DENTAL PULP

Dr. Madhu Billa

I MDS
DEPT OF CONSERVATIVE DENTISTRY AND ENDODONTICS
SIBAR INSTITUTE OF DENTAL SCIENCES 1
Dr.MadhuBilla
 CONTENTS
Introduction
Anatomy
Structural organization of pulp
Cells of pulp
Extra-cellular matrix
Circulation & Innervation of pulp
Functions of pulp
Pulp calcification
Age changes
Clinical significance
Dr.MadhuBilla 2
 INTRODUCTION
The Pulp is a soft mesenchymal connective
tissue that occupies pulp cavity in the central
part of the teeth.

It is a special organ because of its unique

environment

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 FEATURES OF PULP
Enclosed within dentin

Resembles embryonic connective tissue

Microcirculatory system with no collateral

system

Retains ability to form dentin throughout life

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 ANATOMY OF PULP
52 pulp organs – 32 + 20

Total pulp volume in permanent teeth is 0.38

cc. with mean being 0.02 cc.

The pulp cavity is divided into coronal pulp

and radicular pulp

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 CORONAL PULP
It is the pulp occupying the pulp chamber of
the crown of the tooth
In young teeth it resembles the shape of the
outer dentin
It has six surfaces: occlusal, mesial, distal,
buccal, lingual and floor
Pulp horns are projections into the cusp
This pulp constricts at the cervical region
where it continues as the radicular pulp
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 RADICULAR PULP
It is the pulp occupying the pulp canals of the
root of the tooth

In the anterior tooth it is single and in the

posterior teeth it is multiple

It is more fibrous & whitish color, which

protects the neurovascular bundle

As age advances the width of the radicular

pulp is reduced, and so is the apical foramen
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 APICAL FORAMEN
It forms the portal of entry or exit for the
contents of the pulp

Mean size:
Maxillary teeth – 0.4 mm
Mandibular teeth – 0.3 mm

Migration or horizontal pressure causes the

apex to tilt, changing the position of the apical
foramen Dr.MadhuBilla 8
There may be 2-3 foramina separated by
cementum or dentin- APICAL DELTA.

Largest in palatal root of maxillary teeth and

distal root of mandibular teeth.

It is usually 0.5-0.75 mm
occlusal to the anatomic apex.
Dr.MadhuBilla 9
 ACCESSORY CANAL
Leading laterally from the radicular pulp into
the periodontal tissue.

Present in the apical third of the root.

Formed due to premature loss of HERS or

when developing root encounters a blood
vessel.

May also be present at the furcation region.

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ACCESSORY CANALS

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CANAL CONFIGURATION
by Weine in 1982

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VERTUCCI CLASSIFICATION

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DEVELOPMENT
Bud stage

The primitive oral cavity or

stomodeum, is lined by a
stratified squamous epithelium
called as oral ectoderm.
During 6th week of the
intrauterine life or two to three
weeks after the rupture of the
buccopharyngeal membrane,
basal cells of the oral ectoderm
in certain areas proliferate faster
than the adjacent cells and forms
dental lamina.

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Early cap stage;

Certain areas along the

dental lamina,
ectodermal cells
multiply rapidly and
forms knob like
structures called as
enamel organs.
As cell proliferation
continues enamel organ
increases in size and
resembles a cap in shape
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Late cap stage;

On the inside of the

cap ectomesenchymal
cells proliferate faster
than surrounding
mesenchyme and
forms dental papillae.

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Bell stage

 After the inner enamel

epithelium differentiates
into ameloblasts, the
peripheral connective
tissue cells of the dental
papillae differentiates into
odontoblasts and start
producing dentine.
 It is at this time, when the
first layer of dentine has
formed that dental papillae
is the called the dental pulp
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 ZONES OF PULP
ODONTOBLAST LAYER

CELL-POOR ZONE

CELL-RICH ZONE

PULP PROPER

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 ODONTOBLAST LAYER
Present next to predentin with odontoblastic
process passing through predentin into dentin

Contains nerve fibers(Aδ), capillaries,dendritic

cells
In the Coronal pulp
– Cells tall columnar, palisading
– Layers of 3-4 cells
– More odontoblasts per unit area
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Cells in the mid-root region are cuboidal and
appear flattened at the apical region.

No.of odontoblasts per unit area in the

radicular pulp is reduced.

Neighbouring odontoblasts exhibit junction

complexes.
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 CELL POOR ZONE
Present in coronal pulp next to odontoblast
layer, also called WEIL’S zone

40µ wide & relatively free of cells

Traversed by
blood vessels
unmyelinated nerves
cytoplasmic process of fibroblasts
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 Nerve plexus of Rashkow

 Presence/ absence of this zone depends on

the functional status

 Relatively diminished in
younger pulp
older pulp
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 CELL RICH ZONE
Present in subodontoblastic layer

Prominent in coronal pulp

Contains more proportions of fibroblast than

pulp proper

Also contains macrophages, dendritic cells and

lymphocytes. Dr.MadhuBilla 23
 PULP PROPER
It is the central mass of the pulp

Contains larger blood vessels and nerves

Pulpal cells and fibroblasts are also seen

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STRUCTURAL ORGANIZATION

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 Dentin Pulp

Odontoblast process Odontoblast cells

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 CELLS OF PULP
ODONTOBLASTS

FIBROBLASTS

UNDIFFERENTIATED CELLS

IMMUNOCOMPETENT CELLS

MAST CELLS Dr.MadhuBilla 27

 ODONTOBLAST
Highly differentiated cells derived from neural
crest cells

40μ length and 5-7μ wide

During active phase, cells show increase in

ER, golgi apparatus & secretory vesicles

After primary dentin formation dentin forming

activity slows down with decrease in no.of
Dr.MadhuBilla 28
ODONTOBLASTIC PROCESS
It is a direct extention from cell body into the
dentinal tubule

Diameter 3-4μ, no cell organelles

Has well developed cytoskeleton with

microfilaments & microtubules. Mainly
composed of protein- tubulin, actin and
vimentin.
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 JUNCTIONAL COMPLEX

Neighbouring odontoblasts exhibit a series of

junctional complexes

They promote cell to cell adhesion and play a

role in maintaining polarity of odontoblasts.

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 Junctional complexes have been classified by Seltzer
and Bender as.
Impermeable junctions/ zona occludens- The tight
junction, or zona occludens, is so classified because of
the fusion of adjacent plasma membranes.
Adhering junctions/ zona adherens: where a gap of
200-300A is seen. Under light microscopy, adhering
junctions were referred to as intercellular bridges.

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Communicating junctions/ gap junction :
where a gap of 10-20A is seen. Communicating
junctions, or gap junctions (nexus-type
junctions), are sites of cell-to-cell
communication between adjacent odontoblasts
and between odontoblasts and fibroblasts of the
subodontoblastic layer.

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JUNCTIONAL COMPLEXES

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 FUNCTIONS OF
ODONTOBLASTS
Synthesis of organic matrix

Synthesis of non collagenous substances like

sialoprotein, phosphophoryn, osteocalcin,
osteonectin& osteopontin

Intracellular accumulation of calcium

Degradation of organic matrix

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 FIBROBLASTS
Maximum in number and have the capacity to
synthesise and maintain connective tissue
matrix.
Main functions
synthesise type I & type III collagen
synthesise non-collogenous protein
matrix- proteoglycans & GAGs
Synthetic cells have branched cytoplasmic
extentions with nucleus at one end of the cell.
Common in young pulpDr.MadhuBilla 35
 Also have the capability of ingesting and
degrading the same matrix. Thus these cells
have dual function with pathways for both
synthesis and degradation of small size.
They play important role in inflammation and
healing
They release inflammatory mediators
cytokines and growth factors

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FIBROBLAST

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 UNDIFFERENTIATED
MESENCHYME
These mesenchymal cells are distributed
through out the pulp, frequently around the
perivascular area
They are stellate shaped with a high nucleus :
cytoplasmic ratio
Under adequate stimulus they may
differentiate into odontoblast or fibroblast.
In older pulp, their number and ability to
differentiate comes down
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Appear larger than fibroblasts and are
polyhedral in shape
Found along the pulp vessels in cell rich zone
and scattered throught out the central pulp
These are mainly totipotent cells and and when
need arises they may become odontoblasts
,fibroblasts or macrophages

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IMMUNOCOMPETENT CELLS
They play a major role local inflammation and
immunity.
They are recruited from blood stream &
remain as transient inhabitants in pulp
These cells are
Lymhpocytes
Macrophages
Dendritic cells
Mast cellsDr.MadhuBilla 40
 LYMPHOCYTES IN PULP
Present along the walls of blood vessels

CD8+ T lymphocytes > CD4+ T

lymphocytes, B lymphocytes are very rare.

Involved in initial immunodefense

Plasma cells may be present in coronal pulp

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 MACROPHAGES IN PULP
Described as histiocytes

Located close to blood vessel

Have several phenotypes

They express varying combinations of several

macrophage associated antigens and so help in
T lymphocyte activation
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 MACROPHAGES

Dark staining nucleus with cytoplasmic

granules
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 DENDRITIC CELLS
Discrete populations of hematopoetically
derived leucocytes
Characterised by
▪ peculiar dendritic morphology
▪ expression of high amount of
class II MHC molecules
▪ high motility
▪ capacity of antigen presentation
to T lymphocytes
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 MAST CELLS
Occur in small groups in relation to blood
vessels

Present only during pulpal inflammation

Cytoplasmic granules of these cells contain

▪Heparin- anticoagulant
▪Histamine- inflammatory mediator
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EXTRACELLULAR MATRIX
Connective tissue fibers
▪ Collagen
▪ Elastin
▪ Fibronectin
Ground substance
▪ Proteoglycans
▪ Glycosaminoglycans
Basement membrane
Dr.MadhuBilla 46
 COLLAGEN
Extra cellular structural protein, major
constituent of connective tissue

It has a triple helical domain, formed by 3

polypeptide chains(αchains) bound by
hydrogen bonds & hydrophobic interaction

Fibrils display characteristic striation at

intervals of 64nm. Hallmark for identification
of collagen fibrils.Dr.MadhuBilla 47
COLLEGEN FIBRE

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Type I:
▪present as thick striated fibrils
▪responsible for pulp architecture
Type III:
▪thinner fibrils, mainly distributed in cell free & cell
rich zones
▪contributes to the elasticity of pulp
Type IV:
▪present along the basement membrane of
blood vessels
Type V & VI:
▪seen to form dense meshwork of thin micro 49
Dr.MadhuBilla
fibrils through out the stroma
 COLLAGEN FIBRES

Seen in relation with fibroblasts

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Collagen turnover is maintained by pulp
fibroblasts

During bacterial infection & inflammation,

collagenolytic activity is accelerated following
collagenase produced by bacteria, PMN &
fibroblasts

Collagen synthesis is accelerated during

reparative dentin formation.
Dr.MadhuBilla 51
 ELASTIC FIBER
Elastin molecules form the unit structure of
Elastic fibers
These elastin molecules join to form a random
coil structure
This has the ability to expand and contract like
a rubber band.

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Elastic fibers are first formed in bundles of
thin micro filaments called Oxytalan fibers

Elastin is then deposited inbetween oytalan

fibers to form elastic fibers.

Always associated with larger blood vessels

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 FIBRONECTIN
It is a multifunctional stromal glycoprotein
that exists as
• a circulatory plasma protein
• a protein that attaches to cells
• insoluble fibrils forming a part of the extra
cellular matrix

It plays a role in cell-cell & cell-matrix

adhesion
Has a major effect on the proliferation,
Dr.MadhuBilla 54
 GROUND SUBSTANCE
It is a structureless mass, gel-like consistency,
makes up the bulk of the pulp

Consists complexes of proteins, carbohydrate

and water.

Broadly classified as
Glycoaminoglycans
Proteoglycans Dr.MadhuBilla 55
 GLYCOSAMINOGLYCANS
GAG are branched polymers of glucosamine &
galactoseamine, along with ester sulfate groups,
uronic acid & carboxyl group
4 main types:
Chondroitin sulphate/dermatan sulphate
Keratin sulphate
Heparin sulphate
Hyaluronic acid (non-sulphated)
GAG found in pulp is mainly chondroitin
sulphate, dermatan sulphate & hyaluronic acid
Dr.MadhuBilla 56
 PROTEOGLYCANS
Proteoglycans consists of a central protein core
with side chains of GAGs

Due to presence of various structural groups of

GAG, proteoglycans are hydrophilic & act as
polyanions

Thus proteoglycans carry high –ve charge that

prevent diffusion of larger molecules but
attract cationic material.
Dr.MadhuBilla 57
 ROLE IN PULP
During dentinogenesis, the ground substance
show affinity for collagen and influence
fibrinogenesis

Chondroitin sulfate has strong capacity to bind

with calcium and help in mineralisation

Decorin is suggested to be synthesized by

odontoblasts and may play a role in mineral
nucleation
Dr.MadhuBilla 58
 BASEMENT MEMBRANE
It is a sheet like arrangement of extra cellular
protein matrix at the epithelial-mesenchymal
interface
Composed of 2 layers
lamina densa - electron dense
lamina lucida - electrolucent
Basement membrane is a product of
connective tissue and epithelium
Dr.MadhuBilla 59
1-4µm wide, relatively cell free
Ultrastructurally it is also called as basal
lamina, but it is not just a membrane but but a
basal complex consisting of lamina and fibres
Lamina densa contains type IV collagen
coated with heparin sulphate and appears as
chicken wire configuration
Anchoring fibrils which contain type VII
collagen are inserted into lamina densa
Dr.MadhuBilla 60
FUNCTIONS:
▪ Act as sieve between epithelium &
connective tissue
▪ Helps in organisation & differentiation by
enabling interactions between extracellular
molecules & cell surface receptors

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CIRCULATION OF THE PULP
Pulp organ is extensively vascularised with
blood vessels arising from superior & inferior
alveolar arteries.

Pulp has a micro circulatory system which

lacks true arteries & veins.

The largest vessels are arterioles & venules

which regulate the local interstitial
environment.
Dr.MadhuBilla 62
PULP VASCULATURE

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Pulpal blood flow is more rapid than in most
areas of bodythis is perhaps attributable to the
fact that pulpal pressure is highest of body
tissues
Flow of blood in arterioles- 0.3-1mm/sec in
venules 0.15mm/sec and in capillaries
0.08mm/sec

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Vessles consists of 3 layers
• tunica intima: consists of squamous or cuboidal
endothelial cells
•Tunica media: 5µ thick consists of smooth
muscle cells, ocassionally the endothelial cell
wall is in contact with muscle cells which is
termed myoendothelial junction
•Tunica adventitia: made of collagen fibres
forming a loose network around larger arteries

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CAPILLARIES:
•Function as exchange vessels regulating
the transport or diffusion of substances
between blood and local interstitial tissue
elements
• They consists of single layer of
endothelium surrounded by basement
membrane
• Capillary pressure: 35 mmHg
• Capillary wall is 0.5μ thick & acts as
semi permeable membrane
Dr.MadhuBilla 66
 VENULES:

• Collecting venules receive pulpal blood flow

from the capillaries & transfer it to the venules
• Arterio-venous anastomosis permits direct
shunting from arterioles to venules
• Venular pressure-19mmHg

Dr.MadhuBilla 67
 LYMPHATICS
Lymphatic vessels are formed from a fine
meshwork of small, thin walled lymph
capillaries

They start as blind openings near Weil’s zone

& odontoblastic layer

The larger lymphatic vessels run along the

blood vessels & nerves
Dr.MadhuBilla 68
More numerous in in central part of pulp than
in peripheral areas
Those draining the anterior teeth pass to
submental lymphnodes and those draining the
posterior teeth pass to submandibular and deep
cervical lymphnodes.

Dr.MadhuBilla 69
 INNERVATION
Principle role is to help in conscious
recognition of irritants to the pulp,

Dental pulp contains sensory and motor fibers

to fulfill the vasomotor and defense function

Sensory afferent fibers are branches of

maxillary & mandibular divisions of
trigeminal nerve.
Dr.MadhuBilla 70
 After entering the foramen, they arborize.
Larger fibers are present in the central zone.
They divide as they proceed peripherally and
coronally.

Subjacent to the cell rich zone, the nerves

branch extensively forming a parietal layer of
nerves- NERVE PLEXUS OF RASHKOW.
This layer contains both Aδ and C fibers
.
In the cell free zone, they form a rich network
responsible for pain.
Dr.MadhuBilla 71
TYPES OF NERVE FIBRES

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 NERVE FIBERS
A-fibers C-fibers
•Myelinated •Unmyelinated
•20% •80%
•Diameter – 2-5µm •0.3-1.2µm
•Conduction velocity • 0.4-2m/sec
6-30m/sec
•Distributed in odontoblastic & •Distributed throughout the pulp
subodontoblastic zones & tissue & associated with pain
associated with Dental pain. due to pulp damage.
•Impulses are intercepted as •Conduct throbbing & aching
sharp & prickling pain. pain.
•Low threshold of excitability. •High threshold of excitability.
Dr.MadhuBilla 73
 FUNCTIONS OF DENTAL
PULP
INDUCTIVE

FORMATIVE

NUTRITIVE

PROTECTIVE

DEFENSE Dr.MadhuBilla 74
 INDUCTIVE
It induces epithelial differentiation into dental
lamina & enamel organ

It also induces the enamel organ to become a

particular type of tooth

Dr.MadhuBilla 75
 FORMATIVE
Pulp induces dentin formation that surrounds
& protects the pulp

This involves formation of primary &

secondary dentin

The primary dentin is tubular & regularly

arranged. Formed before root closure
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 NUTRITIVE
Dental pulp maintains the vitality of dentin by
providing O2 & nutrients to the odontoblasts

Also provides continuing source of dentinal

fluid

Nutrition made possible by rich peripheral

capillary network Dr.MadhuBilla 77
 PROTECTIVE
Pulp helps in recognition of stimuli like heat,
cold, pressure, chemicals by way of sensory
nerve fibres

Vasomotor innervation controls the muscular

wall of blood vessels. This regulates the blood
volume & rate of blood flow & hence the
intrapulpal pressureDr.MadhuBilla 78
 DEFENSE
When irritated or injured the pulp will respond
by
1. Dentinal pain
2. Smear layer formation
3. Tubular sclerosis
4. Irritation dentin formation
5. Inflammation of subjacent connective
tissue Dr.MadhuBilla 79
REGRESSIVE CHANGES
(AGING)

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Cell changes
-in addition to appearance of fewer cells in the
aging pulp the cells are characterized by
decrease in size and number of cytoplasmic
organelles
Fibrosis:
In aging pulp accumulation of both diffuse
fibrillary components and bundles of collagen
fibres usually appear

Dr.MadhuBilla 81
 PULP CALCIFICATIONS
It is a common occurrence with incidence of 50%
of all teeth
Size may range from microscopic particle to
stones that may occlude the pulp chamber
Composed of carbonated hydroxyapitite crystals
Pulp calcification may be
Pulp stones
Diffuse calcifications
Calcific Metamorphosis
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 Pulp denticles, are classified as -
According to structure:
1)True denticles
2)False denticles
3)Diffuse calcifications
According to location:
1)Free- entirely surrounded by pulp
2)Attached-partially fused with dentine.
3)Embeded- entirely surrounded by dentine
Goga, R., Chandler, N. P. and Oginni, A. O. (2008), Pulp stones: a review.
International Endodontic Journal, 41: 457–468
Dr.MadhuBilla 83
 TRUE DENTICLES
Round or ovoid with smooth surfaces and
concentric lamellae.

Appear to grow by addition of collagen on

their surface

Believed to be formed around HERS

They contain dentinal tubules, and are

frequently found near root apex.
Dr.MadhuBilla 84
 FALSE DENTICLES

They have a rough surface no particular shape &

laminations

Grow due to mineralization of preformed

collagen fibers

Cause of such calcification may be, degenerating

cells, blood thrombi or collagen fibrils all of which
form a nidi for calcification
Usually present in the pulp chamber.
Dr.MadhuBilla 85
 True denticles are not dystrophic structures, since they
are composed of dentin and formed by detached
dentinoblasts or fragments of Hertwig's sheath, which
may stimulate undifferentiated cells to assume
dentinoblastic activity.

 False denticles are formed when a degenerating tissue

structure serves as a nidus for deposition of concentric
layers of calcified tissue.

Goga, R., Chandler, N. P. and Oginni, A. O. (2008), Pulp stones: a review.

International Endodontic Journal, 41: 457–468

Dr.MadhuBilla 86
Dr.MadhuBilla 87
 Calcifications

These are found in both healthy and aging pulps,

although their incidence increases with age

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 Dystrophic calcification is a deposition of calcium salts in

dead or degenerating tissue. It may be due to local

alkalinity of the destroyed tissue that attracts the salts.
This mineralization thus may occur in minute areas of
young pulp tissue affected by minor circulatory
disturbance.
 Diffuse calcifications are generally observed in the root

canal but may also be seen in the pulp chamber.

Goga, R., Chandler, N. P. and Oginni, A. O. (2008), Pulp stones: a review.

International Endodontic Journal, 41: 457–468

Dr.MadhuBilla 89
 AGE CHANGES
Formation of secondary dentin through out
life, reduces the size of the pulp chamber &
root canals

Decrease in cellularity

Odontoblast decrease in size & number, &

may disappear in certain areas. Especially on
pulpal floor over bifurcation & trifurcation
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Increase in number & thickness in collagen
fibers particularly in radicular pulp
Reduction in the nerve fibers & blood vessels
Increase resistance of pulp against action of
enzymes
In dentin,
Increase in peritubular dentin
Dentinal sclerosis, reduces permeability
Increase in dead tracts
Dr.MadhuBilla 91
CLINICAL CONSIDERATIONS
Anatomic considerations

Effect of dental materials on pulp

Effect of Operative Procedures

Effects subsequent to restoration

Dr.MadhuBilla 92
 ANATOMIC
CONSIDERATIONS
Dimensions of tooth preparation are dictated
by pulpal morphology
Young permanent teeth have wider pulp
chamber and so do deciduous teeth
Cervical horns present in maxillary molars
complicate class V restoration and endodontic
treatment
developmental disturbances and advanced age

Dr.MadhuBilla 93
 ANATOMIC
CONSIDERATIONS

Dr.MadhuBilla 94
 EFFECT OF DENTAL
MATERIALS ON PULP
Amalgam
corrosion products inhibit cell growth
high thermal conductivity
Glass ionomers
well tolerated by pulp
RMGI used for direct pulp capping
Zinc Oxide Eugenol
has an anti-bacterial and anodyne effect
higher concentrations leads to chronic
inflammation & thrombosis of vessels
Dr.MadhuBilla 95
Zinc Phosphate
strong to moderate cyto-toxic reactions is due to
leeching of zinc ions and low pH
Resin adhesive systems
The formation of hybrid layer secures the enamel-
resin interface with a continuous seal which acts as a
biometric barrier Dentin bonding agents monomer
molecules reaching the pulp can irritate the pulp
causing inflammation

Dr.MadhuBilla 96
 EFFECTIVE DEPTH
The effective depth is the area of minimum
thickness of sound dentin separating the pulpal
tissue from the carious lesion

 2mm or more, healthy reparative reaction

 0.8 – 2mm, unhealthy reparative reation
 0.3 – 0.8mm, pulpal destructon
(Marzouk, 2006)
Dr.MadhuBilla 97
 CONCLUSION

 Pulp to the tooth is like heart to the body,

providing constant source of nutrition to maintain
the vitality of the tooth. Every precaution should
be taken to preserve the vitality of the tooth.
 The preservation of the healthy pulp during
operating procedure and successful management in
cases of diseases are two most important challenge
to the clinicians

Dr.MadhuBilla 98
 REFERENCES

 GROSSMANS ENDODONTIC PRACTICE

 S.COHENS PATHWAYS OF PULP-9TH EDITION
 ORBANS ORAL HISTOLOGY
 TEN CATES ORAL HISTOLOGY
 SELZERS AND BENDERS THE DENTAL PULP
 R. INOKIS DYNAMIC ASPECTS OF DENTAL PULP
 FRANKLIN S. WEINE – 5TH EDITION

Dr.MadhuBilla 99
THANK YOU….

Dr.MadhuBilla 100