Dental Pulp

Dental pulp is an unmineralized oral tissue

composed of soft connective tissue, vascular,
lymphatic and nervous elements that occupies
the central pulp cavity of each tooth. Pulp has a
soft, gelatinous consistency. Figure 1 (adjacent),
indicates that by either weight or volume, the
majority of pulp (75-80%) is water. Aside from
the presence of pulp stones, found pathologically
within the pulp cavity of aging teeth, there is no
inorganic component in normal dental pulp.
There are a total of 32 pulp organs in adult
dentition. The pulp cavities of molar teeth are
approximately four times larger than those of
incisors.

The pulp cavity extends down through the root of the tooth as the root canal which
opens into the periodontium via the apical foramen. The blood vessels, nerves etc. of
dental pulp enter and leave the tooth through this foramen. This sets up a form of
communication between the pulp and surrounding tissue - clinically important in the
spread of inflammation from the pulp out into the surrounding periodontium.

Developmentally and functionally, pulp and dentin are closely related. Both are
products of the neural crest-derived connective tissue that formed the dental papilla.

Histology of Dental Pulp

Dental pulp is a loose connective tissue with an appearance similar to mucoid CT. It
contains the components common to all connective tissues:

 Cells: fibroblasts and undifferentiated mesenchymal cells (Lab Image 1 ) as

well as other cell types (macrophages, lymphocytes, etc.) required for the
maintenance and defense of the tissue .
 Fibrous matrix: collagen fibers, type I and II, are present in an unbundled and
randomly dispersed fashion, higher in density around blood vessels and nerves.
Type I collagen is thought to be produced by the odontoblasts as dentin,
secreted by these cells, is composed of type I collagen. Type II is probably
produced by the pulp fibroblasts as this type increases in frequency with the
age of the tooth. Older pulp contains more collagen of both the bundled and
diffuse types.
 Ground substance: the environment that surrounds both cells and fibers of the
pulp (Lab Image 2 ) is rich in proteoglycans, glycoproteins and large amounts
of water.
The large number of undifferentiated mesenchymal cells (present as perivascular
cells) within the pulp facilitates the recruitment of newly differentiating cells to
replace others when they are lost - specifically odontoblasts.

Odontoblasts (examined in greater detail in the module on dentin) comprise the

outermost region/layer of the pulp, immediately adjacent to the dentin component of
the tooth. These cells are responsible for the secretion of dentin and the formation of
dentinal tubules in the crown and root.

Architecture of the Pulp

  Figure 2
indicates the 4 zones or regions of
 The peripheral aspect of dental dental pulp (Lab Image 4 ) :
pulp, referred to as the
odontogenic zone (1),
differentiates into a layer of
dentin-forming odontoblasts (A).
 Immediately subjacent to the
odontoblast layer is the cell-free
zone (of Weil). This region (2)
contains numerous bundles of
reticular (Korff's) fibers (B).
These fibers pass from the central
pulp region, across the cell-free
zone and between the
odontoblasts, their distal ends
incorporated into the matrix of
the dentin layer. Numerous
capillaries (C) and nerves (D) are
also found in this zone.
 Just under the cell-free zone is
the cell-rich zone (3) containing
numerous fibroblasts (E) - the
predominant cell type of pulp.
Fibroblasts of the pulp have
demonstrated the ability to
degrade collagen as well as form
it. Perivascular cells
(undifferentiated mesenchymal
cells) are present in the pulp and
can give rise to odontoblasts,
fibroblasts or macrophages.

Since odontoblasts themselves

are incapable of cell division, any
dental procedure that relies on the
formation of new dentin (F) after
 destruction of odontoblasts,
depends on the differentiation of
new odontoblasts from these
multipotential cells of the pulp.
Lymphocytes, plasma cells and
eosinophils are other cell types
also common in dental pulp.

 Medial to the cell-rich zone is the

deep pulp cavity (4) that contains
subodontoblastic plexus (of
Raschkow; parietal layer) of
nerves (G).

Vascular Supply to the Pulp

Figure 3

Illustrates the extensive vascular pattern of dental pulp -

emphasizing its primary function - supportand maintenance of
the peripheral odontoblast layer. The odontoblasts in turn
maintain the overlying layer of dentin.
The walls of pulpal vessels are very thin as the pulp is protected by a hard unyielding
sheath of dentin. One or more small arterioles enter the pulp via the apical foramen
and ascend through the radicular pulp of the root canal. Once they reach the pulp
chamber in the crown they branch out peripherally (Lab Image 4 ) to form a dense
capillary network immediately under - and sometimes extending up into - the
odontoblast layer. The capillaries exhibit numerous pores, reflecting the metabolic
activity of the odontoblast layer. Small venules drain the capillary bed and eventually
leave as veins via the apical foramen.

Blood flow is more rapid in the pulp than in most areas of the body and the blood
pressure is quite high. Arteriovenous anastomoses of arteriolar size are frequent in the
pulp. For many years, investigators found it very difficult to establish the presence of
lymphatics in the pulp. Most believed there was no lymphatic drainage of the teeth.
Tissue fluid was speculated to have drained back into the capillary or postcapillary
sites of the blood vascular system. In recent years a number of studies have
demonstrated the presence of thin-walled, irregularly shaped lymphatic vessels. They
are larger than capillaries and have an incomplete basal lamina facilitating the
resorption of tissue fluid and large macromolecules of the pulp matrix.

The continued formation of cementum at the apical foramen can lead to

occlusion of the opening. The walls of pulpal veins are first affected by the
cemental constriction. Vascular congestion may occur. This ultimately leads to
necrosis of the pulp.

Innervation of the Pulp

Several large nerves enter the apical foramen of each molar and premolar with single
ones entering the anterior teeth. A young premolar may have as many as 700
myelinated and 2,000 unmyelinated axons entering the apex. These nerves have two
primary modalities:

1. Autonomic Nerve Fibers. Only sympathetic autonomics fibers are found in the

pulp. These fibers extend from the neurons whose cell bodies are found in the superior
cervical ganglion at the base of the skull. They are unmyelinated fibers and travel
with the blood vessels. They innervate the smooth muscle cells of the arterioles and
therefore function in regulation of blood flow in the capillary network.

2. Afferent (Sensory) Fibers. These arise from the maxillary and mandibular
branches of the fifth cranial nerve (trigeminal). They are
predominantly myelinated fibers and may terminate in the central pulp. From this
region some will send out small individual fibers that form the subodontoblastic
plexus (of Raschkow) (Lab Image 5) just under the odontoblast layer. From the
plexus the fibers extend in an unmyelinated form toward the odontoblasts where they
then loose their Schwann cell sheath. The fibers terminate as "free nerve endings"
near the odontoblasts, extend up between them or may even extend further up for
short distances into the dentinal tubule. They function in transmitting pain
stimuli from heat, cold or pressure. The subodontoblastic plexus is primarily located
in the roof and lateral walls of the coronal pulp. It is less developed in the root canals.
Few nerve endings are found among the odontoblasts of the root.

Figure 4

illustrates the free nerve endings (F) arising from the

subodontoblastic plexus (E) and passing up between
odontoblasts (A) to enter the dentinal tubule where they
terminate (G) on the odontoblast process (D). B =
predentin, C = dentin

The origin and concepts involved in pain in the pulp-dentin complex will be
examined in the module on dentin.

Types of Pulp

Figure 5 illustrates the regions where the two

types of dental pulp are located:

1. Coronal pulp (A) (Lab Image 3) occupies

the crown of the tooth and has six surfaces;
occlusal, mesial, distal, buccal, lingual and
the floor.

Pulp horns (B) are protrusions of the pulp that

extend up into the cusps of the tooth. With
age, pulp horns diminish and the coronal pulp
decreases in volume due to continued
(secondary) dentin formation - often the result
of continued masticatory trauma. At the
cervix of the tooth the coronal pulp joins the
second type.

 
2. Radicular pulp (C) (Lab Image 2) extends from the cervix down to the apex of the
tooth. Molars and premolars exhibit multiple radicular pulps. This pulp is tapered and
conical. In a fashion similar to coronal pulp, it also decreases in volume with age due
to continued dentinogenesis. Pulp passing through the apical foramen may be reduced
by continued cementum formation.

Age-Related and Pathologic Changes in the Pulp

Specific changes occur in dental pulp with age. Cell death results in a decreased
number of cells. The surviving fibroblasts respond by producing more fibrous matrix
(increased type I over type II collagen) but less ground substance that contains less
water. So with age the pulp becomes:

a) less cellular

b) more fibrous

c) overall reduction in volume due to the continued deposition of dentin

(secondary/reactive)

Stages in Pulp Aging

 Figure 6

illustrates the normal appearance of the pulp cavity (P) at a young

stage.

 
 Figure 7

illustrates some attrition of the pulp as the result of normal aging

as well as trauma from wearing of the enamel at the cusp (A).
Note the pulp horn (B) is not as well defined due to responsive
ingrowth of secondary dentin below the worn cusp. Cementum
has begun to thicken on the root (C).

Figure 8
shows the changes in pulp cavity size by middle age. The pulp
horn continues to be reduced in response to increased wearing of
the overlying enamel. Anoverall reduction in pulp cavity
dimensions through the continued deposition of normal secondary
dentin has occurred. Histology of the pulp reveals a decreased
cellularity coupled with increased fibrosis. Cementum (C)
deposition continues and the apical foramen subsequently has
undergone a reduction in diameter (D).
 

Figure 9 
is illustrative of the pulp cavity in old age. Continued wearing of
the enamel on the cusp has resulted in the formation of dead tracts
of dentin (E). It has also stimulated the formation of reactive
secondary dentin (F) that has obliterated the pulp horn and now
grows into the coronal pulp cavity. The pulp cavity, coronal and
radicular regions, has been markedly reduced from that in the
young stages. Cementum (C) continues to be deposited and the
apical foramen (D) isnow considerably narrower.

 
 

Aging decreases the ability of dental pulp to respond to injury and repair itself.
The fact that the pulp is surrounded by mineralized dentin makes relatively
minor pathologic events like inflammation, that cause swelling elsewhere, lead to
a compression of the pulp leading to intense pain. This generally results in the
death of the pulp.

Calcified Bodies in the Pulp (Pulp Stones) (Lab Image 6, Lab Image 7)

Small calcified bodies are present in up to 50% of the pulp of newly erupted teeth and
in over 90% of older teeth. These calcified bodies are generally found loose within the
pulp but may eventually grow large enough to encroach on adjacent dentin and
become attached. These bodies are classified by either their development or histology:

1. Development

Epithelio-Mesenchymal Interactions. Small groups of epithelial cells become

isolated from the epithelial root sheath during development and end up in the dental
papilla. Here they interact with mesenchymal cells resulting in their differentiation
into odontoblasts. They form small dentinal structures within the pulp.

Calcific Degenerations. Spontaneous calcification of pulp components (collagen

fibers, ground substance, cell debris, etc.) may expand or induce pulpal cells into
osteoblasts. These cells then produce concentric layers of calcifying matrix on the
surface of the mass - but no cells become entrapped.

Diffuse Calcification. A variation of the above whereby seriously degenerated pulp

undergoes calcification in a number of locations. These bodies resemble calcific
degenerations except for their smaller size and increased number.

2. Histology

Calcified bodies in the pulp may be composed of dentin, irregularly calcified tissue,
or both. A calcified body containing tubular dentin is referred to as a "true" pulp
stone or denticle (Lab Image 7). True pulp stones exhibit radiating striations
reminiscent of dentinal tubules. Usually those bodies formed by an epithelio-
mesenchymal interaction, are true pulp stones.

Irregularly calcified tissue generally does not bear much resemblance to any known
tissue and as such is referred to as a "false" pulp stone or denticle (Lab Image 6).
False pulp stones generally exhibit either a hyaline-like homogeneous morphology or
appear to be composed of concentric lamellae.
Figure 10

shows both types of stones: A and B are false pulp stones, C is

a true pulp stone. A is an "attached" stone (which may become
embedded as secondary dentin deposition
continues. B and C are "free" stones found within the pulp
cavity.

Functions of Dental Pulp

The primary function of dental pulp is providing vitality to the tooth. Loss of the
pulp following a root canal) does not mean the tooth will be lost. The tooth then
functions without pain but, it has lost the protective mechanism that pulp provides.

Dental pulp also has several other functions:

 inductive: very early in development the future pulp interacts with surrounding
tissues and initiates tooth formation.
  
 formative: the odontoblasts of the outer layer of the pulp organ form the dentin
that surrounds and protects.
 protective: pulp responds to stimuli like heat, cold, pressure, operative cutting
procedures of the dentin, caries, etc.. A direct response to cutting procedures,
caries, extreme pressure, etc., involves the formation
of reactive (secondary) dentin by the odontoblast layer of the pulp. Formation
of sclerotic dentin, in the process of obliterating the dentinal tubules, is also
protective to the pulp, helping to maintain the vitality of the tooth.