|Year : 2010 | Volume
| Issue : 3 | Page : 369-373
|A radiographic correlation between systemic disorders and pulp stones
Moksha Nayak, Jitendra Kumar, L Krishna Prasad
Department of Conservative Dentistry & Endodontics, KVG Dental College and Hospital, Kurunjibagh Sullia, Karnataka, India
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|Date of Submission||26-Nov-2009|
|Date of Decision||06-Jan-2010|
|Date of Acceptance||21-May-2010|
|Date of Web Publication||29-Sep-2010|
| Abstract|| |
Aim: The purpose of this study was to determine the correlation between pulp stones and cardiovascular disorders, Type II diabetes mellitus, autoimmune disorders and dental wear defects. This study also aims to evaluate the frequency of pulp stone in population of Dakshina Kannada district (Karnataka, India) and to determine association of pulp stones in different sexes, tooth type, dental arches and sides.
Patients and Methods: A total of 1432 teeth of five groups were examined, comprising of patients with C.V.S. disorders; Type II diabetes mellitus, autoimmune disorders, dental wear defects and control group. Teeth were examined under 2Χ magnification on radio visiograph (RVG) and conventional intra-oral periapical radiograph. The presence or absence of pulp stones were recorded.
Statistical Analysis Used: Chi-square analysis was used to compare the frequency of occurrence of pulp stones between sexes, tooth type, dental arches and sides.
Results: Pulp stones were found in 134 (9.35%) of 1432 teeth detected. Significantly, higher numbers of pulp stones were recorded in patients with cardiovascular disorder (15.86%) than other groups. The occurrence of pulp stones were significantly higher in molars (18.29%) than premolars (6.6%) and in maxillary arch (12.36%) than in mandibular arch (5.95%). No significant difference was found between sexes and sides.
Conclusion: Positive correlation was found between systemic disorder and pulp stones. Cardiovascular patients had maximum number of pulp stones followed by dental-wear defects and least number of pulp stones were evident in control group.
Keywords: Autoimmune disorder, cardiovascular disorders, dental wear defects, pulp stones, type II diabetes mellitus
|How to cite this article:|
Nayak M, Kumar J, Prasad L K. A radiographic correlation between systemic disorders and pulp stones. Indian J Dent Res 2010;21:369-73
Pulp stones are discrete calcifications and are amongst changes that include more diffuse pulpal calcifications such as dystrophic calcification. Johanson and Bevelander stated that stones may exist freely within pulp tissue or it may be attached to, or embedded in dentin. A single tooth may have stones ranging from 1 to 12 or even more, with sizes varying from minute particle to large masses that occlude the pulp space. 
|How to cite this URL:|
Nayak M, Kumar J, Prasad L K. A radiographic correlation between systemic disorders and pulp stones. Indian J Dent Res [serial online] 2010 [cited 2019 Sep 19];21:369-73. Available from: http://www.ijdr.in/text.asp?2010/21/3/369/70806
The prevalence of pulp stones in teeth, based on radiographic examination, has been reported to be around 20-25%, while histological examinations reveal higher percentages.  Many etiological factors have been claimed to pre-dispose pulp stone formation such as aging, caries, operative procedures, periodontal disease and epithelial rest in pulp tissue.
Pulp stones have been noted in patients with systemic or genetic disease such as dentin dysplasia, dentinogenesis imperfecta and in certain diseases such as Vander Woude syndrome.  There is also evidence that hypercalcemia, gout and renal lithiasis are pre-disposing factors to pulpal calcification.  Maura and Paiva confirmed an increased pulpal calcification in subjects with coronary atherosclerosis upon radiographic examination. Edds et al. suggested that 74% of patients with reported cardiovascular disease had detectable pulp stone, while only 39% of patients without a history of cardiovascular disease had pulp stones. 
Bernick and Nedelman found decrease in the size of pulp chamber due to the deposition of secondary dentin, with increasing age and progressive deposition of calcified masses originated in the root.  Carious lesion stimulates inflammatory changes within pulp, leading to secondary (reparative) dentin formation and increased calcification.
To date, there is no literature, which determines the association between systemic disorders and pulp stones. The purpose of this study was to determine correlation between patients with cardiovascular disorders, diabetes mellitus (Type II), autoimmune disorders, dental wear defects and pulp stones to evaluate the prevalence of pulp stone in the population of Dakshina Kannada district (Karnataka) and to determine prevalence of pulp stones in different sexes, tooth type, dental arches and sides.
| Patients and Methods|| |
A total of 150 patients were randomly selected for this study from the population of Dakshina Kannada district (Karnataka, India). The patients were between the age of 20 and 55 years. Patients suffering from cardiovascular disorders, Type II diabetes mellitus, autoimmune disorders and patients with dental-wear defects (attrition, abrasion, erosion) were also included in this study.
Patients, whose ages were above 55 years, were excluded from this study, because the incidence of pulp stone increases with age.  The scientific committee approved the study. Clearance was obtained from the ethical committee. The patients were informed and a formal written consent was obtained from all the patients. The eligibility criteria for the participation was that the patient had to have fully erupted, minimally restored, non-carious teeth, free from radiographically observable periodontal disease and pulpal sclerosis.
One hundred and fifty patients were equally divided into five equal groups.
Group I: Patients with history of cardiovascular disorders such as wise angina pectoris, myocardial infarction, heart surgery, hypertension, congestive heart failure, cerebrovascular accident, hypercholesterolemia or arrhythmia were included.
Group II: Patients with a history of diabetes mellitus, diagnosed according to WHO criteria - RBS ≥200 mg/dl or FBS ≥ 126 mg/dl or glycolated Hb (HbA 1 C) > 7% were selected.
Group III: Patients with history of Type I diabetes mellitus, autoimmune thyroiditis, Sjφgren's syndrome, SLE and multiple sclerosis were included under autoimmune disorder group.
Group IV: Patients with dental-wear defects.
Group V: Control group.
Patients of group I, II and III were differentiated from group IV patients based on clinical features. Patients with small facets on a cusp tip, ridge or incisal edge along with proximal wear, or having V-shaped defect on the cervical surface with angulated and highly polished surface were not included to rule-out any attrition or abrasion of dental tissues. Patients without any deep, narrow V-shaped notch on labial/buccal cervical surface were included to rule-out defects of abfraction among patients of group I, II and III. Patients having incisal translucency, broad concavities within smooth enamel surface were also excluded from study to eliminate erosive dental-wear defects.
Patients periapical radiograph with conventional film and radio visiograph (RVG) from full mouth series were recorded using bitewing radiographic technique and viewed over a light source under 2Χ magnification to determine the presence or absence of pulp stones.  Pulp stones were identified as definite radio opaque masses inside the pulp cavity and based on this, they were recorded as being present or absent.  [Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5] depicts presence of pulp stones in subjects of groups examined in this study. Chi-square analysis was used to compare the frequency of occurrence of pulp stones in different sexes, tooth type, dental arches and sides. Regression analysis for age was done.
In this study, 4296 teeth were analyzed and 402 (9.35%) pulp stones were detected. Groups II and III patients had lesser number of pulp stones (7.69 and 7.63%, respectively), compared to Group I patients (15.86%), Group I had maximum pulp stones (15.86%) followed by Group IV (10.94%). The least number of pulp stones were evident in control group (4.76%) as summarized in [Table 1].
| Results|| |
Correlation between systemic disorder and pulp stone
Pulp stones were found in 90 (10.41%) out of 864 teeth from the systemic disorder group and 14 (4.76%) out of 294 from the control group. Significant difference was found between systemic disorder group and control group (P < 0.05) [Graph 2]. Highest number of pulp stones among systemic disorder patients were recorded for cardiovascular patients (15.86%) in comparison to Type II diabetes mellitus (7.69%) and autoimmune disorders (7.63%) [Table 1].
Highest number of patients with pulp stones were recorded for group I (28) followed by group IV (23) and the least number of patients were recorded for group V (15). Similarly, the average number of teeth involved with pulp stones in each patient was highest in group I (4.92) followed by group IV (3.91) and lowest average was recorded for group V (2.83) [Table 1].
Age of patients for every group was ranging from 39 to 45 years [Table 2]. Mean age of patients for all the groups was 41 years without any significant relationship between age and pulp stones (P>0.05). There was a significant relationship among patients of group I (P<0.05) and group II (P<0.05). Patients of group III (P>0.05), group IV (P>0.05) and group V (P>0.05) have not shown any significant relationship between age and the presence of pulp stones.
Frequency of pulp stone occurrence in different sexes
Pulp stones were found in 222 teeth (8.89%) out of 2496 teeth in 90 males and 180 teeth (10.0%) out of 1800 teeth in 60 females. The overall occurrence of pulp stones in females (10.0% of 1800 teeth) was higher to that of males (8.89% of 2496 teeth). However, statistically there was no significant difference found between sexes (P>0.05).
Frequency of pulp stone occurrence and tooth types
Pulp stones were observed in 72 teeth (6.6%) out of 1080 premolars and 276 teeth (18.69%) out of 1476 molars. The difference was found to be statistically significant between premolars and molars (P<0.05). The frequency of pulp stones was higher in molars than premolars.
Frequency of pulp stone occurrence between sides
Seventeen percent of the subjects displayed bilateral occurrence of pulp stones. Presence of pulp stone was evident in 234 (9.39%) out of 2490 teeth on left side and 168 (9.30%) out of 1806 on right side of the arch. No significant difference was found between sides (P>0.05).
Frequency of pulp stone occurrence and dental arches
Total 282 (12.36%) out of 2280 teeth in maxillary arch and 120 (5.95%) of 2016 on mandibular arch were recorded with pulp stones and statistically, a significant difference was found between the arches (P<0.05). The total occurrence of pulp stones was higher in maxillary molars (12.36%) as compared to (5.95%) mandibular arch.
| Discussion|| |
The correlation to pulp stones has been plethoric as opposed to anemic personalities, metabolic imbalance or dysfunction, orthodontic treatment and traumatic occlusion. Generalized pulp stones are found in the dentition of individuals with various conditions. These include tumoral calcinosis, dentin dysplasia Type II, Elfin facies syndrome, familial expansile osteolysis, 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 deceased person. 
The highest numbers of pulp stones, among all the examined groups were evident in cardiovascular patients. A pilot study of the correlation of pulp stones with cardiovascular disease demonstrated that patients with cardiovascular disease have an increased incidence of pulp stones.  High incidence of calcification was reported by Maura and Paiva in the dental pulp of patients with coronary atherosclerosis upon radiographic examination. Bernick found calcification and lumen narrowing within extirpated dental pulp vessels, in both medium and small precapillary arteriole of cardiovascular patients.
Type II diabetic patients, in the present study, were detected with pulp stones higher than control group but lower than cardiovascular disorders group and dental-wear defects group. 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. 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. 
Dental-wear defects group demonstrated pulp stones lesser than cardiovascular disorder patients. Seltzer demonstrated that attrition, abrasion, erosion and trauma could accelerate dental pulp complex aging changes. The circulation and innervations can rapidly become compromised, reparative dentin can be laid down at accelerated pace, and fibrosis and calcification can occur.  Protective pulpal response to irritation, such as secondary dentin formation, results in a decrease in the size of pulp chamber, and degenerative diffuse calcification might result in reduced ability to detect pulp stones in these teeth during radiographic examination. 
Dental radiographs require minimal radiation, especially the newer digital imaging technology. Increased sensitivity of digital imaging allows decrease in the radiation dosages from 10 to 40%. IOPA radiographs were selected to determine both coronal and radicular pulp stones. In this study, the size of pulp stone ranged from small particles to calcified bodies of large diameter that occlude most of the pulp chamber. However, the true prevalence is likely to be higher than the figure from these radiographic studies, because radiographs are not likely to detect pulp stones less than 200 ΅m in diameter. But radiographs are the only means of evaluating pulp stones non-invasively in clinical studies.  Radiographic differentiation between pulp stone and pulpal sclerosis was demonstrated by White who explained that early pulpal sclerosis, a degenerative process that proceeds the formation of pulp stones, is not demonstrable radiographically. Diffuse pulpal sclerosis produces a generalized calcification throughout a large area of pulp chamber or pulp canal. However, pulp stones may be seen as a definite single or multiple radiopaque structures within the pulp chamber or root canals. 
The study sample included 4296 teeth identified in full mouth series of IOPA radiographs of patients aged between 20 and 55 years. Pulp stones were found in 9.35% of the total teeth examined. The incidence of pulp stone varies according to different studies. James et al. found pulp stones in 56% of permanent teeth. In contrast, S. Ranjitkar  found pulp stones in 10.1% of teeth examined and Tamse et al. showed that 20.7% of the teeth had pulp stones based on radiographic examination.
The frequency of pulp stones noted in males and females in this study agrees with some previous investigations , and the finding that the occurrence of pulp stones tended to be higher in molars than in premolars is consistent with other reports. , Hamasha and Darwazeh assumed that molars are the largest teeth in the arch and have a better supply of blood to pulp tissue, which may precipitate more calcification. 
In the present study, frequency of pulp stone on the right side was higher than left side, in contrast to S. Ranjitkar.  Higher frequency of pulp stones were reported in maxillary arch compared to mandibular arch, but similar frequency in both arches  or higher occurrence in mandibular arch have also been reported. 
Pulp stones have been described as symptoms of changes in the pulp tissue rather than their cause. Presence of pulp stone does not affect the threshold of electric pulp testing. The larger size of pulp stones in pulp chamber may block access to canal orifice and alter the internal anatomy. Attached stones may deflect or engage the tip of exploring instrument, preventing their easy passage down the canal. 
This study suggests that routine dental radiograph could possibly have prognostic significance or even theoretically be used as a rapid screening method for early identification of potential cardiovascular disease. 
The limitation in this present study was the small size of the sample. A larger sample size would have enabled a more detailed assessment of the relationship between pulp stones formation, caries and restorations. Other limitations were that a detailed configuration of pulp stones were not noted, and other factors that may cause pulpal irritation such as periodontal problems were not considered.
Further research is indicated to elucidate the etiological factors involved in pulp stone formation. The use of pulp stones in this branch of medicine might be enhanced if a relationship between systemic disorders and pulp stones formation could be confirmed by longitudinal studies.
| Conclusion|| |
Positive correlation was found between systemic disorder and pulp stones. The findings suggest that dental radiographic determination of pulp stones may have possibilities for early detection of systemic disorders. Such a screening method can easily be employed on a large-scale basis, as a public health measure, perhaps many years before vascular disease symptoms occur.
| Acknowledgment|| |
I would like to express my deep gratitude to Mr. S. Kotian and Ms. Rupashree Rao K for their valuable support at every stage of this research.
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Department of Conservative Dentistry & Endodontics, KVG Dental College and Hospital, Kurunjibagh Sullia, Karnataka
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]
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