Radiographic Assessment of the Prevalence of Pulp Stones in Malaysians Kannan et al. JOE — Volume 41, Number 3, March 2015 Pulp stones are discrete calcified bodies found in the dental pulp. They have calcium phosphorous ratios similar to dentin and can be seen in healthy, diseased, or even unerupted teeth Radiographically, pulp stones appear as radiopaque structures in the pulp space that frequently act as an impediment during endodontic treatment

1. Radiographic
Assessment of the
Prevalence of Pulp
Stones in Malaysians
Kannan et al.
JOE — Volume 41, Number 3, March 2015
GUIDED BY:
DR.RAHUL MARIA
PRESENTED BY:
DR. ANUBHUTI
Conservative Dentistry &
Endodontics

3. INTRODUCTION
Pulp stones are discrete
calcified bodies found in
the dental pulp.
They have calcium phosphorous
ratios similar to dentin and can
be seen in healthy, diseased, or
even unerupted teeth
JOE -Vol 41,No 3,March 2015 3

4. These pulp stones, also known as
denticles, may exist freely within the pulp
tissue or be attached or embedded in the
dentin.
They are found more frequently at
the orifice of the pulp chamber or
within the root canal.
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5. A tooth may have pulp stones of varying sizes,
from minute particles to large masses, which
can occlude the pulp space.
They are seen in all tooth types but occur most
commonly in molars
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6. Size
Radiographic
examinations
are not likely
to detect
pulp stones
less than
200μm in
diameter
6
Radiographic assessment of the prevalence of pulp stones in Australians
2008.Australian Dental Journal 2002;47:(1):36-40

7. Radiographically, pulp stones
appear as radiopaque
structures in the pulp space
that frequently act as an
impediment during
endodontic treatment
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8. 8
Pulp stones were
histologically classified by
Kronfeld
Radiographic assessment of the prevalence of pulp stones in Australians
2008.Australian Dental Journal 2002;47:(1):36-40

9. PULP
STONES
True
pulp
stones
False
pulp
stones
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10. PULP STONES Asymptomatic unless they impinge on nerves (or) blood vessels.

Goga, R.; N. P. Chandler & A. O. Oginni (2008). "Pulp stones: a review". International Endodontic Journal 41: 457–468.
CLASSIFICATION
True
denticles
False
denticles
Diffused
calcifications
10

11. Based on location
Embedded
Adherent
free
JOE -Vol 41,No 3,March 2015 11

12. They rare and contain
dentin with distinct
dentinal tubules lined by
odontoblasts.
it contains a concentric layers
of mineralized tissue formed
by surface accretion around
blood thrombi, dying or dead
cells, or collagen fibers
JOE -Vol 41,No 3,March 2015 12
True pulp stones False pulp stones

13. Found mostly in radicular
portion.
It arise as a result of
epithelial mesenchymal
interactions
Found mostly in coronal
portion
It arise from degenerating
cells of the pulp that
eventually get mineralized
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True pulp stones False pulp stones

14. Increasing
age
Circulatory
disturbances
in the pulp
Orthodontic
tooth
movement
Transplantat
ion of teeth
Trauma
Other etiologic factors
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15. Pulp stones have been associated with systemic problems
Cardiovascular
disease
Systemic
sclerosis
A genetic
predisposition
Idiopathic .
JOE -Vol 41,No 3,March 2015, A radiographic correlation between systemic disorders and pulp stones.Nayak, et al.Indian J Dent Res, 21(3),
2010 15

16. Genetic disorders
Dentin
dysplasia
Dentinogenesis
Imperfecta
Van der Woude
syndrome
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17. Pulpal calcifications can
develop throughout life, and
studies have reported
prevalence rates from 8%–90%
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18. The prevalence of pulp stones in
teeth based on radiographic
examinations has been reported
to be around 20%–25% whereas
histologic examinations yield
higher prevalences
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19. The purpose of this study was to determine the
prevalence of pulp stones in Malaysians using
radiographs and to investigate any association
between the occurrence of pulp stones with sex,
age, tooth type, dental arch, and tooth status.
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20. In Malaysia, the population is largely composed of
3 major ethnic backgrounds (Malays, Chinese,
and Indians), which further permitted to compare
the occurrence of pulp stones among racial
groups.
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21. Materials and Methods
Records of patients between the ages of 10 and 70 years,
which contained intraoral periapical radiographs of
diagnostic quality, were included in the study.
A random sample of 1000 dental records of patients who were
treated at the AIMST Dental Centre, Faculty of Dentistry, AIMST
University, Kedah, Malaysia, were reviewed.
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22. A total of 1779 teeth were examined from these radiographs;
only permanent teeth with complete roots were analyzed
All radiographs were taken in the oral radiology department
using the parallel cone technique.
The final sample consisted of 361 patient records that had 507
intraoral periapical radiographs of diagnostic quality.
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23. The data were recorded in
a detailed spreadsheet
prepared for the study
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24. The data were statistically analyzed using
the Pearson chi-square test of significance
to report any association of pulp stone
occurrence with sex, age, race, tooth type,
dental arch, and tooth status.
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25. Results
A total of 60 (38.5%) male and 102 (49.8%) female subjects exhibited pulp
stones
Among the total 361 subjects, 162 (44.9%) had pulp stones in 1 or more
teeth.
Overall Prevalence of Pulp Stones and Distribution between Sexes Of the 361
subjects examined, 156 were males and 205 were females.
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26. Pulp Stone Distribution among Age
Groups
There was a higher prevalence
in patients 50–59 years of age
(56.8%) when compared with
the other age groups.
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27. Pulp Stone Distribution among the 3
Races in Malaysia
Among the ethnic groups
(Malays, Chinese, and Indians),
the Indian population (52.6%)
had more pulp stones as
reflected
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28. Pulp Stone Occurrence in Tooth Types
and Dental Arches
The occurrence of pulp stones
in the mandibular (15.5%) and
maxillary (15.9%) arches were
almost equal.
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29. Of the teeth exhibiting pulp stones, the maxillary left
second molar showed the highest occurrence (36.5%)
followed by the mandibular right second molar (30.4%).
A relatively low frequency was seen in mandibular
incisors followed by maxillary left first premolars (3.2%),
which were the least affected teeth
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30. Pulp Stones and Tooth Status
pulp stones were not associated
with any other tooth
abnormalities (both
developmental and acquired).
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31. Discussion
The true prevalence is likely to be higher in
microscopic examinations of teeth than
figures from radiographic studies , the latter
is the only noninvasive technique available
for evaluating pulp stones in clinical
investigations
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32. However, Tamse et al stated that bitewing and periapical
radiographs showed no significant difference in the identification
of pulp stones.
Bitewing radiographs do not show the complete radicular pulp, so
we examined only periapical radiographs to avoid underreporting
of pulp stones.
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33. The prevalence of pulp stones
was higher in females compared
with males.
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34. The prevalence was high in patients older than 30 years; however, there
was no significant difference between the various age groups
The maximum number of pulp stones was seen in a 34-year-old female
patient who exhibited more than single pulp stones in several teeth.
In the study, the youngest individual was a 12-year-old female who
exhibited a single pulp stone in her maxillary left first molar tooth.
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34

35. Hamasha and Darwazeh stated that
molars, being the largest teeth in the
arch, have a better supply of blood
to the pulp tissues, leading to more
precipitation of calcifications.
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35

36. Recent researches have
incriminated as a factor which
initiates these calcium depositsa
small bacteria – Nanobacterium
sanguineum – which has the
possibility to form around itself,
a real “mineral carcass
36
Radiographic assessment of the prevalence of pulp stones in Australians
2008.Australian Dental Journal 2002;47:(1):36-40

37. The tendency for the occurrence of
pulp stones was high in teeth that
were not intact
This may be caused by chronic
pulpal irritation in both carious
and restored teeth.
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38. Hamasha and Darwazeh noted a high
incidence of pulp stones associated
with Dilacerations, impactions,
Taurodontism, and enamel pearls.
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39. JOE -Vol 41,No 3,March 2015 39

40. Use of magnification and trans illumination as well as
careful examination of colour changes and pulp chamber
spaces ,can help the clinician safely locate the canals
Clinician should search for root canal orifices only after
completely preparing the pulp chamber and cleaning and
drying its floor(95% denatured ethanol )
40
Pathways of cohen 13th edition page no 171

41. A fiber optic light directed
towards through the CEJ can
reveal subtle landmarks and
colour changes that may not
otherwise be visible
Pathways of cohen 13th edition.pg 171
41

42. Clinician must be aware of these
colour changes and must keep in mind
that orifices are located at the angles
formed by the floor and walls at the
end of the developmental grooves
42
Pathways of cohen 13th edition.pg 171

43. Additional aid
Staining the pulp chamber floor
with 1% methylene blue dye
Sodium hypochlorite ‘champagne
bubble test’ and searching for
canal bleeding points
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44. Clinician should use a long
shank #2 or #4 round bur to
remove dentin, attempting
to locate calcified canals
44
Pathways of cohen 13th edition.pg 173

45. An endodontic explorer,DG 16
is used to probe the pulp floor.
A straight ultrasonic tip may
be used to remove the dentin
45
Pathways of cohen 13th edition.pg 173

46. 46
Pathways of cohen 13th edition.pg 173

47. As the first indication of a canal space, the
smallest instrument (#.06#.08 file) should
be introduced in the canal .
Gentle passive movement, both apical and
rotational, often produces some
penetration.
A slight pull, signaling resistance, usually is
an indication that the canal has been
located this should be confirmed by
radiographs
47
Pathways of cohen 13th edition.pg 173

48. A small hand K- file
negotiates the canal to its
terminus .a radiograph is
used to confirm the file’s
position
48
Pathways of cohen 13th edition.pg 173

49. The file should not be
removed until some canal
enlargements has
occurred.
49
Pathways of cohen 13th edition.pg 173

50. The wise clinician stops excavating dentin if a canal orifice
cannot be found to avoid weakening the tooth structure.
Serious errors can arise from overzealous or inappropriate
attempts to locate canals.
Root wall or furcation perforations can occur even with the
most careful search
50
Pathways of cohen 9th edition.pg 185

51. Conclusion
The prevalence of pulp stones in the Malaysian population studied was 44.9%.
Stones were found significantly more often in molars and in teeth that were
not intact (either restored or carious). Pulp stones occurred predominantly in
restored teeth.
The occurrence of pulp stones had no significant association with sex, age, or
the different Malaysian ethnic races.
However, these findings require further investigation. The size, shape, location,
and number of pulp stones on radiographs can be used as an adjunctive
feature for forensic identification.JOE -Vol 41,No 3,March 2015 51

52. REFERENCES
A radiographic assessment of the prevalence of pulp stones in a group of Turkish
dental patients. Gulsahi et al.International Endodontic Journal, 42, 735–739, 2009
A radiographic correlation between systemic disorders and pulp stones.Nayak, et
al.Indian J Dent Res, 21(3), 2010
Radiological and microscopic aspects of the denticles. Romanian Journal of
Morphology and Embryology 2006, 47(3):263–268
Pilot Study of Correlation of Pulp Stones with Cardiovascular Disease. Edds et
al.JOE—Volume 31, Number 7, July 2005
Correlation of pulp stone prevalence with dietary habits - A pilot study Health
Sciences 2012;1(3):JS003C
JOE -Vol 41,No 3,March 2015 52

53. REFERENCES
Association between dental pulp stones and calcifying nano particles. Zeng et al
.International Journal of Nanomedicine 2011:6
Pulp stones: a review. Goga et al.International Endodontic Journal, 41, 457–468, A
Radiographic assessment of the prevalence of pulp stones in Australians 2008.Australian
Dental Journal 2002;47:(1):36-40
Ingle’s 6th edition
Pathways of cohen 8th ,9th,13th edition
Grossman’s 13th edition
Textbook of endodontics by anil kohli
JOE -Vol 41,No 3,March 2015 53