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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 11  |  Issue : 3  |  Page : 140-143

An unusual presence of pulp stones in a pulp chamber of the permanent maxillary incisors


1 Department of Semiology and Clinics, Faculty of Dentistry, University Federal of Pelotas, Pelotas, RS, Brazil
2 Department of Endodontics, Araçatuba School of Dentistry, Universidade Estadual Paulista - UNESP, Araçatuba, SP, Brazil

Date of Submission09-Apr-2020
Date of Decision21-Aug-2020
Date of Acceptance15-Jun-2021
Date of Web Publication22-Dec-2021

Correspondence Address:
Josué Martos
Department of Semiology and Clinics, Faculty of Dentistry, Gonçalves Chaves Street, 457, Pelotas, RS 96015-560
Brazil
Prof. Otávio Silva Sposito
Department of Semiology and Clinics, Faculty of Dentistry, Gonçalves Chaves Street. 457, Pelotas, RS 96015-560
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_20_20

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   Abstract 

Anatomy of the root canal system determines the pathways of the endodontic treatment, which directly affect the success of the therapy. A pulp stone is often located in the pulp chamber and radiographically is viewed as radiopaque structures. This manuscript presents a case report of endodontic treatment performed in two permanent central maxillary incisors with pulp stones in a young female patient. Conclusively, the presence of pulp stones did not interfere in the quality of the endodontic procedures, and the outcome of the treatment was successful.

Keywords: Endodontics, pulp stones, root canal


How to cite this article:
Sposito OS, Martos J, Jacinto RC. An unusual presence of pulp stones in a pulp chamber of the permanent maxillary incisors. J Interdiscip Dentistry 2021;11:140-3

How to cite this URL:
Sposito OS, Martos J, Jacinto RC. An unusual presence of pulp stones in a pulp chamber of the permanent maxillary incisors. J Interdiscip Dentistry [serial online] 2021 [cited 2022 Jan 25];11:140-3. Available from: https://www.jidonline.com/text.asp?2021/11/3/140/333336




   Clinical Relevance to Interdisciplinary Dentistry Top


An adequate therapeutic approach requires knowledge of anatomical structures and their variations.


   Introduction Top


Anatomy of the root canal system defines the parameters for performing endodontic treatment, which directly affect the success of the therapy. Pulp calcifications or pulp stones are discrete calcifications, which are one among the alterations that include more diffuse pulp calcifications such as dystrophic calcifications and are seen radiographically observed in the pulp chambers. Depending on the population studied, the age range of the individuals examined, the dental groups, and the method used, the prevalence of pulp nodules is quite varied in the literature with rates varying from 10% to 46%. Pulp stones are described to occur more frequently in the coronal segment but also are found in the pulp canal space and can be seen free, adherent, or embedded.[1] On rare occasions, the pulp stones are generalized, appearing on all teeth.[2] They can be classified according to the structure as false pulp stones which are formed from degenerating cells of the pulp which mineralize or true pulp stones that are composed by dentine and coated with odontoblasts, the distinction being morphological.[3]

The causes that lead to the appearance of the pulp stones are many, i.e., pulp degeneration, age, circulatory disturbances, orthodontic tooth movement, long-standing irritants, such as caries, deep fillings, and chronic pulp inflammation. Apart from these factors, pulp stones can also be associated with systemic conditions, such as gout, renal disease, and cardiovascular diseases. Pulp canal obliteration occurs frequently following some traumatic injuries to teeth, and pulp stones are described to develop more often in the teeth after concussion and/or subluxation injuries.[4] An extensive variety of fixed orthodontic appliances and techniques exist, and the potential association between type of force/tooth movement and pulp stone formation is still undetermined; however, orthodontic treatment can trigger the formation of stones in the dental pulp.[5],[6]

These mineral formations ranged from 0.05 to 3.3 mm in size, do not have a uniform shape or number, and can be round or oval, inhabiting most of the pulp chamber space.[1] The literature shows some methods of pulp stone removal such as the use of long-stem drills, ultrasonic tips, endodontic explorers, chelating agents, and manual and rotary instruments.[7],[8] Besides from the evident endodontic problem of hindering root canal access and their subsequent cleaning and shaping, it is not known whether they have any other significance. This case report describes the endodontic treatment of an uncommon case of a 23-year-old girl exhibiting pulp stones in two central maxillary incisors.


   Case Report Top


A 23-year-old female patient was referred by an orthodontist for the evaluation of the right and left permanent maxillary central incisors. The patient reported being healthy, without any medical treatment, and also not having any oral parafunctional habits. The clinical history revealed the completion of orthodontic treatment, and during this treatment, she had some episodes of acute, rapid, and localized pain related to the left maxillary central incisor (21). During the clinical examination, no soft tissue abnormality was observed. On hard tissue examination, a slight and discreet crown darkening of tooth 21 and composite resin restorations in the palatal surface of the teeth 12, 11, 21, and 22 were observed.

On clinical examination, there was no mobility, pain on palpation, or tenderness to percussion in any of the teeth. Pulp sensibility tests were carried out to assess the eventual pulp status. A refrigerant spray of tetrafluoretane gas mixture (Endo-Ice, Maquira, Maringá, PR, Brazil) was used. The negative response provided by the pulp sensibility tests indicated that the teeth 21 and 11 were nonvital. Radiographic examination showed the presence of diffused periapical alteration in the apical region of 21 and periodontal ligament widening in the apical root of the tooth 11 and the occurrence of unusual radiopacity extending in the coronal part of pulp chamber, suggestive of pulp stone in the teeth 12, 11, and 21 [Figure 1] and [Figure 2]. The endodontic treatment was indicated exclusively for teeth 21 and 11 due to the diagnosis of pulp necrosis, and tooth 12, even with calcifications suggestive of pulp stones, did not have an indication for endodontic treatment because its diagnosis was consistent with pulp vitality.
Figure 1: Preoperative radiograph evaluation of the maxillary central incisors

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Figure 2: Periapical radiographic view of the maxillary central incisors showing the pulp stones

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The endodontic procedure was performed under local anesthesia using lidocaine 3% with adrenaline 1:100,000. After that, a rubber dam has been installed and the access cavity of the central incisors was prepared by using a diamond burs (KG Sorensen, Barueri, SP, Brazil) mounted in a water-cooled high-speed handpiece. After accessing the pulp chamber, the roof was removed and the lateral walls were prepared by using a safe-end tungsten carbide bur (Endo Z; Dentsply/Maillefer, Ballaigues, Switzerland) parallel to the long axis of the tooth. At this moment, it was possible to observe the pulp stones. During the endodontic therapy of the central incisors, removal of the pulp stone was attempted using a K-type file # 15. The pulp stones were not attached to the dentinal walls and could be removed easily during the canal preparation. The teeth were profusely irrigated with 2.5% sodium hypochlorite, and the working length determined by using the apex locator (Root ZX II, J. Morita, Tokyo, Japan). The endodontic procedures were performed in a single visit employing the crown-down technique and after the root canals were filled with gutta-percha (Dentsply/Maillefer, Dentsply/Maillefer, Ballaigues, Switzerland) and MTA-based cement (MTA Fillapex, Angelus, Curitiba, PR, Brazil) using Tagger's hybrid technique [Figure 3]. After that, the immediate restorative procedures were carried out with light-cured composite resin [Figure 4]. Due to the fact that teeth 11 and 21 have extensive restorations and are also necrotic, they appeared a certain degree of darkening. After endodontics, the patient opted for an esthetic procedure, and two metal-ceramic crowns were then performed.
Figure 3: Obturation with gutta-percha points and MTA-based cement using Tagger's hybrid technique

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Figure 4: Immediate radiograph appearance after root canal filling

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After 35 months of clinical and radiographical follow-up, the central incisors remained asymptomatic with no evidence of periapical periodontitis [Figure 5].
Figure 5: Radiograph aspect at the 35-month follow-up

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   Discussion Top


In the present case, radiographic examination revealed pulp stones in three of the four maxillary incisors; however, the root canal treatment was performed only in the 11 and 21, as they were nonvital with periapical pathosis. The etiological factors that lead to the constitution of the pulp stones are still unclear. Age, dental wear, and caries have been suggested as possible conditions in the development of pulp calcification. All the patient's teeth that showed pulp stones possessed extensive restorations; however, we do not know the last clinical history, but it seems that the restorations were made due to carious processes. Interestingly, some authors have described that calcification of the pulp tissues is more common in teeth affected by carious lesions than in noncarious teeth.[1],[9] Pulp stones occur most commonly in the posterior teeth of both permanent and deciduous dentitions, being most commonly observed in females than males. The incidence of pulp stones is most frequently among members of older age groups, while members of the younger age have an elevated number of multiple pulp stones, because the initial process of calcification is the formation of small islands that eventually coalesce into a single mass.[10]

The orthodontic force application could produce a significant alteration in the pulp tissues, such as rupture of blood vessels, hemorrhage, dental darkening, and necrosis. Dental trauma following orthodontic tooth movement has been classified as mild transient injury of the pulp tissues that do not induce abscess formation or invasion of leukocytes, but it can cause neurogenic inflammation that is sufficient damage to stimulate reactive dentinogenesis.[11] Histologically, human pulp response to orthodontic extrusive forces shows, in some cases, the formation of several large pulp stones.[12] In this case report, we cannot affirm that the orthodontic tooth movement was able to induce the formation of pulp stones, but we believe that this hypothesis cannot be discarded.

Preoperative radiographs are employed to identify anatomical modifications of the root canal system. The analysis of the anatomical aspects of the pulp chamber can also help identifying internal variations, thus facilitating the future treatment.[13] Large size of the stones located at the pulp chamber may block access to canal orifices and hinder access to the root canal. When they cannot be passed with a file alongside large stones, they may also be removed by using burs or ultrasonic instrumentation.[7],[8] As seen in this case report, a pulp stone presents a minor difficulty during the root canal treatment, especially when good access, visualization, and suitable instruments are employed.

We also report that we use an obturation method and obturation material for routine use in this case since the pulp stones, after their removal, did not interfere in this clinical step. MTA-based cement was used, due to the ease of handling and good fluidity, thus providing an adequate sealing of the root canal. In addition to having MTA in its composition, the material has a potential for tissue repair.[14] In the case of upper central incisors, the choice of obturation with the hybrid Tagger technique can be justified because they are unique root canal and considerable dimensions. The use of this technique allowed a more compact and homogeneous filling.

Finally, the great clinical significance of the presence of pulp stones is in their potential to interfere with the treatment of the root canal, if they are of significant size or if they are located in a position that may interfere with the endodontic approach.


   Conclusion Top


Despite the presence of pulp stone, they did not interfere in the quality of the endodontic procedures, and the outcome of the treatment was successful.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Goga R, Chandler NP, Oginni AO. Pulp stones: A review. Int Endod J 2008;41:457-68.  Back to cited text no. 1
    
2.
Ozkalayci N, Zengin AZ, Elekdag Turk S, Sumer AP, Bulucu B, Kirtiloglu T. Multiple pulp stones: A case report. Eur J Dent 2011;5:210-4.  Back to cited text no. 2
    
3.
Seltzer S, Bender IB. The Dental Pulp. 3rd ed. Philadelphia, PA: J.B. Lippincott Company; 1984.  Back to cited text no. 3
    
4.
McCabe PS, Dummer PM. Pulp canal obliteration: An endodontic diagnosis and treatment challenge. Int Endod J 2012;45:177-97.  Back to cited text no. 4
    
5.
Ertas ET, Veli I, Akin M, Ertas H, Atici MY. Dental pulp stone formation during orthodontic treatment: A retrospective clinical follow-up study. Niger J Clin Pract 2017;20:37-42.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Bauss O, Röhling J, Rahman A, Kiliaridis S. The effect of pulp obliteration on pulpal vitality of orthodontically intruded traumatized teeth. J Endod 2008;34:417-20.  Back to cited text no. 6
    
7.
Nanjannawar GS, Vagarali H, Nanjannawar LG, Prathasarathy B, Patil A, Bhandi S. Pulp stone--An endodontic challenge: Successful retrieval of exceptionally long pulp stones measuring 14 and 9.5 mm from the palatal roots of maxillary molars. J Contemp Dent Pract 2012;13:719-22.  Back to cited text no. 7
    
8.
Malhotra N, Mala K. Calcific metamorphosis. Literature review and clinical strategies. Dent Update 2013;40:48-50, 53-4, 57-8.  Back to cited text no. 8
    
9.
Sayegh FS, Reed AJ. Calcification in the dental pulp. Oral Surg Oral Med Oral Pathol 1968;25:873-82.  Back to cited text no. 9
    
10.
Tomczyk J, Komarnitki J, Zalewska M, Wiśniewska E, Szopiński K, Olczyk-Kowalczyk D. The prevalence of pulp stones in historical populations from the middle Euphrates valley (Syria). Am J Phys Anthropol 2014;153:103-15.  Back to cited text no. 10
    
11.
Grünheid T, Morbach BA, Zentner A. Pulpal cellular reactions to experimental tooth movement in rats. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:434-41.  Back to cited text no. 11
    
12.
Sübay RK, Kaya H, Tarim B, Sübay A, Cox CF. Response of human pulpal tissue to orthodontic extrusive applications. J Endod 2001;27:508-11.  Back to cited text no. 12
    
13.
Cleghorn BM, Christie WH, Dong CC. The root and root canal morphology of the human mandibular second premolar: A literature review. J Endod 2007;33:1031-7.  Back to cited text no. 13
    
14.
Shetty N, Kundabala M. Biominerals in restorative dentistry. J Interdiscip Dent 2013;3:64-70.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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