The Dental Pulp and Periradicular Tissues

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Chapter 1 cz
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The Dental Pulp and 03
Periradicular Tissues
The beginning of all things is small . ...
PARTI : EMBRYOLOGY specific areas in each quadrant of the jaw to mark

the position of the future primary teeth.
The pulp and dentin are different components
of a tooth that remain closely integrated , both FORMATION OF ECTOMESENCHYME
functionally and anatomically, throughout the
life of the tooth . The two tissues are referred The stratified squamous oral epithelium covers an
to as the pulp-dentin organ or the pulp-dentin embryonic connective tissue that is called the ectomes-
complex. enchyme because of its derivation from the neural crest
cells. By a complex interaction with the epithelium,
this ectomesenchyme initiates and controls the devel-
DEVELOPMENT OF THE DENTAL opment of the dental structures. The ectomesenchyme
LAMINA AND DENTAL PAPILLA below the thickened epithelial areas proliferates and
begins to form a capillary network to support further
The dental pulp has its genesis at about the sixth nutrient activity of the ectomesenchyme-epithelium
CD
week of the intrauterine life, during the initiation complex. This condensed area of ectomesenchyme o
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of tooth development ( Fig. 1.1 ) . The oral strati- forms the future dental papilla and subsequently the
fied squamous epithelium covers the primordia of pulp ( Figs 1.2 and 1.3 ) . CD
the future maxillary and mandibular processes in a

horseshoe- shaped pattern. BUD STAGE ( FORMATION CD
OF ENAMEL ORGAN ) E
FORMATION OF DENTAL LAMINA
The thickened epithelial areas continue to prolifer-
Tooth development starts when stratified squa- ate and to migrate into the ectomesenchyme and co
mous epithelium begins to thicken and forms the in the process forms a bud enlargement called the
dental lamina. The cuboidal basal layer of the den - enamel organ. This point is considered the bud
tal lamina begins to multiply and thicken in five stage of tooth development ( Fig. 1.4 ) .
1

2 Grossman’s Endodontic Practice
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Brain space
Developing Cavum nasi

eye
Concha
Nasal
nasalis medialis
septum
Concha
Palatal shelf nasalis inferior
Maxilla
Cavum oris
Developing
Meckel’s tooth
cartilage
Mandibula
Tongue
2 mm
(a)
Concha
nasalis Cartilage
inferior
Nasal
septum
Cavum
nasi Fusing
lines
Epithelial
Palatal rests
shelf
https://t.me/LibraryEDent
Palatal
shelf
Cavum oris
200 µm
(b)
Figure 1.1 (a) Human fetus, head. This is a frontal section of the head of a human fetus. You can see the maxilla
and the mandible taking shape. You can also see Meckel’s cartilage in the mandible. The mandible also contains two
dental buds in this section (stain: Azan). (b) At higher magnification, you can see the fusing lines between the nasal
septum and the palatal shelf. If something goes wrong during this process, the fetus may develop a cleft palate (stain:
Azan). (Courtesy: Mathias Nordvi, University of Oslo, Norway.)
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Chapter 1 The Dental Pulp and Periradicular Tissues 3

Brain space Developing brain
Cavum
nasi
Developing eye
Nasal
septum Concha nasalis
media
Concha nasalis
inferior
Maxilla Tooth bud

(cap stage)
Cavum Tooth bud
oris (bud stage)
Tongue
Muscle
Mandibula
Meckel’s Mandibula
cartilage
Muscle
Muscle
Muscle
Developing Cartilago
thyroid gland thyroidea
2 mm
Figure 1.2 Human fetus, head. This is a frontal section of the head of a human fetus. The nasal cavity (Latin cavum
nasi) is divided into two by the nasal cartilage within the nasal septum. At both sides of the septum, you can see
the nasal conchae (Latin concha nasalis media et inferior). They are made up of cartilage at this stage of develop-
ment. The palate and the maxilla also contain a few spicules of bone. (Courtesy: Mathias Nordvi, University of Oslo,
Norway.)
Ch_01_GEP.indd 3 08/08/14 1:58 PM


Muscle
Cavum
oris
Mandibular
bone
Tooth bud
Tongue (bud stage)
Nervus
mandibularis
Mandibular
bone
Meckel’s
cartilage
Figure 1.3 Dental lamina with its tooth bud. Around the bud, the mesenchyme is condensated. Just below the
tooth bud in the mandible, you can see the alveolar nerve (Latin n. alveolaris). Meckel’s cartilage can also easily be
spotted. The tongue is also developing. It consists of muscular fibers oriented in different directions. At both sides
of the tongue, you can see salivary glands. Cartilage comprising parts of the larynx can be seen below the tongue.
(Courtesy: Mathias Nordvi, University of Oslo, Norway.)
a tage ( uter an in glycogen that forms a branch reticular arrange-

C
p
S
O
d
nner namel ithelium) ment called the stellate reticulum.
I
E
Ep
The enamel organ continues to proliferate into the Formation o Dental Pa illa
f
p
ectomesenchyme with an uneven rhythmic cell
division producing a convex and a concave surface The ectomesenchyme, which is partially enclosed by
characteristic of the cap stage of tooth development the inner enamel epithelium, continues to increase
(Fig. 1.5). its cellular density. The cells are large and round or
The convex surface consists of the cuboidal polyhedral with a pale cytoplasm and large nuclei.
epithelial cells and is called the outer enamel epi- This structure is the dental papilla (Fig. 1.6) which
thelium. The concave surface, called the inner differentiates into the dental pulp.
enamel epithelium, consists of elongated epithelial Formation o Dental
cells with polarized nuclei that later differentiate
f
Follicle (or Dental ac)
into ameloblasts. A distinct basement membrane
S
separates the outer and the inner enamel epithe- When the ectomesenchyme surrounding the den-
lium from the ectomesenchyme. In the region of tal papilla and the enamel organ condenses and
the inner enamel epithelium, a cell-free or acellu- becomes more fibrous, it is called the dental follicle
lar zone also separates the enamel organ from the or the dental sac—the precursor of the cementum,
ectomesenchyme. This acellular zone contains the the periodontal ligament (PDL), and the alveolar
extracellular matrix, where the future predentin bone (Fig. 1.6). The dental lamina continues to
will be deposited. Between the inner and the outer proliferate at the point where it joins the deciduous
enamel epithelium, the cells begin to separate due enamel organ and thereby produces the permanent
to the deposition of intercellular mucoid fluid rich bud lingual to the primary tooth germ.
Ch_01_GEP.indd 4 08/08/14 1:58 PM


Tooth bud Palatum durum
Tongue Cavum
nasi
Concha
nasalis
Meckel’s
cartilage Maxilla
Nervus
mandibularis
Mandible
Cavum Eye
oris
2 mm
(a)
Cavum
Meckel’s oris
cartilage
Mandibular
bone
Tooth
bud
Nervus
mandibularis
200 µm
(b)
Figure 1.4 Tooth development, bud stage: (a) and (b) This is a frontal section of the head of a human fetus (tilted 90°
to the right). The bone has started to develop in the maxilla as well as in the mandible. Because of the stain used to
color this tissue sample, the bone has a blue color. Within the two quadrants seen here, there are dental laminae, and
encircling these laminae, a condensation of the mesenchyme takes place. In between the spicules of bone in the man-
dible, you can see a cross-section of the alveolar nerve (Latin n. alveolaris inferior). Meckel’s cartilage is situated medi-
ally to the mandibular bone. If you look closely, you can see the downgrowth of the parenchyma of the salivary glands
and the developing muscular fibers of the tongue. (Courtesy: Mathias Nordvi, University of Oslo, Norway.) (continued)
Ch_01_GEP.indd 5 08/08/14 1:58 PM


Tooth bud
Basal
membrane
Ectodermal Mesenchymal
cells cells
50 µm
(c)
Basal lamina
Ectodermal
cells in
tooth bud
20 µm
(d)
Figure 1.4 (continued) (c) and (d) At higher magnifications, you can see the ectodermal cells within the developing
tooth bud (stain: Azan). (Courtesy: Mathias Nordvi, University of Oslo, Norway.)
Bell tage ( ervical oo ) at the rim of the enamel organ becomes a distinct
S
C
L
p
zone called the cervical loop. The deep invagination
The cells of the inner enamel epithelium continue to of the inner enamel epithelium and the growth of
divide and thus increase the size of the tooth germ. the cervical loop partially enclosing the dental papilla
During this growth, the inner enamel epithelium begins to give the crown its form. This point is called
invaginates deeper into the enamel organ, and the the bell stage of development (Fig. 1.7).
junction of the outer and the inner enamel epithelium
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Maxilla
Cavum
nasi
Dental
organ
Oral
epithelium
Cavum
oris Mandibula
Lingua
1 mm
Figure 1.5 Tooth development, cap stage. This is a frontal section of the head of a human fetus. In the maxilla, you
can see a developing tooth at the cap stage. The dental papilla is proliferating with cells. (Courtesy: Mathias Nordvi,
University of Oslo, Norway.)
Dental
papilla
Dental
Dental
organ
follicle
200 µm
Figure 1.6 At higher magnification, you can appreciate the dental organ, dental papilla, and dental follicle. (Courtesy:
Mathias Nordvi, University of Oslo, Norway.)
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Dental
Oral
organ
epithelium
Dental
papilla
Mandibular
bone
500 µm
(a)
Outer
dental
epithelium Internal
dental
epithelium
Stellate
reticulum
Dental https://t.me/LibraryEDent
papilla
200 µm
(b)
Figure 1.7 (a) and (b) Tooth development, bell stage. This section displays a developing tooth that has reached
the bell stage. At the border between ectoderm and mesoderm (internal dental epithelium and dental papilla), at
the incisal part of the tooth bud, you can see a narrow blue zone. This is the beginning of the dentin production.
(Courtesy: Mathias Nordvi, University of Oslo, Norway.) (continued)
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Outer
dental
epithelium
Stratum
intermedium
Internal
dental
Stellate epithelium
reticulum
Odontoblast
layer
Dental
papilla
50 µm
(c)
Figure 1.7 (continued) (c) This section also displays the different layers of the tooth bud (stain: Azan). (Courtesy:
Mathias Nordvi, University of Oslo, Norway.)
During this stage, the dental lamina that DE E ES S

NTINOG
N
I
migrated into the ectomesenchyme degenerates,
the primary and permanent buds are thus sepa- In a complex series of events, the inner enamel
rated from the oral epithelium, and the distal por- epithelium exerts an inductive influence on the

tion of the dental lamina proliferates to form the ectomesenchyme to begin dentinogenesis, and con-
buds of the permanent molars, which have no pri- sequently, dentinogenesis has an inductive influence

mary predecessors. on the inner enamel epithelium to start amelogen-
As the development progresses, several layers of esis. This series of events begins in the area of the
the squamous cells between the stellate reticulum future cusp tips and continues to the cervical loop,
and the inner enamel epithelium form the stratum the future cementoenamel junction.
intermedium. This layer of cells is limited to the
area of the inner enamel epithelium and seems to Preo onto lasts
d
b
be involved with enamel formation. The periphery of the adjacent dental papilla consists
of the polymorphic mesenchymal cells that develop
into the cuboidal cells and align themselves paral-
Clinical Note lel to the basement membrane of the inner enamel
Stratum intermedium  Enamel
epithelium and the acellular zone. These cuboidal
Ectomesenchyme  Dentin
cells stop dividing and develop into the columnar
Dental papilla Pulp
cells with polarized nuclei away from the basement
Dental follicle or dental sac  Cementum, the peri-
membrane of the inner enamel epithelium. At this
odontal ligament (PDL), and the alveolar bone stage, these cells are called preodontoblasts.
Ch_01_GEP.indd 9 08/08/14 1:58 PM

antle Dentin Formation

odontoblastic processes is reduced peripherally.
M
Along with this, there is a reduction in size due
The preodontoblasts mature into odontoblasts by to the circumferential deposition of dentin in the
elongating themselves, by contacting adjacent odon- walls of the dentinal tubules. This dentin, which is
toblasts through an increase in size, and by sending more mineralized and is harder than primary den-
the cytoplasmic processes into the acellular zone. tin, is called peritubular dentin.
These odontoblastic processes continue to elon-
gate and move the odontoblast cell body toward the
center of the dental papilla. During this movement, E E ES S
AM
LOG
N
I
large-diameter collagen fibers known as von Korff
fibers are deposited at right angles to the basement Concomitant with dentinogenesis, the cells of the
membrane in the extracellular matrix of the acellu- inner enamel epithelium cease to divide. These cells
lar zone. This process creates the organic matrix of are the elongated epithelial cells called preameloblasts.
the first-formed dentin or mantle dentin. As more
collagen fibrils are deposited, the inner enamel melo lasts
A
b
epithelium basement membrane starts to disinte-

grate. The vesicles carrying apatite crystals bud off The preameloblasts differentiate into tall columnar
from the odontoblastic processes and the crystals epithelial cells with their nuclei polarized toward
are deposited in the organic matrix for the initia- the stratum intermedium and the ameloblasts.
tion of mineralization. The dental papilla becomes While the ameloblasts are differentiating, the base-
the pulp at the moment of the mantle dentin ment membrane of the inner enamel epithelium is
formation. being resorbed and dentin is being deposited to fol-
low the contour established by the basement mem-
brane. This process forms the future dentinoenamel
Primary Dentin junction. The ameloblasts begin to secrete enamel
After the deposition of mantle dentin, the odonto matrix to follow the contour of the already depos-

blasts continue to move toward the center of the ited dentin (Fig. 1.9).
pulp and to leave the odontoblastic processes
behind. The organic matrix or predentin (Fig. 1.8a De osition o namel atrix
p
f
E
M
and 1.8b) is deposited around the odontoblastic
processes. The predentin later calcifies and thereby The deposition of enamel matrix causes the ame-
forms the dentinal tubules. Primary dentin differs loblasts to migrate peripherally and form conic
from the mantle dentin in which the matrix origi- projections called Tomes’ processes on their secretory

nates solely in the odontoblasts. The collagen fibers surfaces. The migration of ameloblasts peripher-
are smaller, are more closely packed, and they are at ally (as they secrete enamel) outlines the crown of
right angles to the tubules and are interwoven. The the tooth, but blocks the source of nutrition from
the dental pulp. To gain a new source of nutrition, the
mineralization of primary dentin originates from
the previous mineralized dentin. outer enamel epithelium becomes a flattened layer of
cells that folds because of the loss of the intracellular
material of the stellate reticulum. This change brings
Clinical Note
the capillary network of the dental follicle, the new
Primary dentin is formed in increments of 4–8 µm per source of nutrition, closer to the ameloblasts.
day and is continually deposited until the end of tooth
development.
aturation o namel
M
f
E
The orderly deposition of enamel continues until
Peritu ular Dentin
the form of the crown is fully developed. At this time,
b
As the incremental deposition of dentin continues the ameloblasts lose their Tomes’ processes, and the
toward the center of the pulp, the diameter of the outer enamel epithelium, the stellate reticulum, and
Ch_01_GEP.indd 10 08/08/14 1:58 PM


Ameloblasts
Enamel
Oral epithelium Dentin
Lamina propria
Inner enamel
epithelium
Stellate
reticulum
Dental papilla
Vein
External enamel
epithelium
1 mm
(a)
Lamina propria of
the oral mucosa Enamel
Oral
epithelium Ameloblasts
Dentin
Predentin
Outer dental Odontoblasts

epithelium
Odontoblasts
Predentin
Stellate
reticulum Dental
pulp
200 µm
(b)
Figure 1.8 (a) This is a section of the developing tooth at the bell stage. The mineralization has just started. This can
be seen at the incisal part of the bud. (b) At higher magnification, you can see the odontoblasts. They are surrounded
by a blue layer which is the predentin (stain: Azan). (Courtesy: Mathias Nordvi, University of Oslo, Norway.)
Ch_01_GEP.indd 11 08/08/14 1:58 PM


Outer dental
Ameloblasts
epithelium
Enamel Stellate
reticulum
Dentin
Stratum
Predentin
intermedium
Odontoblasts
100 µm
(a)
Stellate
reticulum
Ameloblasts
Enamel
Dentin
Nucleus of
Artifact ameloblast
Stratum
intermedium
Dentinal
tubules
Predentin Enamel
Odontoblasts
Dentin
20 µm
(b)
Figure 1.9 (a) and (b) Developing enamel: the dentin stains pale red in this section. The dentin is easily identified by
its dentinal tubules. Surrounding the dentin, there is a thin layer of enamel. This layer is again surrounded by a layer
of ameloblasts. The white zone between the dentin and the enamel is just an artifact. The distance between the
outer dental epithelium and the incisal part of the bud is quite small. If this was not so, the ameloblasts would not
get the nutrients they need from the blood because the stellate reticulum is not vascularized. The highest magnifica-
tion shows all layers beautifully. (Courtesy: Mathias Nordvi, University of Oslo, Norway.)
Ch_01_GEP.indd 12 08/08/14 1:58 PM


the stratum intermedium form a protective layer the dental follicle; this process partially encloses the
of stratified epithelium around the newly formed dental papilla and delineates the apical foramen or
crown. This marks the beginning of enamel matu- foramina. This proliferation is called the epithelial
ration or the higher mineralization of the existing
diaphragm.
enamel. This maturation process begins in the In single-rooted teeth, the epithelial diaphragm
dentinoenamel junction and progresses peripher-
has a single opening which guides the forma-
ally to the enamel surface. During the final phase tion of the root, root canal, and apical foramen.
of the maturation process, the ameloblasts join the In double-rooted teeth, the diaphragm evaginates

stratified epithelium to form the reduced enamel epi- in two predetermined places that come together
thelium and to cover and protect the enamel until and form two openings. In three-rooted teeth, the
eruption of the tooth. evagination occurs in three predetermined places to
form three openings.
DE E V LO P E M NT OF THE ROOT
Clinical Note
On completion of the crown, the cervical loop, In multirooted teeth, the epithelial diaphragm guides
formed by the union of inner and outer enamel epi- the formation of the furca, roots, root canals, and api-
thelia, proliferates to form Hertwig’s epithelial root cal foramina.
sheath, which determines the size and shape of the
root of the tooth (Fig. 1.10). The vertical section of the epithelial root sheath
continues to grow in an apical direction and forces
the fully formed crown toward the oral cavity
ertwig’s ithelial oot heath
while maintaining the epithelial diaphragm in a
H Ep R S
The tip of Hertwig’s epithelial root sheath prolifer- stable position in the jaw. This process marks the
ates horizontally between the dentinal papilla and beginning of the tooth eruption.

Dentin Odontoblasts
Pulp
Enamel
Ameloblasts
Hertwig’s
epithelial
root sheath
200 µm
Figure 1.10 Development of the Hertwig’s epithelial root sheath. (Courtesy: Mathias Nordvi, University of Oslo,
Norway.)
Ch_01_GEP.indd 13 08/08/14 1:58 PM


The inner enamel epithelium below the future dentinogenesis, or the presence of a small blood
cementoenamel junction induces the peripheral vessel produces a gap that results in the formation
mesenchymal cells of the dental papilla to differ- of an accessory canal.
entiate into odontoblasts. Matrix formation and
mineralization of the dentin occur as previously Clinical Note
described.
Accessory canals are more prevalent in the apical
third of the root.
emento lasts
C
b
As dentin is formed, the basement membrane of the
inner enamel epithelium disintegrates and the epi- Formation o ementum
f
C
thelial cells lose their continuity. The disintegration Two kinds of cementum are laid down on the root. If
of the basement membrane and the loss of conti- the cementoblasts retract as the cementum is laid, it
nuity of the epithelial cells allow the mesenchymal will be acellular cementum; on the other hand, if the
cells from the dental follicle to penetrate the newly cementoblasts do not retract and are surrounded by

deposited dentin. These mesenchymal cells differ- the new cementum, the tissue formed will be cellular
entiate into cementoblasts, which are round, plump cementum and the trapped cementoblasts are called
cells that have basophilic cytoplasm with an open cementocytes (Fig. 1.11). The acellular cementum is
nucleus in the active phase of cementogenesis and a found adjacent to the dentin. The cellular cemen-
closed nucleus with reduced cytoplasm during the tum is found usually in the apical third of the root
resting phase. overlying the acellular cementum and in alternating
The collagen fibers followed by the ground sub- layers with it. The cementocytes receive their nutri-
stance elaborated by the cementoblasts are depos- ents from the PDL; the cementum is completely
ited between the epithelial cells. The cluster of cells avascular. Because cementum is deposited in lay-
left behind from the epithelial root sheath migrates ers throughout the life of the tooth, the cemento-
toward the dental follicle and the future PDL. This cytes are separated from the PDL, their source of
cluster of epithelial cells comprises the cell rests of nutrition, and die, leaving empty lacunae in the
Malassez. When some matrix production has taken cementum.
place, mineralization of the cementum starts by the The incremental deposition of cementum con-
spread and deposition of the hydroxyapatite crys- tinues throughout the life of the tooth and leaves
tals from the dentin into the collagen fibers and the rest lines on the tooth’s surface, and makes the layer
matrix. As dentinogenesis progresses in incremental of cementum thicker on the apical third of the root
phases, the apical foramen or foramina are formed by than on the cervical third.
an apposition of dentin and cementum that reduces
the size of the opening of the epithelial diaphragm.
Clinical Note
Clinical Note Cementum is deposited in a thin layer at the
cementoenamel junction to form one of the
The cell rests of Malassez remain dormant in the

following three configurations:
mature PDL and have the potential of proliferat-

ing into periradicular cysts if stimulated by chronic - Butt joint (30%)
inflammation. - An overlap joint (60%)
- A gap between cementum and enamel (10%)

(this gap may produce cervical sensitivity or
ccessory anal Formation may predispose the tooth to cervical caries)
A
C
The accessory canals, which are an inefficient source The continued incremental deposition of cemen-
of collateral circulation for the pulp, are formed tum in the apical third maintains the length of the
during the development of the root. A defect in the tooth, constricts the apical foramen, and deviates
epithelial root sheath, a failure in the induction of the apical foramen from the center of the apex.
Ch_01_GEP.indd 14 08/08/14 1:58 PM


Cementum
PDL
Granular layer
of Tomes
Dentin
1mm
(a)
Dentin
PDL
Cementum
Dentinal
tubules
Granular layer
of Tomes
200 µm
(b)
Figure 1.11 Premolar, cross-section: (a) This is a ground section of a premolar, showing dentin, cementum, and
periodontal ligament (PDL). (b) At higher magnification, the dentinal tubules are easily distinguished as well as the
granular layer of Tomes. (continued)
DE E V LO P E
M NT OF TH E PE RIO D ONTAL
the cells in the periphery of the follicle differentiate
LIGAM E NT AN D ALVE OLAR BON E into osteoblasts to form the bony crypt or alveo-
lus of the tooth, and the mesenchymal cells of the
The periodontal ligament and alveolar bone center of the follicle differentiate into fibroblasts.
develop at the same time as the root of the tooth. These fibroblasts deposit obliquely oriented col-
As the mesenchymal cells of the dental follicle adja- lagen fibrils that develop into fiber bundles. These
cent to the tooth differentiate into cementoblasts, obliquely oriented fiber bundles become entrapped
Ch_01_GEP.indd 15 08/08/14 1:58 PM


Acellular
Cellular cementum
cementum
Cementocytes
in lacunae
100 µm
(c)
Figure 1.11 (continued) (c) Cellular and acellular cementum evident along with cementocytes in the lacunae (stain:
ground section). (Courtesy: Mathias Nordvi, University of Oslo, Norway.)
in bone and cementum as they are deposited and established and leaves the vessels that connect with
thereby give rise to the PDL fibers. The deposition the circular reticulated plexus to form the pulpal
of bone to form the alveolus and deposition of vessels. As the tooth matures, the circular reticu-
cementum to cover the dentin of the root give form lated plexus develops into the periodontal plexus.
to the attachment apparatus, the periodontium. The formation of the root elongates the pulpal
vessels, causes the reappearance of the subodonto-
blastic plexus, and constricts the pulpal vessels into
Clinical Note
a small apical foramen. In the multirooted teeth,
The surface of the bony crypt becomes known as the the epithelial diaphragm divides the pulpal vessels
lamina dura radiographically.
randomly into the different foramina.

In the early stages of tooth development, the
nerve fibers can be seen in the dental follicle. At
Cir ulation an nn rvation the beginning of dentinogenesis, some of the nerve
c
d
I
e
of D v lo ing ooth fibers from the dental follicle migrate into the
e
e
p
T
dental papilla. Not until the beginning of the root
The blood vessels of the pulp originate from an formation does the nerve proliferation of the pulp
oval or circular reticulated plexus. When fully begin. The sensory nerve fibers traverse the den-
developed, this plexus encircles the enamel organ tal papilla and, on reaching the coronal pulp, they
and the dental papilla in the region of the dental branch toward the periphery to form a plexus of
follicle. A series of vessels arise from this plexus nerves called the plexus of Raschkow. This plexus of
and grow into the dental papilla. At the beginning Raschkow is located in the subodontoblastic zone
of dentinogenesis, the vessels that have penetrated of the coronal pulp. These sensory nerve fibers are
the dental papilla give rise to a vascular subodonto- myelinated; therefore, they are enclosed in a sheath
blastic plexus, which follows the shape of the newly made of Schwann’s cells. A number of nerves leave
formed dentin. This subodontoblastic plexus atro- the plexus and extend into the odontoblastic layer.
phies as soon as the mature thickness of dentin is Some contact the odontoblasts, whereas others lose
Ch_01_GEP.indd 16 08/08/14 1:58 PM

y Protective: Protection against and repairing of

their myelin sheath and enter the predentin and the y
dentinal tubules. The unmyelinated nerve fibers the effects of noxious stimuli
that enter the dentinal tubules lie in the proximity y Nutritive: Preserving the vitality of all the cel-
y
of the odontoblastic processes. lular elements

Nair addressed the structural and quantitative y Sensory: Perception of stimuli
y
aspects of human tooth innervations and formula-

The elaboration of dentin creates a special envi-
tion and clinical relevance of tooth axons. Human
ronment for the pulp. The pulp space becomes
premolars receive almost 2300 axons at the root
limited by dentin formation in permanent adult
apex, of which about 13% are myelinated and 87%
human teeth. This volume is continuously reduced
are nonmyelinated fibers. Most apical myelin-
by the deposition of secondary dentin throughout
ated axons are fast-conducting Aδ fibers with their
the life of the pulp as well as by the deposition of
receptive fields located at the pulpal periphery and
reparative dentin in response to noxious stimuli.
inner dentin. These fibers are probably activated by
The encasement of the pulp in dentin creates an
a hydrodynamic mechanism and conduct impulses
environment that allows only small amounts of
that are perceived as a short, well-localized, sharp
intercellular accommodation of exudate during
pain. Most C fibers are slow conducting and fine
inflammatory reactions.
sensory afferents. Their receptive fields are located
The anatomic limitation of encasement of den-
in the pulp and these transmit impulses that are
tin on the pulp makes the pulp an organ of terminal
experienced as a dull, poorly localized, and linger-
circulation, with limited portals of entry and exit:
ing pain. In addition to nociceptive alarm signaling,
the apical and accessory foramina. This feature lim-
the intradental sensory axons may play a regulatory
its the vascular supply and drainage of the pulp and
role in the maintenance and repair of the pulpo-
thereby limits its collateral circulation.
dentinal complex.
The blood vessels entering the dental papilla dur-
ing the development bring with them the sympathetic Clinical Note
nerve fibers which are unmyelinated. These sympa- The inability of the pulp to swell creates abnormally
thetic nerve fibers play a role in the vasoconstriction high pressure in an area of inflammation, with inter-
of the blood vessels. As the apical foramen matures ruption of blood flow due to the collapse of the
and reduces the size of its opening, the myelinated pulpal veins, possibly resulting in anoxia and localized
necrosis.
nerve fibers form bundles located in the center of the
pulp in conjunction with the blood vessels.
Zon of Pul
Part 2: normal Pul
es p
Starting at the periphery, the pulp is divided into

Pulp is a connective tissue consisting of nerves,
four zones:
blood vessels, ground substance, interstitial fluid,
odontoblasts, fibroblasts, and other cellular 1. Odontoblastic zone, which surrounds the
components. The dental pulp consists of vascular
periphery of the pulp

connective tissue contained within rigid dentinal 2. Cell-free zone

walls. Although similar to other connective tissues 3. Cell-rich zone
in the human body, it is specialized, owing to its 4. Central zone
functions and environment.
.
I Od onto lastic Zone
b
F un tion of th Pul
c s e p
The odontoblasts are specialized cells that gener-
ally last the entire life of the tooth. The odonto-
y Formative: Elaboration of dentin to form the
y
blasts consist of cell bodies and their cytoplasmic
tooth processes. The odontoblastic cell bodies form the
Ch_01_GEP.indd 17 08/08/14 1:58 PM


Dentin
Predentin
Odontoblastic
layer
Pulp core
Figure 1.12 H/E-stained decalcified section of tooth showing dentin, predentin, odontoblastic layer, and pulp (10x).
(Courtesy: B. Sivapathasundharam and K. Manjunath, India.)
odontoblastic zone, whereas the odontoblastic pro- and the action in unison of these cells. These cell
cesses are located within the predentin matrix and bodies vary in size, shape, and arrangement from
the dentinal tubules, extending into the dentin. In the coronal pulp to the apical pulp. In the coronal
this odontoblastic zone, capillaries and unmyelin- pulp, the odontoblasts are tall, columnar cells with
ated sensory nerves are found around the odonto- a nucleus polarized toward the center of the pulp.
blastic cell bodies (Fig. 1.12). They change shape gradually to flattened cells in the
The odontoblasts lining the predentin repre- apical third, and their arrangement changes from a
sent the link between the dentin and the pulp. The six- to eight-cell layer in the pulp horns to a one-cell
odontoblasts are the matrix-producing cells and layer in the apical pulp.
show characteristic features associated with protein
synthesis.
Clinical Note
Clinical Note The crowded arrangement of the coronal odon-

toblasts is due to the rapid reduction of the pulp
The primary function of the odontoblasts throughout chamber by the deposition of dentin, which com-
the life of the pulp is the production and deposition presses the existing cells to a stratified layer.
of dentin. This crowding of odontoblasts produces more cells
per unit area and, therefore, more dentinal tubules
(45,000/mm2) in the pulpal side than in the enamel
istology side (20,000/mm2).
H
In histologic sections, the odontoblasts appear to be
lined up in a palisading arrangement at the periph-
ery of the pulp. The cell bodies of the odontoblasts As a result of this phenomenon, the configuration
have junctional complexes, such as gap junctions, of the dentinal tubules in these areas is “S” shaped.
which unite the cells and allow an interchange of Reduction of odontoblasts per unit area produces
metabolites. These cytoplasmic bridges among fewer tubules and results in a straighter course, as
odontoblasts may explain the palisading formation seen in the cervical third of the root or beneath the
Ch_01_GEP.indd 18 08/08/14 1:58 PM


incisal edges or cusps (Fig. 1.13). Further reduc- and collagen fibrils. Calcium and phosphorus salts
tion in the number of cells and, consequently, in are deposited into this matrix to produce the miner-
the number of dentinal tubules produces dentin alized structure known as dentin. The pattern of cal-
typically found in the apical third. The presence of cification around the odontoblastic processes forms
“S”-shaped tubules is a consideration in clinical end- the dentinal tubules, and the dentin between these
odontic practice. Operative procedures in areas with tubules is called intertubular dentin.
such tubules produce inflammatory changes in the
odontoblastic layer further apically than expected. O dontoblastic Processes
The odontoblastic processes, also referred to as
Predentin ayer
L Tomes’ processes, are housed within the dentinal
Dentinogenesis includes the production, deposition, tubules. The extent of the odontoblastic processes
and calcification of the matrix. This matrix is the in dentin has not been determined. During the early
predentin layer deposited around the odontoblastic stages of tooth development, the processes extend
processes and is found between the calcified dentin into the entire thickness of the dentin. Studies in
and the odontoblastic zone (Fig. 1.14). This preden- adult teeth have given conflicting information on
tin layer, elaborated by the odontoblasts, is a protein– the extent of the processes. Some studies claim that
carbohydrate complex consisting of proteoglycans, these processes extend into one-third of the thick-
phosphoproteins, plasma proteins, glycoproteins, ness of the dentin (0.7 mm), whereas others claim
Enamel
Dentin
Root canal
Cementum https://t.me/LibraryEDent
2 mm
(a)
Figure 1.13 (a) Premolar: cross and longitudinal sections. (continued)
Ch_01_GEP.indd 19 08/08/14 1:58 PM


Enamel
Dentin
Dentinal
tubules
Pulpa
Cementum
1 mm
(b)
Enamel
Dentin
Dentinal
tubules
200 µm
(c)
Figure 1.13 (continued) (b) and (c) Longitudinal section: the enamel is brown in this section. In some areas of the
enamel, you can even see the direction of the enamel prisms. The dentinal tubules can easily be tracked through the
dentin (stain: ground section). (Courtesy: Mathias Nordvi, University of Oslo, Norway.)
Ch_01_GEP.indd 20 08/08/14 1:58 PM


Dentin
Interglobular
dentin
Predentin
Odontoblasts
Pulp
200 µm
(a)
Dentin
(mineralized)
Globule of
mineralized
dentin
Dentinal
tubules Predentin
(unmineralized
dentin)
Odontoblasts
Pulp
50 µm
(b)
Figure 1.14 (a) Predentin layer and odontoblastic zone surrounding the periphery of the pulp. (b) Predentin layer
and odontoblastic zone surrounding the periphery of the pulp at a higher magnification. (Courtesy: Mathias Nordvi,
University of Oslo, Norway.) (continued)
Ch_01_GEP.indd 21 08/08/14 1:58 PM


Predentin
Dentinal tubules
Erythrocyte
10 µm
(c)
Figure 1.14 (continued) (c) Dentinal tubules, pulpal view. This image shows predentin with dentinal tubules. This is
the pulpal side of the dentin. The odontoblasts have been removed (scanning electron microscopy, SEM). (Courtesy:
Randi F. Klinge, University of Oslo, Norway.)
that the processes extend through the thickness of dentin, the matrix has not calcified or is hypocal-
the dentin and reach the dentinoenamel junction. cified. These areas are called interglobular dentin
The space around the odontoblastic processes, (Fig. 1.15a and 1.15b). One also sees spaces in the
the periodontoblastic space, and the space peripheral root dentin near the cementodentinal junction
to the end of the odontoblastic processes are filled called the granular layer of Tomes.
with extracellular fluid. This fluid originates from
the capillary transudate and plays an important role Clinical Note
in sensory transmission. The incremental lines represent rest periods in den-
tinogenesis, whereas the interglobular dentin and the
Clinical Note granular layer of Tomes probably represent a defect in
The unmyelinated nerves for sensory perception are matrix formation.
also found in the pulpal end of the periodontoblastic
space of the dentinal tubules.
Dentinal ubules
T
The dentinal tubules extend from the predentin
ncremental ines border to the dentinoenamel and the dentino

I
L
During dentinogenesis, there are periods of activity cemental junctions (Fig. 1.16). They are conical in
and periods of rest. These periods are demarcated shape, with a 2.5 µm mean diameter in the pulpal
by the presence of lines, called incremental lines. wall and a 0.9 µm mean diameter in the dentino

These lines are accentuated during periods of ill- enamel or dentinocemental junctions because of
ness, by deficiencies in nutrition, and at birth. The the deposition of the peritubular dentin (Fig. 1.17).
accentuated incremental line that occurs at birth is As the dentinal tubules approach the dentino

called the neonatal line. In some areas in the mature enamel junction, they branch and increase the ratio
Ch_01_GEP.indd 22 08/08/14 1:58 PM


Interglobular
dentin
Dentinal
tubules
(a)
Enamel
Dentinoenamel
junction
Interglobular
dentin
(b) https://t.me/LibraryEDent
Figure 1.15 (a) Dentinal tubules, cross-section. This section is not decalcified. It is colored by toluidine blue. The
interglobular dentin can be seen (stain: toluidine blue). (Courtesy: Randi F. Klinge, University of Oslo, Norway.)
(b) Longitudinal section of tooth showing enamel, dentinoenamel junction, and areas of interglobular dentin (ground
section, 10x). (Courtesy: B. Sivapathasundharam and K. Manjunath, India.)
per unit area over that of the middle third of the dentin. tubules. As the fully mature odontoblast migrates
The branching of the dentinal tubules occurs during pulpally, the processes unite to form a single dentinal
the beginning of dentinogenesis. Each preodontoblast tubule with terminal branches at the dentinoenamel
sends various cytoplasmic processes into the acellu- junction. This branching may explain the extreme sen-
lar zone and thereby produces several future dentinal sitivity of the dentinoenamel junction (Fig. 1.18).
Ch_01_GEP.indd 23 08/08/14 1:58 PM


Dentinal
tubules
Erythrocyte
(a)
Dentinal tubule
Erythrocyte
(b)
Figure 1.16 (a) and (b) Dentinal tubule. This is an image of a piece of dentin acquired using a scanning electron
microscope. It illustrates the number of dentinal tubules and their size. (Size may vary as to what part of the dentin
you look at and the age of the individual.) An erythrocyte can be seen at the bottom of the image telling us about the
scale involved. (Diameter of an erythrocyte is approximately 7.5 µm; scanning electron microscopy, SEM.) (Courtesy:
Randi F. Klinge, University of Oslo, Norway.)
Ch_01_GEP.indd 24 08/08/14 1:58 PM


Dentin
Peritubular
dentin
Dentinal
tubules
(a)
Dentinal tubule
Dentin
Peritubular
dentin
Dentin
(b)
Figure 1.17 (a) and (b) Peritubular dentin, dentinal tubules, highly mineralized dentin: dentinal tubules containing
highly mineralized dentin. The section is made halfway through the dentin (scanning electron microscopy, SEM).
(Courtesy: Randi F. Klinge, University of Oslo, Norway.)
Ch_01_GEP.indd 25 08/08/14 1:58 PM


Enamel
Dentinal
tubules
Terminal
branching
of dentinal
tubules
Figure 1.18 Longitudinal section of tooth showing wavy enamel rods and dentinal tubules along with their terminal
branching (ground section, 10x). (Courtesy: B. Sivapathasundharam and K. Manjunath, India.)
Because the peritubular dentin has an organic Primary Dentin

matrix with fewer collagen fibers than the inter- Primary dentin is elaborated before the teeth erupt
tubular dentin, it is more mineralized and harder. and is divided into mantle and circumpulpal dentin.
As the pulp ages, the continuous deposition of peri- Mantle dentin, the first calcified layer of the dentin
tubular dentin may obliterate the dentinal tubules deposited against the enamel, forms the dentinal
peripherally. This obliteration of tubules results in side of the dentinoenamel junction. Circumpulpal
the formation of the sclerotic dentin, which has a dentin is the dentin formed after the layer of mantle
glassy appearance under transmitted light. dentin. Primary dentin fulfills the initial formative
function of the pulp.
Clinical Note Secondary Dentin
Sclerosis reduces the permeability of the dentin and Secondary dentin is elaborated after eruption of
may serve as a pulp-protective mechanism. A mild the teeth. It can be differentiated from primary
stimulus of short duration may accelerate the produc- dentin by the sharp bending of the tubules produc-
tion of the peritubular dentin, may produce sclerosis
ing a line of demarcation. It is deposited unevenly
peripherally, and may thus reduce the permeability of
on primary dentin at a low rate and has incremen-
dentin and enhance pulp protection.
tal patterns and tubular structures less regular than
those of primary dentin. For example, secondary
By dentinogenesis, the odontoblasts are involved dentin is deposited in greater quantities in the floor
in the formation of the teeth and the protection of and roof of the pulp chamber than on the walls.
the pulp from noxious stimuli. To fulfill the forma- This uneven deposition explains the pattern of
tive and protective functions of the pulp, the odon- reduction of the pulp chamber and pulp horns as
toblasts deposit primary, secondary, and tertiary teeth age. This deposition of secondary dentin pro-
dentin. tects the pulp.
Ch_01_GEP.indd 26 08/08/14 1:58 PM

Tertiary Dentin

When a mild stimulus is applied to the odon-
Two types of tertiary dentin are recognized: toblasts for a prolonged period of time, such as
1. Tertiary dentin formed by primary odonto- abrasion, reparative dentin may be deposited at a
blasts following a mild stimulus is called reac- slower rate. This tissue is characterized by slightly
tionary dentin. irregular tubules. On the other hand, an aggressive
2. Tertiary dentin formed by newly differentiated carious lesion or other abrupt stimulus stimulates
or secondary odontoblasts is termed reparative
the production of reparative dentin with fewer
dentin. and more irregular tubules. If the odontoblast is
injured beyond repair, the degenerated odonto-
Clinical Note blasts will leave empty tubules, called dead tracts,
which allow bacteria and noxious products to enter
Reparative dentin, also known as irregular or ter-
tiary dentin, is elaborated by the pulp as a protective
the pulp (Fig. 1.19). Reparative dentin is deposited
response to noxious stimuli. on the pulpal wall of a dead tract unless the pulp
These stimuli can result from caries, operative pro- is too atrophic. Because reparative dentin has fewer
cedures, restorative materials, abrasion, erosion, or tubules, although it is less mineralized, it blocks
trauma. the ingress of noxious products into the pulp. As
The reparative dentin is deposited in the affected the caries progress and as more odontoblasts are
area at an increased rate that averages 1.5 µm injured beyond repair, the layers of reparative dentin
per day. become more atubular and may have cell inclusions,
The rate, quality, and quantity of repara- i.e., trapped odontoblasts. The cellular inclusions
tive dentin deposited depend on the severity are uncommon in human teeth. On removal of the
and duration of the injury to the odontoblasts
caries, the mesenchymal cells of the cell-rich zone
and is usually produced by “replacement” odon-
toblasts.
differentiate into odontoblasts to replace those that
have necrosed. These newly formed odontoblasts
Enamel
Dead
tracts
Enamel
spindle
Figure 1.19 Longitudinal section of crown showing dead tracts and enamel with enamel spindle emerging from
dentinoenamel junction (ground section, 10x). (Courtesy: B. Sivapathasundharam and K. Manjunath, Department of
Oral and Maxillofacial Pathology, Meenakshi Ammal Dental College, India.)
Ch_01_GEP.indd 27 08/08/14 1:58 PM

round ubstance

can produce well-organized dentin or an amor-
G
S
phous, poorly calcified, permeable dentin. The Ground substance, the main constituent of the
demarcation zone between secondary and repara- pulp, is the part of the matrix that surrounds and
tive dentin is called the calciotraumatic line. supports the cellular and vascular elements of the
nterphase Dentin This is the first formed pulp. It is a gelatinous substance composed of
I
tertiary or reparative dentin. This has a marked proteoglycans, glycoproteins, and water. Ground
physiological effect because it locally reduces the substance serves as a transport medium for metab-

permeability of dentin. It reduces the direct com- olites and waste products of cells and as a barrier
munication between physiologic, primary, second- against the spread of bacteria. Age and disease

ary, and/or tertiary dentin. may change the composition and function of the
ground substance.
. -F Z
II
CELL
REE
ONE
The cell-free zone, or zone of Weil, is a relatively acel- Fibroblasts
lular zone of the pulp, located centrally to the odon- The fibroblasts are the predominant cells of the
toblast zone (Fig. 1.20). This zone, although called pulp (Fig. 1.20). They may originate from undif-
cell-free, contains some fibroblasts, mesenchymal ferentiated mesenchymal cells of the pulp or from
cells, and macrophages. Fibroblasts are involved in the division of existing fibroblasts. The fibro-
the production and maintenance of the reticular blasts are stellate in shape, with ovoid nuclei and
fibers found in this zone. When odontoblasts are cytoplasmic processes. As they age, they become
destroyed by noxious stimuli, mesenchymal cells rounder, with round nuclei and short cytoplasmic
and fibroblasts differentiate into new odontoblasts. processes. Although fibroblasts are present in the
Macrophages are present for the phagocytosis of cell-free and central zones of the pulp, they are
debris. concentrated in the cell-rich zone, especially in the
The main constituents of this zone are a plexus coronal portion.
of capillaries, the nerve plexus of Raschkow, and the The function of the fibroblasts is elaboration of
ground substance. The capillary plexus is involved ground substance and collagen fibers, which con-
in the nutrition of the odontoblasts and the cells of stitute the matrix of the pulp. The fibroblasts are
the zone and is conspicuous only during periods of also involved in the degradation of collagen and
dentinogenesis and inflammation. The ground sub- the deposition of calcified tissue. They can elabo-
stance is involved in the metabolic exchanges of the rate denticles and can differentiate to replace dead
cells and limits the spread of infection because of odontoblasts, with the potential for reparative den-
its consistency. The zone of Weil is more prominent tin formation.
in the coronal pulp, but it may be completely absent As compared to the coronal third, the api-
during periods of dentinogenesis. cal third of the mature pulp contains more colla-
gen fibers and is therefore more fibrous and has a
Clinical Note whitish coloration. This fibrous characteristic of
The unmyelinated nerve plexus of Raschkow is
the apical third protects the neurovascular bundle
involved in the neural sensation of the pulp. from injury and is of clinical significance because
it facilitates the removal of the pulp during pulp-
ectomy. Because of the reduction of the pulp space
. - Z
through the continuous deposition of secondary
III
CELL
RICH
ONE
The cell-rich zone is located central to the cell-free dentin and because of the increased deposition of
zone (Fig. 1.20). Its main components are ground collagen, the pulp becomes more fibrous with age.
substance, fibroblasts with their product, i.e., the Concomitantly, one sees a decrease in cellular ele-
collagen fibers, undifferentiated mesenchymal cells, ments and a reduction in the reparative potential
and macrophages. of the pulp.
Ch_01_GEP.indd 28 08/08/14 1:58 PM


Dentin
Pulp
Predentin
Odontoblast
Nerve layer
Cell-free zone
of Weil
Blood
vessel Cell-rich zone
Fibroblasts
50 µm
(a)
Cell-rich Dentin
zone
Pulp Predentin
Odontoblasts
Fibroblasts
Cell-free
zone of Weil Dentinal
tubules
50 µm
(b)
Figure 1.20 (a) and (b) Zones of pulp in a demineralized tooth, longitudinal section. The pulp (Latin pulpa) comprises
loose connective tissue, blood vessels, and nerves. At higher magnification, you see that the concentration of cells
close to the dentin is much higher than in the pulp in general. This “concentration of cells” is divided into three zones:
the cell-rich zone, the cell-free zone of Weil, and the odontoblast layer. The predentin stains light pink/red, while the
dentin stains pink/red. Within the predentins, you can see globules of mineralizing dentin. Dentinal tubules are seen
throughout the dentin (stain: H + E). (Courtesy: Mathias Nordvi, University of Oslo, Norway.) (continued)
Ch_01_GEP.indd 29 08/08/14 1:58 PM


Blood vessel
Dentin
Pulp
Odontoblasts
Cell-free zone
of Weil
Predentin
Cell-rich zone
Dentinal
tubules
Capillary
Blood vessel
100 μm
(c)
Figure 1.20 (continued) (c) Zones of pulp in a demineralized tooth, cross-section. If you take a look at the pulp, you
can see the same structures as in Figure 1.20b. Try to compare the two images and bear in mind that this is a cross-
section and Figure 1.20b is a longitudinal section (stain: H + E). (Courtesy: Mathias Nordvi, University of Oslo, Norway.)
ndifferentiated the coronal subodontoblastic region. The function

U
esenchymal ells of these cells in the normal pulp may be immune
M
C
The undifferentiated mesenchymal cells are surveillance.
derived from the mesenchymal cells of the den-
tal papilla. Because of their function in repair . Z
IV
CENTRAL
ONE
and regeneration, they retain pluripotential char-
acteristics and can differentiate into fibroblasts, The central zone or pulp proper contains blood
odontoblasts, macrophages, or osteoclasts. They vessels and nerves that are embedded in the pulp
resemble fibroblasts as they are stellate in shape, matrix together with fibroblasts. From their cen-
with a large nucleus and little cytoplasm. These tral location, the blood vessels (Fig. 1.21) and
cells, if present, are usually located around blood the nerves send branches to the periphery of the
vessels in the cell-rich zone and are difficult to pulp.
recognize.
Blood essels of Pulp and irculation
V
C
acrophages, ymphocytes, The neurovascular bundle enters the pulp through
M
L
and Plasma ells the apical foramina. It consists of one or two arteri-
C
Macrophages are found in the cell-rich zone, espe- oles with their sympathetic nerve fibers and myelin-
cially near the blood vessels. These cells are blood ated and unmyelinated sensory nerves entering
monocytes that have migrated into the pulp tissue. the pulp, and two or three venules and lymphatic
Their function is to phagocytize necrotic debris vessels exiting the pulp. In some teeth, accessory
and foreign materials. Lymphocytes and plasma foramina may serve as portals of entry and exit for
cells, if present in the normal pulp, are found in blood vessels only.
Ch_01_GEP.indd 30 08/08/14 1:58 PM


Figure 1.21 Centrally located blood vessels of the pulp. (Courtesy: Department of Oral Pathology, A. J. Institute of
Dental Sciences, India.)
The pulpal blood flow mainly determines the The transfer of nutrients and metabolic waste
speed of diffusion between the blood and the inter- through the capillary walls is controlled by the
stitial fluid; the higher the blood flow, the faster the laws of hydrostatics and osmosis. The walls of the
diffusion. Regulation of an adequate blood flow is capillaries are an average of 0.5 µm thickness and
a crucial point for survival and normal function in serve as a permeable membrane that permits the
any tissue. exchange of fluids. The absorption of metabolic
wastes and fluids prevents their accumulation in
i. Afferent circulation of the pulp consists of the
the pulpal tissues and also precludes increases in the
arterioles entering the apical foramen. As these
pulpal tissue pressure.

vessels traverse the center of the pulp, they branch
into terminal arterioles, metarterioles, precapillar-
ies, and finally capillaries. The capillaries end in the
Clinical Note
cell-poor zone and form a rich subodontoblastic
In areas of pulpal injury, the permeability of the capil-
plexus.
ii. Efferent circulation consists of postcapillary lary walls permits the seepage of blood proteins into
the pulpal tissues and increases the osmotic pressure
venules and collecting venules, which empty into
of tissues of the area. This increase in osmotic pres-
two or three venules that exit through the apical
sure attracts more fluid to the area; the result is the
foramina and empty into the vessels in the PDL. stagnation of fluid known as edema.
Lymphatic vessels follow this same pattern.
The function of blood vessels is to transport
nutrients, fluids, and oxygen to the tissues and to L ymphatic Drainage of Pulp
remove metabolic waste from the tissues by main- Lymphatic vessels are present in the pulp. The func-
taining an adequate flow of blood through the tion of these vessels is the removal of interstitial
capillaries. This metabolic exchange occurs in the fluid and metabolic waste products to maintain
capillary bed. the intrapulpal tissue pressure at a normal level.
Ch_01_GEP.indd 31 08/08/14 1:58 PM

Box 1.1 Afferent Pain Pathway

These lymphatic vessels follow the course of the
venules toward the apical foramen. Stimulated impulse travels from
C or Ad fiber nerve endings
Interstitial Fluid 
Interstitial fluid bathes all the pulpal tissues and fills The plexus of Raschkow
the dentinal tubules in their distal extension and 
around the odontoblastic processes. The interstitial Nerve trunk in the central zone of the pulp that exits
fluid that fills the dentinal tubules is called the den- the tooth through the apical foramen
tinal fluid. As previously discussed, the encasement 
Maxillary or the mandibular division of the
of the pulp in dentin produces a limited environ-

trigeminal nerve
ment permitting only a small amount of interstitial 
fluid. Pons

Tissue Fluid Pressure Thalamus
The hydrostatic pressure in the interstitial fluid sur- 
rounding the pulpal cells is called the pulpal tissue Cortex
fluid pressure. 
Interpreted as pain
Clinical Note
The presence of fluid in the pulpal cavity produces an
the tunica adventitia. The sympathetic nerves
average intrapulpal tissue pressure of approximately provide vasomotor control to circulation
10 mm Hg. and therefore regulate the blood flow and
A small increase in intrapulpal pressure to 13 mm
intrapulpal blood pressure in response to

Hg during inflammatory changes causes revers- stimuli.
ible changes in the pulp, but if intrapulpal pressure
increases to 35 mm Hg, it produces irreversible Approximately, 80% of the nerves of the pulp are
C fibers and the rest are Aδ fibers (Table 1.1).

changes.
Owing to the structural makeup of the matrix, in

which the ground substance is reinforced by collagen
fibers, the pulp seems to be able to limit the area Clinical Note
of increased intrapulpal pressure during periods of The hydrodynamic theory explains the painful reac-
inflammation. tion of the pulp to heat, cold, cutting of the dentin,
and probing of the dentin.
nnervation of Pulp Heat expands the dentinal fluid

Cold contracts the dentinal fluid
I
The sensory mechanism of the pulp is composed
Cutting the dentinal tubules allows the dentinal

of sensory afferent and autonomic efferent systems.
fluid to escape
y The afferent system conducts impulses per- Probing the cut or exposed dentinal surface may

y
ceived by the pulp from a variety of stimuli deform the tubules and produce fluid movement
to the cortex of the brain, where they are
interpreted as pain, regardless of the stimulus

(Box 1.1). in rali ation
y The efferent motor pathway in the dental pulp
M
e
z
s
y
consists of sympathetic fibers from the cervi- The other histologic structures found in the dental
cal ganglion that enter through the apical pulp are mineralizations. Although their presence

foramina in the outer layer of the arterioles, has been related to age and disease, they are also

Ch_01_GEP.indd 32 08/08/14 1:58 PM

Table 1.1 Nerve Fibers of the Pulp: C and Ad
C Nerve Fibers Ad Nerve Fibers
� C fibers are unmyelinated and fine sensory a fferents. � Most apical myelinated axons are fast-conducting Aδ
yyC fibers have a diameter of 0.3–1.2 µm and a fibers with their receptive fields located at the pulpal
conduction velocity of 0.4–2 m/s. periphery and inner dentin.
yyThe conduction of these fibers, which are of smaller yyThe Aδ fibers have a diameter of 2–5 µm and a
diameter than Aδ fibers, is slow. c onduction velocity of 6–30 m/s.
yyThese fibers are probably distributed throughout the yy The Aδ fibers, with a larger diameter than that of the
pulp tissue. With their receptive fields located in the C fibers, conduct impulses at a higher velocity.
pulp, C fibers transmit impulses that are experienced yyThey conduct impulses that are interpreted as a
as a dull, poorly localized, and lingering pain; they short, well-localized, sharp, and pricking pain.
conduct throbbing and aching pain associated with yyThe Aδ fibers are distributed in the odontoblastic
pulp tissue damage. and subodontoblastic zones and are associated with
yyIn addition to the nociceptive alarm signaling, the dentinal pain.
intradental sensory axons play a regulatory role in yyMechanism of stimulation: Three theories have been
the maintenance and repair of the pulpodentinal proposed to explain the sensitivity of dentin.
complex.
– Direct Stimulation Theory: The first is the direct
yyMechanism of stimulation: Inflammation that ac- stimulation of the nerve endings of the pulp; the
companies tissue injury leads to increase in tissue lack of nerve endings at the periphery of the den-
pressure and release of chemical mediators. This in tin negates this theory.
turn stimulates the C fibers that result in pain.
– Odontoblastic Theory: The second theory
proposes that the odontoblasts function as

nerve endings. This theory cannot be accepted,
however, because no one knows for certain how
far the odontoblastic processes extend in the
dentinal tubules, and no evidence indicates that
the odontoblasts are able to function as nerve
endings.
– H
ydrodynamic Theory: The third theory, the
hydrodynamic theory, states that any fluid move-
ment in the dentinal tubules and around the
odontoblasts as the result of a stimulus excites
the nerve endings and produces an impulse. This
theory is the most acceptable of the three.
found in young normal dental pulps. They are pres- tubules, surrounded by odontoblast-like
ent as: cells.
–– False denticles (Fig. 1.22) are of two types
yy
Nodules called denticles or pulp stones: The den-
histologically:
ticles are either true or false denticles, according
- Round or ovoid with concentric calcified
to their histologic structure.
layers and smooth surfaces
–– True denticles are uncommon, are usually
- Amorphous without lamination and
found near the apex, and are composed of
rough surfaces
dentin or dentinal-type calcifications with
Ch_01_GEP.indd 33 08/08/14 1:58 PM


Dentin
Predentin
False free
pulp stone
Odontoblastic
layer
Pulp core
Figure 1.22 H/E-stained decalcified section of tooth showing dentin, predentin, odontoblastic layer, and false free
pulp stone in pulp (10x). (Courtesy: B. Sivapathasundharam and K. Manjunath, India.)
Pulp stones form under a number of differ- denticles to obtain access into the orifices of the root

ent conditions. True pulp stones with the dentin canals.
structure probably form from fragmented por- Calcifications in the root canals usually are not
tions of Hertwig’s epithelium on the pulpal side. seen radiographically, but they are detectable
Odontoblasts may also be differentiated from the during exploration of the root canal. This type
immature cells in the dental pulp and initiate histo- of calcification may prevent the clinician from
genesis of denticles. Dentin fragments introduced reaching the apical foramen and may therefore
into the pulp following pulpal exposures may act as prevent complete instrumentation of the root
foci for pulp stone formation. canal.
y Diffuse calcifications: They usually follow the

y
trajectory of the blood vessels, the nerves, and
the collagen fiber bundles. They are most often Eff t of ging on Pul
ec
s
A
p
found in the walls of blood vessels. Diffuse cal- Age causes important changes in the pulp.
cifications seem to be related to aging because
their incidence increases with age. y The continuous deposition of secondary den-
y
tin throughout the life of the pulp and the
deposition of reparative dentin in response to
Clinical Note stimuli reduces the size of the pulp chambers
The denticles predominate in the pulp chamber,
and root canals and thereby decreases the pulp

whereas diffuse calcifications are predominantly volume. This diminution of the pulp is called
found in the root canals. atrophy.
Radiographs may show denticles in the coro-
y A concomitant decrease in the diameter of the
nal chamber. This finding should alert the cli-
y
dentinal tubules by the continuous deposition
nician to the possible need for removal of the
of peritubular dentin also occurs.
Ch_01_GEP.indd 34 08/08/14 1:58 PM

y Some of these tubules close completely and C m ntum

y
e e
form sclerotic dentin. The decrease in pulp

volume reduces cellular, vascular, and neural Cementum is a bone-like calcified tissue that cov-
content of the pulp. The odontoblasts undergo ers the roots of the teeth. As previously discussed, it
atrophy and may disappear completely under is derived from the mesenchymal cells of the den-
areas of sclerotic dentin. tal follicle that differentiate into cementoblasts. The
y y A reduction in the fluid content of the den- cementoblasts deposit a matrix, called cementoid,
tinal tubules is also seen. These changes make that is incrementally calcified and produces two
the dentin less permeable and more resistant to types of cementum: acellular and cellular (Fig. 1.11).
external stimuli. Chronologically, the acellular cementum is
y y The fibroblasts are reduced in size and num- deposited first against the dentin forming the
bers, but the collagen fibers are increased cementodentinal junction, and as a rule, it covers the
in number and in size, probably because of cervical and the middle thirds of the root. The cel-
the decrease in the collagen solubility and lular cementum is usually deposited on the acellular
turnover with advancing age. This change is cementum in the apical third of the root and alter-
referred to as fibrosis. Fibrosis is more evi- nates with layers of the acellular cementum. The cel-
dent in the radicular portion of the pulp than lular cementum is deposited at a greater rate than the
elsewhere. acellular cementum and thereby entraps the cement-
y y The blood vessels decrease in number, and oblasts in the matrix. These entrapped cells are called
arteries undergo arteriosclerotic changes. cementocytes. The cementocytes lie in the crypts of
Calcific material is deposited in the tunica cementum known as lacunae (Fig. 1.11). From the
adventitia and tunica media. These changes lacunae, canals, called canaliculi, which contain pro-
reduce the blood supply to the pulp. toplasmic extensions of the cementocytes and serve
y y The number of nerves is also reduced. as pathways for nutrients to the cementocytes inter-
y y The ground substance undergoes metabolic lace with other canaliculi of other lacunae to form a
changes that predispose it to mineralization. system comparable to the Haversian system of bone.
Changes in the blood vessels, nerves, and Because cementum is avascular, its nutrition comes
ground substance predispose the pulp to dys- from the PDL. As incremental layers of cementum
trophic calcifications. are deposited (Fig. 1.24), the PDL may be further
displaced, and some cementocytes may die as a result
and may leave empty lacunae.
The thickness of cementum reflects one of its
Part 3: normal P rira i ular
e d c
functions. The greater thickness of cementum at

i u T ss es
the apex is due to its continuous deposition during

the eruptive life of the tooth to preserve its height
The periradicular tissues consist of the following:
in the occlusal plane. The continuous deposition
y Cementum, which covers the roots of the teeth
y of cementum also gives form to the mature api-
y Periodontal ligament, whose collagen fibers,
y cal foramen. The foramen, as it matures, becomes
embedded in the cementum of the roots and conical, with the apex of the cone, called the minor
in the alveolar processes, attach the roots to the diameter (constriction), facing the pulp and the
surrounding tissues (Fig. 1.23) base, called the major diameter, facing the PDL.
y Alveolar process, which forms the bony troughs
y
containing the roots of the teeth Clinical Note

In the region of periradicular tissues portals Cementum is about 20–50 µm thick at the cemen-

of entry and exit between root canals and the toenamel junction and 20–150 µm thick in the apical
surrounding tissues are located, and pathologic

third of the root.
reactions to diseases of the pulp are manifested. (continued)
Ch_01_GEP.indd 35 08/08/14 1:58 PM


Alveolar bone
Dentin
Cementum
Cementum
PDL
Alveolar bone
2 mm
Figure 1.23 Root, apex. This is a longitudinal section of the apical part of a root. The apical supportive tissues are
also shown. You may already have noticed the thick layer of cementum covering the dentin at the apex indicating
that this tooth once belonged to an old individual. The cementum is mostly of the cellular type. Incremental lines can
be seen and illustrates the “rhythmical” deposition of cementum (stain: H + E). (Courtesy: Mathias Nordvi, University
of Oslo, Norway.)
Ch_01_GEP.indd 36 08/08/14 1:58 PM


Dentin Cementum
Incremental PDL
lines in
cementum
Cementocytes
Blood vessel
Alveolar
bone
500 µm
(a)
Acellular
Dentin
cementum
Border between
Dentin tubules dentin and
cementum
Cellular
cementum
Cementocytes
Incremental line
100 µm
(b)
Figure 1.24 (a) and (b) This is a longitudinal section of the apical part of a root. Cellular and acellular cementum along
with cementocytes and incremental lines can be appreciated (stain: H + E). (Courtesy: Mathias Nordvi, University of

Oslo, Norway.)
Ch_01_GEP.indd 37 08/08/14 1:59 PM


(continued) Repair is another function of the cementum.
The continuous deposition of cemen- Root fractures and resorptions are usually repaired
tum increases the major diameter and by cementum. The closing of immature roots
results in an average deviation of the apical by apexification procedures is accomplished by
foramen of 0.2–0.5 mm from the center of the deposition of cementum or cementum-like tis-
root apex. sue. Cementum also has a protective function. It is
The minor diameter dictates the apical termination more resistant to resorption than bone, probably
of root canal instrumentation and obturation and is because of its avascularity. As a result, orthodontic
located:
movement of roots can usually be performed with
- An average of 0.5 mm from the cemental surface a minimum of resorptive damage. Other functions

in young teeth are the maintenance of the periodontal width by
- An average of 0.75 mm from the cemental surface
the continuous deposition of cementum and the

in mature teeth
sealing of accessory and apical foramina after root
Although the cementodentinal junction may coin-
canal therapy.
cide with the minor diameter, cementum may grow
unevenly and may alter this relationship.
P rio ontal igam nt
e
d
L
e
The periodontal ligament is a dense, fibrous connec-
tive tissue that occupies the space between the cemen-
The fibers of the PDL occur between the osteo- tum and the alveolar bone. It surrounds the necks
blasts and cementoblasts and are embedded into the and the roots of the teeth and is continuous with the
bone and cementum, respectively. These embed- pulp and gingiva (Fig. 1.25). The PDL is composed
ded fibers, called Sharpey’s fibers, attach the PDL to of ground substance, interstitial tissue, blood and
bone and cementum. lymph vessels, nerves, cells, and fiber bundles.
Enamel space
Crown
Dentin Gingiva
Pulp
Gingiva
Peridontal
ligament
Cementum
Alveolar bone Root
2 mm
Figure 1.25 Tooth and its supportive structures. Longitudinal section: periodontal ligament, the alveolar bone, the
pulp, and some parts of the gingiva (stain: H + E). (Courtesy: Mathias Nordvi, University of Oslo, Norway.)
Ch_01_GEP.indd 38 08/08/14 1:59 PM


Variations in width occur from tooth to tooth bone resorption. As the osteoclasts demineral-
and in different areas of the ligament in the same ize and disintegrate the matrix, scooped-out
root. Teeth with heavy occlusal loads have wider areas in the bone, called Howship’s lacunae, are
PDLs than teeth with minimal occlusal loads, in formed. Osteoclasts are usually found in these
which PDLs are thinner. With advancing age, the lacunae. This pattern of resorption gives the
width of the PDL is reduced. border of the bone an irregular shape.
yy Cementoblasts, as previously discussed, are
Clinical Note aligned in the periphery of the PDL opposite
The width of the PDL varies from 0.15 to 0.38 mm. the cementum. Their function is the deposition
of a matrix consisting of collagen fibrils and
ground substance called cementoid. Cementoid
nterstitial issue
is found between calcified cementum and the
I T
The interstitial tissue is the loose connective tis- layer of cementoblasts that thickens in periods
sue that surrounds the blood vessels and the lym- of activity. The fibers of the PDL are found
phatic vessels, nerves, and fiber bundles. This tissue between cementoblasts and are entrapped in
contains collagen fibers independent of the fiber the cementoid. As the cementoid calcifies, the
bundles of the PDL. Changes in its configuration fibers of the PDL become anchored in the newly
are due to continuing changes in the fiber bundles. formed cementum and are called Sharpey’s
The spaces in the PDL, filled with interstitial tissue, fibers, the same as PDL fibers anchored in bone.
blood vessels, lymph vessels, and nerves, are called Cementoid may protect the cementum against
interstitial spaces. erosion.
yy Cementoclasts, or cementum-resorbing cells,
C ells o the Perio ontal igament
f d L
are not found in the normal PDL because
cementum does not normally remodel. They
The active cells of the PDL are the fibroblasts, osteo- are found only in patients with certain patho-
blasts, and cementoblasts. logical conditions.
y Fibroblasts synthesize collagen and matrix and
y
yy Other cells present in the normal PDL are the
are involved in the degradation of collagen for epithelial cell rests of Malassez, undifferenti-
its remodeling. The result is a constant remod- ated mesenchymal cells, mast cells, and macro-
eling of the principal fibers and maintenance phages. The epithelial cell rests of Malassez are
of a healthy PDL. Because of these important remnants of Hertwig’s epithelial root sheath.
functions, the fibroblasts are the most impor- These cells are located in the cementum side of
tant cells of the PDL. the PDL. Their function is unknown, but they
y Osteoblasts, or bone-forming cells, are found
y
can proliferate to form cysts in the presence of
in the periphery of the PDL lining the bony noxious stimuli.
socket. They are usually seen in various stages y Undifferentiated mesenchymal cells are usually
y
of differentiation. The function of osteo- stellate cells with large nuclei located near the
blasts is the deposition of collagen and matrix, blood vessels. These cells may differentiate into
which is deposited on the surface of the bone fibroblasts, odontoblasts, or cementoblasts.
and to which Sharpey’s fibers are attached.
Calcification of the osteoid anchors Sharpey’s
Perio ontal Fi ers
fibers. The constant remodeling of bone pro-
d b
vides for the continued renewal of the attach- The periodontal fibers are the principal structural
ment of the PDL to bone. components of the PDL. Two types are known:
y Osteoclasts, or bone-resorbing cells, are found
y collagen and oxytalan fibers. Collagen fibrils are orga-

in the bone periphery during periods of bone nized into fibers, which, in turn, are organized into
remodeling. They are multinucleated cells with bundles. The fibers that constitute the bundles are
a ruffle or striated border toward the area of not continuous from bone to cementum, but consist
Ch_01_GEP.indd 39 08/08/14 1:59 PM


of strands that can be continually and individually distribution of the arteries. The alveolar branches
remodeled by fibroblasts without causing loss of the innervate the apical region, the interalveolar
continuity of the bundles. The terminal fibers of the branches innervate the lateral PDL, and branches of
bundles insert into cementum on one side and bone the inter-radicular nerve innervate the furcal PDL
on the other side. These terminal fibers are called of the posterior teeth.
Sharpey’s fibers regardless of cementum or bone The nerve endings of the PDL enable one to
insertion. The fibers are arranged in bundles with a perceive pain, touch, pressure, and proprioception.
definite functional arrangement. These bundles fol- Proprioception, which gives information on move-
low an undulating course that allows some movement and position in space, enables one to perceive
ment of the tooth in its alveolar socket. the application of forces to the teeth, movement of
The fiber bundles are arranged into principal the teeth, and the location of foreign bodies on or
fiber groups: trans-septal, alveolar crest, horizontal, between the surfaces of the teeth. This propriocep-
oblique, apical, and inter-radicular. tive sense may trigger a protective reflex mecha-
nism that opens the mandible to prevent injury to
yy
The trans-septal group is embedded into the
the teeth or PDL when one bites into a hard object.
cementum of adjacent teeth traversing the
Proprioception permits the localization of areas of
alveolar crest interproximally.
inflammation in the PDL. Such inflammatory reac-
yy
The alveolar crest group is embedded into the
tions in the PDL can be identified by percussion
cementum below the cementoenamel junction,
and palpation tests.
is situated obliquely, and ends in the alveolar
crest.
yy
The horizontal group is embedded into the Alveolar Process
cementum apical to the alveolar crest group
and moves horizontally into the alveolar bone. The alveolar process is divided into the alveolar
yy
The oblique group is embedded into the cemen- bone proper and the supporting alveolar bone.
tum apically to the horizontal group and travels
obliquely in a coronal direction to be embed- Alveolar Bone Proper
ded into the alveolar bone.
The alveolar bone proper is the bone that lines the
yy
The apical group is embedded into the api-
alveolus or the bony sockets that house the roots of
cal cementum and the fundus of the alveolar
the teeth. It begins its formation by intramembra-
socket.
nous ossification at the initial stage of root forma-
yy
The inter-radicular group is embedded in ce-
tion. The osteoblasts at the periphery of the PDL
mentum and alveolar bone of the furca of mul-
deposit an organic matrix called osteoid, which
tirooted teeth.
consists of collagen fibrils and ground substance
The functions of the fibers of the PDL are to that contains glycoproteins, phosphoproteins, lip-
attach the tooth to its alveolar socket, to suspend ids, and proteoglycans. As the osteoblasts deposit
it in its socket, to protect the tooth and the alveolar the matrix, some are trapped in it; these cells are
socket from masticatory injuries, and to transform called osteocytes. The matrix is calcified by the
vertical masticatory stresses into tension on the deposition of hydroxyapatite crystals consisting
alveolar bone. principally of calcium and phosphates.
The osteocytes in calcified bone lie in the oval
spaces, called lacunae, which communicate with
Innervation
each other by means of canaliculi. This system of
The alveolar nerves which originate in the tri- canals brings nutrients into the osteocytes and
geminal nerve innervate the PDL. They are divided removes their metabolic waste products.
into ascending periodontal or dental, interalveo- The alveolar bone proper consists of bundle
lar, and inter-radicular nerves. The nerves of the bone in the periphery of the alveoli and lamellated
PDL, as in any other connective tissue, follow the bone toward the center of the alveolar process.
Ch_01_GEP.indd 40 08/08/14 1:59 PM


The peripheral bone is called bundle bone because The cortical (compact) bone covers the cancel-
Sharpey’s fibers of the PDL are embedded in it. lous bone and is formed by the lamellated bone.
Because the peripheral Sharpey’s fibers may be This lamellated bone has lacunae arranged in
calcified, and because lamellae are almost indis- concentric circles around central canals called the
tinct, this bone is thick and has a more radiopaque Haversian system. The cortical bone comes together
appearance in radiographs than cancellous bone or with the alveolar bone proper to form the alveolar
PDL spaces. The radiographic image of the alveolar crest around the necks of the teeth.
bone proper is called the lamina dura. Bone serves as the calcium reservoir of the body.
The alveolar bone proper can also be referred to The body, under hormonal control, regulates and
as the cribriform plate. This term refers to the many maintains calcium metabolism. Therefore, constant
foramina that perforate the bone. These foramina physiologic remodeling of bone by osteoclastic and
contain vessels and nerves that supply teeth, perio- osteoblastic activity occurs. This activity can be seen
dontal ligament, and bone. more readily in the trabeculae. The trabecular pat-
tern is constantly altered in response to the occlusal
forces. In the trabeculae are resting lines, which are
Supporting Alveolar Bone
characteristic of periods of osteoblastic activity, and
Adjacent to the alveolar bone proper is cancel- resorptive lines, which are characteristic of periods
lous (spongy) bone covered by two outer tables of of osteoclastic activity. Resting lines are character-
compact bone. One of the outer tables of compact istically dark lines parallel to the surface, whereas
bone is vestibular and the other is lingual or pala- resorptive lines are scalloped and point to the areas
tal. The cancellous bone consists of lamellated bone of resorption known as Howship’s lacunae.
arranged in branches called the trabeculae. Between Diseases of the pulp can affect the tissues of the
the trabeculae are the medullary spaces, filled with periradicular area. Acute inflammatory changes
the marrow. The marrow can be fatty or hematopoi- in the PDL that originate in the pulp produce
etic. In adults, the marrow in the mandible and max- extrusion of the tooth. The chronic inflamma-
illa is usually fatty, but hematopoietic tissue is found tory changes of pulpal origin in the PDL can cause
in certain locations such as the maxillary tuberosity, resorption of the lamina dura, external root resorp-
maxillary and mandibular molar periradicular areas, tion, areas of bone resorption, or areas of bone con-
and premolar periradicular areas. Hematopoietic densation. Systemic diseases may also produce bony
marrow spaces appear radiolucent in radiographs. changes in the periradicular area. These pathologic
Also present in the cancellous bone are the changes are discussed in Chapters 4 and 5.
nutrient canals. These canals contain vessels and The reader is advised that the discussions in
nerves. They usually terminate in the alveolar crest the chapter on embryology, normal pulp, and nor-
in small foramina through which vessels and nerves mal periradicular tissues are intended as a review
enter the gingiva. of embryology, physiology, and histology as they
The amount of cancellous bone varies among apply to the clinical science of endodontics. The
areas of the maxilla and mandible and depends on reader is referred to standard textbooks on these
the width of the alveolar process and the size and subjects for more comprehensive and detailed
shape of the root of the teeth. discussion.
Bibliography
1. Ash, M., and Nelson, S.: Wheeler’s Dental Anatomy, 4. Baume, L.J.: The Biology of Pulp and Dentin. Basel:
Physiology and Occlusion, 8th ed. Philadelphia: Saun- S. Karger, 1980.
ders, 2003. 5. Bernick, S.: J. Dent. Res., 43:406, 1964.
2. Aubin, J.E.: J. Dent. Res., 64:515, 1985. 6. Bhaskar, S.N.: Synopsis of Oral Histology. St. Louis: C.V.
3. Avery, J.R.: Oral Surg., 32:113, 1971. Mosby, 1962.
Ch_01_GEP.indd 41 08/08/14 1:59 PM


7. Bhaskar, S.N.: Orban’s Oral Histology and Embryology, 31. Mjör, I.A.: J. Dent. Res., 64:621, 1985.
9th ed. St. Louis: C.V. Mosby, 1980. 32. Mjör, I.A.: Reaction Patterns in Human Teeth. Boca
8. Brännstrom, M., and Garberoglio, R.: Acta Odontol. Raton, FL: CRC Press, 1983.
Scand., 30:291, 1972. 33. Mjör, I.A., and Fejerskon, A.: Histology of the Human
9. Brown, P., and Herbranson, E.: Dental Anatomy & 3D Tooth, 2nd ed. Copenhagen: Munksgaard, 1979.
Tooth Atlas Version 3.0, 2nd ed. Illinois: Quintessence, 34. Mjor, I.A., and Heyarass, K.: In D. Orstavik and T. Pitt
2005. Ford (eds.) Essential Endodontology, 2nd ed. Oxford:
10. Byers, M.R.: J. Comp. Neurol., 191:413, 1980. Blackwell Munksgard, 2008.
11. Carranza, F.A.: Gllckman’s Clinical Periodontology, 35. Nanci, A.: Ten Gate’s Oral Histology: Development,
6th ed. Philadelphia: W.B. Saunders, 1984. Structure, and Function, 6th ed. St. Louis: C.V. Mosby,
12. Cohan, B., and Kramer, I.R.H.: Scientific Foundation 3 July 2003.
of Dentistry. Chicago: Year Book Medical Publishers, 36. Närhi, M.V.O.: J. Dent. Res., 64:564, 1985.
1976. 37. Nery, E.B., et al.: Arch. Oral Biol., 15:1315, 1970.
13. Cohen, S., and Burns, R.C.: Pathways of the Pulp, 3rd ed. 38. Olgart, L.M.: J. Dent. Res., 64:572, 1985.
St. Louis: C.V. Mosby, 1984. 39. Oor, T.: Human Tooth and Dental Arch Development.
14. Cutright, D.E.: Oral Surg., 30:284, 1970. Tokyo: Ishiyaka, 1981.
15. Fearnhead, R.W.: Proc. R. Soc. Med., 54:877, 1961. 40. Osborn, J.W., and Ten Cate, A.R.: Advanced Dental
16. Finn, S.B.: Biology of the Dental Pulp Organ: A Sympo- Histology, 3rd ed. Bristol, England: J. Wright and Sons,
sium. Alabama: University of Alabama Press, 1968. 1976.
17. Garberoglio, R., and Brännström, M.: Arch. Oral Biol., 41. Pashley, D.H.: J. Dent. Res., 64:613, 1985.
21:355, 1976. 42. Provenza, D.V.: Fundamentals of Oral Histology and
18. Green, D.: Morphology of the Endodontic System. New Embryology. Philadelphia: J.B. Lippincott, 1972.
York: David Green, 1969. 43. Ruch, J.V.: J. Dent. Res., 64:489, 1985.
19. Heverass, K.J.: J. Dent. Res., 64:585, 1985. 44. Seltzer, S., and Bender, I.B.: The Dental Pulp, 3rd ed.
20. Holland, G.R.: J. Dent. Res., 64:499, 1985. Philadelphia: J.B. Lippincott, 1984.
21. Ingle, J., and Bakland, E.: Endodontics, 5th ed. Hamilton: 45. Siskin, M.: The Biology of the Human Dental Pulp.
B.C. Decker, 2002. St. Louis: C.V. Mosby, 1973.
22. Ingle, J.I., and Taintor, J.F.: Endodontics, 3rd ed. 46. Stanley, H.R.: Human Pulp Response to Restorative
Philadelphia: Lea & Febiger, 1985. Dental Procedures, rev. ed. Gainesville, FL: Storter
23. Jernvall, J., and Thesleff, T.: Mech. Dev., 92:19–29, Printing, 1981.
2000. 47. Takahashi, K.: J. Dent. Res., 64:579, 1985.
24. Johnsen, D.C.: J. Dent. Res., 64:555, 1985. 48. Takahashi, K., et al.: J. Endod., 8:131, 1982.
25. Kim, S.: J. Dent. Res., 64:590, 1985. 49. Ten Cate, A.R.: Oral Histology: Development, Structure
26. Kuttler, Y.: J. Am. Dent. Assoc., 50:544, 1955. and Function. St. Louis: C.V. Mosby, 1980.
27. Linde, A.: Dentin and Dentinogenesis, Vols. I and II. 50. Ten Cate, A.R.: J. Dent. Res., 64:549, 1985.
Boca Raton, FL: CRC Press, 1984. 51. Thomas, H.F.: J. Dent. Res., 64:607, 1985.
28. Linde, A.: J. Dent. Res., 64:523, 1985. 52. Van Hassel, H.J.: Oral Surg., 32:126, 1971.
29. Lindhe, J.: Textbook of Clinical Periodontology. 53. Veis, A.: J. Dent. Res., 64:552, 1985.
Copenhagen: Munksgaard, 1984. 54. Weine, F.S.: Endodontic Therapy, 3rd ed. St. Louis: C.V.
30. Maniatopoulos, C., and Smith, D.C.: Arch. Oral Biol., Mosby, 1982.
28:701, 1983. 55. Yamamura, T.: J. Dent. Res., 64:530, 1985.
Ch_01_GEP.indd 42 08/08/14 1:59 PM

i
1.
3*
Jo
Chapter 2
o
Q
LU
Microbiology 03
That it will never come again is what makes life so sweet.

—Emily Dickinson
HISTORICAL BACKGROUND
1901: Onderdenk suggested the need for

bacteriologic examination of the root canal.
1910: Hunter proposed the focal infection
theory, in which he condemned the ill -fitting
crowns and bridgework of his day that inex- Clinical Note
plicably resulted in the extraction of countless Microorganisms virtually cause all the diseases of
numbers of treated pulpless teeth. the pulpal and periapical tissues.
1931: Coolidge suggested that bacteriologic The root canal infection usually develops after
examination be used in treating the root canal. pulpal necrosis that can occur as sequelae of
caries, trauma, periodontal diseases or operative
1936: Fish and MacLean demonstrated that the
procedures.
pulp and periapical tissues of vital healthy teeth Endodontic infection is the infection of the root
are invariably free of the evidence of microor- canal system and is the major etiologic factor of
ganisms when examined histologically. apical periodontitis.
1939: Histologic studies of repair were reported cz
by Kronfeld. o
o
1965: Classic study of Kakehashi and colleagues, LU
BACTERIAL PATHWAYS
who reported that exposed pulps in gnotobiotic INTO THE PULP CD
rats healed without treatment in a germ -free
environment. Bacteria enter the pulp in various ways:
CD
In the last few decades, many reports have been Dentinal tubules following carious invasion E
published on the bacterial flora of the pulp and Crown or root following traumatic exposure of
periapical and periodontal tissues, the pathways of the pulp CO
infection, the immunologic reactions, and the Coronal leakage following restorative proce-
inflammatory responses. Although treatment dures and restorations
43

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The Dental Pulp and 03

PARTI : EMBRYOLOGY specific areas in each quadrant of the jaw to mark

the future maxillary and mandibular processes in a

@LibraryEDent ‫ﻣﻛﺗﺑﺔ طب اﻷﺳﻧﺎن‬

Developing Cavum nasi

Ch_01_GEP.indd 2 08/08/14 1:58 PM

Maxilla Tooth bud

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a tage ( uter an in glycogen that forms a branch reticular arrange-

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During this stage, the dental lamina that DE E ES S

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antle Dentin Formation

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Oral epithelium Dentin

Outer dental Odontoblasts

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y Protective: Protection against and repairing of

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of the odontoblastic processes. lular elements

aspects of human tooth innervations and formula-

Starting at the periphery, the pulp is divided into

connective tissue contained within rigid dentinal 2. Cell-free zone

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Clinical Note The crowded arrangement of the coronal odon-

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Clinical Note The crowded arrangement of the coronal odon-