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DENTAL PULP

Seminar by Dr. SATHYA KUMAR.S Postgraduate Student

DEPARTMENT OF ONSER!AT"!E DENT"STRY # ENDODONT" S SR" RAMA HANDRA DENTA$ O$$E%E AND HOSP"TA$S HENNA"

CONTENTS
Introduction The Pulp as a Connective Tissue The Cells of the Pulp Fibers Ground Substance Systemic Factors that affect the Pulp The Circulation of the Pulp Clinical Correlations Aging Periodontal Disease Changes due to Inflammation Dental Caries Defense against Caries The dynamics of the Development of Pulpitis from Dental Caries Indirect Pulp Capping Relationship of Depth of Preparation to Reparative Dentin Formation ther Physical Trauma Polishing of Restorations Dentin Sterili!ing Agents Permanent Restorative "aterials Pulp Capping and Pulpotomy Drugs in Pulp Capping and Pulpotomy #ateral $ Accessory Canal Anatomic Considerations %ffects of Periodontal Treatment $ #ocal "edication Correlation of Periodontal Involvement &ith Pain Retrogressive and Age Changes of the Dental Pulp Decrease in Cellular Components #ocal Factors "NTRODE T"ON

The living pulp creates and shapes its o&n local in the center of the tooth' The pulp under normal conditions tends to form dentin eventually( faciolingullay and mesiodistally' The pulp therefore tends to lie in the center of the tooth and shapes itself to a miniaturi!ation' The pulp is bunch of tissues made of nerves( blood vessels( connective tissues

THE PU$P AS A ONNE T"!E T"SSUE The dental pulp is composed of cells( ground substance and fibers' The cells manufacture a fundamental matri)( &hich then acts as site and precursor for the fiber comple)' The fiber comple) is composed of collagen and reticulum'

THE E$$S OF THE PU$P Fibrob&asts The basic cells of the pulp are fibroblasts( &hich are similar to connective tissue fibroblasts found else&here in the body' In the young pulp there is a great preponderance of fibroblasts as compared &ith collagen fibers'

Fibroblasts are active in collagen synthesis' The fibroblasts reveal &ell*developed organelles &ith e)tensive( dense( rough*surfaced

endoplasmic reticulum in the form of dilated cisternae'

Ro&s and clusters of ribosomes are present' The Golgi apparatus has an e)tensively developed stac+ and a large number of vesicies and vacuoles' The mitochondria are large &ith straight cristae running transversely across the matri)' A cilium is fre,uently found near the nucleus and an additional centriole may be located perpendicular to the long a)is of the cilium' Collagen fibers are present on the cell body and its processes'

Dental pulp synthesi!e at least si) glycoproteins( the ma-or one being fibronectin'

Pulp fibroblasts also synthesi!e and secrete chondroitin sulfate a ma-or sulfated In addition( they manufacture heparin and dermatan sulfates'

The fibroblasts e)hibit faint metachromasia( and phosphatase and adenosine triphosphate activity' .#ipid/ particles are present in their

cytoplasm' As the individual gets older( glycogen and other periodic acid*

Schiff Positive materials increase( In older tissues( the cellular elements begin to decrease' This fiber increase and cell reduction has clinical implications( in that a more fibrous pulp is less able to defend itself against irritants than is a young( highly cellular pulp'

0oth fibroblasts and odontoblasts are derived from the mesenchyme( but odontoblasts are more highly differentiated cells than are fibro*blasts'

ODONTO'$ASTS The odontoblast is a highly differentiated cell in the pulp' The main function of the odontoblasts is the production of dentin' "orphologic

variations occur in the odontoblasts( ranging from the tall columnar cells in the cro&n of the tooth to a lo& columnar type in the middle of the root' In the root portion of the tooth( the odontoblasts are shorter and are more or less cuboidal' To&ard the ape)( they are flattened and loo+ more li+e fibroblasts'

In the coronal portion of the pulp( odontoblasts are more columnar( they elaborate regular dentin &ith regular dentinal tubules'

0oundaries bet&een predentin and dentin

E$E TRON M" ROS OPE F"ND"N%S In Scanning electron micrographs( odontoblasts appear as large( closely aligned( multilayered( s&eet potato*shaped cells' Nu(&eus. The

nucleus of a typical odontoblast is ellipsoidal and contains chromatin and nucleoli' T&o*thin membranes surround the nucleus( the inner membrane appears to be continuous( but the outer one is interrupted at points by openings'

NU $EO$US In electron microscope e)aminations of human teeth( differentiated odontoblasts contained one to four nucleoli' developed teeth &ere ring*shaped' The nucleoli from fully

In less developed teeth( compact

nucleoli( representative of types active in R1A production(

YTOP$ASM "ost of the cytoplasm is occupied by an e)tensive rough*surfaced endoplasmic reticulum and by numerous transitional vesicles of the r%R'

Fine fibrillar material is present &ithin the cisternae of the r%R' The central portion of the odontoblast is occupied by a large Golgi apparatus'

2esicles are concentrated near each immature face of the Golgi apparatus' "embrane*bound granules of varying si!es and shapes( possibly lysosomes containing a highly dense material are found in the cytoplasm' Secretory granules containing mineral deposits are present in the area of the Golgi comple)' "itochondria are evenly distributed throughout most of the cell body( Centrioles are present throughout the region of the Golgi comple)' #arge numbers of microtubules are also present'

The odontoblasts are lined up in palisade formation along the predentin border' Generally( the odontoblastic layer is about si) to eight cells deep' The organelles( &hich are situated in the cell body( e)tend as far as the level of the modified terminal bar apparatus(

THE ODONTO'$AST" PRO ESS %ach odontoblastic process traverses the predentin( and then occupies a canaliculus in the dentin' The odontoblastic processes .called dentinal fibers( or Tomes fibers3 are cytoplasmic tubular pro-ections'

The odontoblastic processes are usually devoid of ma-or cytoplasmic organelles' Dense .secretory/ granules and lysosome li+e bodies are also

present' 1umerous filaments are oriented parallel to the cell membrane' These fine filaments are the most characteristic feature of the odontoblastic process and its branches' Groups of microvesicles similar to those seen in the Golgi apparatus( are situated near the plasma membrane'

"NTERE$$U$AR )UN T"ONS. Small regions of the plasma membranes bet&een cells are visible only by electron microscopy' There are three types of intercellular -unctions3 .4/ impermeable( .5/ adhering( and .6/ communicating'

"MPERMEA'$E )UN T"ONS also +no&n as tight -unctions( help the cell maintain a distinct internal environment'

ADHER"N% )UN T"ONS are maintained by desmosomes( &hich are the intercellular bridges seen in light microscopy' There are three types of desmosomes7 belt( spot( and hemidesmosomes'

OMMUN" AT"N% )UN T"ONS* also +no&n as gap -unctions( are structures that mediate direct transfer of chemical messages bet&een cells' They enable cells to e)change nutrients and signal molecules for coordination of function'

ODONTO'$AST" )UN T"ONA$ OMP$E+ES. Surface epithelial cells possess terminal bars at their apical e)tremities' The terminal bars are seen to consist of several components( designated as -unctional comple)es'

In the border region bet&een odontoblastic processes and cell bodies( neighboring odontoblasts are in close contact &ith each other and &ith other pulp cells' Such -unctions permit the passage of small substances bet&een cells' Thus( the -unctional comple) present at the apical end of the

odontoblast may not be entirely similar to that seen at the apical ends of epithelial cells'

Tight adhesion occurs bet&een odontoblasts( and they are not easily separated'

NER!E END"N%S Although the presence of nerves in the dentinal tubules is controversial( nerve endings in -u)taposition to the odontoblastic processes have been reported'

Structure of odontoblastic process

ODONTO'$AST"

OMMUN" AT"ONS

The odontoblastic nuclei al&ays remain at the inner border of the dentin( and unli+e the osteoblasts they do not become buried unless they are pathologically involved' The odontoblastic processes are in contact &ith ad-acent processes through an e)tensive lateral branch' The odontoblasts may be regarded as part of a mesenchymal syncytium'

If an odontoblast is in-ured( other odontoblasts are affected' The cytoplasm of the odontoblasts contains a basophilic stippling attributable to the presence of R1A' "inute sudanophilic .probably lipid7 granules and vacuoles are scattered throughout the cytoplasm and the dentinal fibers'

These findings these cells are capable of glycolysis and fatty acid metabolism plus a functional citric acid cycle and pentose shunt' %sterases of various types have been detected in the odontoblasts and subodontoblastic layers of the pulp and in pulp homogenates( indicating intracellular anabolic or digestive functions'

The function of odontoblasts is the secretion of ground substance and collagen' 8nder the layer of odontoblasts in the coronal portion of the tooth( there is a cell*free !one that contains nerve elements'

DEFENSE AND OTHER E$$S Some of the cells in the pulp are defense cells' 9istiocytes( or resting &andering cells( are usually found near the blood vessels'

8ndifferentiated mesenchymal cells are capable of becoming macrophages during in-ury' They also may become fibroblasts(

odontoblasts( or osteoclasts' 0efore in-ury( they appear elongated7 follo&ing in-ury( they differentiate into macrophages and( as such can ingest foreign material' Fat cells are not ordinarily found in the pulp'

#ymphocytes are not found usually in the un*inflamed pulp( Plasma cells and eosinophils are found there follo&ing in-ury'

Pericytes are found in the &alls of the precapillaries and metarterioles the function of pericytes is to manufacture the connective tissue of the precapillary region'

F"'ERS The fibers of the pulp are the same as those of other connective tissues' Reticular fibers are found around blood vessels and around the odontoblasts in the pulp'

Collagen fibers are by the pulpal fibroblasts' There are t&o prominent patterns of collagen deposition in dental pulp3 diffuse( in &hich the collagenous fibers lac+ of definite orientation( and bundle type7 in &hich large( coarse bundles run parallel to nerves or independently' In young pulps( fe& collagen fibers are found' As the pulp gets older more and more collagen is elaborated'

Pulp collagen fiber turnover is fairly high compared &ith that of other dental tissues'Regardless of age( the apical portion of the pulp is usually more fibrous than the coronal portion'

%ROUND SU'STAN E The ground substance of the pulp is part of the system of ground substances in the body' It influences the spread of infection( metabolic changes in cells( stability of crystalloids( vitamins( and other metabolic substances' and the effects of hormones(

The ground substance of the pulp is similar to that of connective tissue else&here in the body7 it is composed of protein associated &ith glycoproteins and acid mucopolysaccharides 5:; of the pulpal carbohydrate is in glycosaminoglycans'

The follo&ing properties have been attributed to glycosaminoglycans &ater retention( ion binding and electrolyte distribution during

minerali!ation .0o&ness( 4<=>/( and influence on collagen fibrillogenesis

The pulps of gro&ing teeth stain metachromatically( The metabolism of the cells and the fibers of the pulp is mediated through the ground substance' The ground substance( a viscid fluid( through &hich metabolites pass from the circulation to the cells and through &hich brea+do&n products from the cells come bac+ to the venous circulation' There is no &ay for nutrients to get fro the blood supply to the cells other than through the ground substance'

In a similar manner( substances e)creted by the cell must go through the ground substance to get into the efferent circulation'

Depolymeri!ation by en!ymes elaborated by microorganisms found in pulp inflammation may change the ground substance of the pulp' "ucopolysaccharidase activity has been detected ( by histochemical techni,ues( &ithin the pulps of resorbing deciduous teeth( .4<>:/ these en!ymes are capable of degrading the ground substance of the pulp and dentin by disrupting the glycosaminoglycan*collagen lin+age' Thus( the ground substance plays a significant role in health and disease of the pulp and dentin'

SYSTEM" FA TORS THAT AFFE T THE PU$P Certain systemic conditions affect the cells( fibers( and ground substance of the connective tissue of the pulp'

!"TAM"N DEF" "EN Y Deficiency of certain vitamins( notably vitamin C affects fibroblasts generally and specifically affects the fibroblasts in the dental pulp'

HORMONES AND HORMONA$ "M'A$AN E STERO"DS. Systemic administration of high doses of corticosteroids to rabbit?s collagen synthesis in the dental pulps'

D"A'ETES. Diabetics tend to age more ,uic+ly because of obliterative endarteritis' There is impairment of nutrition and metabolic processes' Tissue repair is interfered &ith in diabetics'

T,yroid De-i(ien(y. There &as rapid deposition of dentin( &hich narro&ed the lumen of the pulp( and all tissues sho&ed a decreased amount of cellular elements'

PROTE"N DEF" "EN Y Dietary proteins are essential for the formation and maintenance of tissue structure7 they constitute the main sources of amino acids and nitrogen( Dietary proteins may also serve as energy sources'

HERED"TARY D"SEASES A number of diseases have been reported to affect the dental pulp' These include diseases of the blood'

THE "R U$AT"ON OF THE PU$P The circulation of the blood is the transportation system by means of &hich the various cells of the body are supplied &ith nutrients and the &aste products from the cells are removed for elimination from the body'

The development of the vascular system structurally and functionally is related directly to the needs of the tissues'

M" RO "R U$AT"ON The primary function of microcirculation is to transport nutrients to( and to remove metabolic &aste products from( the tissues'' The ma-or

microcirculatory vessels are the arterioles' the capillaries( and the venules' The arterioles are resistance vessels measuring appro)imately @:um in diameter and have several layers of smooth muscle( &hich provide for control of vascular geometry'

The arterioles( the capillaries( and the venules are( to some e)tent( able to respond to the variations in the re,uirements of the functioning tissues'

AP"$$AR"ES Capillaries have an average diameter of > um to 4:um' They are the e)change vessels responsible for the transport of materials bet&een blood and tissues'

Capillaries are surrounded by a loose group of reticular and collagenous fibers' The main morphologic characteristic of the capillaries is the general absence of smooth muscle cells' The luminal surface of the endothelial cell lined by a thin layer of glycoprotein( and the tissue side is covered by the basement membrane'

TYPES OF AP"$$AR"ES Depending on its morphologic features( the capillary endothelium can be classified into three basic types3 continuous( fenestrated( and discontinuous'

Continuous endothelium is devoid of fenestrations' Fenestrated endothelium has regional thinning .fenestrations/ of the capillary &alls' Fenestrated capillaries e)ist in the renal glomerulus( in the intestinal mucosa( in the sulcular gingiva( and in the pulp among odontoblasts near the predentin' The basement membrane is discontinuous' Discontinuous

endothelium is found in the spleen( liver( and bone marro&' In the venous system( capillaries coalesce into postcapillary venules'

TRANS AP"$$ARY E+ HAN%E 1utritional material moves from the blood vessel to the cells according to the la&s of hydrostatic and osmotic pressures'

Transcapillary e)change is the ma-or function of the microcirculation( &hich includes transporting nutrients and o)ygen to( and removing &aste products from( the tissues' Transcapillary e)change occurs by diffusion( filtration*absorption( and micropinocytosis' The driving force behind

diffusion is a concentration gradient7 i'e' the direction of flu) is from the high to the lo& concentration'

Capillary ple)us

Aater*soluble substances do not diffuse readily through the membrane7 1ormally( the higher pressure in the arteriolar capillaries favors filtration( &hereas the lo&er pressure in the venular capillaries causes fluid absorption' The number of capillaries in a given area depends on the number of cells in that area'

ONTRO$ OF '$OOD F$O. The blood supply to any given area is controlled by nerve impulses and humoral agents' A hormonal mechanism also is involved in the control of blood flo&' %pinephrine( &hich is liberated from the adrenal medulla( causes vasoconstriction' thereby limiting the flo& of blood'

STUD"ES OF PU$PA$ !ESSE$S Pulpal and periodontal blood vessels have been studied by a variety of techni,ues including cinematography and optical( electron( and )*ray microscopy' The casts sho&ed that the main feeding arterioles entered the root canal through the apical foramina and traversed the central portions to reach the coronal portion of the pulp Some arterioles looped in a 8*turn configuration'

Pulp chamber arterioles could be separated into t&o groups7 one advanced coronally to&ard the pulp horn( branching and forming a dense terminal capillary net&or+ to&ard the dentin' The other ran bet&een the floor and the roof of the pulp chamber( also branching into a dense terminal capillary net&or+' The terminal capillaries drained into the venules beneath the dentin( and merged to form the primary venules' Arteriovenous and veno*venous anastomoses and 8*turn loops appeared to be uni,ue features of the pulpal vessels'

U$TRASTRU TURE OF THE PU$P AP"$$ARY They found that the cytoplasm of the endothelial cells contained rough endoplasmic reticulum .r%R/( a small Golgi comple)( occasional mitochondria( and filaments'

RE%U$AT"ON OF PU$PA$ HEMODYNAM" S ,emi(a& Regu&ation 1erves help to regulate the blood supply to the dental pulp' Sympathetic nerve fibers liberate norepinephrine( &hich constricts the vessels'

The catecholamines( called adrenoreceptors'

There are t&o types of

adrenoreceptors( alpha .a/ and beta .0/( The blood vessels of the pulp contain both A and 0 adrenoreceptors' The A receptors are responsible for contraction of the vascular musculature and produce vasoconstriction' Stimulation of 0 receptors causes a rela)ation of the vascular musculature' Circulating catecholamines such as adrenaline or noradrenaline e)ert less of a vasoconstrictor effect than local sympathetic nerve activation'

!ASO ONSTR" T"ON Intra*arterial administration of norepinephrine decreases pulpal blood flo&' The flo& reduction &as bloc+ed by the A*adrenergic antagonist

pheno)yben!amine .P0B/( indicating the presence of an A*adrenergic system that &as responsible for the decrease in pulpal blood flo&' Sympathetic adrenergic vasoconstrictor system causes variations in systemic hemodynamics( &hich( in turn( influence pulpal hemdynamics' In addition to the sympathetic adrenergic system( other chemical mediators cause vasoconstriction'

VASODILATION Pulpal vessels are apparently e,uipped &ith 0 adrenergic receptors( Activation of 0 receptors by intra*arterial in-ection of isoproterenol caused a parado)ical reduction of pulpal blood flo& the flo& response to IS &as

bloc+ed by the 0*antagonist propranolol7 propranolol alone caused no flo& changes in the pulp' These microcirculatory responses to IS by propranolol' &ere bloc+ed

%ffects of various humoral substances and biogenic amines on pulp blood flo& have been studied( &ith conflicting results'

RATES OF PU$PA$ '$OOD F$O. Pulp blood flo& has been measured in the teeth of e)perimental animals' It can be seen that blood flo& in the pulp is relatively high( compared to that of other oral tissues and s+eletal muscle'

STRU TURA$ AND FUN T"ONA$ HETERO%ENE"TY "N PU$PA$ "R U$AT"ON The anatomic heterogeneity of the vascular net&or+ &ithin the pulp is closely related to the heterogeneous regional flo& distribution' ."eyer and

Path 4<C<( Dim 4<>4/'

The highest capillary density occurs in the

peripheral layer of the coronal region' The core of the apical region has the lo&est density'

"NTRA!"TA$ MO" ROS OP" STUDY "any investigators have observed the living pulp circulation directly' Dim et al .4<>6/ studied microcirculatory dynamics of the pulp in Dim et al found that the fastest mean intravascular flo& velocity in a E5 8m arteriole &as 5'4 mmFsec7 the slo&est mean intravascular flo& velocity .:'44 mmFsec/ &as measured in an 44 8m postcapillary venule'

$YMPHAT" S The lymphatic system is a second circulatory system &hose primary function is to recirculate the interstitial fluid to the bloodstream'' The

lymphatic system also serves as a transport system for the products of cells into the blood circulation'

#ymph and fluid from the teeth and subcutaneous tissues drain into the subma)illary and submental glands and eventually to superficial and deep cervical glands that are distributed along the e)ternal and internal

-ugular veins' From these ducts the fluid is returned to the bloodstream at the -unctions of the left and the right internal -ugular and subclavian veins'

$YMPHAT" S "N THE DENTA$ PU$P The presence of lymphatic vessels in the dental pulp has been the sub-ect of controversy( because of the close morphologic resemblance of lymphatic vessels and veins or capillaries'

The main structural differences bet&een the lymphatic vessels and capillaries are the lac+ of a basement membrane and the absence of fenestration in the endothelial cells' 0ro&n et al .4<=</ have claimed that a recording of osmotic pressure in the pulp is indirect evidence that pulpal lymphatics do e)ist' 0ernic+ .4<CC/ sho&ed that lymph capillaries

originated as blind openings near the Bone of Aeil and the odontoblastic layer' The collecting vessels then passed apically in the pulp( accompanying blood vessels and nerves'

INTRAPULPAL PRESSURE #ea+age of blood proteins and other substances through the &alls of the capillaries into the tissue spaces produces interstitial fluid' The results indicated that the tooth pulp pressure &as pulsatile( &ith the number of pulses perminute corresponding to the dogGs heart rate' 9o&ever( the

pressure &as less than that of the systemic arterial pulse' The pulpal blood vessel response is due to activation( of adrenoreceptors'

Increased tissue pressure apparently occurs e to pulp inflammation' pulp pressure increases up to @:mm 9g &hen pulps are e)posed' The pressure drops dramatically to bet&een @ and 4@ mm 9g &hen the pulp tissue at the e)posure site becomes necrotic'

$"N" A$ ORRE$AT"ONS $o(a& Anest,eti(s 2asoconstrictors are added to a local anesthetic agent for the purpose of prolonging the anesthetic state and for obtaining a deeper anesthesia by confining the anesthetic to the in-ection site'

$"%AMENTA$ "N)E T"ON Recently( the ligamental in-ection techni,ue has become popular' 1either carbocaine nor saline solutions anestheti!e the pulp &hen in-ected ligamentally' The anesthetic must contain epinephrine if the ligamental in-ection is to be effective' Cardiovascular changes may follo& the in-ection of an epinephrine*containing anesthetic agent' Thus( the &isdom of using the ligamental in-ection techni,ue is open to ,uestion'

%ENERA$ ANESTHET" S General anesthetics apparently do have an effect on the velocity of blood flo& in the pulp' &hether or not such blood flo& interferences &ould adversely affect the pulp remain con-ectural'

TEMPERATURE HAN%ES AND DRU%S Temperature changes and drugs applied to the dentin affect the microcirculation of the dental pulp'

TEMPERATURE E$E!AT"ON A 4:cc to 4@oc increase in pulp temperature induced by a heating &ire &rapped around the tooth( caused arteriolar dilation and a linear increase in intrapulpal pressure of 5'@ mm hg per degree centigrade'

9eat generated by tooth preparation may cause pulpal inflammatioon and thereby affect pulpal blood flo&' tooth preparation &ith copious &ater spray to the dentin from all angles resulted in insignificant changes in pulpal blood flo&' 9o&ever( tooth preparation &ithout &ater spray caused

considrable reduction in pulpal blood flo&'

TEMPERATURE REDU T"ON At temperatures lo&er than H5c( the pulp tissues e)hibit immediate pulpal pathology( such as vascular engorgement and necrosis' Substances such as hydrogen pero)ide and carbon dio)ides produce gas emboli in the capillaries of the odontoblastic layer and reduce the blood flo&'

ENDODONT" THERAPY During endodontic therapy( if only part of the pulp is e)tirpated( profuse hemorrhage occurs( because of the increased diameters of the vessels in the central part of the pulp From a clinical standpoint( there &ould be less hemorrhage if the pulp &ere e)tirpated closer to the ape) of the tooth' %)cessive bleeding during instrumentation of the canal may

indicate that some pulp tissue has remained in the apical third of the root canal'

A%"N% In older pulps( circulation is decreased' Atherosclerotic changes ta+e place in the blood vessels( &hich narro& and become increasingly calcified'

PER"ODONTA$ D"SEASE Periodontal disease also causes reduction of the circulation in the dental pulp' As a conse,uence( degenerative pulp changes may ta+e place .Fig'@*5=/' Reparative processes in older fibrotic pulps are diminished as result of a reduction in the blood supply' %)cessive irradiation also

produces a mar+ed degree of arteriosclerosis and arteriolosclerosis( resulting in pulp necrosis'

ANTER"OR OSTEOTOMY cclusal abnormalities may be corrected by ma)illary or mandibular segmental osteotomies' The results indicate that( of all the tissues( pulpal blood flo& &as most severely decreased immediately after surgery

CHANGES DUE TO INFLAMMATION In acute inflammation( chemical mediators released from in-ured cells e)cite sensory nerve fibers( &hich then act on the muscular elements of the blood vessels and cause dilation of the vessels' During chronic inflammation

pulp( tissue pressure is elevated( although reduced from the high pressures resulting from acute inflammation' During inflammation( the effects of infiltration anesthesia are diluted( &hich results in a diminution of anesthesia'

PU$P "R"TANTS M" RO'"A$ Denta& (aries Dental caries is a locali!ed( progressive decay of the teeth' The disease is initiated by deminerali!ation of the surface of tooth by organic acids such as lactic acid produced by microorganisms' The acid is produced by several different microorganisms( most notably streptococcus mutans'

Thus caries of the enamel results from contact of acids and en!ymes that accumulate in pla,ues of microorganisms' The disintegrating substances remain in contact &ith the tooth surface for an e)tended period of time'

arious dentin arious dentin (onsists o- t/o &ayers 0

4' The outer layer( in &hich there is irreversible denaturation and infection' 5' The inner layer( in &hich the denaturation is reversible and there is no infection' This layer can be remineralised physiologically'

In the early stages( carious dentin has the morphologic patter typical of sound dentin' As decalcification progresses( the fibrils of the intertubular matri) are destroyed and the dentinal tubules are distended'

M" ROOR%AN"SMS "N AR"OUS DENT"N "icroorganisms or their products most commonly impinge on the dental pulp during the process of dental caries formation' They are al&ays found in caries of the enamel and the dentin and are involved in both deminerali!ation?s'

0acterial invasion of the dentin occurs in t&o &aves' In the primary invasion( the dentin structure is altered by predominant lactobacilli' A mi)ed bacterial invasion in the secondary &ave is associated &ith gross dentinal destruction'

EFFE TS OF DRU%S The use of Icavity Hsterili!ing agentsG to +ill microorganisms in the dentinal tubules is to be discouraged' It is difficult( if not impossible( to sterili!e the base of a cavity &ith medicaments' Since the medicaments are often more damaging to the dental pulp than are the microorganisms( the use of cavity Hsterili!ing agents should be avoided' Far greater harm to the pulp results from the use of irritating drugs than from leaving the fe& microorganisms that may be present &ithin the dentinal tubules'

DEFENSE A%A"NST AR"ES The pulp defends itself if against dental caries by producing changes in the primary dentin( by elaborating ne& dentin( and by inflammatory and immunologic reactions'

The e)tension of Tomes fibers( form peritubular dentin' The matri) immediately surrounding the odontoblastic process is highly minerali!ed( sclerosis of the dentin Han increase in peritubular dentin constitutes the initial defense of the pulp against dental caries( tending to slo& do&n the decay'

The pulp underlying reparative dentin remains relatively normal until the carious process comes close to it' Just prior to actual e)posure by caries( inflammatory changes become manifest' Thus before e)posure the pulp demonstrates ade,uate defense capacity against caries' The pulp does not become inflamed until reparative dentin is invaded and &ide areas of dentinal tubules are demateriali!ed'

"MMUNO$O%" REA T"ONS TO AR"ES In addition to the dentinal changes( the pulp apparently manufactures antibodies against the antigenic components of dental caries' These immunoglobulins are capable of migrating into the dentin' Immunoglobulins IgG( Ig"( IgA( complement components C6( and CE and secretory component'

THE DYNAM" S OF THE DE!E$OPMENT OF PU$P"T"S FROM DENTA$ AR"ES The persistence of dental caries for &ee+s( months( or years provides a continuous stimulus for an inflammatory response &ithin the dental pulp' The pulp protects itself ade,uately in several &ays( depending on the type of caries and its penetration( the structure of the tooth( the reaction of the underlying dentinal tubules and the age of the patient' The pulp reacts to the

process of dental caries by forming sclerotic dentin in the primary dentinal tubules and also by the elaboration of reparative dentin under the region of the involved tubules'

"ND"RE T PU$P APP"N% Ahat procedure should be employed in deep seated caries &here there is danger of e)posing the pulp if all of the decay is e)cavatedK Should all of the decay be e)cavated( resulting in e)posure( or should some decay be left( in order to avoid e)posure of the pulpK The latter procedure is referred to as indirect pulp capping' Pulps that are uninflammated( in a transitional stage( or in a stage of chronic partial pulpitis &ithout li,uefaction necrosis' Are amenable to indirect pulp capping procedures'

The number of microorganisms remaining in the dentin is reduced by the use of indirect pulp capping agents( such as !inc o)ide eugenol or calcium hydro)ide' In deeply carious teeth( it may be advisable to use hand instruments to remove undermined enamel &alls' The decay then may be e)cavated and !inc o)ide Heugenol placed into the cavity( provided the operator is sure that a pulp e)posure is not present'

Severe pulp damage may develop originally normal pulp after full cro&n preparation'

ODENTO%EN" PU$P"T"S Some commonly used operative procedures endanger the health of tooth more than do the disease processes they are intended to correct' Pulp inflammation for &hich the dentists o&n procedures are responsible may &ell be designated Identistogenic pulpitisG .i'e dentist*inducedG pulpitis/'

REASONS FOR PREVENTING PULPITIS The effect of postoperative inflammation may be to shorten the period during &hich the pulp remains vital and to impair resistance of the pulp to subse,uent irritation' If the dentist by modifying his operative techni,ues( can reduce damage to the pulp'

Cutting of the dentinal tubules or odontoblastic processes causes changes in the in-ured protoplasm that result in lea+age of fluid' This out&ard flo& of fluids causes displacement of the odontoblastic nuclei into the dentinal tubules through capillary action' Ahen the pulp of a tooth is e)amined histological after an operative procedure such as cutting of the dentin( the odontoblastic layer sub-acent to the cavity preparation typically e)hibits changes attributable to the fluid e)udates7 these include displacement of odontoblastic nuclei( disturbance of the pulpodentinal membrane and various degrees of inflammation of the pulp'

DEPTH OF A!"TY PREPARAT"ONS Cavity preparation causes an increased rate of dentin collagen turnover and some odontoblastic cell damage protein synthesis by the odontoblasts directly under( and ad-acent to the cavity preparation is curtailed the deeper a cavity is cut and therefore the closer the odontoblastic nucleus is approached the more severe is the in-ury to the odontoblasts' A superficial cavity preparation that cuts the odontoblastic processes close to the dentinoenamel -unction usually produces only mild irritation'

RE$AT"ONSH"P OF DEPTH OF PREPARAT"ON TO REPARAT"!E DENT"N FORMAT"ON The relationship bet&een increased rate of reparative dentin formation and increased depth of cavity preparations holds only if the dentin remaining bet&een the pulp and the dentinal enamel -unction is at least half the original thic+ness' At that level( the ma)imal threshold of stimulation is reached' Further cutting of the dentin causes greater in-ury to the odontoblasts'

SPEED OF ROTAT"ON Ahen dentin is cut by instruments at the in-ury varies in degree only' The greatest amount of odontoblastic damage occurs are speeds up to

@:(::: rpm( provided that a coolant is used properly' 9igh speed cutting is disadvantageous &hen burs are countersun+ into the dentin( since &ater is e)cluded in a confined region'

8sually( heat is generated in the tooth in operative procedures by cutting instruments and impression materials' 9eat may also be delivered to the tooth and by electrosurgical procedures for gingivoplasty' Factors in the production of heat &ithin the dental pulp as a result of cavity preparation are the depth of the preparation the speed of rotation'

Grinding and drilling of tooth structure &ithout a coolant produces both reversible and irreversible pulp changes' The circulation of the dental pulp is affected by elevation of temperature' The intrapulpal pressure is also affected by e)cessive heat generation' That the thermal damage &as greater &ith steel burs than &ith carbide burs' Aith proper cooling( carbide burs produce negligible pulp damage' 9o&ever uncooled carbide burs and diamond instruments produce severe damage to the dental pulp &hich is uncompensated for by intermittent grinding or variations in preparation time' %ven &ith the use of a coolant( diamond instruments are capable of producing damage to the pulp'

EFFE TS OF HEAT FROM TOOTH '$EA H"N% A rise in pulp temperature that occurs in some tooth bleaching procedures did not produce deleterious pulp changes'

EFFE TS OF HEAT FROM E$E TROSUR%ERY 9eat may be delivered to the pulp by electro surgical gingivoplasty' %ven the placement of a calcium hydro)ide base( covered by copal varnish( under the metallic restorations did not prevent pulpal damage'

S"1E OF .HEE$S AND 'URS The larger si!es produce greater pulp damage' Ahen a large instrument is used( a greater area at a time is cut' The coolant cannot get to the tooth as readily( resulting in more severe reactions'

SMEAR $AYER Ahen cavities are prepared an amorphous layer of dentinal debris remains attached to the dentin' The nature of cutting instrument is unrelated to the development of this layer'

OO$ANTS In order to reduce or eliminate the heat generated by the cutting procedures( coolants must be employed'

A"R SPRAY The average of observed temperature rise on all cuts &as &ithout coolant' Ahen an air coolant &as employed( the average rise in temperature &as reduced to 4C:C' Through &ere no significant differences in the cooling effectiveness bet&een air*&ater spray and air alone'

DRY"N% OF DENT"N Air blast are damaging to the pulp' It has been a blast of air on the dentin( &ith either an ordinary chip syringe or compressed air( for 4: seconds is enough to produce displacement of odontoblastic nuclei' Thus the use of air spray or air coolant( especially during deep cavity preparation( presents a potential ha!ard to the pulp( and therefore cavity cutting should not be performed &ith air*cooling alone' During cavity toilet( the cavity should not be dried &ith air blasts cotton pellets should be used instead'

.ATER SPRAY Immediate damage to the dental pulp &as greater in air*cooled than in &ater*cooled teeth up to 4@ days postoperatively' Full cro&n preparations both &ith and &ithout &ater spray' The pulpal blood flo& &as reduced by 45; in the tooth prepared &ith &ater spray' After 4 hour( the blood flo&

returned to &ithin C; of the control' Aithout &ater spray( there &as a EE; reduction of blood flo&( after 4 hour( pulpal blood flo& &as even further decreased'

To be effective( the &ater should be delivered directly at the point of contact bet&een the bur and the tooth' 9igh speed cutting should be done &ith a brush stro+e similar to that employed by a painter using &ater colors'

TEMPERATURE OF OO$ANTS The temperature of the &ater*cooling used during cavity preparation apparently has little significant effect on the pulp' Thus it appears that the temperature of coolants used clinically &ould have to significant effects on the dental pulp'

OTHER PHYS" A$ TRAUMA '&o/s Physical trauma such as a blo&( &ith or &ithout fracture( may cause hemorrhage in the pulp( resulting in nutritional disturbances to the cells( hyalination of the pulp tissue( e)cessive minerali!ation and tooth discoloration' The pulp may recover completely or it may become necrotic(

depending on the severity of the hemorrhage( on &hether or not the ape) is completed and on the establishment of infection'

Fra(ture The changes for pulp survival increase &hen the cro&n is fractured( compared to traumati!ed teeth &ithout cro&n fractures' Should the cro&n fracture e)posure the pulp( pulp capping or pulpotomy is usually highly successful' 9ealing &ith calcification of the pulp7 healing &ith interposition of the pulp 9ealing &ith interposition of connective tissue bet&een the fragments( 9ealing &ith interposition of bone and connective tissue and Persistence of granulation tissue bet&een the fragments'

9igher recovery or survival rates of pulps occur in permanent teeth &ith transverse IARFs than in traumati!ed teeth &ith no root fractures'

Traumati( o((&usion #ight occlusal forces produced by the placement of high amalgam restorations in rats? teeth has not caused significant pulpal changes over short periods' PO$"SH"N% OF RESTORAT"ONS Polishing of restorations &ithout ta+ing precautions for dissipation of heat is dangerous to the pulp' A significant elevation in temperature occurs as a result of friction' Sandpaper discs or rubber cups( rub dry at high speeds( can generate sufficient heat to damage the pulp'

DENT"N STER"$"1"N% A%ENTS "any compounds .each &ith its advocates/ have been used for sterili!ation of dentin phenols and phenolic derivatives such as thymol( eugenol and beech &ord creosotes silver nitrate and combination of drugs( such as parachlorophenol and penicillin'

P,eno& It has been stated that phenol combines &ith organic matter in the dentinal tubules and forms a coagulam that bloc+s the tubules and limits the action of the phenol' Demonstrated that the phenol actually increased rather than decreased( the permeability of the dentinal tubules'

Si&2er Nitrate Silver salts diffuse rapidly through the dentinal tubules and regardless of the depth of the cavity( eventually reach the pulp tissue' Eugeno& %ugenol( mi)ed &ith !inc o)ide in a paste form is often applied to deep cavities to allay pain associated &ith inflammation of the pulp'

!arnis,es Cavity liners of the varnish type have limited value for protection of pulp against silicates or cements' There is evidence that some liners reduce the degree of dentin dehydration by various filling materials and aid in the prevention of recurrent caries around amalgam restorations observed that teeth &ith cavities that &ere lined only &ith varnish and filled &ith silicates remained sensitive for varying periods of time' In many the pulps became necrotic( and periapical areas of rarefaction developed'

a&(ium ,ydro3ide The presence of the Ca5L ion may activate adenosine triphosphatase( &hich may then enhance dentin minerali!ation' Ahen applied to dentin may

also stimulate mitosis of pulp fibroblasts' Ahen applied to neutrali!er for the acidity of silicate and !inc phosphate cements and prevents penetration of the acid into the pulp'

Calcium hydro)ide is an insoluble base that dissociates( to a limited degree( into CaL and 9 ions' The hydro)yl ions are available for

neutrali!ing the 9L ions from the acids of the cements' There is a significant elevation of p9 in the dentin sub-acent to calcium hydro)ide application after 4 to 6 days' #arger silicate restorations the amount of hydro)yl ions liberated by the calcium hydro)ide may not be sufficient to neutrali!e the acidity of silicates' Some free acid may remain unneutrali!ed'

Binc o)ide eugenol is a temporary filling material that is also used fre,uently as liner under other restorative materials' Binc o)ide eugenol base under amalgam restorations is a better thermal insulator than calcium hydro)ide or !inc phosphate cements' Binc o)ide eugenol to)ic to

pulp cells and some reports have suggested that !inc o)ide eugenol may be more irritating to the pulp than !inc phosphate cement'

The greater the amount of free eugenol in the mi)ture( the greater the chance of in the mi)ture( the greater the chance of the pulpal irritation' There is litter li+elihood that a thic+ mi)ture of !inc o)ide eugenol &ill irritate the pulp'

%UTTA4PER HA This sensitivity is attributable to marginal lea+age that per must oral fluids to penetrate the freshly cut dentin' Gutta percha does not seal the dentinal tubules fluids and bacteria from the mouth are pumped into the dentin and the odontoblasts are in-ured'

The chances for marginal lea+age &ere reduced by covering the applied gutta percha &ith !inc o)ide eugenol pulp inflammation( characteri!ed by displaced odontoblastic nuclei and the presence of polymorph nuclear leu+ocytes( lymphocytes( plasma cells( macrophages and circulatory disturbances &as induced'

PERMANENT RESTORAT"!E MATER"A$S Si&i(ates Silicate cements &ere the most popular anterior esthetic restorative material' Its popularly has declined because of its high solubility( color instability and tendency to produce severe damage to the pulp( especially &hen used &ithout a liner'

The penetrations &as associated &ith the liberation of dio)ide that entered the pulp and resulted in thrombosis of the entire vascular system of the pulp' Silicates also cause a centrifugal flo& of fluid in the dentinal tubules( &hich may result in displacement of the odontoblasts'

0acteria have also been demonstrated to persist in the dentinal tubules under silicate restorations' Thus( it appears as if pulpal damage under silicates is not due to chemical is not due solely to chemical irritation of the filling but results from irritation caused by bacterial &alls in the gap bet&een the filling and cavity &alls'

Tests of tooth*pulp reactions have not been made for all composite resins' It may generally be concluded that all composite resins( &ith or &ithout resin liners( irritate the dental pulp'

Ad,esi2e restorati2e resins In addition to conventional restorative resins( several ne& resins are reported to be adhesive to both enamel and dentin' %tching of the tooth structure &ith phosphoric or citric acid is supposed to enhance adhesion'

Several reports indicate that &ith the use of these ne&er adhesive resins( pulpal damage is slight to absent' Furthermore( etched dentin &ith a liner such as calcium hydro)ide is both undesirable and contraindicates'

o55er ama&gam 9igh copper*content amalgam alloys have been increasingly utili!ed in dentist because of their higher compressive strengths and resistance to creep and corrosion' 9o&ever( copper has been found to be to)ic in various cell culture systems'

The pulps under high*copper amalgam alloys e)hibited slight inflammation and e)tensive irregular reparative dentin formation' The

disparity in the results of the t&o studies may be due to the fact that in the latter study the cavities &ere lined'

PU$P APP"N% AND PU$POTOMY Pulp capping is the covering of an e)posed pulp &ith a medicated dressing in an attempt to preserve vitality' Pulpotomy is the removal of the coronal portion of the pulp and the covering of the remaining pulp stump &ith a medicated dressing in order to maintain the vitality of the radicular pulp tissue' Pulp capping has been employed after carious pulp e)posures( mechanical e)posure of the pulp during operative procedures( and traumatic e)posures resulting from tooth fractures'

P,ysi(a& 5,enomena asso(iated /it, me(,ani(a& 5u&5 e35osures Ahen a dental pulp is e)posed mechanically( a number of physical phenomena occur in the coronal pulp tissue that influence the subse,uent reactions and prognosis' The phenomena involved are 3

Heat The closer a cavity preparation is to the pulp( the greater is the li+elihood of heat in-ury' Dentin is an effective insulator7 as more and more

dentin is removed heat damage to the underlying pulp tissue becomes more li+ely unless ade,uate cooling has been employed'

Pressure Ahen the pulp is e)posed pressure is transmitted directly to the pulp by the bur or hand instrument' Pressure is damaging the greater the pressure( the less favorable the prognosis' Pulp tissue pressure is also increased intrinsically by pulp e)posure' rus,ing o- 5u&5 tissue Pulp tissue is inevitably contused by the e)posure or surgical removal of a portion of the pulp'

Hemorr,age %)posure of the pulp invariably results in some hemorrhage from the capillaries in the odontoblastic layer and sometimes the underlying pulp tissue'

"ntrusion o- dentin (,i5s As a result of e)posure or pulpotomy( dentin debris .chips/ from the grinding of the dentin is pushed into the remaining pulp tissue'

E35osure To saliva influences the end result' Short periods of e)posure are not as harmful as long periods'

Margina& &ea6age Is the another important factor to be considered in pulp repair follo&ing pulp capping and pulpotomy' If the restoration lea+s( inflammation persists and repair cannot occur' The end result is li+ely to be pulp necrosis' Drugs in 5u&5 (a55ing and 5u&5otomy There has been too much emphasis on drugs employed in pulp capping and pulpotomy rather than on diagnosis'

a&(ium ,ydro3ide Calcium hydro)ide has been the drug of choice for use in pulp capping and pulpotomy' It has antibacterial activity' Their e)periments suggested that the calcium in the granulations observed in the calcium hydro)ide group came not from the bloodstream but from the capping material'

Tri(a&(ium P,os5,ate

Another calcium*containing compound( tricalcium phosphate has been reported to be nonirritating to connective tissue' Ahen implanted into bone( it stimulated ne& bone formation'

o&&agen 5re5arations %nriched collagen gels have been reported to enhance &ound healing by promotin fibroblastic proliferation'

Forma&de,yde 5re5arations Formocresol .0uc+ley?s formula/ consists of formaldehyde( 4<; and cresol( 6@; in a vehicle of 4@; glycerin in &ater'M It and other formaldehyde*containing pastes have been advocated for pulpotomy procedures in both primary and permanent teeth' 9o&ever the reports on efficacy are contra indicatory'

$ATERA$ # A

ESSORY ANA$ ANATOM"

ONS"DERAT"ONS

#ateral and accessory canals are ubi,uitous and their distribution is readily observed in histologic specimens of anterior and posterior human teeth'

In molars( a great many accessory canals &ere seen these canals &ere present in both the apical third and the coronal portions of the teeth' The tissue in the lateral canals &as composed of capillaries( pulp cells( ground substance( and fibers and &as confluent &ith the pulp tissue proper'

'&ood su55&y The main blood supply of the pulp enters through the apical foramen or foramina' In addition to the vessels entering the apical foramina( other vessels occasionally come into the pulp in the furcation areas' T,e e--e(t o- 5eriodonta& disease on t,e denta& 5u&5 A definite relationship appears to e)ist bet&een the presence of periodontal lesions and the status of the pulp tissue first by Turner and Dre& bacteria &ere present in periodontally involved teeth but absent in normal teeth inflammatory pulp changes to ingress of to)ins through these lateral canals' The incidence of pulp inflammation &as slightly higher( and the incidence of pulp degeneration &as distinctly greater in periodontally involved teeth'

Atro5,i( (,anges 7Pu&5osis8

Atrophic pulps are present in many periodontally involved teeth( the largest number in any specific diagnostic category' Atrophic pulpal changes t&ice as often in periodontally involved teeth &ith caries'

The atropic pulps invariably had fe&er than the number of cells in both the coronal and the radicular portions of the pulp' Collagen deposition &as increased' Abundant dystrophic pulp tissue'

Me(,anisms The mechanisms for the production of atrophy &ithin the pulps appear to be interference &ith the blood supply through the lateral canals( both &ithin the furcation regions and along the sides of the roots' #oss of the blood supply to a small region of the pulp tissue leads to the death of the pulp tissue leads to the death of the pulp cells supplied by the affected capillaries'

EFFE TS

OF

PER"ODONTA$

TREATMENT

$O A$

MED" AT"ON Dee5 s(a&ing Deep scaling and curettage in periodontal treatment may possibly be instrumental in causing pulp damage' Deep scaling may sever blood vessels( especially in the furcation regions of molars' The conse,uent loss of blood supply to a small region of the pulp can produce a pain spasm and ultimately death of the pulp cells supplied by the affected capillaries H a phenomenon comparable to a cardiac anginal attac+'

T,e e--e(t o- 5u&5 &esions on 5eriodonta& &esions Granulomas develop in the apical periodontal ligament follo&ing inflammation of the pulp from caries( trauma( or restorative procedures' Interradicular periodontal lesions can be initiated and perpetuated by inflamed or necrotic pulps' %)tensive pulp lesions cause periodontal changes through the lateral and the accessory foramina and also( through the crestal e)tension of the periapical granulomatous lesions'

ORRE$AT"ON OF PER"ODONTA$ "N!O$!EMENT ."TH PA"N "n(iden(e Pain is felt in periodontally involved teeth that have no caries or restorations but less fre,uently than in periodontally involved teeth &ith caries or restorations' Atrophy or inflammation of the pulp is responsible for the highest incidence of pain in periodontally involved teeth' The superimposition of periodontal lesions appeared to increase the incidence of pain to @@;' In the teeth &ith periodontal disease but no caries or restorations( the incidence of pain &as E:;'

THE PU$PA$4PER"ODONTA$ SYNDROME The etiology of periodontal lesions can be either pulpal or periodontal' Furthermore( a particular aggregation of signs and symptoms( radiographic findings( and test results( has led to the identification of a clinical entity( the pulpal periodontal syndrome' This syndrome may be defined as one involving inflammation or degeneration of the pulp' Aith a clinical poc+et of the same tooth( and it can be initiated by either pulpal or periodontal disease'

RETRO%RESS"!E AND A%E HAN%ES OF THE DENTA$ PU$P The science of gerontology is receiving more attention as the life span of the individual increases' Aging of human tissues is genetically controlled' It has often been said in -est that living to a ripe old age involves selection of the proper parents' "any theories about the causes of aging have been advanced'

The &ear and tear theory simply postulates that the organism &ears out &ith use' %ach cell is endo&ed &ith specific amounts of vital substances( such as en!ymes' Ahen these substances are used up( they are not replaced'

%ventually( death of the cells and the organism ensues' "athematical theories have been postulated in &hich an empirical mortality curve fits into a formulated e,uation' The cellular interaction theory is based on every other part'

The collagen theory postulates that collagen fibers form continuously at a slo& rate and the collagen is eliminated slo&ly or not at all' In the &aste product theory( metabolic &aste products are not readily e)creted from the cells or intercellular fluids' In the endocrine theory( endocrine functions

slo&ly decrease and cell metabolism is gradually affected adversely' The calcium theory suggest that aging is caused by a defect in calcium metabolism'

"any of these theories can be applied to concepts concerning retrogressive and age changes in the dental pulp' Among the age changes that have been reported to occur in the pulp and dentin are Decrease in cellular components Dentinal sclerosis Decrease in number and ,uality of blood vessels and nerves Reduction in si!e and volume of the pulp( o&ing to continued .secondary/ dentin deposition and to reparative dentin formation Increase in number and thic+ness of collagen fibers' Increase of pulp stones and dystrophic minerali!ation

DE REASE "N E$$U$AR OMPONENTS Fibrob&asts Aging effects a reduction in the number of cells of the pulp possibly as a conse,uence of reduced circulation' There is also significant decrease

in the number of regenrable cells &ith increasing maturity the pulpal fibroblasts e)hibit a decreased o)ygen upta+e'

Odontob&asts The odontoblasts appear to undergo degenerative changes &ith advancing age' Gradually( the odontoblasts atrophy and disappear over some or all areas of the dental pulp'

Dentina& s(&erosis The primary dentinal tubules are also affected by aging' Increases in peritubular dentin' The dentinal tubules are ultimately occluded( a condition called sclerosis of dentin' Sclerosis of the dentin is also initiated by dental caries' Dental caries elicits reactions &ithin the primary dentinal tubules &hich tend to slo& do&n the progress of the disease'

DE REASE "N NUM'ER AND 9UA$"TY OF '$OOD !ESSE$S AND NER!ES '&ood 2esse&s Aging has an adverse effect on the number and ,uality of blood vessels supplying the dental pulp' 0lood vessels of aged pulps undergo arteriosclerotic changes( resulting a diminished blood supply to the cells of

the coronal portions of the pulps' The pulpal arterioles from young teeth typically consisted of endothelial layers abutting directly on a thin internal elastic membrane' In contrast( the arterioles of the older pulps e)hibited hyperplasia of the intima( resulting in a narro&ing of the vessel lumen'

Formation o- se(ondary dentin Continuous deposition of the dentin( &hich tends to reduce the volume of the dental pulp( ta+es place throughout life' As an individual ages( the tubules become less regular and more &avy and they change direction' This indicates that changes are occurring in the odontoblasts( possibly as a result of continuous ionic e)change from the saliva' Re5arati2e dentin in Root ana&s Reparative dentin is present in significant amounts in the root canals of all teeth that are chronically inflamed and especially in those that are periodontally involved' There are al&ays some viable tissue elements remaining &ithin the root canal'

Formation o- dentin matri The pulp cells secrete collagen precursors' The collagen precursors found &ithin the cells are no sulfated amino*polysaccharides associated &ith

protein' Pulp cells other than odontoblasts are capable of elaborating dentin matri)'

"nter-eren(e /it, matri3 -ormation and minera&i:ation Interference &ith the formation of reparative dentin may occur under certain local and systemic conditions

$O A$ FA TORS Se2ere 5u&5 in-&ammation Ahen pulp inflammation is severe( there may be interference &ith both the elaboration and the minerali!ation of the predentin' The ,uantity of dentin formed depends on the severity of the in-ury' The rate of production of dentin alters the morphology of the odontoblasts( &hich( inturn( affects the structuring of the dentin'

O5erati2e mani5u&ations perative procedures involving the dentin cause degeneration of the odontoblasts' After the initial in-ury to the odontoblasts caused by cutting of a cavity or other operative procedures( certain subtle changes occur' The

in-ured odontoblasts may recover( but in all probability most undergo necrosis'

perations on the dentin( &ith resultant damage to the involved odontoblasts( cause temporary derangement in minerali!ation sho&n by the formation of a basophilic line' This has been defined as a calciotraumatic reaction'

The calciotraumatic response is a record &ithin the dentin( sho&ing that there &as an interference &ith the minerali!ation of the dentinal matri) at the time of the cutting procedure'

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