|Year : 2022 | Volume
| Issue : 4 | Page : 163-167
Prevalence of pulp stones using digital panoramic radiograph: A preliminary retrospective study
Jawahar Indrapriyadharshini1, Ayyapan Narendira Sharma1, Ramanathan Vineeth1, Mouttoukichenin Surenthar1, Satyanarayanan Mohanapriya2, Subramanian Vasudevan Srinivasan1
1 Department of Oral Medicine and Radiology, Mahatma Gandhi Postgraduate Institute of Dental Sciences Pondicherry, India
2 Undergraduate, Mahatma Gandhi Postgraduate Institute of Dental Sciences Pondicherry, Puducherry (U.T), India
|Date of Submission||23-Aug-2022|
|Date of Decision||27-Oct-2022|
|Date of Acceptance||29-Oct-2022|
|Date of Web Publication||15-Dec-2022|
Dr. Jawahar Indrapriyadharshini
Department of Oral Medicine and Radiology, Mahatma Gandhi Postgraduate Institute of Dental Sciences, Puducherry
Source of Support: None, Conflict of Interest: None
Background: Isolated calcified masses found in the pulpal space of teeth are called pulp stones (PS). Different populations demonstrate a varied prevalence of PS. Aim: The aim of this preliminary study was to evaluate the prevalence of PS in the Pondicherry population, along with its relationships with gender, age, tooth type, and location using digital panoramic radiographs. Materials and Methods: One hundred good-quality digital panoramic radiographs of healthy individuals between 18 and 70 years were selected from the records of the Department of Oral Medicine and Radiology. PS were recognized as well-defined dense radiopaque masses in the intrapulpal space. Two examiners independently analyzed the radiographs for the presence of PS. Results: Out of 100 radiographs, PS were found in 54 radiographs. Males showed a higher incidence (57.4%) than females (42.6%). Furthermore, patients between 20 and 35 years showed a greater prevalence (64.81%) and the incidence was higher in the maxillary arch (70%) than the mandibular arch (30%) with the right side being more frequent. In addition, first molars showed a greater overall prevalence. Conclusion: It was found that the prevalence of PS was 54%. Digital panoramic radiographs can be used as a preliminary investigative technique for the identification of PS.
Keywords: Digital panoramic radiographs, Pondicherry population, prevalence, pulp stones
|How to cite this article:|
Indrapriyadharshini J, Sharma AN, Vineeth R, Surenthar M, Mohanapriya S, Srinivasan SV. Prevalence of pulp stones using digital panoramic radiograph: A preliminary retrospective study. SRM J Res Dent Sci 2022;13:163-7
|How to cite this URL:|
Indrapriyadharshini J, Sharma AN, Vineeth R, Surenthar M, Mohanapriya S, Srinivasan SV. Prevalence of pulp stones using digital panoramic radiograph: A preliminary retrospective study. SRM J Res Dent Sci [serial online] 2022 [cited 2023 Feb 7];13:163-7. Available from: https://www.srmjrds.in/text.asp?2022/13/4/163/363794
| Introduction|| |
Pulp stones (PS), also known as denticles, are discrete calcified masses found within coronal and/or radicular pulps of both primary and permanent teeth. They may affect a single tooth or multiple teeth, and they can be found in healthy, carious, and sometimes even in teeth that are unerupted. The size of PS ranges from tiny microscopic particles to enormous masses that nearly fill the pulp chamber. Individual differences and tooth type can affect the shape, size, and frequency of PS in a tooth. Based on the location, PS may be present either freely or adhered to or embedded in dentin within the pulp tissue. According to their structural makeup, PS can either be true, made of normal tubular dentine and bordered by odontoblasts, or false, produced from degenerating pulp cells that get mineralized. Collagen fibrils, ground substances, and necrotic cell remnants are presumed to form a core nidus around which PS form.
PS has an unknown etiology. The risk of developing PS is influenced by a number of risk factors, including genetic predisposition, orthodontic therapy, circulatory vasculature changes in pulp, age, idiopathic causes, chronic inflammation, long-term irritants like caries and deep restorations, and Van der Woude syndrome. PS prevalence ranges from 8% to 90% among different populations. Varied incidence of PS in different populations warrants a population-specific evaluation. As far as we are aware, the population of Pondicherry has not been included in any published studies on the prevalence of PS. Small calcified masses <200 μm are not detected easily in radiographs causing an underestimation in their incidence. The more realistic and precise images produced by digital imaging methods, such as periapical, panoramic radiography, and cone-beam computed tomography (CBCT), can be utilized to detect PS. PS development was found to be more likely in patients with systemic illnesses such as cardiovascular disease and diabetes mellitus. It is also established that conditions such as hypercalcemia, gout, cholelithiasis, and renal lithiasis predispose to pulpal calcification.,
Digital orthopantomography (OPG) is catering to the needs of mass screening considering its availability, accessibility, and cost-effectiveness and hence can be considered a screening tool for detecting PS before CBCT evaluation. Furthermore, identifying PS is crucial for successful endodontic outcomes helping endodontists to be well equipped for their removal with the modified techniques accordingly. Thus, by employing digital panoramic radiographs, this preliminary study intended to determine the prevalence of PS and correlate its relationship with gender, age, tooth type, and location.
| Materials and Methods|| |
The study was designed as a single-centered retrospective radiographic study.
One hundred digital panoramic radiographs were retrieved from the archives of the Department of Oral Medicine and Radiology. The radiographs were obtained using PROMAX Digital Planmeca Machine (Planmeca OY, 00880 Helsinki, Finland) with exposure parameters of 68–74 kVp and 8–10 mA for 15.8–16 s taken between September 2021 and November 2021.
The institutional research committee and ethical committee board approved the study on October 18, 2021, and October 25, 2021, respectively, and the ethical approval number is 290/MGPGI/Aca-I/2022-23/2050. All procedures performed in the study were conducted in accordance with the ethical standards given in 1964 Declaration of Helsinki, as revised in 2013.
The inclusion criteria included good-quality radiographs of healthy patients without systemic diseases belonging to 18–70 years, radiographs with optimal image characteristics without undue magnification or distortion, and radiographs with full complement of teeth up to the second molar. The exclusion criteria included endodontically treated teeth, grossly destructed teeth, and teeth having crown or bridge causing difficulty in proper evaluation of pulp and third molars.
When the power of the study was kept at 95%, a sample size of 79 was obtained by G*Power software. The study size was increased to 100 such that the standard error of the distribution is reduced. One hundred digital panoramic radiographs that fulfilled the inclusion criteria were chosen, a record of 250 radiographs taken between September 2021 and November 2021. Interpretation of radiographs was done independently by two examiners trained in radiology. If a distinct mass of opacity was seen in the pulpal area, as shown in [Figure 1], it was scored as present and the tooth was considered to have a PS. Gender, age, tooth type, and dental arch were noted for each radiograph.
|Figure 1: Digital panoramic radiograph and cropped view of digital panoramic radiograph showing pulp stones. Black rectangle represents the area cropped and yellow arrows represent the pulp stones|
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Stats for Windows version 14.2 was used for the statistical analysis. Based on normality, continuous variables were summed up as mean (standard deviation) and median (interquartile range). Frequency and proportions were used to summarize categorical variables. The frequency and proportions of PS prevalence were shown with a 95% confidence interval. The Chi-square test was used to evaluate the relationship between the independent variables and the result variables. P value of 0.05 or lower was regarded as statistically significant.
| Results|| |
Out of 100 radiographs, 53 belonged to male patients and 47 to female patients. Of the 100 radiographs, 15 radiographs belonged to individuals between the ages of 18 and 20 years, 48 to individuals between the ages of 21 and 30 years, 20 to individuals between the ages of 31 and 40 years, 11 to individuals between the ages of 41 and 50 years, and 6 to those between the ages of 51 and 70 years. The average age of the total sample was 28.82 years. PS were present in 54 (54%) of the 100 radiographs, of which 31 (57.4%) belonged to men and 23 (42.6%) to women. This distribution is depicted in [Figure 2] and the p value = 0.54. Out of the total 54 radiographs with PS, 35 radiographs were of individuals in the age group 20–35 years (64.81%), 16 radiographs were from 36 to 50 years (29.63%), and 3 radiographs were from 51 to 70 years (5.56%) as shown in [Figure 3] and the p value = 0.96.
|Figure 2: Distribution of pulp stones in males and females and their prevalence|
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|Figure 3: Distribution of pulp stones among different age groups and their prevalence|
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There were 127 PS in total. As shown in [Table 1], 30% were found in the mandibular arch and 70% in the maxillary arch and the p value= 0.12. Thirty-five percent of the radiographs had PS in more than one tooth. In the maxilla, the total number of PS was 89, out of which 32.5% were prevalent in the right maxillary first molar followed by the left maxillary first molar (31.4%) as shown in [Table 2]. The mandible had a total of 38 PS, of which 39.47% were found in the first molars of the right and left mandibles, as shown in [Table 2].
|Table 1: Distribution of pulp stones in maxilla and mandible and their prevalence|
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|Table 2: Distribution of pulp stones in maxillary and mandibular dentition and their prevalence|
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| Discussion|| |
The prevalence of PS was 54% in this study, which was in accordance with studies done by Jayam and Srivastava in 2017 in Tirupati, Andhra Pradesh population (51.4%), Tassoker et al. in 2018 in Turkey population (52.0%), and Chen et al. in 2021 in Taiwan population (58%). Few other studies reported a lower prevalence rate as in the study done by Kalaji et al. in 2017 in the Yemeni Population (18.6%) and by Turkal et al. among Malaysians (12.7%). Therefore, it is possible that the occurrence of PS varies among the various populations even on the same continent, necessitating further studies in their specific population to enable the endodontist to be well equipped to face the procedural difficulties during root canal treatment.
We found that PS was slightly high in males and this was consistent with some studies by SR Patil et al., al-Hadi Hamasha and Darwazeh, and Baghdady et al. This could be possibly due to the increased incidence of trauma, pulp degeneration, and greater grinding forces among men. Our study was in discordance with studies done by Chen et al., Tassoker et al., Raviraj et al., Kannan et al., Yousuf and Selvanayagam, Turkal et al., Kalanji et al., Ravanshad et al., Alaajam et al., and Bains et al., which found that women experience a higher prevalence of PS, which can be ascribed to the greater prevalence of bruxism in women leading to chronic irritation, suggesting that there is no marked or definitive gender predilection.
Contradicting the established fact that the prevalence of PS increases with increasing age, we found that PS was prevalent between the ages of 20 and 35 years. This result was in agreement with that of al-Hadi Hamasha and Darwazeh. This can be backed up by the fact that pulp calcifications may not simply result from aging, but other reactive responses such as stress, parafunctional habits, increased awareness of orthodontic treatment, and restorations of decayed teeth among young adults could also possibly contribute. In addition, only patients with full complement of teeth were included for analysis; hence, our sample had 83 radiographs out of 100 belonging to individuals under the age of 40 years with the average of total sample being 28.82 years.
When compared to the mandibular arch, the maxillary arch had a higher prevalence of PS, with the right maxillary first molars having the highest prevalence. This outcome was consistent with Chen et al., Yousuf and Selvanayagam, Jayam and Srivastava, Turkal et al., Kalaji et al., Ravanshad et al., Alaajam et al., and Bains et al. This might be due to the fact that first molars are the first permanent teeth to erupt and have a larger surface area, making them more susceptible to occlusal stresses and possibly causing early degenerative alterations and an increase in PS incidence. The maxillary first molar is also the largest tooth in the maxillary arch, with a large pulp chamber volume, superior load-bearing ability due to the presence of three roots, and a better blood supply, all of which may play a role in the circumstances that favor calcifications.
The advantages of the study are that the digital panoramic radiograph displays the entire maxillary and mandibular dentition in a single image compared to intraoral periapical radiographs, thus reducing patient dose and allows a magnified view of the region of interest, unlike conventional OPG. It is critical at government institutions that serve the masses, to maximise the services using available resources. The fact that OPG is affordable and accessible in most outpatient sectors is an additional advantage to the study. The limitation of this study are the small sample size, relatively lower resolution of digital panoramic radiographs compared to intraoral periapical radiographs, and the fact that only two-dimensional information of PS was obtained from the images compared to CBCT. Knowing the prevalence and degree of expression of PS can help us understand the differences, if any, within our population and between different population groups and may aid as a potential tool in forensic odontology. Thus, in this preliminary study, the increased incidence of PS in the Pondicherry population suggests the need for longitudinal studies with larger samples.
The greater prevalence of PS in a younger population means that there are increased chances the endodontist would encounter pulp chambers with PS more frequently than earlier. Hence, an early word of caution or information to the endodontist can add to the preparedness of the endodontist. A radiographic proof of PS configuration, along with other dental records, may provide valuable information in postmortem personnel identification in forensic odontology. Furthermore, PS screening can be used to screen for systemic illnesses such as hypertension, diabetes, cardiac disorders, and renal stones, among others.
| Conclusion|| |
The prevalence of PS was 54% in the current study, which signifies that early detection of PS is essential for successful endodontic therapy. Digital panoramic radiographs are a cost-effective mass screening tool in the detection of dental pathologies and can be considered as a preliminary investigating tool for the identification of PS.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Chen G, Huang LG, Yeh PC. Detecting calcified pulp stones in patients with periodontal diseases using digital panoramic and periapical radiographies. J Dent Sci 2022;17:965-72.
Tassoker M, Magat G, Sener S. A comparative study of cone-beam computed tomography and digital panoramic radiography for detecting pulp stones. Imaging Sci Dent 2018;48:201-12.
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.
Srivastava KC, Shrivastava D, Nagarajappa AK, Khan ZA, Alzoubi IA, Mousa MA, et al.
Assessing the prevalence and association of pulp stones with cardiovascular diseases and diabetes mellitus in the Saudi Arabian population – A CBCT based study. Int J Environ Res Public Health 2020;17:9293.
Kalaji MN, Habib AA, Alwessabi M. Radiographic assessment of the prevalence of pulp stones in a Yemeni population sample. Eur Endod J 2017;2:1-6.
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.
Patil SR, Ghani HA, Almuhaiza M, Al-Zoubi IA, Anil KN, Misra N, et al.
Prevalence of pulp stones in a Saudi Arabian subpopulation: A cone-beam computed tomography study. Saudi Endod J 2018;8:93.
Yousuf M, Selvanayagam DP. Radiographic assessment of prevalence of pulp stones in South Indian population. Drug Invent Today 2018;10:3162-5.
Alaajam WH, Saleh AA, Alghamdi NS, Ain TS, Algarni YA, Abubaker M. Incidence and distribution of pulp stones among Southern Saudi Arabian sub-population. SAGE Open Medicine. 2021;9. doi:10.1177/20503121211062796.
Bains SK, Bhatia A, Singh HP, Biswal SS, Kanth S, Nalla S. Prevalence of coronal pulp stones and its relation with systemic disorders in northern Indian central Punjabi population. ISRN Dent 2014;2014:617590.
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]
Jayam R, Srivastava R. Prevalence of pulp stones – A radiographic study. International Journal of Contemporary Medicine, Surgery and Radiology 2017;2:4.
Turkal M, Tan E, Uzgur R, Hamidi M, Colak 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.
] [Full text]
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.
Baghdady VS, Ghose LJ, Nahoom HY. Prevalence of pulp stones in a teenage Iraqi group. J Endod 1988;14:309-11.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]