DENTAL PULP

and its clinical

significance
PRESENTED BY : Dr. Harshneet Kaur
PG 1ST YEAR
MODERATOR: Dr. Manju Kumari
Contents 1 Introduction
2 Anatomy
3 Histology
4 Structural Features
5 Functions
6 Clinical Consideration
7 General Consideration
8 Conclusion
9 References
2
 3

Dental pulp occupies the center of each tooth

It is housed in the pulp chamber of the crown and in the root

canal of the root
Soft connective tissue of mesenchymal origin that supports
dentin
Total volume of all permanent teeth pulp organ is 0.38cc

Mean volume of a single adult human pulp is 0.02cc

It is surrounded by dentin forming a protective casing

Orban’s oral histology 13th edition

DEVELOPMENT OF PULP
• Embryonic studies show that pulp is derived from the
cephalic neural crest.
• During the 6th week of IUL, there is condensation of the
mesenchyme under the enamel organ
• The enamel organ enlarge and enclose the dental papilla in
their central portion
• Dental papilla controls the morphology and the type of
tooth formed
• The pulp originates from the ectomesenchymal cells of
dental papilla
• Dental pulp is identified when these cells mature and dentin
is formed

Ingle’s endodontics 6th edition

5
Located centrally in the crown of the teeth

Coronal pulp has six surfaces occlusal,mesial,distal,buccal,lingual and floor

Pulp horns are present in coronal pulp

Pulp horns are the protrusions that extend into the cusp of the tooth

Orban’s oral histology

6
Extends from cervical region of the crown to the root apex

Vary in size,shape and number

May be straight or curved

Radicular pulp is continous with the periapical connective tissue through apical
foramen

Orban’s oral histology

7
As growth proceeds,more dentin is formed,so that when the
root of teeth are matured the radicular pulp is narrower

The apical pulp canal becomes smaller also because of apical

cementum deposition

Divided into cervical 1/3rd,middle 1/3rd and apical 1/3rd

Orban’s oral histology

8
Average size of apical foramen of the :

Maxillary teeth in the adult is 0.4mm

Mandibular teeth 0.3mm

Sometimes it is found on the lateral side of the

apex although the root itself is not curved
Orban’s oral histology9
Leading from the radicular pulp laterally through the
root dentin to the periodontal tissue

May be seen anywhere along the root but are most

numerous in the apical third of the root

10
Formed due to the premature loss of root sheath cells or when
developing root encounters a blood vessel
May also be present in the furcation area

Overall occurrence is 33%

They play an important role in the spread of infection,either from

the pulp to the periodontal ligament or vice-versa
Orban’s oral histology And shafer's text book of oral pathology;5th edition 11
 A lateral canal extends from the main canal
to the periodontal ligament

Most frequently it is perpendicular to the main

canal

The lateral canal is generally found in the main body of

the tooth and may be quite near to the gingival margin

Orban’s oral histology 12

• APICAL CONSTRICTION (MINOR DIAMETER):
It is the apical part of the root canal having the
narrowest diameter short of the apical foramina or
radiographic apex.

• APICAL FORAMINA (MAJOR DIAMETER):

It is the main apical opening on the surface of
root canal through which blood vessels enter the
canal.

Pathways of the pulp;stephen cohen 9th edition

13
Apical constriction :

• Is considered the part of the root canal with smallest diameter

• It is the reference point used most often as a apical

termination for shaping,cleaning,and Obturation

• Postoperative discomfort generally is greater when this

area is violated by instruments or filling materials, and healing
process may be compromised

14
Pathways of the pulp;stephen cohen 9th edition
Dentin and pulp tissue are specialized
connective tissue of mesenchymal origin
formed from dental papilla of the tooth bud
The specialized cells of the pulp,
odontoblasts are arranged peripherally in
direct contact with matrix
This close relationship between odontoblasts
and dentin is known as pulp dentin complex
Pathways of the pulp;stephen cohen 9th edition
Odontoblasts are considered part of the pulp and dentin
tissue because their cell bodies are in the pulp cavity but
their long, slender cytoplasmic cell processes(Tomes Fibers)
extends well into the tubules in the mineralized dentin
Odontoblastic processes (Tomes fibers ) lying in the dentinal
tubules,extend from odontoblast into dentin

Pathways of the pulp;stephen cohen 9th edition 16

Nerve enter the pulp through apical foramen, along
the afferent blood vessels, and together form the
neurovascular bundles

Each nerve fiber has been estimated to provide at

least eight terminal branches

These branches ultimately contribute to an extensive

plexus of nerves in the cell free zone just below the
cell bodies of the odontoblasts in the crown portion
of the tooth 17
 This plexus of nerves, which is called the sub-odontoblastic plexus of
Raschkow, occupies the cell- free zone of Weil and can be demonstrated
in silver nitrate stained sections under the light microscope or by
immunocytochemical techniques

 The nerve bundles that enter the tooth pulp consist principally of
sensory afferent nerves of the trigeminal nerve and sympathetic
branches from the superior cervical ganglion.

Orban’s oral histology and shafer’s

18
• The pulp organ is extensively vascular with vessels arising from
the external carotids to the superior or inferior alveolar arteries.
It is drained by the same vein.

• The blood flow is more rapid in the pulp as compared to most

areas in the body and hence the pressure inside the pulp is quiet
high.

• The walls of the pulpal vessels become very thin as they enter
the pulp.

19
Function as exchange vessels regulating the transport of diffusion of
substances between the blood and local interstitial tissue element.

They consist of single layer of endothelium surrounded by the

basement membrane

Capillary wall is 8-12 micrometer in thickness and acts as a

semipermeable membrane.

Orban’s oral histology 13th edition

Lymphatic vessels are formed from fine meshwork of small, thin
walled lymph capillaries.

The larger lymphatic vessels run along the blood vessels and nerves

Multiple collecting lymph vessels exit through apical foramen and

drain lymph from pulp to periodontium.

Role in pulp: They remove high molecular solutes from the interstitial
fluids thus maintain interstitial capillary osmotic pressure.
Orbans oral histology 13th edition
Average Intrapulpal Tissue Pressure is 10mm Hg

Slight inflammatory changes that raise the intra pulpal

pressure to 13 mm Hg is a reversible response

Pressure of approx. 35 mm Hg indicates an irreversible

state
Seltzer and Bender’s Dental Pulp22
23iIngle’s endodontics 6th edition
 • More sensitive to stimulation than A-delta fibers
• Carry touch ,pressure and propioceptive impulses
A-beta fibers • At a speed of 70m/sec

• Form 90% of A fibres

• Carry pain sensation ranging from 2-30m/sec
A-delta fibers
• Lower threshold
• Produce sharp,pricking and unpleasant but bearable pain

• Carry pain sensation at a slower speed of 0.4-2m/sec because of their lack of myelin and smaller
diameter
Afferent
sensory C • Continous, constant or throbbing pain is a result of sustained smaller C fiber activity
fibers are • Have a higher threshold of excitability
unmyelinated
• Stimulation is associated with tissue damage and inflammatory process. 24
The pulpodentin complex has a unique kind of defense and repair
reaction which is not seen in most other connective tissue

Reaction involves the formation of new mineralized tissue in

response to injury.

Primary odontoblasts in adult tooth produce secondary dentin at

a very slow rate
25
Seltzer and Bender’s Dental Pulp
When primary odontoblasts are injured,the dentin production may be accelerated
as a defense/repair reaction

The dead cells are replaced by secondary odontoblasts that produce new dentin
matrix

New dentin is laid down on the dentinal walls corresponding to the site of injury by
the action of newly recruited secondary odontoblasts

The new dentin produced in response to injury is called tertiary dentin

26
Seltzer and Bender’s Dental Pulp
Odontogenic pain is caused by either noxious physical stimuli or the release of
inflammatory mediators that stimulate receptors located on terminal endings of
nociceptive afferent nerve fibres

Physical stimuli

Effect on dentinal fluid

flow

Activate nociceptors that

innervate dentinal tubules

Leading to perception of
dentinal pain 27
Seltzer and Benders Dental Pulp
The odontogenic zone
The cell free zone or ZONE
composed of
OF WEIL
odontoblasts

4 Zones

The central zone

The cell rich zone containing large nerves
and blood vessels

Pathways of the pulp- Stephen cohen 9th edition

29
A layer of odontoblasts are found along the pulp periphery

They are dentin forming cells

The cell bodies are columnar with large oval media basally

This is a formative zone of the pulp

Seltzer and Bender’s Dental pulp

30
It is also called weil’s zone

40 microns wide and relatively free of cells

Traversed by :
• 1) Blood vessels
• 2) Unmyelinated nerves
• 3) Cytoplasmic process of fibroblasts

31
Seltzer and Bender’s Dental pulp
This zone is found below the odontoblastic
zone

Represents the space in which the

odontoblasts move during tooth development

32
Seltzer and Bender’s Dental pulp
Present in subodontoblastic region

Contains more proportions of fibroblasts

and undifferentiated mesenchymal cells

Also contains macrophages,dendritic cells

and lymphocytes
33
Zone formed due to migration of cells from pulp proper

Mitosis seen when dead odontoblasts are replaced

Also contain young collagen fibres during early

dentinogenesis
34
Seltzer and Bender’s Dental pulp
It is the central region of the
pulp

It contains blood vessels and

nerves embedded in the pulp
matrix together with fibroblasts
35
This zone contains
• 1) Fibroblasts, the most abundant cell type.
• 2) Large blood vessels.
• 3) Undifferentiated mesenchymal cells and
defense cells.
• 4) Collagen fibre bundles.
36
Seltzer and Bender’s Dental pulp
ODONTOBLASTS

FIBROBLASTS

DEFENSE CELLS

UNDIFFERENTIATED CELLS

37
Seltzer and Bender’s Dental pulp
The peripheral area of pulp where the odontoblasts reside is termed as
odontogenic region
Shape may vary:

Coronal pulp=columnar

Mid portion=cuboidal

Apical region=flatened

Pathways of the pulp;stephen cohen 9th edition

These cells have large processes extending
into dentin
Average number of odontoblasts estimated
are 45000 per sq.mm of odontogenic zone
Odontoblasts are larger in crown than in
root
Seltzer and Benders Dental Pulp And pathways of pulp;stephen cohen 9th edition
39
40
They have oval nucleus situated at the pulpal
end
They also have

1)Rough endoplasmic reticulum

2)Golgi apparatus

3)Mitochondria

4)Vesicles and granules

Pathways of the pulp;stephen cohen 9th edition

Odontoblast extend their cytoplasm and
plasma membrane into the dentinal
tubules as an odontoblastic process
(Tomes fiber)
It may extend to the DEJ

Lateral branching of the process is seen at all

levels

42
Processes
are larger
at the
pulpal
end than
at the
periphery
Seltzer and Bender’s Dental pulp 43
Greatest number in the pulp

Numerous in coronal pulp where they form the

cell rich zone
The function is to form and maintain pulp matrix

Seltzer and Bender’s Dental pulp

44
Varies from fusiform (cigar shaped) with long,
slender, protoplasmic processes to stellate(star
shaped) with shorter numerous branches

Seltzer and Bender’s Dental pulp 45

Young fibroblasts undergo mitosis and differentiate into
replacement odontoblasts
These cells synthesize

1) Type 1 and 2 collagen.

2) Proteoglycans.

3) Glycosaminoglycans.

46
Seltzer and Bender’s Dental pulp
• Histiocyte (tissue macrophage) is a defense cell

• When activated histiocytes migrate to the inflammatory site become

phagocytes that engulf bacteria, foreign bodies and dead cells

• Macrophages participate in immune reactions, When activated

macrophages produce soluble factors like interleukin-1, TNF, growth
factors, & other cytokines

Seltzer and Bender’s Dental pulp

47
• Macrophages are monocytes that have left
the blood stream

• Large oval or spindle shaped irregular cells

with short blunt processes

• Have clear cytoplasm with mitochondria,

rough endoplasmic reticulum & free
ribosomes

• Small round dark staining nucleus

Seltzer and Bender’s Dental pulp
48
Represents the pool from which connective tissues of the
pulp are derived

They have the capacity to differentiate into various cell

types like fibroblasts,odontoblasts and macrophage

Found along the capillaries in the cell rich zone

49
Polyhedral in shape with peripheral
processes and large oval nucleus

More in young pulp and decreases with

age,which reduces the regenerative potential
of pulp
Seltzer and Bender’s Dental pulp
50
 Dendritic cells

Lymphocyte

Mast cells

Plasma cells- production

of antibodies

Seltzer and Bender’s Dental pulp

51
 Bone marrow derived, antigen presenting dendritic cells

 Beneath the odontoblast layer

 They capture and present foreign antigen to the T cells

 Infiltrate odontoblast and project their processes into the tubules

 8% of total cell population

52
• They are found in
normal pulp and
increase during
inflammation

53
• They have a round
nucleus and their
cytoplasm contains
many granules
• They are demonstrated
using a special stain
named ‘toluidine blue’

54
Principally Type I and Type III collagen

Composed of glycosaminoglycans, glycoproteins,

and water

Overall collagen content increases with age

55
 DEFENSIVE
NUTRITIVE
SENSORY
FORMATIVE

Seltzer and Bender’s Dental Pulp

56
Produces dentin that surrounds and protects the pulp

Pulpal odontoblasts develop the organic matrix and

function in its calcification

Primary dentin is the regular tubular dentin formed before

eruption

Seltzer and Bender’s Dental57Pulp

Secondary dentin is the regular dentin formed
after tooth eruption, odontoblast secrete dentinal
matrix and retreat towards the pulp center

Secondary dentin forms on all internal aspects of

the pulp cavity, but in the pulp chamber in the
multirooted teeth it tends to be thicker on the
roof and floor than on the side walls

Seltzer and Bender’s Dental Pulp

58
Tertiary dentin or irritation dentin is the irregular
dentin that is formed in response to abnormal stimuli
,such as
• Excess tooth wear
• Cavity preparation
• Restorative materials
• Caries

This is a defense mechanism to compensate for

regional dentin loss on the surface

Seltzer and Bender’s Dental Pulp

59
Blood vascular system of the pulp; nourishes dentin
through the odontoblasts and their processes

Maintains the vitality of the dentin

60
Terminal Capillary Network (TCN) maintains the vitality of
dentin by its numerous projections into the odontoblastic zone

Filtration of water-soluble substrates takes place across the

capillary wall

Seltzer and Bender’s Dental Pulp

61
The defensive function of the pulp is related to its
response to irritation by mechanical, thermal,
chemical or bacterial stimuli.

First line of defense to injuries and infection of

dentin

• Tertiary dentin
• Immuno-competent cell action
• Clearance of toxic substances

Seltzer and Bender’s Dental Pulp62

Maintain tissue’s physical properties and integrity

Control of growth and development and repairs

Control of cell migration

Control of diffusion of macromolecules

Seltzer and Bender’s Dental Pulp 63
Concentration varies from species to species, 32% in human pulp

Higher content in the middle and apical pulp

Total collagen decreases with age

Seltzer and Bender’s Dental Pulp

64
65
1. Pulpitis
a) Reversible
-Symptomatic (acute)
-Asymptomatic ( chronic)
b) Irreversible pulpitis
i) Acute
a. Abnormally responsive to cold
b. Abnormally responsive to heat
ii) Chronic
a. Asymptomatic with pulp exposure
b. Hyperplastic pulpitis
Pathways of pulp;stephen cohen 9th edition66
c. Internal resorption
2. Pulp degeneration
a. Calcific(radiographic diagnosis)
b. Other(histopathological diagnosis)

3. Necrosis
a. coagulative necrosis
b. liquefaction necrosis

Pathways of pulp;stephen cohen 9th edition

67
 Marginal
Abrasion leakage Microbial

Cracked
Traumatic tooth
restorative Dental caries
procedure
Coronal
Advanced fracture
periodontitis
(periodontal- Traumatic
endodontic Attrition exposure
lesion)

68
Presents as pain which patient may have difficulty in
localizing to a particular tooth
Pain may radiate to adjacent jaw, face, ear, or neck

May be continuous for several days or may occur

intermittently over a longer period
Pulpitis is often described as acute or chronic based on
duration and severity of symptoms
Endodontic practice-Louis Grossman 12th edition
69
Severe throbbing, lancinating pain on thermal stimulation or lying
down, keeps patient awake

Generally lasts 10-15 minutes but may be more or less continuous

(reversible pulpitis)

With progression, may become spontaneous & continuous

(irreversible pulpitis)

Endodontic practice-Louis Grossman 12th edition

70
Dull aching pain which can last for an hour or more

Pain on thermal stimulation or spontaneously

Endodontic practice-Louis Grossman 12th edition

71
 Pulpitis: Chronic Hyperplastic Pulpitis
(Pulp Polyp)

Open pulpitis or chronic hyperplastic pulpitis (pulp polyp):

 Large carious cavities

 Young molar teeth with wide apices and good blood supply

Pathways of pulp;stephen cohen 9th edition72

Mild to moderate inflammatory condition of pulp
caused by noxious stimuli in which pulp is capable of
returning to uninflammed state on removal of stimulus

SYMPTOMS: sharp pain is of brief duration produced

by thermal stimuli and subsides on removal of stimulus

73
 REVERSIBLE PULPITIS:
• DIAGNOSIS: cold, sweet or sour usually causes pain, each
peroxysm is of short duration
• Application of cold is an excellent method of locating the involved
tooth

• RADIOGRAPHIC FEATURES:
It is a persistant inflammatory
condition of the pulp,
symptomatic or
assymptomatic,caused by a
noxious stimuli such as caries
Pain persists for several
minutes to hours even after
removal of the stimuli
Most common cause is
bacterial involvement of the
pulp through caries or
chemical,mechanical or
thermal factor

Endodontic practice-Louis Grossman 12th edition

75
 Pulp Stones

Pulp stones, or denticles, frequently are found in pulp tissue

Discrete calcified masses that have calcium phosphorus ratio comparable to

that of dentin

More frequently at the orifice of the pulp chamber or within the root canal

Occasionally a pulp stone may contain tubules and be surrounded by cells

resembling odontoblasts

Pathways of pulp ;Stephen Cohen 9th edition and Shafer’s

oral pathology 76
I. ACC. TO THEIR STRUCTURES
1. TRUE DENTICLES
Remnants of epithelial root sheath
Possess dentinal tubules and odontoblastic processes
2. FALSE DENTICLES
No dentinal tubules or odontoblastic processes
Concentric layers of calcified tissue
Pathways of pulp;stephen cohen 9th edition and shafer's oral pathology 77
78
3. DIFFUSE CALCIFICATIONS

Irregular calcific deposits in the pulp tissue

Diffuse calcification are usually found in the root canal whereas denticles
are seen more frequently in the coronal pulp

Pathways of pulp;stephen cohen 9th edition and shafer's oral pathology

79
II. ACCORDING TO THEIR LOCATION:
1. FREE DENTICLES
Entirely surrounded by the pulp tissue
2. ATTACHED DENTICLES
Partly fused with the dentin
3. EMBEDDED DENTICLES
Entirely surrounded by dentin Pathways of pulp;stephen cohen 9th edition
80
 Such stones are rare and, if seen, occur close to the apex of the tooth
Such stones are referred to as ‘true’ pulp stones as opposed to ‘false’
stones having no cells associated with them

shafer's oral pathology 81

 If during the formation of a pulp stone, union occurs between it and the
dentin wall, or if secondary dentin deposition surrounds the stone, the
pulp stone is called an attached stone

82
shafer's oral pathology
Pulp stones are normally asymptomatic unless they impinge on
blood vessels or nerves

They usually do not present a problem to the dentist

Pulp calcification may hinder root canal shaping

shafer's oral pathology 83

Decrease in the volume of pulp chamber and root canal brought
about by continued dentin deposition

On occasion can appear to be obliterated almost completely

From about the age of 20 years, cells gradually decrease in number

until age 70, when the cell density has decreased by about half

Pathways of pulp;stephen cohen 9th edition

84
Fibrosis is due to aging and injury

Increase in collagen fiber bundles which becomes more

evident with the decrease in pulp size

Pathways of pulp;stephen cohen 9th edition

85
Loss and a degeneration of myelinated and unmyelinated
axons that correlate with an age- related reduction in
sensitivity

Irregular areas of dystrophic calcification, especially in

central pulp

Gradual reduction of tubule diameter

Pathways of pulp;stephen cohen 9th edition

86
The continued deposition often leads to complete
closure of the tubule;

As can be seen in a ground section of dentin, because

the dentin becomes translucent (or sclerotic).

Sclerotic dentin is found frequently near the root apex

in teeth from middle aged individuals

Pathways of pulp;stephen cohen 9th edition

87
 Barotrauma (aerodontalgia)

 Flying at high altitude in unpressurized aircraft, or rapid

decompression in divers

 Attributed to formation of nitrogen bubbles in pulp

tissue or vessels

 Thought not to be a direct cause, but rather an

exacerbating cause in presence of caries

Pathways of pulp;stephen cohen 9th edition 88

 Pulp Necrosis

 May follow pulpitis or trauma to apical blood vessels

Types:

 Coagulative necrosis after ischemia

Pathways of pulp;stephen cohen 9th edition

89
 Liquefactive necrosis after pulpitis;

may become gangrenous with foul odor upon infection by

putrefactive bacteria from caries.

Pathways of pulp;stephen cohen 9th edition

90
Restorative factors contributing to
pulpal injury

91
Effects of cavity preparation
:

 Frictional heat

 Desiccation

 Exposure of dentinal
tubules

 Direct damage to
odontoblast processes

 Chemical treatment to
exposed dentinal surface

92
 Cavity preparation: speed, heat, pressure & coolant may all cause
pulp irritation

 Aspiration or displacement of odontoblasts into dentinal tubules, with

reduction of numbers

Marzouk
93
Factors associated with the restorative
material and its placement :

• Material toxicity

• Insertion pressure

• Thermal effects

• Induced stresses

94
 Effects subsequent to restoration

 Marginal leakage

 Cuspal fracture

Effects of cavity preparation & restorative materials may further

complicate pulpitis caused by caries or other causes

Thickness & nature of remaining dentin may affect pulp response to

dental material
Marzouk 95
 Heat production
Is one of the damaging factor
If pulpal temperature is elevated by 11°f,destructive reactions will occur
• Rotation per minute: if the rotation per minute is more heat production
is more

The most deleterious speed is from 3,000 to 30,000 rpm

• Pressure is directly proportional to heat production

• Surface area of contact

The more the contact between the tooth structure and the revolving tool,
the more heat is generated 96
Seltzer and Bender’s Dental Pulp
 Thermal and mechanical injury

Cutting of dentin with bur or stone always produces some

amount of heat which is determined by several factors:
• Size and shape of cutting instruments
• Speed of rotation
• Length of time ,the instrument is in contact with dentin
• Amount of pressure exerted

Seltzer and Bender’s Dental Pulp

97
 Remaining Dentin Thickness :
1. Remaining dentin thickness between the floor of the cavity
preparation and the pulp chamber is one of the most important
factors in determining the pulpal response

2. Dentin permeability increases with decreasing remaining dentin

thickness

3. Remaining dentin thickness of 2mm or more effectively

precludes restorative damage to the pulp

4. At remaining dentin thickness of .075mm effects of bacterial

invasion are seen 98
Seltzer and Bender’s Dental Pulp
 Cavity liners and varnishes
The use of cavity liner is advocated under restorative
material to reduce
• Sensitivity of freshly cut dentin
• Protect the pulp
Unlined cavity restored with composites resin will
show
 Dense accumulation of bacteria, from contraction
of restoration

Seltzer and Bender’s Dental Pulp

99
RESPONSE OF PULP TO RESTORATIVE MATERIALS

ZINC PHOSPHATE
ZINC OXIDE EUGENOL
Cause severe pulpal damage
Is temporary filling material
because of its irritating
Used as liner and base
properties.
Safest from biological aspect.

Marzouk 100
 AMALGAM
Mild to moderate
CALCIUM inflammation.
HYDROXIDE Harmful effect due to
It stimulates proliferation corrosion products.
of pulp fibroblasts and Inhibition of reparative
reparative dentin dentin formation due to
formation. damage to odontoblasts.

101
Marzouk
 RESTORATIVE
RESINS
These materials have
ZINC high coefficient of
POLYCARBOXYLA thermal expansion
TE and polymerisation
It is well tolerated by on shrinkage which
the pulp result in marginal
leakage, recurrent
caries and pulp
damage.

Marzouk 102
 General consideration

Primary objective of operative procedure must

be preservation of the health of the pulp

Knowledge of the contour and size of the pulp

cavity is essential during tooth preparation

103
Decreasing pulp cavity with the age

Due to extensive caries, preparation or traumatic

injury pulp undergoes inflammation , or pulpitis

Pressure from confined pulpitis leads to pain

104
An accidently, minimally infected exposed pulp
can be preserved by pulp capping procedure

Dentin barrier is formed at the site of exposure

and pulp vitality is maintained

Usually the closer the restoration is to the pulp

the greater will be the pulp response

105
Dehydration and desiccation procedures should be
avoided

An appropriate cavity liner should be used

 An endodontically treated teeth may become darken

and
become brittle and break during mastication
106
Seltzer and Bender’s Dental Pulp And pathways of pulp ;stephen cohen 9th edition
 VITAL PULP THERAPY

1) INDIRECT PULP CAPPING

Advocated in cases of deep carious lesions.

2) DIRECT PULP CAPPING

Advocated in cases of pulp exposure.

Pathways of pulp;stephen cohen 9th edition

107
 INDIRECT PULP CAPPING
• Procedure where the deepest layer of the
remaining affected carious dentin is covered
with a layer of biocompatible material in order
to prevent pulpal exposure and further trauma to
pulp

• Due to the high alkalinity and ability to produce

a dentinal bridge CALCIUM HYDROXIDE is
used as an indirect pulp capping agent
Pathways of pulp;stephen cohen 9th 108
edition
DIRECT PULP CAPPING
• Procedure in which the exposed vital
pulp is covered with a protective
dressing or base placed directly over
the site of exposure to preserve pulpal
vitality

• Materials used for direct pulp capping

are
1) Calcium Hydroxide
2) Mineral Trioxide Aggregate

Pathways of pulp;stephen cohen 9th edition

109
 Pulp vitality

•Is determined by the intactness and health of the

vascular supply, not the status of the pulpal nerve fibres

• Pulp vitality tests are important tools of diagnostic

armamentarium, since these tests not only determine
the vitality of the tooth, but also the pathological status of the pulp

• The treatment plan is also greatly influenced by these tests

110
Pathways of pulp;stephen cohen 9th edition
 PULP VITALITY

ELECTRIC PULP TEST THERMAL TEST

BITE TEST ANESTHESIA TESTING

Pathways of pulp;stephen cohen 9th edition

111
 ELECTRIC PULP TEST
• The evaluated teeth should be carefully isolated and dried Electrical
Pulp testing
• The tip of the testing probe that will be placed in contact with the tooth
structure must be coated with water or petroleum based medium

• Most commonly used medium is tooth paste

• First the control tooth is tested in order to establish a baseline response

and to inform the patient what normal sensation is.
Pathways of pulp;stephen cohen 9th edition 112
 • The coated probe tip is placed in the incisal third of the facial or buccal
area of the tooth to be tested

• Now the patient is asked to touch or grasp the tester probe

• This completes the circuit and initiates the delivery of electric current to
the tooth

• Now the patient is asked to remove finger from the probe when the
tingling or warming sensation is felt in the tooth

ELECTRIC PULP • Then the readings from the pulp tester are recorded
TESTER WITH
PROBE

Pathways of pulp;stephen cohen

113
9th edition
 COLD TEST
• Frozen carbon dioxide also called dry ice or
carbon dioxide snow or CO2 stick is used

• Teeth should be isolated

• Oral soft tissues should be protected with cotton

rolls so the frozen CO2 will not come in contact
with these structures

• CO2 stick is applied to the facial surface of the

crown and the response is noticed
114
Pathways of pulp;stephen cohen 9th edition
 HEAT TEST

Each tooth is isolated with the rubber dam

An irrigating syringe is filled with water that has the temperature similar to that which would cause the painful
sensation

Then it is expressed from the syringe onto the isolated tooth to determine whether the response is normal or
abnormal

The offending tooth will exhibit an immediate, intense painful response to the heat

115
With heat testing a delayed response may occur ,so waiting
10 sec between each tooth will allow sufficient time for the
onset of symptoms

Pathways of pulp;stephen cohen 9th edition

116
PULP TESTING

PULSE OXIMETRY

DUAL WAVE LASER DOPPLER

SPECTROPHOTOMETRY FLOWMETRY

117
Pathways of pulp;stephen cohen 9th edition
 LASER DOPPLER FLOWMETRY
•It is the method used to assess blood flow in microvascular systems

•Used to assess the pulpal blood flow

•A diode is used to project an infrared light beam through the crown

and pulp chamber of a tooth

•The infrared light beam is scattered as it passes through pulp tissue

•The Doppler principle states that the light beam’s frequency will shift
when hitting moving red blood cells but will remain unshifted as it passes
through static tissue
118
 •Average Doppler frequency shift
will measure the velocity at which
the
red blood cells are moving

•Collected data are based on

objective finding rather than
subjective patient
responses

ALDF probe applied to a sectioned tooth

showing the passage of light via the enamel Pathways of pulp:stephen cohen
119
prisms and
 PULSE OXIMETRY

•Used to measure the oxygen concentration in the blood and the pulse rate

•It works by transmitting two wavelengths of light, red and infrared through
a translucent portion of a patients body

•Some of the light is absorbed as it passes through the tissue; the amount
absorbed depends on the ratio of oxygenated to deoxygenated hemoglobin
in the blood

•On the opposite side of the targeted tissue, a sensor detects the absorbed
light
Review article on pulp vitality testing 2014
120
• On the basis of the difference between the light
emitted and the light
received, a microprocessor calculates the pulse rate
and oxygen concentration
in the blood

•Transmission of light to the sensor requires that

there be no obstruction from
restorations, which can sometimes limit the
usefulness of pulse oximetry to
test pulp vitality

Review article 2014: recent advances on pulp vitality testing121

 DUAL WAVE SPECTROPHOTOMETRY

•It is a method independent of a pulsatile circulation

•The presence of arterioles rather than arteries in the pulp and its rigid
encapsulation by surrounding dentin and enamel make it difficult to detect
a pulse in the pulp space

•This method measures oxygenation changes in the capillary bed rather than
in the supply vessels and hence does not depend on the pulsatile blood flow

•It detects the presence or absence of oxygenated blood at 760nm or 850nm

122
Recent advances in pulp vitality testing: review article 2014
 RECENT ADVANCEMENTS
• The newer pulp testing devices, detect the blood
supply of the pulp, through light absorption and
reflection and are considered to be more accurate and
non-invasive.
• Other than testing devices, new advancements have
been made in storing pulp stem cells for regenerative
purposes.

123
 DENTAL PULP STEM CELLS
• Dental pulp stem cells (DPSCs) are stem cells present in the dental pulp. They are multipotent, so
they have the potential to differentiate into a variety of cell types.

• There are various studies where the importance of these cells and their regenerative capacity has
been demonstrated.

• Various study groups have concluded that these cells are capable of producing bone, both in vivo
and in vitro

• Several cytotypes can be obtained from DPSCs owing to their multipotency

• Transplantation of new formed bone tissue obtained from DPSCs leads to the formation of
vascularized adult bone and integeration between the graft and the surrounding host blood supply.
Human dental pulp stem cells: from biology to clinical applications , journal of experimental zoology 2008 124
 CONCLUSION
• Pulp is a soft connective tissue

• A vital pulp is essential to good dentition

• It can be damaged by a variety of ways like

-Due to caries

-During operative procedure (iatrogenic injury)

125
-By restorative materials like acids liberated by the
restorative materials

-By extreme heat Trauma

-Attrition, abrasion, erosion etc

126
 REFERENCES
• Pathways of the Pulp – Stephen Cohen 9th edition
• Ingle’s endodontics 6th edition
• Seltzer and Bender’s Dental pulp
• Orban’s Oral Histology – S.N. Bhaskar
• Shafer’s oral pathology
• Endodontic Practice – Louis Grossman 12th edition
• Review article 2014: recent advances on pulp vitality testing.
• Human dental pulp stem cells: from biology to clinical applications; journal
of experimental zoology 2008

127
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