Calcific metamorphosis. Literature review and clinical strategies.

UNLABELLED: Calcific metamorphosis (CM) is a commonly observed phenomenon following traumatic injuries like concussion, subluxation and luxation. Depending on the severity of the injury and the developmental stage of the tooth, there can be either complete or partial obliteration of root canals. However, histologically, there is always persistence of fine residual filaments of pulp tissue or tracts of organic material without the presence of any inflammatory component. A periodic clinical and radiographic follow-up examination is preferred and usually, for cosmetic reasons, only a conservative aesthetic treatment is required. Endodontic treatment is only advocated if there is development of apical periodontitis and, if executed properly, can be highly successful. CLINICAL RELEVANCE: Appropriate management of calcific metamorphosis can present a clinical dilemma to the clinician. Thus a judicious and prudent decision should be made between endodontic intervention for the involved tooth and other available restorative (and/or aesthetic) treatment options.

The Association of Dental Pulp Stones to Cardiovascular and Renal Diseases: A Systematic Review and Meta-Analysis.

BACKGROUND: Pulp stone (PS) is a dystrophic calcification in the tooth's pulp chamber and was suggested in the literature to be associated with other calcifications in the body. This study aimed to investigate the association of PS to cardiovascular diseases (CVD) and renal stones (RS). METHODS: Three databases were searched until June 2021 in addition to manual searching of Google Scholar and grey literature. Original studies were only included and critically appraised using an adapted version of the Newcastle-Ottawa scale. The odds ratio (OR) effect measure was calculated using the Mantel-Haenszel statistical test (95% confidence interval [CI]) to investigate the association of PS with CVD and or RS (P value ˂ .05). RESULTS: The database search identified 4933 studies, and 19 studies were finally included. The risk of bias was low in 13 studies, moderate in 4 studies, and high in 2 studies. The meta-analysis of the moderate and low risk of bias studies revealed a significant association between PS and CVD (OR, 3.35; 95% CI, 1.91-5.89; P < .001, I2 = 65%), but no association was found between PS and RS. The results also revealed an association between PS and CVD in patients older than 40 (OR, 8.78; 95% CI, 3.64-21.17; P < .001, I2 = 0%). CONCLUSIONS: The current study results showed an association between PS and CVD, but no association was found between PS and RS. PS in patients older than 40 years, compared with younger patients (<40 years), was associated with CVD.

Management of compound odontoma with 70 denticles and impacted lateral incisor over an 8-year follow-up.

Odontomas are benign developmental tumors formed by the improper growth of completely differentiated epithelial and mesenchymal cells of odontogenic origin. The etiology of odontoma is unknown and it is detected during routine radiographic examination. The ideal management is early detection and surgical enucleation. The commonly associated clinical problems of odontomas are delayed exfoliation of primary teeth, delayed eruption or impaction of permanent teeth, displacement of teeth, root resorption, congenital missing, and widening of follicular space. Here, we describe a unique case of compound odontoma with a high number of denticles managed based on a definite decision support system over 8 years. An 8-year-old boy with 70 denticles in the left maxillary region underwent enucleation. On periodic follow-up, the associated impacted lateral incisor was extruded orthodontically.

Distal renal tubular acidosis, autoimmune thyroiditis, enamel hypomaturation, and tooth agenesis caused by homozygosity of a novel double-nucleotide substitution in SLC4A4.

BACKGROUND: Mutations in SLC4A4 have been reported to be associated with proximal renal tubular acidosis (RTA), short stature, band keratopathy, cataract, glaucoma, and hypoplastic-type amelogenesis imperfecta. In this study, the authors describe the clinical manifestations, and investigate the molecular etiology, in a patient with RTA. CASE DESCRIPTION: The authors report on a girl with distal RTA who carried a novel homozygous base substitution of 2 consecutive base pair variants (NM_001098484.3:c.808-2A>C and NM_001098484.3:c.808-1G>C) in the SLC4A4 gene. The patient had clinical manifestations of autoimmune thyroiditis and distal RTA, including hypercalciuria, nephrocalcinosis, and nephrolithiasis. In addition to the presence of hypoplastic-type amelogenesis imperfecta, generalized enamel hypomaturation, a feature seen in mice lacking Slc4a4, was also observed in the patient. The basic defect in this patient appeared to be impaired hydrogen ion secretion, leading to an inability to acidify the urine, resulting in alkaline urine (despite a normal serum anion gap), hypokalemic, and hyperchloremic metabolic acidosis. The pulp stones found in the patient may likely be the consequences of a disrupted acid-base homeostatic environment that precipitated mineral deposits. Even with proper treatments for distal RTA, the patient has had frequent recurrences of band keratopathy, pupillary membrane, and cataract. PRACTICAL IMPLICATIONS: This is the first report of distal RTA, autoimmune thyroiditis, tooth agenesis, enamel hypomaturation, and pulp stones associated with an SLC4A4 mutation. It is important for dentists to be aware that amelogenesis imperfecta in patients may be a sign of systemic diseases including RTA, nephrocalcinosis, or nephrolithiasis.

Association of pulp stones with coronary artery stenosis.

BACKGROUND: Dental pulp stones are discrete calcifications in the pulp chamber which are often seen in deciduous and permanent teeth. It has been hypothesised that atherosclerosis can be associated with their development. OBJECTIVE: To determine whether a higher prevalence of dental pulp stones is correlated with coronary artery stenosis. CLINICAL SETTING: Sixty-one patients aged 20-55 years referred to Afshar Heart Center for invasive coronary angiography were invited to undergo panoramic dental radiography. The panoramic radiographs were independently examined for the presence of pulp stones. RESULTS: Pulp stones were present in 82% (31/38) of patients with at least one clinically significant coronary artery stenosis and in 48% (11/23) of patients with normal coronary angiography. They were present in 13% of the teeth in the former group and in 5% of the teeth in the latter. The findings show a statistically significant association between coronary artery stenosis and presence of pulp stones (odds ratio 4.83, 95% confidence interval 1.5-15.4). CONCLUSION: Coronary artery stenosis and dental pulp calcification are significantly associated. Dental radiography has the potential to be used as a rapid screening method for the early detection of coronary artery stenosis.

Pulp vitality in teeth suffering trauma during orthodontic therapy.

OBJECTIVE: To examine pulpal vitality in teeth suffering dental trauma during orthodontic therapy with fixed appliances. MATERIALS AND METHODS: Pulpal condition was evaluated in 59 teeth that had suffered dental trauma during orthodontic treatment (TO-group), in 800 orthodontically treated teeth without previous dental trauma (O-group), and in 193 orthodontically untreated teeth with previous dental trauma (T-group). Pulpal vitality was examined clinically and with radiographs. Degree of pulp obliteration was rated as absent, partial, or total. All teeth in the TO-group showed a positive sensibility test prior to resumption of orthodontic therapy. RESULTS: Teeth in the TO-group revealed a significantly higher frequency of pulp necrosis than teeth in the O-group or teeth in the T-group (P < .001, respectively). In the TO-group, teeth with extrusive or lateral luxation (P = .031) and teeth with intrusive luxation (P = .015) injuries showed a significantly higher rate of pulp necrosis than teeth with fracture of enamel. In addition, teeth with total pulp obliteration showed a significantly higher frequency of pulp necrosis than teeth without pulp obliteration (P = .013). CONCLUSION: Teeth with severe periodontal injury during orthodontic therapy and subsequent total pulp obliteration have an increased risk of pulp necrosis during additional orthodontic treatment stages.

Association between Pulp Stones and Kidney Stones: A Systematic Review and Meta-analysis.

INTRODUCTION: A systematic review and meta-analysis were performed to evaluate the association between pulp stones and kidney stones. METHODS: A search for observational studies was performed in PubMed, Scopus, Web of Science, Biblioteca Virtual em Saúde, and the gray literature. The Newcastle-Ottawa Scale for Risk of Bias criteria were used to evaluate the internal quality of the included studies. A fixed-effects meta-analysis was performed to evaluate the association between the conditions. RESULTS: A total of 213 studies were identified after the removal of duplicates. Of these, 9 studies were selected after screening the titles and abstracts. Finally, after full-text reading for qualitative analysis, 7 studies were selected, and of these, 2 were used in the meta-analysis. A significant association was found between pulp stones and kidney stones (1.97 [95% confidence interval, 1.21-3.18]; P < .05). CONCLUSIONS: This study revealed an association between pulp stones and kidney stones. Further well-designed studies should be conducted in order to confirm whether pulp stones are predictive indicators of undiagnosed kidney stones.

The effect of pulp obliteration on pulpal vitality of orthodontically intruded traumatized teeth.

Limited information exists on the impact of pulp obliteration on pulpal vitality of orthodontically treated traumatized teeth. Pulpal condition was examined in 269 traumatized maxillary incisors after orthodontic intrusion (OT group) and in 193 traumatized maxillary incisors without subsequent orthodontic treatment (C group). According to the degree of initial pulp obliteration, the teeth were divided into three categories: teeth without, teeth with partial, and teeth with total pulp obliteration. Teeth in the OT group revealed a significantly higher rate of pulp necrosis than teeth in the C group (p < 0.001). In addition, teeth in the OT group with total pulp obliteration showed a significantly higher rate of pulp necrosis than teeth without (p < 0.001) or only partial pulp obliteration (p = 0.025). The results indicate that traumatized teeth with total pulp obliteration have a higher susceptibility to pulpal complications during orthodontic intrusion than traumatized teeth without or only partial pulp obliteration.

Guided Endodontic Access of Calcified Anterior Teeth.

Pulp canal calcification is characterized by the deposition of calcified tissue along the canal walls. As a result, the root canal space can become partially or completely obliterated. Recently, "guided endodontics" has been reported as an alternative solution in cases of partial or completed canal obliteration. Although this technique can enhance minimally invasive access to the calcified canal, it has been shown that the incisal surfaces are often removed during the access of anterior teeth. This report describes 2 cases of guided endodontics using conventional palatal access in calcified anterior teeth and discusses the applicability of this approach in cases of pulp canal calcification with apical periodontitis and acute symptoms. The method demonstrated high reliability and permitted proper root canal disinfection expeditiously, without the unnecessary removal of enamel and dentin in the incisal surface.

Pilot study of correlation of pulp stones with cardiovascular disease.

We propose that calcification of dental pulp may have a similar pathogenesis as calcified atheromas and could lead to use of routine dental radiographs as a rapid screening method for early identification of potential cardiovascular disease (CVD). Fifty-five dental patients ages 20 to 55 were chosen because pulp stones in pulpally noninflamed teeth were not expected in this age group. They completed a questionnaire regarding their CVD status and that of their parents and siblings. Entry criteria included at least one asymptomatic, minimally restored, noncarious molar and no history of gout, renal disease, or renal lithiasis. Patients' periapical radiographs of record were viewed to determine the presence of pulp stones. There was a significant relationship between pre-existing CVD and pulp stones (odds ratio of 4.4 with a 95% confidence interval of 1.1, 18.7), but no relationship was found for family history of CVD and pulp stones (odds ratio of 1.7 with a 95% confidence interval of 0.5, 5.5). Seventy-four percent (14/19) of patients with reported CVD had detectable pulp stones while only 39% (14/36) of patients without a history of CVD had pulp stones. This pilot study demonstrates that patients with CVD have an increased incidence of pulp stones in teeth with noninflamed pulps compared to patients with no history of CVD. No relationship was found between presence of pulp stones and family history of CVD. The findings suggest that dental radiographic determination of the presence or absence of pulp stones may have possibilities for use in CVD screening.

Incidence of pulp necrosis subsequent to pulp canal obliteration from trauma of permanent incisors.

Little long-term data are available on the frequency by which pulp canal obliteration (PCO) subsequent to trauma leads to pulp necrosis (PN). In this study, 82 concussed, subluxated, extruded, laterally luxated, and intruded permanent incisors presenting with PCO were followed for a period of 7 to 22 yr (mean 16 yr). At final clinical examination, 51% of the observed teeth responded normally to electric pulp testing (EPT). An additional 40% of the teeth although not responding to EPT were clinically and radiographically within normal limits. Yellow discoloration was a frequent finding. During the observation period, periapical bone lesions suggesting PN developed in seven teeth (8.5%). Twenty-yr pulp survival rate was 84%, as determined from life-table calculations. There was no higher frequency of PN in obliterated teeth subjected to caries, new trauma, orthodontic treatment, or complete crown coverage than intact teeth. Although the incidence of PN in teeth displaying PCO seems to increase over the course of time, prophylactic endodontic intervention on a routine basis does not seem justified.

Prevalence of pulp stones in Jordanian adults.

OBJECTIVE: The purpose of this study was to describe the prevalence of pulp stones in a sample of Jordanian dental patients. The article also presents frequency distributions of this condition among different types of teeth. STUDY DESIGN: Data were collected through radiographic examinations of a random sample of periapical and bitewing films of 4573 teeth from 814 dental records from the Faculty of Dentistry's filing system. RESULTS: Pulp stones were identified in 22% of the teeth examined. First and second molars were the teeth most commonly affected. Pulp stone incidence was not significantly different among different age and gender groups.

Dentinogenesis imperfecta: endodontic implications. Case report.

Dentinogenesis imperfecta is a hereditary disorder resulting in defective dentin in both the primary and secondary dentitions. The complications of dentinogenesis imperfecta are difficult to manage and provide a challenge to the dentist. This case report concerns treating an African American patient with dentinogenesis imperfecta who appeared for treatment with endodontic pathosis. It illustrates the need for appropriate and timely restorative treatment to prevent pulpal pathosis. Also demonstrated is the difficulty of endodontically treating dentinogenesis imperfecta teeth because of pulpal obliteration and abnormal dentin mineralization. Early and correct diagnosis of dentinogenesis imperfecta is imperative to enable appropriate preventive interventions and optimal dental treatment. Although pulpal pathosis is rarely reported with dentinogenesis imperfecta, endodontic treatment is occasionally necessary and has a guarded prognosis if initiated after pulp canal obliteration has occurred.

Dental anomalies associated with amelogenesis imperfecta: a radiographic assessment.

Amelogenesis imperfecta, a group of hereditary conditions primarily affecting the enamel, has been associated with dental anomalies, including taurodontism, congenitally missing teeth, delayed eruption, crown resorption, and abnormal enamel density. The purpose of this study was to assess the prevalence of these anomalies in an amelogenesis imperfecta population. The study group consisted of members of 9 unrelated families--22 family members with amelogenesis imperfecta and 13 unaffected family members. Panoramic radiographs were evaluated for taurodontism, congenitally missing teeth, delayed tooth eruption, pathologic dental resorption, pulp calcification, and radiographic enamel density. The prevalence of taurodontism was similar in people with amelogenesis imperfecta and normal people; all of the remaining parameters were more commonly observed in people with amelogenesis imperfecta. The radiographic enamel density was quantitatively reduced in teeth affected by amelogenesis imperfecta in comparison with teeth with normal enamel. These findings suggest that some of the features associated with amelogenesis imperfecta result from abnormal enamel formation (eg, decreased enamel density, crown resorption) whereas others may occur as a result of expression of the genetic mutation in cells other than ameloblasts (eg, abnormal eruption, pulp calcification).

Unusual cervical resorption after reinjury.

The root canal of a maxillary central incisor apparently completely calcified after an injury. Eight years later, this tooth was injured again and massive resorption developed. The resorption began as an unusual pattern of cervical destruction, and ultimately the entire root apparently was destroyed. However, the tooth was still serving satisfactorily without other symptoms seven years after the reinjury--15 years after the original injury. Calcification of the pulp space can develop in a tooth and the root structure can be resorbed in a tooth after an injury. Therefore a similar stimulus can produce opposite responses, in this instance in the same tooth at different times. Luxation of teeth is a treatable injury, and replantation of luxated teeth is an acceptable technique that can result in long-term retention of the replanted tooth. Replantation of the patient's own tooth is usually preferred to artificial replacement of the luxated tooth at the time of injury. Interceptive endodontic care for a tooth that has been traumatized and in which the pulp space appears on the radiograph to be calcifying is probably best for the patient.

Combined treatment of a large periodontal defect using GTR and DFDBA.

The regeneration of periodontal structures lost to inflammatory disease is an elusive yet attainable goal of periodontal therapy. This article reports the successful treatment of a large periodontal defect using a combination of demineralized freeze-dried bone allograft (DFDBA) and guided tissue regeneration (GTR). The case presents endodontic and mucogingival complications in the combined GTR osseous graft technique. The combined techniques used in this 27-year-old patient achieved a reduction in probing depth, radiographic evidence of bone fill, and a reduction in clinical mobility.

Obliteration of pulp canal space after concussion and subluxation: endodontic considerations.

Concussion and subluxation injuries to permanent teeth lead to obliteration of the pulp canal space in 3% to 11% of cases, depending on the severity of the injury and the developmental stage of the tooth. Obliteration of the pulp canal space may make root canal treatment necessary because of the development of apical periodontitis or for cosmetic reasons. If carefully executed, root canal treatment in teeth with an obliterated pulp canal space is highly successful and may act as a basis for internal bleaching.

Combined endodontic and surgical treatment of a three-rooted maxillary first premolar.

A case is reported in which endodontic treatment of a maxillary first premolar was complicated by the fact that the tooth had three roots. One of the roots was completely calcified and therefore could not be negotiated with endodontic files. There was a large periapical lesion associated with the tooth and this was surgically removed. During the surgical procedure a retrograde cavity was prepared on the calcified root using ultrasonic instruments and this was filled using Super EBA cement. Twelve months later the tooth was asymptomatic and the periapical tissues had completely healed.

Whitening of endodontically untreated calcified anterior teeth.

Definitive treatment for whitening endodontically untreated anterior teeth with dystrophic calcification is provided by removing the coronal sclerotic dentin and utilizing internal and external bleaching as necessary.

The aesthetic and endodontic dilemmas of calcific metamorphosis.

Traumatic injuries to dentition can initiate either a resorptive or calcific pulpal response. In the sequelae of calcific degeneration, the clinical crown frequently becomes discolored, requiring an aesthetic correction to restore the tooth to its natural color. Four potential solutions are currently available to achieve this goal. The learning objective of this article is to describe the etiology of calcific metamorphosis, discuss the four potential solutions, and present the responses of endodontists polled as to the treatment indications. While the posterior dentition may experience the identical pathologic response to trauma and crown discoloration, this article focuses on the restoration of the anterior dentition. Several cases are presented to illustrate the four treatment modalities, and recommendations for follow-up of traumatic injuries are indicated.