An unusual case report of generalized pulp stones in young permanent dentition.

Pulp stones are relatively frequent finding on bitewings and periapical radiograph, but their occurrence in the entire dentition is unusual. Such an unusual occurrence of generalized pulp stone was reported in a 13-year-old girl. The dental, medical and family histories as well as the findings from the clinical examination of the patient were not contributory. Biochemical analysis of the removed pulp calcification from one of the teeth during endodontic treatment showed large amount of calcium, phosphorus, and carbonate. However, metabolic evaluation of patient through liver function test, kidney function test , and blood investigation did not show any metabolic disorders. Patient was also evaluated for any systemic, syndromic or genetic involvement, but this was also non-contributing. Therefore, it is suggested that this unusual cases may be of idiopathic origin.

Introduction

Pulp stones are discrete calcified masses found in the dental pulp, exist freely in the pulp tissue or become attached to or embedded into the dentine. Structurally, pulp stones can be classified as true or false, the former being made of dentine and lined by odontoblasts, whereas false pulp stones are formed from degenerating cells of the pulp that gets mineralized.[1] Etiological factors that have been implicated in stone formation include pulp degeneration, inductive interactions between epithelium and pulp tissue, age, circulatory disturbances in pulp, orthodontic tooth movement, idiopathic factors and genetic predisposition,[2] i.e., dentine dysplasia, dentinogenesis imperfecta and in certain syndromes such as Van der woude syndrome. In spite of higher occurrence of pulp stones in adult population, the presence of generalized pulp stone in young children is rare. The present case report depicts generalized pulp stone presence in a 13-year-old young girl, without any metabolic disturbances and syndrome, which may be suggestive of its idiopathic origin.

Case Report

A 13-year-old female patient reported to the Department of Pedodontics with Preventive Dentistry, Faculty of Dental Sciences, CSM Medical University, Lucknow, with a chief complaint of pain in the back of lower jaw on both sides, since 15 days. Intraoral clinical examination revealed deep carious lesion with both mandibular first permanent molars. The initial intraoral periapical radiograph [Figures 1 and 2] revealed radiolucency extending to the pulp chamber, associated with radio-opacity within the pulp chamber, suggesting pulp stones in both permanent mandibular first molars. The radiographic examination of all the teeth was performed by full mouth intraoral periapical radiograph which revealed pulp stones in the pulp chamber and some in the root canals, of entire dentition [Figure 3]. So, treatment planned was endodontic treatment with those teeth indicated for the same, by removing the pulp stone and the remaining asymptomatic teeth were left untreated. Pulp stones were carefully removed from the pulp chamber by sharp excavator and were placed in 0.5 ml of distilled water.[3] The removed pulp stones were then sent to the laboratory for biochemical analysis. At the same time, patient was evaluated for any systemic and metabolic disorder by performing liver function test (LFT), kidney function test (KFT), and blood investigation, which were non-contributory.

Figure 1

Initial periapical radiograph of carious exposed 36 and 37 shows presence of solitary pulp stones.

Figure 2

Initial periapical radiograph of carious exposed 46 and 47 shows presence of solitary pulp stones

Figure 3

Full mouth periapical radiograph showing generalized pulp stone formation

The result of the biochemical analysis of the patient revealed a slight increase in amounts of urates, proteins and phospholipids, which was not significant. However, the biochemical analysis of the removed pulp stone showed high calcium concentration (23.69 mg%) with average phosphorus concentration (3.8 mg%). The relative high concentration of Na+ (average 291 mmol/l) and low concentration of K+ (average 0.2 mmol/l) in a pulp stone may be the indication of the extreme ionic imbalance in the localized area of pulp which initiates the precipitation of Ca++ ion to form a nidus. The nidus might be increased gradually in the presence of high concentration of magnesium (average 12.39 mmol/l) in a well-defined pulp stone mass in high vascularized pulp tissue of young permanent teeth.

Discussion

Although many reports have been documented in the literature concerning pulp stones, few of them describe cases of pulp stones appearing in all teeth of a young person.[3-8]

In the present case, the generalized pulp stones were found in a young patient, which is contrary to the general concept of pulp stone formation usually seen in older age group or in association with certain syndrome. However, in the presented case, no correlation could be established between the generalized pulp stone and any genetic, systemic or metabolic findings. Thus, it may be suggested that these pulp stones are of idiopathic origin. The case is of particular clinical interest due to the presence of generalized pulp stones in a young child patient. Further studies and investigations are required to evaluate the exact mechanism and etiology of generalized pulp calcification which would be able to clarify the fact that the generalized pulp calcification is not merely an age change phenomenon of the pulp tissue but some other factors may be attributed for this condition.