Progressive changes in the pulpo-dentinal

complex and their clinical consequences

F.M. Burke and D.Y.D. Samarawickrama

Department of Conservative Dentistry, St Bartholomew's and the Royal Eondon School of Medicine
and Dentistry, London, UK.

With changes in the age stmcture and oral health in the population, changes in the pulpo-
dentinal complex are becoming more relevant clinically. Age-related changes in the structure
of dentine and pulp are reviewed. The influence of these changes on restorative dentistry
are considered with particular emphasis on endodontics and the use of adhesive restorative
materials.

Keywords: age changes, dentine, pulp, endodontics, adhesive deutistjy

Gerodontology 1995; 12(2): 57-66

Introduction Unerupted teeth

Because of the acknowledged change in the age
structure of the population together with changes in
oral health' an appreciation of the microscopic age
changes in particular of the dental tissues assumes an
even greater relevance for the provision of restorative
care particularly adhesive restorations and
endodontics.
Causes of pulpo-dentinal change
The pulpo-dentinal complex is capable of responding
to a variety of stimuli over a period of time. These
stimuli can be physiological, relating to the normal
stresses to which a tooth would be exposed over a
lifetime, but are also frequently pathological due to
caries, tooth surface loss, or restorative treatment.
Often these factors occur in combination with each
other. The responses of the pulpo-dentinal complex
can influence the diagnosis, planning and provision of
oral health care.
Of the factors which can cause change, normal
ageing is the most fundamental; there are several
theories as to why ageing per se can occur-.
Most studies have been carried out on coronal
dentine rather than root dentine-, this review will
consider age changes in both coronal and radicular
dentine.
There is contradictory evidence regarding sclerosis
in unerupted teeth. Eittle evidence of peritubular
sclerosis in unerupted teeth from older individuals
has been noted so it is possible that physiological
sclerosis is initiated by stimuli in the oral environ-
ment"*. No change in the amount of peritubular
dentine in unerupted canines of varying ages has been
shown'' implying that peritubular dentine deposition
is environmentally detennincd. However an increase
in sclerotic dentine found in unerupted teeth associ-
ated with ageing has also been noted^ The fact that
this can occur without environmental factors does not
necessarily preclude them as secondary factors.
There is an increase in pre-dentine and cementum
with ageing. Some secondary dentine appears to be
laid down from the apex coronally as opposed to from
the crown apically as occurs in erupted teeth^
Erupted teeth
Odontohlasts
Odontohlast process
The odontoblast process extends across the second-
ary dentine into the primary dentine at least until
sclerosis or closure of tubules in secondary dentine
occurs". This has also been demonstrated using a

Volume 12, No. 2

5S Hurko and Saiii;u;i\vickr;una
scamiing electron microscope cast technique to
examine the interface between primary and bolh
angular and irregular secondary dentine". Although
there is continuity of dentinal tubules between
primary and regular secondary dentine, no such
continuity exists in irregular secondary dentine'".
Odotitohlast changes
Degeneration of odontoblasts has been reported with
vaeuoles being visible prior to their atrophy and
disappearance from areas of the dental pulp" ' \
Odontoblasts lining sclerotic dentine become reduced
in number and disappear, perhaps due to a cell-
mediated change'"*.
Odontoblast life cycle
Aged odontoblasts are those which continue to
function after the fonnation of primary dentine albeit
with a reduced activity. The secretory eells which are
responsible for laying down the collagen precursors
for dentine formation change during their lifecycle.
Aged odontoblasts have a decreased secretory
function with a reduction in number and relocation
of the synthetic machinery to the infranuclear region
and an increase in lipid-tllled vacuoles'\ Older rat
odontoblasts have exhibited a reduced number of
ribosomes attached to the endoplasmie reticulum and
the Golgi apparatus had become less polarised'".
Differenees also occur in nucleoli morphology'^ A
slight shortening in cellular height and a reduced
number of intraeellular organelles have also been
reported'^ It is also evident that odontoblasts lay down
secondary dentine at a slower rate'''. The formative
rate of aged odontoblasts is one fourth of the value
displayed by aetively functioning eells''\ The four or
five eoronal layers of odontoblasts in young teeth may
be reduced to a single layer in old teeth-''. The size of
the odontoblast layer changes from columnar in young
(11-15 year old) to cuboidal in older {50-60 year old)
samples'\ This may be caused by the crowding of
eells resulting from eontinuous dentine formation'**.
If odontoblasts are destroyed, for instance after
operative procedures, new odontoblasts are reeruited
from the subjacent cell-rich zone-.
Odontoblastic activity can increase if the
odontoblasts are stimulated by carious attack in the
outer third of dentine, but the activity of the
odontoblast can decrease with more severe carious
attack affecting the middle third of dentine'^
Metabolic activity of odontoblasts
When secondary dentine formation begins after
completion of primary dentine, the rate of dentine
fonnation and the metabolic activity of the odonto-
blast layer are reduced by about 70%-^ However, mild
insult to the odontoblasts results in increased
Gerodontology
metabolic activity by 30-50%, but more severe
injuries can result in organisational degradation and
the release of lysosoma! enzymes.
In monkeys, the rate of primary dentine formation
has been shown to be 4.0 \xm /day, secondary
dentine formation 0.8 ^m /day and reparative
dentine formation 3.0 |am /day--. In humans the rate
of reparative dentine formation has been shown to
average 1.5 \xm /day, with variation of 3.5 mm /day
2 7 ^ 8 days after stimulus to 0.23 i^m /day 72-137
days after stimulus-^. New odontoblasts may be
recruited for reparative processes in the pulp'''. It may
be that the new odontoblasts are diflerentiated from
existing odontoblasts or that they are derived from
unditTerentiated odontoblasts within the pulp. This
question has yet to be resolved satisfactorily-^.
It has also been postulated that that fibroblasts may
have a role in the fonnation of some mineralised
tissue-^ Such tissue would be a diffuse mineralised
deposit and the false pulp stone. It has been
hypothesised that the stimulus required to activate
the fibroblast would also have a role in the death of
part of the odontoblast layer.
The reparative secondary dentine would be
irregular because the new odontoblasts do not achieve
the same degree of morpho-differentiation as the
primary odontoblasts. The cytoplasmic age changes
reported ineluded a reduction in the volume of
organelles.
Intertubular dentine
The peripheral dentine which is intertubular exhibits
little change throughout life in terms of structure or
composition^ It has been shown, using volume fraction
analysis, that the amount of intertubular dentine
remains eonstant at a particular site irrespective of a
patient's age or degree of attrition'. However,
intertubular dentine is laid down pulpally throughout
life as secondary dentine. This secondaty dentine ean
be described as that circumpulpal portion of regular
dentine (orthodentin) in continuity with the primary
structure and is produced circumpulpally throughout
the life of the vital tooth-''. It is laid down even in
unerupted teeth''^. In contrast, reparative dentine is
more or less inegular in structure, deposited at sites
on the pulpal aspects of primary or secondary dentine,
corresponding to areas of extemal irritations-", e.g.
caries, tooth surface loss or tooth instiaimentation. The
rate of secondary dentine fonnation depends on its
localisation-*". Between regular secondary dentine and
reparative dentine some atubular dentine with cellular
inclusions ean be detected. This is referred to as
interface dentine. It is speculated that this is formed
by pulpal fibroblasts when odontoblasts are destroyed
by local irritation. Subsequently, odontoblasts are

recruited from undillerentiated cells in the pulp which
in tum Ibnn irregular secondary dentine".
Perituhuhr Dentine
Structure
This dentine whieh lines the walls ofdentinal tubules
is formed at the same time or just after intertubular
dentine but it is more mineralised than intertubular
dentine'^ It extends from the amelo-dentinal junction
or eementum to within 100-150 yim of the predentine.
In older teeth, it may extend into seeondary dentine.
Development
The development of peritubular dentine is a source
of some speculation^- with it being laid down in the
presenee of the odontoblastic process'-'"' after the
retreat of the odontoblastic proces'- or even with a
contribution from saliva-\ The peritubular matrix has
been found to consist of fibrillar structures and
inorganic elements. The fibrillar structures are in
continuity with intertubular dentine but the reason
for the greater mineralisation of peritubular dentine
is unknown^". It has also been claimed that the
organic matrix is devoid of fibrous structures".
A eollagenase-resistant matrix has been discovered
lining the inner aspect of peritubular dentine'\ whieh
may have a role in peritubular calcification as it
appears to extend through the entire width of the
dentine whereas the odontoblastie process appears to
be eonfined to the pulpal quarter of the dentine even
in young teeth-^ The organie lining of the dentinal
tubules has been referred to as the latninu liniitans-".
Distribution
With increasing age the number of patent dentinal
tubules obser\'ed at the dentine-secondary dentine
interface in human maxillary incisors decreases at all
levels from the crown to the apex. One report showed
a reduction in the cervical region from an average of
49,500 tubules per mm- for the 20-34 year age group
to 31,317 tubules per mm- in the over 80 year age
group-*", the same phenomenon in the apical region
has been reported although no specific data were
quoted'"\
It is possible that there is some initial peritubular
dentine deposition independent of any pathological
factors but that subsequent deposition may be
influenced by ageing or protective phenomena.
One study has shown no significant difference in
tubule number and diameter in dentine from
individuals aged 8-25 years and 40-60 years'". Near
the pulp there were 45,000 tubuies/mm-with a mean
diameter of 2,5 |im , in the middle there were 29,500
tubuIes/mm- with a mean diameter was 1.2 nun and
peripherally there were 20,000 tubules/mm^ with a
Volume 12. No,2
Changes in the pulpo-dcntinal complex 59
mean diameter of 0.9 |im .
Scanning electron microscopy of old dentine
(45-69 yrs) has demonstrated deposition of a
phosphoric acid-resistant intratubular material. This
dentine has a reduced permeability when compared
with younger dentine"*-.
Complete obturation of the tubules by highly
mineralised tissue has also been demonstrated'^'.
Clinical significance
The pulps of young teeth with open dentinal tubules
would be more susceptible to toxic stimuli from
dental materials than older teeth with sclerosed
canals'*^
Secondary Dentine
Secondary dentine forms pulpally throughout life
mainly on the floor-"-^-'•"' and to a lesser extent, on
the roof of the pulp chamber in molars rather than on
the side walls resulting in shallower but not neces-
sarily narrower pulp chambers. In older patients, the
dentine deposited on the pulpal floor is thicker and
more irregular than that on the roof of the pulp
chamber'^ this irregular floor dentine also appeared
to be more radiolucent, perhaps due to relatively few
odontoblasts in this site having to cover an inereas-
ing surface area with a consequent irregular
deposition of dentine.
In upper central incisors, deposition of irregular
secondary dentine occurs preferentially on the palatal
surface of the pulp chambers probably as a result of
the stimulus from the occlusion from the opposing
lower incisors'". In the root canal, regular secondary
dentine is followed later in life by irregular secondary
dentine either from apical development of coronal
dentine or because of crowding of the root
odontoblasts.
Diminution in size of the root canal has also been
associated with gender, with males being more
affected, and with calcification-related diseases such
as arthritis, gout, kidney-stones, gallstones,
atherosclerosis and hypei1ension^\ However, ageing
was still held to be the most significant cause of
change in canal size"*^ due to the continued deposition
of secondary dentine.
Clinical significance
While it is more difficult to expose the pulp during
tooth preparation it is also more ditTicuIt to locate the
pulp chamber and canals when carrying out root
canal therapy. Increasing pulpal and radicular calcifi-
cation also increase the diffieulty in eanal negotia-
tion. Increasing deposition of dentine in the pulp eanal
reduces the amount of instmmemation necessary
during root canal treatment and the increased amount
 00 kL' and Samarawickrama

ofdcminc M (he apical tbranicii leads lo the dcvclop- and the ensuing tag development was less reliable.
mont of more delliiite apieal slops. Highly sclerotic dentine was resistant to the elTects
ofthe primer^-. In the central area of deep sclerotic
Pen tine transluccney dentine calcified material has been observed protrud-
ing from the tubules. No explanation is given for this
Sclerosis is more coninion in older teeth'". An
phenomenon nor on the potential effect on the
increase in the transluceney o\' the primary root
peritubular dentine. It is probable that intertubular
dentine with ageing has been noted'". This coineides
dentine is selectively demineralised because it
w all an mereased dentine translueency in the root with
contains little collagen and is more acid-labile^''".
age and has little association with dental pathol-
On application of one resin (CIcarfil Liner Bond
ogy'"-'*'. In saggittal section the transluceney appears
System, Kuraray, Osaka, Japan) to normal dentine
to spread eoronally from the apical region with age-
there was extensive resin tag development into the
ing"*', ln transverse seetion the translueency spreads
opened tubules and the resin-dentine inter diffusion
from the eemento-dentinal junetion pulpally and to
zone was 2.0|^m . However when the same resin was
be greatest on the mesial and distal surtaees giving a
applied to sclerotic dentine there were few resin tags
eharaetenstie "buttcrtly' appearance on sectioning*^'.
and the resin-dentine inter diffusion zone was ofthe
Occlusion of the tubules with mineralised tissue
order 0.5 to LOpm ^\
renders the dentine translucent as the occluding ma-
Cervical lesions which were more highly sclerosed
terial has the same refraetive index as peritubular
perfonned less well than less sclerosed lesions in
dentine. Histologieal examination has revealed that
terms of loss of retention, marginal integrity and
translueeney could manifest itself before the major-
discolouration^-\
ity ofthe tubules were occluded^-.
Age related factors do seem to be significant in
Increased transparency ofthe primary root dentine
the retention rate of cervical resin based restorations'*^.
is believed to be due to a gradual metamorphosis or
After 12 months, in those patients under the age of
calcification ofthe terminal branches ofthe tubules
40 years, 13% ofthe restorations were lost while in
which eventually affects the tubules from the
those aged over 60 years 67% ofthe restorations were
penphery to the pulp with occlusion ofthe tubules
lost. After two years, in those patients under the age
by mineral salts'". The increased transluceney is
of 40, 25% ofthe restorations were lost while for
associated with narrowing ofthe dentinal tubules with
those aged over 60, 75% ofthe restorations were lost".
a radio dense material. Decalcification reveals a
It is of interest that there was a different rate of
relatively homogeneous organie matrix thought to be
restoration loss with a continuing steady rate of loss
odontoblast cell extensions remaining within the
for the younger patients but for the older patients,
tubules. It is speeulated thai the tubules are occluded
most losses were in the first six months. It may be
by a combination of mineralised tissue of pulpal
that there were different modes of failure between
origin which can be rod-like or spherical and some
the age groups-^^ based on dentine changes, increased
peritubular dentine deposition. The final stage prior
microcraeks in the enamel and dentine decreasing the
to total tubule obliteration may be calcification ofthe
rigid enamel structure for bonding, increased tooth
odontoblastic process which has been observed
flexure due to excessive occlusal loading"^, whether
under carious lesions^\ Three types of intratubuiar
the tooth was in the maxilla or mandible'" and type
mineralisation were thought to be possible: 1)
of composite with there being a greater loss of
localised precipitation of small spheroidal mineral
restoration with the macrofilled composite (Prisma-
deposits distributed in close relation to collagen fibres
Fil, L.D. Caulk/Dentsply, DE, USA) compared to the
and the odontoblast process. 2) deposition of mineral
microfilled composites, (Prisma Miero-Fil, L.D.
crystals within the organic material and 3) a centripetal
Caulk/Dentsply, DE, USA and Silux, 3M, MN, USA)
wave of uniform crystal deposition obliterating al!
possibly due to the greater potential flexure of the
organic material leading to complete tubular
microfilled". Decreased periodontal support may lead
occlusion^"*.
to an increase in stresses applied also predisposing to
restoration loss*""*.
Clinical significance
It is possible that a combination of these factors
Sclerosis ofthe dentinal tubules may have a profound occurs. Analysis of occlusal stresses applied to
influence on surface treatment techniques for cei"vical lesions has been commenced*'''"- but a number
adhesive materials. When non-sclerotic dentine was of other studies show that age change are clinically
treated with maleic acid primer, patent tubules resulted important.
into which resinous tags could penetrate. However, In one study of older patients, there was an greater
with increasing sclerosis of the dentine the primer loss of cervical resin-based restorations with a dentine
solution was less effective in opening patent tubules bonding agent which relied on the removal \:\\' the

Gerodontology

smear layer (Scotchbond 2, 3IV1, MN, USA) Ihan a
system that relied on the retention ofthe bonding agent
(Scotchbond Dual Cure, 3M MN, USA)".
Although it is noteworthy that dentine sclerosis
commences on proximal radicular surfaces^" there is
little research on this on coronal dentine where less
sclerosis may have occured. Use of an adhesive
system which bonded chemically to calcium, N
(p-toly) giycine glycidyl methacrylate (Tenure/
Marathon. Den-Mat Corp., CA, USA) resulted in
rcdticed microleakage eompared to an adhesive which
bonded to the organic potiion of dentine (Prisma
Universal Bond 2, L.D. Caulk/Dentsply, DE, USA )
in aged teeth^". The higher content of ealcified tissue
in aged dentine may be responsible for this. The
altered response of scleroscd dentine may have an
influence on the usage of dentine adhesive systems
and alteration in tooth preparation; application or
composition of adhesive systems will have to be
explored further. Not enough is understood about
dentine changes with age and how tbis affects
bonding'". In eoronal dentine sclerosis would tend to
confine caries to tbe dentinoenamel junetion as
opposed to the dead tracts in younger dentine which
allow caries to progress towards tbe pulp more easily^
Effect of dentine exposure
Dentine from sensitive surfaees has been shown to
have patent tubules whereas insensitive dentine has
been occluded by rhomboid-shaped erystalline
deposits''^ In such insensitive areas tubular structures
witbin odontoblastic spaces appear to be ealeified and
it is speeulated that calcification of odontoblastie
processes is a result from the external irritation of
dentine similar to attrition or caries"^.
Clinical significance
It has been demonstrated tbat dentine exposed to the
oral environment can have an increased resistance to
aeid-attack^'*^. This may be due to the remineralising
effect of the saliva. Exposed dentine in the mouth
becomes hypermineraiised probably eovering the
ntertubular and peritubular dentine as well as tbe
tubule-^". Furthermore, older sclerotic dentine would
tend to eonfine caries to the dentinoenamel junction
as opposed to the dead traets in younger dentine which
would allow caries to progress towards the pulp more
easily^.
Effect of attrition and aging
An inerease in the amount of peritubular dentine has
been reported with attrition^". With inereasing levels
of attrition as measured by the Gustafson seale^'^, the
amount of peritubular dentine deposition increased
Volume 12, No.l
Changes in the pulpo-dentinal complex 61
on the outer dentine surface with less peritubular
dentine being laid down further away from the the
exposed surface\
Tubules in worn dentine involving occlusal
attrition contained cuboid or rbomboid crystals of
varying sizes, from 1.0 i^m to particles of O.lfim or
less, to a deptb of 2.0 to 2.5 mm from the worn
surface^'. Occlusion ofthe tubules by crystalline
deposits has also been reported on teeth exhibiting
cervical tooth surface loss^'. Similar findings have
been reported by another study which reported
approximately 70,000 to 80,000 dentinal tubules per
mm^ at the pulp-dentine interface in younger
individuals witb 30,000 to 40,000 tubules per mm-
in older teeth subjected to oeelusal wear and trauma--\
Tbe tubule diameter is approximately 0.3 to 1.0 ^m
at the dcntino-cnamel junction and 4.0 to 5.0 iim at
the pulpal interface.
Tbe prevalence and intensity of 'reactive dentin
sclerosis' to attrition has also been reported to be
greater in older age groups^"^. Tubule occlusion has
also been found in eoronal dentine. Sclerosis was
evident long before tbe majority of tubules were
obliterated. Tbere is considerably more tubule
sclerosis present in dentine whieb had been exposed
to pathologieal as opposed to pbysiological stimulii"*.
In erupted teeth with no attrition, there is some
evidence of increased deposition of peritubular dentine
with age^: the ratio of partly closed tubules to
completely closed tubules falls, leading to a decrease
in the number of patent tubules".
The factors attrition and age are inevitably inter-
related and their effect is unavoidably eompoundcd.
Both affect tubule elosure, witb attrition baving the
stronger influenced
Cementum
Cementum deposition is also an age-related
phenomenon with possibly some influence from
environmental faetors'". Tbe eementum increase is
evident in the cerv ieal and middle thirds of the root
length; apical hypereementosis bas made analyses in
tbis region more difficult".
Clinical significance
Apical deposition of eementum would serve to
increase the radiographie length of a root. Considera-
tion should be made for this wben estimating the
working length for endodontics radiographically.
Pulpal Tissues
As witb dentine, pulpal changes can be due to ageing
alone or a eombination of ageing, pathology and
02 Burke and Samamwickraiiia
Size of the pulp chamber
The size of the pulp chamber and canal system o\'
course decreases due to the progressive deposition of
dentine with increasing agc"-^" ".
Whether a narrowing of the apical constriction
occurs" has been disputed**"'. Increased apical
deposition of cemcntum with ageing can lead to
deviation of the foramen opening from the apical
vertex"".
Blood vessels
A decrease in blood vessels occurs'''^"". Blood
vessels undergo arteriosclerotic changes resulting in
a decreased blood supply to the cells in the coronal
portion of the pulp especially in the subodontoblastic
area'^'. Arterioles in older teeth have hyperplasia of
the intima leading to narrowing of the vessel lumen.
The intemal elastic membrane is marked by PAS-
positive material and increased thickness of the
basement membrane'\ Also noted are dystrophic
changes in the media and adventitia^^". In some
instances fine mineral deposits are observed to have
progressed to complete obliteration of the adventitia
and media. There is a decrease in the number of
arterioles and terminal branches in the coronal pulp
especially in the subodontoblastic region. Up to 90%
of those sampled over the age of 40 years had pulpal
calcifications especially in the apicaliy located blood
vessels. This study was carried out in nomiotensive
patients thus eliminating the effect of hypertension
on the arteriosclerotic changes^^.
Furthemiore there is a reduction in the number of
artenes supplying the apical foramen: people under
20 years of age have 3 ^ main branches at the apex
with numerous branches ending in a sub-odontoblastic
plexus. By the age of 30 there is a reduction in the
number of afferent vessels and the peripheral plexus.
Those over 40 years may only have one primary
vessel with an associated reduction in the
subodontoblastic plexus*^-.
Clinical signiftcance
The decrease in blood supply in the pulp would have
an adverse effect on the reparative capacity of the
pulp. Consequently it would be expected that the
effectiveness of pulp capping would decrease with
ageing. One study on the effect of age on direct pulp
capping has shown an overall success rate after 5 years
as being 82% and the success rate for those over 50
years of age as being 70%*^^
As the amount of secondary dentine increases so
does the difTiculty in accurate vitality testing. With
the decrease in pulpal nerve supply the effectiveness
of conventional vitality testing has also be called into
Gerodontology
question"''. A system based on the measurement of
the pulpal blood flow, which in effect determines
pulpal vitality, would be more accurate and objective.
Ground substance
Alteration in ground substance appears to occur with
ageing'* leading to a decreased reactivity and
predominance of highly aggregated macromol-
ecules^-. Such changes may contribute to cellular
degeneration and increased dystrophic mineralisation.
The ground substance still appears to consist mainly
of acid mucopolysaccharides'^.
Calcification
Exposure of dentine can lead to increased pulpal
fibrosis with frequent mineralisation of fibre
bundles^^ There may also be mild inflammation
without leading to pulpal necrosis.
There is an increase in pulpal calcification"'-"'*'
and circulatory disturbances may be an initiating
factor. Mineralisation has been found in association
with collagen fibres, nerves and arteriosclerotic blood
vessels. There are a variety of pulpal calcifications
present-^, with the coronal end of the pulp showing
small chains of spherical or ovoid calcifications and
the root canal showing diffuse calcifications consisting
of a fine lattice of tubes and rods. But the formation
of denticles is less clear-cut^^.
Nerves
There are fewer nerve bundles with ageing'-. The
nerves or the nerve sheaths can undergo fatty degen-
eration to produce calcifications, pulp stones or
nodules. Calcification first involves the endoneurium
and perineurium and then the nerves themselves. The
calcification appears to initiate in the apical portion
of the root which can result in a reduction in the nen^e
branches in the coronal portion of the pulp"^'*.
Fibroblasts
There is a decrease in cellular components including
fibroblasts with ageing" ^' although one other study
maintains that fibroblasts are the predominant cell
population'\
However, with ageing, it seems clear that there is
an increase in collagen fibres'-"' especially in the
sub-odontoblastic layer'^ with an increase in cross-
linkages and mature collagen fibres^'. It is noteworthy,
however, that synthesis of collagen has been reported
to decrease with age"-"". This is based on the decrease
in both collagen concentration and in particular the
reducible cross linking agent, dihydroxylsino-
roleucine, which is associated with collagen synthesis.

There is also an increase in resistance to proteolytic
enzymes and decreased collagen solubility"''. The
reported increase in fibrous elements may therefore
be only relative, due to the amount of fibrous tissue
remaining constant but the size ofthe pulp chamber
becoming smaller due to the progressive laying down
of dentine\ The fibrous tissue may also be derived
from the sheaths surrounding the blood vessels and
nerves^
, 67
Clinical significance
A two year recall study of suceesstul endodontic
therapy for those over 60 years showed in a success
rate of 96% compared to 92% for all age groups^^
This confirmed a previous smaller two year study
which had demonstrated an endodontic success rate
for those over 60 years of 94% compared to 90% for
all age groups'*^. The rate of healing of periapical
radiolucencies has been shown to be comparable
between those 30 years of age and younger (3-2 mmV
month) and those 50 years of age and older (3.0 mm-/
monthf^ In this study there was a greater percentage
of periapical lesions with complete resolution in the
older, 50 years and over, age group (68%) than in the
younger, 30 years and under, age group (43%). The
observation period for the older group was longer
(10.6 months) than for the younger group (9.0
months).
Sclerosis ofthe tubules in root dentine may be a
contributory factor towards the high success rate for
endodontic therapy in the older age groups as this
sclerosis of the dentinal tubules would lead to a
decrease in leakage especially apically.
Other changes
Changes such as fat droplet deposition, fat replacement,
vacuolisation ofthe odontoblasts, pulp cysts and reticular
References
1. Ettingcr R L. Demography and dental needs, an
intemational perspective. GeroJort/o/og)' 1993; 10: 3-9
2. Morse D R. Age-related changes ofthe dental pulp
complex and their relationship to systemic ageing. Oral
Surg Oral Med Oral Pathol 1991; 72: 721-745
3. Mjor I A. Dentin-predentin complex and its
permeability: pathology and treatment overview. J Dent
Res 1985; 64: 621-627
4. Weber D F. Human dentine sclerosis: a microradiogra-
p\\\cs\XT\ty. Arch Oral Bu>l 1974; 19: 163-169
5. Mendis B R R M, Darling A I. Distribution with age
and attrition of peritubular dentine in the crowns of human
teeth. Arch Oral Biol 1979; 24: 131-139
Volume 12, No. I
Changes in the pulpo-dentinal complex 63
atrophy may be age related or artefactuaP.
Macroscopic changes
With ageing, the teeth become darker. This can be
due to extrinsic causes such as staining brought about
by tobaceo, tea, coffee, red wine, chlorhexidene or
discoloured restorations. Intrinsic staining can involve
factors such as increased visibility of the dentine
through the enamel which is lost progressively or
staining by leakage of breakdown products of
haemoglobin into the dentinal tubules in non-vital
teeth or contaminants from root-filling materials or
caries.
Tooth shape can alter due to tooth wear as well as
trauma and enamel fragments chipping off'.
Clinical significance
The alterations to tooth colour and contour may in
some cases lead the patient to request treatment to
modify the appearance. A range of treatment options
are now available ranging from the use of adhesive
restorations through bleaching, veneers and crowns
to the provision of prostheses. This is very subjective
area as patients' perception of their oral self image
varies from individual to individual.
Conclusion
The pulpo-dentinal complex exhibits changes in terms
of composition and structure. These changes can
influence the provision of endodontic and restorative
care. It can be appreciated that the age changes per se
may not have a totally deleterious effect. There is
particular importance in the interrelationship between
the pulpo-dentinal complex. This area will be one of
the most challenging and fruitful in the coming years.
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