CLINICAL ASPECTS OF

FUNCTIONS AND STRUCTURE

O F PULP & ORAL MICROFLORA
• Normal pulp is a coherent soft tissue, dependent on its normal hard dentin
shell for protection. Therefore once exposed, it is extremely sensitive to
contact and temperature but this pain does not last for more than 1-2sec.
after the stimulus is removed.
• Pulp is totally surrounded by dentin which limits the area for expansion and
restricts the pulp’s ability to tolerate edema.
• Pulp has almost total lack of collateral circulation, which severely limits its
ability to cope with bacteria, necrotic tissue and inflammation.
• Pulp consists of unique cells, the odontoblasts, as well as cells that can
differentiate into hard-tissue secreting cells, in an attempt to protect pulp
from injury.
• Pulpal responses are unpredictable. “Some pulps die if you look at them
cross eyes, while others would not die even if you hit them with an axe”.
• Correlation of clinical signs and symptoms with corresponding specific
histological picture is often difficult
 NORMAL PULP

• Pulp is connective tissue consisting of

nerves, blood vessels, ground substance,
interstitial fluid, odontoblasts, fibroblasts
and other cellular components.
• Zones of Pulp - starting at the periphery,
pulp is divided into 4 zones:
1. Odontoblastic zone,
2. Cell-free zone
3. Cell-rich zone
4. Central zone
• A normal pulp gives moderate response to pulp
test and this response subsides when the stimulus
is removed. The tooth is free of spontaneous pain.
Radiograph shows an intact lamina dura, absence
of any pulpal abnormality, calcifications, and
resorption

• Pulpitis is an inflammation of the dental pulp

resulting from untreated caries, trauma, or
multiple restorations. Its principal symptom is pain.
Diagnosis is based on clinical finding and is
confirmed in X-ray.
Photomicrograph illustration of numerous dentin tubules on the dentin
wall adjacent to the canal lumen. The density of the tubules increases
closer to the pulpal side of the dentin wall.
19-21, 25-27
 ODONTOBLASTIC ZONE

• The odontoblasts consist of cell bodies, and cytoplasmic processes, located

within the predentin matrix and the dentinal tubules.
• In this zone are found capillaries and unmyelinated sensory nerves around the
cell bodies.
• Odontoblasts lining the predentin represent the link between the dentin and
pulp.
• Odontoblasts are matrix-producing cells and their primary function is the
production and deposition of dentin throughout the life of the pulp.
• By dentinogenesis odontoblasts are involved in the formation of the teeth and
protection of the pulp from noxious stimuli.
• To fulfill the formative and protective functions of the pulp the odontoblasts
deposit primary, secondary and tertiary dentin
• Primary dentin is elaborated before teeth erupt and is divided into mantle and
circumpulpal dentin. Primary dentin fulfils the initial formative function of the
pulp.
• Secondary dentin is elaborated after eruption. It can be differentiated from
primary by the sharp bending of the tubules producing a line of demarcation. It
is deposited unevenly on primary dentin at a low rate and has incremental
patterns and tubular structures are less regular than those of primary. It is
deposited in greater quantities in the floor and roof of the pulp chamber then
on the walls. (reduction & protection)
• Tertiary dentin can be two types:
1. Type of tertiary dentin formed by primary odontoblasts following a mild
stimulus is called reactionary dentin
2. Type of tertiary dentin formed by newly differentiated or secondary
odontoblasts is termed reparative dentin.
• Cell-free Zone or zone of Weil, is a relatively acellular zone of the pulp,
located centrally to the odontoblast zone. This zone contains some
fibroblasts, mesenchymal cells and macrophages. Fibroblasts are involved
in the production and maintenance of the reticular fibers found in this zone.
When odontoblasts are destroyed by noxious stimuli, mesenchymal cells
and fibroblasts differentiate into new odontoblasts. Macrophages are
present for the phagocytosis of debris. The main constituents of this zone
are a plexus of capillaries, the nerve plexus of Raschkow, and the ground
substance.
• Cell-rich Zone is located central to the cell-free zone. Its main components are
Ground Substance - the main constituent of the pulp, the part of the matrix that
surrounds and supports the cellular and vascular elements of the pulp. It is a
gelatinous substance composed of proteoglycans, glycoproteins, and water.
Ground substance serves as a transport medium for metabolites and waste
products of cells and as a barrier against the spread of bacteria. Fibroblasts -
the predominant cells of the pulp. They may originate from undifferentiated
mesenchymal cells of the pulp or from the division of existing fibroblasts. The
fibroblasts are stellate in shape, with ovoid nuclei and cytoplasmic processes.
Collagen fibers, Undifferentiated mesenchymal cells, and Macrophages
• Central Zone or pulp proper contains blood vessels and nerves that are
embedded in the pulp matrix together with fibroblasts. From their central
location, the blood vessels and the nerves send branches to the periphery of the
pulp.
 PULP FUNCTION

• Induction - Pulp participates in the initiation and development of dentin. When dentin is
formed, it leads to the formation of enamel.
The epithelial-mesenchymal interactions are the core processes of tooth formation.
• Formation - Odontoblasts form dentin. These highly specialized cells participate in dentin
formation in three ways:
1. by synthesizing and secreting inorganic matrix,
2. by initially transporting inorganic components to newly formed matrix,
3. by creating an environment that permits mineralization of the matrix
• Secondary dentinogenesis -
• Tertiary dentinogenesis, that has two forms.
1. Tertiary reactionary dentin - is formed by the original odontoblasts and is tubular in
structure,
2. Tertiary reparative dentin - is formed after the original odontoblasts have been killed and
is created by odontoblasts differentiated from stem cells, this is largely atubular.
 PULP FUNCTION

• Nutrition - The pulp supplies nutrients that are essential for dentin formation and for
maintaining the integrity of the pulp itself.
• Defense - In the mature tooth, the odontoblasts form dentin in response to injury,
particularly when the original dentin thickness has been reduced by caries, attrition,
trauma, or restorative procedures. Dentin formation occurs in this situation by the
induction, differentiation, and migration of new odontoblasts to the exposure site.
• Also has the ability to identify foreign substances, such as the toxins produced by
bacteria of dental caries, and to elicit an immune response to their presence.
• Sensation - Nerves in the pulp can respond to stimuli applied directly to the tissue or
through enamel and dentin.
• The stimulation of myelinated sensory nerves in the pulp results in fast, sharp pain.
Activation of the unmyelinated pain fibers results in a slower, duller pain.
 EFFECTS OF AGING ON PULP

• The continuous deposition of secondary dentin throughout the life of the pulp and the deposition of reparative
dentin in response to stimuli reduces the size of the pulp chambers and root canals and thereby decreases the pulp
volume. This diminution of the pulp is called atrophy.
• A concomitant decrease in the diameter of the dentinal tubules by the continuous deposition of peritubular dentin
also occurs. Some of these tubules close completely and form sclerotic dentin.
• The decrease in pulp volume reduces cellular, vascular, and neural content of the pulp. The odontoblasts undergo
atrophy and may disappear completely under areas of sclerotic dentin.
• A reduction in the fluid content of the dentinal tubules is also seen. These changes make the
dentin less permeable and more resistant to external stimuli.
• The fibroblasts are reduced in size and numbers, but the collagen fibers are increased in
number and in size, probably because of the decrease in the collagen solubility and turnover
with advancing age. This change is referred to as fibrosis. Fibrosis is more evident in the
radicular portion of the pulp than elsewhere.
• The blood vessels decrease in number, and arteries undergo arteriosclerotic changes. Calcific
material is deposited in the tunica adventitia and tunica media. These changes reduce the
blood supply to the pulp.
• The number of nerves is also reduced.
• The ground substance undergoes metabolic changes that predispose it to mineralization.
 EFFECTS OF AGING ON PULP
• A reduction in the fluid content of the dentinal tubules is seen. These changes
make the dentin less permeable and more resistant to external stimuli.
• The fibroblasts are reduced in size and numbers, but the collagen fibers are
increased in number and in size, probably because of the decrease in the
collagen solubility and turnover with advancing age. This change is referred to
as fibrosis. Fibrosis is more evident in the radicular portion of the pulp.
• The blood vessels decrease in number, and arteries undergo arteriosclerotic
changes. Calcific material is deposited in the tunica adventitia and tunica
media. These changes reduce the blood supply to the pulp.
• The number of nerves is also reduced.
• The ground substance undergoes metabolic changes that predispose it to
mineralization. Changes in the blood vessels, nerves, and ground substance
predispose the pulp to dystrophic calcifications
 ORAL MICROFLORA

●There are probably some 500 to 700 common oral

species or phylotypes of which only 50 to 60% are
cultivable. The remaining unculturable flora are
currently being identified using molecular techniques.
●Gram-positive and Gram-negative organisms, and
secondarily as
either anaerobic or facultatively anaerobic.
DIFFERENCE BETWEEN GRAM-POSITIVE AND
GRAM-NEGATIVE BACTERIA
 MICROBIOTA

●Gram-positive cocci
(Aerobic)
-Streptococcus mutans
-Streptococcus salivarius
-Streptococcus mitis
Streptococcus sanguinis
●Gram-positive cocci
(Anaerobic)
-Streptococcus anaerobius
●Gram-negative cocci
-Neisseria
-Veillonella
●Actinomyces (Actinomyces israelii)
●Lactobacillus
●Eubacterium
●Prevotella (Prevotella intermedia)
●Fusobacterium (Fusobacterium
nucleatum)
●Treponema (Treponema denticola)
 ● Commensal Flora –exists in harmony with the
host.
● Transient Flora- exists short time of period.
MICROBIOTA ● Oral habitats:
-buccal mucosa
-dorsum of the tongue
-tooth surfaces (both supragingival and subgingival)
-crevicular epithelium
-prosthodontic and orthodontic appliances, if present.
●Tooth Surface and bacteria
adhesion
-Anatomical factors
-Saliva (Pellicle, bacteria, pH)
-Crevicular fluid
-Microbial factors (toxins, low
pH, receptors for adhesion)
 WHAT IS DENTAL CARIES?

●Is a chronic endogenous infection caused

by the normal oral commensal flora. The
carious lesion is the result of
demineralization of enamel and later of
dentine by acids produced by
microorganisms as they metabolize dietary
carbohydrates. Enamel demineralization is
usually followed by remineralization.
 CARIES FORMATION PATHWAY

●The process begins when sucrose is broken down by bacterial extracellular

enzymes such as glucosyl and fructosyl transferases, with the release of glucose
and fructose. These mon-osaccharides are then converted into polysaccharides
that are either water-soluble or water-insoluble – glucans and fructans. Glucans
are mostly used as a major bacterial food source. The insoluble fructans
contribute to the plaque matrix while facilitating the adhesion and aggregation of
plaque bacteria and serving as a ready, extracellular food source.
●the frequency of intake of fermentable carbohydrates increases, then the plaque
pH level falls and remains low for prolonged periods, promoting the growth of
acid-tolerant (aciduric) bacteria while gradually eliminating the communal
bacteria that are acid-labile.
●Dental caries is caused by acids from bacterial metabolism diffusing into enamel
and dentine and dissolving the mineral.
 PERIODONTAL DISEASE

●Periodontal disease can be broadly categorized into gingivitis

and periodontitis.
●The periodontium includes: periodontal ligament, cementum
and alveolar bone
●The dentogingival junction is perhaps the most vulnerable site
for microbial attack.

●Main bacteria: Porphyromonas gingivalis, Prevotella

Intermedia, Actynomicetes Comitans, Tannerella Forsythia
 HOST DEFENSE FACTORS

●Polymorphonuclear leukocytes (phagosytosis)

●Antibodies (IgM, IgG and IgA)
●B and T lymphocytes
●Complement system
●Proteases
●Lysozyme
●Lactoferrin
 ●Dentoalveolar abscess
●Focal osteomyelitis-> Sequelae
DENTOALVEOLAR
●Might be localized or spread (ex: into sinus); the occlusion of the
INFECTIONS airway by oedema (e.g. Ludwig’s angina-The infection of
sublingual and submandibular spaces).
●primary sinusitis if not arrested, may rarely spread to the central
nervous system, causing serious complications such as subdural
empyema, brain abscesses or meningitis.