times and cell types,
indicating that at least two dna replications had occurred between initial treatment and final
odontoblast-like cell differentiation.

3. Mast cells in human dental pulp

volume 10, issue 6, pages 250-252 (june 1984)

ali farnoush, 1
controversy exists regarding the presence of mast cells in the dental pulp. As mast cells are
present in other soft tissues throughout the body, their reported absence in the dental pulp
seems puzzling and anomalous. Dental pulps from 10 caries-free permanent and 10 carious
primary teeth were expamined for the presence of mast cells. The pulps were removed by
splitting the teeth, frozen-sectioned at 5 μm, and stained for mast cells utilizing a technique
which is proven to be highly selective for identification of mast cells in various tissues.
Additional sections from inflamed and noninflamed pulps were stained with hematoxylin and
eosin to assess the inflammatory response. The results indicated that mast cells were present in
noninflamed as well as inflamed pulps. Mast cells from the inflamed pulps showed signs of
degranulation with granules appearing outside the cell membrane.

4. Kim s, et al: effects of local anesthetics on pulpal blood flow in dogs, j dent res 63:650, 1984

abstract
Effects of 2% lidocaine with epinephrine (1 :100,000) administered by the various local
anesthetic techniques - i.e., infiltration, mandibular block, and intraseptal injection - on pulpal
blood flow in dogs were determined using the 15 μm radioisotope-labeled microsphere
injection method. The pulpal blood flow decreased significantly with all three techniques;
however, the most drastic reduction occurred in the molar teeth with the intraseptal injection.
When 2% lidocaine without epinephrine was used in the intraseptal injection, pulpal blood flow
increased significantly.

7. The effect of orthodontic force application on the pulpal tissue respiration rate in the
human premolar

paul a. Hamersky, d.d.s., m.s. , allan d. Weimer, d.d.s., m.s. , jerry f. Taintor, d.d.s., m.s

abstract

This study investigates the effect of an orthodontic force on pulpal respiration in the human
premolar. The participants in this study required the removal of four first premolars for
orthodontic treatment. After written consent was obtained, these teeth were used in the
following manner. Randomly, the premolars on one side of the mouth were designated as
experimental and the premolars on the opposing side served as controls. The four teeth were
removed following a 3-day application of an orthodontic force. The pulp tissue was then
extirpated and used for the investigation. A radioactively labeled carbon dioxide production
system was used to evaluate the effect on pulpal respiration of the orthodontic force. It is
thought that this method has been proved to provide a viable and sensitive biochemical
analysis of tissue respiration on very small samples over short observation periods. The data
were collected and prepared for statistical analysis. This investigation demonstrated that the
pulp tissue respiration in seventeen subjects was depressed an average of 27 percent as a result
of orthodontic force application. A positive correlation between the age of the participant and
the amount of tissue respiratory depression was also demonstrated. It was therefore concluded
that orthodontic forces of very short duration do cause biochemical and biologic pulpal tissue
alterations and that orthodontic forces may be less biologically safe as the age of the patient
increases.

8. Johnsen dc, harshbarger j, and rymer hd: quantitative assessment

Of neural development in human premolars, anat rec 205:421,
1983.
D. C. Johnsen 1, j. Harshbarger 2, h. D. Rymer 2

abstract
The number of nerve fibers entering a tooth gives an indication of the tooth's capacity to
perform a sensory function. Nerve fiber development was quantitated from cross sections of
the apical portions of 49 erupted human premolars at various stages of root development and
in subjects up to 71 years of age. Neural development was incomplete in immature teeth,
greatly variable in young mature teeth, and complete in older teeth. Myelinated axons changed
in number but not in size during tooth development. There were significantly fewer myelinated
axons in teeth with open and parallel apical foramina than in older teeth. Unmyelinated axons
did not change significantly in number with development but fewer large axons were found in
older teeth. The number of unmyelinated axons enclosed in a single boundary lamina tended to
be lower in older teeth. As a physiologic correlate, threshold responses to electrical stimulation
were also determined prior to premolar removal. Threshold stimulation decreased significantly
with apical foramen maturation. A significant negative correlation was found between the
threshold stimulus and the number of myelinated axons in fully developed teeth, but not in
immature teeth.

10. Avery jk, cox cf, and chiego dj jr: presence and location of adrenergic nerve endings in the
dental pulps of mouse molars, anat rec 198:59, 1980

Abstract
In all, 30 adult (45-day-old) swiss webster mice were used for light and electron microscopic
examination of the presence, number, and location of adrenergic endings in the first molar
teeth. Prior to sacrifice, 10 animals received i.p. injections at 8, 6, 4, and 2 hours of 0.5 cc of 20
mg/kg solution of 5-hydroxydopamine (5-oh-da) as a label for adrenergic endings. The animals
were then anesthetized, perfused with karnovsky's fixative, and the teeth were postfixed in
osmic acid, decalcified, embedded in methacrylate, and serial-sectioned. The sections were
surveyed by light microscopy, and the number and location of nerve endings containing the
reduced 5-oh-da were recorded. Ten control mice were injected with the vehicle solution and
prepared in the same manner. A third series of mice were given a single injection of 5-oh-da,
sacrificed, and prepared for ultrastructural study. The molar pulps were divided into four areas
to facilitate examination: pulp horns, coronal pulp, bifurcation area, and root pulp. These four
areas were further divided into three zones: odontogenic, vascular-related, and nonvascular-
associated. The location and number of endings were evaluated, and an average of
approximately 70 endings containing the 5-oh-da were found in each tooth using light
microscopy. These represented 35.5 ± 5.2 in the pulp horns; 26.1 ± 2.4 in the central coronal;
5.4 ± 0.7 in the bifurcation, and 5.6 ± 0.9 in the root pulp per tooth. Vascular related endings
were found in greatest number, the odontogenic zone next, and free endings least. Verification
of location of 5-oh-da by ultrastructural analysis revealed the false transmitter in vesiculated
endings in the four areas and zones of the pulp.

11.
Edwall l, and scott d jr: influence of changes in microcirculation on the excitability of the
sensory unit in the tooth of the cat, ada physiol scand 82:555, 1971.

Abstract
Simultaneous determinations of radioactive iodide disappearance rate (k-value) and sensory
nerve impulse frequency from dentinal cavities were performed on canine teeth of
anesthetized cats. Changes in k-value reflecting changes in pulpal microcirculation were
obtained by direct sympathetic nerve stimulation or by thermal stimulation. Sympathetic nerve
stimulation re duced the k-value and induced an initial increase in nerve impulse frequency.
During maximal sympathetic nerve stimulation this initial increase was followed by a marked
depression in impulse frequency. Application of heat increased k-value as well as impulse
frequency, while cold reduced k-value and induced an initial increase in nerve impulse
frequency followed by a decrease. Thermal stimulation superimposed during maximal
sympathetic stimulation, when k-value was depressed, was inadequate to evoke an appreciable
increase in sensory nerve in pulse frequency. It is suggested that the excitability of sensory units
in the tooth is strongly modulated by changes in pulpal microcirculation induced by, for
example, stimulation of sympathetic vasoconstrictor fibres

14.
Applications of microscale
Technologies for regenerative
Dentistry

S.a. hacking and

A. Khademhosseini

J dent res 88(5):409-421, 2009

Abstract
While widespread advances in tissue engineering have occurred over the past decade, many
challenges remain
In the context of tissue engineering and regeneration of the tooth. For example, although tooth
development is
The result of repeated temporal and spatial interactions between cells of ectoderm and
mesoderm origin, most
Current tooth engineering systems cannot recreate such developmental processes. In this
regard, microscale
Approaches that spatially pattern and support the development of different cell types in close
proximity can be
Used to regulate the cellular microenvironment and, as such, are promising approaches for
tooth development.
Microscale technologies also present alternatives to conventional tissue engineering
approaches in
Terms of scaffolds and the ability to direct stem cells. Furthermore, microscale techniques can
be used to
Miniaturize many in vitro techniques and to facilitate high-throughput experimentation. In this
review, we
Discuss the emerging microscale technologies for the in vitro evaluation of dental cells, dental
tissue engineering,
And tooth regeneration.

15.
Dental pulp tissue engineering with stem cells from
Exfoliated deciduous teeth
Mabel m. Cordeiro, dds, ms, phd,* zhihong dong, md, phd,*
Tomoatsu kaneko, dds, phd,*† zhaocheng zhang, md, phd,*
Marta miyazawa, dds, ms, phd,* songtao shi, dds, phd,‡ anthony j. Smith, bsc, dds, phd,§
And jacques e. Nör, dds, ms, phd*_
Abstract
Stem cells from human exfoliated deciduous teeth (shed) have been isolated and characterized
as multipotent cells. However, it is not known whether shed can generate a dental pulp-like
tissue in vivo. The purpose of this study was to evaluate morphologic characteristics of the
tissue formed when shed seeded in biodegradable scaffolds prepared within human tooth slices
are transplanted into immunodeficient mice. We observed that the resulting tissue presented
architecture and cellularity that closely resemble those of a physiologic dental pulp.
Ultrastructural analysis with transmission electron microscopy and immunohistochemistry for
dentin sialoprotein suggested that shed differentiated into odontoblast-like cells in vivo.
Notably, shed also differentiated into endothelial-like cells, as demonstrated by b-galactosidase
staining of cells lining the walls of blood-containing vessels in
Tissues engineered with shed stably transduced with lacz. This work suggests that exfoliated
deciduous
Teeth constitute a viable source of stem cells for dental pulp tissue engineering. (j endod
2008;34:962–969)

16.
Efficacy of revascularization to induce
Apexification/apexogensis in infected, nonvital,
Immature teeth: a pilot clinical study
Naseem shah, mds, ajay logani, mds, uday bhaskar, mds, and vivek aggarwal, mds
Abstract
Endodontic treatment options for immature, nonvital teeth conventionally include surgical
endodontics, apexification with calcium hydroxide, or single visit mineral trioxide aggregate
plug. A new treatment option of revascularization has recently been introduced. It involves
disinfecting the root canal system, providing a matrix of blood clot into which cells could grow,
and sealing of the coronal access. The present pilot clinical study was undertaken to evaluate
the efficacy of revascularization in 14 cases of infected, immature teeth. Endodontic treatment
was initiated, and after infection control, revascularization was performed. The access cavity
was sealed with glass ionomer cement. The cases were followed up at regular intervals of 3
months; the range in follow-up was 0.5–3.5 years. The outcomes were as follows. Radiographic
resolution of periradicular radiolucencies was judged to be good to excellent in 93% (13 of 14)
of the cases. In the majority of cases, a narrowing of the wide apical opening was evident. In 3
cases, thickening of apical dentinal walls and increased root length were observed. The striking
finding was complete resolution of clinical signs and symptoms and appreciable healing of
periapical lesions in 78% (11 of 14) of cases. Thickening of lateral dentinal walls was evident in
57% (8/14) of cases, and increased root length was observed in 71% (10/14) of cases. None of
the cases presented with pain, reinfection, or radiographic enlargement of preexisting apical
pathology. This pilot study documented a favorable outcome of revascularization procedures
conducted in immature nonvital, infected permanent teeth. (j endod 2008;34:919–925)

17.
Regenerative treatment of an immature, traumatized
Tooth with apical periodontitis: report of a case
Elisabetta cotti, dds, ms, manuela mereu, dds, and daniela lusso, dds
Abstract
This case report describes the treatment of a necrotic
Immature permanent central incisor with complete
Crown fracture, suspected root fracture, and sinus tract,
Which was not treated with conventional apexification
Techniques. Instead, a regenerative approach based on
The trauma literature’s methods for revascularization
Was provided. The root canal was gently debrided of
Necrotic tissue with a sharp spoon excavator and irrigated
For only one third of its length with naocl and
Then medicated with calcium hydroxide. After 15 days
The sinus tract had healed, and the tooth was asymptomatic.
The tooth was accessed, calcium hydroxide
Was removed, bleeding was stimulated to form an
Intracanal blood clot, and mineral trioxide aggregate
Was placed coronally to the blood clot. After 8 months,
A coronal calcified barrier was radiographically evident
And accompanied with progressive thickening of the
Root wall and apical closure. Two and a half years after
Treatment was initiated, the tooth remained asymptomatic,
And the sinus tract had not reappeared. The progressive
Increase in the thickness of the dentinal walls
And subsequent apical development suggest that appropriate
Biologic responses can occur with this type of
Treatment of the necrotic immature permanent tooth
With sinus tract. (j endod 2008;34:611– 616)

18.
The hidden treasure in apical papilla: the potential role
In pulp/dentin regeneration and bioroot engineering
George t.-j. Huang, dds, msd, dsc,* wataru sonoyama, dds, phd,§ yi liu, dds, phd,‡
He liu, dds, phd,_ songlin wang, dds, phd,‡ and songtao shi, dds, phd†
Abstract
Some clinical case reports have shown that immature
Permanent teeth with periradicular periodontitis or abscess
Can undergo apexogenesis after conservative
Endodontic treatment. A call for a paradigm shift and
New protocol for the clinical management of these
Cases has been brought to attention. Concomitantly, a
New population of mesenchymal stem cells residing in
The apical papilla of permanent immature teeth recently
Has been discovered and was termed stem cells from
The apical papilla (scap). These stem cells appear to be
The source of odontoblasts that are responsible for the
Formation of root dentin. Conservation of these stem
Cells when treating immature teeth may allow continuous
Formation of the root to completion. This article
Reviews current findings on the isolation and characterization
Of these stem cells. The potential role of these
Stem cells in the following respects will be discussed:
(1) their contribution in continued root maturation in
Endodontically treated immature teeth with periradicular
Periodontitis or abscess and (2) their potential utilization
For pulp/dentin regeneration and bioroot Engineering. (j endod 2008;34:645– 651)