Regressive changes of pulp

age changes

1. Sandakphu , Darjeeling, west Bengal, India

2. Regressive changes of PULP Presented by Dr Abhisek Guria 2 nd year MDS Dept of Conservative dentistry & Endodontics SHDCH, Hassan

3. Contents Introduction Aging biologic theories of senescence programmed theory stochastic theory roles of oxidative stress Telomeres Classification Atrition , abrasion, erosion & abfraction Regressive changes of pulpo dentine cmplex Odontoblast & aging effect of aging of the extracellular matrix Dentinogenesis & aging Intratubular and intertubular dentin 11/13/2018 regressive changes of pulp 3

4. Dentinal sclerosis Dead tracts Secondary dentine Tartiary dentine DEGENERATIVE CHANGES OF PULP Characteristics Histologic and histomorphologic changes Biologic consideration Blood vessels Sensory nerves Reticular atrophy of pulp 11/13/2018 regressive changes of pulp 4

5. Pulp calcification Etiology Associated with Classification Characteristics Endodontic implication Response to pulp testing Radiographic signs of aging Calcification of canal Management of calcified canal Orifice Recognition Biomechanical Preparation Chelating Agents-Is There Any Role ? 11/13/2018 regressive changes of pulp 5

6. Resorption of tooth Internal resorption Inflammatory resorption Replacement or metaplastic resorption External resorption Surface Inflammatory Replacement Spontaneous ankylotic Multiple site of ankylotic or infected Conclusion References 11/13/2018 regressive changes of pulp 6

7. Introduction They are not developmental abnormalities or inflammatory lesions. No bacterial involvement 11/13/2018 regressive changes of pulp 7

8. Results from general aging process 11/13/2018 regressive changes of pulp 8

9. aging vs disease Age changes occur in every multicellular animal that reaches a certain size when reproductively mature . 11/13/2018 regressive changes of pulp 9

10. 11/13/2018 regressive changes of pulp 10 Aging in a particular tissue or area of the body is based on

11. Theories of senescence Programmed theory - aging is regulated by biologic clocks operating throughout human lifetimes Stochastic theory - environmental conditions impact living organisms, causing cumulative damage to DNA 11/13/2018 regressive changes of pulp 11

12. Oxidative stress Accumulation of ROS inside of cells as a function of cellular activity Cellular damage caused by ROS Impairs physiologic functions, Increases the risk of tissue disease Reduces life span (Lee and Wei) 11/13/2018 regressive changes of pulp 12

13. Telomeres limited capacity of normal cells to divide is an expression of aging, leading to the determination of the longevity of the organism. At a certain shorter length, telomeres signal a cell to stop dividing 11/13/2018 regressive changes of pulp 13 Hayflick and Moorhead

14. classification Enamel Attrition Abrasion Erosion A b fr a ct i o n Dentin Dentinal sclerosis Dead tracts Secondary dentine Pulp Reticular atrophy of pulp Pulp calcifications Resorption of teeth External Internal Cementum H y p er c e m e n to s i s Cementicles 11/13/2018 regressive changes of pulp 14

15. Attrition 11/13/2018 regressive changes of pulp 15

16. Abrasion 11/13/2018 regressive changes of pulp 16

17. Erosion 11/13/2018 regressive changes of pulp 17

18. abfraction 11/13/2018 regressive changes of pulp 18

19. Regressive changes of pulpo -dentine complex 11/13/2018 regressive changes of pulp 19

20. 11/13/2018 regressive changes of pulp 20

21. Structural organization of pulp 11/13/2018 regressive changes of pulp 21

22. Odontoblasts and aging An SEM analysis of cell processes in caries-free and attrition-free premolars in 14- to 16-year-old and 59- to 72- year-old patients. In the younger pulps , the odontoblast processes extended into the dentinal tubules, often reaching the DEJ . in the older pulps , fewer processes were found in sclerotic dentin and they never extended close to the DEJ. 11/13/2018 regressive changes of pulp 22

23. Odontoblasts are actively secreting during primary dentinogenesis become less active during secondary dentinogenesis . The actual time of switching from the primary stage to the secondary stage is still not well defined. 11/13/2018 regressive changes of pulp 23

24. Expression of DMP-1 and osteocalcin genes was upregulated in the mature odontoblasts Expression of type I collagen, DSPP, TGF-β1 receptor genes was downregulated Some author suggested consider young and old ( odontocytes ) odontoblasts as two different cell types 11/13/2018 regressive changes of pulp 24

25. A Japanese group highlighted differential expression of cbfa1, VEGF, and HSP-27 mRNAs in young and old odontoblasts in rat teeth. Expression of CBFA 1 mRNA was higher in young rats While expression of VEGF and HSP-27 mRNAs was higher in the adults . 11/13/2018 regressive changes of pulp 25

26. effect of aging of the extracellular matrix on cells Exposed aged pulp cells to juvenile-conditioned medium and juvenile cells to adult-conditioned medium. Adult pulp cells cultured with juvenile conditioned medium showed enhanced proliferation but a reduced ability to differentiate . In contrast, young cells cultured with adult-conditioned medium changed their behavior and proliferated and differentiated as adult cells 11/13/2018 regressive changes of pulp 26

27. Dentinogenesis In erupted teeth secondary dentin formation from coronal to apical direction. In impacted teeth reverse direction Constriction of chamber occurs in mesiodistal direction. Slower in women than in men. One study evaluated ground sections from 273 maxillary central incisors Young teeth (6 to 11 years old) demonstrated metamorphosed ( transparent) tracts at the incisal and cervical areas. Teenagers (11 to 15 years old) showed initial signs of irregular dentin formation ( fewer tubules ) In older individuals as dentin was deposited on the lingual walls of the coronal samples. 11/13/2018 regressive changes of pulp 27

28. In a study with monkeys, restorative procedures evoked a fourfold greater rate of tertiary dentin formation than secondary dentin formation   Capacity to mineralize predentin ( MMP gelatinase A ) may decrease with age So, teeth of elderly individuals less protected from external stimuli. 11/13/2018 regressive changes of pulp 28

29. Intratubular and intertubular dentin formation Peritubular and intratubular dentin forms throughout life Intratubular dentin formation sometimes leading to full occlusion or total sclerosis of the dentinal tubules. Contains rhomboidal whitlokite From the apical third toward the cervical area 11/13/2018 regressive changes of pulp 29

30. Dentinal sclerosis Syn : Transparent dentine Causes calcification of dentinal tubules injury to the dentinal tubules DC Abrasion Aging process 11/13/2018 regressive changes of pulp 30 Source of Ca Dental lymph s ali va

31. 11/13/2018 regressive changes of pulp 31 Sclerosed dentin (1) Dead tracts (2) secondary dentin (3 )

32. appearance Translucent zone in transmitted light Seen in Apical 3 rd of root In crown- midway b/w DEJ and pulp Dentin underlying cavity More calcified than reparative dentin. 11/13/2018 regressive changes of pulp 32

33. Result: Decreased conductivity of odontoblastic process. Slows the advancing carious process. Dye cant penetrate through the sclerotic dentine 11/13/2018 regressive changes of pulp 33

34. Dead tracts Dead tracts are empty dentinal tubules filled with air. Formed due to degeneration of odontoblastic process These appear dark in under transmitted light white under reflected light. develop in the region of cusp or incisal edge 11/13/2018 regressive changes of pulp 34

35. Secondary dentine Physiological secondary dentin : Formed after root completion and eruption of teeth It is regular, uniform laid down throughout the life 11/13/2018 regressive changes of pulp 35

36. Tertiary dentin 11/13/2018 regressive changes of pulp 36 Reactionary Reparative Stimulus for formation Mild Aggressive Formative cell Surviving post mitotic odontoblast New odontoblast from progenitor cell Structure Physiologic dentin Change in direction of tubules Heterogenus Tubular – osteodentin Disorganized - fibrodentin

37. CLINICAL FEATURES: Decrease in the sensitivity Forms additional insulating layer in tooth. Seen in in pulp horn areas 11/13/2018 regressive changes of pulp 37 Change in the direction of the dentinal tubules as they pass from primary (b) to secondary ( a) dentin

38. DEGENERATIVE CHANGES OF PULP 11/13/2018 regressive changes of pulp 38

39. 11/13/2018 regressive changes of pulp 39

40. Characteristics Number of cells in the pulp diminishes Alters the dentinogenic activity of the surviving odontoblasts Progressive reduction of pulp space IgG levels diminish Increase in fibrosis and levels of calcification Increase collagen 11/13/2018 regressive changes of pulp 40

41. Histologic and histomorphologic changes Levels and distributions of the cytoskeletal proteins actin, cytokeratin, and vimentin diminish Reductions in odontoblast processes Capillaries form a dense plexus beneath the predentin Loss of fenestrations in the capillaries Reduction of odontoblast function, become smaller and flattened Increased calcification of the extracellular matrix, Decreased numbers of blood vessels and nerves , Fusion of von Korff fibers in the odontoblastic area 11/13/2018 regressive changes of pulp 41 Bernick and Nedelman

42. Increase in calcium Decrease in levels of dihydroxy-lysin-on-leucine (DHLNL) Star-shaped fibroblasts are seen in the pulp of young individuals, yet they are diminished in size and number Amount of predentin are also diminished Genes encoding specific markers such as DSPP, ameloblastin , or osteonectin are higher in the older dental pulp. 11/13/2018 regressive changes of pulp 42

43. Aim: Evaluation of matrix components in 332 human teeth in three age groups (10 to 30 years, 31 to 51 years, and 52 to 72 years). Results: Collagen types I, IIl , V, and VI are present at all ages. With advancing age type I collagen increase Types III, V, and VI collagen disappear or are replaced by thick fiber bundles 11/13/2018 regressive changes of pulp 43

44. Biologic consideration connexin 43 was abundantly expressed in young adult dental pulps dramatically decreased in aged dental pulps 11/13/2018 regressive changes of pulp 44

45. Blood vessel The number of vessels diminishes and the vascular plexus becomes reduced intimal hyperplasia of arterioles, narrowed vessel lumens calcification of the vessel wall   Vessel degeneration near the incisal end of the pulp. Loss of fenestration in the capillaries 11/13/2018 regressive changes of pulp 45

46. As secondary dentin formation continued, causing narrowing and elimination of medium-sized vessels and capillaries decreases in both ALP and ATPase enzymes , accompanied by a reduction in metabolic activity of the pulp In the endothelial cell cytoplasm of older pulpal vessels, pinocytotic vesicles, microvesicles , and microfilaments were more numerous 11/13/2018 regressive changes of pulp 46

47. Sensory nerves Decrease in number of nociceptors calcification of the endoneurium and perineurium and ultimately the nerve proper loss of the plexus of nerve fibers number of myelinated fibers increased threshold of response to stimulation Two neuropeptides CGRP and substance P also diminish loss of small Aδ fibers and unmyelinated C fibers 11/13/2018 regressive changes of pulp 47

48. Pulp calcification 11/13/2018 regressive changes of pulp 48

49. Etiology 11/13/2018 49 Local metabolic dysfunction T ra u m a Hyalinization of injured cells Vascular damage Fibrosis Mineralization (Nidus formation) Growth with time Pulp stone

50. Associated with Dentine dysplasia, Dentinogenesis imperfecta Van der Woude syndrome ( Kantaputra et al. 2002) 11/13/2018 regressive changes of pulp 50

51. classification True Made of dentine lined by odontoblasts. False Formed from degenerating cells which mineralize.   Free Stone not related to pulp space wall surrounded by soft tissue.   Adherent Stone attached to wall of pulp space not fully enclosed by dentine.   Embedded Stone enclosed within canal wall 11/13/2018 regressive changes of pulp 51

52. Denticle An alternative term for pulp stone, more usually a calcification filled with epithelial remnants surrounded by odontoblasts. Fibrodentine Material produced by fibroblast-like cells against dentine prior to differentiation of a new generation of odontoblast-like cells. Dystrophic calcification Inappropriate biomineralization of the pulp in the absence of mineral imbalance. 11/13/2018 regressive changes of pulp 52

53. characteristics In underdeveloped root - thimble shape with the open end facing apically in primary teeth 6.7% - had pulp stones 11.7% having diffuse calcification some pain of an idiopathic nature may be caused by pulp stones (Seltzer & Bender 1984) 11/13/2018 regressive changes of pulp 53

54. Endodontic implication 11/13/2018 regressive changes of pulp 54

55. Response to pulp testing Reduced responsiveness to thermal testing in the elderly Decrease in number of fast-conducting afferents and impaired nerve activation 11/13/2018 regressive changes of pulp 55

56. change of permeability disturbs the homeostasis and can lead to pulpal disease , notably inflammation diminution of permeability can be considered an advantage in preventing the movement of bacteria and toxins into the tubules, 11/13/2018 regressive changes of pulp 56

57. the reduction in size of the tubules - bonding systems require the penetration of the resin to create tags inside the dentin thickness penetration and efficiency of disinfectant solutions are more limited that biofilm is more difficult to eliminate from mature teeth 11/13/2018 regressive changes of pulp 57

58. Radiographic signs of aging Do not reveal the actual types of dentin present in calcified root canal systems they provide a measure of age-related changes occurring in root canal systems due to secondary or tertiary dentin formation. 11/13/2018 regressive changes of pulp 58

59. Calcification of canal Certain drugs such as calcium hydroxide and corticosteroids, when placed on the dentin after cavity preparation cause sclerosis . In upper anterior teeth deposition is more on the lingual wall 11/13/2018 regressive changes of pulp 59 Seltzer & Bender Deciduous Permanent Secondary dentin 4 microns/ day reparative dentin 2.8 microns 1.5 microns Schour et al

60. Management of calcified canal A) Orifice Recognition The LN bur (Caulk/ Denstply , Tulsa, OK, USA) Mueller bur ( Brasseler , Savannah, GA, USA) DG-16 explorer thin ultrasonic tips 11/13/2018 regressive changes of pulp 60

61. No. 8 or No. 10 K –file is placed into the orifice, to negotiate the canal. Or use instruments with reduced flute, such as a Canal Pathfinder (JS Dental, Ridgefield. Conn.) or instruments with greater shaft strength such as the Pathfinder CS ( Kerr Manufacturing Co.)   11/13/2018 regressive changes of pulp 61

62. The uncovering of the floor of the pulp chamber can be accomplished with the help of the CPR 2D or BUC 1 tips . The pulp stones sometimes can be vibrated or teased out by these tips Grind the floor until the dark- colored dentine becomes visible. 11/13/2018 regressive changes of pulp 62

63. B) Biomechanical Preparation Coronal flaring in a crown- down fashion is preferred. Incremental instrumentation is achieved by cutting off a portion of the file tip, thus making it slightly wider in diameter. 11/13/2018 regressive changes of pulp 63

64. C) Chelating Agents-Is There Any Role ? liquid EDTA solution be introduced into the pulp chamber (pipette, cotton pellet) to identify the entrance to calcified canals Within narrow canals ultrasonics should ideally be coupled with the dissolving action of sodium hypochlorite to produce a synergistic effect 11/13/2018 regressive changes of pulp 64 (Cunningham & Balekjian 1980)

65. Calcified teeth that were not treated endodontically developed radiographic or clinical symptoms in upto 16% of the cases. Studies of the success and failure of conventional endodontic therapy reported failure rates of 10% to 19%. it appears that a calcified tooth treated endodontically would have no better chance of success than if it were left alone 11/13/2018 regressive changes of pulp 65 Smith et al

66. Resorption of tooth 11/13/2018 regressive changes of pulp 66

67. INTERNAL RESORPTION Synonym Chronic perforating hyperplasia of pulp Internal granuloma Odontoclastoma Pink tooth of mummery 11/13/2018 regressive changes of pulp 67

68. begins centrally Two main patterns 11/13/2018 regressive changes of pulp 68

69. INFLAMMATORY RESORPTION Resorbed dentin is replaced by inflamed granulation tissue. Site – cervical zone Resorption continues as long as vital pulp remains Coronal pulp – necrotic and apical pulp – vital 11/13/2018 regressive changes of pulp 69

70. Appear as uniform , well circumscribed symmetric radiolucent enlargement in the pulp chamber or canal When the root surface is perforated, it is impossible to determine whether the lesion began externally or internally. 11/13/2018 regressive changes of pulp 70

71. REPLACEMENT RESORPTION Here portion of pulpal dentinal wall are resorbed and replaced with bone or cementum like bone R/F : less radiolucent than the surrounding dentin. central zone appears partially obliterated . The out line of destruction is less defined than that seen in inflammatory resorption. 11/13/2018 regressive changes of pulp 71

72. H/F Variable degree of resorption and proliferation of pulp tissue filling the defect . Lacunae shows - odontoclasts or osteoclasts so called as odontoclastoma . Ch. Inflammatory cells are present. Enamel is also resorbed when the internal resorption occurs in the crown portion. 11/13/2018 regressive changes of pulp 72

73. External resorption Etiology Periapical inflammation Reimplantation of teeth Tumors and cysts Excessive mechanical or occlusal forces Impaction of teeth Dental trauma Hormonal imbalance Intra coronal bleaching of pulp less teeth Local involvement of herpes zoster Paget's disease of bone PDL treatment 11/13/2018 regressive changes of pulp 73

74. 11/13/2018 regressive changes of pulp 74

75. conclusion 11/13/2018 regressive changes of pulp 75

76. References Seltzer and bender's dental pulp – 2 nd edition Shafer’s textbook of oral pathology – 7 th edition Cohen's pathways of the pulp – 10 th edition Patterson SS & Mitchell DR. 1965. Calcific metamorphosis of the dental pulp. Oral Surg Oral Med Oral Pathol , 20: 94–101. Abdel Wahab MH, Kennedy JG (1986) Pulp stones as a cause of dental pain: a case report. Journal of the Irish Dental Association 32, 19–21. Gutmann J.L, Dumsha T.C, Lovdahl P.E, Hovland E.J. Problem Solving in Endodontics: prevention, identification and management. Third edition.1997 Mosby. Andreasen FM, Yu Z, Thomsen BL & Andersen PK. 1987. Occurrence of pulp canal obliteration after luxation injuries in the permanent dentition.Endod Dent Traumatol , 3: 103–5. Stenvik A, Mlor IA. Epithelial remnants and denticle formation in the human dental pulp.ActaOdontolScand 1970;28:721-8. 11/13/2018 regressive changes of pulp 76

77. Thank you!!!!!!