Circulation of the Pulp
Hideharu Ikeda, DDS, PhD
Hideaki Suda,
The microcirculatory system of dental pulp serves
many essential roles. This system is critically impor­
tant in maintaining tissue homeostasis and yet is
capable of undergoing a dynamic response to injury
by altering local capillary filtration rates, initiating
immunologic responses to injury and inflammation
via endothelial expression of adhesion molecules,1
and even sprouting via angiogenesis. This chapter
reviews the anatomy and physiology of this impor­
tant system and emphasizes its response character­
istics following pulpal inflammation caused by dental
procedures, infection, or trauma. This information is
critical for clinicians so that they can minimize injury
to pulp during dental procedures and assess the sta­
tus of the pulp's microcirculatory system in individual
patients.
Organization of Pulpal
Vasculature
The dental pulp is a microcirculatory system because
it lacks true arteries and veins; the largest vessels
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DDS, PhD
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 dynam­
ic system that regulates blood and lymph flow in
response to nearby metabolic events (including den­
tinogenesis). It also responds to inflammatory stimuli
with a great change in circulatory properties and the
endothelial expression of certain proteins, leading
to the recruitment of immune cells to the site of
tissue injury (see chapters 4, 7, 11, and 12). Clearly,
knowledge of this system is essential to an under­
standing of the dental pulp in health and disease.
Blood vessels (arteriole-capillary-venule
system)
The pulp has an extensive vascular supply2 (Fig
6-1 ) . The organizational structure of dental pulp
is presented in Fig 6-2. Arterioles and venules are
arranged axially in the pulp with capillary loops
extending out toward the dentin.2
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 Circulation of the Pulp
Fig 6-1 Montage of
scanning electron micro­
graphs of dental pulp illus­
trating the extensive vas­
cular network in the dog
mandibular first molar. The
superficial capillary layer
has been removed to better
illustrate the organizational
features of the pulpal cir­
culatory system. (Reprinted
from Kishi and Takahashi2
with permission.)
Arterioles
The arterioles are resistance vessels, measuring
approximately 50 µm in diameter. They have sev­
eral layers of smooth muscle, which regulate vascular
tone. The transitional structure between arterioles
and capillaries is called the terminal arteriole. 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 orga­
nized in a spiral fashion surrounding the endothelial
cells.3 lntercellular electrical coupling exists between
adjacent endothelial cells of arterioles. Howev­
er, the resistance of myoendothelial couplings is
appreciable, and the endothelium therefore may be
important as a low-resistance path connecting many
smooth muscle cells.4
The arterioles divide into terminal arterioles and
then precapillaries. Scanning electron micrographs
of resin injection casts of dental pulp vasculature
illustrate the extensive arborization of capillaries
from the metarterioles.2 Metarterioles give off capil­
laries, which are about 8 µm in diameter (Fig 6-3).
The arterioles, the capillaries, and the venules form
110
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Fig 6-2 Major organiza­
tional features of the micro­
circulatory system of dental
pulp. AVA, arteriovenous
anastomosis.
Fig 6-3 (a) Scanning electron micrograph of a resin injec­
tion cast of dental pulp vasculature illustrating the extensive
arborization of capillaries from the metarterioles. TCN, ter­
minal capillary network; CN, capillary network; VN, venular
network. (b) The superficial layer of the vascular network
has been removed to show the venular network (VN). The
terminal capillary network (TCN) is on the left side, the capil­
lary network (CN) is in the middle, and the venular network
is on the right side. (Reprinted from Kishi and Takahashi2
with permission.)
functional units that respond to signals elaborated
from the nearby tissue (discussed later in the chap­
ter). This is an important concept because virtually
every cell in the body is within 50 to 100 µm of capil­
laries. Thus, there is a functional coupling between
cellular activity and nearby capillary blood flow.
The branch points of terminal arterioles and cap­
illaries are characterized by the presence of clumps
of smooth muscle that serve as precapillary sphinc­
ters. These sphincters are under neuronal and local
cellular control (via soluble factors) and act to regu­
late 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.5
Capillaries
Capillaries serve as the workhorse of the circula­
tory system because they function as the exchange

vessels regulating the transport or diffusion of sub­
stances (eg, gases, fluids, proteins) between blood
and local interstitial tissue elements. At any given
moment, only about 5% of the blood supply cir­
culates in capillaries, but these are the major sites
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 region2 (see Fig 6-3). The base­
ment membrane is composed of fine reticular fila­
ments embedded in a mucopolysaccharide matrix.
The wall of a capillary is about 0.5 µm thick and
serves as a semipermeable membrane. This semi­
permeable membrane restricts egress of proteins
and cells from the vascular compartment under nor­
mal conditions, and it is this filtering property that
generates a colloidal osmotic pressure within the
vascular system. This has important implications for
the regulation of capillary filtration under normal and
inflamed conditions, as described in detail later in
the chapter.
There are several major classes of capillaries that
differ dramatically in their properties as semiperme­
able membranes.6 The first class of capillary is the
fenestrated capillary. These structures are character­
ized by endothelium with openings (fenestrations) in
the capillary walls. These fenestrations can be open
or occluded by a thin diaphragm. Fenestrated capil­
laries are found in dense networks in dental pulp as
well as in the renal glomerulus, the gastrointestinal
mucosa, and the sulcular gingiva.7·a
The second class is the continuous (or non­
fenestrated) capillary; these vascular structures are
defined by endothelium devoid of fenestrations.
Continuous capillaries are found in dental pulp as
well as in the heart, lungs, skin, and muscle.a The
intercellular space contains gap junctions, which
are localized openings with a width of 5 to 10 nm.
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 cap­
illary bed switches back to a continuous capillary
morphology and retreats to below the odontoblastic
layer.a Thus, the morphology and location of pulpal
capillary beds follow odontoblast activity levels dur­
ing development (see chapter 1 ).
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Organization of Pu/pal Vascu/ature
The third major class of capillary is the discontin­
uous capillary. These capillaries consist of discontin­
uous endothelium with wide intercellular 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 fourth major class of capillary is the tight­
junction capillary, found in the central nervous sys­
tem and the retina. The differences in the semiper­
meable properties of these classes of capillary play
an essential role in defining the basal filtration prop­
erties of these vessels.
The microcirculatory organization of the subodon­
toblastic region is divided into three major layers2
(see Fig 6-3). The terminal capillary network is located
in the first layer, called the odontoblastic layer. The
second layer, also known as the capillary network,
contains precapillary and postcapillary vessels orga­
nized adjacent to the odontoblastic layer. The third
layer consists of a venu/ar network of vessels. During
aging, there is a general reduction in pulpal metabo­
lism, and the capillary organization is often simplified
and becomes one single layer of capillaries terminat­
ing directly in venules2 (see chapter 18). This change
may be associated with an electrophysiologic finding
that odontoblasts function as a syncytium through
electrical coupling and that young odontoblasts have
greater electrical conductance.9•10 Measurement of
oxygen distribution with an oxygen-sensitive elec­
trode has shown that odontoblasts may be a major
oxygen consumer in the rat incisor pulp11 (Fig 6-4).
Thus, odontoblasts, especially in the younger stage,
may need more metabolic support from circulating
blood during development.
Venules
The venular organization in dental pulp has several
important characteristics. First, the collecting venules
receive pulpal blood flow from the capillary bed and
transfer it to the venules. As described earlier, these
structures are characterized by a spiral organization
of smooth muscle. Accordingly, the contractile state
of these vessels plays an important role in regulating
postcapillary hydrostatic pressure. Moreover, arterio­
venous anastomosis (AVA) shunts and vascular loops
permit regional control of pulpal blood flow via direct
shunting of blood from arterioles to venules following
tissue injury2·12-14 (Fig 6-5; see also Fig 6-2).
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