Professional Documents
Culture Documents
CONTENTS
INTRODUCTION
DEVELOPMENT
ANATOMY
STRUCTURAL FEATURES
FUNCTIONS
PRIMARY AND PERMANENT PULP ORGANS
REGRESSIVE CHANGES
CLINICAL CONSIDERATIONS
INTRODUCTION
Every individual has a heart study, reliable yet as every lover knows, oh so
fragile.
So, too does every tooth have a heart. Amazingly dependable, highly
functional and yet as every dentist knows oh so fragile.
Encased in the rigid, unyielding loosening of tooth enamel, dentin and
dentin, this freshly mass of complex connective tissue presents a unique
niche of specialization. The only soft part of the tooth its loving entity is
the pulp.
Being in a low compliance environment, the pulp has a fabulous defense
arsenal to help it perform its function increasingly. However, it is equally
in a pressure cooker situation and can very easily succemd to
environmental stimuli. It is this variability that has led to the saying some
pulps die if you look crossly at them, this wont if you chop than with an
axe.
So let us look at the fascinating tissue complete with an electrical supply
and the throbbing heart to see what makes it tick.
result of proliferation of the cells within it. The young dental papilla is
highly visualized and a well organized network of vessels appears by the
time dentin formation begins.
Capillaries crowd among the odontoblasts during this period of active
dentinogenesis. The cells of the dental papilla appear as undifferentiated
mesnechymal cells. Gradually these cells differentiate into stellate shaped
fibroblasts. After the inner and outer enamel organ cells into ameloblasts,
the odontoblasts then differentiate from the peripheral cells of the dental
papilla production begins. As this occurs, the tissue is no longer called
dental papilla but is now designated the pulp organ. 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 zones in the pulp horns. The
sympathetic nerves, however, follow the blood vessels into the dental
papilla as the pulp begins to organize.
Anatomy:
General features: The dental pulp occupies the center of end of tooth and
consists of soft connective tissue. Every person, normally has a total of 52
pulp organs. 32 in permanent teeth and 20 in primary teeth with the shape
confirming to that of the respective tooth. The total volume of all
permanent teeth pulp organs is 0.38 cc and the mean value of a single adult
human pulp is 0.02 cc.
Each pulp organ is composed of a coronal pulp located centrally in the
crowns of teeth and a root or radicular pulp.
Coronal pulp:
In young individuals, the coronal pulp resembles the shape of the outer
surface of the crown.
It has 6 surfaces occlusal, mesial, distal, buccal, lingual and the floor. It
has pulp horns which are protrusions that extend into the cusps of each
tooth. The number of horns hence, depends on the cuspal number. The
cervical region constricts as does the contour of the crown and at this zone
the coronal pulp joins the radicular pulp.
RADICULAR PULP:
The pulp extending from the cervical region of the crown to the root apex
is radicular pulp. Single in anterior and multiple is posteriors, they are not
always straight and vary in size, shape and number. The radicular portions
are continuous with the periapical connective tissues through the apical
foramen or foramina. The shape is tubular and as tooth matures, radicular
pulp narrows. The apical pulp canal is made smaller also because of apical
cementum deposition. In its apical 3 rd multiple accessory canals form the
apical delta which may complicate endodontic therapy.
APICAL FORAMEN:
The small openings at the root through which enter and exit vascular,
lymphatic and nerve elements is the apical foramen. It may be composed of
dentin surfaced by cementum or cementum alone. They vary in diameter,
location, shape and number. The average diameter for mandibular teeth is
about 0.3m and 0.4m for maxillary teeth. They are large and centrally
locted in developing teeth and become smaller and eccentric in position on
maturation. The largest diameter foramen are in the palatal root of
maxillary molars and distal root of mandibular molars.
Foramen may be located at the very end or anatomic apex but are usually
located slightly more occlusally. They covered with anatomic apex only in
17-46% and are located at average 0.5-0.7m away from the apex). There
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1. Acid mucopolysacchairdes.
2. Protein polysaccharide compounds i.e. glycosaminoglycans and
proteoglycans.
During early development chondritis A and B and hyaluronic acid have
been demonstrated.
Also glycopeptide and glycosaminolipids are present.
The proteoglycans are hyaluronic acid, chondroitin sulfate, dermatis sulfate
and heparin sulfate.
Major glycoprotein is fibronectin along with laminin and tenascin.
Its functions include:
1. Lend support to the cells of the pulp.
2. Serves as a means for transport of nutrient from the blood vessels to
cells as well as for transport of metabolites from cells to blood
vessels.
3. Serves as a barrier against the spread of bacteria and limits spread of
infection because of its consistency.
4. Regulates osmotic pressure. Age and disease may change the
composition and function of the ground substance.
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From the capillaries blood flow into postcapillary venules and then into
larger venules. This blood is drained by a system of venules that are
comparison venules of arterioles. Veins and venules that are larger than
arteries appear in the central region of root pulp measuring 100-150m in
diameter with less regular walls. They have luminar walls in relation to
lumen size, flatter endothelial cells and their cytoplasm does not project
into the lumen.
The tunica media consists of a single layer or 2 of this smooth muscle cells
that wrap around the endothelial cells and appear discontinuous or absent
in small venules. The basement membranes are thinner and the adventitia is
lacking or appears as fibroblasts and fibres confirm with pulp tissue.
Another important feature are the AVAs or arteriovenous anastomoses.
These vessels directly connect arterioles with venules and thus shunt or
bypass the capillary network. Present both coronally and radicular, more
particular in the latter. These have an important role to play in regulation of
pulpal circulation.
The most vascularized area is the periphery at the odontogenic layer. Also
pulpal blood flow is substantially lower than a major visceral organs
indicating that the respiratory rate of pulp cells is relatively low.
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constitute the plexus. There is profile branching of the fibres in the plexus
producing a tremendous overlap of receptor fields. Full development of
this plexus does not occur until the final stages of root formation.
Finally come the NERVE ENDINGS OR TERMINALS:
Nerve axons from the parietal zone pass through the cell rich and cell free
zones and either terminate among or pass between the odontoblasts to
terminate adjacent to the odontoblast processes at the pulp predentin border
or in the dentinal tubules.
Nerve terminals consisting of round or oval enlargements of the terminal
filaments contain microvesicles, small dark granular bodies and
ribochondria. These terminates are very close to the odontoblast plasma
membrane separated only by 20. Most of these endings are believed to be
sensory receptors with some sympathetic endings too.
Nerve axons found among the odontoblasts and in the cell free and cell rich
zones are non myelinated but are enclosed in a Schwan cell covering. More
nerve fibres and endings are found in the pulp horns than in other
peripheral areas of the coronal pulp.
4 types of terminal configuration are seen:
1. Simple marginal pulpal nerve fibres seen from subodontoblastic
nerve plexus to odontoblastic layer.
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immense
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The period of pulp aging is much accelerated in primary teeth about 7 yrs,
5 months. Aging of permanent teeth requires much of the adult life span.
Finally, for both primary and permanent teeth, the maxillary arches require
slightly longer to complete each process than mandibular.
AGE AND REGRESSIVE CHANGES IN THE PULP:
1. DIMENSIONAL CHANGES: The most conspicuous age change
is the reduction in volume of the pulp due to continous deposition of
secondary dentin and reparative dentin in response to stimuli. This
dimunition is called atrophy.
2. CELL CHANGES: Cells become fever in number and also
characterized by decrease in size and number of cytoplasmic
organelles.
3. FIBROSIS: In the aging pulp accumulation of tooth diffuse fibrillar
componenets as well as bundles of collagen fibres appear. The
increase in fibers is gradual and generalized throughout the organ.
Any external trauma causes a localized fibrosis or scaling effect.
The increase in collagen fibres may be more apparent than actual,
attributable to decrease in pulp size, making the fibres occupy less
space and look more concentrated. It has even been theorized that
pulpal fibrosis does not increase as a result of age.
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Another important age change are the calcification of the dental pulp.
So now we come to the :
PULP STONES OR DENTICLES:
Pulp stones are nodular, calcified masses appearing in the coronal or root
portions of the pulp.
They develop in teeth quite normal in other aspect and can be seen in
functional as well as embedded unerupted teeth. Their etiology is still
unclear and have not been associated with any abnormalities of the pulp
yet.
CLASSIFICATION:
According to their structure:
1. True denticles.
2. False denticles.
3. Diffuse calcifications.
TRUE DENTICLES: their structure is similar to dentine. They are rare
and are usually seen close to the apical foramen. They exhibit dental tubuli
containing odontoblasts processes.
A theory put forth states that the development of true denticles is caused by
the inclusion of remnants of the epithelial root sheath within the pulp
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which induce the pulpal cell to differentiate into odontoblasts and form
pulp stones.
FALSE DENTICLES: These do not exhibit dentinal tubules but appear
instead as concentric layers of calcified tissue and can appear with a bundle
of collagen fibres or in a pulp force of collage accumulations. Some arise
around vessels, having remnants of necrotic and calcified cells centrally.
Calcification of thrombi in blood vessels called phleboliths may also serve
as mid for false denticles.
All denticles begin as small nodules but increase in size by incremental
growth or their surface. The surrounding pulp tissue may appear quite
normal. Pulp stones may eventually fill substantial parts of the pulp
chamber.
DIFFUSE CALCIFICATIONS:
They appear as irregular calcific deposits in the pulp tissue usually
following collagenous fibre bundles or blood vessels. Sometimes they
develop into larger masses but usually persist as fine calcified spicules.
Pulp appears normal. They are usually found in the root canal whereas
denticles are more frequent in the coronal pulp.
Pulp stones are also classified according to their location in relation to the
surrounding dentinal wall:
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neural vitality of pulp not vascular which is the true indicator. Latest
techniques like laser Doppler flowmetry and pulse oximetry are
slowly making inroads as means of measuring pulpal vitality and
determining therapeutic options.
CONCLUSION:
It is often in the past that we find the future. Thus a thorough and complete
assimilation of the myriad and fantastic database on the dynamics of the
pulp and a knowledge of various elucidations past, present and future will
go a long way in ensuring that we, as dental physicians, provide the highest
level of technical and scientific accuracy and artistic flair in the holistic
well being of the tooth organ and in turn fulfill the aspiration of those
individuals who place in us their unwavering trust - our patients.
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