*Corresponding Author:
Dr. Enes Tan
Department of Orthodontics, Faculty of Dentistry, Kırıkkale University, Kırıkkale, Turkey.
E-mail: [email protected]

Citation: Turkal M, Tan E, Uzgur R, Hamidi MM, 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.

Abstract

Background: Pulp stones (PS) are discrete calcified masses found in the dental pulp, in the pulp tissue or become attached to or embedded into the dentine. The formation of pulp stones is still something of an enigma, leading to existence of some epidemiological gaps. Aim: To determine the prevalence and distribution of pulp stones in posterior tooth group by using panoramic radiograph. Materials and Methods: Panoramic radiographs from 6912 patients attending Kirikkale University Dental Faculty Hospital, Kirikkale, Turkey during the period from July 2009 to August 2011 were reviewed for the presence of pulp stones. The overall incidence of pulp stones in the patients and their correlations between female and male patients and between the right‑side and left‑side occurrences were analyzed by computer program, SPSS 15. (SPSS Inc. Chicago, USA) with using the χ2 test. Differences were considered as significant when P < 0.05. Results: Pulp stones were detected in 879 out of 6912 patients (person prevalence 12.7%). Pulp stones were detected in 2009 teeth out of a total of 96240 teeth to give a tooth prevalence of 2.1%. Their occurrence was higher in the maxilla than in the mandible for each tooth type. Pulp stones were found to involve the right side more (1224/2009) (61%) than the left side (785/2009)(39%) and they were significantly more common in females than males (P < 0.001). Conclusions: Attention should be paid to the presence of pulp stones and the treatment problems associated with them.

Keywords

Prevalence, Pulp stones, Turkish

Introduction

Pulp stones (PS) are discrete calcified masses found in the dental pulp, in the pulp tissue or become attached to or embedded into the dentine.[1] Structurally, pulp stones can be classified as true or false, the former being made of dentine and lined by odontoblasts, whereas false pulp stones are formed from degenerating cells of the pulp that gets mineralized.[2]

The formation of pulp stones is still something of an enigma. Studies show that a high frequency of cell islands, considered to be of epithelial origin, were observed together with pulp stone formation in teeth that had been subjected to experimental intrusion.[3,4] A number of predisposing factors, including ageing, caries, operative procedures, as well as periodontal disease have been reported.[2] The pathological effect of irritation by the microorganisms of dental caries on the pulpal tissue can cause a vascular wall injury, resulting in the deposition of calcium salts within the tissue.[5] Others are orthodontic tooth movement, idiopathic and genetic predisposing factors.[2]

Pulp stones appear radiographically as round or ovoid opacities within the pulp. In addition, they may occur as a single dense mass or as several small opacities.[6] The radiographically observed incidence of pulpal calcification was substantially lower than the histologically observed incidence.[7] This was related to the fact that the radiographical studies do not give a clear picture of the entire pulp cavity.

Pulp stones may occur in one or all of the teeth in one person, even in unerupted or impacted teeth.[2] Located in the pulp cavity or root canal, these stones often narrow or even obstruct the access to the apical point root canal. The calcification of pulp tissue might lead to the failure of root canal therapy and loss of the teeth.[8]

Pulp stones have been noted to vary in number from one to 12 or more in a single tooth, their size varying from minute particles to large masses occluding the pulp cavity.[9,10] They have been reported to occur more often in coronal pulp[9] although they are also found in radicular pulp.[10,11]

The frequency of occurrence of pulp stones has been reported to increase with age.[12,13] Some studies did not find any difference in occurrence between genders,[10,13‑15] whereas other studies have found females to have more pulp stones than males.[1517]

The prevalence of PS varies from 8% to 90%, depending on the study type, design and radiographic technique employed.[18] Histological method of evaluation is reported to yield higher values than radiographic method.[10]

The purposes of this study were to describe the prevalence of pulp stones in a sample of Turkish dental patients using panoramic radiographs and; to explore possible associations between pulp stones and sex, tooth type, dental arch, side and dental status; and to compare the results with published data. This will provide the dental practitioner with information about the types of the teeth which are more likely to exhibit technical difficulties associated with the endodontic treatment of such teeth.

Materials and Methods

This is a retrospective study carried out in Turkey from July 2009 to August 2011. Before then such studies do not require prior ethical approval in our institution. This information is available in Turkey at http://www.resmigazete.gov.tr/ eskiler/2011/08/20110819.htm. We designed a descriptive study composed of panoramic radiographs from 8568 patients (4324 women and 4243 man, age range from 15 to 50 years) attending Kirikkale University Dental Faculty Hospital, Kirikkale, Turkey for routine dental examination during the period from July 2009 to August 2011 were reviewed for the presence of pulp stones. Digital panoramic radiographs were taken using PAXUNI3D (Vatech Co., Králové-Březhrad, Czech Republic) digital radiography systems. All data (age and sex) was obtained from the files. Radiographic interpretation was undertaken by two experienced examiners.

Exclusion criteria included patients who were less than 15 years of age at the time of radiographic examination, records with poor quality radiographs and record with radiographs of only primary teeth. In addition, carious, restored and fractured teeth were not included. The final sample included 6912 patients (3860 females and 3052 males, mean age: 29.0 years from 15 to 50 years). Inclusion criteria included: A tooth was recorded as having a pulp stone only when a definitive radiopaque mass was identified in the pulp chamber. Each radiograph exhibiting this criterion was re‑examined carefully by both examiners twice and a combined decision was made to either consider the tooth is having pulp stones or not. For each patient with pulp stones we recorded the demographic variables (including age, sex), number, location (maxilla or mandible).

The examiners were calibrated by reading 100 radiographs separately; containing 15 different cases of pulps stones before the investigation began. The examiners re‑read together a sample of panoramic radiographs containing pulp stones 2 week after the first examination and a 100% agreement was obtained. The observations were entered and analyzed using the computer program, SPSS 12 (SPSS Inc. Chicago, USA). The overall incidence of pulp stones in the patients and their correlations between female and male patients and between the right‑side and left‑side occurrences were analyzed by using the χ2 test. The bilateral incidences of pulp stones were also evaluated. Differences were considered as significant when P < 0.05.

Results

Panoramic radiographs of 6912 patients, 3860 females and 3052 males, with age range of 15-50 year and average of 29.4 (8.7) were studied.

Almost equal numbers of maxillary (48437) and mandibular teeth (47803) were examined. Pulp stones were detected in 2009 teeth out of a total of 96240 teeth to give a tooth prevalence of 2.1% [Table 1].

Tooth Number of teeth examined Number of teeth with pulp stones Percentage of pulpstones
Maxilla
First premolar 12124 7 0.06
Second premolar 12158 8 0.07
First molar 12023 733 6.1
Second molar 12132 683 5.6
Total 48437 1431 3
Mandibula
First premolar 12267 34 0.28
Second premolar 12311 10 0.08
First molar 11642 274 2.35
Second molar 11583 260 0.54
Total 47803 578 1.21
Total 96240 2009 2.1

Table 1: Frequency of the prevalence of pulp stones amongst different tooth types

Eight hundred seventy nine patients had at least one tooth with a pulp chamber calcification. Thus the person prevalence was 12.7%.

Table 2 presents the distribution and prevalence of pulps stones according to the gender of patients. Pulp stones were detected in 14.2% (574/3680) of female patients and in 10% (305/3052) of male patients with significant difference between the genders (P < 0.001) [Table 2].

Location Female Male Total
  Right (%) Left (%) Total (%) Right (%) Left (%) Total (%) Total (%)
Maxilla
First premolar 5 0.25 0 0.00 5 0.25 2 0.10 0 0.00 2 0.10 7 0,35
Second premolar 3 0.15 2 0.10 5 0.25 1 0.05 2 0.10 3 0.15 8 0,40
First molar 336 16.72 184 9.16 520 25.88 134 6.67 79 3.93 213 10.60 733 36,49
Second molar 307 15.28 165 8.21 472 23.49 130 6.47 81 4.03 211 10.50 683 34,00
Mandible
First premolar 14 0.70 4 0.20 18 0.90 12 0.60 4 0.20 16 0.80 34 1,69
Second premolar 3 0.15 1 0.05 4 0.20 2 0.10 4 0.20 6 0.30 10 0,50
First molar 105 5.23 86 4.28 191 9.51 45 2.24 38 1.89 83 4.13 274 13,64
Second molar 98 4.88 85 4.23 183 9.11 27 1.34 50 2.49 77 3.83 260 12,94
Total 871 43.35 527 26.23 1398 69.59 353 17.57 258 12.84 611 30.41 2009 100.00

Table 2: The distribution of pulp stone according to dental arches, sex and location

The distribution of pulp stones among different teeth in the upper and lower arches is shown Table 3. Pulp stones were significantly more common in the maxilla 3% (1431 of 48437 teeth) compared with mandible 1.21% (578 of 47803 teeth). Pulp stones were found in only 0.12% (59/48860) of the premolars and in 4.12% (1950/47380) of the molars examined, with differences in occurrence being statistically significant (P < 0.001). The frequency of pulp stones was higher in the first molars than in the second molars in each dental arch and when data for both arches were combined (P < 0.001) [Table 4]. However, in the maxilla, pulp stones occurred more frequently in second premolars than first premolars whereas in the mandible, first premolars accounted for more pulp stones than in second premolars. Pulp stones were more prevalent on the right side (1224 teeth, 61%) than on the left side (785 teeth, 39%). Association between increasing age and pulp stones occurrence were not observed [Table 5]. Figure 1 shows examples of pulp stones with different tooth types detected by panoramic radiography.

Location Right (%) Left (%) Total (%)
Maxilla
First premolar 7 0.35 0 0.00 7 0.35
Second premolar 4 0.20 4 0.20 8 0.40
First molar 470 23.39 263 13.09 733 36.49
Second molar 437 21.75 246 12.24 683 34.00
Mandbile
First premolar 26 1.29 8 0.40 34 1.69
Second premolar 5 0.25 5 0.25 10 0.50
First molar 150 7.47 124 6.17 274 13.64
Second molar 125 6.22 135 6.72 260 12.94
Total 1224 60.93 785 39.07 2009 100

Table 3: The distribution of pulp stone according to dental arches and location

Location Maxilla Mandible Total
Right   Left     Right Left
FM SM FP SP FM SM FP SP FM SM FP SP FM SM FP SP
N 470 437 7 4 263 246 0 4 150 125 26 5 124 135 8 5 2009
N 907   11   509   4   275   31   259   13   2009
N 918       513       306       272       2009
N 1431               578               2009

Table 4: The occurrence of pulp stones in each tooth type, arch and location

Patient No. of patients No. of patientswith PS Percent ofpatients with PS
Age (years)
15-19 538 30 5.58
20-29 1322 333 25.19
30-39 1071 336 31.37
40-49 715 180 25.17
Total 3646 879 24.11

Table 5: Distribution pulp stone by age

annals-medical-health-sciences-pulp-stones

Figure 1: Examples of pulp stones belonging different tooth types on formed panoramic radiography

Discussion

The data of the present study were collected from the examination of panoramic radiographs from patients who attended Kırıkkale University Dental School (KUDS).Caution was taken in extrapolating the results of the present survey to larger population. This study investigated pulp stones in adults. No attempt was made to include examination of pulp stones in the permanent teeth of children The results reflect the prevalence of pulp stones only in patients who attended dental clinics at KUDS. However, there is no reason to believe that this group of patients is different from other Turkish adults. No data were found indicate genetic, social and geographical differences in the prevalence of pulp stones among other nations.

Pulp stones (PS) are calcified bodies in the dental pulps of the teeth in the primary and permanent dentition. They can be seen in the pulps of healthy, diseased, and even unerupted teeth.[2]

Most publications concerning pulp stones are case reports and only a few have reported the prevalence of this anomaly. The incidence of pulp stones has been reported to be from 8% to 95% in the permanent dentition.[5,10,13,16,17,19,20] The results of the present study on a group of Turkish dental patients has shown an overall prevalence of 12.7% for individuals and 2.1% for all teeth examined teeth. This figure is higher than the results of the study by Renjitker et al.[10] (10.3%) young Australian adults and less than the study by Hamasha et al. among Jordanians[13] (22.4%) and Baghdady et al.[5] (14.8%) among teenage Iraqi group. The variation in the pulp stones prevalence could be explained by variation of the condition among different nations or variation in the sample examined or examination criteria. In a recent study[17] performed in Turkish population revealed the prevalence of pulp stones 57.6% which was considerably higher than our study. However, Gulsahi et al.[18] reported a prevalence of 12% pulp stones in Turkish dental patients which was very close to our findings. These contradictory findings in the same population may be explained with marked differences in the sample size.

In the present study, women presented a higher prevalence of pulps stones than men and these differences were statistically significant (P < 0.001). This finding is consistent with other studies previously reported.[5,16,17,21] However, according to another studies, significant difference were not observed between genders.[10,20] In the literature, bruxism which causes longstanding irritation on the dentition was thought to be the reason of this difference because it is more prevalent in women.

Regarding the location of observed pulp stones in the present study, most of the pulp stones were found to be in the maxillary arch especially the first molar teeth. This finding is consistent with other studies which were performed by of Sisman et al.,[17] Tamse et al.,[16] and Ranjitkar et al.[10] However, Hamasha[13] found pulp stones to be more frequent in the mandibular first molar teeth. This result may be related to the fact that the molars are the largest teeth in the arch, provide a better supply of blood to the pulp tissue and have the strongest chewing force in the arch. This may lead to greater precipitation for calcification[17]

According to the results of our study, pulp stones occurred more frequently on the right side than on the left side (P < 0.001). This result was conflicted with the results of Turkish population[17] and Australians.[10] The noted inter‑study variation may relate to sample size and case selection so further investigations are necessary to clarify the issue.

Earlier studies showed association between advancing age and increasing rate of PS occurrence.[16,20,22] In present study age was not found related with pulp stones which was consisting with other reports.[5,17] This may be due to the fact that, the majority of the patients were in the second and third decades of their lives and there were no patients older than 50 years in our study. According to our findings showed decrease in prevalence of pulp stones in the 40-49 age range compared to the 30-39 age range. However, this results is questionable whether prevalence and distribution vary across studies, possibly due to variations in study design, sampling procedures and type of radiograph and techniques employed.

As far as the etiology of pulp stones is concerned, much controversy exists. Some factors that have been implicated in pulp stone formation include age,[12,23] impaired pulpal blood supply,[14] genetic predisposition,[24] or long‑standing irritants such as caries, deep fillings, or abrasion.[11,12,25]

There are conflicting reports in the literature regarding association between presence of pulp calcification and systemic disturbance. In their study Moura and Paiva[26] confirmed increased pulpal calcifications in subjects with coronary atherosclerosis upon radiographic examination. Likewise, a pilot study of correlations of pulp stones with cardiovascular disease demonstrated that patients with cardiovascular disease have an increased incidence of pulp stone.[27] However, recent study, Horsley et al. did not find a strong correlation between the presence of pulp calcification and carotid calcification.[23] Further studies that have longitudinal data on larger samples would help to investigate this association

At the end of the discussing the findings in detail, it would be worthwhile describing some limitations and strengths of this study. One of the main limitations would be results from included the method of radiographic assessment which included only panoramic radiographs, did not give a clear picture of the posterior teeth with pulp stones. The presence of pulpal calcification is often determined from bitewing projections due to compared to panoramic radiographs, these radiographs are normally accurate images of the object without major distortion or magnification. Beside these disadvantages, panoramic radiographs show the entire mouth area—all teeth on both upper and lower jaws—on a single X‑ray. It would seem apparent that panoramic images would be excellent for screening for pulpal calcifications as all the teeth can be evaluated using the same image.[23,28,29]

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