PULP

- SHIVIKA DUGGAL
DEFINITION:
Dental Pulp can be defined as a richly vascularized and innervated connective tissue of mesodermal
origin enclosed by Dentin with communications established to the Periodontal Ligament.

GENERAL FEATURES:

 Occupies the center of each tooth and consists of soft connective tissue.
 The pulp is housed(present) in the pulp chamber of the crown and in the root canal
of the root.
 Pulp present in the crown: CORONAL PULP
 Pulp present in the root: RADICULAR PULP
 The shape of the pulp varies in different teeth and resembles the outer surface of
the crown.
 Total volume of all permanent teeth pulp: 0.38 cm^2
 Mean volume of a single adult human pulp is: 0.02 cm^2
 Molar pulps are 3-4 times larger than incisor pulps (Size of the pulp: posteriors >
anteriors )

CORONAL PULP

RADICULAR PULP

 The radicular pulp extends from the cervical region of the crown to the root
apex.
 In the anterior teeth, the radicular pulps are single but in posterior ones
multiple.
  The dentinal walls taper and the shape of radicular pulp is tubular.
 They vary in size, shape and number.
 They communicate with the periapical connective tissues via a large foramen
called APICAL FORAMEN. { apical: relating to APEX}
 During root formation, the apical root end is limited by epithelial diaphragm.
 As the growth proceeds, more dentin is deposited so that when the root of
the teeth has matured , the radicular pulp is narrower.
 With age, the apical pulp canal becomes smaller because of apical cementum
deposition.
APICAL FORAMEN

 The location and the shape of apical foramen may undergo changes(not constant) as
a result of functional changes / influences on the teeth,
 The apical foramen is generally located centrally in a developing tooth; as the
development is complete, it assumes an eccentric position.
 For instance, a tooth may be tipped from horizontal pressure or it may migrate
mesially causing the apex to tilt in the opposite direction. Under these conditions,
the tissues entering the pulp through apical foramen may exert pressure on the walls
of foramen, causing resorption. At the same time, cementum is laid down on the
opposite side of the apical root canal , resulting in relocation of the original foramen
to an eccentric position.
 Sometimes the apical foramen is found on the lateral side of the apex of root canal.
 If there are two or more apical foramen present, then they are separated by a
portion of dentin and cementum or by cementum only.

ACCESSORY CANALS
HISTOLOGY OF DENTAL PULP

(The cell free zone is inconspicuous during early stages of rapid dentinogenesis since
odontoblast migration would be the greatest at that time.
The cell rich zone is formed during the pre-eruptive phase of the tooth.)

INTERCELLULAR SUBSTANCE(GROUND
SUBSTANCE)

FIBRES
CELLULAR COMPONENT

SUPPORTING ELEMENTS- BLOOD

VESSELS,LYMPH VESSELS AND NERVES

STRUCTURAL FEATURES OF
PULP
INTERCELLULAR  The ground substance is DENSE AND GEL LIKE IN NATURE, varies in
appearance from FINELY GRANULAR TO FIBRILLAR.
COMPONENT  It is composed of ACID MUCOPOLYSACCHARIDES
{GROUND (glycosaminoglycans) AND PROTEIN POLYSACCHARIDE
SUBSTANCE) COMPOUNDS (proteoglycans)
 Functions of ground substance:
1. Lends support to the cells of pulp.
2. Serves as a means of transport of nutrients from blood
vessels to the cells.
3. Transport of metabolites from cells to the blood vessels
 Glycosaminoglycans present in the ground substance contributes
to the high tissue fluid pressure of the pulp due to their hydrophilic
and gel like nature.

HYALURONIC  MECHANICAL FUNCTION

ACID  CELL MIGRATION
VERSICAN  FORMS THE BULK OF PROTEOGYLCANS
SYNDECAN  IMPORTANT PROTEOGLYCAN
 ACTS AS AN ADHESION MOLECULE BETWEEN
THE FIBROBLAST AND COLLAGEN.
 ALSO BINDS SIGNALLING MOLECULES LIKE
FIBROBLASTIC GROWTH FACTOR.

TENASCIN AND  PROMOTE CELL ADHESION AND CELL

FIBRONECTIN MIGRATION
 ABSENT IN AREAS OF INFLAMMATION
LAMININ  PRESENT IN LAMINA LUCIDA LAYER OF
BASAL LAMINA
 TRIPLE CHAIN MOLECULE
 COATS THE ODONTOBLAST CELL MEMBRANE

INTEGRINS  IMPORTANT GLYCOPROTEIN

 INTERACT TO FORM CELL SURFACE
ADHESION RECEPTORS AND GET ATTACHED
TO BIOLOGICALLY ACTIVE MOLECULES LIKE
LAMININ AND FIBRONECTIN.

FIBRES  Collagen fibres in the pulp exhibit typical cross striations at 64 nm

and range in length from 10 -100 nm or more.
 The main type of collagen fiber in the pulp is type I.
 TYPE III is also present.
 Bundles of these fibers appear throughout the pulp.
 In very young pulp fine fibers ranging in diameter from 10 to 12 nm
(100 to 120 Å) have been observed. These fine fibers are called
fibrillin.
 Significance of FIBRILLIN: Down-regulation and degradation of
fibrillin helps in release of TGF-beta which in turn promotes the
formation of mineralised tissue barrier in exposed pulps.
  Pulp collagen fibers do not contribute to dentin matrix production,
which is the function of the odontoblast.
 After root completion the pulp matures and bundles of collagen
fibers increase in number. They may appear scattered throughout
the coronal or radicular pulp, or they may appear in bundles.
 These are termed diffuse or bundle collagen depending on their
appearance, and their presence may relate to environmental
trauma.
 Bundled collagen are most prevalent in the root canals, especially
near the apical region.

CELLS OF THE PULP

FIBROBLASTS  Predominant cell of the pulp.
 The pulp organ is said to consist of specialized connective tissue because it lacks elastic
fibers.
 Fibroblasts are the most numerous cell type in the pulp.
 They function in collagen fiber formation throughout the pulp during the life of the
tooth.
 They have the typical stellate shape and extensive processes that contact and are
joined by intercellular junctions to the processes of other fibroblasts.
 Under the light microscope the fibroblast nuclei stain deeply with basic dyes, and their
cytoplasm is lighter stained and appears homogeneous.
 Electron micrographs reveal abundant rough-surfaced endoplasmic reticulum,
mitochondria, and other organelles in the fibroblast cytoplasm. This indicates these
cells are active in pulpal collagen production.
 In the young pulp the cells divide and are active in protein synthesis, but in the older
pulp they appear rounded or spindle shaped with short processes and exhibit fewer
intracellular organelles. They are then termed fibrocytes.
 The fibroblasts of the pulp, in addition to forming the pulp matrix, also have the
capability of ingesting and degrading this same matrix. These cells thus have a dual
function with pathways for both synthesis and degradation in the same cell.
 Fibroblasts play an important role in inflammation and healing. Fibroblasts secrete
angiogenic factors like FGF-2 and VEGF, especially after injury, which help in healing.
They also release inflammatory mediators cytokines and growth factors.
UNDIFFERENTIATED  Undifferentiated mesenchymal cells are the primary cells in the very young pulp, but a
MESENCHYMAL few are seen in the pulps after root completion.
CELLS  They appear larger than fibroblasts and are polyhedral in shape with peripheral
processes and large oval staining nuclei.
 The latter are distinctive because they lack a ribosome-studded endoplasmic reticulum
and have mitochondria with readily discernible cisternae.
 They are found along pulp vessels, in the cell-rich zone and scattered throughout the
central pulp. Viewed from the side, they appear spindle shaped.
 They are believed to be a totipotent cell and when need arises they may become
odontoblasts, fibroblasts, or macrophages.
 They decrease in number in old age.
ODONTOBLASTS  Odontoblasts, the second most prominent cell in the pulp, reside adjacent to the
predentin with cell bodies in the pulp and cell processes in the dentinal tubules.
 The number of odontoblasts corresponds to the number of dentinal tubules.
  They are approximately 5 to 7 m in diameter and 25 to 40 m in length. They have a
constant location adjacent to the predentin, in what is termed the “odontogenic zone
of the pulp”.

 Recently, primary cilia have been identified in odontoblast. These cilia may play a role
in response of odontoblasts to external stimuli.
 The form and arrangement of the bodies of the odontoblasts are not uniform
throughout the pulp. They are more cylindrical and longer (tall columnar) in the crown
and more cuboid in the middle of the root.
 Close to the apex of an adult tooth the odontoblasts are ovoid and spindle shaped and
ultrastructurally, ring-layered structures have been observed between aging
odontoblasts that might be characteristic of aging teeth.
 Odontoblasts are end cells. They have lost the ability to divide. When they die they
have to be replaced by cells, which differentiate from the cell-rich zone. Odontoblast
and subodontoblastic cells have been shown to undergo apoptotic cell death by
apoptotic cell markers like bcl-2.
 Odontoblasts release inflammatory chemokine interleukin-8 which is chemotactic for
neutrophils
 Nitric oxide synthetase have been identified in odontoblasts and endothelial cells of
the pulp which are important enzymes for vasodilatation and blood pressure
regulation. This finding suggests that odontoblasts may have a role in mediating cell
proliferation and vasodilatation.
DEFENSE CELLS
PULPAL STEM CELLS  Stem cells that have been identified from the pulpal tissues include dental pulp
stem cells (DPSCs) and stem cells from human exfoliated deciduous teeth (SHED).
 The stem cells were shown to undergo proliferation and migrate to the site of
injured odontoblasts and produce dentin.
 The pulpal tissues of the exfoliated deciduous teeth and third molars may
serve as a suitable source of stem cells for future stem cell based therapies as they
are found to be viable after cryopreservation.

 BLOOD VESSELS
 The pulp organ is extensively vascularized.
 It is known that the blood vessels of both the pulp
and the periodontium arise from the inferior or
superior alveolar artery and also drain by the same
veins in both the mandibular and maxillary regions.
 Pulpal blood flow is more rapid than in most areas
of the body. This is perhaps attributable to the fact
that the pulpal pressure is among the highest of
body tissues.

 LYMPH VESSELS
1. Lymph capillaries are described as endothelium-lined tubes that join thin-walled lymph
venules or veins in the central pulp.
2. The lymphatic capillaries have thin walls.
 3. Cellular projections arise from the endothelial cells. The cells contain multivesicular
structures, Weibel-Palade bodies and paracrystalline inclusions.
4. The lymphatic vessels were more numerous in the central part of the pulp than in the
peripheral areas.
5. The larger vessels have an irregular-shaped lumen composed of endothelial cells surrounded
by an incomplete layer of pericytes or smooth muscle cells or both.
6. In inflamed pulps, due to increased interstitial fluid pressure, gap junction develops between
the endothelial cells of the dilated lymph capillaries.
7. Lymph vessels differ from venules in that their walls and basement membrane show
discontinuities, with the absence of RBCs but with the presence of lymphocytes in the
lumen.
8. Lymph vessels draining the pulp and periodontal ligament have a common outlet. Those
draining the anterior teeth pass to the submental lymph nodes; those of the posterior teeth
pass to the submandibular and deep cervical lymph nodes.

 NERVES
1) The dental pulp is highly innervated.
2) The majority of the nerves that enter the pulp through apical foramen are nonmyelinated.
3) The nonmyelinated nerves are found in close association with the blood vessels of the pulp
and many are sympathetic in nature. They have terminals on the muscle cells of the larger
vessels and function in vasoconstriction.
4) The large myelinated fibers mediate the sensation of pain that may be caused by external
stimuli. The peripheral axons form a network of nerves located adjacent to the cell-rich
zone. This is termed the parietal layer of nerves, also known as the plexus of Raschkow.
5) Both myelinated axons, ranging from 2 to 5 m in diameter, and minute nonmyelinated fibers
of approximately 200 to 1600 m (2000 to 16,000 Å) in size make up this layer of nerves
(plexus of Raschkow). The parietal layer develops gradually, becoming prominent when root
formation is complete.

FUNCTIONS
1) Inductive:
The primary role of the pulp anlage is to interact with the oral epithelial cells,
which leads to differentiation of the dental lamina and enamel organ
formation. The pulp anlage also interacts with the developing enamel organ as
it determines a particular type of tooth.
 2) Formative:
The pulp organ cells produce the dentin that surrounds and protects the pulp.
The pulpal odontoblasts develop the organic matrix and function in its
calcification. Through the development of the odontoblast processes, dentin is
formed along the tubule wall as well as at the pulp–predentin front.

3) Nutritive:
The pulp nourishes the dentin through the odontoblasts and their processes and by means of the
blood vascular system of the pulp.

4) Protective:
The sensory nerves in the tooth respond with pain to all stimuli such as heat, cold, pressure,
operative cutting procedures, and chemical agents. The nerves also initiate reflexes that control
circulation in the pulp. This sympathetic function is a reflex, providing stimulation to visceral motor
fibers terminating on the muscles of the blood vessels.

5) Defensive or reparative:
The pulp is an organ with remarkable reparative abilities. It responds to irritation, whether
mechanical, thermal, chemical, or bacterial, by producing reparative dentin and mineralizing any
affected dentinal tubules.

After injury to the mature tooth, the fate of the odontoblast can vary according to the intensity of
the injury. Milder injury can result in functional activity leading to focal secretion of a reactionary
dentin matrix, called regeneration, while greater injury can lead to odontoblast cell death.
Induction of differentiation of a new generation of odontoblast-like cells can then lead to
reparative dentinogenesis.

Both the reparative dentin created in the pulp and the calcification of the tubules (sclerosis) are
attempts to wall off the pulp from the source of irritation. Also, the pulp may become inflamed due
to bacterial infection or by cutting action and placement of an irritating restorative material.

The pulp has macrophages, lymphocytes, neutrophils, monocytes, and plasma and mast cells, all of
which aid in the process of repair of the pulp.

During inflammation of the pulp, hyperemia and edema may lead to the accumulation of excess
fluid outside the capillaries. An imbalance of this type, limited by the unyielding enclosure, can lead
to pressure on apical vessels and ischemia, resulting in necrosis of the pulp. In most cases, if the
inflammation is not too severe, however, the pulp will heal since it has excellent regenerative
properties.

DIFFERENCES IN PRIMARY AND PERMANENT PULP TISSUES

Primary pulp: The primary pulp (pulp of deciduous teeth) functions for a shorter period of
time than do the permanent pulps. The average length of time a primary pulp functions in the oral
cavity is only about 8.3 years. This amount of time may be divided into three time periods—that of
pulp organ growth, which takes place during the time the crown and roots are developing; that
period of time after the root is completed until root resorption begins, which is termed the time of
pulp maturation; and finally the period of pulp regression, which is the time from beginning root
resorption until the time of exfoliation. The maximum life of the primary pulp including both
prenatal and postnatal times of development and the period of regression is approximately 9.6
years.

Permanent pulp: During crown formation the pulps of primary and permanent teeth are
morphologically nearly identical. In the permanent teeth this is a process requiring about 5 years.
During this time the tissues are highly cellular, exhibiting a high mitotic rate especially in the
cervical region. The young differentiating odontoblasts exhibit few organelles until dentin
formation begins; then they rapidly change into protein-synthesizing cells. The period of pulp aging
is much accelerated in the primary teeth and occupies the time from root completion to
exfoliation, or about 7 years, 5 months. Aging of the pulp in the permanent teeth, on the other
hand, requires much of the adult life span.

REGRESSIVE CHANGES (Age changes in PULP)

CELL CHANGES A. In addition to the appearance of fewer cells in the aging pulp, the
cells are characterized by a decrease in size and number of
cytoplasmic organelles.
B. The typical active pulpal fibrocyte or fibroblast has abundant
rough-surfaced endoplasmic reticulum, notable Golgi complex,
and numerous mitochondria with well developed cristae. The
fibroblasts in the aging pulp exhibit less perinuclear cytoplasm
and possess long, thin cytoplasmic processes. The intracellular
organelles are reduced in number and size; the mitochondria and
endoplasmic reticulum are good examples of this.
FIBROSIS A. In the aging pulp accumulations of both diffuse fibrillar
components as well as bundles of collagen fibers usually appear.
B. The increase in fibers in the pulp organ is gradual and is
generalized throughout the organ. Any external trauma such as
dental caries or deep restorations usually causes a localized
fibrosis or scarring effect. Collagen increase is noted in the
medial and adventitial layers of blood vessels as well.
C. The increase in collagen fibers may be more apparent than
actual, being attributable to the decrease in the size of the pulp,
which makes the fibers present occupy less space, and hence
they become more concentrated without increasing in total
volume.
VASCULAR A. Vascular changes occur in the aging pulp organ as they do in any
CHANGES organ.
B. Atherosclerotic plaques may appear in pulpal vessels.
In other cases the outer diameter of vessel walls becomes
greater as collagen fibers increase in the medial and adventitial
layers. Also calcifications are found that surround vessels.
C. Calcification in the walls of blood vessels is found most often in
the region near the apical foramen.
D. The capillary endothelium shows changes due to age. The
endothelium in the elderly shows numerous pinocytic vesicles,
 microvesicles and microfilaments. In addition lipid like vacuoles,
glycogen granules and many Golgi complexes are present.
E. Blood flow decreases with age.
PULP STONES A. Pulp stones, or denticles, are nodular, calcified masses appearing
(DENTICLES) in either or both the coronal and root portions of the pulp organ.
B. They often develop in teeth that appear to be quite normal in
other respects. They usually are asymptomatic unless they
impinge on nerves or blood vessels. They have been seen in
functional as well as embedded unerupted teeth.
C. Pulp stones are classified, according to their structure as true
denticles or false denticles.
D. True denticles are similar in structure to dentin in that they have
dental tubules and contain the processes of the odontoblasts
that formed them and that exist on their surface.
E. True denticles are comparatively rare and are usually located
close to the apical foramen. A theory has been advanced that the
development of the true denticle is caused by the inclusion of
remnants of the epithelial root sheath within the pulp. These
epithelial remnants induce the cells of the pulp to differentiate
into odontoblasts, which then form the dentin masses called true
pulp stones.
F. False denticles do not exhibit dentinal tubules but appear instead
as concentric layers of calcified tissue.
G. In some cases these calcification sites appear within a bundle of
collagen fibers. Other times they appear in a location in the pulp
free of collagen accumulations.
H. Some false pulp stones undoubtedly arise around vessels. In the
center of these concentric layers of calcified tissue there may be
remnants of necrotic and calcified cells.
I. Calcification of thrombi in blood vessels, called phleboliths, may
also serve as nidi for false denticles.
J. All denticles begin as small nodules but increase in size by
incremental growth on their surface. The surrounding pulp tissue
may appear quite normal. Pulp stones may eventually fill
substantial parts of the pulp chamber.
K. Pulp stones may also be classified as free, attached, or
embedded, depending on their relation to the dentin of the
tooth.
L. . The free denticles are entirely surrounded by pulp tissue,
attached denticles are partly fused with the dentin, and
embedded denticles are entirely surrounded by dentin. All pulp
stones are believed to be formed free in the pulp and later
become attached or embedded as dentin formation progresses.
M. The incidence as well as the size of pulp stones increases with
age. According to one estimate, 66% of teeth in persons 10 to 30
years of age, 80% in those between 30 and 50 years, and 90% in
those over 50 years of age contain calcifications of some type. A
 statistically significant relationship has been found between
patients with cardiovascular disease and presence of pulp stones.
DIFFUSE A. Diffuse calcifications appear as irregular calcific deposits in the
CALCIFICATIONS pulp tissue, usually following collagenous fiber bundles or blood
vessels .Sometimes they develop into larger masses but usually
persist as fine calcified spicules.
B. The pulp organ may appear quite normal in its coronal portion
without signs of inflammation or other pathologic changes but
may exhibit these calcifications in the roots.
C. Diffuse calcifications are usually found in the root canal and less
often in the coronal area, whereas denticles are seen more
frequently in the coronal pulp.
D. Diffuse calcification surrounds blood vessels.These calcifications
may be classified as dystrophic calcification.