GDA Face n’ Tooth: Histology & Physiology of Dental Pulp (Kang)

Embryology of Pulp
- Tooth formation:
o Morphogenesis: Lamina including Bud stage, Cap stage, early Bell stage
o Cytodifferentiation: Late Bell stage, crown formation & the rest
- Stages:
Initiation oral epithelium thickens & invades into the mesenchyme of the jaw; ectomesenchyme forms the
dental papillae
▪ Note Board question: Ectomesenchyme are mesenchymal cells in CT not derived from
mesoderm but from NCC which came from ectoderm!
Cap stage dental organ takes cap shape, massive cell proliferation, condensation of ectomesenchyme (dental
papillae)
Bell stage oral epithelium separates into the internal & external dental epithelium (IDE & EDE); dental lamina
disintegrates; dental papillae begins to form pulp; dental papillae in direct contact with IDE, subset of
dental papillae differentiates into odontoblasts, which begin to produce dentin; the IDE & EDE will
continue to proliferate & migrate apically (& form the root sheath)
Mineralization, - Stellate reticulum is the space btw the EDE & IDE; and between the IDE odontoblasts is the
Root formation basement membrane (which becomes the DEJ)
- Through reciprocal induction odontoblasts & ameloblasts differentiate
o IDE (pre-ameloblasts) stimulate → dental papillae to differentiate to odontoblasts, which
secretes pre-dentin which causes→ IDE to differentiate into ameloblasts
- Root formation begins during the late bell stage where the IDE & EDE come together to form
Hertwig’s Root Sheath

- Factors related to tooth development

o Growth factors: extracellular proteins that bind surface receptors & trigger downstream intracellular events
➢ TGF-: is a bone morphogenic protein (BMP), its roles:
▪ highly expressed in EARLY stage tooth formation (early lamina stage, the thickening of the oral
epithelium)
▪ important role in tooth development & repair…mutation= poor tooth mineralization
▪ also responsible for inducing Smad TF & Cbf TF
o Transcription factors: are nuclear proteins that bind to promoter regions of DNA & regulate target gene expression
➢ Smad TF: involved in the determining size & shape of tooth bud AND induces Cbf
➢ Cbf TF: Core binding factor  is responsible for inducing osteogenesis & dentinogenesis; mutation of Cbf
severely alters tooth morphology
- Trace back embryology:
o Odontoblasts  dental papillae  ectomesenchyme  NCC  Ectoderm
o Pulp  dental papillae  ectomesenchyme  NCC  Ectoderm
o Ameloblasts  IDE  Oral epithelium  NCC  ectoderm
o Hertwig’s root sheath  migration of IDE & EDE  ectoderm
o Dentin formed before enamel!
- Pulp anatomy:
o Pulp chamber: pulp horn (coronal portion, careful with bur); pulp proper
(central & main body)
o Root canal (main, lateral & accessory canals), radicular pulp is the pulp tissue
inside the root
▪ Coronal: called root canal orifice…its important to know location so
you know where to access canals when doing RCT tx
▪ Apical: called root canal foramen
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GDA Face n’ Tooth: Histology & Physiology of Dental Pulp (Kang)
Histology & Pathology
Pulp Histology, pulp divided into 2 parts:
1. Peripheral pulp: dentin, pre-dentin, odontoblasts
o Cell-free zone: lines outer pulp, composed of capillary plexus,
nerve plexus of Raschlow
o Cell-rich zone: faces the inner pulp, fibroblasts, undifferentiated
mesenchymal cells
o dentin→ pre-dentin→ odontoblast process→ odontoblast→ cell-
free zone→ cell-rich zone→ pulp
2. Central pulp: large vessels & nerves, resembles CT, fibroblasts are the
principal cells
- Cellular content of pulp
Odontoblasts Odontoblasts  dental papillae  ectomesenchyme  NCC  Ectoderm
- produce pre-dentin (which gets mineralized) & dentin-specific proteins (dentin sialophosphoprotein
DSPP)
- odontoblast process found in the inner 1/3rd of tubule, NOT in the DEJ
- primary odontoblasts replaced by secondary odontoblasts→reparative (tertiary) dentin
Fibroblasts - most abundant CT cells in pulp, synthesize & maintain CT matrix→ collagen type 3; are widely
distributed in pulp, esp. in cell-rich zone
Immune cells 1. PMNs (polymorphonuclear leukocytes): NOT found in healthy pulp, it’s the most common form of
leukocyte in inflamed pulp
2. Lymphocytes: normal pulp will contain low # of T cells, but NO B cells or plasma cells→ presence of B
cells in pulp indicates chronic inflammation
o Normal healthy pulp: contains CD4+ Th cells and CD8+ cytotoxic T cells
o however, the naïve CD4+ Th cell can be activated by dentritic cells & differentiate into 4 diff cells: Th1,
Th2, Th17 & Treg cells
3. Macrophages & monocytes: highly phagocytic, abundant esp along BVs
o Macrophages are histiocytes (stationary) pulp “scavengers, are major producers of inflammatory
cytokines/mediators; secondary role is antigen presenting
4. Dendritic cells: located in peripheral pulp adjacent to odontoblasts, are the major antigen presenting
cells (APC), weakly phagocytic
o Dendritic cells derived from macrophage lineage, located in perivascular area of inner pulp & para-
odontoblastic region of outer pulp
o surveillance system, first ones to get antigen, go to regional lymphoid tissue, present & activate naïve
CD4+ cells, activate immune response
Stem cells

Pulpal disease:
- is Progressive! caries→ necrotic pulp (tooth dying) → bone loss → sinus tract
o pt will experience lots of pain with temperature, percussion, pressure…but without any treatment tooth will become
asymptomatic because pulp dies→ will progress to sinus tract
- Pathogenesis:
→ bacteria enters deep fissure
→ travels through enamel & makes it to dentin (DEJ will show up radiolucent on x-ray)
→ travels through dentin tubules (dentin tubules ~1-2.5 m & bacteria are smaller); one of the main culprits: Strep
sanguinis, part of the normal oral flora found in some caries, can travel from dentin tubule to pulp in as little as 10 days!
Depth of penetration ~ 0.5mm; can also cause some endocarditis!
▪ Clinical Implication - depth of penetration; time-dependence; thus pt cannot wait on RCT!

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GDA Face n’ Tooth: Histology & Physiology of Dental Pulp (Kang)
→ pulpal & periradicular dz
- Pulpal & periradicular inflammation: Local irritants cause release of→ inflammatory mediators→ vasodilation → increased
pulpal pressure→ pain since pulp is encapsulated in non-compliant space (like cranium) → ischemic→ pulp necrosis
o Pulp is a highly vascularized tissue; **AVA shunt is the most important structure in the pulp, it’s the bypass btw the
arteriole and venule; if you have localized injury and inflammation, AVA shunt enables pulpal blood flow

Disease process of pulp & Tx options

1. Pulpitis:
Reversible Pulpitis Irreversible Pulpitis
- “reactive inflammatory process” - “unrepairable pulpal injury”
- cc: pain with pressure & temp following incident - cc: spontaneous sharp shooting pain to hot/cold
- radiographically normal - will progress to pulpal necrosis if untreated
- ex: incipient caries, acute trauma, restorative procedure - diagnostic feature: coronal breakdown, lingering hot/cold
- inflammation is self-limiting with time & after removal of sensitivity
insult (ex. when bite down on something you get pain but - radiographically: widened PDL
once you remove stimulus, pain gone) - histologically: caries into pulp, lots of inflammatory cells,
- RCT NOT indicated, monitor for 2 weeks micro-abscess formation
- tx: RCT
2. Periapical disease: apical bone loss (apical periodontitis)
o Necrotic pulp tissue will become INFECTED, always…leading to bone resorption (indicated by dark area on x-ray,
which is not completely empty as it has granulation tissue)
▪ Radiographic terminology: Peri-apical radiolucency
▪ Clinical terminology: apical periodontitis
o Mice experiment: introduced bacteria to pulp→ Pulpal exposure will lead to periapical lesion→ thus apical
periodontitis is measurable and time-dependent.
o Mediators of apical periodontitis:
▪ IL 10 & IL6: have a role in suppressing the inflammation (see below), so a deletion of these mediators
resulted in increased lesion size – THEY ARE ANTI-INFLAMMATORY
- IL10: inhibits formation of new osteoclasts (less osteoclasts, less bone loss)
- IL6: increases the # of osteoclasts & increases resorption…?
▪ IL1 alpha: responsible for BONE DESTRUCTION, thus deletion reduces lesion size
o Molecular mechanisms of apical periodontitis
▪ Effectors of AP:
- Inflammatory mediators: inflammatory signaling & cytokines, chemokines
- Cellular constituents
▪ Regulators of AP:
- Transcription factors
- Epigenetic modulators
Conventional Root Canal Therapy:
- Clean/remove infection, fill with gutta percha, will see bone resolution (since endo is encapsulated, the bone will recover
unlike for periodontitis)
- High success rate ~91%
▪ Except when apical lesion has been existing for long time, or when apical lesions > 5mm (success rate ~38%,
might be better to XB)
- When might an apicoectomy (removal of infected root tip) be indicated?
▪ Necrotic cases left untreated for too long
▪ Isthmus (canal connections) filled with biofilm
▪ Oval canals making it difficult for files to clean completely

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GDA Face n’ Tooth: Histology & Physiology of Dental Pulp (Kang)
Stem cells of dental tissues
Endo regeneration:
“Biologically based procedures designed to replace damaged structures, including dentine and root structures, as well as cells of
the pulp-dentin complex”
- Postnatal human dental pulp stem cells (DPSCs) experiment: identified mesenchymal stem cells in pulp, compared them
with bone marrow stem cells and found them to be very similar
▪ Pulpal mesenchymal stem cells form pulp while bone marrow mesenchymal stem cells differentiate to form
bone
- Characterization of apical papilla & its residing stem cells study: found that apical papilla cells cells will differentiate into
odontoblasts that will form root dentin this is important for clinical endo because this means that if you are dealing with:
1. an immature tooth that is infected and not fully developed, or
2. a case of dens evagniatus (aka dens in dente, or dens invaginatus)
…these are cases where the tooth is infected and root not fully formed, thus you know there is some existing root forming
cells so you just need to remove thing that is causing infection and allow apical papilla do its THANG! That is, finish root
formation!

Regenerative dental procedures

- Therapeutic implications of dMSCs (Dermal mesenchymal stem cells) means we can apply to clinic:
Direct pulp - Case: immature tooth with large caries, but NO APICAL LESION (which means tooth is still vital)…you
capping as don’t want to do a root canal or this will arrest root formation, so instead you do pulp cap which
Regenerative allows for root formation & apical closure
Therapy - Procedure: remove caries, irrigate with 5.25% NaOCl, place bio-compatible material on top of
exposed pulp (such as MTA) and then place restoration over
▪ Pulp maintains the regenerative potential (pulp still alive!)
Revascularization - Case: Necrotic immature tooth with chronic abscess – WITH APICAL LESION
Using dMSCs - Procedure: remove caries, disinfect canal(s), induce bleeding from apical region by poking with
instrument through apex…this induces re-vascularization which removes the infection, allows for
root formation & apical closure
- Even in NECROTIC pulp, stem cells in apical papillae continue root formation
▪ Control of inflammation is critical!
- Considerations of revascularization:
o **re-vascularization is good for removing infection but does NOT induce dentin formation, it induces bone, cementum
and fibrous tissue formation! Why? Because you are causing the bleeding, recruiting stem cells from bone and PDL tissue
(mesenchyme!) thus they form bone, cementum and fibrous tissue!
▪ Allows increased root thickness/length
▪ Lack of odontoblast layer, pulp dentin complex
▪ It’s a repair, NOT regeneration…will not generate functional pulp
o MSCs from pulp, BM, PDL are different - Tissue specificity.
o Revasc triggers: Ectopic bone, cementum, fibrous tissue formation; most likely due to recruitment of MSCs from BM &
PDL.
o Pulp-dentin regeneration requires pulpal MSC transplantation
Summary, main points to focus on:
- Pulpal embryology & cell origin
- Pulpal histology (layers)
- Pulpal disease occurs primarily by inflammation caused by bacterial penetration (caries, fracture, & developmental defects)
- Role of AVA shunt in inflammation
- Dental pulp is a regenerative organ
- Endodontic regeneration: Pulp capping & Revascularization