2. Pulp Biology Flashcards
• RCT is essential
○ In 60’s - half of population had no teeth
○ Now, we don’t have complete denture exams - things have cahnged
• Contributions to preservation
○ Root canal work
• Endo is not just RCT, there’s a ____ component > RCT may fail bc of the different branches containing bacteria
○ Endo is 90%, if fails > ____
• Implant has no comparison to actual tooth
○ Short life span
surgery
microsurgery
• 1 year follow up has PA abcess > surgical approach
• Alveolar bone regens better than cortical bone
○ 6 month left > bone ____ w/o infection
○ Microsurgery!
• Shouldn't touch \_\_\_\_ if you can • Do less on a tooth > small filling is better than a whole crown • \_\_\_\_ knowledge ○ Is required or else you're a plumber
regen
pulp
biological
• Once dentin is infected > PA lesion > can be solved with RCT; but if cystic lesion, RCT won’t work > ____ procedure
• Pain is important, but it’s a good model to study inflammation (tooth pulp)
○ Tooth is completely isolated > microcirculation, encased in rigid structure (enamel and dentin) > ____ compliance system (like brain and bone marrow)
§ Tooth will not ____ > gives crazy reactions
surgery
low
expand
- Finger connected to brain, all the material is coming in
* ____ > revascularization > creation of new pulp cell tissue
stem cell
Injurious agents (mechanical/chemical/bacterial)
> >
____ degranulation
disruption of blood vessels
____ damage
stimulation of sensory nerve
> >
histamine, 5-HT, PGs, BK, SP, CGRP, and NKs
> >
to nerves: ____
to arterioles: ____
to venules: ____
to lymphocytes: ____
mast cell
cell
pain
vasodilation
leakage
chemotaxis
The dentin/pulp complex a functional unit!
• LEFT IS DENTIN • RIGHT IS OB RICH LAYER • Drilling teeth > this area becomes crazy if you don't \_\_\_\_ the tooth while drilling ○ Tooth doesn't become necrotic
cool
Dentin is an important barrier in the ____ of the pulp
Normally highly ____
• Asymptomatic > can take care of \_\_\_\_ pulp capping > will most likely need RCT • Keep natural teeth as long as you can ○ Implants do not last for as long as you'd like § Esp not in the aesthetic zone • Dentin is permeable
immune defense
indirect/diret
- CS of tooth
- Tubular at the peripheral > holes are ____; 3 mm in pulp dentin junciton
- Fluid from pulp tissue pushes outside
- Anything placed on outside, will not be able to get into ____ tissue
- But if you prep ____ between > will have the chance higher chance getting into pulp tissue
- Remaining dentin ____ is very important
smaller
pulp
halfway
thickness
dentinal tubules
• OB Process into dentinal tubule
○ ____um into dentinal tubule; not all the way to 3mm
○ Why pain? Enamel peel > pain > ____ theory > fluid is filled w dentinal tubule > any ____ in fluid, rapid movement > exert on ____ tissue and experience pain
100
hydrodynamic
pressure
nerve
Dentinal tubules
dentin surface area
vs
surface area covered by the tubules
• Deep prep > leaving less half of dentin > won't expect the pulp to be \_\_\_\_
healthy
• Iodine131
• Circulation is good, peel enamel and place iodine into one side of dentin > will travel into ____ tissue
• Opposite side > empty space > ____ fluid
• Take venous blood out > if showing iodine, you can see it and it’s transferring
• Vasoconstrict after epi
○ Communicating
○ ____ are communicating [???]
131 Iodine collection
• Iodine cxn of plasma
• Iodine is inc with time
• Iodine in pulp tissue and circulation and removed
• Epinephrine injection > lingual chmaber increases > compeltely ____
• Dentin is permeable
pulp
collect
tubules
permeable
DENTIN (rate of solute permeation) PULP (rate of removal solute by microcirculation)
DENTIN:
- molecular ____, charge
- degree of ____
- dentin ____
- dentin ____
- proximity to the ____
PULP:
- number of ____
- rate of ____
- ____ pressure
- colloid ____ pressure
- pre vs postcapillary ____
size occlusion surface area thickness pulp
capillaries capillary flow perfusion osmotic resistance
• Restoration > there are gaps full of bacteria
○ None of the material is ____
○ All of it is hydrophobic; now we’re going hydrophilic
§ Production of bioceramic (not gutta percha)
○ Take restoration out > can smell the bacteria
• Dynamic events
hydrophilic
Dentin-pulp complex
* Cut tooth in half > leaving a little bit of the dentin; and placed different materials > slowly push (16 mmHg - inflam pressure) > what happens in restoration > is it sealed or leaking * All the materials \_\_\_\_
leaked
Constituents of the normal pulp
- ____
- vessels
- ____
- ground substance
- ____
Goldner’s ____ stain
(primate pulp, premolar)
cells
nerves
fibers
trichrome
Pulpal microcirculation
Vascular structure
•Arteriole - φ < \_\_\_\_ μm - \_\_\_\_ into the pulp •Capillaries - φ \_\_\_\_ μm - transport \_\_\_\_ and metabolites •Venule - φ up to \_\_\_\_ μm - thin \_\_\_\_ coat
100 multi-entry 8-10 fluid 200 muscular
• Control of microcirc is based on the ____
• Big vessels ○ Cannot tell whether one is vasodilating or constricting - it's all a \_\_\_\_ experience
sphincter
dynamic
- ____ into the tooth
- A lot of BV at the ____ junction
- And connecting the ____ ligament
- Perio and endo problems
- Dilated BV in a tooth pulp
- At the end are small fibers and vessels
india ink
dentin-pulp
perio
- Red is dentin
- Light is ____ zone
- Hemostasis is maintained if the insult is mild
- Vessel cast
- Infused BV > get rid of hard tissue
cell-rich odontoblastic
• Large magnification
* All BV on a young tooth * At the end are \_\_\_\_ branches
capillary
- All capillary beds are where ____ are located
- In middle are trasnferring blood
Coronal pulp
____ ml/min100g
• If fluid is in between vessels > inflammation
○ Can analyze inflam based on these studies
• Can measure blood flow based on unit volume of tissue
○ And ____ and ____
odontoblast
125
osmotic
capillary
Apical pulp
____ ml/min/100g
• BF is smalelr in \_\_\_\_ area • Configuration is different ○ Coronal BV is \_\_\_\_, apical is \_\_\_\_
22
apical
dense
fish net type
Arterio-venous Anastomosis (AVA) •\_\_\_\_ in nature •Diameter = \_\_\_\_ μm •\_\_\_\_ > coronal •Regulation of \_\_\_\_ circulation
• AV skips capillary ○ Arteriole into \_\_\_\_ • Inside tooth pulp ○ Bc tooth pylp circ changes > bc of low compliance enviro > cannot accommodate any of prolonged \_\_\_\_ ○ AV shunts open up > tissue press inc bc capillary making [???] § Prep of tooth w/o water spray > inside tooth it's heated > inflammation > inc BF (normal) > critical state > \_\_\_\_ opens > prevent engorgement of area and relieve BF
capillary
10
radicular
pulpal
venule
vasodilation
AV shunt
Pulpal microvascular units
• \_\_\_\_ layer, and capillaries and larger vessels • \_\_\_\_ - all exhcahnge takes place ○ Terminal capillary network
Characteristics of Pulpal Microcirculation •Dense capillary network in the \_\_\_\_ •\_\_\_\_ of the network •\_\_\_\_ > Central •\_\_\_\_ > Radicular •Arterio-venous anastomosis (AVA) •Venous-venous anastomosis (VVA) •\_\_\_\_ loop arteriole •True isolated microcirculation network
OB
TCN
peripheral heterogeneity peripheral coronal U-turn
Microcirculatory methods
* Vital microscopy > directly recording a circ using \_\_\_\_ * Micropuncture of tooth to measure \_\_\_\_ * Use diff \_\_\_\_ to measure the blood flow * Many technologic things to get one data - difficult to study tooth pulp bc encased in solid tooth structure
SEM/TM
pressure
radioisotope
Blood flow rate
• \_\_\_\_ and \_\_\_\_ blood flow are about the same ○ Brain is \_\_\_\_ compliance, as well as pulp ○ \_\_\_\_ is low compliance § All have same blood flow
brain
pulp
low
femur
• Prepare both side - leave dentin structure with ____ um (stacking three RBC together)
○ Peel 10 um each stroke
○ Leaving dentin - 20-30 um both side
• Our hands are better than microtomes
• ____ and a TV camera recording the circulation
* Dentin > a lot of \_\_\_\_ * Bypassing > AV shunts
30
transillumination
capillaries
In vivo microcirculation of the dental pulp
• Epinephrine is in it • Measuring and showing different examples of blood flow • Measure the speed in the \_\_\_\_ of the vessel • Many vessels may be coalesced together • U-turn loop happens when coronal pulp has \_\_\_\_ > AV shunt ○ So no \_\_\_\_ takes place ○ Maintains homeostasis of pulp tissue • \_\_\_\_ stick around the side of the vessel > during inflammation • Give a lot of LA > vasoconstriction occurs, speed of flow \_\_\_\_ ○ BF picks up, but \_\_\_\_ still remains • Pulp hemorrhage ○ Cannot see the \_\_\_\_ ○ The tooth is unrecoverable • Zn PO4 cement liquid (phosphoric acid) ○ Thorugh 30 um dentin thickness > put the liquid > hits the BV > went in and something is wrong > it disturbs flow, and changes RBC completely > completely \_\_\_\_ § If close to pulp tissue > you cannot use \_\_\_\_ > can have irreversible damage on the area § Done on the large vessels as well > same thing happens > becomes smaller
center
inflammation
edema
WBC decrease vasoconstriction vessel gone acid
Innervation of dental pulp
- Trigeminal ganglion - ____ nerve
- Superior cervical ganglion - ____ nerve
- Parasympathetic nerve - ____
• 3 innervations ○ Trigeminal comes from head ○ Superior cervical § Controls \_\_\_\_ ○ Cannot identify the parasymp
Innervation of the Dental Pulp
- trigeminal ggl
- ____ nerve
- Trig in the brain
- They mix in the jaw > ____ and ____ innervating the teeth
- Symp > ____/vasodil of microcirc
- Sensory > gives you ____
sensory
sympathetic
unclear
blood flow
mandibular sensory somatic vasocon pain
NT of Sympathetic system
• If a BV > symp ending has a NT > \_\_\_\_ or \_\_\_\_ are secreted if stim symp nerve > cross > and attach to a receptor on a BV (arteriole - smooth muscle) > \_\_\_\_ > sphincter constrict and no BF • Stim symp nerve > dec \_\_\_\_ • \_\_\_\_ blocker > symp BF goes back to normal ○ Equiped with \_\_\_\_-adrenergic receptor nerve
NE
NP-Y
vasoconstrict
BF
alpha
alpha
• BF is different with each material
• ISO, Brady, Sub P > vasodilator, has a ____ response
• ST and NE > straight forward ____ in BF
• This biphasic response > why tooth becomes so ____
○ In a tissue > vasodilate > flexible
○ In a tooth > rigid > vasodilate > no place to expand > goes down constricting
§ Pulp ____ > inflam occurs > pulp has no way of recovering
§ Pulp circ stops > dentin fluid doesn’t work > enters the pulp > ____ and PA lesion
§ This is why all the teeth are dying!
• Occurs in a normal level w protection; if becomes more severe, inc and dec in BF
• Explains bizarre behavior of ptooth pulp beocming necrotic so easily
Low compliance system
• Is cause of ____ death easily
• 20M RC done in USA each year
biphasic dec painful dies necrotic
pulpal
Nerves in Pulp - Functions
- Transmit ____ sensations
- Modify/support inflammation
- Regulate ____ formation and repair/healing processes ____ sensation?• Sensory nerve!
pain
dentin
pressure
A-delta PAIN CHARACTER: \_\_\_\_ THRESHOLD: \_\_\_\_ activated by hydrodynamic stimuli LOCATION: extensive terminal \_\_\_\_ with free nerve endings in \_\_\_\_ pulp; ca 100-200 μm into dentinal tubules
C PAIN CHARACTER: \_\_\_\_, aching THRESHOLD: \_\_\_\_ \_\_\_\_ in healthy pulps LOCATION: receptive fields in \_\_\_\_ tissue proper
• A delta and C fibers are most impt • A delta ○ Sharp pain ○ Located at dentin-pulp junciton (odontoblast area) • C fibers ○ Dull, aching pain ○ Tough to stiulate C fiber, bc in the center of pulp tissue • Can dx of how deeply the pulp is inflamed
sharp
easily
branching
peripheral
dull
high
silent
pulp
The specific distribution of sensory nerves
* \_\_\_\_ area has heavier branch of sensory nerve * As you get down > much \_\_\_\_ * Scraping of coronal area > elicitation of pain easily
coronal
lower
NT of the sensory nerve system
• Symp nerve stimulation you are releasing NE and NP-Y • In sensory > different > two important NP > \_\_\_\_ and \_\_\_\_ > these cxn of unit/volume, the \_\_\_\_ has the second highest (\_\_\_\_ is the highest) > released when sens nerve stim > receptor on BV > \_\_\_\_ ○ \_\_\_\_ > vasoconstriction
SP CGRP pulp brain vasodilation NE
Substance P (SP) •Consisted of \_\_\_\_ amino acids •Involved in \_\_\_\_ transmission •Potent \_\_\_\_ agent •\_\_\_\_ located in \_\_\_\_ sensory neurons
* Very small molecules * Has a \_\_\_\_ in middle of pulp tissue
10 pain vasodilatory peripherally unmyelinated C fiber
• Can inc BF by SP injected and can see the inc in BF
- Pulp has the highest ____ outside CNS
- SP-containing fibers are closely associated with pulpal ____• Pulp tissue > lots of ____ (sensory) > intertwined with the BV > when stim > release NP > attach to BV and dilate
○ Intimate relationhip
SP-like-immunoreactivity (SPLI)
blood vessels
nerve ending
SP levels in the pulp following various stimulations
• Put small cap on naked tooth structure after enamel is peeled > collecting \_\_\_\_ • Then measrue the SP > at control, don’t do anything > prep certain amount • On the other hand > a little tooth prep in apical area > double amount of SP level (4pg) > stim sens nerve on canal > release 7 pg ○ Can indriectly correlate: by \_\_\_\_ (aggressive) > stim sens nerve > release SP > vasodilation § Can be controlled § If cannot be controlled bc of low compliance > goes downhill > blood circ stops > bac comes in and tooth becomes necrotic
dentinal fluid
tooth prep
Calcitonin Gene-related Peptide (CGRP) • Consists of \_\_\_\_amino acids • Involved in \_\_\_\_ transmission • Potent \_\_\_\_, \_\_\_\_ > SP • \_\_\_\_ located in \_\_\_\_ sensory nerves • Closely associated with \_\_\_\_ vessels
* Larger molecule * Does pretty much the same thing * In pulp tissue > SP is stronger vasodilator acc to him
37 pain vasodilator CGRP peripherally unmyelinated pulpal
• BF inc much slower, not as much as ____
• CGRP is more impt in ____ formation
○ Fluid from venule into tissue
SP
edema
Calcitonin Gene-related Peptide (CGRP)
•CGRP-like immunoreactivity coexists with SPLI in ____ and dental pulp
•Both SP and CGRP are involved in regulation of pulpal ____
• CGRP > sprouting ○ Once nerve is inflamed > sprouting of CGRP fibers > specifically CGRP (SP doesn't do this!) ○ Involved in initiation progression of inflam in pulp ○ SP may just be vasodilation
trigeminal ganglion
blood flow
• ____ > inflam > ____ activation (sensory C fiber) > antidrom impulse > release ____ (CGRP, SP, etc.) > inc ____, BV vol, vasc permeability, ____ formation > hell breaks loose
injury nerve NP BF edema
- Sensory neuron stim > BV
- BV is not the cause of inflam, caused by nerve releasing ____
Neurogenic inflammation
• Stim > ganglion > release NP in the BV > hell breaks loose > neurogenic inflammation
• Inflam is not only ____, but ____ as well!
• Tooth pulp is fantastic to study > Adelta/C fibers > microvessels > able to manipulate all these things > key factor of physiologic neurogenic inflam came from (the pulp tissue!)
NP
vessel
sensory nerve
• Inc in sensitivity to inflamed pulp > determined by ____ of nerve and normal > receptive field increases tremendously
sprouting
Tissue pressure is a function of ____, especially in a low compliance environment like the dental pulp
blood flow
Pulp tissue & blood pressures
• Tissue pressure > expose tooth pulp under mirco > oil on it to restablish hemodynamic enviro > \_\_\_\_ > puncture vessel/tissue > whatever pressure pushes fluid and record it
micropuncture
- Arterial presusre - 100-150
- Interior tissue pressure - 7
• Arterial - 100-125 • Pulp arterial pressure ○ Can punc arteriole of BV in pulp ○ 43-45 • Punc venous ○ 20 • Capillary ○ 36 mmHg • Pressure is high in \_\_\_\_ (45), then 36-37 in \_\_\_\_, in \_\_\_\_ and 20
arteriole
capillary
venule
Pulp tissue pressure (PTP)
• Don't worry ab the equations • Capillary bed/arteriole > everything tries to come out of arteriole to the tissue • Venule sucks it out • Net filtration must be balanced normally ○ Nutrient is going out (\_\_\_\_), and net absorption is \_\_\_\_ is sucked in ○ Homeostasis must be established
O2
CO2
Pulp tissue & blood pressures (in mmHg)
* Art - 43, capillary - 35 and tissue pressure is 6 and venule 15 * Normal > maintained > pulp is happy
• Once inflam: ○ 45 -> \_\_\_\_ ○ 35 -> \_\_\_\_ for capillary ○ Tissue 6 > \_\_\_\_ ○ Venule from 20 to \_\_\_\_ § Where \_\_\_\_ stops! § Everything comes out strongly, but no draining power > more pressure increase > pulp becomes caput § Circulation stops > from dentin, things keep on coming
53 40 18 9 BF
Increased tissue pressure a local phenomenon
recorded ____ pressures through ____ mm hand drilled holes to the pulp in two areas ____ mm distant from each other -
one ____ vs one ”chronic”
* Doesn't spread quickly all through the pulp * If tooth pulp is comparmentalized > happens on area, then it stays there, but then it spreads (doesn't all occur like strangulation theory all at once)
pulp tissue
1
5
fresh
• Peripheral flow > ____ is going out to meet them
tissue
Rupture of TJ
• dilutes \_\_\_\_ elements • counteracts diffusion • carries plasma proteins - \_\_\_\_ - fibrinogen increased \_\_\_\_
• Protect the pulp tissue • Dentin is a \_\_\_\_, wonderful protector of pulp tissue ○ Manipulate the dentin > prevent RCT
noxious
immunoglobulins
viscosity
permeable
Usually limited, often transient, tissue destruction followed by repair
• Deep preparation > bacteria enters > dentin fluid cannot take care of it > small necrotic area > if properly taken care of > repair \_\_\_\_ formatino covering the dentin zone > \_\_\_\_pulp capping when the tooth is asymptomatic
dentin
direct/indirect
- Prepare a lot of dentin
- Frequent appearance of board certified prosthodontist
Dentin serves as a ____ - bacterial elements
> >
Pulp can ____ and organize
defense responses
* Short lived > don't take care of it * When detect > when one little cavity > do a RCT > WRONG! * RC has to be done correctly and at the right time
filter
adapt
• Summary:
• Local insult > local inflam > vasodilation > perm inc > ____ > pulp tissue pressure inc at local site (compartments) > in resist of venule >
○ > ____ pulp necrosis > finally become ____ pulp necrosis > swelling, tooth ache etc
○ > Resist inc > velocity dec > metabolic product In > ____ or circumferential spread
• For dx: ○ Ice cream > good indication something's wrong > shallow caries > \_\_\_\_ is not involved § Dentist, clean it out § Hits \_\_\_\_ fiber ○ Coffee in the morning > game over > tooth needs a RCT § Exciting \_\_\_\_fiber inside • I cannot bite ○ Is tooth vital > patient responds to cold ○ Occlusal adjustment instead of RCT • If tooth is fracture > cannot stay in mouth > has to come out
edema
local
total
vasodilation
pulp
adelta
C
• PA lesion > ____ has NOTHING to do with healing > they always heal
○ Have to clean it up completely > all healed
○ Must do RCT > will heal > if doesn’t heal > surgically clean it out > may be cystic
size
Root canal treatment - now and then
• Tool doensn't allow to do small preparation, but now they're \_\_\_\_ ○ Using 3D cleaning files now ○ Using a microscope, and microsurgery and sealer-based RCT • \_\_\_\_ sealer ○ Requires three years of research • Only dept in world where company cannot come in; Penn is the only one in the world where advertise what we produce
smaller
bioceramic
