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pulp Flashcards

1
Q

what is pulp

A

soft connective tissue occupying the pulp space and root canals

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2
Q

what does the pulp provide

A

vitality to teeth with its cells (odontoblasts, fibroblasts, undifferentiated ectomesenchymal cells, macrophages, other immunocompetent cells), fibre, vascular and nerve supply
richly vascularised + innervated tissue

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3
Q

what is the apical foramen

A

opening of root pulp into the pdl near the tip of the roots

makes pulp continuous w the pdl

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4
Q

why may pulp necrosis occur

A

following

1) exposure
2) contamination

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5
Q

what may pulp be termed and why

A

1) coronal = in the pulp chamber in the crown of the tooth
2) radicular = extends throughout root canal spaces of roots
depending on part of tooth it occupies

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6
Q

how can pulp tissue communicate with the pdl and explain these

A

lateral and accessory canals

  • small communication channels between the 2
  • may arise from the floor of pulp chamber or walls of the main root canal
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7
Q

main function of pulp

A 
producing, maintaining and repairing both primary and secondary dentine
also tertiary (reactive + reparative) dentine due to injury
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8
Q

what happens to the pulp in response to disease like caries

A

pulpitis

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9
Q

what is the role of odontoblasts in the pulp

A

form peripheral cells

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10
Q

what function of pulp mandates use of anaesthesia during cavity prep

A

protective sensory function

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11
Q

how is the pulp environment sterile

A

protected from oral organisms and injury by the mineralised hard tissue walls of the coronal and root dentine (and indirectly by enamel and cementum)

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12
Q

pulp morphology for every tooth is unique. what imaging techniques enable us to assess their anatomy

A

1) plain radiography (2d image)

2) cone beam computed tomography (CBCT) (3d image) = image modality used to evaluate root canal treatment

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13
Q

how does pulp produce
a) primary
b) secondary
dentine

A

primary

1) Pulp tissue develops from dental papilla of tooth germ
2) peripheral cells of the papilla differentiate into odontoblasts

secondary

1) produced by odontoblasts (slowly but regularly during lifespan of tooth)
2) maintains resilient property of dentine and may help compensate for loss of coronal dentine thickness by tooth surface loss, caries or fracture

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14
Q

explain the sensory function of the pulp dentine complex

A

1) detect chemical (and indirectly thermal / mechanical) stimuli
2) forms part of feedback mechanism to cns (of noxious stimuli that can be associated with tissue damage)

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15
Q

what are the components of pulp

A

odontoblasts, nerve fibres and antigen presenting cells
undifferentiated stem cell role in tissue’s response to significant injury as lay down tertiary dentine at specific sites on the walls of the pulp chamber

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16
Q

what is dental pulp a likely source of and why

what will increased outward flow of this help do

A

DENTINAL FLUID
bc maintains a positive interstitial tissue fluid pressure
may help dilute bacterial toxins in exposed dentinal tubules + detected by the pulp

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17
Q

what does blood supply to the pulp

a) transport
b) dilute and remove

A

a) immune cells and inflammatory mediators to the area

b) damaging agents to resisting infection

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18
Q

what is the process of tertiary dentine formation following a large injury or pulp exposure

A

1) stem cells from blood vessel differentiate into odontoblast like cells
2) odontoblast-like cells interact w dentine matrix components
3) reparative dentine / mineralised bridge formed

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19
Q

what is the process of tertiary dentine formation following a minor injury

A

1) odontoblasts interact w dentine matrix components

2) form reactionary dentine

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20
Q

what 4 distinct regions or histological ‘zones’ can be identified from coronal pulp soft tissue

A

1) SUPRA-ODONTOBLAST REGION
2) ODONTOBLAST LAYER
3) CELL-FREE ZONE (OF WEIL)
4) CELL-RICH ZONE

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21
Q

describe the SUPRA-ODONTOBLAST REGION

A

1) space between most peripheral of these zones +unmineralised predentine
2) Nerve axons (most enter + terminate in dentinal tubules) AND the dendritic antigen presenting cells
3) axons on front line + positioned to detect changes in dentinal fluid movement and composition

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22
Q

describe the ODONTOBLAST LAYER

A

1) most peripheral zone
2) single layer of odontoblast cells (may appear stratified)
odontoblasts reach into pre + mineralised dentine

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23
Q

describe the CELL-FREE ZONE (OF WEIL)

A

1) beneath odontoblasts
2) prominent in coronal pulp
3) cant see nuclei of cells BUT cell processes of fibroblasts, odontoblasts, nerve axons + capillaries cross this area
4) capillaries, korff fibres, nerves present
4) suggestion its an artifact due to tissue shrinkage

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24
Q

describe the CELL-RICH ZONE

A

1) high cell density
2) adjacent to cell-free zone in coronal pulp
3) high conc of capillaries (subodontoblastic capillary plexus) AND axons (subodontoblastic neural plexus) and fibroblast cells
4) Schwann cells + endothelial cells associated with these ‘plexi’ result in ‘cell-rich’ appearance

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25
Q

what layer is beneath the CELL-RICH ZONE

A

deep pulp cavity

- contains subodontoblastic plexus of rashcow

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26
Q

what other areas of the pulp exist

A

1) central core = occupied by main arterioles, venules (enter by apical and accessory foramina) and nerves (enter by apical foramen)
2) bulk of dental pulp = made up of above + loose connective tissue
3) root canal = neurovascular bundle most evident
4) crown = repeated branching of nerves and blood vessels makes it less obvious

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27
Q

describe pulp composition

A

1) 75% water 25% organic material
2) loose connective tissue
3) cells embedded in an extracellular matrix of fibres in a ground substance

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28
Q

what is the predominant extracellular matrix component

A

COLLAGEN

  • concentrated in most apical part of pulp
  • content incs w age, fibrils organise into bundles
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29
Q

what is the non-fibrillar matrix of pulp

A

1) secreted by pulps cells
2) glycosaminoglycans, proteoglycans, glycoproteins, and water
3) supports cells + acts as medium for transport between cells + vasculature

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30
Q

what is the neurovascular bundle

A

formed by nerves together w blood vessels

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31
Q

describe the fibrous component of dental pulp

A

1) combo of collagen types I (60%) and III (40%) fibrils grouped into fibres thinly + irregularly scattered throughout the tissue
2) at periphery fibres more organised as aligned parallel to the forming predentine surface

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32
Q

what are GLYCOSAMINOGLYCANS (GAGS) and explain their content in mature pulp

A

1) unbranched polysaccharide chains mostly bound to a protein core to form proteoglycans (in pulp)
2) hydrophilic so in combo with h2o give pulp its unique gel-like properties (allow it to swell + fill most of extracellular space stabilising positions of cellular components + making movement of h2o + ions possible also reservoir for growth factors + bioactive molecules)
CONTENT
60% hyaluronic acid
20% dermatan sulphate
12% chondroitin sulphate

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33
Q

what are GLYCOPROTEINS / PROTEOGLYCANS

A

1) non-collagenous matrix components
2) Fibronectin (also occurs in fibrous form) and tenascin = most abundant near odontoblast layer + involved in deposition of dentine
3) Fibronectin = binds to membrane receptor proteins (integrins), mediating adhesion between cells, matrix components + vascular endothelium = maintaining structural integrity of pulp

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34
Q

what molecules can be detected at the periphery of the pulp

A

those more closely associated w dentine

ie dentine sialoprotein + dentine phosphoprotein (both produced by odontoblasts)

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35
Q

list the GLYCOPROTEINS / PROTEOGLYCANS of the dental pulp and their functions

A

1) versican + syndecan = form large hydrated aggregates creating a gel
2) decorin = binds to type I collagen
3) biglycan = regulate collagen fibrillogenesis
4) integrins = cell surface adhesion receptors
5) fibronectin = conc near odontoblast layer + binds cells to extracellular matrix
6) tenascin = cell movement, conc near odontoblast layer
7) osteoadherin = mineralisation

36
Q

list the cells of the dental pulp

A
  • FIBROBLASTS
  • ODONTOBLASTS
  • DENTAL PULP STEM CELLS (DPSCs)
  • MACROPHAGES
  • T LYMPHOCYTES
  • DENDRITIC CELLS
37
Q 
explain 
a) presence
b) histological appearance
c) role 
of pulp fibroblasts
A

a)
loose network throughout tissue + numerous in cell rich zone
b)
variable, reflects metabolic activity
some star shaped
some flattened and spindle shaped
c)
tissue dvlpmt = produce extracellular fibres + ground substance
ingest + degrade collagen
mature teeth = slowly produce + turnover extracellular matrix

38
Q 
explain 
a) presence
b) histological appearance
c) role 
of pulp odontoblasts
A

a)
single cell layer attached to predentine surface in mature teeth
BUT ‘pseudostratification’ = false appearance of multiple layers bc nuclei of adjacent cells in layer at different levels
b)
at crown / coronal = columnar outline
root = more cuboidal
fully differentiated are polarised columnar cells w long cell process extending into predentine + dentine in a dentinal tubule AND smaller processes linking it to adjacent odontoblasts and other pulp cells
c)
lay down secondary dentine at slow rate throughout life (at this stage odontoblast layer becomes a flatter cell layer + no of cells declines by apoptosis)
odontoblast layer provides controlled barrier between pulp + dentine
integrity of odontoblast layer and its limited permeability maintained by cell-to-cell junctions (these also link it to other pulpal cells ie fibroblasts)

39
Q

what are the two major components of odontoblasts

A

1) cell bodies = lie adjacent to unmineralised dentine matrix (predentine)
2) cell processes = extend outward for variable distance through tubules in predentine + dentine

40
Q

explain DENTAL PULP STEM CELLS (DPSCs)

A

1) in 2 regions = peripherally beneath odontoblast layer + centrally around blood vessels
2) multipotent so differentiate into = odontoblasts, chondrocytes, adipocytes, vascular endothelial and neurons

41
Q

explain MACROPHAGES

A

1) most abundant + widely distributed defense cells in pulp

2) eliminate dead cells (presence of these indicates turnover of dental pulp fibroblasts occurs)

42
Q

explain T LYMPHOCYTES

A

1) small numbers in normal dental pulp

2) numbers increase when pulp injured or subjected to toxins

43
Q

explain DENDRITIC CELLS

A

1) most prominent immune cells in pulp
2) bone marrow–derived + antigen-presenting (APCs)
3) non-erupted teeth = in and around odontoblast layer
4) erupted teeth = beneath odontoblast layer + around nerves and blood vessels
5) immunosurveillance = inc in number in carious teeth (infiltrate odontoblast layer + project their processes into dentinal tubules)
6) recognise many foreign antigens + act as APCs stimulating division and activity of T lymphocytes in regional lymph nodes

44
Q

list vessels of the pulp

A
  • ARTERIOLES + VENULES
  • SUBODONTOBLASTIC CAPILLARY PLEXUS
  • LYMPTHATIC VESSELS
45
Q

how do arterioles and venules enter pulp and what do they do once inside

A
  • via apical foramina (+ lateral canals) as components of neurovascular bundles
  • as pass up through radicular portion of pulp = give off smaller lateral branches to periphery
    3) lateral branches branch into subodontoblastic area
    4) no of branches given off incs as arterioles pass up through root
    5) coronal region = divide + subdivide to form extensive vascular capillary network
46
Q

explain the SUBODONTOBLASTIC CAPILLARY PLEXUS

A

1) capillary network in subodontoblastic area, beneath odontoblasts
2) terminal capillary loops extend to lie between odontoblasts in odontoblast layer OR between odontoblasts and predentine
- fluid in dentine = ultrafiltrate of pulpal interstitial fluid

47
Q

explain LYMPTHATIC VESSELS

A

1) arise as small, blind, thin-walled vessels in coronal region of pulp
2) pass apically to exit through apical foramen

48
Q

describe the arrangement of pulpal blood vessels

A

1) supply o2 + nutrients where most needed during dentinogenesis
2) 5% of capillaries in subodontoblastic zone are fenestrated = rapid movement of materials out of them
3) arteriovenous anastomoses found between peripheral pulpal vessels + allow rapid changes in blood perfusion

49
Q

what nerves are principally contained in the nerve / neurovascular bundles in the pulp

A
  • entering pulp = sensory afferent nerves of the trigeminal nerve (CN V)
  • sympathetic efferent (motor) branches from superior cervical ganglion
  • each bundle contains myelinated and unmyelinated axons
50
Q

where do nerve fibres travel in the root

A
  • some leave central nerve bundle @ intervals + travel to periphery
  • most continue to coronal pulp + end in odontoblastic or subodontoblastic regions
51
Q

where do nerve fibres travel in the pulp chamber

A
  • follow course of blood vessels
  • initially large nerve bundles
  • spread apart peripherally as extend occlusally through pulp core
  • before terminating = myelinated axons lose myelin sheath + most terminate as free unmyelinated nerve endings (in subodontoblastic plexus of Raschkow)
52
Q

explain the subodontoblastic plexus of Raschkow

A

extensive plexus of nerves beneath cell-rich zone in crown

1) small no of nerves = exit + travel to and terminate around odontoblasts
2) subset of these = continue into tubules along with odontoblast processes (dont synapse w the processes BUT remain in close proximity w them for part of their length)
3) no of tubules containing nerve fibres in relation to overall no of tubules is small (incidence higher in pre than mineralised dentine)

53
Q

what are the 2 main sensory nerve fibres, explain them

A

myelinated A-fibres

1) 90% narrow A-delta + 10% wider A-beta fibres
2) terminate at sub-odontoblast, odontoblast and predentine/dentinal tubules
3) responsible for rapid, sharp pain sensation associated w dentine hypersensitivity

unmyelinated C-fibres (75%)

1) terminate in pulp core or sub-odontoblast region (as free nerve endings or branches around blood vessels)
2) conduct slow, dull, throbbing pain associated w significant pulpal inflammation
3) afferent or sympathetic efferent

54
Q

explain process of innervation of dental pulp

A

1) branches from alveolar nerve enter apical area
2) Multiple bundles enter pulp through apical foramen and branch further on their way to the crown
3) Most nerve axons terminate at pulp/dentine border of coronal pulp (most densely innervated area in the tissue)
4) fewer nerve endings in cervical area
5) pulp/dentine border in root pulp is sparsely innervated
6) mechanical, thermal + chemical stimuli initiate impulse that travels along pulpal axons in maxillary (V2) or mandibular (V3) of trigeminal nerve to trigeminal ganglion

55
Q

what do trigeminal afferents do

A

control local environment (pulpal homeostasis + its defence mechanisms) rather than carry sensory information centrally (dentine sensitivity and pain)

56
Q

what is the role of UNSHEATHED NERVE AXONS IN DENTINAL TUBULES (lack myelinated Schwann cell covering)

A

1) susceptible to changes in extracellular environment at pulp–predentine border + among odontoblast cell bodies
2) changes affect membrane properties of these nerve terminals
3) sense changes in fluid movement through dentinal tubules
4) AND changes in extracellular fluid composition (delayed in reaching core of pulp bc of barrier properties of odontoblast layer)

57
Q

what is the role of NEUROPEPTIDES

A

1) activity in afferent terminals doesnt reach level of sensation
2) BUT causes release of neuropeptides (ie CGRP + substance P) by axon reflexes bc in these reflexes impulses generated in 1 terminal branch, travel centrally then, pass back down to peripheral branches
4) local control of blood flow as affect vasodilation (build-up of metabolites locally also has effect on blood flow control)

58
Q

what is CALCITONIN-GENE-RELATED PEPTIDE (CGRP)

A

1) potent vasodilator
2) main agent controlling blood flow locally in periphery of dental pulp
3) role in pulpal blood flow
4) initiate / control hard-tissue production by stimulating increased production of bone morphogenetic protein-2 [(BMP)-2)
5) BMP)-2 = signalling molecule in dentine formation

59
Q

what vascular changes occur in pulp inflammation following injury

A

1) mediated by local nerves (sensory and sympathetic fibres)
2) Unmyelinated autonomic C-fibres terminate in pulp core + supply arteriolar smooth muscle, act to maintain vasomotor tone so control pressure + distribution of blood in health
3) vasoactive contribution of afferent nerves largely in peripheral pulp + significant when theres inflammation

60
Q

explain the steps in induction of neurogenic vasodilation + inflammation at the pulp/dentine border

A

1) external stimulus causes fluid flow (induces change in membrane properties in nerve endings at pulp/dentine border)
2) result = nerve impulse conduction along collateral endings of same axon
3) some endings are adjacent to blood vessels 4) in response to activation, terminals release sensory neuropeptides (induce vasodilation + inc permeability of vessel wall)

61
Q

which changes to dental pulp occur with age

A
  • REDUCTION IN VOL OF PULP CAVITY
  • GRADUAL DEPOSITION OF PERITUBULAR DENTINE
  • REDUCED CAPACITY FOR REPAIR FOLLOWING INJURY
  • ALTERATIONS IN COMPOSITION OF THE NON-FIBRILLAR MATRI
62
Q

explain the reduction in volume of pulp cavity

A

1) Secondary dentine deposition throughout life of tooth (sometimes accompanied by tertiary dentine formation) reduces size of pulp
2) pulp horns usually recede (this along w reduced innervation + addition of dentine = causes lack of sensitivity associated w older teeth)
3) root canals become thin channels + can appear almost completely calcified

63
Q

explain the effects of gradual deposition of peritubular dentine

A

1) completely occludes groups of dentinal tubules producing translucent dentine
2) lead to increased brittleness + decreased permeability of dentine

64
Q

what is - reduced capacity for repair following injury caused by

A

diminishing vascularity + perfusion of pulp
loss and degeneration of nerve axons
reduction in cellularity

65
Q

explain the effects of alterations in composition of non-fibrillar matrix

A

1) interfere with its functions to produce…
metabolic changes
reduced cellular function
irregularities in mineral deposition
2) pulp fills with increasing amount of collagen fibres (along w reduction in stem cell no’s = impact regenerative capacity of pulp)
ie pulp capping procedures have poor outcome in elderly patients bc reduced pulpal blood supply

66
Q

what are pulp stones

A

age-related change

1) pulp mineralises in this form (lamellated pulp stones consist of concentric layers of mineralised tissue)
2) discrete calcified masses w similar composition to dentine
3) singular or multiple in any tooth
4) resemble dentine in being (partially) tubular (‘true’ denticles)
5) more often resemble bone by having cells embedded within them (‘false’ denticles)

67
Q

where do we find larger pulp stones

A
  • attached to dentine
  • orifice of pulp chamber
  • in root canals
68
Q

explain the presence of pulp stones

A

1) no +/or vol incs w age
2) presence signif as reduces overall no of cells in pulp
3) usually detected on radiographs (presence not an indication for active treatment)
4) can prevent access to the root canal orifices if large + attached to dentine in the pulp chamber SO these stones require removal using ultrasonic instruments prior to debridement and shaping of the root canals during endodontic treatment

69
Q

how do we determine health status of the pulp

A

pulp vitality (sensibility) tests

  • practical chairside test
  • need vital, healthy pulp to ensure long term survival of tooth
70
Q

when would a pulp vitality test be required

A

1) if tooth appearance, clinical signs or symptoms suggest compromised vitality
2) ie investigating cause for discolouration or signs of infection in mouth adjacent to specific tooth/teeth
3) indicated in planning stage prior to carrying out certain treatments which further harm compromised pulp e.g. preparing a tooth for a crown

71
Q

what 2 tests are used to confirm vitality and explain them

A

temp stimulation

1) cold from cotton wool pledgets soaked in ethyl chloride
2) use to stimulate vital nerves in pulp on clean air-dried tooth

electrical stimulation

1) electric pulp test (EPT)
2) test unit passes a small current through the patient + tooth its in contact with
3) probe of electric pulp tester placed on clean dry tooth surface w a conducting gel

72
Q

what does a vitality test suggest

A

1) confirm a response from a tooth
2) indication of health of pulp tissue
3) if pulp is inflamed or non- vital (partially or fully necrotic)
4) warrant further investigation
BUT
2) damage to pulp tissue causes unpleasant clinical symptoms + limits treatment options

73
Q

what is pulp response at early stage of caries

A

3) pulpitis detected histologically when caries limited to enamel = painful, induces short, sharp pain (pts would seek treatment)
4) inflam is normal healing response of pulp
5) removal of caries allows inflam to subside

74
Q

what happens to the pulp upon further caries progression / damage to dentine

A

1) irreversible pulpitis (pain lasting more than few secs aft a stimulus)
2) = limited chance to revert to normal if only caries removed SO also remove inflamed pulp tissue
3) irreversible pulpitis = confined to coronal pulp
4) radicular pulp = uninflamed

75
Q

how is EXTENSIVE IRREVERSIBLE PULPITIS treated

A

1) complete removal of pulp tissue + endodontic treatment
2) following it pulp become necrotic, total loss of tissue functions
3) necrotic pulp tissue = becomes infected (bacteria (biofilm) + their products reach + trigger inflam reaction around root apex)
4) inflam + sepsis follow and spread to supporting tissues around tooth

76
Q

what are the 4 adverse reactions to to caries, trauma, and iatrogenic injury (ie unintentional exposure of pulp during caries removal)

A

pulpitis
pulpal necrosis
periapical lesions
pain

77
Q

what do we use when small exposure of uninfected pulp during cavity prep occurs

A

REGENERATION OF DENTINE BRIDGE

  • repairs + forms bridge of dentine over the exposure
  • odontoblast-like cells differentiate + lay down tertiary reparative dentine
78
Q

CLINICAL CONSIDERATIONS: REGENERATION OF DENTINE BRIDGE (Reparative dentinogenesis)

what are biocompatible materials

A

biodentine

  • facilitate (tertiary) dentine bridge formation
  • place over exposure as a ‘pulp cap’ protects pulp
79
Q

CLINICAL CONSIDERATIONS: REGENERATION OF DENTINE BRIDGE (Reparative dentinogenesis)

what are bioactive materials

A

Mineral Trioxide Aggregate (MTA)

  • induce reparative dentinogenesis = stimulate pulpal stem cells to induce matrix formation + mineralisation
  • interact w phosphate-containing fluids to form apatite precipitates
80
Q

CLINICAL CONSIDERATIONS: REGENERATION OF DENTINE BRIDGE (Reparative dentinogenesis)

what are biologically active molecules

A

bone morphogenetic protein (BMP), TGF-β + other components dentine matrix
- direct, +ve effect on differentiation + activation of dentine-producing cells
- release + aid dentine bridge formation during demin of dentine w caries
NOT widely applied clinically

81
Q

CLINICAL CONSIDERATIONS: REGENERATION OF DENTINE BRIDGE (Reparative dentinogenesis)

in what cases would bridge formation be unsuccessful

A

infected (carious exposure) / contaminated (fail to isolate tooth in trmnt) exposed pulp

instead remove dental pulp + replace w inert root canal filling material

82
Q

CLINICAL CONSIDERATIONS: PULP REGENERATION TECHNIQUES

what is root canal treatment / therapy

A

1) root canal anatomy complex
2) variable root canal shape
3) parts of root canal system (lateral/ accessory canals) inaccessible for mechanical debridement = prevents complete biofilm removal
4) root canal treated teeth = weakened w reduced survival rate
5) reliable outcomes

83
Q

CLINICAL CONSIDERATIONS: PULP REGENERATION TECHNIQUES

what is a better approach

A

tissue engineering to stimulate synthesis of new pulp inside empty root canal

84
Q

CLINICAL CONSIDERATIONS: PULP REGENERATION TECHNIQUES

what is the 1st approach to tissue engineering method

A

1st APPROACH

1) remove og necrotic pulp
2) prep root canal space to retain positive features of dentine surface to encourage pulp regen
3) transplanted stem cells in suitable scaffold + w morphogenetic signalling agents (ie BMPs + FGFs) introduced into prepared pulp/root canal space

85
Q

CLINICAL CONSIDERATIONS: PULP REGENERATION TECHNIQUES

what is the 2nd approach to tissue engineering method

A

1) fill root canal w
suitable scaffold
2) morphogenetic signalling agents that may chemotactically encourage stem cells from the environment of the root apex to populate the scaffold

86
Q

CLINICAL CONSIDERATIONS: PULP REGENERATION TECHNIQUES

what is the revascularisation technique of tissue engineering

A

1) stem cells from apical (SCAP) (obtained by disorganising tissue at tooth apex w endodontic file)
2) blood flow carries stem cells into empty canal space + form blood clot
3) BUT doesn’t achieve regen of new pulp tissue

87
Q

from which teeth do we commonly isolate stem cells

A

3RD MOLARS

  • most commonly extracted + often not completed root development
  • Dental pulp stem cells (DPSCs) isolated
  • Root apical papilla (root foramen area) stem cells (SCAP) isolated

IOE (22 decks)

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