INTRODUCTION. DEFINITIONS. MORPHOLOGY OF PULP OF PERMANENT TEETH.

STRUCTURE FEATURE DEVELOPMENT PULP PATHOSIS

*CONTENTS

PULP is defined as a special organ with a unique

environment of unyielding dentine surrounding a resistant, resilient soft tissue of mesenchymal origin reinforced with a ground substance.

MOROHOLOGY OF PULP basically deals with

configuration or structure of dental pulp.

1. Intercellular substance 2. Fibroblast 3. Fibres 4. Undifferentiated mesenchymal cells 5. Odontoblasts 6. Defense cells 7. Blood vessels 8. Nerve 9. Lymph vessels 10.Nerve endings

*Intercellular substance :- it is dense & gel like

in nature varies in appearance from finely granular to fibrillar. * It is composed of both acid mucopolysaccharides & protein polysaccharide compounds. * The ground substance lends support to the cells of the pulp, while it also serves as a means for transport of nutrient. * Transport of nutrients from blood vessels to the cell as well as for transport of metabolites from cells to blood vessels.

*Fibroblast:- Most numerous cells in the pulp ,

* They have typical stellate shape & extensive * In young pulp the cells divide & are active in

they function in collagen fibre formation throughout the pulp during the life of tooth. processes that contact & are joined by intercellular junction to the processes of other fibroblast. protein synth. But in older one they appear rounded or spindle shaped with short processes & exibit fewer intracellular organelles.

* They then are termed as fibrocytes. * Fibroblast in addition to forming pulp matrix

also hav capability of ingesting & degrading the same matrix.

*Fibers;- collagen fibres in pulp exhibit typical

cross striations.

* Bundle of these fibres appear throughout the pulp . * In young pulp fine fibres have a diameter range of
10-12nm .

* These do not contribute to dentin matrix

production as this is the function of odontoblast collagen fibres increase in no ..& may appear scattered throught out coronal or radicular pulp, or they may appear in bundles.

* After root completion pulp matures & bundles of

* Hence termed as diffuse or bundle collagen

depending on their appearence.

* Bundles are most prevalent in apical region.

*Undifferentiated mesenchymal cells.:* Are the primary cells in very young cells but a few
may be seen even after root complition. in shape.

* They appear larger than fibroblast & are polyhedral * Are found along pulp vessels, in cell rich zone &
scattered through out central pulp.

* Are believed to be totipotent & when need arises

they may become odontoblasts , fibroblast or microphages.

* They decrease in no. with old age.

* Odontoblast:* 2nd most prominent cell in pulp, reside adjacent to * Their constant location adjacent to predentin is
termed as odontogenic zone of pulp predentin with cell bodies in pulp & cell processes in dentinal tubules.

* Their cell bodies are columnar in appearance with

large oval midline which fill the basal part of cell. are not uniform throughout the pulp.

* The form & arrangement of the bodies of odontoblast

* They are more cylinderical & longer in crown &

more cuboid in middle of root.

* Close to apex they are ovoid & spindle shaped.

* Defense cells :* Are a part of neural & vascular system of pulp. * The cells imp. To defense of pulp are Histiocytes or
macrophages, Mast cells ,Plasma cells.

* In addition there are blood vascular elements such

as neutrophills ,eosinophills, basphills, lymphocytes & monocytes. characterstics In response to inflammation.

* These emigrate from pulpal blood vessels & develop

* Blood vessels :* Pulp organ is extensively

vascularized.

* It is known as blood vessels of both

pulp & peridontium arise from inferior or superior alveolar artery and also drain by same veins in both maxillary & mand. regions. of pulp & peridontium which is responsible for the spread of infection .

* There is continuity b/w blood vessels

* Lymph vessels :* L.V. draining the pulp & PDL have a common outlet. * Those draining the ant.. Teeth pass to submental lymph
nodes those of the post teeth pass to submand. & deep cervical lymph nodes.

* Small arteries & arterioles enter the apical canal

& pursue a direct route to the coronal pulp.

* Along their course they give numerous branches

in redicular pulp that passes peripheraly to form a plexus in odontogenic region.

* Nerves :* Majority of these entering the pulp are nonmyelinated.

* Many of these gain a myelin sheath later in life. * Non myelinated nerves are found in close association
with blood vessels of pulp & many are sympth. in nature. & functn. In vasoconstriction.

* They have terminals on muscle cells of larger vessels * Thick nerve bundles enter apical nerve foramen &
pass along radicular pulp to the coronal pulp where their fibres separate & radiate peripherally to parietal layer of nerves.

* Large mylinated fibres mediate the sensation * Peripheral axons form a network of nerves
adjecent to cell rich zone.

of pain that may be caused by external stimuli.

* This is termed as the perital layer of nerve also

known as plexus of rashkow

* Nerve endings:* Nerve axons from the parietal zone pass through
the cell rich zone & cell free zones & either terminate among or pass b/w odontoblast to terminate adj. to the odontoblast processes at the pulp predentin border or in the dentinal tubules.

* More nerve fibres & endings are found in pulp

horns than in other peripheral areas of the coronal pulp.

1-Inductive function 2- Formative

3- Protective
4- Nutritive 5- Reparative

*MORPHOLOGY OF PULP IN PERMANENT

TEETH

* Tooth pulp is initially called dental papilla * The development of dental pulp begins at * The cells of dental papilla appear as
shapes fibroblasts. undifferentiated mesenchymal cells.

this tissue is designated as PULP only after dentin forms around it. about 8th week of embryonic life in humen.

* Gradually these cells differentiate into stellate

* After the inner & enamel organ cells differentiate

into amyloblast, odontoblast, then differentiate form the peripheral cell of dental papilla. & hence dentin production begin. the dentin is well advanced, at that time nerve reach the odontogenic zone in the pulp horns.

* Few large mylinated nerves are found in pulp until

* The sympathetic nerves however follow the

blood vessels into the dental papilla as the pulp begins to organize.

* Regressive changes in the pulp * Fibrous changes * Pulp stones

* Fibrous changes in pulp:* Fibrosis is due to aging & * Injury. * -increase in collagen fibers * bundles which becomes * more evident with the * decrease in pulp size.

Pulp stones

*Pulp stones
* Classified according to its structure into:
* True & False
True denticles: have dentinal tubules like

* dentin, odontoblastic processes & few * odontoblasts

False denticles: are concentric layers of

* calcified tissue with a central cellular area * (which might be necrotic & acts as nidus of * denticle formation)
Classified according to its structure into:

* free, attached & embedded

* Pulp stones or denticles

Are round to oval

* calcified masses in: * normal pulps or injured * Pulps (microtrauma)

False pulp stones

* True pulp stone * Free & true

* Attached & true

* Pulp stones
Results from ectopic calcification due to microtrauma or aging

Normally are asymptomatic, unless they

impinge on blood vessels or nerves

* Microbial: dental caries * Mechanical: operative procedure (iatrogenic),

trauma

* Chemical: pulpal (acid etching, bond),

periapical (irrigation)

*Systemic Disorders
Diabetes

*
*General symptoms of the inflammation
* rubor * calor * tumor (oedema) * dolor * Loss of function

*The special anatomical aspects of the

pulp: enclosed chamber

1.
*
* *

Pulpitis
Acute pulpitis & hyperemia
Chronic pulpitis Hyperplastic pulpitis( pulp polyp)

6. Calcification
7. Internal resorption
8. Metaplasia

2. Anachoresis
3. Aeriodontalgia 4. Necrosis

5. Reticular Atropy

* PULPITIS :- may be

ACUTE,
CHRONIC HYPERPLASTIC

* Acute pulpitis & hyperemia :* Characterised by : severe pain that varies from
a continuous , throbbing type & less severe intermittent attacks.
down & with changes in temperature . dence infilteration by neutrophills & disorgination of odontoblastic layer.

* Severity of pain increases while patient is lying

* Microscopically char. By : oedema, moderate to

* In some cases there is dense localized of

neutrophills such a area is associated with tissue liquefication & is called pulp abcess.

*Chronic pulpitis:
* cause is same as that of acute pulpitis except the
irritant is of low virulance therefore the response is milder.

* Clinically there is intermittent dull tooth aching. * Sensitivity to heat & cold is less striking as
compare to acute pulpitis .

* Microscopically infilteration of pulp by plasma cells

& lymphocytes & a mild degree of fibrosis are found.

* Hyperplastic pulpitis (pulp polyp)

* Particularly in deciduous molars with extensive caries
leading to wide exposure of pulp tissue, inflammatory changes are char. and terminate in what is called as PULP POLYP .

*Clinical features: tooth involved has a large cavity

* The growth is not painful & tooth remains vital.

that is usually on the occlusal surface , a red fleshy mass of tissue lies in the cavity or projects beyond the occlusal level.

* Microscopically : infiltration by plasma cells ,

lymphocytes & neutrophills .

* Entire lesion is covered by stratified squamous

epithelium.

* Anchoresis :
* If bacteria circulating in blood stream settle in
areas of inflammation or of lower resistance in pulp & produce pulpitis, abcess or necrosis , the phenomina is referred to as ANACHORESIS.

* Aeriodontalgia:
* In some persons high altitude flights produce
pain in teeth that at ground level are asymptommatic. This pain is called as aeriodontalgia.

* Occours only in teeth with sub clinical pulpitis.

*Necrosis :
* Untreated pulpitis may lead to death of pulp. * The inflammatory exudates compressed within a hard shell
of dentin brings about compression of blood vessels , particularly the apical leading to infaction & necrosis.

* Clinically char. by cessation of all symptoms * Microscopic section shows either an empty pulp chambers

& canals or isolated areas of necrotic structureless masses.

* Reticular atropy :
* It is really an artifact but at one time was
intertwining bundles of fibres(reticular pattern)in the pulp believed to be a regressive change of the pulp

* Microscopically, it shows numerous spaces and * It is not a change seen in old age.

* Internal Resorption * When the resorption of teeth occurs from within

the pulp cavity it is refered to as internal or idiopathic resorption

* If it occurs in crown of tooth,the dentine may be

destroyed and vascular tissue of pulp can be seen through the enamel as a pink spot.(pink tooth)

* It may be progressive and

lead to perforation or fracture of a tooth or it may cease spontaneously

* Microscopically, few or

numerous irregular areas of resorption of the pulpal surface of dentin and gaint cells adjacent to certain areas of resorption can be seen

* Pulpal diseases can also be classified as * reversible * irreversible

*Reversible pulpitis
* This is the condition where the pulp is inflamed and
is actively responding to an irritant. This may include a carious lesion that has not reached the pulp.

* Symptoms include transient pain or sensitivity

resulting from many stimuli, notably hot, cold, sweet, water and touch. The pulp is still considered to be vital. This means that once the irritant is eliminated, usually by removal of decay and the placement of a filling, that the pulp will return to its normal, healthy state.

*Irreversible pulpitis
* This is the condition where the pulp is irreversibly
damaged. The pulp can not recover from the insult and damage. tooth introduces bacteria into the pulp. The pulp is still alive, but the introduction of bacteria into the pulp will not allow the pulp to heal and it will ultimately result in necrosis, or death, of the pulp tissue. include dull aching, pain from hot or cold (though cold may actually provide relief) lingering pain after removal of a stimulus, spontaneous pain, or referred pain.[11][12]

* For example, decay that has reached the pulp of the

* Symptoms associated with irreversible pulpitis may

* Clinical signs may include reduced response to

electronic pulp testing and painful response to thermal stimuli. * Today electronic pulp testers are rarely used for diagnosis of the reversibility of pulpitis due to their unreliable nature. Instead they should only be used to test the vitality of teeth. * The pulp of a tooth with irreversible pulpitis may not be left alone to heal. The tooth may be endodontically treated whereby the pulp is removed and replaced by gutta percha. * An alternative is extraction of the tooth. This may be required if there is insufficient coronal tissue remaining for restoration once the root canal therapy has been completed.

* By definition, the pulp has been damaged beyond * The pulp will progressively degenerate, causing
necrosis and reactive destruction. years.

repair, and even with removal of the irritant it will not heal.

* Necrosis may occur quickly, or the process may require

* This infection leads to the development of a

microabscess.

* Progression of the inflammatory process to the stage of

acute abscess signifies an irreversible pulpal condition.