ISTOLOGY Ma. Concepcion B. Medina, DDM. Oral Medicine Section College of Dentistry, University of...
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ISTOLOGY
Ma. Concepcion B. Medina, DDM.Oral Medicine Section
College of Dentistry, University of the Philippines ManilaTaft Avenue corner Pedro Gil St., Ermita, Manila
HI NFLAMMATION
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Features of the Pulp• Low compliance environment
• Nature of its blood supply
• High pulpal tissue fluid pressure• Fluid in tubules
- Effect on DF flow?
• Protective mechanisms
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Protective Response of Pulp to Caries1. Decrease in permeability
Kim, et.al., 2002
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Sclerosis
Caries dentin is demineralized Precipitation of minerals
Stimulation of odontoblasts
Sclerosis
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Protective Response of Pulp to Caries1. Decrease in permeability
2. Tertiary dentin formation
Kim, et.al., 2002
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Tertiary dentin
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Protective Response of Pulp to Caries1. Decrease in permeability
2. Tertiary dentin formationWhere formed?
Which histologic feature of the pulp is involved?
Mechanism?
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Caries dentin is demineralized dentin proteins released Cytokine expression by pulp cells (odontoblasts, fibroblasts, dendritic cells) – IL-8 for PMNs; those that induce vascular permeability, promote dentinogenesis & repair, arrest caries progression (TNF, GFs)
Barkhorder, et.al, 1999; Tyler, et.al., 1999; Lim, et.al, 1994
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Protective Response of Pulp to Caries1. Decrease in permeability2. Tertiary dentin formation
3. Inflammatory and adaptive immune reactions
Kim, et.al., 2002
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• Innate immune response
• Adaptive immune response
Immune Response
Macrophages
PMNs
Lymphocytes
First line of defense
Initiates adaptive response
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Injury: bacteria by productsOdontoblasts
Afferent nerves
Cells
INFLAMMATION
cytokines
neuropeptides
mediators of inflammation
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• Vascular, cellular, neurogenic response to injury
• Acute phase – “exudative”
• Chronic phase – “proliferative”
• Protective reaction, BUT …
Inflammation
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Vascular changesInjury VC VD
Plasma extravasation
Blood volumePCAPILLARIES
Permeability
redness heat
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Vascular changesPlasma extravasation
Swelling
PT
ReversibleP nerves
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localized inflammation (reversible)
remove cause
healing
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Countermeasures vs increase in PT • Increased absorption by capillaries in adjacent uninflamed areas
• Increased lymphatic drainage
• No further filtration from capillaries
REMOVE CAUSE HEALING
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Vascular changesPlasma extravasation
Swelling
PT PBV >Blood flow
Reversible
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Vascular changesBlood flow P02
PCO2
pHNecrosis
Pus formation = microabscess
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microabscessinflammation
Irreversible
Necrosed
inflammation
“Injury”
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Vascular changesBlood flow P02
PCO2
pHNecrosis
Pus formation = microabscess
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Cellular changesBlood flow
WBCs (PMNs)
Margination
Emigration
Phagocytosis
Pavementing
Aggregation
Proteolytic enzymes
Microabscess
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Injury: bacteria by productsOdontoblasts
Afferent nerves
Cells
INFLAMMATION
chemokines
neuropeptides
mediators of inflammation
neuropeptides
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Neurogenic changes• Neuropeptides (sensory nerves)
CGRP, SP, VIP,
Neuropeptide Y,
Neurokinin A
• Cause VD, inc. vascular permeability, pain modulation
• Regulate chemokine production by pulp cells
• Promote wound healing
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Injury: bacteria by productsOdontoblasts
Afferent nerves
Cells
INFLAMMATION
chemokines
neuropeptides
mediators of inflammationmediators of inflammation
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•Mediators of inflammationHistamine VD; inc. vascular permeabilityCytokines Kinins pain
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Periradicular LesionsBacteria &/or by products
apical foramenInflammation :
Neuropeptides Chemokines
Inflammatory mediatorsChemokines Macrophages
PMNs Lymphocytes
Macrophages Osteoclasts Fibroblasts
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Other likely inducers of chemokine production in PLs:
Periradicular Lesions
TraumaInjury from instrumentation
Irritation from endo materials
Silva, et.al., 2007
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Injury VC VD
Plasma extravasation
Blood volumePCAPILLARIES
Permeability
redness heat
Periradicular Lesions
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Plasma extravasation
Periradicular Lesions
Inflammatory exudate
Intraperiapical pressure
(+) percussion
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Plasma extravasation
Swelling
PT PBV >Blood flow
Periradicular Lesions
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Blood flow P02
PCO2
pHNecrosis
Pus formation
Periradicular Lesions
(+) palpation
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Chronic state•Lymphocytes
•Plasma cells
•FibroblastsCollagen synthesis +
new blood vessels =
GRANULATION TISSUE
Adaptive IR
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Chronic state• Granuloma
• Cyst
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Localized abscess formation (grinding of rat molars)
12-24 hrs. phagocytosis
48 hrs. collagen synthesis by newly differentiated odontoblasts
Sveen, 1972
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Localized abscess formation (grinding of rat molars)3-8 days mineralization 3oD or scar tissue formation
The inflammation that resulted from the inflicted trauma resolved.
Sveen, 1972
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Localized abscess formation (humans)19 days post-injury differentiation of odontoblast-like cells
100 days reparative dentin barrier 0.12 mm. thick
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Clinical implications• Healing may take place as a result of timely intervention.
(pre-injury status of pulp)
• Minimize trauma to provide the best possible opportunities for future pulpal healing.
Heyeraas, et.al, 2001
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Clinical implications• Healing may take place as a result of timely intervention.
• Healing may be in the form of 3oD or scar tissue formation
Heyeraas, et.al, 2001
volume reparative ability
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Clinical implications• Minimize trauma
Effective water cooling system
Light, intermittent pressure
Avoid prolonged air drying
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Summary
• Inflammation is a protective response.
• Healing will take place if the cause is removed (ie., the cavity is cleaned and restored).
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Summary
• It is the clinician’s duty to minimize trauma to the pulp during restorative procedures.
The principal threat to pulp health is caries. Ingle, et.al., 2008
The 2nd most significant threat is the treatment of caries.
Ingle, et.al., 2008
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Cohen S and Burns R: Pathways of the Pulp 8th ed., 2002.
Walton R and Torabinejad M: Principles and Practice of Endodontics, 2002 and 2009.
References
Cohen and Hargreaves: Pathways of the Pulp 9th ed., 2006.
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Janeway C and Travers P: Immunobiology 3rd ed., 1997.
References
Ingle, et.al.: Ingle’s Endodontics 6 2008.
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Part 1. Normal structure and physiology. #6 pp. 427-446 Part 2. Initial reactions to preparation of teeth for restorative procedures. #7 pp. 537-551 Part 3. Pulpal inflammation and its sequelae. #8 pp. 611-625
Quintessence International 2001 Vol. 32: Pulp-dentin Biology in Restorative Dentistry
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Chemokines in Oral Inflammatory Diseases: Apical Periodontitis and Periodontal Disease Silva, et.al.
Journal of Dental Research 2007 Vol. 86, No. 4