Dr.

Hadil Abdallah Altilbani

BDS Santiago de Compostela University Spain.
MSc. University of Valencia Spain.
Department of Endodontics University of Palestine .
 Why pulp is unique?
 Ability to form dentin throughout life

 Potential for regeneration and repair diminishes with age

 Very sensitive to thermal stimuli

 Encased in a low compliance environment

 Scarcity of collateral circulation

 Decrease below 20C and above 45C pulp hyperaemia

 Introduction
Embryologically and physiologically Dentin
and pulp are so intimately related that
dentin can be considered as the peripheral
calcified portion of the dental pulp.

However This intimate relation extends

beyond embryological and physiologic
considerations.

It has important clinical implications.

It means that pulp would react

when dentin is injured whether the
injury is caused by caries, attrition,
abrasion, erosion or operative procedures.
 “Hydrodynamic Theory” of Brannstrom
The pain associated with dentinal hypersensitivity is explained by
the “hydrodynamic theory” of Brannstrom, according to which
the back-and-forth movements of fluids within the dentinal
tubules stretch and stimulate the nerve fibers.

Brannstrom states that the fluids have a coefficient of dilatation

considerably larger than that of solids and that this explains the
excursions that occur in very restricted spaces such as the dentinal
tubules in response to Variations in Temperature.
The same phenomenon is caused by Burs, Heat produced by Friction, and
surface Pressure, which causes displacement of the intratubular fluids
and thus pain.
A probe or Excavator passed over the dentin also produce similar
pressure and pain.
 Dentin tubule fluid movement

Dehydration Heat Cold

Dentin Dentinal
tubule
and fluid
A-delta
fibers

Odontoblast
movement
 Sensibility Of The Dental Pulp
coronal portion of the pulp and
concentrated in the pulp horns
2 types of sensory nerve fibres

1.myelinated A fibres (A-

Physiology of Pulpal
delta and A-beta fibres)
Pain
Odontogenic pain
2.Unmyelinated C fibres
core of the pulp extend into the cell-free zone
underneath the odontoblastic layer
 no proprioceptive nerve
identify the origin
radiate

Referred Pain
referred pain.

pulpal C-fibers slow conducting

intense, slow, dull pain.
ipsilateral
PULPAL IRRITANTS Wein classification1891
1. Microbial:living
1. Bacterial irritants:
Most common cause for pulpal
irritation are bacteria or their
products which may enter pulp
through a break in dentin either
from:
 – Caries
 – Accidental exposure
 – Fracture
 – Percolation around a restoration
 – Extension of infection from
gingival sulcus
 – Periodontal pocket and abscess
 – Anachoresis (Process by which
microorganisms get carried by the
bloodstream from another source
localize on inflamed tissue).
 Haematogenous infection
ANACHORESIS
PHENOMENON
• In Tonsilitis Meningitis
influenza and diphteria
bacteria circulating in the
blood stream localizes in
irritated pulp and
periapical areas and this is
called
Nonliving irritants
2. Iatrogenic:
– Thermal changes.
– Orthodontic movement
– Periodontal curettage
– Periapical curettage
– Use of chemicals like temporary and permanent fillings.
• local anesthesia
• Cavity preparation
3. Idiopathic
– Aging
– Resorption—internal or external.

4. Traumatic
Acute trauma like fracture
Chronic trauma including parafunctional
• Attrition.
• Abrasion.
3. Iatrogenic
• Cavity preparation

• Heat
• Depth
• Desiccation
• Vibration
• Acid etching
 22

2. Iatrogenic:
– Thermal changes.

Thermal injury:
 During restorative procedures:
frictional heat, irritant substances.

1) Heat from dental procedures

2) Heat from cement setting
3) Deep filling with no base
4) Polishing

 May respond by reactionary dentin

formation.
 Orthodontic movements :
orthodontic movement , can
lead to devitalization of the
pulp
and pulpal hemorrhage
4. Traumatic
A- acute

B- chronic
• Attrition
• Abrasion
Electric irritation
Galvanism

Gold and amalgam come in

contact with each other Saliva
electric current
pulp necrosis or pulp will
attract bacteria which
irritate the pulp
Aeronautical irritation
Barotrauma
(aerodontalgia):

nitrogen bubbles
 LESION PROGRESSION
A consequence of release of a large quantity of
inflammatory mediators, increased vascular
permeability.
Elevated capillary pressure and increased capillary permeability
move fluid from blood vessels into the surrounding tissue.
If removal of fluid by venules and lymphatics does not
match filtration of fluid from capillaries, an exudate forms.

If inflammation is severe, local microcirculation may be

compromised, leading to local necrosis and suppuration of
pulp (pulp abscess), or diffuse suppuration and necrosis.
 PULPAL PATHOPHYSIOLOGY
irritation to clinical crown

initial localized pulpal inflammation

insult
increased local tissue pressure

venous collapse stasis ischemia local necrosis

localized
effect
release of intracellular inflammatory agents

Circumferential vascular disturbance

Mechanism Increased tissue pressure

Of spread
Necrosis of additional tissue

Total pulpitis
Pulpal Reactions

1.Caries
2. Local Anesthetics
3. Restorative Procedures
4. Dental Materials
5. Vital Bleaching
6. Periodontal Procedures
7. Orthodontic Movement
 Dental caries - Facts
• Dental caries is the most common route for
causing irritation to the pulp.

• Dental caries is localized, progressive, decay of the teeth

characterized by demineralization of the tooth surface
by organic acids, produced by microorganisms .

• From the carious lesion, acids and other toxic substances

penetrate through the dentinal tubules to reach the
pulp.

• Destroys dentin at a rate of 1mm/six months

Pulpal Reaction to caries
Three basic reactions protecting pulp

1. Decrease in dentin permeability

2. Tertiary dentin formation
3. Inflammatory & Immune reactions
Dentin permeability -
Importance
• Channels of diffusion – Dentinal tubules

• More no of tubules per unit area

towards pulpal side as compared to
peripheral dentin

• Clinicalimportance – Dentin
beneath a deep cavity
preparation is more permeable
than dentin underlying a shallow
cavity
 Decrease in dentin permeability

• First defense to caries

– SCLEROTIC DENTIN

Combination of
• An increased deposition of intratubular dentin
• Direct deposition of mineral crystals (Whitlokite) into narrowed
dentinal tubules
Whitlockite crystals
PULPAL REACTION TO CARIES
• 2) - Tertiary dentin formation:
 3. Pulpal Immune Response
Progressive inflammation

• The bacterial toxins, enzymes, organic acids and the products of tissue
destruction show inflammatory response in the pulp.
• The degree of pulpal inflammation beneath a carious lesion depends on
closeness of carious lesions with pulp and permeability of underlying
dentin.

• Early response is characterised by focal accumulation of

chronic inflammatory cells

• Dental caries stimulates the accumulation of pulpal dendritic cells in

and around odontoblastic layer
Pulpal Reactions
1. Caries

2.Local Anesthetics
3. Restorative Procedures
4. Dental Materials
5. Vital Bleaching
6. Periodontal Procedures
7. Orthodontic Movement
EFFECT ON PULP
•Intact pulpal blood flow is critical

•Dental pulp is enclosed in a rigid chamber and

cannot benefit from collateral circulation

•Reduction of blood flow – Reduction in clearance

of large molecular weight toxins or waste
products •
•Reduction in blood flow during a restorative
procedure could lead to an increase in
concentration of irritants accumulating within
the pulp.
•Vasoconstrictor of local anesthetic (LA)
potentiates and prolongs anesthetic effect by
reducing blood flow in the area.
• Local Anaesthetic delivered through an intra osseous
route or periodontal ligament route The supplemental
anesthetic techniques can compromise the inflamed pulp’s
ability to heal by reducing the blood flow

•Fortunately, the rate of oxygen consumption in the

healthy pulp is relatively low, and if necessary, pulp cells
can produce energy anaerobically through the pentose
phosphate pathway of carbohydrate metabolism.
Pulpal Reactions
1. Caries
2. Local Anesthetics
3.Restorative Procedures
4. Dental Materials
5. Vital Bleaching
6. Periodontal Procedures
7. Orthodontic Movement
3. Restorative procedures causing pulp injury
1. Tooth Preparation (Restorations/ Crown)

2. Acid Etching

3. Chemicals from restorative materials

(Cements/ Bases)
One key requirement of a successful restorative
procedure maintaining the pulp vitality is to cause
minimal additional irritation of the pulp so as not to
interfere with normal pulpal healing.
• This involves the avoidance of thermal stimuli
caused by operative procedures, toxicity of
restorative materials and bacteria penetration.
3-PULPAL REACTION TO RESTORATIVE
PROCEDURE
Factors affecting response of pulp to tooth preparation

1. • Pressure
2. • Heat
3. • Vibration
4. • Remaining dentin thickness
5. • Thermal and mechanical injury
6. • Speed
7. • Nature of cutting instruments.Heat
Factors affecting response of pulp to tooth preparation
1. The Pressure of instrumentation

On exposed dentin causes the aspiration of the

nuclei of the odontoblasts or the entire
odontoblasts themselves or nerve endings from pulp
tissues into the dentinal tubules.

This will stimulate odontoblasts, disturb their

metabolism and may lead to their complete
degeneration and disintegration.

This can occur by excessive pressure of hand or

rotary instruments, especially in decreased effective
depths.

Sometimes this pressure may move some

microorganisms from infected cavity floor or wall
into the pulp, leading to its irritation.
CR- Cell rich zone
Aspirated odontoblasts
 Factors affecting response of pulp to tooth preparation

• Heat
Cutting of dentin with always produces some amount of
heat which is determined by several factors such as:
Mech.Energy >>>> Cut + Heat
Based on that equation several factors influence the
quantity of the heat produced;

i. Size and shape of the cutting instrument.

ii. Speed of rotation.
iii. Length of time, the instrument is in contact with dentin.
iv. Amount of pressure exerted.
2. Heat production
Is the second most
damaging factor.

Any restorative procedures leads

to increase in pulpal temperatures

Irreversible pulp pathosis → pulp

abscess formation

If the cavity floor ≤ 0.5 mm from

the pulp, areas of coagulation
necrosis could be detected.
That “heat” is a function of:
a. RPM (apeed), i.e. more the RPM more is the heat production.
b. Pressure is directly proportional to heat generation.
c. Surface area of contact, which is related to the size and shape of the
revolving tool.
The more the contact between the tooth structures and revolving tool, the more is the
heat generation.
Heat creates destruction in the pulp tissues, coagulate protoplasm, and burn dentin if
the temperature is amply elevated.
d. Desiccation, if occurring in vital dentin such that water in the protoplasm of
Tome’s fibers is eliminated, can cause aspiration of the odontoblasts into the tubules .
The subsequent disturbances in their metabolism may lead to the complete
degeneration of odontoblasts.
Desiccation increases the permeability of the vital dentin to irritants like
microorganisms or restorative materials.
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 .
Blushing of teeth during or after cavity or crown
preparation has been seen in teeth after cutting.

After dentin is cut, the coronal dentin develops pinkish hue and this hue
is due to vascular stasis and hemorrhage in the sub-odontoblastic layer.
 • First principle to
eliminate sources of
pulp injury is

NEVER
CUT DRY
Coolant sprays should be used even in
nonvital or devitalized tooth structures,
since the heat will burn the tooth
structures, and these burnt areas will be
sequestrated later leaving a space
around the restoration where failures
can occur.
Use of Coolants
In deep cavities air blast should
not be used to dry the cavity,
instead cotton pellets should be
used. Or use short blasts of air.
Air blast can cause desiccation of
dentin which can damage the
odontoblasts.
Water spray is considered as the
ideal coolant.
Coolants are most effective method
to reduce the thermal damage.
3. Vibrations
The higher the amplitude, the more destructive may be the response of the
pulp.
The reaction is termed as the rebound response which is due to
the effect of the ultrasonic energy induced.
It is characterized by:

1. Disruption of the odontoblasts

2. Edema
3. Fibrosis of pulp tissues proper.
4. Changes in ground substance.

In addition to affecting the pulp tissues, vibration can create

microcracks in enamel and dentin.
These cracks may transmit and coalesce, directly joining the oral
environment with pulp and periodontal tissues.
Vibrations also increase the permeability of the dentin and enamel.
Vibratory phenomenon.
 Shock waves produced by vibration are
particularly pronounced when:
 The cutting speed is reduced.
 Distorted bur.
 Loose bur clutch.
 Eccentric rotation looseness of handpiece tip.
 Physical irritation from a procedure
Factors affecting response of pulp to tooth preparation

1) • Pressure
2) • Heat
3) • Vibration
4) • Remaining dentin thickness
5) • Mechanical injury
6) • Speed
7) • Nature of cutting instruments.Heat
4. REMAINING DENTIN THICKNESS

The depth of the cavity

is the most disadvantageous
exasperating factor to the pulp.

Most important is the thickness of

the dentin bridge between the
floor of the cavity and the roof of
the pulp chamber, also termed as
the effective depth.
Lesser is the effective depth,
more destructive the pulpal
response will be.
• Most critical factor in determining the intensity of pulp reaction is RDT

• 2mm of RDT provides adequate protection

• So it is advocated that if RDT < 2mm

• USE OF A PROTECTIVE BASE IS MANDATORY
 Importance of remaining dentin thickness

Remaining Effect of
dentin toxic
thickness substances

0.5mm 25%

1 mm 10%

Minimal
2 mm
or nil
 Physical irritation from a procedure
Factors affecting response of pulp to tooth preparation

1) • Pressure
2) • Heat
3) • Vibration
4) • Remaining dentin thickness
5) • Mechanical injury
6) • Speed
7) • Nature of cutting instruments.Heat
 6. Speed
Speed of Rotation

Ultra high speed should be used for removal of enamel and

superficial dentin.

It should be kept in mind that without the use of

coolant there is no safe speed.

High speed without coolant can produce burning of dentin,

which in turn affects the integrity of the pulp.
7. Nature of Cutting Instrument
 Thermal damage to the pulp was greater with steel burs than
with carbide burs, because of greater heat produced by steel
burs.
 Uncooled carbide burs and diamond instruments produce
severe damage to the dental pulp.
 Diamond burs cause most damage to pulp due to its abrasive
action and need for increased pressure.
 Larger size burs cause greater damage due to increased heat
generation, cutting of larger area and reduced effectiveness of
the coolants.
 Improper use of handpiece, use of old, broken down and
damaged handpiece can cause pulpal damage from eccentric
bur rotation and heavy cutting force necessitated by poor
torque characteristic.
 Effect of Rotary instruments

• Rotary abrasive instruments (stones)

are not recommended for cutting in
vital dentin, as their abrasive action
will elevate the temperature of
surrounding dentin.
• It may crush vital dentin
• It should be confined to enamel

• Rotary cutting instruments (burs) are

biologically acceptable if used over
RDT of 2mm or more
• Carbides provides more cool cutting
 Effects of Cavity Preparation &
Restorative Materials

 Aspiration or displacement of odontoblasts into dentinal tubules,

with reduction of numbers.

72
Restorative procedures causing pulp injury

1. Tooth Preparation (Restorations/ Crown)

2. Acid Etching
3. Chemicals from restorative materials (Cements/ Bases)

Effects of Caries, Microleakage, Restorative procedures

and materials is Cumulative
Acid Etchants
• Acid etching is an important step
in the placement of composite
restorations.
• Commonly used acid etchant is 37
percent phosphoric acid.
• It has been shown that acid etching
does not cause pulpal injury if used
with the recommended time.
• Etching results in the Dissolution
the smear layer opens the dentinal
• tubules and increasing the
permeability of dentin
• On the contrary acid etching also
enhances bacterial penetration of
dentinal tubules
 restorative procedures causing pulp injury

1. Tooth Preparation (Restorations/ Crown) Mechanical and Thermal effect.

2. Acid Etching

3. Chemicals from restorative materials (Cements/ Bases)

Effects of Caries, Microleakage, Restorative procedures

and materials is Cumulative
 EFFECT OF CHEMICAL IRRITANTS ON PULP

 Various filling materials produce some irritation ranging from

mild to severe, as do various medicaments used for
desensitization or dehydration of the dentin.

Restorative Materials on Pulp

1. Acidity
2. Absorption of water from dentin during setting
3. Heat generated during setting
4. Poor marginal adaptation leads to bacterial penetration
5. Cytotoxicity of material
Cavity Varnishes, Liners, and
Bases
The use of cavity liner is advocated
under restorative material to reduce the
sensitivity of freshly cut dentin and to
protect pulp.
All liners and bases reduce dentin
permeability but to different extents.
Bases provide the largest reduction,
varnishes the least.
 PULPAL REACTION TO
RESTORATIVE MATERIALS
Zinc Oxide Eugenol
Zinc oxide eugenol is temporary filling material that is also used
for provisional and permanent cementation of crowns, bridges, inlays
and as liner and base.
Of all the filling materials, it has always been considered the safest from
biological aspect.
• Anesthetic properties:
Zincoxide eugenol has been used as an anodyne for pulpal pain.
The sedative effects are apparently because of ability of eugenol to block
or reduce nerve impulse activity.
This effect is obtained only when a reasonably thin mix of ZOE is used
Eugenol, is toxic when placed in direct contact with tissue. .
Another advantage of ZOE is that there is no heat rise during setting.
• Antiseptic properties:
It inhibits bacterial growth on cavity walls.
• Sealing ability:
It has good adaptation to dentin.
 Zinc Phosphate

 Zinc phosphate cement can cause severe pulpal damage because of

its irritating properties.
 Toxicity is more pronounced when the cement is placed in deep
cavity preparations.
 In deep cavities, zinc phosphate cement should not be used
without an intervening liner of zinc oxide eugenol or calcium
hydroxide.

 Effect of zinc phosphate on pulp are due to:

1. • Components of zinc phosphate
2. • Acidic nature
3. • Heat produced during setting
4. • Marginal leakage.
Zinc Polycarboxylate Cements
Zinc polycarboxylate cement contains modified zinc oxide powder
and an aqueous solution of polyacrylic acid.

It chemically bonds to enamel and dentin and has antibacterial

properties.

Polycarboxylate cement is well tolerated by the pulp, being

roughly equivalent to zinc oxide eugenol cements in this respect.
Used as cavity liner or luting cement.
Glass Ionomer Cement
Calcium Hydroxide
Amalgam
 Amalgam has been used in dentistry since ages.
 It is considered one of the safest filling materials
with least irritating properties.
 Even if varnish is not employed, within a period of a
few weeks, marginal seal develops between the
tooth and the restoration due to its corrosion
products.
 It has been shown to produce discomfort due to its
high thermal conductivity.
 So liners or bases are necessary to provide thermal
insulation.
Effects of Amalgam on Pulp

• Mild to moderate inflammation in deep caries

• Harmful effects due to corrosion products
• Inhibition of reparative dentin formation due to damage
to odontoblasts
• Copper in high copper alloy is toxic
• High mercury content exerts cytotoxic effects on pulp
• Postoperative thermal sensitivity due to high thermal
conductivity.
RESTORATIVE RESINS

Despite having several advantages, they are not

considered best materials because of their high
coefficient of thermal expansion and
polymerization shrinkage, which results in
marginal leakage, subsequently the recurrent
caries and ultimately the pulp damage.
Monomer present in composite resins also acts
as an irritant to the pulp.
Prevention of Pulpal Damage due to Operative Procedure
• To preserve the integrity of the pulp, the dentist should observe
certain precautions while rendering treatment.
• Excessive force should not be applied during insertion of
restoration.
• Restorative materials should be selected carefully, considering
the physical and biological properties of the material.
• Excessive heat production should be avoided while polishing
procedures.
• Avoid applying irritating chemicals to freshly cut dentin.
• Use varnish or base before insertion of restoration.
• Patient should be called on recall basis for periodic evaluation
of status of the pulp.
Science is a mystery that we won’t ever stop trying to reveal its
secrets so what’s the next material we’ll discover?