A study on pulp stones in a group of the population in Andhra Pradesh, India: An institutional study.

AIM: The aim of this study was to determine the occurrence of pulp stones in a group of the population of Andhra Pradesh. This study also aims to determine the association of pulp stones in different sexes, tooth type, dental arches and sides and with systemic diseases.
MATERIALS AND METHODS: A total of 4449 teeth of 2000 patients were examined, comprising of patients with C.V.S. disorders; Type II diabetes mellitus and gastritis were examined. Patients were selected from the radiology department who came for diagnostic radiograph of posterior teeth. The presence or absences of pulp stones were recorded. STATISTICAL ANALYSIS USED: Statistical analysis of the data was done using the statistical package for the social sciences (SPSS 15.0-SPSS Inc., 233 South Waker Drive, 11(th) floor, Chicago, IL 60606-6412.) using Chi-square analysis. Differences were considered as significant when P ≤ 0.05.
RESULTS: Pulp stones were found in 799 (17.9%) of 4449 teeth detected. Significantly, higher numbers of pulp stones were recorded in patients with systemic diseases. The occurrences of pulp stones were significantly higher in maxillary first and second molars. No significant difference was found between sexes and sides.
CONCLUSIONS: Positive correlation was found between systemic disorder and occurrence of pulp stones.

INTRODUCTION

Pulpstones are a group of calcified masses in the dental pulp of healthy, diseased and unerupted teeth.[1] Stones may exist either freely within the pulp tissue or be attached to or embedded in dentin.[2] A single tooth may have 1-12 pulp stones or even more. The size may vary from a small microscopic particle to large masses that almost obliterate the pulp chamber.[3] Two types of pulp stones have been described:[4] Denticles possessing a central cavity filled with epithelial remnants surrounded peripherally by odontoblasts and pulp stones being compact degenerative masses of calcified tissues. They are reported to occur more often in the coronal region, but are also found in the radicular pulp. Pulp stones have been reported in patients with systemic or genetic diseases such as van der Woude syndrome.[5]

Despite several microscopic and histochemical studies, the exact cause of such pulp calcifications remains largely unknown. However, a number of conditions have been claimed to predispose to pulp stone formation such as pulp degeneration, inductive interactions between the epithelium and pulp tissue,[4] age,[6] caries, operative procedures, periodontal diseases, epithelial rests in the pulp tissue, orthodontic tooth movement,[7] circulatory disturbances in pulp tissue,[8] idiopathic factors[9] and genetic predisposition.[10] Recent literature still suggests that pulp stones are a feature of an irritated pulp, attempting to repair itself.[11]

The prevalence of pulp stones varies from 8% to 90%.[3] Many prevalence studies have identified pulp stones using radiography. The true prevalence is likely to be higher because pulp stones with a diameter smaller than 200 μm cannot be seen on radiographs.[24] Some researchers have investigated the prevalence of pulp stones or association of this condition with other dental conditions. However, very few studies have assessed the prevalence of pulp stones in Indian population.

The aim of this study was to determine the occurrence of pulp stones using radiographs and to correlate their association with age, gender, systemic diseases such as hypertension, diabetes and gastritis; tooth type, jaw type, caries and restored teeth.

MATERIALS AND METHODS

A total of 2000 patients were selected randomly from the outpatient Department of Radio diagnosis of three different institutions belonging to three different regions of Andhra Pradesh for a period of 6 months. Patients below the age of 10 and above the age of 60 were excluded from the study. Among these, 2000 patients a total of 4449 teeth were examined.

All the patients who had undergone a diagnostic radiograph of the premolar and molar region were considered for the study. Patients were not subjected for radiographic examination for the purpose of the study. Patient's medical history was recorded for diseases such as diabetes, hypertension and gastritis. Patients with more than one systemic disease and patients with other medical problems apart from diabetes, hypertension and gastritis were excluded from the study. Patient's dental status was thoroughly examined for DMF, which were recorded in the proforma. Diagnostic radiographs were taken using an analog IOPA unit under ICRP standards protecting the patient and the operator with constant exposure parameters (70 KVp, 6 mA and 0.6 s pulse). All the radiographs were processed manually using visual method in a dark room under safe light. The radiographs were evaluated for the presence or absence of pulp stones and were documented in the proforma.

Statistical analysis of the data was done using the statistical package for the social sciences (SPSS 15.0) using Chi-square analysis. Differences were considered as significant when P ≤ 0.05.

RESULTS

The distribution of patients with pulp stones according to the age groups is shown in Table 1. The occurrence of pulp stones was most significant in among the age groups of 31-50 years of age. Of the 2000 patients a total of 518 patients had pulp stones which accounts to 25.9% prevalence. A total of 4449 teeth were examined of which 18% of teeth showed pulp stones.

Table 1

Age distribution and its correlation of presence of pulp stone

The distribution of teeth with pulp stones in comparison to the medical history is shown in Table 2. Patients with diabetes, hypertension and gastritis showed higher prevalence of pulp stones with a P < 0.05, which was statistically significant.

Table 2

Medical history and its correlation of presence of pulp stone

The distribution of teeth with pulp stones according to the location and tooth type is shown in Table 3. When individual tooth type is taken into consideration, maxillary 1st and 2nd molars showed a strongly positive significance with 33% and 31% prevalence respectively to the overall prevalence of 18%.

Table 3

Teeth distribution and its correlation of presence of pulp stone

Regarding the tooth pathology, of the 4449 teeth examined, 1870 teeth had dental caries out of which 224 teeth showed pulp stones which accounts to 11.9% prevalence and 105 teeth were restored out of which 18 teeth showed 17.1% prevalence. The prevalence of pulp stones were statistically significant [Table 4] in teeth with dental caries and teeth without pathology.

Table 4

Pathology and its correlation of presence of pulp stone

DISCUSSION

Detection of pulp stones using dental radiographs is only possible when the diameter is more than 200 μm.[12] Most of the studies in the literature used paralleling technique to take the radiographs. al-Hadi Hamasha and Darwazeh[13] in their study used periapical and bitewing radiographs, Çolak et al.[14] used bitewing radiographs, whereas Satheeshkumar et al.[15] and Syryn΄ska et al.[16] used panoramic radiographs in their study for detection of pulp stones. One study had proved that there is no significant difference in the technique to identify the pulp stones. In our study as we considered all the intraoral periapical radiographs taken in the out-patient department of Radiology, we used bisecting angle technique to take the radiographs.

Al-Hadi Hamasha and Darwazeh[13] examined patient records of 814 Jordanian adults and found that pulp stones were present on radiographs in 51% of the patients and 22% of the teeth studied. Baghdady VS et al.[1] assessed 515 iraqi subjects and recorded that 19% of the teeth had pulp stones. Ranjitkar et al.[17] examined the prevalence of pulp stones in Australian population and found in 46% of the subjects and 10% of the teeth examined. Tamse et al.[18] evaluated full mouth radiograph of 300 patients and reported that 21% had pulp stones. Gulsahi et al.[19] in their study found pulp stones in 12% of the subjects and 5% of the teeth examined. Nayak et al.[20] in a study on Indian population, examined 1432 teeth and found 9.35% prevalence of pulp stones. Sisman et al.[21] examined bitewing radiographs of 469 Turkish patients and found 57.6% prevalence of pulp stones in their patients and 15% prevalence among the teeth examined. In the present study, the prevalence of pulp stones in 26% of the subjects and 18% of the total teeth examined. Our results are almost in par with many of the studies in the literature.

Some investigators have reported that pulp stones were more common in females than in males.[171822] Some showed that there is no significance. In our study, we found a slight higher prevalence in females than in males. According to Ranjithkar S et al[17] pulp stones are reported to increase in frequency with age. The present study also confirmed this finding.

Generalized pulp stones are found in the dentition of individuals with various conditions. These include tumoralcalcinosis, dentin dysplasia Type II, Elfin facies syndrome, familial expansile osteolysis,[2] Elhers-Danlos syndrome Type I, osteogenesis imperfecta Type I and otodental syndrome. In forensic dentistry, a radiographic matching of pulp stone configurations, along with other features recorded in dental records, may provide valuable information in the identification of a deceased person.[17]

The correlation of pulp stones with cardiovascular diseases and other systemic diseases has been investigated. Edds et al.[23] found a significant relation between pulp stones and presence of arteriosclerosis and other cardiovascular diseases. High incidence of calcification in the dental pulp of patients with coronary atherosclerosis upon radiographic examination were reported.[23] Theyalso found calcification and lumen narrowing within extirpated dental pulp vessels, in both medium and small precapillary arteriole of cardiovascular patients. Nayak et al.[20] in their study on Indian population found the prevalence of pulp stone in hypertensive patients was 15.85% higher than normal subjects. The present study also showed a higher prevalence of pulp stones in patients with hypertension, diabetes and gastritis when compared to the overall prevalence of pulp stones.

Type II diabetic patients, in the present study, were detected with pulp stones higher than the overall prevalence of pulp stones. Russell had investigated human pulp histologically on non-carious extracted teeth of seven patients suffering from diabetes for a long term duration and control group of 13 non-diabetics.[24] He concluded that calcification in angiopathies and thickened basement membrane were noted in both large and small blood vessels and vascular changes seemed more pronounced in the central area of the pulp. Calcifications in diabetics were frequent and often sickle-shaped.

In another histopathological study, conducted by Bissada and Sharawy's on 21 human dental pulps of diabetics and 20 matched controls, no vascular changes groups were found in the dental pulp of both. However, amorphous calcified bodies in the pulp of diabetics were found. Dental pulp of patients who suffer from diabetes mellitus tend to age more readily because it of obliterative endarteritis and because it has limited or no collateral blood circulation in fully developed teeth.[24]

CONCLUSION

The occurrence of pulp stones in our study was significantly higher in the younger age group patients and also in those groups of people who had underlying systemic problems.