Journal of Dental Research

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Pulpal Response to Early Dental Caries

Martin Brännström and Per Ove Lind
J DENT RES 1965 44: 1045
DOI: 10.1177/00220345650440050701

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Pulpal Response to Early Dental Caries
MARTIN BRANNSTROM and PER OVE LIND
Department of Dental Histopathology, the Royal School of Dentistry, Stockholm, Sweden
To know how early in the caries process the
pulp may be involved is of interest for the
pathogenesis of dental caries and from the
standpoint of treatment. So far as we know,
no systematic examination has been made
of the response of the pulp in early caries. In
two investigations, changes in the pulp have
been observed beneath fairly deep dentin
caries in only a few cases.1 2 In a recent
study of the effect of dental caries on the
pulp, impairment of the odontoblasts and
inflammation of the pulp were observed
only under very deep active lesions in the
dentin.' No observations of the pulpal re-
sponse under enamel caries alone were made
in these studies.
It has been suggested that there may be
alterations in the pulp in early enamel
caries.4 5 This view appears, however, to be
based on isolated observations with no
thorough investigation.
It is easy to understand the difficulty in
detecting changes in the pulp that are pres-
ent perhaps in only a few sections, corre-
sponding to a small area of the enamel. In
laboratory demineralization the enamel and
the caries lesion are completely lost and with
them the possibility of orienting the tooth
in serial sectioning of the corresponding part
of the pulp. The object of this study was to
overcome this difficulty and to record by
microradiography the depth of deminerali-
zation of the caries lesion.
Materials and Methods
The material consisted of 74 premolars
from young subjects, all of them extracted
on orthodontic indications. The teeth had
superficial carious lesions on proximal sur-
faces. Immediately after cutting off half the
root to expedite fixation, the teeth were fixed
in ethanol-formaldehyde (9: 1). After fixa-
tion for a few days, the enamel surface was
dried and the caries lesion examined. On 28
Received for publication January 1, 1965.
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of the 74 teeth there were white spots but no
detectable cavitation of the enamel. The
other teeth had white spots in the center of
which was a small cavitation or soft lesion
of the enamel surface.
At this examination the position of the
caries lesion in relation to the pulp was
marked in the following manner: a groove
about 1-1' mm. wide was cut with a dia-
mond wheel into the dentin of the occlusal
surface perpendicular to the line from the
center of the caries lesion and the pulp
(Fig. 1). This groove indicated the best di-
rection of section and the approximate level
of the caries lesion. In some cases in which
the lesion was situated more cervically, the
level was indicated by a groove on the op-
posite proximal side (Fig. 2, B).
After indicating the area of the pulp to
be sectioned, the proximal side containing
the lesion was cut away with a thin diamond
wheel (Fig. 1). From this part-comprising
the enamel with the caries lesion-together
with a superficial part of the dentin, a
ground section was prepared in the cervico-
occlusal direction through the center of the
lesion. Some of the ground sections were
made after imbedding in acrylic by sawing
and subsequent manual grinding or by man-
ual grinding alone to the thickness of about
80 M. \Iicroradiograms were made of the
ground sections on which the extent of min-
eral dissolution was determined. Maximum
resolution plates were exposed to soft X-rays
in X-ray diffraction apparatus at 20 kv. The
exposure time was 15-20 minutes.
The other part of the tooth was decalci-
fied in 5 per cent nitric acid or EDTA. Dur-
ing imbedding in paraffin wax, a metal rod
was usually placed in the occlusal groove so
as to project the direction of cutting outside
the wax; this facilitated orientation of the
tooth in the microtome. From each tooth
about 100-180 six-micron serial sections
were cut and stained with hematoxylin and
eosin.
1045
1016 BRA NNSTROM AND LINDf
Results
OBSERVATIONS ON GROUND SECTIONS AND
MICRORADIOGRAMS (TABLE 1).-In 16 out of
28 teeth with white spots but no cavitation,
the microradiograms showed that the de-
calcification involved only the outer one-
third of the enamel. Five ground sections
were lost, but, since none of the other 23
caries lesions displayed decalcification into
the dentin on the microradiograms, these
5 teeth were not rejected.
FIG. 1. Model of premolar with enamel caries
indicated by a clark spot. The occlusal groove indi-
cates required direction of section for examining the
corresponding area of the pulp. The line (X) demar-
cates jcart of tooth with caries lesion. From the an-
terior part of tooth, ground sections are prepared for
assessing depth of demineralization.
In 27 other teeth the white spots were
accompanied by slight cavitation of the
enamel. Ground sections were available in
all cases, and microradiograms of these dis-
closed demineralization of at least two-
thirds of the enamel in 19 cases. In only 1
tooth of this group did the decalcification
reach the dentino-enamel border, and in
none was the dentin penetrated.
In the other 19 teeth there was marked
cavitation of the enamel. All 16 microradio-
grams available for this group showed de-
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J. dent. Res. SePtember-October 1965
mineralization into the outer part of the
dentin.
PULPAL RESPONSE (TABLES 2 AND 3).--In
16 out of 28 teeth with white spots but no
cavitation, a reaction was detected in the
corresponding part of the pulp. In 17 out of
27 teeth with slight cavitation but, accord-
ing to the microradiograms, demineraliza-
tion restricted to the enamel, there were
changes in the corresponding pulp. A re-
sponse in the pulp was observed in 17 out
of 19 teeth with marked cavitation in the
enamel and demineralization also in the
outer part of the dentin.
Impairment of the odontoblast layer was
the most predominant change and was seen
in 39 out of 50 teeth. Usually there was a
reduction in the number of odontoblasts, oc-
casionally with a few cell nuclei in the den-
tinal tubules. In a small number of teeth
there was only a loss of the pulpo-dentinal
membrane and hyperchromasia in the odon-
toblast layer. A hyperchromatic line on the
border of the regular dentin ("calciotrau-
mratic response") was observed in 35 out
of 50 teeth (Figs. 3 and 4).
Accumulation of exudate cells, chiefly
lymphocytes but in a few cases accompanied
by leukocytes, was noted in 32 teeth (Figs.
2-5). The distribution and frequency of the
changes at different depths of early caries
are shown in Table 3. In all cases the reac-
tion was restricted to an area that appeared
to correspond to the caries lesion.
Discussion
As the carious lesion was not sectioned
serially, it is possible that the various de-
mineralization, as it was seen in the micro-
radiograms of ground sections, did not al-
ways represent the deepest part of the lesion.
However, judging from a separate study
with serial sectioning of lesions, the demin-
eralization zone does not seem to reach the
dentin when no surface defect is present.
Thus, 28 teeth with white spots and no cavi-
tation would be expected to represent a
group with demineralization not reaching
the dentin (Tables 1 and 2). In 8 cases of
the group with slight surface cavitation, the
demineralization zones were smaller than
expected (Table 1). This may be due either
to retardation of the various process- for
 .{
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Fil 2. Macroscopic: White spot without cavitation. A, Microradiogram: Demineralization to less than
3 of enamel. B, Demineralized section: In corresponding part of pulp (arrow), there is an accumulation of
exudate cells; on opposite side, a groove showing the level of caries in enamel (X).

TABLE 1
DISTRIBUTION OF TEETH WITH EARLY CARIES ACCORDING TO
MACROSCOPIC AND MICRORADIOGRAPHIC ASSESSMENTS

DEMINERALIZATION (MICRORADIOGRAPHiY) TOTAL

MACROSCOPIC <1/3 of >2/3 of Into Periph- MscRo- TOTAL
OBSnRVATION Enamel Enamel eral Dentin RADIOGRAMS TEETH

White spot without cavitation 16 7 0 23* 28

White spot with slight capitation ....... 8 19 0 27 27
Marked cavitation of enamel .. 0 0 16 16t 19
Total. . 24 26 16 66 74

* Five ground sections lost.

f Three ground sections lost.

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 TABLE 2
NUMBER OF TEE TH WITH AND WITHOUT PUILP REA('Tf0NT BENEXATH EARLY l)ENTTAL CARIES

Macrosc opic Observation lDemineralizationn* Puijp Reaction No Reaction No. Teeth

White spot without cavitation ..... Restricted to enamel 16 12 28

White spot with slight cavitation.... lRestricted to enamel 17 10 27
Marked cavitation of enamel........ Into peripheral dentin 17 2 19
Total number of teeth.......... 50 24 74

* According to mcicroradiograms.
TABLE 3
DISTRIBUTION ANI) THE FREQUENCY OF IDIllt1-,RT.NTT IYPES OF IULVPAL
RP.SPONSES TO EARLY CARIES OF VARIEPI T)EPFr1ii

No. Teeth
with 3 or
Irmnaiirnment of More
Depth of (Caries Hypercicro- Sec ondary Redluction of Odontoblast E xudate (Changes Total
(Mac rosc oplic al) matic Line Dentiic Predentin Layer5 (elis in Pulp Teeth

No cavitation. . 8 5 6 11 12 8 16
Slight cavitation
of enamnel.... 13 5 .j 11 1I) 8 17
Marked cavity a-
tion of enamel 14 9 5 17 10 12 17
Number of
teeth .... 35 19 16 39 32 28 50

* Usually a reduction in the number of cells, in some cases

aspirated nuclei in the tubules and3, in afaw cassca only a loss of the
pulpo-dentinal membrane and hyperchromasia of the cytoplasm.

FiG. 3.-Macroscopic: White spot with slight cavitation. A, Microradiogram: Demineralization to ' of
the enamel. B, Demineralized section: Part of pulp) corresponding to the caries lesion in A. Accumulation of
exudate cells (arrow) and hyperchromatic line in the dentin. Above arrow, hyperchromasia in odontoblast
layercompared with the intact part below.
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Votl. 44, No. 5 PULPAL RESPONSE TO EARLY DENI'4L C(ARIES 1049

example, by remineralization (see Fig. 3, A) Summary

-or to false ground sectioning.
The results of this study indicate that
there may be a pulpal response quite early
in enamel caries. There may also have been
a reaction in the teeth in which the sections
disclosed no changes in the pulp. The sec-
tions in question may have been lost, in
spite of the labeling. This possibility cannot
be ruled out, since the changes, when pres-
ent, could often be observed in only 20-40
serial sections, that is, in an extremely small
area of the pulp.
The decalcification of the enamel would
seem to result in an increase in permeability
with the diffusion of bacterial products to
the pulp via the dentinal tubules. An in-
crease in permeability of the enamel would
also be expected to increase the outward
flow of the contents of the dentinal tubules
and hence to cause aspiration of odonto-
blasts and a reduction in the number of
these cells. Such changes in combination
with stimulation of the adjacent pulp might
also contribute to the production of irregu-
lar secondary dentin.6 7
A study has been performed of the possi-
bility of pulpal response in various stages of
early dental caries. A special technique was
devised for identifying in serial sections the
part of the pulp corresponding to the cari-
ous lesion. The depth of demineralization of
the lesion was studied by microradiography
of ground sections comprising the part of the
enamel with the lesion.
Changes in the pulp were observed be-
neath white spots with and without cavita-
tions in 50 out of 74 teeth. In 33 cases with
pulp reactions, the demineralization of the
lesion was limited to the enamel. The most
frequent changes were an impairment of the
odontoblast layer, a hyperchromatic line in
the dentin, and an aCCUmulation of exudate
cells.
To the staff of the department of Oral Surgery,
Eastman Dental Hospital, Stockholm, we wish to
express our thanks for Jrovi(ling the teeth for this
investigation.

A~~~~~~~A*
Fic. 4.-Macroscopic: White spot without cavitation Demineralized section: Dentin and pull) corre-
sponding to caries lesion showing hyperchromatic line in dentin and incipient formation of secondary
dentin. A few cells of exudate in l)ulp.
FIG. S. -Macroscopic: White spot without cavitation. Demineralized section: Reduction of predentin and
odontoblast layer. Exudate cells in the pulp.

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1050 BRiNNSTR(M AND FIND
References
1. MAcGREGOR, A., MARSLAND, E. A., and BATTY, I.
Experimental Studies of Dental Caries. I. The Rela-
tion of Bacterial Invasion to Softening of the Dentine,
Brit. dent. J., 101:230-35, 1956.
2. CORBETT, M. E. The Incidence of Secondary Dentine
in Carious Teeth, Brit. dent. J., 114:142-47, 1963.
3. MASSLER, M., and KUWABARA, R. Pulpal Reactions to
Active and Arrested Dentinal Caries, J. dent. Res.,
43:807, 1964 (abstract).
4. WESTIN, G. Pulpans och det Periapikala Rummets
J. dent. Res. September-October 1965
Inflammationer jdmte bversikt av pulpakirurgin,
Nord. Med. Odont. Handbook, pp. 471-520. Copenhagen:
Nyt. Nordiskt Forlag, 1943.
5. NYGAARD-OSTBY, B. Pulpans og det apikale perio-
dontiums putologi, Nord. Klin. Odontologi. Copen-
hagen: A/S Forlaget for faglitteratur, 1960.
6. GOTTLIEB, B. The Formation of Secondary Dentin and
Related Problems, J. dent. Res., 25:29-34, 1946.
7. BRXNNSTRfiM, M. Dentinal and Pulpal Response. III.
Application of an Air Stream to Exposed Dentine:
Long Observation Periods, Acta odont. sand. 18:
235-52, 1960.

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