Overview of management of a calcified pulp chamber and canal endodontically

1. MANAGEMENT OF
CALCIFIED PULP CANAL
OGUNLADE.T

2. OUTLINE
• INTRODUCTION
• CAUSES OF PULP CALCIFICATION
• CLINICAL FEATURES
• MANAGEMENT
• CONCLUSION
• REFERENCES

3. INTRODUCTION
• Pulp calcifications stones are nodular, calcified
masses appearing in either or both the coronal or
root portions of the pulp organ
• Pulp stones are primarily a physiological
manifestation and may increase in number and/or
size due to local or systemic pathology.
• Other names; Calcific metamorphosis (CM), pulp
canal obliteration, Pulp stones

4. INTRODUCTION
• Calcification is a process involving the reduction in
size of the intra-dental cavities as a result of hard-
tissue formation by the cells of the vital pulp.
• It may ends in complete calcification as a result of
dentin deposition inside the tooth
• Stones may exist freely within the pulp tissue or be
attached to or embedded in dentine

5. INTRODUCTION
• Calcification of the dental pulp may be discrete or
diffuse in its form.
• Discrete calcification results in the formation of
pulp stones, denticles, or nodules.
• Diffuse calcification results in a symmetric
reduction in the size of the pulp chamber and the
radicular pulp space, which is more commonly
observed in older patients.

6. INTRODUCTION
• A single tooth may have from 1 to 12 or even more
stones, with sizes varying from minute particles to
large masses which occlude the pulp space
• Their large size in the pulp chamber may block
access to canal orifices and alter the internal
anatomy.
• Attached stones may deflect or engage the tip of
exploring instruments, preventing their easy
passage down the canal

7. INTRODUCTION
• Two types of calcified bodies in the dental pulp
have been described;
• Denticles possessing a central cavity filled with
epithelial remnants surrounded peripherally by
odontoblasts
• And pulp stones being compact degenerative
masses of calcified tissues

8. INTRODUCTION
• Occur more often in the coronal region but are also
found in the radicular pulp
• They have been seen in both functional as well as
embedded teeth
• Common in molars than premolars and incisors
• They have also been noted in patients with
systemic or genetic diseases such as dentine
dysplasia, dentinogenesis imperfect and in certain
syndromes such as Van der Woude syndrome

9. AGE CHANGES IN PULP
• Pulp spaces of teeth decrease in size through the
deposition of secondary and tertiary dentine.
• Increase in the number of collagenous bundles in old
coronal pulps occur
• The collagen bundles of vascular and neural sheaths of
old pulps were the loci for calcification
• As a result of calcification of the blood vessels and
nerves in the pulp, their numbers decrease
• As part of the pulp ageing process there is also a
considerable decrease in the number of cells such as
fibroblasts, odontoblasts and mesenchymal cells with
the cell density decreasing by half from 20 to 70 years
• Fat deposits occur in the pulp with age

10. CONTENT OF PULP STONES
• The stones were composed of two major elements:
• Calcium and phosphorus.
• The average concentrations were 32.1% and 14.7%,
respectively
• Other elements included fluorine (0.88%), sodium
(0.75%) and magnesium (0.51%). Potassium,
chlorine, manganese, zinc and iron in trace
concentrations.

11. TYPES PULP STONES
• Pulp stones can be structurally classified and based
on location
• Structurally, there are True and False pulp stones;
the distinction being morphological
• A third type, ‘diffuse’ or ‘amorphous’ pulp stones, is
more irregular in shape than false pulp stones,
occurring in close association with blood vessels

12. TYPES PULP STONES
• True pulp stones are made of dentine and lined by
odontoblasts
• False pulp stones are formed from degenerating
cells of the pulp that mineralize

13. TYPES PULP STONES
• Based on location, pulp stones can be embedded,
adherent and free
• Embedded stones are formed in the pulp but with
ongoing physiological dentine formation they
become enclosed (sometimes fully) within the
canal walls
• They are found most frequently in the apical
portion of the root, and the presence of
odontoblasts and calcified tissue resembling
dentine can occur on the peripheral aspect of these
stones

14. TYPES PULP STONES
• Adherent pulp stones are simply less attached to
dentine than embedded pulp stones
• The difference between adherent and embedded
can be subjective, but adherent stones are never
fully enclosed by dentine.
• Adherent and embedded pulp stones can interfere
with root canal treatment if they cause significant
occlusion of canals or are located at a curve
• They may also become dislodged

16. TYPES PULP STONES
• Free pulp stones are found within the pulp tissue
proper and are the most commonly seen type on
radiographs
• They are very common and vary in size from 50µm
in diameter to several millimetres when they may
occlude the entire pulp chamber

18. TYPES PULP STONES
• Stones can be further subdivided into those with
distinct concentric laminations and those without
distinct laminations.
• Laminated pulp stones are not usually associated with
smaller pulp stones, whereas nonlaminated stones are
rougher and may have smaller stones attached to their
surfaces
• This is in agreement with Pashley & Liewehr (2006) who
histologically recognized two types of stones: those
that are round or ovoid, with smooth surfaces and
concentric laminations
• And those that assume no particular shape, lack
laminations and have rough surfaces.

21. CAUSES
• Dental pulp calcification may occur in response to both
local as well as systemic factors.
• Local factors include caries, cavity preparation, the
presence of restorations, and excessive forces caused by
clenching and trauma
• Pulpal calcification is a common phenomenon that occurs
in young patients’ teeth following calcium hydroxide
(Ca(OH)2) pulpotomy therapy
• The increased number of calcium ions leads to the
reduction in capillary permeability, which will fail to
operate the pyrophosphatase enzyme leading to
uncontrolled mineralization

22. CAUSES
• Ca(OH)2 is characterized by its ability to induce
reparative bridge formation when applied to vital
pulpal tissues
• However, the pulp chamber and the pulp canal
entrances can be subjected to dystrophic
calcification after being exposed to Ca(OH)2 for a
long period
• It was suggested that the high alkaline pH level of
Ca(OH)2 irritates the pulp cells and activates the
release of bioactive molecules, which stimulate
pulpal repair and therefore induce mineralization

23. CAUSES
• Systemic factors include hypercalcemia, gout, and
end-stage renal diseases have also been linked with
pulp calcification

24. CAUSES
• Etiological factors for pulp stone formation are not well
understood
• Pulp degeneration
• Age
• Prolonged infection
• Non Vital tooth without Endodontic treatment for many years
• Circulatory disturbances in pulp
• Orthodontic tooth movement
• Idiopathic factors
• Genetic predisposition dentine dysplasia, Dentinogenesis
imperfect, Van derWoude syndrome

25. CLINICAL FEATURES
• Generally, pulp calcification has no symptoms and
may be noted via tooth discoloration or routine
examination
• visible yellowish discoloration due to a decrease in
tissue transparency
• Also the response to thermal stimuli and electric
pulp tests can be diminished or even absent which
may lead to difficulties to make a diagnosis

27. MANAGEMENT
• There is controversy regarding whether endodontic
treatment is indicated for teeth with pulpal
calcification
• Some authors recommend treatment only after
appearance of symptoms and radiography shows
apical bone rarefaction.
• However, others believe that immediate
endodontic treatment is indicated because pulpal
calcification may develop into an infection

28. EVALUATION
• Conventional radiographs (periapical, bitewings)
• The use of conventional radiographs often do not
give a clear picture of the actual root canal
anatomy because of its inherent limitations
• Since the conventional radiographs are the
representation of a three dimensional structure by
a two-dimensional (2D) image
• It does not provide an accurate depiction of the
internal anatomy of the root canal

29. EVALUATION
• Cone beam computer tomography (CBCT)
• This is an accurate diagnostic tool in endodontics as
it eliminates the superimposition of anatomic
structures
• Can aid in evaluating the extent and nature of
calcification, depth of calcification and can guide
the clinician to access the patent portion of the
canal
• It can reveal the internal morphology of the root
canal better

30. EVALUATION
• CBCT can be a valuable tool in the diagnosis,
treatment and prognosis of teeth with pulpal
calcification
• Despite the advantages offered by CBCT when
compared with conventional radiographs, it should
be used carefully, to gain most useful information
for diagnosis and the radiation exposure to patient
should be at the least possible level

32. EVALUATION
• With CBCT scan we can scroll through the entire
volume and simultaneously view axial, coronal, and
sagittal 2-D sections that range from 0.125–2.0 mm
thick.
• The axial and proximal areas which are generally
not seen with conventional periapical radiography
can be revealed by CBCT.

35. EVALUATION
• CBCT scanning provides an excellent imaging method to
detect differences in external and internal dental
anatomy.
• The ability to visualize the area of interest in thin
sections eliminates the superimposition of surrounding
structures, like dentin and surrounding bone to better
understand the root canal morphology

36. TREATMENT
• The various treatment approaches in teeth with pulp
calcification are as follows;
I. Wait and watch
II. Nonsurgical approach
III. Surgical approach
IV. Non-surgical followed by surgical approach
• The choice of treatment is mainly dependant on the
periapical status and canal patency of the affected teeth
• Depending on critical information revealed by CBCT clinician
can decide whether to go for a surgical or non-surgical
treatment

37. • The patients’ aesthetic requirement also plays a key role in
the choice of the treatment.
• The different options to address the aesthetic concerns of
patients associated with pulp calcification are ;
I. External bleaching
II. Endodontic treatment followed by internal bleaching
III. Internal and external bleaching without root canal
treatment
IV. Full/partial coverage restorations (crown/veneer)

38. • External bleaching is slow and less predictable due
to the nature of discoloration.
• Internal bleaching without root canal therapy has
been mentioned as a likely treatment option
• It has not gained much support due to the
possibility of secondary intraradicular infection.

39. • The difficulty in obtaining the accurate shade and
removal of intact tooth structure are the drawbacks
of extra-coronal restoration (full coverage
crowns/veneers) in masking the discoloration.
• Intra-coronal bleaching after root canal therapy not
only provides seal thus prevent secondary root
canal infection, but also removes tertiary dentin
from the pulp chamber thus contributing to the
faster action of the bleaching agent

40. TREATMENT contd
WAIT AND WATCH
• Since more than three-fourth of the teeth with pulp
canal obliteration are asymptomatic, no
therapeutic intervention is usually indicated, except
for periodic radiographic monitoring
• In the absence of any additional signs or symptoms,
pulp stones should not be interpreted as a disorder
requiring endodontic therapy

41. TREATMENT contd
NONSURGICAL APPROACH
• Teeth that are symptomatic (tender on percussion)
and/or have associated periapical lesion requires
active therapeutic intervention
• Conventional non-surgical endodontic therapy is
the treatment of choice as it is can eliminate the
foci of infection from the root canal space

42. TREATMENT contd
SURGICAL APPROACH
• In cases where the canal cannot be located, a
surgical intervention is required as it offers direct
access to the periradicular area
• This include Apicectomy, curettage or retrograde
filling.

43. TREATMENT contd
NON-SURGICAL FOLLOWED BY SURGICAL APPROACH
• In cases where there is persistence of infection
even after non-surgical treatment a surgical
approach is necessitated

44. NONSURGICAL APPROACH
• The management of teeth with obliterated pulp
chamber and calcified canals, which require root
canal treatment, is a challenging therapy

45. STAGES OF TREATMENT
• Preparation of an adequate access cavity
• Identification of the canal orifices
• Biomechanical preparation
• Obturation

46. ACCESS CAVITY PREPARATION
• After initial clinical and radiographic examination, the
quality of the coronal restoration if present should be
checked and insufficient restorations should be removed,
decayed hard tissue completely excavated
• Access cavity preparation should be performed parallel to
long axis of the tooth using diamond burs in a high-speed
contra angle hand-piece with water cooling under rubber
dam isolation
• Calcifications in the pulp chamber can be gently removed
with a round diamond-coated high-speed bur or diamond-
coated ultrasound tips

48. IDENTIFICATION OF THE CANAL
ORIFICES
• After gaining access to the pulp chamber, its roof must
be completely removed
• The pulp chamber floor must be dried by air stream
and carefully inspected in order to localise colour
changes that may indicate the way to the orifice of the
root canal.
• Locate the canal orifices
• This can be achieved with the aid of the following;
I. Dental operating microscopy (DOM)
II. Ultrasonic tips (US)
III. Dental probe

49. IDENTIFICATION OF THE CANAL
ORIFICES
• Dental operating microscopy (DOM)/endodontic
microscope offers magnification and lighting
• Ultrasonic tips allow working at greater depth within the
pulp chamber safely, with a low risk of iatrogenic injury
• In contrast to drills, it provide a more conservative
approach to conventional treatment
• US tips do not rotate inside the canal, ensuring greater
security and control while maintaining their cutting
efficiency

50. IDENTIFICATION OF THE CANAL
ORIFICES
• It help in breaking up calcifications covering the
canal opening, which allows safe access to deeper
areas, with enough safety and minimal wear, and
the identification of dental structures
• By scouting the pulp floor gently with stainless steel
hand instruments, canal orifice can be localized

51. IDENTIFICATION OF THE CANAL
ORIFICES
• However, in some situations, despite all of these
resources and the skills and expertise of the
operator, (CBCT) is necessary and allows 3D images
without overlapping adjacent structures
• This facilitates the identification of the canals, their
directions, degrees of obstruction and dimensions

53. BIOMECHANICAL PREPARATION
• This involves removal of debri from the root canal
and shaping of the canal for final obturation
• This can be achieved with the use of the following;
• Files and Reamers
• Chelating agent
• Root canal irrigants

54. CHELATING AGENTS
• Chelating agents were introduced into endodontics as an
aid for the preparation of narrow and calcified root canals
in 1957 by Nygaard-Ostby
• A liquid solution of ethylene-diamine-tetra-acetic acid
(EDTA) was thought to chemically soften the root canal
dentine and dissolve the smear layer, as well as to increase
dentine permeability
• Irrigation of the RC with 15-17% EDTA solution to dissolve
the smear layer is recommended by many authors

55. CHELATING AGENTS
• Chelators bind to and inactivate metallic ions
• Chelator preparations include the following;
• LIQUID CHELATORS
I. Calcinase contains 17% sodium edetate, sodium hydroxide as a
stabilizor and purified water
II. EDTAC and DTPAC are produced when 100 mL of EDTA (15%)
and diethyl-triamine-penta acetic acid (DTPA) at pH 8 are
added to 0.75g of the detergent Cetyl-tri-methyl ammonium
bromide (Cetrimide)
III. EDTA-T consists of 17% EDTA + sodium lauryl ether sulfate
(Tergentol) as a detergent
IV. EGTA main component is ethylene glycol bis (β-amino-
ethylether)-N.N.N’.N'-tetra acetic acid.
• It is reported to bind Ca ions more specifically than EDTA

56. CHELATING AGENTS
• PASTE-TYPE CHELATORS :Literature reports the mode of
action of liquid chelator solutions for root canal irrigation is
predominant
• The chelators recommended for use during rotary root canal
preparation must have a paste or gel consistency
I. RC-Prep 10% urea peroxide + 15% EDTA and glycol in an
aqueous ointment base
II. Glyde file Composed of 15% EDTA and 10% urea peroxide
in aqueous solution.
• Developed for use with NaOCl irrigants, because it causes
effervescence

57. CHELATING AGENTS
• When using 17% EDTA always ensure to irrigate
1.5% NaOCl used during recapitulation

58. • After cleaning and shaping of the root canal and
irrigation, dry the canal with paper points
• Obturate canals with appropriate size gutta percha
• Restore the tooth
• Postoperative radiograph

61. CONCLUSION
• Calcified Roots are an enigma in Dentistry for the
Endodontist, treating such cases is a challenge but
it sure brings in a lot of satisfaction after
completing the case successfully

62. REFERENCES
• Oginni AO, Adekoya-Sofowora CA, Kolawole KA. Evaluation of radiographs,
clinical signs and symptoms associated with pulp canal obliteration: an aid to
treatment decision. Endod Dent Traumatol. 2009 Dec; 25(6): 620-625.
• Goga R, Chandler NP, Oginni AO. Pulp stones: a review. International Endodontic
Journal, 41, 457–468, 2008. doi:10.1111/j.1365-2591.2008.01374.x
• McCabe PS, Dummer PM. Pulp canal obliteration: an endodontic diagnosis and
treatment challenge. Int Endod J. 2012;45(2):177-97.
• Abdul Majid. et al., Int J Dent Health Sci 2015; 2(1): 225-229 Prasad Koli, Madhu
Pujar, Viraj Yalgi, Veerendra Uppin, Hemant Vagarali, and Namrata Hosmani,
“Ultrasonic Management of Calcified Canal: A Case Report.” Oral Surgery, Oral
Medicine, Oral Radiology, vol. 2, no. 2 (2014): 11-13. doi: 10.12691/oral-2-2-1.
• de Toubes KMPS, Oliveira PAD, Machado SN, Pelosi V, Nunes E, Silveira FF.
Clinical Approach to Pulp Canal Obliteration: A Case Series. Iran Endod J.
2017;12(4):527-33. Doi: 10.22037/iej.v12i4.18006.
• Other online materials and pictures

63. THANK YOU