Dental pulp /certified fixed orthodontic courses by Indian dental academy


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Dental pulp /certified fixed orthodontic courses by Indian dental academy

  1. 1. INDIAN DENTAL ACADEMYLeader in Continuing Dental Education
  2. 2. CONTENTS Introduction Embryology Anatomy Innervations in pulp Pathways of pain Structural Organisation Cells of Pulp Extracellular matrix
  3. 3.  Microvasculature of pulp Vitality tests Achieving anaesthesia Functions Clinical considerations conclusion
  4. 4. INTRODUCTION Pulp is a soft mesenchymal connective tissue that occupies in the central mass of the teeth. It’s a special organ because of it’s unique environment.
  5. 5. DEVELOPMENT During the 8th week of IUL, there is condensation of the mesenchmye under the enamel organ- Dental papilla. The enamel organ enlarge and enclose the dental papilla in their central portion. Dental papilla controls the morphology & type of tooth to be formed. It shows: extensive proliferation of cells. high vascularity.
  6. 6.  Following the differentiation of the IEE into ameloblasts, odontoblast differentiate from the peripheral cells of dental papilla. Well organized capillaries are found at beginning of dentinogenesis. Rim of the enamel organ(IEE & OEE) is the cervical loop. Root formation is carried out by the proliferation of cells at the cervical loop.
  7. 7. DENTAL
  8. 8. SALIENT FEATURES Enclosed within the dentin. Resembles embryonic connective tissue. Houses a number of tissues. Microcirculatory system with no collateral branches. Retains the ability to form dentin throughout life.
  9. 9. ANATOMY Pulp cavity is divided into coronal and radicular portion. Total pulp organ – 20+ 32= 52. Total pulp volume in permanent teeth is 0.38cc with the mean being 0.02cc per teeth.
  10. 10. CORONAL PORTION It occupies the pulp chamber of the crown of the teeth. Pulp horns are projections into the cusp. It has six surfaces : occlusal,mesial,distal,buccal, lingual, floor. It constricts at the cervical region where it continues as the radicular portion.
  11. 11. RADICULAR PORTION It is the pulp occupying the pulp canals of the tooth. In the anterior tooth, it is single and the posterior tooth it is multiple. The radicular portion of the pulp is continous with the periapical tissues. It is fibrous and protects the neurovascular bundle.
  12. 12. APICAL FORAMEN It forms the portal of entry & exit of the pulp tissue. Mean size : maxillary teeth - 0.4mm. mandibular teeth - 0.3mm. There may be 2 or 3 apical foramen split by cementum or dentin – APICAL DELTA. Subject to change in case of migration. Largest in the palatal root of maxillary teeth and distal root of mandibular teeth.
  13. 13. PULP – DENTIN COMPLEX The dentinal tubules composed of dentinal fluid & the processes of the odontoblasts that respond to noxious stimulus together constitute the P-D complex. The length of the odontoblasts in the tubules – 0.1 – 1mm. There is outflow or inflow of the dentinal fluid due to the stimulus that excites the Od. Processes. Hypersensitivity is well explained by Hydrodynamic theory. Processes have paracrine regulation With the nerve endings in the tubules there by causing pain.
  14. 14. INNERVATION OF PULPAFFERENT FIBRES AUTONOMIC FIBRES SYMPATHETIC FIBRES(Sensory) ( Neurogenic modulation Of (appear with blood vessels microcirculation-dentinogenesis) at the time of devpt.) Adrenergic & cholinergic fibres: regulate dentinogenesis. Neuropeptides.
  16. 16. 68.jpgA fibres C fibres www.indiandentalacademy.comSaltatory conduction
  17. 17. FEATURES OF A & C FIBRES A-beta fibres innervate the dentin & dentin-pulp border , most sensitive fibres to hydrodynamic stimulation of dentin. 25% - 50% are A-delta fibres ,contain CGRP.They Innervate dentin, predentin,Od.layer, concentrated in pulp horn. A paracrine signaling mechanism exists between A-delta fibres and odontoblastic processes. C fibres are polymodal and respond to capsaicin and infl . Mediators - histamine ,bradykinin. They express NGF receptors and neuropeptides,they terminate in peripher pulp along the blood vessels and are activated by pulpal damage.
  18. 18.  The nerve bundle from radicular pulp loose their myelinand branch into smaller bundles, finally ramify into plexusof single nerve axons – PLEXUS OF RASCHKOW. Each nerve fibre entering the canal gives about 8 branchesto the plexus. Many of these fibres pass between the odontoblasticprocesses in the dentinal tubule.
  19. 19. PATHWAYS OF
  20. 20. NEUROPEPTIDES They are proteins associated with the terminals of afferent sensory neurons,sym.fibres,Para sym fibres. CGRP (calcitonin gene related peptide) Neuropeptide K Substance P Neuropeptide Y,Neurokinin A VIP (Vasoactive intestinal polypeptide)
  21. 21. FUNCTIONS Increased production of NP – in initiating and propagating pulpal inflammation. Maintain pulpal pressure by vasodilatation and constriction. Stimulate lymphocytes. Regulate the growth of connective tissue. Stimulate leukochemotaxis.
  23. 23. COLLAGEN Major constituent of all connective tissue. Characterised by the presence of triple helical domain formed by an assembly of three polypeptide chains. Collagen fibres are made up of fibrils in which the collagen molecules are arranged in a highly organised structure. Synthesized by fibroblasts in pulp and odontoblasts in dentin – pulp complex. The fibrils display striation at intervals of 67 nm – characteristic of collagen fibrils.
  24. 24.  Collagen fibres are inelastic but have high tensile strength. About 19 types of collagen from 30 genes has been identified. Type I and Type III are predominantly found in pulp. Type V and VI are also present.
  25. 25. COLLAGEN IN PULP TYPE I Present as thick striated fibrils. Responsible for pulp architecture. TYPE III Thinner fibrils, mainly distributed in cell free and cell rich zone. Contributes to the elasticity of the pulp.
  26. 26. TYPE IV Present along the basement membrane of blood vessels. TYPE V & VI Form a dense meshwork in the form of a thin fibril in the entire stroma of the pulp. Collagen fibres arising from the pulp passing spirally between odontoblasts, enter the predentin - KORFF FIBRES.
  27. 27. ELASTIN Formed in bundles of thin microfibrils called Oxytalan fibres. Elastin is then deposited between Oxytalan fibres to form elastic fibres. They are joined to form a random coil like structure that expands & contracts. Always associated with larger blood vessels.
  28. 28. FIBRINONECTIN A glycoprotein seen around the blood vessels. Regulates the migration and differentiation of secondary odontoblasts. Helps in the migration of cells in the wound healing of connective tissue of pulp. Helps to maintain cell morphology and tight seal of the odontoblasts with the ECM.
  29. 29. GROUND SUBSTANCE PROTEOGLYCANS Central protein core with side chains of GAG and they are hydrophilic. They carry –ve charge and prevent diffusion of larger molecules. GLYCOSAMINOGLYCANS  They are long unbranched polymers of repeating disaccharides units.  Four main types are seen in pulp.
  30. 30. ROLE IN PULP The ground substance show affinity for collagen and influence fibrinogenesis. Regulate tissue organisation and help in mineralisation. Play a major role in dentinogenesis. Maintain the polarity of the odontoblasts.
  33. 33.
  34. 34. ODONTOBLAST LAYER It outermost stratum of pulp,located subadjacent to predentin. Contain cellbodies of odontoblasts, capillaries, nerve fibres & dentritic cells Shape : coronal portion- tall columnar. mid portion - cuboidal. near apical foramen - flattened. Because in the radicular portion , there are fewer dentinal tubules compared with the coronal part, so the odontoblasts cells spread out laterally.
  35. 35. CELL POOR ZONE ( weil’s zone) Layer subadjacent to odontoblast layer. 40µ wide and relatively free of cells. Traversed by blood vessels, unmyelinated nerves and cytoplasmic process of fibroblasts. Relatively diminished in younger and older pulps. PLEXUS OF RASHKOW is seen
  36. 36. CELL RICH ZONE Composed of fibroblasts, macrophages, dentritic cells, lymphocytes. Layer subadjacent to cell poor zone. Zone formed due to migration of cells from pulp proper. Prominent in coronal pulp. Mitosis is seen when dead odontoblasts are replaced.
  37. 37. PULP PROPER Form the central mass of pulp Contain larger blood vessels & nerves Fibroblasts are the only connective tissue cells in this zone.
  39. 39. ODONTOBLASTS Odontoblasts are highly differentiated which derived from neural crest cells. 40μ tall and 5-7μ wide. The shape of the odontoblasts depends on the density of the dentinal tubules. They have a polarised nucleus, RER, golgi apparatus and secretory vesicles. There is decrease in the no of cell organelles after primary and secondary dentin formation.
  40. 40.  Quiescent odontoblasts are shorter and Contain autophagic vacuoles. These vacuoles mediate a reduction in the no of cell organelles.
  41. 41. JUNCTIONAL COMPLEXES Neighbouring odontoblasts exhibit a series of junctional complexes. They promote cell to cell adhesion and play a role in maintaining the polarity of the odontoblasts. Junctional complexes include Zonula adherens - desmosomes Nexuses - gap junctions Zonula occludens - tight junctions. Spot desmosomes present in the apical part join the cells together.
  42. 42.  Tight junctions seen in the apical part are responsible for permeability between predentin & pulp. Gap junctions provide low resistance pathway for the passage of electric signals.
  43. 43. ODONOTBLASTIC PROCESSES Direct extension of cell bodies into the tubules. Has a well developed cytoskeleton with macro tubules and microtubules ,no cell organelles present. Diameter – 3 – 4 microns. Composed of protein – vimentin, tubulin, actin.
  44. 44. UNDIFFERENTIATED MESENCHYMAL CELLS TOTIPOTENT CELLS – the cells that have the ability to form any kind of tissue. Usually formed – 4 days of fertilization. PLURIPOTENT STEM CELLS are the cells which are capable of developing into any type of germ layer. The UMC in the cell rich zone adjacent to the odontoblasts are called as PROGENITORS. The mesenchymal cells are distributed throughout the pulp, the maximum is in the perivascular area.
  45. 45.  Large polyhedral cells with a large nucleus and high nucleus : cytoplasmic ratio. May differentiate into either fibroblasts or odontoblasts depending on the stimulus.
  46. 46. FIBROBLAST Numerous in cell rich zoneTissue specific cells that are capable of giving rise tocells that are committed to differentiation. Synthesize type I,type III collagen & PEG’s ,GAG. Form and maintain the pulp matrix. The activity preceding the differentiation ofreplacement odontoblasts appears to occur primarilyamong fibroblasts.
  47. 47. MACROPHAGES (Histiocytes)Constituents of mononuclear phagocyte systemderived from bone marrow.Majority of macrophages are involved in endocytosis& phagocytosis. Act as scavengers, removing RBC dead cells &foreign bodies. Also participate in immune reactions.
  48. 48. DENTRITIC CELLS (antigen presenting cells) accessory cells of immune system. present subadjacent to odontoblastic layer. Characterised by dentritic cytoplasmic process andthe presence of cell surface class II MHC antigens. MAST CELLSWidely distributed in connective tissue where theyoccur in small groups in relation to blood vessels. seen only in inflammatory pulps. Granules contain heparin & histamine.
  49. 49. LYMPHOCYTEST lymphocytes are scattered along the blood vesselsin the pulp proper. Take part in the initial defense of the pulp. B lymphocytes are rarely found.
  50. 50. MICROVASCULATURE IN PULP Pulp is extensively vascularised tissue containingarterioles, venules, lymphatics. Maintains tissue homeostasis. FUNCTIONS Transport. Regulation. Respond inflammatory stimuli. Initiate the immunologic reactions.
  51. 51. BRANCHING NETWORK Arterioles(50μ) Terminal arterioles Pre capillaries Meta arterioles capillaries(8μ)
  52. 52. ARTERIOLESBranching point of terminal arteriole & capillaries areCharacterised by the presence of clumps of smoothmuscles – precapillary sphincters. Pulpal inflammation elicits a localised circulatoryresponse restricted to the area of inflammation. Under neuronal and local cellular control it regulatelocal blood flow through a capillary bed. Arteriolar pressure- 43mm Hg.
  54. 54. CAPILLARIES Function as exchange vessels regulating the transport ordiffusion of substances between blood and local interstitialtissue elements.Consists of single layer of endothelium surrounded bybasement membrane.Capillary is 0.5μ thick and it acts as semi permeablemembrane Capillary pressure — 35 mm Hg.
  55. 55. Types Class I: Fenestrated capillaries Class II: Continuous capillaries (non fenestrated) Class III: Discontinuous capillaries Class IV: Tight junction capillariesClass I & II are present in the dental pulp.
  56. 56. VENULESCollecting venules receive pulpal blood flow fromcapillary bed and transfer it to venules. AVA shunt permits the regional control of bloodflow from capillary to venules. Venular pressure – 19 mm hg
  57. 57. LYMPHATIC VESSELS Lymphatic vessels are formed from a fine meshwork ofsmall ,thin walled lymph capillaries. They start as blind openings near the weil’s zone. Carries the tissue fluids back to the vascular system. Reduces interstitial colloidal osmotic pressure andregulates the devpt. Of edema.They provide immunosurvilence by transportingantigens to the nodal collections of immune cells.
  58. 58.
  60. 60. METABOLIC Pulp has a lower basal metabolic rate. in metabolic activity such as dentinogenesis causes localised in pulpal blood flow. Not a major regulatory mechanism for the entire pulp.
  61. 61. NEURONAL SYMPATHETIC NERVES The distribution of sympathetic fibres is highest in blood vessels in the pulp horns and lowest in apical region. Activation of SNS Neurotransmitters Epinephrine Local release of Nor epinephrine Neurotransmitters Neuropeptide Y Pulpal blood flow – 80%
  62. 62. PARASYMPATHETIC NERVES Major neurotransmitters Acetyl choline. Vasoactive intestinal polypeptide . Causes blood flow.
  63. 63. PEPTIDERGIC AFFERENT FIBRES Sensory fibres( A & C ) also have afferent action by releasing neuropeptides. These include Substance P. Calcitonin gene related peptide(CGRP). Neurokinin A. Released from C fibres and Aδ fibres. Cause vasodilation and increases blood flow.
  64. 64. PARACRINE / ENDOCRINAL REGULATION Endocrinal regulation is through circulating hormones adrenalin and nor adrenalin. C afferent fibres play a major role in mediating pulpal inflammation. Paracrine regulation is through Bradykinin Prostaglandin Histamine.
  65. 65.
  66. 66. VITALITY TESTS Thermal tests : Heat tests. Cold tests. Electric pulp tester. Test cavity. Anaesthesia test. Laser doppler flowmetry. Pulse oximetry.
  67. 67. THERMAL TESTS HEAT TEST COLD TEST Isolated  Ice sticks, CO2 snow. Gutta percha,hot water  -77.7 degrees 65 degrees
  68. 68. RESPONSE TO THERMAL TESTS RESPONSE INFERENCENo response. Non vital or false +ve result.Mild to moderate response that Healthy pulp.subsides with in 1-2 seconds after theremoval of the stimulus.Strong,momentary painful response Reversible pulpitis.that subsides within 1-2 seconds afterthe stimulus is removed.Moderate to strong painful response Irreversible pulpitis.that subsides after several seconds ofthe removal of stimuli.
  69. 69. ELECTRIC PULP TESTER Designed to stimulate a response of the sensory fibres(A delta) within the pulp by electric stimulation. It does not provide any information of the vascular integrity of the pulp. Not reliable in young permanent teeth.
  70. 70. TEST CAVITY Involves the slow removal of enamel and dentin without anaesthesia with a small round bur. ANAESTHESIA TEST In case of pain of vague origin, LA is given in blocks or infiltrations in order to localise the symptomatic tooth.
  71. 71. PULSE OXIMETRYUsed for recording blood oxygen saturation levelsduring the administration of intravenousanaesthesia.May be able to detect pulpal inflammation or partialnecrosis in teeth that are still vital.
  72. 72. LASER DOPPLER FLOWMETRY Uses a laser beam of known wavelength that is directedthrough the crown of the tooth to the blood vessels in thepulp. Moving RBC cause some of the laser beam to bereflected and this is detected by the photocell on the toothsurface.
  73. 73. PATHOSIS OF PULP REVERSIBLE PULPITIS The pulp is stimulated to the extent thatthermal stimulus usually cold cause a quick,sharperresponse that subsides as soon as the stimulus isremoved. IRREVERSIBLE PULPITIS The pulp is stimulated chronically by noxiousstimulus so that it causes permanent changes in thepulp that are irreversible.
  74. 74. CHRONIC HYPERPLASTIC PULPITIS (PULP POLYP): An asymptomatic irreversible inflammatory condition. Characterised by a reddish cauliflower like growth due to chronic irritation (caries exposure) to the vascular tissue of the pulp. More prevalence in young people.
  75. 75. RESORPTION A condition associated with either a physiologic or apathologic process resulting in the loss of cementumdentin or bone . INTERNAL EXTERNAL
  76. 76. INTERNAL RESORPTION (asymptomatic irreversible pulpitis) Rare in permanent teeth.Characterised by oval shaped enlarged enlargement of RCspace Presence of chronic inflammatory cells.Commonly diagnosed only in radiograph showing internalexpansion of pulp with dentinal destruction.
  77. 77. EXTERNAL RESORPTION (inflammatory) The inflammatory stimulators in the pulp space, diffuse through the dentinal tubules and stimulate an inflammatory response over large areas of periodontal ligament.
  78. 78. IN THE RADIOGRAPH INTERNAL EXTERNAL ( infl.) RESORPTION RESORPTIONMargins are smooth. Margins are rough. Symmetrical AsymmetricalThe rel.ship of the canal The canal shifts withis unaltered regardless respect toof change in angulation change in angulationOutline of the canal is RC appears normal &altered. running through the defect is seen
  79. 79. NECROSIS A histologic condition resulting from an untreatedirreversible pulpitis, traumatic injury or long terminterruption of blood supply. TOTAL NECROSIS will be symptomatic only it affectsthe periodontal ligament. PARTIAL NECROSIS is difficult to diagnose because itproduces some of the symptoms associated with theirreversible pulpitis. The bacterial toxins pass through the apical foramenresulting in an inflammatory reaction in the periodontal www.indiandentalacademy.comligament.
  80. 80. ACHIEVING ANAESTHESIA Pain during access cavity preparation in a vital tooth can be managed by administering intrapulpal injection.
  81. 81.  IPI require a bulk of vital tissue to transport throughout the canals. It must be administered in the roof of the chamber with a 25 or 26 gauge needle before any tissue is extirpated. In molars, the solution is deposited in largest canal.
  83. 83. INDUCTIVE Induces epithelial differentiation into enamel organ& dental papilla.Induces enamel organ to differentiate into aparticular type of tooth.
  84. 84. FORMATIVEPulp induces dentin formation that surrounds & protectsthe pulp. This involves formation of primary & secondary dentin. The primary dentin is tubular & regularly arranged. It isformed before root closure. Secondary dentin contain fewer tubules & is formed afterroot closure.
  85. 85. NUTRITIVEDental pulp maintains the vitality of dentin by providingO2 & nutrients to the odontoblasts. Also provides continous source of dentinal fluid.Nutrition made possible by rich peripheral capillarynetwork.
  86. 86. PROTECTIVE Pulp helps in recognition of stimuli like heat, cold,pressure, chemicals by way of sensory nerve fibres. Motor innervation controls the muscular wall of bloodvessels. This regulates the blood volume & rate of bloodflow and hence the intrapulpal pressure.
  87. 87. DEFENSIVE When irritated or injured pulp will respond by Dentinal pain Tubular sclerosis Irritation dentin formation Inflammation of connective tissue.
  88. 88. CLINICAL CONSIDERATIONS Developmental. Anatomical. Calcifications. Age changes. Dental materials.
  89. 89. DEVELOPMENTALTAURODONTISM More frequently in molars Longer crowns and shorter RC system.Great difficulty in locating canal orifices duringendodontic treatment and may also be associated withadditional root canals.
  90. 90. ANATOMY DECIDUOUS TEETH Pulp chambers are larger and pulp horns are at ahigher level. Roots are long and have slender root canals. Resorption starts soon after root completion.
  91. 91. PERMANENT TEETH The mesio distal view of the root canal is only seen inthe radiograph.The bucco lingual anatomy must also beconsidered.
  92. 92.  Presence of lateral and accessory canals maycause failure of endodontic treatment. Periodontal pocket in a tooth with accessory canalsmay lead to influx of microorganisms to the pulpthrough the accessory foramens.
  93. 93. APICAL FORAMEN According to schilder’s , Apical foramen must be kept as small as practical. Must never be transported. PULPECTOMY The greatest concentration of collagen is in its apical region than the engaging the pulp with a broach apically helps to remove the pulp tissue in a singe piece than placing it coronally.
  94. 94. CALCIFICATIONS It’s a common occurrence of 50% of all teeth. Size may range from microscopic particle to Stones that may occlude the pulp chamber. composed of carbonated hydoxy appatite crystals. Pulp calcifications : Pulp stones. Diffuse calcifications. Calcific metamorphosis.
  95. 95. PULP STONES TRUE DENTICLE FALSE DENTICLERound or ovoid with Rough and have nosmooth surfaces and particular shape.concentric lamellae. By addition of collagen to By mineralisation oftheir surfaces. collagen fibres.The remnants of HERS Cause may beinduce differentiation of degenerating cells,bloododontoblast during thrombi & collagen fibrils.formation.Contain dentinal tubules & Usually in the pulp www.indiandentalacademy.comare found in the root apex. chamber.
  96. 96.
  97. 97. DIFFUSE CALCIFICATIONS They appear as irregular deposits in the pulp. The pulp organ may be free of any pathology but may exhibit these changes in the roots.
  98. 98. CALCIFIC METAMORPHOSIS Results in partial or complete obliteration of pulp chamber. Luxation of the teeth as a result of trauma is the major cause. Teeth may present with a yellowish hue. Resembles cementum or bone along the walls. Disruption of blood flow leads to pulpal infarct and the cells from periodontium proliferates and replaces the infarct tissue.
  99. 99. AGE CHANGES Formation of SECONDARY DENTIN throughout life causes reduction in size of the pulp chamber and root canals. The ‘drop in’ feel of the bur is not felt in older teeth. ODONTOBLAST decrease in size and number and sometimes disappear in certain areas . Increase in the number and thickness of COLLAGEN FIBRES particularly in radicular pulp. Decrease in cellularity. Increase in the resistance of pulp against action of enzymes.
  100. 100. DENTAL MATERIALS AMALGAM High thermal conductivity,irritates pulp in deeper cavities. Needs an insulating base. GLASS IONOMERS Biocompatible to pulp. RMGIC can used as pulp capping agent.
  101. 101. ZINC OXIDE EUGENOL Has an antibacterial and anodyne effect. Higher concentration leads to chronic inflammation & thrombosis of blood vessels. ZINC PHOSPHATE Irritates the pulp (low ph) in deeper cavities. Must be used with a liner. DENTING BONDING AGENTS Monomer molecules present cause irritation of pulp when they come in contact with odontoblastic processes.
  102. 102. RESIN BASED ADHESIVES The formation of hybrid layer secures the enamel - resin interface with a continous seal that acts as biometic barrier. FORMOCRESOL High degree of diffusion causes a chronic inflammation of pulp. Mutagenic and carcinogenic.
  103. 103. Pulp capping agent CALCUIM HYDROXIDE Intracanal medicament PULP CAPPING AGENT Introduced by Hermann in 1930. When it is applied directly over pulp, coagulative necrosis occurs in the adjacent tissue and inflammation of contigious tissue. It maintains a local state of alkalinity that is necessary for dentin formation. Beneath the region of coagulative necrosis, UEM cells differentiate into odontoblasts dentin formation occurs. Available as Dycal, Prisma VLC, Life, Nucap.
  104. 104. The root canal system is very complex and alsosubjected to a number of understanding theform, physiology, and function of pulp is necessary in theselection of treatment and the type of material to beused.
  105. 105. REFERENCES DENTAL PULP Seltzers and benders .PATHWAYS OF PULP Cohen 6th&8thedition. ENDODONTIC PRACTICE Weine 6thedition. ORAL HISTOLOGY Tencate 6th edition. ORAL HISTOLOGY & EMBRYOLOGY Orban 11th edition. ENDODONTICS Ingle 4th edition
  106. 106.  LOCAL ANAESTHESIA Stanley f malamed 5thedition ENDODONTIC PRACTICE Grossman RESTORATIVE MATERIALS Craig COLOUR ATLAS OF ENDODONTICS walkher & Goodman 2nd edition