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VASCULATURA PULPAR

Organization of Pulpal Vasculature


The dental pulp is a microcirculatory system because it lacks true
arteries and veins; the largest vessels are arterioles and venules. Its
primary function is to regulate the local interstitial environment of
dental pulp via the transport of nutrients, hormones, and gases and
the removal of metabolic waste products. However, the pulpal
microcirculation is a dynamic system that regulates blood flow in
response to nearby metabolic events (including dentinogenesis). It
also responds to inflammatory stimuli with a great change in
circulatory properties and the endotelial expression of certain
proteins, leading to the recruitment of immune cells to the site of
tissue injury.
Arteriolas
The pulp has an extensive vascular supply. The arterioles are
resistance vessels, measuring approximately 50 um in diameter, and
have several layers of smooth muscle, which regulate vascular tone.
The transitional structure between arterioles and capillaries is called
the terminal arteriole or metarteriole. This segment of the arteriole
has the same dimensions as a capillary but is surrounded by a few
smooth muscle cells. These smooth muscle cells are organized in a
spiral fashion surrounding the endotelial cells. The arterioles then
divide into terminal arterioles and then precapillaries.
The arterioles, the capillaries, and the venules form functional units
that respond to signals elaborated from the nearby tissue.
Thus, there is a functional coupling between cellular activity and
nearby capillary blood flow.

The branch points of terminal arterioles and capillaries are


characterized by the presence of clumps of smooth muscle that serve
as precapillary sphincters. These sphincters are under neuronal and
local cellular control (via soluble factors) and act to regulate local
blood flow through a capillary bed. These functional units permit
localized changes in blood flow and capillary filtration, so that
adjacent regions of the pulp have substantially different circulatory
conditions. Thus, pulpal inflammation can elicit a localized circulatory
response restricted to the area of inflammation and does not
necessarily produce pulpwide circulatory changes.
Capillaries
Capillaries serve as the workhorse of the circulatory system, because
they function as the exchange vessels regulating the transport or diffusion of substances (gases, fluids, proteins, etc) between blood and
local interstitial tissue elements. At any given moment, only about 5 %
of the blood supply circulates in capillaries, but this is the major site of
nutrient and gas exchange with local tissues. Capillaries consist of a
single layer of endothelium surrounded by a basement membrane and
a loose group of reticular and collagenous fibers. In dental pulp,
capillaries often form extensive loops in the subodontoblastic regin.
The basement membrane is composed of fine reticular filaments
embedded in a mucopolysaccharide matrix. The wall of a capillary is
about 0.5 um thick and serves as a semipermeable membrane. This
semipermeable membrane restricts egress of proteins and cells from
the vascular compartment under normal conditions.
There are several major classes of capillaries that differ dramatically in
their properties as semipermeable membranes.
The first class of capillary is the fenestrated capillary. These structures

are characterized by endothelium with openings (fenestrations) in the


capillary walls. These fenestrations can be open or occluded by a thin
diaphragm. Fenestrated capillaries are found in dense networks in
dental pulp as well as in the renal glomerulus, the intestinal mucosa,
and the sulcular gingiva.
The second class is the continuous (or nonfenestrated) capillary; these
vascular

structures

are

defined

by

endothelium

devoid

of

fenestrations. Continuous capillaries are found in dental pulp as well


as in heart, lung, and muscle. Continuous capillaries are found near
odontoblasts during early tooth development (ie, before dentin is
formed). With the active expression of primary dentin, capillaries
become fenestrated and form a dense network adjacent to the
odontoblastic layer. When dentin formation is nearly complete, the
capillary bed switches back to a continuous capillary morphology and
retreats to below the odontoblastic layer.
The third major class of capillary is the discontinuous capillary. These
capillaries consist of dis-continuous endothelium with wide intercelular
spaces of approximately 5 to 10 nm. The basement membrane is also
discontinuous. Discontinuous endothelium is found in the spleen, liver,
and bone marrow.
The microcirculatory organization of the subodontoblastic region is
divided into three major layers. The terminal capillary network is
located in the first layer, also called the odontoblastic layer. The
second layer, also known as the capillary network,

contains

precapillary and postcapillary vessels organized adjacent to the


odontoblastic layer. The third layer consists of a venular network of
vessels. During aging, there is a general reduction in pulpal
metabolism, and the capillary organization is often simplified and
becomes one single layer of capillaries terminating directly into

venules.
Venulas
La sangre pasa desde el plexo capilar hacia las vnulas poscapilares y
despus a las vnulas mayores. Las vnulas de la pulpa tienen paredes
finas y la capa muscular es discontinua, lo que facilita el movimiento
de lquido hacia fuera del vaso. Las vnulas colectoras se convierten
en progresivamente mayores conforme cursan hacia la regin central
de la pulpa. El dimetro de las vnulas mayores puede
alcanzar un mximo de 200 m, considerablemente mayor que las
arteriolas de la pulpa.
AVA
The dental pulp has a relatively high blood flow. It is estimated to be
4050ml/min/100g of pulp tissue in a mature tooth as determined by
radioactive microsphere techniques. This flow is relatively high,
compared to that of other oral tissues and skeletal muscle. Numerous
shunt vessels have also been observed in the dental pulp, although
their function is less well understood. These vessels can be arteriovenous anastomoses, venous-venous anastomoses or U-turn loops.
They provide a direct communication between arterioles and venules,
hence bypassing the capillary bed. When the intrapulpal pressure rises
during inflammation, these shunt vessels may open up to reduce the
intrapulpal pressure so that the normal blood flow is maintained.
Linfticos
La vasculatura linftica forma una red de vasos en el intersticio que
drenan lquido y protenas filtradas y los devuelve a la sangre a travs
de linfticos ms grandes. Adems, tiene un papel importante en la

defensa inmunitaria del organismo, porque las clulas dendrticas


entran en los capilares linfticos de la pulpa dental y transportan el
antgeno a los ganglios linfticos regionales donde presentan el
antgeno a los linfocitos.
El lquido linftico elimina elementos extraos como bacterias y sus
productos del tejido perifrico y es un sistema de transporte para
agentes infecciosos. Durante la inflamacin, se forman nuevos vasos
linfticos para satisfacer la demanda del mayor aumento del
transporte de lquidos y presentacin de antgenos.
Histricamente, se ha debatido la existencia de linfticos en la pulpa
porque es difcil distinguir entre vasos sanguneos y linfticos con las
tcnicas

microscpicas

habituales,

sin

marcadores

linfticos

especficos.
Recientemente se han aplicado marcadores linfticos especficos y
ahora se ha identificado un sistema extenso de vasos linfticos en la
pulpa. Estos nuevos datos indican que los linfticos van desde la
pulpa coronal a travs de las races.
Adems, haces de linfticos salen de la pulpa por el foramen apical y
a travs de los conductos radiculares laterales.
Los capilares linfticos se llenan cuando la presin intersticial pulpar
aumenta despus de una gran tumefaccin del intersticio y por
tensin sobre la matriz extracelular.
Hace ms de 70 aos se demostr en oreja de conejo que la
velocidad de eliminacin de un colorante intravital inyectado por va
subcutnea era mayor con pulsaciones de presin arterial en el tejido
que sin pulsaciones. Dado que los linfticos de la pulpa drenan por el
ligamento periodontal, es lgico suponer que el movimiento normal
del diente durante la masticacin actuar como un mecanismo de
propulsin extrnseco adicional de linfa.

Functions of the pulp microcirculation


The primary function of the pulp microcirculation, in common with all
circulation in the body, is to supply oxygen and nutrients to its
constituent cells, as well as providing an exit route for metabolic waste
products from the tissue.
Blood is brought to the tissue through pulp arterioles. Oxygen,
nutrients and wastes are exchanged in capillaries by diffusion, and
waste products are removed by pulp venules.
In general, blood flow to any organ must be high enough to ensure
sufficient oxygen and nutrient supply. On the other hand, an
excessively high blood flow level is undesirable as it leads to a waste
of energy. Hence, it is plausible that the main purpose of the relatively
high blood flow in the pulp is to serve the pulp cells, perhaps the
odontoblasts in particular, with important nutrients in an adequately
high concentration in the capillary bed.
The pulp microcirculation also acts to maintain an intraluminal
pressure within the pulp vasculature in harmony with the pulp tissue
pressure. Studies have demonstrated that the dental pulp has a
relatively high tissue pressure but it is considerably lower than the
blood pressure inside the vessels.
Regulacin del flujo sanguneo de la pulpa
En condiciones fisiolgicas normales, el tono vascular de la pulpa est
controlado por diversos mecanismos que mantienen los vasos
sanguneos en un estado de constriccin parcial. El flujo de sangre
pulpar tambin est influido por el tono vascular de los tejidos
circundantes. Se ha observado que la vasodilatacin de estos tejidos
produce una cada del flujo sanguneo pulpar por una reduccin de la
presin arterial local de los dientes y, por tanto, una reduccin de la

presin de perfusin pulpar. El robo de la presin de perfusin


dental hace vulnerable a la pulpa dental en situaciones clnicas con
procesos inflamatorios de los tejidos adyacentes, como gingivitis y
periodontitis.
La regulacin neuronal del flujo sanguneo es extensa en la pulpa. Hay
poco o ningn tono vasoconstrictor de origen simptico en la pulpa
dental en reposo, pero se ha demostrado un tono vasodilatador
neuronal por liberacin de neuropptidos sensitivos.
Hay receptores -adrenrgicos en la pulpa, y la estimulacin del
tronco simptico cervical

(la actividad simptica est dirigida para colocar al individuo en una situacin de

defensa ante circunstancias de peligro, real o potencial. La estimulacin simptica conduce a variaciones de las funciones
viscerales destinadas a proteger la integridad. La activacin masiva del sistema simptico produce un conjunto de reacciones
que se definen como respuesta de alarma (fight or flight). Los fenmenos viscerales ms evidentes de esta respuesta consisten
en: Dilatacin pupilar, para aumentar el campo visual. Piloereccin, para simular un mayor tamao corporal. Sudacin,
para perder calor, que se producir por la actividad muscular. Aumento de la actividad cardaca y de la presin arterial, para
proporcionar un mayor flujo sanguneo muscular. Broncodilatacin, para aumentar la entrada de aire a los pulmones.
Aumento de la glucemia. Inhibicin de las funciones digestivas. Inhibicin de las funciones urinarias y genitales.).

produce vasoconstriccin y cada del flujo sanguneo pulpar.


El neuropptido Y, localizado junto con la noradrenalina en las fibras
nerviosas

simpticas

pulpares,

tambin

contribuye

en

la

vasoconstriccin pulpar.
Se observa un aumento del flujo sanguneo pulpar despus de la
estimulacin elctrica dental y est causado por la liberacin de
neuropptidos sensitivos, seguido de vasodilatacin. El CGRP
liberado de fibras nerviosas sensitivas es el principal responsable
de la vasodilatacin observada.
Another group of factors that regulates pulpal blood flow is
substances of paracrine or endocrine origin.
Paracrine factors are locally produced or released at their site of action
and

do

not

circulate

prostaglandinas, histamina.

in

the

bloodstream:

bradiquinina,

Endocrine factors are released from a distant gland and circulate in


the bloodstream to modify the activity of the target cell. An example
of hormones thought to participate in regulation of pulpal blood flow
include circulating epinephrine and norepinephrine, although the
magnitude of this effect may be relatively small.
Pulpal interstitial pressure
Several experimental techniques have been developed to measure
pulpal interstitial pressures. Determination of this pressure during
homeostasis and during inflammation is critical for understanding
vascular responses to pulpal injury.
Methods to determine pulpal interstitial pressure include photoelectric
methods, pressure transducer systems, tonometric measurements, and
micropuncture techniques.
Many of the earlier methods in this area produced relatively large
injuries to the pulp, and interstitial pressures of about 16 to 60 mm Hg
were recorded. The micropuncture technique is much less invasive;
the pipettes have tip diameters of only 2 to 4 um. These studies
measured pulpal interstitial pressures of about 5 to 6 mm Hg under
controlled conditions.
Studies have demonstrated that PI increases in response to
inflammation. Tonder and Kvinnsland used glass micropipettes
connected to a servocontrolled counter-pressure system to measure
not only the pulpal interstitial pressure but also the intravascular
pressure of cat teeth. The PI in cat dental pulp was 16.3 mm Hg at the
site of pulpal inflammation and 7.0 mm Hg at a site 1 to 3 mm away.
The pulpal interstitial pressure in control teeth (ie, in the contralateral
arch) was 5.5 mm Hg.

REFERENCIAS BIBLIOGRAFICAS
Yu & Abbott. An overview of the dental pulp: its functions
and responses to injury. Australian Dental Journal Endodontic
Supplement 2007;52(1Suppl):S4-S16
Hargreaves & Cohen. Vas de la pulpa. Elsevier Mosby.
Espaa.10 ed. Captulo 12. Pags:483-487.
Hargreaves & Goodis. Seltzer and Benders dental pulp.
Quintessence Publishing Co. E.U.A. Captulo 6. Pags:123-139.