SIsSlReDort

Pulp-dentin biology in restorative dentistry.

Part 1: Normal structure and physiology
Ivar A, Mjor, BDS, MSD, MS, DrodontVOdd B, Sveen. LDS, MS,
Karin J, Heyeraas, Cand Med Dent,

Considerable knowledge has accumulated over the years on the structure and function of the dental pulp
and dentin. Some of this knowledge has important clinical implications. This review, which is the first ol
seven articies, will be limited to those parts ot the normal structure and physiology of the puip and dentin
that have been shown to result in, or are likely lead to, tissue reactions associated with the clinical treat-
ment ot these tissues. Although certain normal structures will be highlighted in some detail, a basic knowl-
edge ot pulpal and dentinal development and structure is a prerequisite tor an understanding of this text,
(Quintessence tnt 2001:32:427-448)

Key words; dentin, dentinal tubule, odontoblast, pulp, tooth structure

I n countties where endodontics has been identified as

a specialty, and especially where it has been adminis-
tratively separated from teacfiing programs in restora-
knowledge will make it possible for tbe dentist to select
materials and methods tbat will produce no or favor-
able reactions in the tissues to optimally conserve dam-
tive and conservative dentistry, there has been a ten- aged teeth. It should also provide opportunities for new
dency to classify studies of dentin and pulp as hiologic approaches to restorative dentistry.
"endodontics," In diagnosing pain and attempting to
clinically predict the physiologic or pathologic state of
the dentin and pulp, endodontists depend on a thor- STRUCTURE OF THE PULP-DENTIN ORGAN
ough knowledge of the tissues. However, this diag-
nostic responsibility also extends to restorative den- Despite tbe differences in structure and composition,
tistry, including operative and conservative dentistry, pulp and dentin are integrally connected in tbe sense
Tbe treatment pbase of restorative dentistry is, or that pbysiologic and patbologic reactions in one of the
should be, more involved tban endodontics witb tbe tissues will also affect tbe otber. This close association
structure, function, tissue reactions, and potential beal- includes reactions to caries and common clinical pro-
ing capacities of dentin and pulp. All caries propbylac- cedures sucb as cavity or crown preparations and
tic measures and treatment phases of restorative den- restorative procedures. Not only do tbe two tissues
tistry sbould be considered "preventive endodontics," bave a common embryonic origin, but tbey also remain
To optimally acbieve tbis goal, clinicians working witb in an intimate relationsbip tbrougbout tbe life of the
dentin and pulp must bave detailed knowledge of nor- vital tootb, Anytbing tbat affects dentin will affect tbe
mal tootb structure; age-related cbanges; tissue pulp and vice versa, Tbe concept of a pulp-dentin
responses to caries, trauma, and restorative procedures; organ or a pulp-dentin complex is, tberefore, well-
and tbe effect of tbe application of different agents and founded and generally recognized. However, tbe con-
materials on tbe tissues. Knowledge of tbe biology of cept has been challenged by reference to the marked
the pulp and dentin, coupled witb an understanding of differences in cbemistry befween dentin and pulp,'
the materials and techniques applied to tissues, will Because tbis review will focus on restorative den-
provide a sound basis for restorative dentistry, Sucb tistry, it will be limited to the coronal and cervical part
of the pulp-dentin organ, recognizing tbat differences in
'Professor AcaOemy 100 Eminenl Scholar, Departmenl of Operative structure and pbysiology exist between pulp and dentin
Dentistry, University ol Florida, College of Dentistry, Gamesvilie, Fiorida; in the coronal and root parts of teeth, Tbe peripberal
NIOM, Scandinavian Institute of Dental Materiais, Hasium, Norway.
coronal dentin is covered by enamel, wbicb acts as a
^Associate Prolessor, Eastman Department of Oentistry, University of semipermeable memhrane,^'' It allows tbe permeation of
Rocfiesler, Scfiool of Medicine and Dentistry, Rochester, New York,
fluids, atoms, and smali molecules. Vital or cellular reac-
^Professor, Department of Physiology, University of Bergen, Faculty of
Medicine, Bergen, Non^ay.
tions do not occur in enamel, but pbysiocbemical reac-
Reprint requests: Dr ivar A. Mpr, NiOM, Kirkeveien 71B, PO BOX 70,
tions, sucb as ion excbange, take place. The interactions
Hasljm, N-1305 Norway. E-maii: [email protected] or imior@dentai,Ljfi,eiiu, between tbe minute liquid phase in enamel and tbat in

Quintessence InternatJonai 427

 Fig 1 Cells, interstitiai liuid, nerves,
and a capillaiy in the dentai puip Biood
enters the capiilary from the iarger ves-
Capillary seis as bulii tlow Diffusion iinks blooä
plasma and interstitial liuid. The cells
are surrounded by interstitial fiuid,
whioh acts as an extension of the
piasma. The normai hydrostatic pres-
sure in the intefstitiai liuid ot the puip is
about 5 to 20 mm Hg.

Nerves .^

dentin, which has a 12% water content by weight, have After odontoblasts have formed the primary dentin
not been established in detail, but they may be particu- artd the teeth have erupted, odontoblasts continue to
larly impotiant in the development of caries lesions. form dentin at a slow rate. This dentin is called physi-
All components of the dental pulp, including the ologic secondary dentin, and often it cannot be distin-
cells, blood and lytitph vessels, nerves, and the intersti- guished irotTi primary coronal dentin. It should be dif-
tial fluid, are important in the response to restorative ferentiated from localized masses of reparative,
procedures. Fibers are scarce in the pulp of the newly irregular, irritation, reactionary, or tertiary dentin
erupted tooth. Most celis are considered to be of an formed in response to localized stimuli of any sort, eg,
undifferentialed or immature type. They are abundant a caries lesion or a restorative procedure {Fig 3), All
in newly erupted teeth and have the potential to these tertns denote basically the same type of local
develop into specialized cells, eg, odontoblast-like additional dentin formed posteruptively,
cells. An interstitial fiuid surrounds the morphologic A distinction between the dentin that is formed by
elements (Fig 1), It is similar in composition to the primary odontoblasts and that formed by new,
plasma, but it contains less protein than plasma. The posteruptive, odontoblast-like cells or secondary
interstitial fluid is an important intermediary link odontoblasts"* may he clinically important. The local-
between cells, blood plasma, and lymph fluid. Pulpal ized tertiary dentin formed by surviving primary odon-
physiology under normal conditions, and especially tobiasts following a mild stimulus, such as attrition,
during inflammatory responses, is dependent on inter- has been referred to as reactionary dentin, while that
actions among cells, the blood and lymphatic vessels formed by a new generation of odontoblasts has been
of the pulp, the interstitial fluid, and nerves. These termed reparative dentin.'' Tbe dentin formed by odon-
processes may be regulated by various factors, includ- toblast-like cells is often irregular in structure, at least
ing the release of neuropeptides from pulpal nerves. the flrst formed tissue at the interface with the existing
dentin (Fig 3), A combination of reactionary and
reparative secondary dentin may he found in the same
CELLS OF THE DENTAL PULP specimen (Fig 4),
The important point in this context is that the pri-
The most prominent cells of the pulp-dentin organ are mary odontoblasts retain their ability to form dentin in
the odontoblasts (Fig 2). A singie layer of these cells vital teeth throughout the life of the tooth, and, if they
lines the peripheral part of the pulp, separating the loose are destroyed, mesenchymal precursor cells in the
connective tissue of the pulp from the predentin. Each pulp are able to differentiate into new, odontoblast-
odontoblast has an extension into a dentinal tubule, the like cells. These progenitor cells arc recruited from
odontoblastic process. Because of crowding of the odon- subodontoblastic cells and pericytes. In fact, an early
toblasts in the coronal portion of the teeth, especially in histopathoiogic reaction to procedures affecting the
pulp homs, they appear pseudostratiOed, Odontoblasts dentin involves an influx of cells into the subodonto-
are attached to each other by ¡unctional complexes. blastic cell-free zone.

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 liör et al •

Fig 2 Eiectron micrograph ot odonioblasts with two insets show-

ing light microscopy ot the odonlcblasiic area of a pulp removed
trom a tooth ttiat was opened immediately after the looth was
extracted The electron micrograph shows cytopiasmic organelies
including rough surface endoplasmic reticuium ¡RFR] Goigi com-
plex (G), mitiochondria ¡M], vacuoles (Va), vesicles (Ve] and
nuclei (N) Note the cell-free zone adjacent to cdontcblasts in the
left insel and remnants of torn odontobiastic processes in the nght
inset. ¡Electron micrograph; original magnification x 14 200' left
inset: hematoxyiin-ecsin slain, originai magnification x220' right
inset: toluidine blue stain, originai magnification x350 ]

Fig 3 (ieft; Tertiary dentin (TD] in a puip

horn as a response to attrition, mainly of the
reactive type. (Hematoxyiin-eosin stain, orig-
inai magnification xgo].

Rg 4 (right) Tertiary dentin (TD¡ in a pulp

horn showing continuily among Ihe tubules
in the primary Oentin (P], physiologic sec-
ondary dentin {SD), and tertiary dentin in
some areas (arrows). However, there is also
an area wilh celluiar inclusion (C], which
indicates that ihe primary odoniobiasts were
destroyed. [Hematoxylin-eosin stain; original
magnificaticn x220.)

Tertiary dentin formation, irrespective of type, repre- be particularly important because the tubules in the
sents an important defense mechanism and a regenera- two dentins do not directly communicate and therefore
tive property of the pulp-dentin organ. If the primary act as a barrier to ingress of agents from the dentin to
odontoblasts are destroyed, the new odontoblasts dif- the pulp,^ This "barrier effect" is a very important
ferentiate from undifferentiated celis that predominate defense mechanism in restorative dentistry.
in pulps from young individuals. The dentin formed The odontoblasts, being matrix-producing cells,
locally may vary in structure and composition (Figs 3 present all the characteristic organeiles associated
to 7), The tubules are often more irregular, the dentin with protein (primarily collagen) and proteoglycan
is less mineralized, and it may have a higher content of (ground substance) production (Fig 2), The activity of
organic material than does primary dentin {Fig 8), The the odontoblasts is reflected in the number and types
interface between the dentin formed by primary odon- of organeiles present in the cytoplasm. An abundance
toblasts and that formed by odontoblast-iike cells may of rough endoplasmic reticuium, a well-developed

Quintessence International 429

 • Mpr et ai

Frg 5 Microradiograph ot an undemineral- Fig 6 Reactionary dentiri with coniinuity between

ized section showing continuity oí ttie denti- tubuies in primary and secondary dehiin (lower fiaif)
nai tuüules trom primary to tertiary dentin. and reparstive dentin (upper hail) in near proximity to
Note tiie higher mineral content ot the bor- each other. Note the iack of continuity of ttie tubuies
der (H¡ between primary and tertiary dentin across the interface dentin (I) between primary dentin
{Original magnification X220.) (P) and tertiary^ dentin (TD]. (Hematoxyiin-eosin stain;
original magnitication x350 )

Fig 7 Demmeralized sections ot tertiary dentin (TD) Fig 6 Microraaiograph taken with uitrasalt x-rays
subiacent to a caries iesion. (P) Primary dentin. showing the distribution ot mass ot organic material.
(Hematoxylin-eosin stain: original magnitication x220.¡ Tertiary dentin (TD) contains more organic materiai (is
more radiopaque) than primary aentin (P], especiaily at
the border between primary and secondary dentin, cor-
responding to the dark (hematoxyphilic] band on the
stained section in Fig 7. (Original magnifioation x220.¡

Golgi apparatus, scattered ribosomes, mitrochondria, The odontoblastic process lacks the major organ-
vesicles, and vacuoles are all characteristic structures elles found in the cell body. Its ultrastructure is char-
associated with protciti synthesis. Microtubules and acterized by microtubules and filaments (Fig 10).
filaments are also seen. Evidence of collagen synthesis Occasional mitochondria and ribosome-like structures
by odontoblasts is seen as discharging cisternae at the may be present under normal conditions. When
cell membrane (Fig 9). enhanced peritubular matrk formatioti takes place, eg,

430 Voiume32, Numher 6, 2001

 Fig 9 Eleclron micrograph ol pan ol an odontoblast
showing peripheral i y located ciste rnae (Ci) with dis-
charging granuiar material (CF) Coiiagen tibers
(Original magnification x 18.500.]

Fig 10 (right) Electron micrograph ot an odonto-

blastic process (OP] passing Irom the predentin {PD¡
into the mineralized dentin (D). Microtubuies and line
filaments are the oniy types ot organeiles in this pad
of the process. (PS) Penodontobiastic space; (CF)
collagen tiber in the periodontobiastic space; (B)
branching ot odontoblastic process. (Original magni-
fication X30,000.]

following certain operative procedures, organdies The lack of cytoplasmic processes in the outer part
such as endoplasmic reticulum and mitochondria may of the tubules suggests that transduction mechanisms
be found in the odontoblastic process.' The odonto- for dentin sensitivity do not directly involve the odon-
blastic process in the predentin region exhibits cbarac- toblasts. However, the limited extent of the odonto-
teristics that reflect the transition from the cell body to blastic process does not exclude the most widely
the process, and the number of types of organeiles accepted theory, which proposes hydrodynamic move-
vary depending on the activity in the area. ment of fluid as a basis for dentin sensitivity," '^
Tbe extent of the odontoblastic process has long because that part of the tubule that does not contain a
been a controversial topic. Because the processes are cytoplasmic process will still be filled with tissue fluid.
lodged within the often more than 3-mm-long coronal The possibihlyi of differences in regulation of growth
dentinal tubules, it is hard to understand how the of the peritubular dentin in the crown and the root
odontobiasts can sustain tbe vitality of tbe process. must be taken into consideration. In the root, and espe-
Many investigations and much discussion have been cially in the apical region of teeth where the dentin is
devoted to the extent of the cytoplasmic processes in narrow, dentin sclerosis is typically found as transpar-
the dentinal tubules in fully formed teeth.*-'" Most ent apical dentin in teeth from old individuals. No such
investigations suggest that the cytoplasmic process complete sclerosis has been shown to occur in coronal
only extends about a third of the distance from pre- dentin, but localized areas of sclerosis frequently occur,
dentin to tbe enamel in normal teeth from young eg, subjacent to caries lesions. This sclerosis reduces the
adults. This finding indicates that vita! tissue changes permeability of the dentin and represents an important
in corona! dentin only occur in the pulpal third of the defense mechanism in restorative dentistry.
tissue. Changes occurring in the outer two thirds of The periodontobiastic space is a fluid-filled space
the dentin are likely either to be (lj of a physiochemi- located between the dentinal tubule and the cell wall of
cal nature by precipitation of mineral salts within the the cytoplasmic part of the odontoblastic process (see
tubules or (2) a growth of the peritubular dentin via Fig 10). This interstitial fluid continues beyond the
components secreted into the periodontobiastic space cytoplasmic part of the process and extends tbe full
at the vital, cytoplasmic part of the process. These length of the tubule, surrounding remnants of the odon-
components may diffuse peripherally to form a matrix toblastic processes found in peripberal circumpuipal
that will mineralize. dentin. It plays an important role when tissue changes

Quintessence internationai 431

 Fig 11 Nerve-iike structure (NF) in the perioaonlo-
biastio space (PS) in human dentin. (OP] OOonlo-
biastic process, (Original magnitioatJOn x19,000.)
[From Dahl and Mjor.^^' Reprinted wilh permission
from Tayior & Francis AS.¡

Fig 12 (right) Freeze-ffactured repiioa showing part

of an odontobiast (0) and a nerve liber (NF¡ crossing
the ceil diagonaily and one nerve fiber running aiong
the odontobiast (GJl Gap lunction vuith intimate con-
tact between the odontobiast and the nerve Inset
assists in orientation ot ihe nerve fiber and odonto-
biast. (Originai magnification X8,OOO. Courtesy of Dr
A. Koling.)

periodontoblastic space, Tbe hydrodynamic tbeory

helps to explain pain transduction in dentin," '^ It pos-
tulates tbat minute movements of tbe fluid in the
tubules initiate impulses in tbe nerve fibers.
Tbe predominant cells in the central part of tbe
pulp in newly erupted teetb are undifferentiated mes-
enchymai cells and ¡ibroblasts (Figs 14 to 16), Judging
by tbe scanty amount of organelles in tbe cytoplasm in
many of the cells (Figs 15 and 16}, tbey have a low
metabolic activity. They are irregularly shaped with
long cytoplasmic processes in the interstitial fluid of
tbe pulp. Collagen fibers are sparse, but tbey are found
mainly associated witb nerves and blood vessels. This
fiber-poor and ccll-ricb state is a cbaracteristic feature
Fig 13 Higher magnilication of gap junction (GJ) of tbe young pulp (Fig 17), but it cbanges witb age. In
between (wo odontobiasls [0). (Origmai magnifica- teeth of older individuals, a large fibrous component is
tion XI 80,000. Courtesy of Dr A. Köiing,)
present and tbe number of cells is low (Fig 18),
Clinically, tbis cliange is important because progenitor
cells are available to differentiate into otber cell types
occur within tbe primary dentin. It is witbin the peri- or to take part in reparative processes in tbe pulps of
odontoblastic space tbat the scanty matrix for tbe young patients and are less effective in tbe pulps of the
bigbly mineralized peritubular dentin is discbarged elderly. Age-related cbanges in tbe pulp nerves and
from the odontobiast or its process, blood vessels accompany tbe cellular changes,"
Tbe odontobiast and its process bave an intimate Otber cells of clinical importance in tbe dental pulp
relationsbip witb pulpal nerves (Pig 11), Nerve end- are macropbages (Fig 19), Tbey are seen in tbe normal
ings, sucb as gap junctions, have been sbown to termi- pulp, and tbeir numbers increase in association with
nate on tbe odontoblastic celi body'^ (Figs 12 and 13), pulpal injury. An occasional polymorpbonuclear
The sensitivity of tbe dentin may be ciosely associated leukocyte (Fig 20) may also be found in the normal
witb tbese nerve endings and tbeir presence in tbe pulpal tissue,'^'* Mast cells are not typically found in

432 Volume 32, Number 6. 200t

 Mjör et ai •

Fig 14 Fibrobiasts (FB) and unditterenti- Fig 15 Eiectron micrograph of an unditfer- Fig 16 Eiectron micrograpii of a fibrobiast
ated cells (UC) in the central part ot the entiated rnesenchyrnai ceii in the pjip The tram the central part cf the puip with reia-
pulp. (Toiuidine biue stain: 1-Mm-thici< sec- nucieus (N] occupies the main part of the tiveiy iarge nuciei (N) in reiation to the cyto-
tion; originai magnification x 1,400.) ceii, and iew organelies may be discerned piasm, which contains few organeiies. Note
in the cytopiasm. Note the laige number of the large number of cytoplasmic processes
oytoplasmic processes (CP) and the lack of (CP) and the scarcity ol cciiagen fibers
coilagen tibers. (Originai magnitication (CF). (REi^) Rough surface endcpiasmic
X 13,000. From Dahl and tuljör.^' Reprinted reticulum: (G) Goigi complex; (Va) vacuoie;
with permission from Tayior & Francis AS.) (Nu) nucleolus. (Originai magnificaron
X 13,500.)

Fig 17 (left) Tissue in the centrai part of

the puip in a newly erupted tooth Note the
iarge number of ceiis. (BV) Blood vessei
(Hematoxyiin-eosin stain; originai magnifica-
tion x350 )

Fig 18 fr/gfiîj Tissue in the centrai pan of a

puip frcm a 67-year-old individual. Few ceils
are found. (BV) Biood vessei (Hematoxyiin-
eosin stain; original magnification K350,)

Quintessence internationai 433

• IV1|ör e t a l

Fig 19 Lidc:iu I iricijgiapi" •:•( r. ma;"irj,ihagí; with dark intra-

cytopiasmic granules in a normal pulp (N) Nucleus (Original
magnification X13,000,)

Fig 20 (rigi^t) Electron micrograph of a neutrophilic leukocyte

with multilobulated nucleus (N] in a noimal pulp. Note the numer-
ous dark intracytoplasmic granuies. (Originai magnification
X I t,000.]

Fig 21 Dendriiic celis in the odontobiastic Fig 22 Dendritic cell in the cdonloblasiic Fig 23 Perivascuiar denfliitic cells sur-
region. The dendrific ceils are visuaiized by region demonstrating specific antibody rounding a blood vessei in the centrai part
immunohistochemistry using human leuko- reaction (green fluorescence) and axons of the pulp. The ceils are visuaiized by
cyte antigen (HLA]-DR, (0] Odontoblasts; with immunoreactivity tc calcitcnin gene- immunchistochemistry using anti-HLA-DB
(D] dentm, (Originai magnification x70. related peptide (red fluorescence]. The antibodies. (Originai magnification >c62,
From Jonteil M. et a l . " Reprinted with per- ciose association between the dendritic ceil Courtesy of Dr T, Okiji,)
mission from Crit Rev Oral Biol Med.] and the nerve fiber is revealed as yellow
areas. (Original magnification X36O, From
Jonteli M, et al, interaction between perivas-
cuiar dendritic ceiis, neuropeptidss and
endolhelial cells in déniai puip. in: Shimono
M, et ai (eds), Dentin/Puip Complex, Quin-
tessence, 1996:182-187, Reprinted wifh
permission,)

434 Volume 32, Number 6, 2001

 • Mjör et ai

the normal pulp, but they become abundant during tion of capillaries (Fig 26). All these characteristics of
pulpal intlatnmation, the blood vessels in the pulp have a physiologic func-
A number of immunocompetent, dendritic cells tion. They facilitate the exchange of nutrients and
in the dental pulp expressing macrophage-related waste products between the interstitial tissue fluid and
phenotypes have been demonstrated by itntnunohisto- the blood plasma. This exchange is particularly impor-
chemical methods"; some are located near the odon- tant at the time of injury, including operative proce-
toblasts (Figs 21 and 22) and others tnore centrally dures, trauma, and earies lesions affecting the pulp.
located in the putp (Fig 23). These eells can induce Lytnphatic vessels transport fluid out of the pulp and
lymphocyte T-cell proliferation. They increase in play a role in maintaining the fluid balanee.^'
number during inflammation and may play roles in
repair processes in the pulp and immunologie defense Interstitial tiuld pressure
reactions.
Tbe interstitial ñuid pressure in tbe pulp is relatively
bigh,^^---' and it plays a role in the sudden pain experi-
PHYSIOLOGY OFTHE PULP-DENTIN ORGAN enced when a eavity preparation reaches unaffected
dentin. The exposure of dentin causes sudden move-
From a functional point of view and especially in rela- ment of the contents of the tubules, leading to activa-
tion to restorative dentistry, dentin and pulp are inte- tion of nerves adjacent to the odontoblasts and result-
grated to an extent that they should be regarded as ing in pain.-'*''' The fluid flow from the pulp to
one tissue or organ. The interstitial fluid of the pulp exposed dentin is dependent on the hydraulic conduc-
and the dentinal tubules form a continuum that tivity of the dentin fluid. A certain threshold has to be
extends from the dentinoenamel and cementodentinal reached to activate the nerve tertninals at the puipai
¡unctions to the central parts of the soft connective tis- ends of the dentinal tubules and close to the odonto-
sue in the pulp. Hydrodynamic effects and fluid shifts blast layer.^' Any reduction in conductance will reduce
are, therefore, important under normal and pathologic the dentin sensitivity, eg, by growth of peritubular
conditions and they will affect the pulp-dentin organ. dentin, occlusion of the tubules by mineral precipita-
tion, adsorption of organic materials in the tubules, or
The mere cutting of dentin, as it occurs during eavity by hypermineralization of the surface dentin. The for-
and crown preparations, will result in a number of mation of atubular dentin at the interface between pri-
reactions in the pulp and the dentin. mary or secondary dentin and tertiary dentin will also
reduce the conductivity of dentin fluid.
Vascularity of the normal puip

Arterioles enter and venules and lymphatics leave the Werve impuises in pulp and dentin
dental pulp through the apical foramen or foramina.
Vessels also enter and leave the pulp via accessory lat- Myelinated and untiiyelinated nerves (Fig 27) enter
eral canals, which may be located anywhere on the the pulp through the apical foramen or foramina and
root but are most commonly found in the apical through accessory canals. They mainly follow the
region.'* Relatively large arterioles pass through the blood vessels as they branch and form a network of
root pulp to supply the eoronal pulp (Fig 24). They terminal endings in the odontoblastic-subcdontoblas-
branch and terminate as capillaries (Figs 25 and 26), tic region (Fig 28) and in tbe periodontoblastie spaces
which are particularly abundant in the coronal sub- of dentinal tubules (see Fig ll).^*"'^'
odontoblastic region'^ (Fig 24), It is clinically impor- Myelinated A fibers and nonmyelinated C fibers are
tant to recognize that many of the capillaries in the somatic afferent nerves that earry pain impuises.
pulp are largely nonfunctional in the normal pulp (Fig Unmyelinated efferent nerves from the sympathetic ner-
26). Because the capillaries are already present, the vous system are more sparse. Bolh the sensory and the
blood flow to specific areas can be increased quickly; sympathetic nerve endings may terminate in the walls of
ie, local and general hyperemia in the pulp can oceur blood vessels in the main pulp, and they are associated
almost instantaneously without requiring the ingrowth with vasomotor control (Fig 29]. They are activated at
of new capillaries. an early stage in the inflammatory process and are, in
The structure of biood vessels in tbe pulp is basi- fact, the initiators of vasodilation, which starts the pro-
cally similar to that in other organs, but the blood ves- tective response to injury by increasing blood volume
sels are thin-walled both in absolute dimension and in and vascular pertneabilily in the affected area. A num-
comparison to the size of the lumen.^" Clinically ber of neuroreactive peptides have been demonstrated
important structural characteristics include disconti- in pulpal nerve endings, including neurokinins, sub-
nuities in the endothelial walls (Fig 25) and fenestra- stance P, and ealcitonin gene-related peptide (CGRP).

Quintessence international 435

 Fig 25 Electron micrograph ot a capillary in tfie pulp
with a red blood cell in the lumen. The endolhelium of
the capiilary waii is discontinuous in one area (X).
(PCI Pericyte; (BL] basement lamina. (Originai mag-
nifioation X14,000.]

Fig 24 Vascuiarity ol the pulp. A monomer is injected into Fig 26 Eieotron micrograph of a nonfunctionai capii-
the apicai blood vesseis and polymerized. The tooth is then iary in the dentai pulp. (N] Endotheliai ceil nucieus; (F]
demineralized, and the organic components are digested fenestration cf endotheiial wali; (L] lumen of capillary;
away, allowing examinalion of the "vascular tree." (0) (BL] basement iamina. (Original magnitioation
Odontoblastic region; (V] venule; (A) arlenole. (Original xl2,000. From Dahl and Mpr.™ Reprinted with permis-
magnification x900. Courtesy of Dr K. Takaheshi.] sion from Taylor & Francis AS.)

Both the sympathetic nerve fibers and the sensory Because nerves play a central role in tissue
flbers have eftects on the pulpal circulation. The num- responses in the pulp, teeth from older individuals are
ber of nerve fibers and the associated neuropeptides less li!ie!y to show reparative processes than are teeth
decrease with age, which explains the reduced sensitiv- from young individuals. Nerves may also have an
ity of teeth in adults and older individuals. Ultra- effect on odontoblasts^" and on dentinogenesis,^' It
structural changes as well as changes in the expression has been suggested that some nerve fibers that termi-
of some neuropeptides have been demonstrated in the nate in the dentinal tubules may be branches of the
cat." Degeneration of axons and demyelinization same nerves that terminate in tbe wall of blood ves-
occur, and immunohistochemicai studies have sbown a sels." Such a dual effect would be an excellent
decrease in CGRP and substance P. These age-related preparatory defense mechanism, ie, an axon reñex. It
changes resuit in botb reduced pulpal sensitivity and may also explain the difticulties in locahzing pulpal
probably altered hemoregulation of the pulp. pain.

436 Volume 32, Number 6, 2001

 M|or et al

Fig 28 Section from a human ,pulp, Fig^ 29 Cross section ol biood vesseis (BV)
immunoiabeied
_ with ant"^""""
,. th antiserum "••^IQÍ- I-."""
iserum protein gene in the
he puip
pu sfiowing sensory nerves in in the
producl 9,5 to iilustrate the complete ilete pulpal vessei wail. The dark libers are ner nerves
iii:i>.c iiLicia QIC t;in,,iui,Bu uy iiripoivainjiI. (D) L/ciiiiii.
ipnefvation. i^ui Dentin. luilyiiiQi
(Originai magnifica- showing
s h o w i n g immunoreactivity
i m m u n o r e a c t i v i t y to
to csicitonin
caicitc
Scfiwann cell c y t o p l a s m . (N) N u c i e u s of 'iion
• " • X250.
^"==1 Courtesy
'^—•— of
- i Dr
n , ii. LJ
H. Kvinnsiand.)
L gene-related peptide. (Originai magnifica-
Schwann ceii. (Original magnification tion XI50,)
x13,000. From Dahi and Mjor^^ Reprinted
with permission from Tayior & Francis AS,]

Nerve activity in tbe pulp can be modified by anes- It has been repeatedly pointed out over the last 150
thetic solutions and epinepbrine,'^^"' wbicb may years that fluid movements in the dentin may transmit
decrease tbe release of neuropeptides. Even epinepb- impulses tbat stimulate nerve endings on odonto-
rine in gingival retraction cord may diffuse across blasts,'"' The experimental evidence for tbe prevailing
the full thickness of root dentin, at least in vitro," bydrodynamic tbeoiY of dentin pain has come from a
Eugenol, known for its sedative effect on pulpal pain, series of in vivo and in vitro experiments by Bränn-
has been sbown to have an inbibitory effect on sen- ström and coworkers,"'*' Coid stimuli were found to
sory nerve action,'*'" It also depresses tbe vasocon- be more painful tban bot stimuli,'" •'^ probably because
strictor responses to epinepbrine and otber vascular of the outward fluid ffow tbat results from sbrinkage
stimulants,^^ of tbe contents of the tubules wben cold is applied,
Pain of short duration is commonly noted when a Wben beat is applied, tbe contents of tbe tubules
clinician first drills tbrougb the enamel and into expand and an inward ffow occurs. Agents tbat pre-
dentin, especially in young patients. Attempts to vent tbe serum albumin ffux across exposed dentin
demonstrate nerve fibers in tbe peripberal dentin have may eliminate or reduce dentin pain,-*^
not been successful, and for a long time it was Pulpal pain is cbaracteristically pulsating, long-last-
believed tbat this observation was due to inadequate ing, and of variable severity, sometimes excruciating. It
methods for demonstration of nerves in dentin,^'' It is also affected by cbanges in blood pressure to tbe
was also believed tbat tbe odontobiast, via the odonto- bead. Typical dentin pain is sbort-lasting, sbarp, and
blastic process, may have tbe ability to act as a sensory may be described as lancinating.
receptor. However, it is considered unlikely tbat tbe
same ceil could bave such diverse, specialized func-
tions as dentinogenesis and sensory reception. STRUCTURE AND PHYSIOLOGY OF DENTIN
Furthermore, it is now generally accepted tbat tbe
odontcblastic process does not extend for more than Tbe mineralized component of the pulp-dentin organ is
about a tbird of the distance toward the enamel and a unique tissue traversed by tubules 1 to 2 pm in diame-
that sensations in dentin are based on bydrodynamic ter, Tbe dentinal tubules in the coronal part of tbe tootb
concepts of fluid movement. extend from tbe enamel to the pulp and are 2,5 to 3,5

Quintessence internationai 437

Mjör el ai •

Fig 30 Scanning eiectrcn micrcgrapii showing

cross-seotioned, fractured dentinal lubuies. (PT)
Peritubuiar dentin, (ID) intertubular dentin. (Originai
magnification x 4,000.)

Fig 31 (rigfit) Microradiograph of dentin from a

newiy erupted tooth showing dentinal tubules as
blaoii, circuiar areas. No highiy mineralized peritubu-
iar dentin is present in the most puipai part of the
dentin, funher peripheraily, peritubulaf dentin borders
most tubules, (inset) Cross-sectioned dentinai
tubuies representative of those in the buik of coronai
dentin. (PD) Predentin area (biack and radioiucent);
(PT) peritubular dentin (white and radiopaque).
(Original magnification X440.)

mm long. They harbor the odontoblastic process or they A gradual development of peritubular dentin occurs
contain the remnants of the processes and tissue fluid. in locations where it is not developed as a primary
The tuhules have a highly mineralized lining, the per- structure, le, in the most pulpal part of coronai dentin in
itubular dentin, along most of their length (Fig 30), The newiy erupted teeth. The continuous growth of the peri-
peritubular dentin is formed as a primary structure in tubular dentin in the main bulk of the dentin as an age-
tbe main part of the coronal circumpulpal dentin; ie, it is related change or for other reasons, eg. due to restora-
formed as a highly mineraiized structure during dcntino- tive procedures, leads to obturation of tbe tubules.
genesis.-''' Highly mineralized peritubular dentin is not Furthermore, nerve fibers extend a short distance into
found in the most pulpal part of the dentin in newly the periodontobiastic space (see Fig 11) of many tubules
erupted teeth (Fig 31), This feature is important in in the crown." They play a significant role in dentin
restorative dentistry, hecause the main part of a deeply hypersensitivity reactions and could also have a regula-
prepared tooth in a young individual will comprise cyto- tory function on the growth of peritubular dentin. In
plasmic material rather than tnineralizcd dentin matrix. addition, the periodontobiastic space is also the likely
In fact, as much as SO^/o of the pulpal floor of a prepara- location for any physiologic changes in the primary
tion may be made up of tubular openings. dentin associated with restorative procedures. The tissue
The highly mineralized peritubular dentin can eas- fluid in the tubuies in peripheral dentin will play a role
ily be distinguished from the other mineralized com- in any physiochemical reactions that may take place.
ponent of dentin, the Iniertubular dentin {Figs 30 and Occluded dentinal tubules, referred to as dentin
31). It contains little collagen, while the intertubular sclerosis, will react differently to acid etching than will
matrix has a dense collagen matrix. The intertubular unaffected dentin. This condition causes differences in
matrix is crisscrossed by numerous branches of vari- the collagen mesh when exposed to acid etching. The
able sizes frotn the tubules (Figs 32 and 33), Anasto- etehing time may have to be modifled to provide an
moses also occur between the branches-*^-"^ (Fig 34), adequate hybrid layer of collagen and resin,""^ The
The numher of tubules per square millimeter and type degree of wetness of the hybrid layer is important for
of branching vary depending on the location in coro- the resin penetration into the collagen mesh,"*' Differ-
nal dentin (Table 1). The further apart the tubules are, ences in wetness because of differences in the tubule-
the more branching is found,''^ intertubule ratio and different degrees of obturation of

438 Volume 3?, Number 6, 2D01

 • Mjör el ai

Fig 32 Scanning electron micrograph showing lon- Fig 33 Scanning eieciron micrograph showing a
gitudinally fractured, undemineralized dentinal longifudinally seolicned dentinal tubuie Irom a de-
tubules (DT]. Nofe fhe openings for side branches mineiaiized tooth with remnants of the odontcblastic
inside the tubules, (PT) Peritubular denlin: (iD) inter- process (OP) and its many side branches (B]. (ID]
tubular dentin. (Original magnificafion x5,000.] Intertubular dentin with numerous holes thai house
the branches of the odontoblastio procesa, (Original
magnification x5,000.]

TABLE 1 Approximate number of dentinal tubules

per square mjllimcter in coronal human teeth in four
locations at three different levels'

Location
Level' Occlusal Guspal Middle crown CEJ
Oufer 8,000 20,000 10,000 10,000
Middle 32,000 36,000 32,000 29,000
inner 5S,000 58,000 43,000 48,000
•Dala frorr Mpr and Nordahl."'
'ÜLter denlir (250 [im from the enamel), rniddle derlin, and inner dentin
(50 |im from Ihe preden(in).
CEJ - cementoenamel lunclion

Fig 34 (ieft) Anastomosing branches (B) between denfinal

tubules located centraiiy in coronal dentin. Ground section.
(Original magnification x400.]

the tubules on the same prepared surface'" cannot be Interface dentin^ with irregular, often atubular dentin
controlled clinically. forms a barrier between the physiologic secondary
The permeability of dentin is an important property dentin and the tertiary dentin (Fig 35), This barrier,
Ihat will influence the extent of pulpal reactions in which corresponds to the "hyahn zone" of the "dead
many ciinical situations,'"' Dentin permeability varies tract,"" reduces the permeability of the affected dentin
with the age of the tooth, the degree of mineralization and may make it impermeable because the tuhules from
of the tubules, tissue changes in the dentin, the loca- primary dentin do not cross the interface dentin. This
tion within the dentin, the tubule-intertubule ratio, type of reaction is impottant for protection of the pulp.
and anything that reduces the conductance of fluids The number of tubules in a given area is dependent
within the tubules. The great variation in the number on the location within the dentin. In coronal dentin it
of tuhules and the type of branching in different loca- varies from about 8,000 to 58,000/mm2 {see Table 1),
tions of coronal dentin is also likely to result in These differences are important in the evaluation of
marked differences in permeability. biologic reactions to restorative procedures. The lowest

Quintessence International 439

• Mjör e l ai

Fig 35 Interface dentin (I) between pnmary (P) and Fig 36 Typioai major brancnes (B] ot ctentinal
(eparative tertiary dentin (TD). Note tiie irreguiar tubuies in coronai dentin near tiie enamel, (tviasson
structure, inciuding celluiar inclusions (C]. ot tiie stain, demineraiized section, original magnitication
interface dentin. (O] Odcntoblasts. (iHematoxyiin- XI,000.]
eosin stain; originai magnification x220.]

number of tubules is found peripberally and especially Dentin in the cervical area of the tooth at the
in areas beiow ocelusal fissures, and tbe bighest num- cementoenamei junction is usually covered by eemen-
ber of tubules is at the pulp horns and at the pulpal tum, but eementum may be missing in this location in
surface under the ocelusal surface. The degree of wet- some teeth. If Hertwig's epithelial root sheath does not
ness of exposed dentin is also dependent on the tubuie- disintegrate to allow contact between root dentin and
intertubule ratio. The more open tubules per square the dental follicle, eementum will not form. If the tooth
millimeter, the wetter the dentin. This relationship is later supererupts, or if the 50- to lOO-i^m-thin cervical
important for resin adhesion to dentin. eementum is worn off, the cervical part of the root
The marked variations in the number of tubules per dentin will be exposed to the oral environment. In
square millimeter have several clinical implications. both instances, this exposure of dentin may lead to
The ratio of tubules to intertubular dentin on the pul- hypersensitivity.
pal wall of a preparation, for example, will be notably The cervical area is also particularly important
different in deep and shallow cavities; consequently, clinically because the cavosurfaee margins of restora-
the vulnerability of the pulp will differ. This ratio will tions are often located below the cementoenamei
also be affected by the age of the tooth, because occlu- junction. The difference between root and crown
sion of tubules by peritubular dentin growtb will dentin-'^ is fairly sharply delineated (Figs 38 to 40),
reduce or even eliminate the lumen of tbe tubules. The structure of the eementum and the dentin below
Branehing of dentinai tubules differs, depending on the cementoenamei junction may form an inferior type
the location within the tooth,''* and it is likely to have a of hybrid layer after acid etching because of the laek of
profound effect on certain clinical procedures, notably or low number of tubules and tubule branches^' (Figs
those associated with adhesive dentistry. In coronal 38 and 40). This situation may predispose the restora-
dentin, the most characteristic branehing is found in tion to leakage, washout of eement, accumulation of
the peripheral 250 pm, where the typical Y-shaped ter- plaque, and possibly development of secondary earies,
minal hranches are found (Fig 36), These branches are Tbc laek of terminal branebes and tubules in tbe most
relatively large, approaching 0.5 to 1.0 pm in diameter. peripheral dentin in the cervical area and the presence
The other type of branches that predominate in coro- of aceflular eementum will result in a relatively thin
nal dentin are mierobrancbes (Fig 37). They are only hybrid layer, which may not provide good microme-
50 to 100 nm in diameter and may be more important chanical attachment of resin-based restorative materi-
for pbysiologic changes in dentin than for adhesion als or luting eements.
arising from penetration of resin materials. Fine
brancbes, 300 to 700 nm in diameter, are predomi- Variation in mineralization
nantly found in the root dentin, but they may be found
anywbere the density of tubules is low, eg, subjacent to The bulk of the eircumpulpal coronal dentin is fairly
fissures in molar and premolar teetb and in cervieal evenly mineralized" (Fig 41), Two locations are less
dentin at or below the neck of the tooth. mineralized than the rest: (1) the mantle dentin adjacent

440 Voiume 32. Number 6, 2001

Rg 37 Scanning eieotron nnicograph ot fractured dentin showing
a mcrobranch (MB] running from a lubule in coronal dentin. This
type ol branch can be found anywhere in dentin but is frequently
present in areas wfiere the tubules are wide apart. (PT) peritubular
dentin. (Originai magnification x17,O0O.]

Fig 38 (ngiit) Cervical area of a tooth showing the cementoe-

ramel ¡unction (CEJ) and adjacent structures. (D) Dentin, (AC)
acellular oementum; (PL] periodontal ligament. {Hematoxylin-
eosin stain; onginal magnification x350.]

Fig 39 Higher magnification of the peiipherai dentir i .-I <z:ywiä Fig 40 Higher magnification of the peripheral dentin just below
lo the eementoenamel lunotion. Note the prese.ncc nf rntiojr the cementoenamei ¡unction. Note the iack of tubuies and major
blanches, simiiar to those shown in Fig 36 (Hematoxyiin-eosin branches in the peripheral dentin compared to the structure ot
stain; original magnification XI,000.] coronal peripheral dentin in Figs 36 and 39. (D) Dentin; (C) cemen-
tum. (Hematoxyiin-eosin stain; original magnification XI.000.]

to the enamel and (2) a zone 150 to 200 jun wide at a A differential staining pattern corresponding to the
variable distance from the dentin-predentin border, iess mineralized zone near the predentin is found if
depending on the age of the tooth, ie, on the thicimess demineralized sections of teeth from young individuals
of the physiologic secondary dentin. This zone is limited are stained for glycosaminoglycans." Tbe dentin stains
to the coronal dentin, and it remains throughout the life more intensely than the main part of the dentin in two
of the tooth. The relatively low degree of mineralization areas (Figs 42 and 43). The stained area at the pre-
of the mantle dentin is important for the clinician to dentin border is due to intense staining of the inter-
keep in mind when a possible spread of caries lesions at tubular matrix (Hg 44), and it may reftect the mineral-
the dentinoenamel junction is considered.'"* ization of the intertubuiar area during physiologic

Quintessence International 441

Ivljür el al •

Tbe nature and significance of tbe less mineralized

band of dentin located a sbort distance from tbe coro-
nal pulp is not clear. It may represent tbe dentin
formed during tbe 3 to 4 years after the crown is fttUy
formed wbile it remains in tbe ¡aw prior to tooth erup-
tion, Tbis band of less mineralized intertubular dentin
also lacks higbly mineralized peritubular dentin linitig
tbe tubules as primary structures (see Fig 31), It may be
an especially vulnerable part of the dentin in teeth of
young individuals during restorative procedures
because tbe tubulc-intertubule rafio is higb. It is also a
particularly reactive area witb a higb water content
tbat is difficult to control during tbe formation of the
bybrid layer witb adhesive restorative tecbniques. The
peripberal part of tbis less mineralized zone represents
a mineralization front in primary dentin that may be of
clinical significance in tbe use of restorative materials,'
After tbe tootb bas erupted, pbysiologic secondary
dentin with a normal degree of mineralization forms
slowly but without bigbly mineralized perituhular
Fig 41 Micrcradiograpli of a grcund section oí a dentin as primary structures, Peritubular dentin may
newiy erupted iooth, The main part of the circumpui- form later as an age-related change or as a result of
pai dentin is evenly mineralized, but the mantie caries and restorative procedures.
dentin (MD) close to the enamel (E) and a daik,
broad zone (Z) of coronal dentin ciose to the puip are Growtb factors are present in the dentin matdx,^^'''
iess mineraiized Ihan the buik of the dentin. These Release of these growth factors as a result of clinical
areas of iess mineralized dentin are limited tc coronai procedures or in association with the development of
dentin (dotted line) Border between the root and the
crown of the tooth. (CEJ) Cementcenamei ¡unction. caries lesions may have important biologic effects on
(Originai magnification xi2,) the healing processes by acting as signaling mole-
cules,^^'^^ Growth factors may also be liberated during
tbe demineralization associated witb caries lesions in
secondary dentin formation, Tbe stained predentin dentin,^'' Identification of tbese bioactive molecules
area is variable, possibly reffecting an incremental pat- higbligbts tbe intimate relationship between cellular
tern of mineralization. The broader stained zone fur- behavior and the matrix secreted by these cells. It is
tber peripherally corresponds to tbe outer part of tbe possible that these bioactive molecules will play an
less mineralized, dark zone seen microradiograpbi- important role in mediating the pulpal responses to
cally (Fig 41), Tbe contents of tbe dentinal tubules are injury, cavity and crown preparation, and restorative
beavily stained in tbis zone (Figs 45 and 46), probably procedures,"' and they may provide the basis for new
reffecting activity witbin tbe tubules at tbe location biologic approacbes to dental tissue repair,
where bigbly mineralized peritubular dentin will form Interglobular areas are poorly mineralized or
as secondary structures, unmineralized islands in the primary denfin, and they
Tbus, two mineralization fronts are found in coro- may be found anywhere in coronal dentin. They are
nal dentin of newly erupted teetb, one at tbe pre- frequently found subjacent to pits and fissures and at a
dentin-dentin interface dealing witb secondary and short distance from the mantle dentin. Their signifi-
possibly also tertiary dentin formation (Fig 47), Tbe cance in restorative dentistry has not been established,
more peripbcrally located mineralization front is not but they may influence the transport of nutrients
as well defined as tbat at tbe predentin-dentin border, within the dentin or have an effect on the reactivity or
but it is considered to reflect peritubular dentin forma- progression of caries lesions in the fissue.
tion as secondary structures in newly erupted teeth, Tbe cuspal and incisai areas of dentin have some
Botb are important for tissue cbanges in denffn associ- characteristic structural features that may be impor-
ated witb restorative dentistry. In teetb from adults, tant in restorative dentistry, especially in relation to
the two intensely stained zones are close togetber (Fig Class IV lesions. Central areas of unmineralized
48), indicating tbat in pbysiologic secondary dentin dentin (Fig 49) may give the cuspal-incisal area a
formation, tbe mineralization of tbe peritubular dentin unique microradiographic appearance. Depending on
does not lag far bebind that of tbe intertubular matrix the position of the section tbrougb the cusp, this
at the predentin border. denfin may appear hypermineralized and bordered by

442 Volume 32, Number 6, 2001

 Z3

Fig 42 Section oí a demineralized, intac! premolar from a 13- Fig 43 Sect,or, of a demineralized, intact piemoiai frcm â ";3-
year-old individual. The two intenseiy stained bands (Z1 and Z3) year-cid individuai. This section shows a zcned staining pattern in
in the coronai dentin oorrespond to tiie microradiographic appear- coronai dentin. Two bands (Zt and Z3) are stained mere intensely
ance (Fig 47) Band Z1 is at the deniin-predentin border Band Z3 than is the rest of the coronal dentin, like those seen in Fig 42, and
corresponds to the periphetal aspect of Z in Fig 41. (Toiuidine they correspond to the zones with different degrees of mineraliza-
ßlue stain; original magnification XtC.) tion, seen in the pulpal part of the dentin in Fig 41. (Aician blue
stain; original magnification xtQ )

Fig 44 iHigher magnification of the dentin-predentin area, corre-

sponding to Zt in Fig 43, showing cross-sectioned dentinal tubuies
The intenubular matrix stains intenseiy in Z l , whiie further peripher-
aily it is unstained. (Aician blue stain; originai magnification x100)

Fig 45 Higher magnification of the area corresponding to Z3 in Fig 46 Tü-jiöino biue-stained {left) and aician biue-siamed
Fig 43, showing cross-sectioned dentinal tubules. The contents of (rigiit) seciions showing longitudinaiiy sectioned dentinai tubuies
the tubules stam intensely, but the intertubular matrix is virtualiy corresponding to Z3 in Figs 42 and 43. Note tfie granular appear-
unstained, (Aician blue stain; originai magnification x260 ) (Frcm ance of the contents of the tubules in this iocation. (Original mag-
Miaras Reprinted with permission from Eisevier Science.) nification X260.) (From M|ör.« Reprinted with permission irom
Eisevier Science,)

Quintessence Internationai
443
 Fig 47 (left) Diagram showing relationship between a stained,
demineraiized section (top) and Ihe microradiographic appear-
anee of a ground section (bottom) The encircied detail from each
zone sfiows details of the denfinai tubules and the intertubular
matrix in the respective areas. The sfainaDie components of the
dentin denote fhe stainabiiify of the corresponding areas in aiciar
biue- and toluidine blue-stained secfions. The variation in gray-
ness in the microradiographic appearance reflects differences rn
Ihe degree of mineralization.

Fig 48 (beiow) Demineraiized section of a looth from a 71-year-

old individual. It appears as il the two zones, Z1 and Z3, seen in
newly erupted teeth (Fig 43) have merged into one stainable area
from the predentin (PD) and peripherally for a short distance
(Original magnification xio.)

Fig 49 Dc tl e cu pal 1 p ^f a r Fig 50 Microradiograph ol an intact incisor Fig 51 Microradiograph of a worn incisor
moiar. Predeniin-iike lissue (PD) extends showing a narrow band of hypermineraiized showing a streak of hypeimineralized denlin
OCClusally. (PH) Pulp horn, (Originai magniti- dentin (D1) bordered by two narrow (DI) in the incisai area iined by hypominer-
cafion X90.) hypomineraiized bands (D2) in the incisaf aiized bands of dentin (D2), The area of
region, (E) Enamei, (MD) manfle denfin. attrition is iarger than thaf corresponding to
(Originai magnification X12, Courtesy of Dr the hypermineraiized denfin, (E) Enamei;
L, Tronstad ) (MD) mantie dentin. (Original magnification
x12. Oourtesy of Dr L. Tronstad.)

444 Volume 32, Number 6, 2001

hypomiiieralized dentin even in intaet teeth from 5. Smith AJ, Cassidy N, Perry H, Bègue-Kirn C, Ruch J-V,
young individuals (Fig 50), These particular structural Lcsot H, Reactionary dentinogenesis. Int | Dev Biol 1995;
characteristics may represent a vestigial extension of 39:273-280.
pulp horns into the cuspal and incisai region. They are Í. Mjör IA. Dentin and pulp. In: Mjör IA |ed). Reaction
Patterns in Human Teeth Boca Raton, FL: CRC Press,
normal variations in structure, and they are not associ- 1983:63-156.
ated with ehanges caused by attritioti^- (Fig 51), They
7 Furscth R, Mjör IA. The fine structure of curtieosteroid-cov-
may represent vulnerable areas during treatment of ered dentine. Arch Oral Biol 1972;17:719-728.
fractured incisors and in the development and treat- 8. Holland GR. The extent of the odontoblast process in the
ment of Class IV iesions because of the apparently cat. ]Anat 1976:120:135-149.
easy access to the pulp. 9, Byers MR, Sugaya A. Odontoblast processes in dentine
revealed by fluorescent Di-I. | Histochem Cytochcm 1995;
43:159-168,
CONCLUDING REMARKS 10. Yoshiba K, E¡iri S, Yoshiba K, Iwaku M, Ozawa H.
Distribution of odontoblast processes in human coronal
dentin. In: Shimono M, Maeda T, Suda H, Takahashi K
A biologic approach to restorative dentistry requires (eds). Dentin/Pulp Complex. Tokyo: Quintessence, 1996:
knowledge of the normal structure and physiology of 'JOT OOQ
dentin and pulp, including age-related changes. Some 11. Brannstrom M. A hydrodynamic mechanism in the trans-
of tbis knowledge that is known to have, or may have, mission of pain-producing stimuli through dentine. In:
ciinical implieations has been outlined in tbis review. Anderson D] (ed). Sensory Mechanisms in Dentine, Oxford,
England: Pergamon Press, 1963:75-79.
Tissue ehanges associated with injury, age, wear, and
12. Brannstrom M, The hydrodynamic theory of dentinal pain:
pathologic processes affecting dentin and pulp, and Sensation in preparation, earies and the dentinal crack. J
those occurring as a result of common clinical proce- Endod 1986:12:453-457,
dures, have been briefly discussed. They will be out- 15, Köling A, Rask-Andersen H, Membrane junctions between
lined in some detail, in a series of articles. odontoblasts and associated cells, A freeze-fracture study of
Further details related to the structure and physiol- tbe human odontoblastic cell layer with special reference to
ogy of the dentin and pulp may be obtained from the its nerve supply. Acta Odontol Scand 1984;42:13-22,
14. Fried K. Changes in pulpal nerves with aging. Proc Pinn
proceedings of two international eonferenees beld in
Dent Soc 1992;88(suppl l):517-528.
1991 and in 1995,"*^ Another Dentin/Pulp Complex 15. Langeland K. Tissue Changes in the Pulp [thesis]. Oslo:
Symposiitm will be held in Japan in 2001 (Shimono University of Oslo, 1957:1-146.
M, personal communication, July 4, 2000), 16. Sveen OB. An Ultrastructurai Study of Pulpal Responses to
Injury [thesis]. Rochester, NY: University of Rochester,
1972.
ACKNOWLEDGMENTS 17 Jontell M, Okiji T, Dahlgren U, Bergenholtz G, Immune
defense mechanisms of the dental pulp. Crit Rev Oral Biol
A Guest Research Fellowship from the Research Council ol Norway Med 1998:9:179-200.
in partial support of Ivar A, MjOr's "Faculty Devetopmentat Leuve" 18. Mjor IA, Smith MR, Perrari M, Mannocci F. The structure
at NIOM. Scandinavian Institute of Dental Materials, ¡s gratefully of dentine in the apical region of human teelh. Int J
acknowledged. Endodont 2001 (in press).
The authors would also like tn thank Dr A. J, Smitli. Professor 19. Takahashi K, liishi Y, Kim S. A scanning electron miero-
and Chairman; Dr A, J. Sloan; and Dr P. E. Murray from the Unit of scope study of the blood vessels of the dog pulp using eorro-
Oral Biology, School of Dentistry, University of Birmingham. sion resin cast. ] Endod 1982;8:131-136,
Birminghani, England, for reviewing the manuscript. 20. Dahl E, Mjör IA. The fine stucture of vessels in the human
dental pulp. Acta Odontol Scand 1971,31:223-250,
21. Bishop MA. Extracellular fluid movement in the pulp: The
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5, Linden L-A. Microscopic observation of ñuid flow through
24. Heyeraas KJ. Pulpal hemodynamics and interstitial fluid
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4, Chiego DJ, An ultrastructurai and autoradiographic analysis Endod 1989:15:468-472.
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