2. Pulp Biology Flashcards by J L

• 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

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• 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

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• 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

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Finger connected to brain, all the material is coming in

* ____ > revascularization > creation of new pulp cell tissue

stem cell

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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

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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

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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

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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
• Try to cover ____ are much as possible after tooth prep

smaller
pulp
halfway
thickness

dentinal tubules

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• 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

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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

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• 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

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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

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• 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

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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

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Constituents of the normal pulp

____
vessels
____
ground substance
____

Goldner’s ____ stain
(primate pulp, premolar)

cells
nerves
fibers
trichrome

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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

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• Control of microcirc is based on the ____

• Big vessels
	○ Cannot tell whether one is vasodilating or constricting - it's all a \_\_\_\_ experience

sphincter

dynamic

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____ 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

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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

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• Large magnification

* All BV on a young tooth
* At the end are \_\_\_\_ branches

capillary

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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

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Apical pulp
____ ml/min/100g

• BF is smalelr in \_\_\_\_ area
• Configuration is different
	○ Coronal BV is \_\_\_\_, apical is \_\_\_\_

22
apical
dense
fish net type

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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