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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 26  |  Issue : 3  |  Page : 248-252

A radiographic assessment of the prevalence of idiopathic pulp calcifications in permanent teeth: A retrospective radiographic study


Department of Oral Medicine and Radiology, Sri Rajiv Gandhi College of Dental Sciences, Bangalore, Karnataka, India

Date of Submission05-Aug-2014
Date of Acceptance11-Nov-2014
Date of Web Publication19-Nov-2014

Correspondence Address:
Sreelakshmi
Department of Oral Medicine and Radiology, Sri Rajiv Gandhi College of Dental Sciences, Cholanagar, PO: RT Nagar, Bangalore - 560 032, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-1363.144993

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   Abstract 

Introduction: Pulp calcifications are relatively frequent findings on dental radiographs. They may be seen in primary, permanent, erupted or unerupted teeth. Calcifications within the pulp are seen in such a frequency that it may be questioned whether their presence represents a pathological state or a mere occurrence of normal biological variation. Aims and Objectives: The aim of this study was to assess the prevalence of idiopathic pulp calcifications in permanent teeth by using digital orthopantomographs (OPG), and to report any association between the occurrence of pulp calcifications with gender, tooth type, dental arches, and the side of the dental arch. Materials and Methods: A total of 150 digital panoramic radiographs of an equal number of male and female patients fulfilling the inclusion criteria were examined. The sample was composed of 150 patients within the age group of 15-50 years. Four thousand three hundred and ninety-nine teeth were evaluated and the pulp calcifications were assessed. The frequency of occurrence of pulp calcifications between gender, tooth type, dental arches, and the side of the dental arch were compared. Results: From 150 orthopantomographs (OPGs), a total of 4399 teeth were examined, and the total number of patients with pulp calcifications were 80 (41 females and 39 males). The overall distribution was more in females, in the maxillary arches, and in the first molars. Patients with bilateral pulp calcifications were more than those with unilateral pulp calcifications. Conclusion: The pulp calcifications assessed in this study were of idiopathic origin, as only healthy patients and healthy teeth were included in the study. Most of the pulp calcifications were seen in the young age group. Therefore, pulp calcifications could be a normal biological variation within the pulp.

Keywords: Age, dental arch, gender, pulp calcifications, tooth type


How to cite this article:
Sreelakshmi, Nagaraj T, Sinha P, Goswami RD, Veerabasaviah BT. A radiographic assessment of the prevalence of idiopathic pulp calcifications in permanent teeth: A retrospective radiographic study . J Indian Acad Oral Med Radiol 2014;26:248-52

How to cite this URL:
Sreelakshmi, Nagaraj T, Sinha P, Goswami RD, Veerabasaviah BT. A radiographic assessment of the prevalence of idiopathic pulp calcifications in permanent teeth: A retrospective radiographic study . J Indian Acad Oral Med Radiol [serial online] 2014 [cited 2022 May 22];26:248-52. Available from: https://www.jiaomr.in/text.asp?2014/26/3/248/144993


   Introduction Top


Pulp calcifications are discrete or diffuse calcified structures present in any portion of the pulp tissue, although certain types are more common in the pulp chamber and others in the root canal. [1] These calcifications under the term of 'dental pulp nodules' have been first mentioned by Norman and Johnston in 1921. This term has in time been replaced by the term 'denticles'. In recent literature, the term 'dental nodules' has appeared. [2] Kronfield has classified pulp calcifications into discrete (denticles and pulp nodules) and diffuse types based on the morphology. Seltzer has classified pulp stones based on their structure into true and false types, and based on size into fine and diffuse mineralization, and based on location into embedded and free types. [3] Various prevalence studies have been carried out in literature and the reported prevalence rate ranges from 8 to 90%. This depends upon the study type, design, and radiographic technique used. [4] Many prevalence studies have identified pulp calcifications using radiography. According to Moss Salentijn and Klyvert (1983), true prevalence is likely to be higher, because pulp calcifications with a diameter smaller than 200 μm cannot be seen on radiographs, and therefore, 15% of the pulp calcifications go undetected or unappreciated.[2] Some researchers have reported the prevalence based on the number of patients, whereas, others represented only the rates based on teeth numbers. [5],[6] The aim of this study is to assess the prevalence of idiopathic pulp calcifications in permanent teeth using digital orthopantomographs, and to report any association of the occurrence of pulp stones with gender, tooth type or dental arches and the sides of the dental arch.


   Materials and Methods Top


This retrospective study was conducted during a time period of five months, from November 2013 to March 2014. A total of 150 digital panoramic radiographs of an equal number of male and female patients (75 females and 75 males), who attended the Department of Oral Medicine and Radiology in Sri Rajiv Gandhi College of Dental Sciences and Hospital, Hebbal, Bangalore, were examined. Digital panoramic radiographs were taken by using the ORTHOPHOS XG machine. Only images of good quality, which had the clearest reproduction of teeth, without any superimposition were included. Orthopantomographs of patients between the age group of 15 and 50 years were included in the study. Previous records of the patients were collected and only OPGs of patients without any systemic diseases and those who were not under any medication were included in the study. All healthy erupted teeth were examined. Teeth with crowns, bridges, deep restorations, orthodontic bands, and brackets were excluded from this study. A total of 4399 teeth were assessed. Definite radiopaque bodies were observed inside the pulp chambers and root canals of all the teeth were identified as pulp calcifications and were assessed. The number of calcifications, tooth type, and side of the dental arches were also recorded. The pulp calcifications were counted by two examiners to ensure accuracy of assessment.

Statistical analysis

The chi-square analysis was used to compare the frequency of occurrence of the pulp stones between genders, tooth types, dental arches, and sides of the dental arches.


   Results Top


Prevalence and distribution of total pulp calcifications in patients

In the present study a total of 4399 teeth were assessed; 2214 teeth in males and 2185 teeth in females. Pulp calcifications were found in 151 teeth in females and 131 teeth in males. Therefore, a total of 282 pulp calcifications were assessed in 4399 teeth (6% of the total teeth) [Figure 1]. The total number of pulp calcifications counted by the two examiners was found to be the same.
Figure 1: Percentage of teeth involved with pulp stone

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Prevalence and distribution of pulp calcifications based on age

In the present study patients within the age group of 15-50 years were included, but increased prevalence of pulp calcifications were found in patients within the age of 30 years. Out of 80 patients with pulp calcifications, 51 patients (63.75%) were within the age range of 30 years. Within this group 18 patients (45%) were less than 25 years.

Prevalence and distribution of pulp calcifications between genders

In the present study out of 150 patients assessed for pulp calcification, 41 females and 39 males had pulp calcifications. Even though the overall distribution was more in females (53.47% of 2185 teeth) compared to males (48.1% of 2214 teeth), the difference in the distribution between the genders was not statistically significant (P-value < 0.05).

Prevalence and distribution based on tooth type

All the calcifications assessed in this study were found in premolars and molars [Table 1]. The anterior teeth did not show any calcifications. The overall distribution of pulp calcifications was more in the first molars compared to the premolars and other molars and the difference in the distribution was statistically significant (P < 0.001).
Table 1: Distribution of pulp stones according to the dental arches and tooth types for males and females

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Prevalence and distribution in the maxilla and mandible

The overall distribution of pulp calcifications were more in the maxilla than in the mandible. The total number of pulp calcifications in the maxilla was 177 (62.6%) and in the mandible was 105 (38.9%) [Table 1] and [Figure 2].
Figure 2: Pulp stone distribution according to the tooth type, for both arches

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Distribution of pulp calcification based on the side of the dental arches

Among 80 subjects who had pulp stones 27 subjects (12 males and 15 females; 9.5%) had unilateral pulp calcifications and 53 subjects (27males and 26 females; 18.7%) displayed bilateral occurrence of pulp calcifications. Fewer subjects displayed unilateral occurrence of pulp stones.


   Discussion Top


pulp calcifications are nodular calcified masses appearing on either or both the coronal and radicular portions of the pulp. Pulp calcifications are not rare. They are routine findings in radiographs. [1] Calcifications may occur as a single mass or as several small radio-opacities within the pulp chambers or root canals and they vary in number from 1 to 12 or more in a single tooth. [7] They often develop in teeth that appear to be quite normal in other respects and are usually asymptomatic unless they impinge on nerves or blood vessels. However, it has been reported under numerous occasions that pulp calcifications are a cause of pain, varying from mild neuralgia to severe excruciating pain, resembling that of tic douloureux. [1] They have been seen in functional and embedded unerupted teeth. Pulp calcifications are broadly grouped into three types: Denticles, pulp stones, and diffuse linear calcifications. [8] Discrete calcifications are formed due to epithelial mesenchymal interaction within the developing pulp; so these are usually seen in the young developing pulp. Pulp stones and diffuse linear calcifications are usually age-related phenomenon triggered by certain pathological conditions. [8]

Most of the previous prevalence studies on pulp calcifications were done with bitewing radiographs and intraoral periapical radiographs (IOPARs). The radiation exposure of OPG is less compared to that of bitewing radiographs and IOPARs and a single exposure was helpful in the detection of pulp calcifications of the entire teeth at the same time. Therefore, OPGs were preferred for the assessment. Some of the researchers have reported two prevalence rates. One, based on the number of subjects involved in the study and the other based on the number of teeth assessed. [9]

Some of the prevalence rates reported in different countries by various researchers include the following: Ranjitkar et al. examined the prevalence of pulp stones in the Australian population and found them in 46% of the subjects and 10% of the teeth examined. Zainab H examined 390 digital panoramic radiographs and reported a prevalence rate of 34.8% in the subjects and 7.3% in the teeth assessed. Nayak et al. in a study on the Indian population examined 1432 teeth and found 9.35% prevalence of pulp calcifications. Sisman et al. examined the bitewing radiographs of 469 Turkish patients and found 57.6% prevalence of pulp stones in their patients and 15% prevalence among the teeth examined. Talla et al. examined 2000 south Indian patients and reported a prevalence of pulp calcifications in 26% of the patients and 18% of the teeth examined. In the present study, the prevalence rate of pulp calcifications was 53.3% of the subjects and 6.4% of the total teeth examined. These values are in accordance with some of the previous prevalence studies. [6]

Two main causes of pulp stone formation include local metabolic dysfunction and trauma. [1] Any local metabolic dysfunction may lead to hyalinization of the cells followed by fibrosis and mineralization of the fibrosed areas, which can act as a nidus for further mineralization and finally lead to pulp stone formation. In a similar manner, trauma may lead to vascular damage followed by mineralization, which may act as a nidus for further mineralization and pulp stone formation.

There are various studies in literature that report an association between pulp stones and systemic diseases. Pulp stones have been noted in patients with systemic or genetic diseases, such as, diabetics, hypertension, dentin dysplasia, dentinogenesis imperfecta, osteogenesis imperfecta, and in certain syndromes such as the Van der woude syndrome, Elfin-facies syndrome, and Ehlers Danlos syndrome. [8],[10],[11] Maura and Paiva confirmed the presence of increased pulpal calcifications in subjects with coronary atherosclerosis upon radiographic examination. [11] Edds et al. suggested that 74% of the patients with reported cardiovascular disease had detectable pulp stone, while only 39% of the patients without a history of cardiovascular disease had pulp stones. [12]

In the present study, an association between pulp calcification and tooth types, dental arches, sides of the dental arches, and genders have been assessed. Some investigators have reported that pulp calcifications are more common in females than in males. Some studies show that there is no significance. In the present study, even though the overall distributions of pulp calcifications were more in females, the difference was not statistically significant. This may be due to the small sample size taken in this study. More incidences in females may be due to the fact that parafunctional habits like bruxism are commonly seen in females, which may trigger degenerative changes in the pulp. [4] However, in this study, only healthy teeth and healthy patients without any parafunctional habits were assessed, that is, the pulp calcifications assessed in this study were of an idiopathic origin.

In the present study, the overall distribution of pulp calcifications was more in the first molars compared to the premolars and other molars, and the difference in the distribution was statistically significant. This finding was in agreement with studies by Sisman et al., Tamse et al., and Ranjitkar et al. However, it was not in agreement with the study by Hamasha et al., who found more distribution in the mandibular molars. The high distribution in molars may be due to the fact that molars are the first teeth to erupt into the oral cavity and due to their large surface area bear most of the occlusal forces, which may lead to early degenerative changes. Another reason is its rich blood supply that may lead to precipitation of calcification in the molars. [13]

In the present study, the pulp calcifications were distributed bilaterally in most of the patients. This finding was in agreement with a previous study conducted by Ranjitkar et al. There are many studies in the literature, which report that pulp calcifications are age-related phenomenon. [14] However, in the present study, even though an age group of 15-50 years was considered, most of the patients with pulp calcifications were within the age group of 15-30 years. This finding was in accordance with a study conducted by Satheeshkumar et al., where he concluded that aging and the reactive process may not be the only reason for pulp calcifications. [15]


   Conclusion Top


In the present study all the calcifications assessed in the pulp were of an idiopathic origin and were distributed more in the second and third decades of life. This showed that their formation could also occur in the absence of metabolic dysfunctions, pathological changes or age-related degenerative changes. Therefore, a further study with a larger sample size is required to assess the exact mechanism involved in pulp stone formation.

 
   References Top

1.Shafer WG, Hine MK, Levy BM. Shafer's Textbook of Oral Pathology. 5 th ed. New Delhi: Elsevier; 2006. p. 799-802.  Back to cited text no. 1
    
2.Goga R, Chandler NP, Oginni AO. Pulp stones: A review. Int Endod J 2008;41:457-68.  Back to cited text no. 2
    
3.Mahajan P, Monga P, Bahunguna N, Bajaj N. Principles of management of calcified canals. Indian J Dent Sci 2010;2(Suppl):3-5.  Back to cited text no. 3
    
4.Turkal M, Tan E, Uzgur R, Hamidi M, Çolak H, Uzgur Z. Incidence and distribution of pulp stones found in radiographic dental examination of adult Turkish dental patients. Ann Med Health Sci Res 2013;3:572-6.  Back to cited text no. 4
[PUBMED]  Medknow Journal  
5.Bevelander G, Johnson PL. Histogenesis and histochemistry of pulpal calcification. J Dent Res 1956;35:714-22.  Back to cited text no. 5
    
6.Talla HV, Kommineni NK, Yalamancheli S, Avula JS, Chillakuru D. A study on pulp stones in a group of the population in Andhra Pradesh, India: An institutional study. J Conserv Dent 2014;17:111-4.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
7.Bahetwar SK, Pandey RK, Singh RK, Bahetwar TS, Wahid A. A biochemical and histopathological evaluation of generalized pulp calcification in young permanent teeth. Indian J Dent Res 2012;23:123.  Back to cited text no. 7
[PUBMED]  Medknow Journal  
8.Neville B, Damm DD, Allen CM, Bouquot J. Oral and maxillofacial pathology. 3rd ed. New Delhi: Elsevier; 2009. p. 126-7.  Back to cited text no. 8
    
9.Zainab H, Najmeej AA. Prevalence of pulp stone (Orthopantomographic-based). J Bagh College Dentistry 2012;24:80-4.  Back to cited text no. 9
    
10.Kantaputra PN, Sumitsawan Y, Schutte BC, Tochareontanaphol C. Van der Woude syndrome with sensorineural hearing loss, large craniofacial sinuses, dental pulp stones, and minor limb anomalies: Reports of four-generation Thai family. Am J Med Genet 2002;108:275-80.  Back to cited text no. 10
    
11.Nayak M, Kumar J, Prasad LK. A radiographic correlation between systemic disorders and pulp stones. Indian J Dent Res 2010;21:369-73.  Back to cited text no. 11
[PUBMED]  Medknow Journal  
12.Edds AC, Walden JE, Scheetz JP, Goldsmith LJ, Drisko CL, Eleazer PD. Pilot study of correlation of pulp stones with cardiovascular disease. J Endod 2005;31:504-6.  Back to cited text no. 12
    
13.Sisman Y, Aktan AM, Tarim-Ertas E, Ciftçi ME, Sekerci AE. The prevalence of pulp stones in a Turkish population. A radiographic survey. Med Oral Patol Oral Cir Bucal 2012;17:e212-7.  Back to cited text no. 13
    
14.Ranjitkar S, Taylor JA, Townsend GC. A radiographic assessment of the prevalence of pulp stones in Australians. Aust Dent J 2002;47:36-40.  Back to cited text no. 14
    
15.Satheeshkumar PS, Mohan MP, Saji S, Sadanandan S, George G. Idiopathic dental pulp calcifications in a tertiary care setting in South India. J Conserv Dent 2013;16:50-5.  Back to cited text no. 15
[PUBMED]  Medknow Journal  


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]


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