|Year : 2018 | Volume
| Issue : 2 | Page : 93-98
Prevalence of pulp stones in a Saudi Arabian subpopulation: A cone-beam computed tomography study
Santosh R Patil1, Huwaina Abd Ghani2, Mohammed Almuhaiza3, Ibrahim A Al-Zoubi4, Kumar N Anil1, Neeta Misra5, PH Raghuram6
1 Department of Oral Medicine and Radiology, College of Dentistry, Aljouf University, Sakaka, KSA
2 Lecturer and Specialist in Endodontics, School of Dental Science, USM Health Campus, Kota Bharu, Kelantan, Malaysia
3 Department of Restorative, College of Dentistry, Prince Sattam Bin Abdulaziz University, Al-Kharj, KSA
4 Department of Preventive Dentistry, College of Dentistry, Aljouf University, Sakaka, KSA
5 Babu Banarasi Das College of Dental Sciences, Lucknow, India
6 Department of Oral Medicine and Radiology, SRM Dental College, Chennai, Tamil Nadu, India
|Date of Web Publication||5-Apr-2018|
Dr. Santosh R Patil
Department of Oral Medicine and Radiology, College of Dentistry, Al Jouf University, Sakaka, Aljouf
Source of Support: None, Conflict of Interest: None
Objective: To determine the prevalence of pulp stones using cone-beam computed tomography (CBCT) and to explore any potential correlation between the occurrence of pulp stones with age, gender, tooth, arch, and tooth status.
Material and Methods: CBCT scans of 428 patients comprising of 2982 teeth were retrospectively evaluated in the present study. All teeth were analyzed in sagittal, axial, and coronal plains by two examiners. The pulp stones were identified as the presence of a definite round or oval opaque or dense mass in the pulp cavity. The location of the involved tooth in terms of jaw and side and the status of involved tooth in terms of caries, restored, attrition, and periodontal disease were recorded. Statistical analysis was carried out by applying Chi-square tests with the Yates correction.
Results: Out of a total of 428 individuals, pulp stones were identified in 50.93% of patients and 13.34% of teeth. The presence of pulp stones was more frequently encountered in males (58.89%) than in females (41.14%) and in individuals belonging to the fifth decade. First molars exhibited the highest incidence of pulp stones (P = 0.0090). No significant difference was observed when maxillary and mandibular arches and the sides were compared. The presence of pulp stones was high in carious, restored, attrited teeth and teeth with periodontal disease, when compared to the intact teeth (P < 0.05).
Conclusion: Pulp stones were observed more frequently in molars and in nonintact teeth. Pulp stones occurred predominantly in males in the fifth decade irrespective of arch and side.
Keywords: Cone-beam computed tomography, prevalence, pulp stones
|How to cite this article:|
Patil SR, Ghani HA, Almuhaiza M, Al-Zoubi IA, Anil KN, Misra N, Raghuram P H. Prevalence of pulp stones in a Saudi Arabian subpopulation: A cone-beam computed tomography study. Saudi Endod J 2018;8:93-8
|How to cite this URL:|
Patil SR, Ghani HA, Almuhaiza M, Al-Zoubi IA, Anil KN, Misra N, Raghuram P H. Prevalence of pulp stones in a Saudi Arabian subpopulation: A cone-beam computed tomography study. Saudi Endod J [serial online] 2018 [cited 2018 Jun 20];8:93-8. Available from: http://www.saudiendodj.com/text.asp?2018/8/2/93/229350
| Introduction|| |
Pulp stones are foci of calcification that are commonly positioned in the pulp chamber or pulp canals of deciduous and permanent teeth. Pulp stones are not clinically determined and are fortuitously ascertained on routine dental radiographs as radiopaque structures. They may reveal as a confined dense mass or as conglomerate radiopacities in coronal or radicular pulp or occasionally seen continuing from the pulp chamber into root canals. Pulp stones can be noticed in all tooth types, but molars are known to be all the more often included. Pulp stones may be freely located in the pulp chamber or may be identified as attached to the dentinal wall. Pulp stones can be classified as embedded, adherent, and free types based on their location and are further classified histologically as “true” or “false” types. True pulp stones are known to be lined by odontoblasts and are comprised of tubular structure resembling the dentin. Hence, it is presumed that true pulp stones arise as a result of epithelial-mesenchymal interactions. False pulp stones are made up of degenerating cellular material of the pulp that mineralizes later. They are comprised of concentric layers of mineralized tissue formed by surface accretion over the blood thrombi, dead and degenerating cells, or collagen fibers. Mineralization of false pulp stones is known to happen gradually; at first, cell nests come to be closed by concentrically structured fibers further develop into impregnated with mineral salts. The false pulp stones are also not known to show dentinal tubules., Another entity of pulp stones, known as “diffuse” or “amorphous” type, is more irregular in shape compared to false pulp stones and is known to be formed in close proximity with the blood vessels. Pulp stones have been regarded as manifestation of alterations in the pulp tissues instead of their etiology. Although the etiology and pathophysiology of pulp stones is not clearly established, numerous etiological elements have been affirmed to predispose the formation of pulp stones, which includes aging, compromised blood supply of the pulpal tissue, attrition, abrasion, caries, degeneration of pulp tissue, operative procedures, periodontal pathology, orthodontic treatment, and epithelial rest in pulp tissue., Pulp stones have been noted in patients with systemic disorders, dentine dysplasia, dentinogenesis imperfect, and Van der Woude syndrome, but no firm evidence exists that they are associated with any systemic components. Limited studies were carried out employing cone-beam computed tomography (CBCT) to assess the prevalence of pulp stone , and the data regarding the prevalence of pulp stones are limited in Saudi Arabian population. This study has been carried out to determine the prevalence of pulp stones by using CBCT and to explore any potential correlation between the occurrences of pulp stones with age, gender, tooth involved, and tooth status. The observations of this study will provide the dentists with knowledge regarding the arch, gender, types of the teeth, and their condition which are more likely to susceptible for the formation of pulp stones so that they can carry out necessary modifications in routine treatment protocol in managing such teeth.
| Materials and Methods|| |
This retrospective observational study analyzed CBCT scans taken between January 2015 to December 2016 in the database of the College of Dentistry, Aljouf University, Kingdom of Saudi Arabia, after obtaining ethical clearance (JU/COD/16-22). CBCT scans of the patients from January 2015 to December 2016 available in the institution database were analyzed. All the CBCT scans were taken for various needs of the patients. A total of 428 randomly selected scans of patients with a mean age 52.8 ± 11.32 years comprising of 2982 teeth were incorporated in the study sample. A total of 236 male and 192 female participants, aged 18 years and above, were included in this study and the teeth which have undergone root canal therapy and with resorbed roots were excluded from the study.
The sample size was calculated using the formula n = Z 2 P(1–P)/d 2, where, n represents the sample size required, Z stands for the standard normal deviate (1 – equals the desired confidence level, e.g., 95%), Pis the estimated proportion in the present population, and d is the desired level of precision (corresponding to effect size).
The CBCT unit used in this study was Scanora 3D; Soredex, Tuusula, Finland, with 6 mA and 89 kVp, and the evaluation of the scans was carried out with the dedicated software (NewTom 3G: NNT, QR SRL; Scanora 3D: OnDemand ®, Cypermed Inc., Irvine, CA). The images were optimized by adjusting contrast and brightness with the aid of processing tool for better viewing. All teeth were analyzed in sagittal, axial, and coronal plains by two qualified and experienced observers. In order to check the intraobserver variations, the same examiners repeated measurements after 14 days.
The pulp stones were identified as the presence of a definite round or oval opaque or dense mass in the pulp cavity [Figure 1]. The location of involved tooth in terms of jaw and side and the status of involved tooth in terms of caries, restored, attrition, and periodontal disease were recorded from the CBCT scans. The obtained data were statistically analyzed using SPSS version 21.0 (IBM SPSS, Chicago, IL, USA) by applying Chi-square tests with the Yates correction. The reliability of measurements was evaluated by kappa statistics.
|Figure 1: Saggital cbct section of first and second molars (a) coronal cbct section of first molar (b), and saggital cbct section of third molar (c) showing pulp stones|
Click here to view
| Results|| |
The reliability was very good, with Kappa values of 0.93 for intraoperator agreement and of 0.82 for interoperator agreement. Out of a total of 428 individuals, pulp stones were identified in 50.93% of patients and 13.34% of teeth. In 236 males, 58.90% were having pulp stones and 41.15% were without pulp stones as compared to 192 females, 41.10% with pulp stones and 58.85% without pulp stones. The association between gender and status of pulp stones is found to be statistically significant (Chi-square = 13.3512, P = 0.0001) [Table 1]. A maximum of 62.92% of individuals belonging to 49–58 years of age groups and a minimum of 38.98% of individuals belonging to 19–28 years of age group were identified with pulp stones as compared to other age groups. The association is between the age groups and occurrence of pulp stone was found to be statistically significant (Chi-square = 10.0622 P = 0.0391) [Table 2].
|Table 1: Comparison of the presence and absence of pulp stones according to gender|
Click here to view
|Table 2: The distribution of the presence and absence of pulp stones by different age groups|
Click here to view
Comparison of the presence and absence of pulp stones according to arch and side is represented in [Table 3]. We observed no significant difference when maxillary and mandibular arches and the sides were compared.
|Table 3: Comparison of the presence and absence of pulp stones according to arch and side|
Click here to view
Out of 398 (13.34%) teeth with pulp stones, a maximum of 112 (26.29%) were seen in teeth with attrition and a minimum of 44 (3.25%) in intact tooth followed by 91 (22.46%) in carious, 79 (20.51%) in restored, and 72 (17.34%) in periodontally involved teeth. A significant association was observed between the existence of pulp stone and nonintact teeth (P< 0.05) [Table 4]. From [Table 5], it can be seen that 30.65% individuals were having pulp stones in maxillary first molars compared to the 30.52% individuals with pulp stones in mandibular first molars. This difference was statistically significant at 5% level of significance (Chi-square = 6.7338, 0.0090). Further, no statistical association was observed between arches and other tooth types at 5% level of significance.
|Table 5: Comparison between the presence and absence of pulp stones according to type of tooth and jaw|
Click here to view
| Discussion|| |
CBCT is a recent diagnostic tool that has been found to be a valuable imaging modality in modern dental practice as it overcomes many of the limitations of conventional radiographs by providing accurate anatomical details in different planar views for diagnosis and treatment planning. The major advantages of CBCT are specificity, accuracy, high resolution, and three-dimensional imaging without superimposition. Considering these benefits of CBCT and its gaining popularity in the dental speciality, the clinical analysis of pulp stones using CBCT seems imminent.
Pulp stones are routinely observed on conventional or digital intraoral and extraoral radiographs such as periapical, bitewing, and panoramic radiographs but only when the dimension of the stones exceeds 200 μm. The prevalence of pulpal calcifications reported to vary from 8% to 90%, and the prevalence of pulp stones observed on radiographic examinations has been reported to be 20%–25% whereas histologic studies reported enhanced prevalence of pulp stones. Histological evaluation has been recognized as a reliable mode of detecting pulp stones and can demonstrate substantially higher number of pulp stones. This methodology has the limitation because of its invasive nature, and it has been mentioned that pulp stones cannot be detected when restricted sections are prepared through each samples.
In the present study, pulp stones were observed in 50.93% of patients and 13.34% of teeth which does not match with the previous similar studies carried out using CBCT. da Silva et al. detected pulp stones in 31.9% of patients and 9.5% of teeth which was less when compared to the results our study, whereas a higher prevalence was observed by Rodrigues et al., who noticed 55% of patients as having pulp stones. Both these studies were carried out employing CBCT in Brazilian population. Kannan et al. reported that pulp stones were noted on periapical radiographs in 51% of the patients and 22% of the teeth studied, and they found no significant correlation between Malay, Chinese, and Indians; this observation was more when compared to the Saudi Arabian population of this study. In comparison to the present study, Al-Naznan and Al-Shammary observed a lower prevalence of pulp stones (10.2%) of teeth of a Saudi Arabian population, using bitewing radiographs. A higher prevalence was observed in Jordanian population compared to our study by Hamasha and Darwazeh; they noted the prevalence in 51% of the patients and 22% of the teeth in Jordanians, and Ranjitkar et al. reported prevalence in 46% of the individuals and 10% of the teeth in Australians, which was lower in contrast to the results of the present study. The comparison of our results with other studies which were carried among different population using different techniques has been provided in [Table 6].
|Table 6: Comparison of results of the present study with the previous studies|
Click here to view
In the present study, the teeth which have undergone root canal therapy and with resorbed roots were not included as the detection of pulp stones in these teeth may not be distinct.
The findings of the present study may be different from those reported in the literature previously. This disparity may be attributed to various factors such as methodology employed, age ethnicity, and size of samples studied.
The prevalence of pulp stones in our sample was more frequently encountered in males (58.89%) than in females (41.14%). In accordance to this, Hamasha and Darwazeh  and Baghdady et al. observed more number of pulp stones in males in comparison to females. In contrast to our findings, most of the studies in the literature report an increased prevalence of pulp stones in females when compared to males.,,,, However, some of the studies observed no significant differences between male and female gender.,,
The highest prevalence of pulp stones was observed in patients in their fifth decade; this observation was consistent with Kannan et al. whereas Rodrigues et al. noted increased prevalence in a younger age group (31–40 years). Similarly, Al-Naznan and Al-Shammary observed increased occurrence of pulp stones in patients over 55 years of age. Hamasha and Darwazeh  and Turkal et al. reported no correlation between age and occurrence of pup stones.
In the present study, no significant difference was observed when maxillary and mandibular arches and the sides were compared. These findings were in accordance with da Silva et al., Kannan et al., and Hamasha and Darwazeh. In contrast to this, studies in the literature reported difference in the occurrence of pulp stones with respect to jaws and sides.,,,, In this study, more numbers of pulp stones were seen in molars, and this may be attributed to the fact that these are the largest teeth in the jaw with better blood supply to the pulp and have the maximum chewing force contributing to enhanced precipitation for calcification.
In the present study, the existence of pulp stones was high in carious, restored, attrited teeth and teeth with periodontal disease, when compared to the intact teeth. This observation was consistent with the findings of other studies reported in the literature.,, The reason for this has been attributed to chronic irritation to pulp tissue because of exposure to long-standing irritants. In contrast to this, Tamse et al., Baghdady et al., Ravanshad et al., and Gulashi et al. observed no significant difference between prevalence of pulp stones due to caries, intact, or restored teeth. Because of the relatively limited sample size, the prevalence of the pulp stones in the present may not be a representative for the overall population of Saudi Arabia, and further multicenter studies need to be carried out with more number of samples.
| Conclusion|| |
The prevalence of pulp stones was observed in 50.93% of patients and 13.34% of teeth. Pulp stones were observed more frequently in molars and in nonintact teeth. Pulp stones occurred predominantly in males in comparison with females in the fifth decade of life, irrespective of arch and side of tooth involved. These observations were in agreement with some of the previous studies on the subject. The characteristics of pulp stones observed in the present study may provide additional knowledge about the dental morphological features of Saudi Arabian population
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Sener S, Cobankara FK, Akgünlü F. Calcifications of the pulp chamber: Prevalence and implicated factors. Clin Oral Investig 2009;13:209-15.
Kaswan S, Patil S, Maheshwari S, Rahman F, Khandelwal S. The relationship between pulp calcifications and salivary gland calcifications. J Clin Exp Dent 2014;6:e474-8.
Goga R, Chandler NP, Oginni AO. Pulp stones: A review. Int Endod J 2008;41:457-68.
Edds AC, Walden JE, Scheetz JP, Goldsmith LJ, Drisko CL, Eleazer PD, et al.
Pilot study of correlation of pulp stones with cardiovascular disease. J Endod 2005;31:504-6.
Kansu O, Ozbek M, Avcu N, Aslan U, Kansu H, Gençtoy G, et al.
Can dental pulp calcification serve as a diagnostic marker for carotid artery calcification in patients with renal diseases? Dentomaxillofac Radiol 2009;38:542-5.
Nayak M, Kumar J, Prasad LK. A radiographic correlation between systemic disorders and pulp stones. Indian J Dent Res 2010;21:369-73.
] [Full text]
Patil S, Sinha N. Pulp stone, haemodialysis, end-stage renal disease, carotid atherosclerosis. J Clin Diagn Res 2013;7:1228-31.
Jain P, Patni P, Hiremath H, Jain N. Successful removal of a 16 mm long pulp stone using ultrasonic tips from maxillary left first molar and its endodontic management. J Conserv Dent 2014;17:92-5.
] [Full text]
Sayegh FS, Reed AJ. Calcification in the dental pulp. Oral Surg Oral Med Oral Pathol 1968;25:873-82.
Rodrigues V, Scamardi I, Schacht Junior CF, Bortolotto M, Manhães Junior LR, Tomazinho LF, et al
. Prevalence of pulp stones in cone beam computed tomography. Dental Press Endod 2014;4:57-62.
da Silva EJ, Prado MC, Queiroz PM, Nejaim Y, Brasil DM, Groppo FC, et al
. Assessing pulp stones by cone-beam computed tomography. Clin Oral Invest 2016;21:2327-33.
Al-Nazhan S, Al-Shamrani S. A radiographic assessment of the prevalence of pulp stones in Saudi adults. Saudi Endod J 2011;1:19-26. [Full text]
Kannan S, Kannepady SK, Muthu K, Jeevan MB, Thapasum A. Radiographic assessment of the prevalence of pulp stones in Malaysians. J Endod 2015;41:333-7.
Al-Hadi Hamasha A, Darwazeh A. Prevalence of pulp stones in Jordanian adults. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:730-2.
Ranjitkar S, Taylor JA, Townsend GC. A radiographic assessment of the prevalence of pulp stones in Australians. Aust Dent J 2002;47:36-40.
Tamse A, Kaffe I, Littner MM, Shani R. Statistical evaluation of radiologic survey of pulp stones. J Endod 1982;8:455-8.
Yaacob HB, Hamid JA. Pulpal calcifications in primary teeth: A light microscope study. J Pedod 1986;10:254-64.
Baghdady VS, Ghose LJ, Nahoom HY. Prevalence of pulp stones in a teenage Iraqi group. J Endod 1988;14:309-11.
Arys A, Philippart C, Dourov N. Microradiography and light microscopy of mineralization in the pulp of undemineralized human primary molars. J Oral Pathol Med 1993;22:49-53.
Hillmann G, Geurtsen W. Light-microscopical investigation of the distribution of extracellular matrix molecules and calcifications in human dental pulps of various ages. Cell Tissue Res 1997;289:145-54.
Chandler NP, Pitt Ford TR, Monteith BD. Coronal pulp size in molars: A study of bitewing radiographs. Int Endod J 2003;36:757-63.
Çolak H, Çelebi AA, Hamidi MM, Bayraktar Y, Çolak T, Uzgur R, et al.
Assessment of the prevalence of pulp stones in a sample of Turkish central Anatolian population. Sci World J 2012;2012:804278.
Turkal M, Tan E, Uzgur R, Hamidi M, Colak H, Uzgur Z, et al.
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.
] [Full text]
Ravanshad S, Khayat S, Freidonpour N. The prevalence of pulp stones in adult patients of Shiraz dental school, a radiographic assessment. J Dent (Shiraz) 2015;16:356-61.
Sandeepa NC, Ajmal M, Deepika N. A retrospective panoramic radiographic study on prevalence of pulp stones in South Karnataka population. World J Dent 2016;7:14-7.
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.
Gulsahi A, Cebeci AI, Ozden S. A radiographic assessment of the prevalence of pulp stones in a group of Turkish dental patients. Int Endod J 2009;42:735-9.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]