PULP-DENTIN COMPLEX

SR NO CONTENT PAGE NO
1 INTRODUCTION
2 REVIEW OF LITERATURE
3 DEVELOPMENT OF PULP AND DENTIN
4 STRUCTURE OF DENTIN
5 STRUCTURE OF DENTAL PULP
6 BLOOD CIRCULATION OF DENTAL PULP
7 LYMPHATIC DRAINAGE OF DENTAL PULP
8 NERVOUS INNERVATION OF DENTAL PULP
9 PAIN PATHWAYS OF THE PULP-DENTIN

COMPLEX
10 REACTIONS OF PULP-DENTINE COMPLEX TO

CARIES AND DENTAL PROCEDURES

11 EFFECTS OF AGEING ON PULP-DENTIN

COMPLEX
12 CONCLUSION
BIBLIOGRAPHY
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INTRODUCTION

Dentin is a unique, avascular, mineralized connective tissue which forms the bulk of the

tooth. It underlies enamel in crown and cementum in root , providing structural support to

the tooth. In a mature tooth, dentin encloses a richly innervated and vascularized soft

connective tissue, the dental pulp. Both dentin and dental pulp are derived from the dental

papilla. These tissues remain closely associated during development and function throughout

life of an adult tooth, hence referred together as pulpodentin complex. The biologic intimacy

between these tissues dictates the response of pulpodentin complex to physiologic and

pathologic stimuli.

Functional coupling between pulp and dentin is exemplified in several aspects:

(1) pulp is capable of elaborating dentin both physiologically and in response to external

stimuli; (2) pulp carries nerves that give dentin its sensitivity; (3) pulpal connective tissue is

able to respond to dentinal injuries, even when it is not directly stimulated; and (4)
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encapsulation in dentin creates a low-compliance environment that influences the defense

potential of the pulp.

Dentin is the only living hard tissue of the tooth which can respond to changes in its

environment. It is exposed to various thermal, mechanical and chemical changes in the oral

environment. The dentin plays a crucial role in alarming the pulp by activating its defence

mechanisms against environmental changes or any bacterial invasion. Exposure of dentin due

to attrition, trauma or caries can result in profound pulpal reaction which may stimulate

tertiary dentinogenesis and reduces permeability of dentin. Thus mechanisms of both these

tissues are inter-dependant

Endodontic practice deals with manipulation of dentin and pulp, hence a sound knowledge of

the pulpodentin complex is essential.

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DEVELOPMENT OF DENTIN AND PULP

Stages of Tooth Development

After about 37 days of embryonic development, a continuous band of thickened epithelium

forms around the mouth in the presumptive upper and lower jaws. These bands are roughly

horseshoe-shaped and correspond in position to the future dental arches of the upper and

lower jaws. Each band of epithelium, called the primary epithelial band, quickly gives rise to

two subdivisions which grow into the underlying mesenchyme colonized by neural crest

cells. These are the dental lamina, which forms first, and the vestibular lamina, which follows

shortly after and is positioned just in front of the dental lamina.1

Vestibular Lamina

The vestibule forms as a result of the proliferation of the vestibular lamina into the

ectomesenchyme soon after formation of the dental lamina. The cells of the vestibular lamina

rapidly enlarge and then degenerate to form a cleft that becomes the vestibule between the

cheek and the tooth-bearing area.1

Dental Lamina

On the anterior aspect of the dental lamina, continued and localized proliferative activity

leads to the formation of a series of epithelial outgrowths into the mesenchyme at sites

corresponding to the positions of the future deciduous teeth. Ectomesenchymal cells

accumulate around these outgrowths.

Ovoid swellings arise from the basement membrane of the dental lamina at 10 different

points corresponding to the future positions of the deciduous teeth. Thus the development of

tooth germs is initiated, and the cells continue to proliferate faster than adjacent cells. Since

the main function of certain epithelial cells of the tooth bud is to form the tooth enamel, these
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cells constitute the enamel organ. While the size and shape of individual teeth are different,

they pass through similar stages of development. They are named after the shape of the

enamel organ (epithelial part of the tooth germ) and are called as follows: 2

 Bud Stage

 Cap Stage

 Early Bell Stage

 Advanced Bell Stage

Bud Stage:

The dental lamina continues to grow and thicken to form a bud while cells of the

surrounding ectomesenchyme proliferate and condense to form the dental papilla. The

epithelium of dental lamina rests on a basement membrane which separates it from the

underlying ectomesenchyme.

In the bud stage, the enamel organ consists of peripherally located low columnar cells and

centrally located polygonal cells. Many cells of the tooth bud and surrounding

mesenchyme undergo mitosis. As a result of the increased mitotic activity and the

migration of neural crest cells into the area , the ectomesenchymal cells surrounding the

tooth bud condense. The area of ectomesenchymal condensation immediately subjacent to

the enamel organ is the dental papilla. The condensed ectomesenchyme that surrounds the

tooth bud and the dental papilla is the dental sac that separates the tooth organ papilla

from the other connective tissues of the jaws

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Cap Stage

The transition from the bud stage to the cap stage is an important step in tooth

development, because it marks the onset of crown formation.

Due to differential growth and shallow invagination on the deep surface of tooth bud, the

enamel organ assumes the shape of a cap that is surrounded by the dental papilla.

The peripheral cells that cover the convexity of the “cap” are cuboidal and are called the

outer enamel epithelium. The cells in the concavity of the “cap” become tall, columnar

cells and represent the inner enamel epithelium. The outer enamel epithelium is

separated from the dental sac, and the inner enamel epithelium from the dental papilla, by

a delicate basement membrane.

Polygonal cells located in the centre of the epithelial enamel organ, between the outer and

inner enamel epithelia, begin to separate due to water being drawn into the enamel organ

from the surrounding dental papilla. This occurs as a result of osmotic force exerted by

glycosaminoglycans contained in the ground substance. Thus the polygonal cells become

star shaped by maintaining contact with each other by their cytoplasmic process. As these

starshaped cells form a cellular network, they are called the stellate reticulum. Stellate

reticulum has a cushion like consistency and acts as a shock absorber that may support

and protect the delicate enamel-forming cells. 3

The cells in the centre of the enamel organ are densely packed and form the enamel knot.

This knot projects in part toward the underlying dental papilla, so that the centre of the

epithelial invagination shows a slightly knob like enlargement. At the same time a vertical

extension of the enamel knot, called the enamel cord occurs. When the enamel cord

extends to meet the outer enamel epithelium it is termed as enamel septum since it would
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divide the stellate reticulum into two parts. The outer enamel epithelium at the point of

meeting shows a small depression and this is termed enamel navel as it resembles the

umbilicus. These are temporary structures that disappear before enamel formation begins.

The function of the enamel knot and cord may act as a reservoir of dividing cells for the

growing enamel organ.3

The proliferating enamel organ epithelium exerts an organizing influence on the

underlying ectomesenchyme. The compartment of ectomesenchyme subjacent to the

invaginated portion of the inner enamel epithelium condenses to form the dental papilla.

The dental papilla is the formative organ of the dentin and the primordium of the pulp.

The changes in the dental papilla occur concomitantly with the development of the

epithelial enamel organ. The dental papilla shows active budding of capillaries and

mitotic figures, and its peripheral cells adjacent to the inner enamel epithelium enlarge

and later differentiate into the odontoblasts.

The dental sac (dental follicle) is formed as a result of marginal condensation in the

ectomesenchyme surrounding the enamel organ and dental papilla. This forms the

primordium of the periodontium.

Early Bell Stage

As the invagination of the epithelium deepens and its margins continue to grow, the

enamel organ assumes a bell shape. It is in this stage, where the shape of the crown is

determined. The folding of enamel organ to cause different crown shapes is shown to be

due to differential rates of mitosis and differences in cell differentiation time.

 PULP-DENTIN COMPLEX

Four different types of epithelial cells can be distinguished on light microscopic

examination of the bell stage of the enamel organ. The cells form the inner enamel

epithelium, the stratum intermedium, the stellate reticulum, and the outer enamel

epithelium. The junction between inner and outer enamel epithelium is called cervical

loop and it is an area of intense mitotic activity.

The inner enamel epithelial cells which lie in the future cusp tip or incisor region begin to

differentiate first while cell differentiation proceeds cervically. The determination of

crown shape is under the control of genes and their signaling molecules and growth

factors.

The inner enamel epithelium consists of a single layer of cells that differentiate into tall

columnar cells called ameloblasts, which lay down the enamel.

The cells of the inner enamel epithelium exert an organizing influence on the underlying

mesenchymal cells in the dental papilla, which later differentiate into odontoblasts. A few

layers of squamous cells between the inner enamel epithelium and the stellate reticulum

form the stratum intermedium.

The stellate reticulum expands further, mainly by an increase in the amount of intercellular fluid.

Before enamel formation begins, the stellate reticulum collapses, reducing the distance between

the centrally situated ameloblasts and the nutrient capillaries near the outer enamel epithelium.

This change begins at the height of the cusp or the incisal edge and progresses cervically.

The cells of the outer enamel epithelium flatten to a low cuboidal form.

The dental papilla is enclosed in the invaginated portion of the enamel organ. Before the inner

enamel epithelium begins to produce enamel, the peripheral cells of the mesenchymal dental

papilla differentiate into odontoblasts under the organizing influence of the epithelium. The
 PULP-DENTIN COMPLEX

basement membrane that separates the enamel organ and the dental papilla just prior to dentin

formation is called the membrana preformativa.

The dental lamina is seen to extend lingually and is termed successional dental lamina as it gives

rise to enamel organs of permanent successors of deciduous teeth (permanent incisors, canines

and premolars. The enamel organs of deciduous teeth in the bell stage show successional lamina

and their permanent successor teeth in the bud stage.

Advanced Bell Stage

This stage is characterized by the commencement of mineralization and root formation. The

boundary between inner enamel epithelium and odontoblasts outlines the future dentinoenamel

junction.

The formation of dentin occurs first as a layer along the future dentinoenamel junction in the

region of future cusps and proceeds pulpally and apically. After the first layer of dentin is formed,

the ameloblast which has already differentiated from inner enamel epithelial cells lay down

enamel over the dentin in the future incisal and cuspal areas. The enamel formation then proceeds

coronally and cervically, in all regions from the dentinoenamel junction (DEJ) towards the

surface.3

It is in this stage where the dental papilla can now be termed as dental pulp.

Development of Root

The development of the root begins after enamel and dentin formation has reached the future

cementoenamel junction. The enamel organ plays an important role in root development by

forming Hertwig’s epithelial root sheath (HERS) which molds the shape of the roots and initiates

radicular dentin formation. It influences the differentiation of odontoblasts from the dental papilla

and cementoblasts from the dental follicle for formation of root dentine and cementum

respectively.
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Hertwig’s root sheath consists of the outer and inner enamel epithelia. The cells of the inner layer

remain short and normally do not produce enamel. When these cells have induced the

differentiation of radicular dental papilla cells into odontoblasts and the first layer of dentin has

been laid down, the epithelial root sheath loses its structural continuity and its close relation to the

surface of the root.

Prior to the beginning of root formation, the root sheath forms the epithelial diaphragm . The

outer and inner enamel epithelia bend at the future cementoenamel junction into a horizontal

plane, narrowing the wide cervical opening of the tooth germ. The plane of the diaphragm

remains relatively fixed during the development and growth of the root. The free end of the

diaphragm does not grow into the connective tissue, but the epithelium proliferates coronal to the

epithelial diaphragm .

The differentiation of odontoblasts and the formation of dentin follow the lengthening of the root

sheath. At the same time the connective tissue of the dental sac surrounding the root sheath

proliferates . As the epithelium moves away from the surface of dentin, the connective tissue cells

come into contact with the outer surface of the dentin and differentiate into cementoblasts that

deposit a layer of cementum onto the surface of the dentin. 3

In the last stages of root development, the wide apical foramen is reduced first to the width of the

diaphragmatic opening itself and later is further narrowed by apposition of dentin and cementum

to the apex of the root.

Role of Signalling Factors in Tooth Development

To better understand morphogenesis, the molecular signals that control cell growth, migration,

and ultimately cell fate and differentiation also must be considered.

The two principal groups of molecules that are involved in the exchange of information between

tooth epithelium and mesenchyme are transcription factors and growth factors.
 PULP-DENTIN COMPLEX

Transcription factors are proteins produced within cells, that bind to DNA near the start of

transcription of a gene. They regulate gene expression by either facilitating or inhibiting the

enzyme RNA polymerase in the initiation and maintenance of transcription. Mutations involving

transcription factors often result in defects of tooth formation.

Growth factors are secreted proteins that are capable of binding to specific receptors on the cell

surface. Subsequent interaction with both membrane and cytoplasmic components leads to a

complex series of intracellular events (signal transduction) that results in altered gene expression.

These changes activate cell growth and differentiation.

Following is a list of genes expressed during tooth development:

Barx - BarH like homologue in vertebrates (TF)

Bmp - Bone morphogenetic proteins (SP)

Cbfa1 - Core binding factor A1 (TF)

Dlx - Distaless homologue in vertebrates (TF)

Fgf - Fibroblast growth factor (SP)

Gli - Glioma-associated oncogene homologue (zinc finger protein) (TF)

Hgf - Hepatic growth factor (SP)

Islt1- Islet1 (TF) Lef Lymphoid enhancer-binding factor 1 (TF)

Lhx - Lim-homeobox domain gene (TF)

Msx - Msh-like genes in vertebrates (TF)

Osf2 - Osteoblast specific factor 2 (TF)

Otlx - Otx-related homeobox gene (TF)

Pax - Paired box homeotic gene (TF)

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Pitx - Transcription factor named for its expression in the pituitary gland

Ptc - Patched cell-surface receptor for sonic hedgehog (SP)

Shh - Sonic hedgehog (SP)

Slit - Homologous to Drosophila slit protein (SP)

Smo - Smoothed PTC co-receptor for sonic hedgehog (SP)

Wnt - Wingless homologue in vertebrates (SP)

Molecular changes in dental mesenchyme are affected by the following families of molecules:

Bone morphogenetic proteins (BMPs), fibroblast growth factors (FGFs), and WNT families; sonic

hedgehog (Shh) as well as transcriptional molecules such as the Msx-I, Msx-2 homeobox genes;

lymphoid enhancerbinding factor 1 (Lef-1); and Pax9, a member of the paired-box-containing

transcription factor gene family. The BMPs are among the best characterized signals in tooth

development. In addition to directly influencing morphogenesis of the enamel organ epithelium,

BMP-2 and BMP-4 are able to induce expression of Msx-1, Msx-2, and Lef-1 in dental

mesenchyme.

The FGFs, in general, are potent stimulators of cell proliferation and division both in dental

mesenchyme and epithelium. Expression of FGF-2, FGF-4, FGF-8, and FGF-9 is restricted to

dental epithelium and can stimulate Msx-1 but not Msx-2 expression in underlying mesenchyme.

FGF-8 is expressed early in odontogenesis, in presumptive dental epithelium, and can induce the

expression of Pax9 in underlying mesenchyme. 5

Odontoblast Differentiation
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Odontoblast differentiation is initiated at the cusp tip in the most peripheral layer of dental papilla

cells and follows three steps:

 Induction

 Competence

 Terminal differentiation

Inductive signals from the inner enamel epithelial cells most likely involve members of the TGF-3

family (BMP-2 and BMP-4; TGF-(31) that become partially sequestered in the basal lamina, to

which peripheral cells of the dental papilla become aligned.

Competence is achieved after a predetermined number of cell divisions is complete and cells

express specific growth factor receptors. In the final round of cell division, only the most

peripheral layer of cells subjacent to the basal lamina respond to the signals from the inner enamel

epithelium to become fully differentiated into odontoblasts. The subodontoblastic layer of dental

papilla cells thus represents dental papilla cells that are competent cells exposed to the same

inductive signals as differentiated odontoblasts, but the competent cells lack the final signal.

Fully differentiated odontoblasts are postmitotic cells that are morphologically distinct from cells

of the dental pulp. They acquire a synthetic and secretory apparatus by developing an extensive

rough endoplasmic reticulum and golgi apparatus along with numerous lysosomes. To

accommodate these organelles and to prepare for the secretion of dentin matrix components in an

apical and unidirectional manner, the nucleus moves to the opposite pole of the cell in a position

opposite to the inner enamel epithelial cells. 6

Dentin matrix proteins and the Biomineralization of Dentin

The formation of dentin follows the same principles that guide the formation of other hard

connective tissues in the body, namely, cementum and bone. The first requirement is the presence
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of highly specialized cells that are capable of synthesizing and secreting components of an

organic matrix that is capable of accepting biologic apatite or mineral.

Other prerequisites include a rich vascular supply and high levels of the enzyme alkaline

phosphatase. This enzyme is capable of cleaving phosphate ions from organic substrates and may

play a role in ion transport through cell membranes.

As odontoblasts begin to secrete a predentin extracellular matrix, they retreat in a pulpal direction

but remain connected to the matrix through cell extensions called odontoblast processes. The

conversion of the organic predentin matrix, which is principally composed of type I collagen, into

a mineralized layer of dentin is a highly complex process that begins at a distance away from the

odontoblastic cell bodies.

Among the proteins, collagen is the most abundant and offers a fibrous matrix for the deposition

of carbonate apatite crystals. The collagens that are found in dentin are primarily type I collagen

with trace amounts of type V collagen and some type I collagen trimer. The importance of type I

collagen as a key structural component of dentin matrix is illustrated by the inherited dentin

disorder called dentinogenesis imperfecta (DGI), which is characterized by severe defects in

dentin mineralization caused by a mutation in type I collagen. This form of dentinogenesis

imperfecta is coupled with osteogenesis imperfecta-related bone diseases.

Among the noncollagenous group of dentin proteins, the most important group is dentin-specific,

dentin phosphoprotein (DPP) and dentin sialoprotein (DSP). After type I collagen, DPP is the

most abundant of dentin matrix proteins and represents almost 50% of the dentin ECM.

DPP is a polyionic macromolecule that is rich in phosphoserine and aspartic acid. DPP has a high

affinity for type I collagen as well as calcium and is therefore considered a key protein for the

initiation of dentin mineralization. It is also thought to affect the shape and size of apatite crystals.
7
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DSP accounts for 5% to 8% of the dentin matrix and has a relatively high sialic acid and

carbohydrate content. Immunolocalization studies demonstrated the presence of DSP throughout

the odontoblastic life cycle during primary, secondary and tertiary dentinogenesis

The importance of DSPP in dentin formation was recently underscored with the discovery that

mutations in this gene are responsible for the underlying dentinal defects in individuals with DGI.

A second category of noncollagenous proteins with calcium-binding properties is classified as

mineralized tissue-specific, because these proteins are found in all the calcified connective tissues,

namely, dentin, bone, and cementum. These include osteocalcin and bone sialoprotein. A serine-

rich phosphoprotein, dentin matrix protein 1, whose expression was first described as being

restricted to odontoblasts, was later shown to be expressed by osteoblasts and cementoblasts" and

by brain cells."

A third group of noncollagenous proteins that is synthesized by odontoblasts is found in soft

connective tissues and organs. These include osteopontin and osteonectin.

The fourth category of dentin noncollagenous proteins is not expressed in odontoblasts but is

primarily synthesized in the liver and released into the circulation. An example of a serum-borne

protein is a 2HS glycoprotein.

The fifth group of noncollagenous proteins is the various growth factors that appear to be

sequestered within dentin matrix. They include the BMPs, insulin-like growth factors and TGF. 7

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