Oral pathology

American Academy of Oral Pathology

Donald Kerr, Editor

The rate of tertiary (reparative) dentine

formation in the human tooth
Harold R. Stanley, D.D.S., M.H., B.S.,* Carl L. White, A.B.,** and
La,rry McCray, *+* Bethesda, Md.
NATIONAL INSTITUTE OF DENTAL RESEARCH, NATIONAL INSTITUTES OF
HEALTH, UNITED STATES PUBLIC HEALTH SERVICE

T he daily rate of primary dentine formation in both man and animals has
been investigated, and specific values have been pub1ished.l However, the litera-
ture appears to contain no information concerning the daily rate of so-called
secondary or irregular or reparative dentine formation in human teeth.
At this time, when the biologic potential of the human dental pulp is receiv-
ing so much attention from the profession, it is essential that studies be made in
an attempt to establish some guidelines for the rate of reparative dentine forma-
tion. The absenceof such guidelines is likely to lead to the publication of errone-
ous and misleading statements concerning the rate of reparative dentine forma-
tion.
Years of experience in pulp studies have provided a good estimate of how
much reparative dentine can form following cavity preparation. In this article
we will report methods of measuring and comparing the results of various pulpal
studies dealing mainly with how quickly reparative dentine begins to form and
the maximum rate of production.

REVIEW OF THE LITERATURE

The terminology used to describe the various forms of dentine has led to
chaos. Kuttle? proposed a classification to end the confusion and merely sepa-
rated dentine into three basic types: primary, secondary, and tertiary. Primary
dentine is the regular, normal dentine, most of which is formed prior to eruption

“Chief, Oral Medicine and Surgery Branch, National Institute of Dental Research.
‘*Epidemiology and Biometry Branch, National Institute of Dental Research.
***Member of the Commissioned Officers Student Training and Extern Program from the
State University of Iowa, College of Dentistry, Iowa City, Iowa, temporarily assigned to the
National Institute of Dental Research.

180
Volume 21 Rate of tertiary dentine formation 181
Number 2

of the tooth. Secondary dentine is that which forms in response to the slight
aggressive effects of normal biologic function. It differs from primary dentine in
that it contains fewer and narrower tubules. A line of demarcation is usually
apparent at the junction of the primary and secondary types. The dentinal
tubules within the secondary dentine bend more or less sharply at this line;
they may be wavy and may stain somewhat darker (Fig. 1). The floor and roof
of the premolar and molar pulp cavities usually receive more of this deposit.
Tertiary dentine develops when there are more intense pulp irritants (abrasion,
mechanical, chemical and thermal, erosion, caries, cavity and crown preparation,
etc.). Tertiary dentine differs from the other two types in that it is localized
exclusively adjacent to the irritated zone, its tubules being very irregular, tor-
tuous, and reduced in number or even absent. The calcification is deficient, cellu-
lar inclusions converting into spaces may be numerous, and a different staining
tonality may be apparent (Fig. 2, A and B) .
Orbanl stated that primary dentine formed at the rate of 4 to 8 microns per
day in human teeth. Weider, &hour, and Mohammed,3 in a study of rat molars
approximately one week following cavity preparation, reported a daily rate of
reparative dentine formation ranging from 3 to 8 microns. The rate increased
with depth of cavity preparation, varied with the type of filling material, but
decelerated with time. James, Schour, and Spence4 observed moderate amounts of
tertiary dentine in five of nineteen teeth extracted 17 to 36 days after various
experimental procedures but did not investigate the rate of tertiary dentine
formation. IJefkowitz,5 in connection with a study on pulpal responsesto ioniza-

Fig. I. Section of an upper lateral incisor exhibiting a clear demarcation between primary
and secondary dentine. P, Pulp; PD, primary dentine; SD, secondary dentine; C, cavity
preparation. (Hematoxylin and eosin stain. Magnification, x68; reduced l/i”.)
 182 Stanley, White, and McCray O.S., O.M. & O.P.
February, 1966

Fig. b. A, Low-power view of large accumulation of tertiary dentinc (TD) due to dental
caries. Note decrease in the number of dentinal tubules and irregularity of their arrangement.
SD, Secondary dentine. (Magnification, x120) ; reduced l/lo.) B, Pulp stained with hematoxylin
and eosin exhibiting an early stage of tertiary predentine formation (T-P&D). Note irregu-
larity of matrix, lack of dentinal tubules, and presence of cellular inclusions CC). (Magnifica-
tion, x335; reduced !/lo.)

tion with sodium fluoride or saliva, reported that considerable amounts of

secondary or reparative dentine were formed 1 to 90 days following the applica-
tion of an ionization device. In our previous studies we have used the term
reparative dentine to describe Kuttler’s tertiary dentine but, for the sake of
clarity, in this article the term tertiary will henceforth be employed.
Volume 21 Rate of tertiary dentine formation 183
Number 2

MATERIALS AND METHODS

This study is based on the histologic examination of 108 human teeth pre-
senting evidence of postoperative tertiary dentine formation, selected from more
t.han 1,000 human teeth previously evaluated for pulpal responsesdue to opera-
t.ive procedures. Previous studies have shown the incidence of tertiary dentine
t,o be much higher (84.2 per cent) in the more traumatic low-speed operative
techniques utilizing diamond stones without a coolant, as compared to the very
mild high-speed operative techniques utilizing an air-water spray and a small
carbide bur (17.0 per cent).6 Only twenty-five of the specimens restored with
zinc oxide and eugenol cement (ZNOE ) in this study came from the high-speed
water-cooled categories. The milder the insult, the longer the time interval before
tertiary dentine begins to form. Class V cavities had been prepared under local
anesthesia and filled with a variety of filling materials, but predominantly with
zinc oxide and eugenol. The postoperative extraction time interval following
cavity preparation and filling of the tooth ranged from 15 to 132 days.
The teeth were extracted under local or general anesthesia. The apical third
of the root was removed to aid pulpal fixation with 10 per cent formalin. The
teeth were then decalcified in 5 per cent formic acid, embedded in paraffin, sec-
tioned, mounted, and stained with hematoxylin and eosin.
The longitudinal serial, nonbiased section of each specimen exhibiting the
greatest combined predentine-tertiary dentine thickness at the ends of the cut
dentinal tubules beneath the cavity preparation area was used. Measurements
were made at a magnification of xl00 with an A. 0. Spencer ocular micrometer.
The micrometer was divided into 100 units, 18.5 of these units equaling 100 ,U
or 0.10 mm. at this magnification. Measurements were also made of the predentine
above, below, and opposite the experimental area. The predentine measurements
were averaged, and the average was subtracted from the maximum predentine-
tertiary dentine measurement. This provided a measurement of the maximum
amount of tertiary dentine produced for that particular time interval. If this
value was 0 or less than zero, because in several instances the preoperatively
formed predentine had been resorbed as part of the pulpal reaction before the
deposition of tertiary dentine began, that particular specimen was eliminated
from the computations. In such cases, the sum of both the predentine and the
tertiary dentine did not equal the thickness of the adjacent undisturbed pre-
operative predentine. Also, at times, the only tertiary dentine found consisted
of erratic calcification of the preoperatively formed predentine (Fig. 3). Such
specimens were likewise eliminated from the computations. Thus, there remained
eighty-five specimens in which the tertiary dentine was greater in thickness than
the undisturbed predentine located adjacent to the experimental area.
Measurements were also made of the amount of primary and secondary den-
tine remaining (R.D.) between the axial wall of the cavity and the tertiary
dentine.
Since the main purpose of this study was to determine the average daily
rate of tertiary dentine formation, the possible varied effects of different opera-
t.ive procedures and filling materials were not stressed. However, where it was
possible to group teeth that had experienced similar degrees of trauma, the
184 Stanley, White, and McCray 03, O.M. & OP.
February, 1966

IGg. 3. Erratic calcification of preoperatively formed predentine on nineteenth day of the

experimental period. T-PR-D, Tertiary predentine; SD, secondary dentine; P, pulp. (Magnifica-
tion, x315; reduced ?/lo.)

Table I. Average amount of tertiary dentine formation found postoperatively

1 Totals
Range of postoperative time interval
(days) 27 to 48 49 to 71 72 to 132 27 to 132
Sumber of specimens 55 16 14 85
Mean day 36.6 58.6 106.3 52.2
Averago number of active days (mean
day - 19) 17.6 39.6 87.3 33.2
Total number of microns of tertiary
dentine (p) 3,395.7 1,250.3 1,248.S 5,894.S
Average number of microns (,u) per
specimen (? S.E.) 61.7 + 4.97 78.1 ? 8.46 89.2 k 17.06 69.4 + 4.64
Bate of microns (p) of tertiary dentine
xxodueed Der dav per specimen 3.51 0.74 0.23 1.49

effects of trauma and remaining dentine thickness on tertiary dent!ine formation

were investigated.
To find the daily rate of tertiary dentine format.ion, it was first necessary
to determine the average thickness of tertiary dentine to be found after certain
postoperative intervals.
Because of the range of postoperative time intervals (27 to 132 days), it
was decided to divide the time intervals arbitrarily into three major groups:
27 to 48 days, 49 to 71 days, and 72 to 132 days. Little t,ertiary dentine ap-
parently is found in man before a postoperative period of 30 days has passed.
However, the first instance of definite tertiary dentine was observed on the
nineteenth day in one case and on the twenty-seventh postoperative day in two
Volume 21 Rate of tertiary dentine formation 185
Number 2

other eases. After that, there was a gradual increase in thickness up to the
132nd day (Table I).
After the average amount of tertiary dentine to be found after a certain
number of postoperative days for each major time interval had been ascertained,
it was then possible to determine an approximate rate of tertiary dentine pro-
duction. This was accomplished by dividing the average amount of tertiary den-
tine found by the average number of active days of potential production in each
major time interval (Table I). This value represented the average number of
microns produced per day per specimen. Since no tertiary dentine was found
prior to 19 days, this period of time was eliminated from the computations in
order to establish a realistic period of deposition or formation. Subtracting 19
days from the postoperative interval gave the number of days existing for active
deposition of tertiary dentine.
In ordrr to determine the rate of tertiary dentine formation per day in the
later time intervals, the usual statistical methods were employed. Formulas’” that
allowed for the accumulation of the tertiary dentinc in the earlier periods w(re
used.

FINDINGS
The average amount of tertiary dentine formed was 61.7 TVafter 36.6 mean
postoperative days; 78.1 p after 58.6 mean postoperative days; and 89.2 p after
106.3 mean postoperative days (Table I). The average amount of tertiary dentine
formation found for the entire experimental period after 52.8 mean postoperative
days was 69.4 p. The maximum individual amount of tertiary dentine in any of
the specimens was 225.4 p. This occurred in a specimen in the 72- to 132-day
interval.

“Formula 1 Average
Total number Rate Sample active
of microns c_ (27- to 4%day group) x size x days (27- to 47.day group)
(49- to 71.day group)

divided by
Sample size
Average active day
(49. to 71-day group) x Average active
(49. to 71.day
day
group) (27- to 4%day group) 1
Formula d
Total number
of microns ~ Sample size
(72- to 132.day group)

11
Average Average
active active
X days __ days
(49- to 71-day group) (27- to 48-day group)

divided by
Sample size
(72- to 132.day group) x
Average
(72.
active day
to 132.day group)
-__ Average active
(4% to 71-day
day
group) 1
186 Xtanley, White, and McCray O.S., O.M. & O.P.
February, 1966

In the 27- to 4%day interval, when the average amount of tertiary dentine
found was divided by the average number of act.ive days of pot.ential tertiary
dentine production, a rat.e of 3.5 p per day per specimen was obtained (Table I .).
By substituting in the previously mentioned formulas, the rate of tertiar)
dentine formed per day in the 49- to 71- and 72- to 132-day groups was detrr-
mined :
Fornzzlla 1
1250.3 __ 3.51 (16) (17.6) 262.8
= ~ E 0.74 p (daily rate of tertiary dentine
16 (39.6 __ 17.6) 352 formation in the 49- to 71.day
group)
Formula d
1248.8 - 14 [3.51 (17.6) + 0.74 (22)] 156.02
= 0.23 p (daily rate of tert.i-
14 (87.3 __ 39.6) =m ary dentine forma-
tion in the 71. to
132day group)

The rate of tertiary dentine formation was 0.74 p in the 49- to 77-day group
and 0.23 ,u in the 72- to 132-day group. The average daily rate for the entire
study was I..49 p per active day.
Since the largest number of specimens (fifty-fire) occurred in the first t.ime
interval (27 to 48 days) and the average ages of the patients and the postopera-
tive intervals were quite similar, it was thought that the influence of remaining
dentine thickness might be studied by separating the specimens according to
remaining dentine thickness. It was found that the average amount of tertiary
dentine formed was not significantly affected by the amount of remaining dentine
thickness per se (Table II). However, if t,he specimens were subdivided accord-
ing to the remaining dentine thickness and the traumatic capacity of the cutting
and restorative procedures, a slightly different result occurred.
Eighteen specimenswere placed in the “minimal trauma” group (Table III).
This category included teeth prepared by a high-speed cutting technique
(50,000 r.p.m. and over) with a No. 35 carbide bur and a water coolant and
restored with ZNOE. Thirty-five teeth were placed in the “considerable trauma ”
category, which included teeth prepared at low speed with a No. 37
diamond stone or at high speed with a No. 35 carbide bur, both without a water
coolant and restored with ZNOE, or at high speed with a No. 35 carbide bur
with a water coolant but restored with either amalgam, silicate, or a toxic
experimental restorative material. It has been shown previously that. the con
densation of amalgam upon virgin dentinal tubules after a cavity has been
prepared at high speed great.ly intensifies the early pulpal reaction.’ Silicates
and certain experimental restorative materials inserted without a suitable liner
also greatly intensify the pulpal response. Two specimens prepared at low speed
but with a water coolant were eliminated because the pulpal response is usually
moderate in character and falls between t,hc two extremes represented here.
In Table III it appears that ir trend toward greater production of tertiary
dentine does occur when operative techniques capable of producing considerable
pulpal response or trauma are used. However, the number of specirncns is not
ndcquatc in many of the R. n. subdivisions. When the specimens in each major
Volume 21 Rate of tertiary dentine formation 187
Numher 2

Table II. The effect of remaining dentine thickness on the amount of tertiary
dentine formation (range : 27 to 48 days)
R.D. grouping (mm.) 0.00 to 0.49 0.50 to 0.99 1.00 to 2.03
Number of specimens 8 33 14
Average R.D. (mm.) 0.36 0.76 1.19
Average postoperative interval 34.8 36.1 38.9
(days)
Average microns* 68.12 9.99 59.4 + 6.31 63.6 2 11.78
Age range (years) 25-46 23-58 25-49
Average age (years) 32.4 38.0 37.6
*No significant difference in p.

Table Ill. The influence of trauma and remaining dentine thickness on t.he amount
of tertiary dentine formation (27 to 48 day interval)
Minimal trazlma* Consideral e trazcmat
AWT- Aver-
we aw
tertiary tertiary
dent&e Aver- dentine Aver-
Number Aver- thick- we Number Aver- thick- we
Remaining of age ness time of we ness time
dentine speci- R.D. (mi- interval speci- R.I). (mi- interval
/mm.) mens (mm.) crons) (days) mens fmm.) crons) (days)
0.08 to 0.49 2 0.42 60.5 33 6 0.35 70.3 35.3
0.50 to 0.99 10 0.83 49.7 35 22 0.74 63.8 36.7
1.00 to 2.03 6 1.25 55.7 38.2 7 1.16 78.4 38.9
0.08 to 2.03 18 0.83 55.3 32.1 35 0.75 70.8 33.6
*Prepared at high speed with No. 35 carbide bur, water coolant, and ZNOE.
t Prepared as follows :
1. Low-speed, No. 37 diamond bur, no coolant, and ZNOE
2. High-speed, No. 35 carbide bur, no coolant, and ZNOE
3. High-speed, No. 35 carbide bur, water coolant, and amalgam or silicate
4. High-speed, No. 35 carbide bur, mater coolant, and experimental restorative material.

category arc totaled, the result is clearer. A slight average increase in the
thickness of the tertiary dent,ine occurred in the specimenswithin the “consider-
able trauma’! category.

DISCUSSION
The amount of tertiary dentine formed is directly related to the post-
operative interval following cavity preparation and slightly effected by the de-
gree of operative trauma, From Fig. 4, it is obvious that the formation of
tertiary dentine is most rapid initially and decreases considerably after about
30 active days of production (about 48 postoperative days).
If the operative technique is considerably traumatic, a slightly greater amount
of tertiary dentine will be formed in the 27- to 4%day interval. As previously
stated, other studies have shown that the incidence of tertiary dentine is much
higher in the more traumatic operative techniques than in the mild techniques.6
This meansthat following mild operative procedures the initiation of tertiary den-
tine production requires a longer postoperative time interval. In many specimens
prepared with high-speed techniques and restored with ZNOE, tertiary dentine
 30 50 70 90 110 130
DAYS

Fig. 4. Tertiary dentine formation (rate deceleration with time).

has not begun to form even after 90 postoperative days. The milder the operative
technique, the longer it apparently takes for the primary odontoblasts to de-
generate and be replaced by regenerated odontoblasts whose function is to
produce tertiary dentine. It may be that no matter how great the lag period
before the initiation of tertiary dentine, once it begins to form, a similar schedule
or rate of production is followed.
It has been shown that the average daily rate of tertiary dentine formation
for 36.6 mean days was 3.5 p. From 36.6 to 58.6 mean days the daily rate de-
creased to 0.74 ,u, and from 58.6 to 106.3 mean days it decreased to 0.23 p. Con-
sequently, when one evaluates the amount of tertiary dentine formed following
an experimental procedure, the most that is likely to form 100 days following
the procedure could be estimated as follows:
100 postoperative days-19 days = 81 da.ys for the production of
tertiary dentine
If the initial production rate of 3.5 p was sustained for the entire period of
81 days, which is most unlikely, the total amount of tertiary dentine produced
would be
81 days x 3.5 p = 283.5 p, or approximately 0.28 mm.
However, if one assumed that the initial rate of 3.5 p was sustained for only
about 22 active days (the difference between the mean postoperative days of the
first two intervals as shown in Table I), then only 77.0 Al.would be produced
during that period, and 59 remaining days at 0.74 p per day would produce an
additional 43.7 ,U for a total of 120.7 JL, or approximately 0.12 mm. Therefore,
Volume 21 Rate of tertiary dentine formation 189
Number 2

one should be quite cautious about accepting data which suggest that much larger
quantities of tertiary dentine can be produced in much shorter periods of time.
It should be emphasized here that these rates of tertiary dentine formation
were determined from specimens in which Class V cavity preparations were
made. Different rates of tertiary dentine formation might possibly occur in
specimens intentionally exposed and treated with certain pulp-capping agents.

SUMMARY
In view of the increased interest in the biologic potential of the human
dental pulp, the rather misleading statements concerning the rate of tertiary
(reparative) dentine formation indicate the necessity of establishing some guidc-
lines for this process.
A histologic study of 108 human teeth with Class V cavities prepared by
high- and low-speed methods with and without coolants was carried out. Little
evidence of tertiary dentine formation was apparent prior to the thirtieth post-
operative day. The rate of formation w-ashighest initially in the 27- to 4%day
interval (3.5 p per day) ; it decreased markedly after the forty-eighth day of the
cxpcrimental period to 0.74 p per day; and it decreased further to 0.23 p in the
72- to 132-day period. The average rate for t,he total length of the study was
1.49 ,Uper active day.
The factor of remaining dentinc t,hickness by itself did not appear to effect
tertiary dentine production. However, operative techniques inducing considerable
trauma were capable of slightly incrtasin g the production of tertiary dentinc.

REFERENCES
1. Orban, B.: Oral Histology and Embryology, ed. 5, St. Louis, 1962, The C. V. Mosby Com-
pany, chap. IV, p. 118.
2. Kuttler, Y.: Classification of Dentin Into Primary, Secondary, and Tertiary, ORAL SURG.,
ORAL MED. & ORAL PATH. 12: 996-1001,1959.
3. Weider, S., S&our, I.! and Mohammed, C.: Rate of Formation and Structural Quality of
Experimental Reparatrve Dentin in Rat Molars, J. D. Res. 34: 734, 1955.
4. James, V., &hour, I., and Spence, J.: Responses of Human Pulp to Gutta-Pereha and
Cavity Preparation, J. Am. Dent. A. 49: 639, 1954.
5. Lefkomitz, W.: Pulp Response to Ionization, J. Pros. Den. 12: 966, 1962.
6. Stanley, H., Jr., and Swerdlo~v~, H.: Reactron of the Human Pulp to Cavity Preparation:
Results Produced by Eight Drfferent Operative Grinding Technics, J. Am. Dent. A. 58:
49.59, 1959.
7. Swerdlom, H., and Stanley, H. R. : Response of the Human Dental Pulp to Amalgam Rcstora-
tion, ORAL SURG., ORAL Mm. & ORAL PATH. 15: 499.508,1962.