3. Pathogenesis of Pulpal Disease Flashcards
Dentin pulp complex
• We are still talking about pulp biology and things that are connected to inflammation and
disease in the pulp
• Dr. Kim talked about the aspect from the pulp side
• Dr. Wolff talked about cariology
• Setzer is going to go into more detail and sum up those two topics
• Particularly on innervation of pulp
• Recap - This slide is just a quick review:
• Number 1: we always talk about a dentin + pulp complex
• We are not just talking about the pulp, because we always know that it is
part of an encasing in dentin and in enamel and in cementum
• It is important to note that we have the dentin, the shell that encases the pulp
tissue, and at the border we have the ____ (responsible for building the
tooth and secreting the dentin
odontoblasts
DENTIN PULP COMPLEX
Characteristically, these odontoblasts are lined like a wall in the periphery of the pulp
• That is why we call it the ____ cell layer, towards the end of the ____,
towards the center part of the dentin, on the outer layer of pulp tissue
odontoblast
dentin
DENTIN PULP COMPLEX
• This is the enlarged view of the blue box in the previous slide
• We also have a characteristic zone between the mineralized dentin and the odontoblast
itself, that’s the ____, that is the un-____ portion of the dentin, before
mineralization sets in, since this was just produced by the odontoblasts
• This is something to keep in mind for later, as it will play a role in resorption. Because resorption can only eat up ____ tissue, thus it will always stop at the ____ layer, the pre-dentin
• Or if the resorption is happening externally, it will stop at the ____
layer, if it comes form outside the root
• Then we have the dentinal tubules, which is where the ____ processes were, and still are housed inside the dentin, form the secretion/formation of the dentin itself
pre-dentin
mineralized
mineralized
un-mineralized
precementum
odontoblastic
Types of dentin
Primary: circumpulpal ____, mantle dentin, bulk of tooth
Secondary: continuing deposition by ____
Tertiary (reparative dentin): reaction to ____ (attrition, caries, restoration)
• We have primary dentin,
• Secondary dentin, which are the initial deposition of the dentin while the dentin is made and the tooth is filled
• And in the secondary dentin, you have the continuing deposition by the
odontoblasts
- Tertiary dentin, which is formed when we have an ____ to the pulp (attrition, carious restoration, bacterial onslaught, etc.)
- The other word for this type of dentin is ____ dentin (or reactionary dentin)
dentin
odontoblasts
stimuli
attack
reparative
Structure of Dentin
Dentinal tubules number
42360 - ____
39010 - middle
8190 - apical
Apical root dentin
fewer and more ____
dentinal tubules
• This is different density of dentinal tubules
• If you look at the root dentin:
• Usually you have less dentinal tubules in the apical portion of the root canal
• Coronal dentin has more
• Middle has a little less than coronal
• It is significant to note that the apical has far fewer dentinal tubules
• Because: if you have invasion of dentinal tubules with bacteria, you will have
much more of an infection in the ____ aspect than the apical
• More tubules that can be filled in coronal
coronal
sclerotic
coronal
Structure of dentin
• Pics of dentinal tubules
• Important thing to know:
• “is that we have different types of dentin, also how this is called (points to the stuff
in between the little tube openings), the ____ dentin, for example, and the
intratubular dentin in between the dentinal tubules”
• I think peri and intra are synonyms. He didn’t clarify.
peritubular
Odontoblast
• Inside those dentinal tubules, we will have ____, nerve fibers and
some other things (we will see later)
odontoblastic processes
Microscopic Zones of the Dental Pulp
OB layer
Lines the outer ____ wall and consists of the ____ of odontoblast. ____ dentin may form in this area from the apposition of odontoblast.
Cell-free zone
____ cells than odontoblastic layer. ____ and capillary plexus located here
Cell-rich zone
Increased ____ of cells as compared to cell- free zone and also a more extensive ____ system
Pulpal-core
Located in the ____ of the pulp chamber, which has many cells and an extensice vascular supply, similar to ____ zone
• We also have characteristic zones of the pulp:
1) Odontoblastic layer – outr later – reads box
2) Cell-free zone – reads box then adds: ____-fibers that are going to make the
innervation of the dentin, they will have a lot of nerve fiber concentration in this
layer
3) Cell-rich zone – reads box then adds: it is interesting because you are going to
have the ____-fibers, the other fibers that innervate the pulp, are going to be mostly
located here, around the central portion near the blood vessels that will be in that
area
4) Pulpal core – even more extensive vascular supply
pulpal
cell bodies
secondary
fewer
nerve
density
vascular
center
cell-rich
Adelta
C
- [NOTES TO HERE]
- ____ > OB goes into tubules > ____ with cell bodies > ____ zone with nerve fibers into the tubules > ____ zone and ____ core
pre-dentin OB CF CR pulpal
Functions of the Dental Pulp
____: blood supply for pulp and dentin.
____: changes in temp., vibration and chemical that affect the dentin and pulp.
____: the pulp involve in the support, maintenance and continued formation of dentin.
____: triggering of inflammatory and immune response.
____: Development and formation of secondary and tertiary dentin which increase the coverage of the pulp.
nutrition sensory formative defensive protective
Constituents of the Dental Pulp
Cells: Odontoblast, Fibroblast, white-blood cells,
Macrophages and Lymphocytes. No fat cell. ____ stem cells
Blood Vessels
Nerves
Extracellular Matrix: Mostly ____ fibres and collagen fibres (Type ____ and Type ____, Elastin, Glycosaminoglycans, Fibronectin, Basement Membrane).
Ground substance: Act as a medium to transport ____ to cells and metabolites of the cell to the blood vessels.
• The pulp is described as a loose conn tissue > lots of fibros • Adult stem cells > dental pulp SC ○ New formation and resvasc of pulp following trauma, or necrotic pulp § SC from PA area can regrow tissue
adult reticular I III nutrients
Healthy pulp
• Where pulp is open > and pulp is healthy: will see network of BV inside the pulp
○ If pulp is not inflamed > would not see a lot of ____
§ Description for appearance of pulp > if pulp has undergone inflam changes > profuse ____
Pathogenesis of Pulpal disease
• See changes in the dentinal structure > the decay area corresponds to the same section in the pulpal tissue
○ Dentinal tubules from OB connect them, and then extend OB processes from the dentin
bleeding
bleeding
Pathogenesis
• If the pulp is affected by decay and endotoxins (LPS) > causes pulp to react with an ____ defense reaction
○ First: OB, then ____ cells that will start to trigger the first immune response from the pulp
○ ____ tries to wall pulp if assault is not too quick/aggressive, at the same time the pulp tries to hold off bacteria by building a wall > ____ dentin > pulp is trying to get away from toxins of any bacteria
* Reaction to a cavity prep * No decay > \_\_\_\_ irritation from preparing a cavity > would see corresponding again > \_\_\_\_ dentin formation
immune dendritic OB tertiary/reactionary mechanical tertiary
Possible causes of pulpal inflammation
____
trauma
____ disease iatrogenic (perio, prosth)
BUT No. 1 Cause of Pulpal Inflammation: ____!!
• Different types of irritation that cause pulpal inflammation ○ Caries is the foremost cause of inflam from bacteria • Doesn't mean you have a fracture where pulp is open > can be a \_\_\_\_ > irritation to the pulp ○ Where trauma is exerted on teeth a long time ago > no explanation why it happens \_\_\_\_ later you may see reactions to the pulp (5-15 years ago) § Internal resorptions > cells start to eat up dentin structure from inside (OC's), can also see external (PDL might've been damaged) > go through calc/sclerofication of the root canal chamber § Long term changes assoc with low grade inflam that's constantly going on in the pulp • P disease may affect pulp > connections of inner portion of root canal to root structure [???] ○ General perio disease with 4-5mm pocket > internal inflam inside the pulpal tissues • Iatrogenic ○ SRP > transient inflam inside pulpal tissues ○ Cavity > transient inflam inside the pulp Chemical and maybe mechanical inflam
fracture
periodontal
caries
concussion
Pulpa response to carious lesion
• \_\_\_\_ theory > causes pain coming from the tooth from fluid movement coming from inside the dentin tubules ○ Showed when early enamel caries (small decay) could be remineralized; in these situations > see \_\_\_\_ changes if only enamel is affected inside the dental pulp ○ When does endo start? § The very moment when you have initial \_\_\_\_ decay > changes to the inside of the tooth (\_\_\_\_ tissues) > dental decay > carious exposure of the pulp tissues
hydrodynamic
inflam
enamel
pulpal
Progression of Caries-induced pulp diseases
• Microbial insult > responsible in the beginning for a pulpitis (inflam that happens inside the pulpal tissues) ○ This may happen w/ or w/o pain § Pain threshold is too high, or not enough inflam going on at this point § Pulp necrosis > no pain sometimes! • [???] • May have inflam that may \_\_\_\_ itself it it's not strong enough ○ Repaired decay > filling > arrested and inflam regresses ○ If bacteria are strong enough > may go from reversible pulpitis to \_\_\_\_ and then leads to pulp necrosis and to a AP w/ inflam around the root tip
reverse
irreversible pulpitis
Pulpitis
Inflammatory disease
requiring endodontic therapy (root canal treatment) The
• Bacteria starting to cause havoc > when bacteria hit enamel and dentin > can be \_\_\_\_ (took bacteria out) > can be \_\_\_\_ pulpitis • If the inflame has progressed too much > inflam cannot be reversed > \_\_\_\_ > endodontic therapy ○ Most commonly used endo therapy > RCT § For an adult person w/ a \_\_\_\_ mature root developmen • Inflam on right isn't just superficial, and not reversible > massive inflammation taking over ○ Will not have a situation where one snapshot in time your entire pulp from a horn down ot the end of RC is just inflamed in the same way across the board § Always diff \_\_\_\_ of this inflam inside the pulpal tissues > related to the location of bacteria and their toxins in relation to their pulpal tissues § Inflammation in this example centers around where the decay is trying to break through the pulpal tissues § Also in this example > only one pulp horn is inflamed; the other pulp is healthy § Could be calcification or RC that's split • Vital pulp therapy > only remove the \_\_\_\_ part ○ Now we have materials that can be placed directly into the pulp and it tolerates it > now becoming more popular ○ Only problem > no one can say how deep the level of inflam inside the pulp > can only go by clinical signs of inflam > bleeding § Pulpotomy > removed part of the pulp > drill until the \_\_\_\_ stops and place the filling material and hope for the best § More difficult for irreversible pulpitis > don't know how deep to take parts of the pulp out • Filling materials that we had caused inflam by themselves • Looking into deeper portion of the RC > healthy pulp
arrested reversible irreversible completed stages inflamed bleeding
Case 1
• First thing when patient arrives > \_\_\_\_ history form • And then ask for the \_\_\_\_ ○ Correct treatment is to address the CC ○ Then tests on a patient to figure out dx • The inflammation here is very severe ○ Cold test > spray on cotton and place on tooth (on a number of them!) § Inform the patient of the normal response □ \_\_\_\_ ourselves and the patient § Pain on the tooth in question > take cotton pellet and place it slightly □ If severe inflam > will feel it \_\_\_\_ > cold causes fluid movement in the tubules, and the nerve fibers will react with a painful response
medical
CC
calibrate
right away
Case 1
• Test teeth adj to the one with a problem • \_\_\_\_ > artifact that something appears very dark next to an opaque filler material ○ Clinical test, or may appear different on a BW • On #2 ○ The pulp is adjusted > when cold > no \_\_\_\_ ○ Even if there is pulp, in the roots, the cold will not reach this area § The pulp that reacts to the cold is normally in the \_\_\_\_ portion • On #3 ○ Feels it a lot (+++) > strong reaction to the cold from the patient ○ Also \_\_\_\_ > 10-30 seconds • On #4 ○ Still has a strong reaction ○ Patient says its lingering > place the cold § Temp change to the tooth is pain; the receptors in \_\_\_\_ is only the receptors that respond to temperature! Both teeth give a lingering response > unlikely > patient gives a lingering response when cold on tooth > two fillings are \_\_\_\_ > extremely good conductor for temp > clinically: separate the fillings so they don't transmit the cold
burnout reaction crown lingering pulp metal
Case 1
• Percussion ○ Tap on tooth from two directions: § Occlusal in the \_\_\_\_ axis of the tooth □ Testing the apical part of the tooth; any inflam at the tip of the root > would hurt ® Apical changes if disease progresses > bacteria reaching the end of the RC > may cause inflam at the apical PDL § Hit the crown from the \_\_\_\_ □ Testing lateral inflam, but most of the the time it's at the end of the \_\_\_\_ tip § Place finger on soft tissues next to the root tip > swelling bc of an abscess from a root tip • Palpation ○ Pressure in area of the root tip to see if it hurts the patient • Question response from cold test > electricity ○ Patient holds onto something > electric current through the patient > may feel a tingling in the tooth ○ The electricity would get to the roots if part of the pulp was \_\_\_\_ (like the previous example) • If goes to the end > nerve probably isn't alive anymore • From CC, dental history and test > severe pulpitis in #3 it is an irreversible pulpitis ○ Some pulpitis may be w/o pain ○ This patient had symptoms > \_\_\_\_ • Any diagnosis is two fold > the \_\_\_\_, and the status of the \_\_\_\_ (apical) structures ○ So far we described the pulpal dx, and since the patient had pain when tapping on the tooth > know that there's something in the \_\_\_\_ area as well > \_\_\_\_ in addition! • Pulp is bleeding a lot > severe inflam
long axis
side
root
removed sympamatoic irrev pulp pulp periapical periapical sympto apical perio
