Pulp (tooth)

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Pulp
Blausen 0863 ToothAnatomy 02.png
Section of a human molar
Details
Identifiers
Latinpulpa dentis
MeSHD003782
TAA05.1.03.051
FMA55631
Anatomical terminology
Nerves in the pulp.png

The pulp, or endodontium, is the part in the center of a tooth made up of living connective tissue and cells called odontoblasts. The dental pulp is a part of the dentin–pulp complex (endodontium).[1] The vitality of the dentin-pulp complex, both during health and after injury, depends on pulp cell activity and the signaling processes that regulate the cell's behavior.[2][3][4][5][6][7][8]

Anatomy[edit]

The pulp is the neurovascular bundle central to each tooth, permanent or primary. It comprises a central pulp chamber, pulp horns, and radicular canals. The large mass of pulp is contained within the pulp chamber, which is contained in and mimics the overall shape of the crown of the tooth.[2] Because of the continuous deposition of dentin, the pulp chamber becomes smaller with age. This is not uniform throughout the coronal pulp but progresses faster on the floor than on the roof or side walls.

Radicular pulp canals extend down from the cervical region of the crown to the root apex. They are not always straight but vary in shape, size, and number. They are continuous with the periapical tissues through the apical foramen or foramina.

The total volumes of all the permanent teeth organs is 0.38cc and the mean volume of a single adult human pulp is 0.02cc.

Accessory canals are pathways from the radicular pulp, extending laterally through the dentin to the periodontal tissue seen especially in the apical third of the root. Accessory canals are also called lateral canals because they are usually located on the lateral surface of the roots of the teeth.

Development[edit]

The pulp has a background similar to that of dentin, because both are derived from the dental papilla of the tooth germ. During odontogenesis, when the dentin forms around the dental papilla, the innermost tissue is considered pulp.[9]

Internal structure[edit]

Pulpal dentin junction. 1) outside tooth/enamel 2) dentin tubule 3) dentin 4) odontoblastic process 5) predentin 6) odontoblast 7) capillaries 8) fibroblasts 9) nerve 10) artery/vein 11) cell-rich zone 12) cell-poor zone 13) pulp chamber

The central region of the coronal and radicular pulp contains large nerve trunks and blood vessels.

This area is lined peripherally by a specialized odontogenic area which has four layers (from innermost to outermost):

  1. Pulpal core, which is in the center of the pulp chamber with many cells and an extensive vascular supply; except for its location, it is very similar to the cell-rich zone.
  2. Cell rich zone; which contains fibroblasts and undifferentiated mesenchymal cells.
  3. Cell free zone (zone of Weil) which is rich in both capillaries and nerve networks.
  4. Odontoblastic layer; outermost layer which contains odontoblasts and lies next to the predentin and mature dentin.

Cells found in the dental pulp include fibroblasts (the principal cell), odontoblasts, defence cells like histiocytes, macrophage, granulocytes, mast cells and plasma cells.The nerve plexus of Raschkow is located central to the cell-rich zone.[9]

The plexus of Raschkow[edit]

The plexus of Raschkow monitors painful sensations. By virtue of their peptide content they also play important functions in inflammatory events and subsequent tissue repair. There are two types of nerve fiber that mediate the sensation of pain: A-fibers conduct rapid and sharp pain sensations and belong to the myelinated group, whereas C-fibers are involved in dull aching pain and are thinner and unmyelinated. The A-fibers, mainly of the A-delta type, are preferentially located in the periphery of the pulp, where they are in close association with the odontoblasts and extend fibers to many but not all dentinal tubules. The C-fibers typically terminate in the pulp tissue proper, either as free nerve endings or as branches around blood vessels. Sensory nerve fibers that originate from inferior and superior alveolar nerves innervate the odontoblastic layer of the pulp cavity. These nerves enter the tooth through the apical foramen as myelinated nerve bundles. They branch to form the subodontoblastic nerve plexus of Raschkow which is separated from the odontoblasts by a cell-free zone of Weil, therefore this plexus lies between the cell free and cell rich zones of the pulp.

Functions[edit]

The primary function of the dental pulp is to form dentin (by the odontoblasts).

Other functions include:

  • Nutritive: the pulp keeps the organic components of the surrounding mineralized tissue supplied with moisture and nutrients;
  • Protective/Sensory: extremes in temperature, pressure, or trauma to the dentin or pulp are perceived as pain;
  • Defensive/reparative : the formation of reparative or tertiary dentin (by the odontoblasts);
  • Formative: cells of the pulp produce dentin which surrounds and protects the pulpal tissue.

Pulp Testing[edit]

Dental pulp tests are valuable techniques used to establish the pulpal health status of a tooth in dentistry. The diagnostic information obtained from pulpal testing is then used alongside a patient's history, clinical and radiographic findings to determine a diagnosis and prognosis of the tooth.

Pulp tests are useful for the following procedures in dentistry:

a) diagnosis of endodontic pathology,

b) localisation of tooth pain,

c) differentiating between odontogenic and non-odontogenic pain,

d) assessing pulpal status following dental trauma,

e) establishment of pulpal health prior to prosthodontic treatment.

Pulpal tests may be conducted via stimulation of the sensory fibres within the pulp (sensibility testing) or by assessing pulpal blood flow (vitality testing). All available techniques are reported to have limitations in terms of accuracy and reproducibility [10] and therefore require careful interpretation in clinical practice.

Sensibility testing[edit]

Sensibility tests assess the sensory response of a tooth to an external stimulus, results which may be extrapolated to indirectly determine pulpal health status. Sensory stimuli, such as heat, cold or an electrical current, are applied to the tooth in question in order to stimulate the nocireceptors within the pulp. The type of sensory fibres activated and therefore the response felt by the patient depends on the stimulus used. Sensibility testing is based on Brännström's Hydrodynamic Theory, which postulates that the activation of nocireceptors is caused by fluid movement within the dentinal tubules in response to thermal, electrical, mechanical or osmotic stimuli[11].

Responses To Sensibility Testing

There are three primary outcomes of a pulp sensibility test, as described.

a)Normal Response: Healthy pulps are expected to respond to sensibility testing by eliciting a short, sharp pain which subsides when the stimulus is removed, indicating that the nerve fibres are present and responsive.

b) A Heightened or Prolonged Response: An exaggerated or lingering response to sensibility testing indicates some degree of pulpal inflammation. If the pain is pronounced yet subsides once the stimulus has been removed, a diagnosis of reversible pulpitis may be probable. However, a lingering pain which continues despite the removal of the stimulus is indicative of irreversible pulpitis.

c) No Response; A lack of response to sensibility testing suggests that the nerve supply to the tooth has been diminished, as in the case of pulpal necrosis or in previously root treated canals.

Types of Sensibility Tests[edit]

1. Thermal Tests[edit]

Thermal testing, which involves the application of either a hot or cold stimuli to the tooth, is the most common form of sensibility test.

A number of products are available for cold testing, each with varying melting points. Although household ice (0°C) is cheap and easy to obtain, it is not as accurate as colder products[12]. Dry ice (-78°c) can be used, however there have been concerns regarding the damaging effects of using something so cold in the oral cavity[13] despite evidence to suggest that dry ice has no negative impact on mucosal[14] or tooth structure [15][16]. Refrigerant sprays, such as ethyl chloride (-12.3°C), 1,1,1,2-tetrafluoroethane (-26.5°C) or a propane/butane/isobutane gas mixture are further commonly used cold tests. Cold testing is thought to stimulate Type Aδ fibres in the pulpal tissue, which elicit a short, sharp pain.

Heat tests include using heated instruments, such as a ball-ended probe or gutta-percha, a rubber commonly used in root canal procedures. Such tests are less commonly used as they are thought to be less accurate than cold tests, and are more likely to cause damage to the teeth and surrounding mucosa [17].

2. Electric Pulp Testing (EPT)[edit]

An electrical current can be applied to the tooth in order to generate an action potential in the Type Aδ fibres within pulp, eliciting a neurological response. Such tests are conducted by applying a conducting medium (e.g. toothpaste) on a dried tooth and placing the probe tip of an electric pulp tester on the surface of the tooth closest to the pulp horn(s). The patient is then directed to hold the end of the conducting probe to complete the circuit and asked to let go of the probe when a ‘tingling’ sensation [18] is felt. The use of electric pulp testing has been questioned in patients with traditional cardiac pacemakers, despite no evidence of interferences in humans, particularly with more modern devices [19]. Care must be taken if using an electric pulp test on a tooth adjacent to metallic restorations, as these can create electrical conduction and yield false negative results.

3. Bite test[edit]

The patient is asked to bite on a hard object such as cotton swab, tooth pick, or an orange wood stick. Pain on biting may indicate a fractured tooth.

4. Anaesthesia Testing[edit]

A single tooth is anaesthetised until the pain is diminished. If the pain continues, the procedure is repeated to the next tooth mesial to it. This procedure is continued until the pain is gone. If source of pain cannot be determined, the same technique on the opposite arch is repeated.

5. Test cavity[edit]

This technique is only used when the results produced by all other methods above are inconclusive and is regarded as the last resort. High speed burs are used, without anaesthetic, to drill a small window through either enamel or a restoration to dentine. The patient is asked whether a painful sensation is experienced during drilling, indicating pulpal vitality. In the event of a vital pulp, a painful response is provoked when dentin is invaded and a simple restoration will then be placed. On the contrary, a partially necrotic pulp will not be stimulated to the same extent as a vital pulp. In this case, the dentist would initiate access and invade progressively deeper into dentine, without a sensory response. This invasive method can be influenced by the anxiety levels of the patient, and therefore is generally avoided.

Limitations of Sensibility Testing[edit]

Sensibility testing is routinely used to establish pulpal status in clinical dentistry and is an invaluable diagnostic aid. Nevertheless, all tests have some limitations and therefore the results should be interpretated by an experienced dentist in light of clinical and radiographic symptoms. Sensibility tests only indicate the presence or absence of the nerve supply to a chosen tooth and, although a prolonged response to such tests indicate pulpal inflammation, the degree of inflammation or innervation cannot be inferred from these tests.

False positive or false negative results are possible when sensibility testing. A false positive response occurs when a patient responds to sensibility testing despite the lack of sensory tissue in the test tooth. Such responses may occur due to innervation of adjacent teeth due to inadequate isolation of the test tooth, in anxious patients who perceive pain despite no sensory stimulus, or in multi-rooted teeth which still have residual pulpal tissue in one canal[20] [21]. False negative results, which refer to innervated teeth which do not respond to sensibility testing, can occur in teeth which have been recently traumatised, those which have incomplete root development, are heavily restored or have a significantly reduced pulp size due to the production of tertiary or sclerotic dentine [22].

Pulpal sensibility testing may be regarded as inferior to vitality testing as they do not definitively prove that the tooth has a blood supply and is vital. Nevertheless, electric pulp testing and cold testing, particularly with Endo-Ice, have been found to be accurate and reliable methods of assessing pulpal health, especially when used in combination [23] [24]. However, cold testing is more accurate than electric pulp testing in immature or traumatised teeth[25].

Vitality testing[edit]

Vitality tests assess the vascular supply of a tooth. Vascular supply is a more accurate and reliable indicator of pulpal health than sensibility testing; however their use in clinical practice is hindered due to cost, time and equipment requirements [26]. The diagnostic methods to assess the vascular response of the pulp include:

1. Laser-Doppler Flowmetry[edit]

A laser beam directed onto the tooth follows the path of dentinal tubules to the pulp.[27] The viability of the vascular supply of the pulp is determined by the output signal generated by the backscattered reflected light from circulating blood cells.[28] The reflected light is Doppler-shifted and has a different frequency to those reflected by the surrounding tissues which are static. An arbitrary unit of measurement, ‘perfusion unit’ (PU, is used to measure the concentration and velocity (flux) of blood cells[27][29]. The output of laser doppler flowmetry may be influenced by the blood flow in surrounding tissues, and therefore the test tooth must be adequately isolated to avoid inaccuracies [30].

2. Pulse Oximetry[edit]

This method utilises the difference in red and infrared light absorption by oxygenated and deoxygenated red blood cells within blood circulation to determine the oxygen saturation level (SaO2) [31][32].

3. Dual Wavelength Spectrophotometry [edit]

The use of dual wavelength light establishes the contents within the pulp chamber.[33]

Pulpal Diagnoses[edit]

Normal Pulp[edit]

In a healthy tooth pulp, the pulp is well-protected from infection by the enamel and dentin layers.

A healthy normal pulp: -is vital and normally responsive to pulp testing -is symptoms and inflammation free -has a mild or transient response clinically to thermal and cold testing which should last no more than 1–2 seconds after stimulus is removed

Reversible Pulpitis[edit]

A mild to moderate inflammation of dental pulp caused by any momentary irritation or stimulant whereby no pain is felt upon removal of stimulants.[34] The pulp swells when the protective layers of enamel and dentine are compromised. Unlike irreversible pulpitis, the pulp still gives a regular response to sensibility tests and inflammation resolves with management of the cause. There is no significant radiographic changes in the periapical region hence further examination is mandatory to ensure that the dental pulp has returned to its normal healthy state.[35]

Common Causes [34][edit]

- Bacterial infection from caries

- Thermal shock

- Trauma

- Excessive dehydration of a cavity during restoration

- Irritation of exposed dentine

- Repetitive trauma caused by bruxism(tooth grinding) or jaw misalignment

- Fractured tooth exposing pulp

Symptoms [34][edit]

- Temporary post-restoration sensitivity

- Pain is non- spontaneous and is milder compared to irreversible pulpitis

- Short sharp pain due to a stimulant

How it is diagnosed[6][edit]

- X-rays to determine extent of tooth decay and inflammation

- Sensitivity tests to see if pain or discomfort is experienced when tooth is in contact with hot, cold or sweet stimuli

- Tooth tap test (lightweight, blunt instrument gently tapped onto affected tooth to determine extent of inflammation)

- Electric pulp test

Treatment [6][edit]

- Treatment aetiology should resolve reversible pulpitis; treating it early may help prevent irreversible pulpitis - Follow-up after treatment required to determine whether the reversible pulpitis has returned to a normal status

Prevention [34][edit]

- Regular check-ups for carcinogenic or non-carcinogenic caries

- When preparing cavities, dehydrate with adequate amount of alcohol or chloroform and apply enough varnish to protect the pulp

Irreversible Pulpitis[edit]

Pulpitis is established when the pulp chamber is compromised by bacterial infection. Irreversible pulpitis is diagnosed when the pulp of the tooth is inflamed and infected beyond the point of no return, healing of the pulp is not possible. Removal of the aetiological agent will not permit healing and often root canal treatment is indicated. Irreversible pulpitis is commonly a sequel to reversible pulpitis when early intervention is not taken.[6][8] It is key to note that in this stage of the disease progression, the pulp is still vital and vascularised; it is not classified as ‘dead pulp’ until necrosis occurs.[3]

Irreversible and reversible pulpitis are differentiated from each other based on the various pain responses that they have to thermal stimulation. If the condition is reversible then the pulp's pain response will last momentarily upon exposure to cold or hot substances; a few seconds. However, if the pain lingers from minutes to hours, then the condition is irreversible. This is a common presenting complaint that facilitates diagnoses before further investigations e.g. sensibility tests and peri-apical radiographs are proceeded.[3][5]

Diagnosis of irreversible pulpitis is branched into two sub-divisions: symptomatic and asymptomatic. Asymptomatic irreversible pulpitis is a transition of symptomatic irreversible pulpitis into to an inactive and quiescent state. This is due to the nature of its causation; the inflammatory exudate can be quickly removed e.g. through a large carious cavity or previous trauma that caused painless exposure of pulp. It is the build-up of pressure in a confined pulp space that stimulates nerve fibres and initiates pain reflexes. When this pressure is relieved, pain is not experienced.[4][7]

As the names imply, these diseases are largely characterised by the symptoms they present, duration and location of pain, causing and relieving factors. A clinician's role is to gather all this information systematically. This will be a compilation of clinical tests (cold ethyl chloride, EPT, hot gutta percha, palpation), radiographic analysis (peri-apical and/or cone beam computed tomography) and any further tests deemed necessary. Thermal tests are subjective by nature, so performed on not only the compromised tooth, but the adjacent and contra-lateral teeth as well, allowing the patient to compare information and give the clinician more accurate responses. Normal healthy teeth are used as a baseline for diagnoses.[36][8][6]

The following are key characteristics of each pathology:

Symptomatic irreversible pulpitis:

-      Very spontaneous and unpredictable pain. Can occur at any time of day and specific causing factors cannot be labelled.

-      Patient may complain of sharp lingering pains, that last longer than 30 seconds even after removal of stimulus.

-      There may be referred pain

-      Pain may be more pronounced after changes of posture e.g. from lying down to standing up

-      Analgesics tend to be ineffective

-      As the bacteria have not yet progressed to the peri-apical region, there is no pain on percussion.

Asymptomatic irreversible pulpitis

-      There are no clinical symptoms

- Pulp will respond to sensibility tests as a healthy pulp would   [6][8]

Treatments: Require endodontic (root canal) treatment or tooth extraction. In endodontic therapy, removal of the inflamed pulp relieves the pain. The empty root canal system is then obturated with Gutta-Percha which is a rubber material that acts as a pressure and pain reliever.[37]

Complications[edit]

Pulp acts as a security and alarm system for a tooth. Slight decay in tooth structure not extending to the dentin may not alarm the pulp but as the dentin gets exposed, either due to dental caries or trauma, sensitivity starts. The dentinal tubules pass the stimulus to odontoblastic layer of the pulp which in turns triggers the response. This mainly responds to cold. At this stage simple restorations can be performed for treatment. As the decay progresses near the pulp the response also magnifies and sensation to a hot diet as well as cold gets louder. At this stage indirect pulp capping might work for treatment but at times it is impossible to clinically diagnose the extent of decay, pulpitis may elicit at this stage. Carious dentin by dental decay progressing to pulp may get fractured during mastication (chewing food) causing direct trauma to the pulp hence eliciting pulpitis.

The inflammation of the pulp is known as pulpitis. Pulpitis can be extremely painful and in serious cases calls for root canal therapy or endodontic therapy.[38] Traumatized pulp starts an inflammatory response but due to the hard and closed surroundings of the pulp pressure builds inside the pulp chamber compressing the nerve fibres and eliciting extreme pain (acute pulpitis). At this stage the death of the pulp starts which eventually progresses to periapical abscess formation (chronic pulpitis).

The pulp horns recede with age. Also with increased age, the pulp undergoes a decrease in intercellular substance, water, and cells as it fills with an increased amount of collagen fibers.This decrease in cells is especially evident in the reduced number of undifferentiated mesenchymal cells. Thus, the pulp becomes more fibrotic with increased age, leading to a reduction in the regenerative capacity of the pulp due its loss of these cells. Also, the overall pulp cavity may be smaller by the addition of secondary or tertiary dentin, thus causing pulp recession. The lack of sensitivity associated with older teeth is due to receded pulp horns, pulp fibrosis, addition of dentin, or possibly all these age-related changes; many times restorative treatment can be performed without local anesthesia on older dentitions.[2]

Pulp Necrosis[edit]

Pulp necrosis describes when the pulp of a tooth has become necrotic. The pulp tissue is either dead or dying, this may be for a number of reasons including: untreated caries, trauma or bacterial infection. It is often subsequent to chronic pulpitis. Teeth with pulp necrosis will need to undergo root canal treatment or extraction to prevent further spread of infection which may lead to an abscess.

Symptoms[edit]

Pulp necrosis may be symptomatic or asymptomatic for the patient. If the necrosis is symptomatic it could result in lingering pain to hot and cold stimuli, spontaneous pain that may cause a patient to wake up during sleep, difficulty with eating and being tender to percussion.[39][40] If the necrosis is asymptomatic it will be non-responsive to thermal stimuli or electric pulp tests, the patient may even be unaware of the pathology.[40]

Diagnosis[edit]

If the pulpal necrosis is asymptomatic it may go unnoticed by the patient and so a diagnosis may be missed without the use of special tests. To determine if pulp necrosis is present a dentist may take radiographic images (X-rays) and sensitivity testing e.g. hot or cold stimuli (using warm gutta percha or ethyl chloride); or they may use an electric pulp tester. Vitality of a tooth, which refers to blood supply to a tooth, may be assessed using doppler flowmetry.[41] Sequelae of a necrotic pulp include acute apical periodontitis, dental abscess, or radicular cyst and discolouration of the tooth.[42]

Prognosis & Treatment[edit]

If a necrotic pulp is left untreated it may result in further complications such as infection, fever, swelling, abscesses and bone loss.[43] Currently there are only two treatment options for teeth which have undergone pulpal necrosis.[44][45] Future treatments aim to assess revascularisation of pulp tissue using techniques such as cell homing.[44]

See also[edit]

References[edit]

  1. ^ http://endodontistrootcanal.com/endodontium/
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  6. ^ a b c d e f "Endodontic diagnosis" (PDF). American Association of Endodontics. 2013.
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  9. ^ a b Antonio Nanci, Ten Cate's Oral Histology, Elsevier, 2007, page 91
  10. ^ Chen, Eugene (September 2009). "Dental Pulp Testing; A Review". International Journal of Dentistry. 2009 (Article ID 365785): 365785. doi:10.1155/2009/365785. PMC 2837315. PMID 20339575.
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  12. ^ Fuss, Zvi; Trowbridge, Henry; Bender, I.B.; Rickoff, Bruce; Sorin, Solomon (January 1986). "Assessment of reliability of electrical and thermal pulp testing agents". Journal of Endodontics. 12 (7): 301–305. doi:10.1016/S0099-2399(86)80112-1. PMID 3461119.
  13. ^ Chen, Eugene; Abbott, Paul V. (2009). "Dental Pulp Testing: A Review". International Journal of Dentistry. 2009: 365785. doi:10.1155/2009/365785. PMC 2837315. PMID 20339575.
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  25. ^ Fuss, Zvi; Trowbridge, Henry; Bender, I.B.; Rickoff, Bruce; Sorin, Solomon (January 1986). "Assessment of reliability of electrical and thermal pulp testing agents". Journal of Endodontics. 12 (7): 301–305. doi:10.1016/S0099-2399(86)80112-1. PMID 3461119.
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  36. ^ Chen, Eugene; Abbott, Paul V. (2009). "Dental Pulp Testing: A Review". International Journal of Dentistry. 2009: 365785. doi:10.1155/2009/365785. PMC 2837315. PMID 20339575.
  37. ^ Agnihotry, Anirudha; Fedorowicz, Zbys; Van Zuuren, Esther J.; Farman, Allan G.; Al-Langawi, Jassim Hasan (2016). "Antibiotic use for irreversible pulpitis". Cochrane Database of Systematic Reviews. 2: CD004969. doi:10.1002/14651858.CD004969.pub4. PMID 26886473.
  38. ^ "Root canal treatment (endodontic therapy) explained: What is it? Why is it needed? What does it do?".
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