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Year : 2020  |  Volume : 11  |  Issue : 1  |  Page : 46-49

Dens evaginatus: A diagnostic dilemma

1 Department of Oral Medicine, Diagnosis and Radiology, SGRD Institute of Dental Science and Research, Amritsar, Punjab, India
2 Prosthodontics and Crown and Bridge and Implantology, SGRD Institute of Dental Science and Research, Amritsar, Punjab, India
3 Ex Intern, SGRD Institute of Dental Science and Research, Amritsar, Punjab, India

Date of Submission25-Nov-2019
Date of Acceptance23-Jan-2020
Date of Web Publication11-Mar-2020

Correspondence Address:
Dr. Preeti Chawla Arora
Department of Oral Medicine, Diagnosis and Radiology, SGRD Institute of Dental Science and Research, GT Road, Mall Mandi, Amritsar - 143 006, Punjab
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/srmjrds.srmjrds_84_19

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Dens evaginatus (DE) is a developmental disturbance that clinically appears as an accessory occlusal tuberculated cusp composed of enamel and dentin, enclosing a thin pulp tissue. It mainly involves the mandibular premolars. These cusp-like protrusions are susceptible to wear and fractures with subsequent pulp exposure leading to pulpal necrosis. In most cases, DE is discovered due to periapical inflammation in the absence of obvious clinical presentation of caries, trauma, or other pathologies, thus making it a diagnostic challenge. A case of nonvital tooth with an obscured DE in an 18-year-old male is reported here with a review of literature.

Keywords: Dens evaginatus, dental anomaly, immature apex, leong's premolar

How to cite this article:
Arora PC, Arora A, Kalair T, Kharbanda SK. Dens evaginatus: A diagnostic dilemma. SRM J Res Dent Sci 2020;11:46-9

How to cite this URL:
Arora PC, Arora A, Kalair T, Kharbanda SK. Dens evaginatus: A diagnostic dilemma. SRM J Res Dent Sci [serial online] 2020 [cited 2023 May 28];11:46-9. Available from:

  Introduction Top

Dens evaginatus (DE) is a rare dental anomaly which appears as a projection above the tooth surface. It has an enamel covering a dentinal core that contains a slender pulp horn, extending various distances up to the full length of the tubercle.[1] When DE is seen in the anterior teeth involving the lingual or labial aspect of incisors, it is called Talon cusp.[2]

DE is caused by a defect in morphodifferentiation, and its etiology remains undetermined. A multifactorial etiology involving both genetic and environmental factors has been suggested.[3] This anomaly could be possibly from pressure exerted upon the developing tooth bud from trauma.

DE can be seen in both primary and mostly in permanent teeth. Early detection is important to avoid pulpal complications and periapical inflammation. Frequently, it goes unnoticed and is discovered late when pulpitis and periapical pathology occur. The aim of this article is to report a case of a nonvital tooth with abscess formation with an obscured DE, which presented as a diagnostic dilemma.

  Case Report Top

An 18-year-old male reported with intermittent pain in the lower right posterior region of the jaw for 6 months. It was also associated with swelling for 4 days and intraoral pus discharge. The patient did not have a history of any trauma, systemic illness, or drug allergies. Family history was also negative regarding the occurrence of facial swelling associated with dental pain.

Clinical examination revealed facial asymmetry and diffuse swelling on the right side of the face. [Figure 1]. There was no clinical evidence of caries or discoloration in the lower right posterior teeth. Intraorally, there was presence of a sinus in 44 and 45 regions and slight tenderness on percussion in 45 [Figure 2]. There was absence of local factors and periodontitis. Temporomandibular joint examination revealed no abnormality, and there was no trismus present. A provisional diagnosis of chronic periapical abscess in 45 with sinus formation was made. Intraoral periapical radiograph revealed a periapical radiolucency with open apex in 45, however, no radiographic evidence of caries was noticed in 45 [Figure 3]. Panoramic radiograph showed similar findings in 45 [Figure 4]. In addition, 12 showed the presence of infolding of the enamel suggestive of dens invaginatus. A well-defined radiopacity irregular in shape, with density like that of enamel and dentin, was present at the apex of 35, suggestive of compound odontome.
Figure 1: Extraoral image showing swelling on the right side of the face

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Figure 2: Intraoral image showing worn-out dens evaginatus in the lower right second premolar

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Figure 3: Radiograph showing periapical abscess in relation to lower second premolar on the right side

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Figure 4: Panoramic radiograph showing periapical abscess in relation to lower second premolar on the right side and odontome in periapical region of the lower left second premolar

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Thorough clinical examination was done to reveal the etiology of the periapical lesion. Presence of a worn-out area on the occlusal aspect of 45 was correlated radiographically. A final diagnosis of DE with periapical pathology was made.

  Discussion Top

DE has been variously described as an abnormal tubercle, protuberance, excrescence, extrusion, or bulge. It was first described by Mitchell in a human tooth in 1892.[4] The term DE was first recommended by Oehlers in 1967.[5] It has also been described as evaginated odontome, occlusal enamel pearl, dilated odontome, tuberculum dentis, odontome of the axial core type, occlusal anomalous tubercle, and occlusal pearl.[6]

It is most predominant in mandibular premolars. M.O. Leong first drew the attention of this entity in a meeting of Malaysian Dental Association in 1946, hence the name.[7] It occurs five times more in mandible than maxilla and affects females more than males with a high frequency in Asians than people of European descent. The prevalence of DE has been reported as 0.5%–4.3%.[3] A higher incidence is reported in Eskimos, North American Indians, and Asians.[3],[8] In our case, the patient was of North Indian origin, with a reported prevalence of 7.7%. The reported prevalence of DE in population is given in [Table 1].
Table 1: Prevalence of dens evaginatus in various populations

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DE has been reported in association with other developmental anomalies such as shovel-shaped incisors, mesiodens, dens invaginatus, and root anomalies, suggesting a genetic inherited component.[3] In our case, there was presence of multiple dental anomalies in the same patient namely DE in mandibular premolar, dens invaginatus in maxillary right lateral incisor, and odontome in the periapical region of the left premolar.


Schulge (1987)[3] has classified DE into five types based on the location of the tubercle in posterior teeth, as follows:

  • Type 1: Cone-like enlargement of the lingual cusp
  • Type 2: Tubercle on the inclined plane of the lingual cusp
  • Type 3: Cone-like enlargement of the buccal cusp
  • Type 4: Tubercle on the inclined plane of the buccal cusp
  • Type 5: Tubercle arising from the occlusal surface obliterating the central groove.

Based on the pulp content within tubercle, Oehlers has classified DE as wide, narrow, constricted, isolated pulp horn, and no pulp horn.[5]

Lau has also classified DE into smooth, grooved, terraced, and ridged.[9]

Clinical significance

It is difficult to maintain a clean area between the nodules, predisposing to caries. DE often causes occlusal interference and is abraded as soon as the tooth comes into occlusion, leading to a nonvital tooth even before root completion. It usually goes unnoticed and is often discovered as a nonvital tooth with an immature root apex. Nearly 14.1%–40.2% of DE are known to exhibit periapical lesions.[8] At this stage of immature pulps, pulp tests are unreliable, leading to delayed diagnosis. Periapical pathology secondary to DE which occurs prematurely even before root completion may resemble a developing dental follicle radiographically. This further adds to the diagnostic dilemma. The absence of an obvious etiology such as caries, trauma, or pathological alterations such as attrition, abrasion, or erosion obscures the detection of this pathology. The most important clinical finding leading to diagnosis is the presence of a small, elevated flat wear facet at the occlusal surface. DE is typically diagnosed when a patient reports with pulpal necrosis, and careful examination may reveal the presence of a worn-out occlusal tubercle, as was observed in our case. Alternatively, the tubercle may be progressively worn down, showing no symptoms.

It can also be associated with compromised esthetics and occlusal interference, leading to accidental cuspal fracture and TMJ problems.[9] A case of DE with complication of osteomyelitis has been reported by Allwright.[10]

Radiographic features

DE is visible as a radiopaque structure composed of enamel and dentin and occasionally with a pulpal extension. The occlusal surface has a tuberculated appearance, often worn out. It may be seen incidentally on a radiograph even before tooth eruption and root completion.

Differential diagnosis

Early pulpal infection leading to nonvitality of the tooth in DE may be misdiagnosed as pulpitis due to trauma. Vitamin D-resistant rickets is also associated with draining periapical abscesses and large pulp horns extending into cusp tips. Giant cell granulomas in hyperparathyroidism may present radiographically as multiple periapical radiolucencies.

Morphological variants such as talon's cusp, Bolk's cusp, and cusp of Carabelli may be included in the differential diagnosis of DE.[11] Talon's cusp appears as a projection on the lingual aspect of the anterior teeth, resembling an eagle's talon. Bolk's cusp is a dental anomaly that affects premolars and molars and is characterized by supernumerary tubercle or cusp on the buccal aspect of the tooth. Cusp of Carabelli is a supplemental cusp present in maxillary molars and without pulpal tissue.


Treatment depends on the stage of diagnosis of DE. If the tooth with DE has a mature apex, then the opposing tooth is reduced up to 0.5 mm to eliminate traumatic occlusion with the tubercle, followed by application of topical fluoride and 0.25 mm of protective resin. Root canal therapy should be performed if pulp exposure of a tooth with mature apex occurs. Re-evaluation at 6-month intervals and yearly radiographic evaluation is suggested. In case the tooth has been diagnosed with DE with an immature apex, then repeated monitoring is required every 3–4 months. In immature apex, placement of mineral trioxide aggregate should be done to allow complete root development.

In our case, the patient was suggested root canal treatment and follow-up for the same. However, the patient was lost to follow-up after the initiation of treatment.

  Conclusion Top

Dental surgeons should be cognizant of this anomaly so that delayed diagnosis and further complications associated with it can be avoided. DE should be suspected if a nonvital tooth, especially mandibular premolar, presents without an obvious pathology. Careful examination may reveal the presence of the worn-away tubercle of the associated tooth.

Declaration of patient consent

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

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Neville B, Damm D, Allen C, Bouquot J. Oral and Maxillofacial Pathology. 2nd ed. Philadelphia: WB Saunders; 2002. p. 77-9.  Back to cited text no. 1
Mellor JK, Ripa LW. Talon cusp: A clinically significant anomaly. Oral Surg Oral Med Oral Pathol 1970;29:225-8.  Back to cited text no. 2
Kocsis G, Marcsik A, Kokai E, Kocsis K. Supernumerary occlusal cusps on permanent human teeth. Acta Biol Szeged 2002;46:71-82.  Back to cited text no. 3
Mitchell W. Case report. Dent Cosmos 1892;34:1036.  Back to cited text no. 4
Oehlers FA, Lee KW, Lee EC. Dens evaginatus (evaginated odontome). Its structure and responses to external stimuli. Dent Pract Dent Rec 1967;17:239-44.  Back to cited text no. 5
Sharma A. Dens evaginatus of anterior teeth (talon cusp) associated with other odontogenic anomalies. J Indian Soc Pedod Prev Dent 2006;24 Suppl 1:S41-3.  Back to cited text no. 6
Chakravarthy PV, Telang A. Management of an innocuous looking dens evaginatus. J Dent Sci 2013;1:5-7.  Back to cited text no. 7
Hamasha AA, Safadi RA. Prevalence of talon cusps in Jordanian permanent teeth: A radiographic study. BMC Oral Health 2010;10:6.  Back to cited text no. 8
Cho S, Ki Y, Chu WY. Management of dens evaginatus: A case report. Hong Kong Dent J 2006;3:45-7.  Back to cited text no. 9
Allwright WC. Odontomes of the axial core type as a cause of osteomyelitis of the mandible. Br Dent J 1958;104:363-5.  Back to cited text no. 10
Rao YG, Guo LY, Tao HT. Multiple dens evaginatus of premolars and molars in Chinese dentition: A case report and literature review. Int J Oral Sci 2010;2:177-80.  Back to cited text no. 11


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

  [Table 1]

This article has been cited by
1 A Novel Presentation of Submerged Supernumeraries as Bilateral Dens Evaginatus Using Cone-beam Computed Tomography
Sumit Munjal,Seema Munjal
Journal of South Asian Association of Pediatric Dentistry. 2021; 4(2): 138
[Pubmed] | [DOI]


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