* Definition
* Development : from the dental papilla.
* Anatomy of the pulp : coronal part in the pulp chamber and a radicular part in
the root canal
* Accessory root canals
* Histology of the pulp : odontogenic zone ( odontoblastic zone , cell- free zone ,
cell- rich zone ) - The pulp core
* Cells of the pulp : Synthetic cells (fibroblasts , odontoblasts) - Defensive cells
( dendritic cells , macrophages , T-lymphocytes , plasma cells , mast cells ) -
Progenitor cells (UMC).
* Fibers : type I & III collagen.
* Ground Substance : mucopolysaccharides, glycoprotein and water.
* Blood supply :
* Structure of the blood vessels ( Arteries and terminal arterioles )
* Venous blood (veins and venules) :
* Arterio–venous anastomoses
* Lymph vessels
* Nerve supply :
1. Non- myelinated sympathetic nerves from superior cervical ganglion
2. Myelinated parasympathetic sensory afferents of the trigeminal nerve
* Functions of the Pulp:
1. Inductive 2. Formative 3. Nutritive 4. Protective 5. Defensive or reparative
* Age changes of the pulp
* Localized calcification of the pulp (False pulp stones ,True pulp stones or true
denticles )
* Diffuse pulp calcification
* pulp calcification significance.
* Clinical considerations
* Definition : loose delicate connective tissue that occupies the central cavity of
the tooth.
* Development: from the dental papilla.
- dental papilla cells are ectomesenchymal cells.
- Its central cells differentiate into star or spindle shaped fibroblasts.
- Its peripheral cells differentiate into odontoblasts
* Anatomy of the pulp : coronal part in the pulp chamber and a radicular part in
the root canal
- The shape of the coronal part resembles D.E.J with extension into the pulp horns.
- With age, the coronal pulp decreases in size with obliteration of the pulp horns ;
due to continued secondary dentin formation
- The radicular pulp is part of the pulp extending from the cervical region of the
crown to the root apex.
- In anterior teeth, the radicular pulp is single while in posterior teeth is multiple.
- The radicular part terminates at the apical foramen
- The size of the apical foramen varies from 0.3 to 0.6mm.
* Accessory root canals :
- lateral extensions from the radicular pulp through the root dentin to reach the
periodontal ligament.
- Mechanism of accessory root canal formation is unknown; it may occur:
1. In an area where a large blood vessel interferes with the continuity of the root
sheath
2. early degeneration of the epithelial root sheath of Hertwig occurs before the
differentiation of the odontoblasts.
3. lack of complete union of the tongue like projections of the epithelial diaphragm
during root formation in multirooted teeth.
* Histology of the pulp : cells embedded in an extracellular matrix with fibers and
ground substance :
1. The odontoblastic zone :
- lines the pulpal wall of dentin adjacent to predentin.
- consists of a layer of cell bodies of the odontoblasts.
2. The cell- free zone (zone of Weil) : prominent in the coronal pulp.
- Some believed that it is an area of mobilization and replacement of odontoblasts
3. The cell- rich zone : composed mainly of fibroblasts and undifferentiated
mesenchymal cells.
- These 3 zones are termed together the odontogenic zone.
4. The pulp core : characterized by the large vessels and nerves
* Cells of the pulp
a- Synthetic cells (fibroblasts – odontoblasts).
I) Fibroblasts
- the most numerous cells seen in pulp
- linked by gap and adherence junctions
- have a dual functions, both synthesis and degradation of collagen and ground
substance occur in the same cell.
- In young pulp, the fibroblasts appear large with multiple processes, centrally
placed nucleus, numerous mitochondria, well developed Golgi bodies and RER (
- With age, appear smaller, round or spindle-shaped, with few organelles and they
are termed fibrocytes.
II) Odontoblasts
- Second largest group of cells in the pulp
- linked by junctional complexes
- In the coronal pulp; they are large columnar cells about 35μ in length whereas in
the mid portion of the pulp are more cuboidal and in the apical part become more
flattened.
- By light microscopy, the active cell have an open- faced basally located nucleus
and basophilic cytoplasm.
- Ultrastructurally, there are: prominent Golgi complex on the dentinal side of the
nucleus, and numerous RER and mitochondria
- On the other hand, the resting cells appeared flattened with little cytoplasm and
closed faced nucleus.
b- Defensive cells
I) dendritic cells
- at least 50 um long and have three or more main dendritic processes which
branch.
- act as antigen-presenting cells stimulating the division and activity of native T-
lymphocytes
II) macrophages
- involved in the elimination of dead cells during turnover of dental pulp.
- remove bacteria and interact with inflammatory cells during inflammation.
- Both the dendritic and macrophage constitute 8 % of the total pulpal cell
III) T-lymphocytes
- associated with the immune defense system and increase when pulp is injured
- either in the form of small rounded cell with large rounded nucleus or large cells
with eccentric kidney-shaped nucleus.
IV) plasma cells
- active in antibody production.
- appear as large rounded cells with eccentric nucleus having cart-wheel distribution
of chromatin
V) mast cells
- have a rounded central nucleus with granular cytoplasm.
- demonstrated by specific stains as toluidine blue.
- produce histamine and heparin.
c- Progenitor cells (UMC).
- Under light microscope, similar to fibroblasts but smaller
- have the potentiality of forming other types of formative or defensive connective
tissue cells.
- In old pulp, their numbers diminish leading to reduction in the regenerative
potential of the pulp.
* Fibers : type I & III collagen.
- In young pulp, single fibrils of collagen.
- With age, becomes organized into fiber bundles
* Ground Substance : mucopolysaccharides, glycoprotein and water.
- supports the cells and acts as a medium for transport of nutrients from the
vasculature to the cells and of metabolites from the cells to the vasculature.
- Alteration in the composition by age or disease, leads to metabolic changes,
reduced cellular function
* Blood supply :
- The pulp is highly vascularized, with vessels arising from the external carotids to
the superior and inferior alveolar arteries. It drains by the same veins.
- The arterioles and venules enter the dental pulp via the apical foramina.
- They enter in conjunction with the sensory and sympathetic nerve bundles that
innervate the pulp.
- Along their course, they give off numerous side branches in the radicular pulp
which pass peripherally to end in a network of capillaries beneath the odontoblastic
region called (subodontoblastic capillary plexus).
- These capillaries do not enter the dentinal tubules.
- The blood flow of the pulp is more rapid than in most areas of the body
* Structure of the blood vessels : Arteries and terminal arterioles:
- Pulp arteries consist of:
A- Tunica intima: formed of a single layer of endothelial cells.
B- Tunica media: formed of 1-3 layers of smooth muscle cells.
C- Tunica adventitia: formed of a loose network of collagen fibers.
-There is progressive decrease in the diameter of vessels from 100μ in the arteries
to 8μ in the capillaries.
- the arterioles have thinner walls than the artery
- The fine branches are called precapillaries and their walls are formed of
endothelial cells and just one layer of muscle cells. When they lose the muscle cells,
they are termed capillaries.
- These are small pores covered by plasma membrane which permit rapid transfer
of metabolites during dentin matrix formation.
- The capillaries have cells called pericytes or Rouget cells that :
a) form a partial sheath around the endothelial wall.
b) control the size of the lumen of fine capillaries.
* Venous blood (veins and venules) :
- Their diameter (100-150μ) is larger than the arteries, their walls are thinner
- Arterio–venous anastomoses : points of direct communication between the arterial
and venous sides important in diverting blood away from capillaries
* Lymph vessels :
- endothelial lined tubules that join thin walled lymph venules or veins in the pulp.
- distinguished from the venules by absence of red blood cells in their lumen.
- The lymph drainage of the anterior teeth passes to the submental lymph nodes
while that of the posterior teeth passes to the submaxillary and deep cervical lymph
nodes.
* Nerve supply :
- The nerves enter the pulp through the apical foramen; along with blood vessels
forming neurovascular bundles
- Two types of nerves are present:
1. Non- myelinated sympathetic nerves from superior cervical ganglion that supply
the smooth muscles of the large blood vessels in the central pulp to function in their
contraction or dilatation.
2. Myelinated parasympathetic sensory afferents of the trigeminal nerve which
cannot differentiate between heat, touch, pressure or chemicals ; as the pulp
organs lack those types of receptors, and the only identified sensation is pain.
- Thick myelinated nerve bundles enter the apical foramen and proceed to the
coronal part giving off smaller branches till reaching cell-rich zone, where they lose
their myelin sheath.
- The peripheral axons forms a network of nerves adjacent to the cell- rich zone and
called the parietal nerves or plexus of Rashkow ( not evident until the tooth has
erupted) .
- Most of the nerve bundles terminate in this plexus as free nerve endings especially
in the pulp horns
* Functions of the Pulp:
1. Inductive;
the dental papilla (future pulp) induce tooth formation. It also determines the
morphology ( anterior or posterior tooth ).
2. Formative:
The pulpal odontoblasts form the dentin matrix and function in its calcification
during dentinogensis.
3. Nutritive:
The pulp is the source of nutrition to the dentin through the odontoblasts and their
processes
4. Protective:
Having only free nerve endings, pulp respond to all types of stimuli by pain
5. Defensive or reparative:
The pulp responds to irritation by producing reparative dentin and mineralizing any
affected dentinal tubules.
- This reparative reaction is an attempt to wall off the pulp from the source of
irritation.
- Also, the presence of macrophages, lymphocytes and leucocytes aids in the
process of repair of the pulp.
* Age changes of the pulp:
• Volume: decrease in the size of the pulp chamber and root
• Apical foramen: narrowing due to continuous formation of dentin from inside and
cementum from outside.
• Cells:
- decrease in cellularity, vascularity and innervation of the pulp with age
- reduction in the regenerative potential of the pulp, its defense ability.
- degeneration of odontoblasts due to crowding in some areas.
• Fibers : No significant change occurs in the collagen content As a result of
diminished collagen synthesis and a lowered rate of collagen degradation.
• Nerves: both loss and degeneration of myelinated and unmyelinated nerve fibers
that correlate with an age related reduction in sensitivity.
• Calcification: occurrence of irregular areas of dystrophic calcification which are
either localized or diffuse.
- This dystrophic calcification may be found also in young normal pulp but they tend
to increase both in size and number by aging.
1. Localized calcification of the pulp (pulp stones or denticles) : classified
into true or false according to their structure:
a- False pulp stones :
- found at the orifice of the pulp chamber
- consist of concentric layers of mineralized tissue formed around degenerated cells
or blood thrombi which act as a central nidus.
- may enlarge till filling up the pulp chamber.
- Over doses of vitamin D may favor the formation of numerous false pulp stones.
b- True pulp stones or true denticles :
- rare than false denticles.
- occur in the root canal close to the root apex.
- formed of calcified tissue similar to irregular dentin, contain traces of dentinal
tubules surrounded by cells resembling odontoblasts.
- It has been suggested that during root formation, remnants of epithelial
root sheath of Hertwig (epithelial rests of Malassez) invade the pulp tissue causing
UMC of the pulp to differentiate into odontoblasts that form irregular dentin.
- Both types of pulp stones are classified according to their location in relation to
the dentinal wall as being free, attached and embedded.
- Free denticles are completely surrounded by pulp tissue
- attached denticles are attached to the dentinal wall
- embedded denticles are found within dentin developed by continued formation of
dentin around the attached denticles.
2. Diffuse pulp calcification
- commonly on top of hyaline degeneration in the root canal
- not common in the pulp chamber.
- irregular calcified deposits in the pulp tissue following the course of blood vessels
or collagen bundles.
- amorphous with no specific structure.
- The presence of pulp calcification significance : reduce the overall number of
cells within the pulp and interfere with the enlargement of the root canal system
during endodontic treatment.
* Clinical considerations:
1. For all operative procedures the shape of the pulp chamber and pulp horns is
important to remember.
2. The shape and location of the apical foramen may play an important part in
treatment of root canal.
3. With advancing age, the pulp chamber becomes smaller, and because of
excessive dentin formation , it is sometimes difficult to locate the root canal.
4. A vital pulp is essential for healthy dentin, but loss of the pulp after a root canal
treatment doesn’t mean that tooth will be lost; on the contrary, the tooth will
function without pain. The tooth however, has lost its protective mechanism that
the pulp structure provides.
5. In clinical practice, thermal stimuli (heat and cold) are often used to test the
sensitivity of the pulp and not its vitality.
6. When accessory canals are located near the coronal part of the root , a deep
periodontal pocket may cause inflammation profound influence on pulp integrity.
Conversely, a necrotic pulp can cause disease of the periodontium through an
accessory canal.
7. The exposed pulp can be preserved if proper pulp capping procedures are
applied.
8. All operative procedures cause an initial response of the pulp, which is dependent
on the severity of the insult.
9. The pulp is highly responsive to stimuli. Even a slight stimulus will cause
inflammatory cell infiltration.