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Table of Contents   
CASE REPORT  
Year : 2012  |  Volume : 23  |  Issue : 1  |  Page : 123
A biochemical and histopathological evaluation of generalized pulp calcification in young permanent teeth


1 Department of Pedodontics with Preventive Dentistry, Faculty of Dental Sciences, CSM Medical University, Lucknow, Uttar Pradesh, India
2 Department of General Pathology, Faculty of Dental Sciences, CSM Medical University, Lucknow, Uttar Pradesh, India

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Date of Submission05-Jan-2011
Date of Decision04-Aug-2011
Date of Acceptance27-Jan-2012
Date of Web Publication26-Jul-2012
 

   Abstract 

Pulp calcifications are a frequent finding on bitewing and periapical radiographs in older age-groups but their occurrence in the entire dentition in young subjects is unusual. We report such an unusual occurrence of generalized pulp calcification in a 13-year-old Indian female. Radiographic examination of the dentition revealed pulp calcifications in all permanent teeth, located mostly in the pulp chamber but with some in the root canals. The patient's dental, medical, and family history was noncontributory. Biochemical analysis of the removed pulp calcification from one of the teeth during endodontic treatment showed large amounts of calcium, phosphorus, and carbonate. However, metabolic evaluation of patient through liver and kidney function tests and other blood investigations did not reveal any metabolic disorder. The patient was also evaluated for any systemic, syndromic, or genetic involvement but this was also noncontributory. Therefore, we propose that this unusual case of generalized pulp calcification is of idiopathic origin. In this work, histopathological and biochemical evaluations of the pulp calcification was done to try and understand the initiation and progress of calcifications in pulpal tissue.

Keywords: Generalized pulp calcification, pulp calcification, pulp stone

How to cite this article:
Bahetwar S K, Pandey RK, Singh RK, Bahetwar T S, Wahid A. A biochemical and histopathological evaluation of generalized pulp calcification in young permanent teeth. Indian J Dent Res 2012;23:123

How to cite this URL:
Bahetwar S K, Pandey RK, Singh RK, Bahetwar T S, Wahid A. A biochemical and histopathological evaluation of generalized pulp calcification in young permanent teeth. Indian J Dent Res [serial online] 2012 [cited 2015 Sep 1];23:123. Available from: http://www.ijdr.in/text.asp?2012/23/1/123/99062
Two distinct types of calcifications occur in a pulp tissue: The diffuse or linear calcification that is frequently found in radicular pulp and the pulp stones or denticles that are more commonly found in coronal pulp. [1],[2] Pulp stones or denticles are discrete islands of calcified masses that may be found in the dental pulp tissue of any tooth, deciduous or permanent, erupted or unerupted. These calcified masses may exist freely in the pulp tissue or may be attached to or embedded in the dentin. [3] They vary in number from 1 to 12 or more in a single tooth and in size from minute particles to large masses occluding the pulp chamber. [4] They can be classified structurally as true or false. True pulp stones are made up of dentine and show a lining of odontoblasts, while false pulp stones are formed from degenerating cells of the pulp that get

mineralized. [3] Despite several microscopic and histochemical studies, the exact cause of such pulp calcification remains largely unknown. [3] However, a number of conditions have been claimed to predispose to pulp stone formation, including trauma, caries, periodontal diseases, epithelial rests in pulp tissue, orthodontic tooth movement, alteration in pulpal circulation, aging, fibrosis, idiopathic factors, genetic conditions like dentine dysplasia and dentinogenesis imperfecta, and certain syndromes such as van der Woude syndrome. [5],[6],[7],[8],[9],[10],[11]

Although there are many reports in the literature concerning pulp stones, few describe cases of pulp stones appearing in all the teeth of a young person. [12],[13],[14],[15],[16],[17] This paper reports an unusual case of generalized pulp stone in a 13-year-old girl that was not associated with any metabolic disturbance or any syndrome, which suggests an idiopathic origin.


   Case Report Top


A 13-year-old female patient reported to the department of Pedodontic with Preventive Dentistry, Faculty of Dental Sciences, CSM Medical University, Lucknow, UP, India, with the chief complaint of pain in the lower left back region of the oral cavity for the last 2 months. The intraoral clinical examination showed superficial carious lesions in the mandibular left permanent first molar. Intraoral periapical radiograph [Figure 1] revealed a radiolucency confined to the enamel, along with a radiopacity within the pulp chamber that was suggestive of pulp stone. Because of this finding, radiographic examination of the entire dentition was performed by full-mouth intraoral periapical radiographs [Figure 2], which revealed pulp stones in the entire dentition, mostly in the pulp chamber but with some in the root canals of the teeth. Endodontic treatment was planned for the mandibular left permanent first and second molars with removal of the pulp stones as both these teeth were painful at night and were also non vital, as indicated by electric pulp tester (Digitest™, model No. D626D; Parkell Electronics). However, the remaining asymptomatic teeth were left untreated. The removed pulp stones were sent to the laboratory for biochemical and histopathological analyses. At the same time the patient was also evaluated for any systemic metabolic disorder by performing liver function tests (LFT), kidney function tests (KFT), and other blood investigations, all of which were however normal.
Figure 1: Initial periapical radiograph of 36 shows presence of superficial caries and pulp calcification

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Figure 2: Full-mouth periapical radiograph shows generalized pulp calcifications

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Histopathological examination of the stone revealed the presence of mature calcified tissue at the periphery and immature calcified tissue at the core of the pulp stone [Figure 3]. For biochemical analysis the pulp stone was demineralized in 30% hydrochloric acid for 90 min and the solution was sent for biochemical estimation of calcium, phosphorus, and magnesium. The residual pulp stone from the above demineralized solution was further immersed in 100% hydrochloric acid for 36 h and the solution was sent for biochemical estimation of calcium, phosphorus, sodium, potassium, and magnesium. A comparison of the results of the above analysis revealed that at the core of the pulp stone the concentration of calcium (9.42 mEq/l) was lower than at the periphery (13.22 mEq/l), while the concentrations of sodium (298 mmol) and magnesium (8.50 mEq/l) were higher at the core (Na 282 mmol and Mg 6.53 mEq/l). The remnants of the fully demineralized pulp stone were subjected to histopathological examination, which showed the fibrin meshwork of pulpal tissue with entrapped erythrocytes and damaged mesenchymal cells [Figure 4].
Figure 3: Presence of mature and immature calcified tissues at the periphery and the core of the pulp stone

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Figure 4: Fibrin meshwork of pulpal tissue with entrapped erythrocytes and damaged mesenchymal cells

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Radiographic examinations of patient's sister and parents were also performed to rule out any genetic inheritance.


   Discussion Top


In this paper we report generalized pulp calcification in the young permanent dentition of a 13-year-old child. Generally, pulp calcification is seen in older age-groups and in association with certain syndromes but, in the present case, although the calcification was generalized there was no evidence of any genetic, systemic, or metabolic disorder in the patient. Thus, we suggest that in this case the generalized pulp calcifications are of idiopathic origin.

The previous case reports in literature [12],[13],[14] have not placed much emphasis on the initiation and progression of pulp calcification and hence we make an attempt to explain how calcifications in pulpal tissue occur. The removed pulp stone was subjected to sequential demineralization and the supernatant was subjected to biochemical analysis, while the tissue remnant was sent for histopathological examination.

The biochemical estimation of calcium, magnesium, phosphorus, sodium, and potassium in the pulp stone revealed values of 11.82 mEq/l, 7.83 mEq/l, 1.22 mEq/l, 291 mmol/l, and 0.2 mmol/l, respectively. The relatively low concentration of magnesium affects the pulp tissue and induces localized degeneration, with subsequent formation of pulp stone. The relatively high concentration of Na + (average: 291 mmol/l) and low concentration of K + (average: 0.2 mmol/l) in the pulp stone may be an indication of the extreme ionic imbalance in the localized area of pulp, which initiates the precipitation of Ca ++ ion to form a nidus. This nidus might increase gradually in size to form a well-defined pulp stone mass in the high vascularized pulp tissue of young permanent teeth.

Klein et al., [18] has confirmed that a diet containing 13 ppm of magnesium caused various stages of degeneration in ameloblasts, labial to the growing apices of the roots of teeth. The present study is consistent with this finding, with the relatively high concentration of magnesium entrapped in the core of the pulp stone initiating the degeneration: Disturbing the local ionic balance and leading to the formation of pulp stones.

The findings of the biochemical and histopathological analyses of the pulp stones in this case is in accordance with the findings of Ninomiya et al., [19] who described the presence of organic matrix with entrapped cells in pulp stone. Schroeder [20] has described the variations in the size and morphology of the crystallites that compose the pulp stone; these represent different forms of calcium phosphate as seen in the periphery and core of the pulp stone in the present case report.

 
   References Top

1.Walton RE, Torabinejad M. Principles and practice of endodontics. Philadelphia: Saunders; 1989:18:162-3.  Back to cited text no. 1
    
2.Cohen S, Burns RC. Pathways of the pulp. St Louis: Mosby; 1984. p. 367-71.  Back to cited text no. 2
    
3.Goga R, Chandler NP, Oginni AO. Pulp stones: A review. Int Endod J 2008;41:457-68.  Back to cited text no. 3
[PUBMED]    
4.Ranjitkar S, Taylor JA, Townsend GC. A radiographic assessment of the prevalence of pulp stones. Aust Dent J 2002;47:36-40.  Back to cited text no. 4
[PUBMED]    
5.Sayegh FS, Reed AJ. Calcification in the dental pulp. Oral Surg Oral Med Oral Pathol 1968;25:873-82.  Back to cited text no. 5
[PUBMED]    
6.Bernick S, Nedelman C. Effect of aging on the human pulp. J Endod 1975;3:88-92.  Back to cited text no. 6
    
7.Bernik S. Age changes in the blood supply to human teeth. J Dent Res 1967;46:544-50.  Back to cited text no. 7
    
8.Sundel Jr, Stanley HR, White CL. The relationship of coronal pulp stone formation to experimental operatory procedures. Oral Surg Oral Med Oral Pathol 1968;25:579-89.  Back to cited text no. 8
    
9.Stenvik A, Major IA. Epithelial remnants and denticles formation in the human dental pulp. Acta Odont Scand 1970;28:721-8.  Back to cited text no. 9
    
10.Seltzer S, Bender JB. The dental pulp, 3 rd ed. Philadelphia: USA: J.B. Lippincott; 1985.  Back to cited text no. 10
    
11.Kantaputra PN, Sumitsawan Y, Schutte BC, Tochraeontanaphol C. Vander woude syndrome with sensorineural hearing loss, large craniofacial sinuses, dental pulp stones and minor limb anomalies: Reports of four -generation Thi family. Am J Med Genet 2002;108:275-80.  Back to cited text no. 11
    
12.Siskos GJ, Georgopoulou M. Unusual case of general pulp calcification (pulp stones) in young Greek girl. Endod Dent Traumatol 1990;6:282-4.  Back to cited text no. 12
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13.Piattelli A. Generalized "complete" calcific degeneration or pulp obliteration. Endod Dent Traumatol 1992;8:259-63.  Back to cited text no. 13
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14.Weiss LR. Unusual case of pulp stones. D Cosmos 1927;69:750-2.  Back to cited text no. 14
    
15.Hitchin AD. Pulp stones in every tooth in a girl of 13 years. Br Dent J 1936;61:539-41.  Back to cited text no. 15
    
16.Rao S, Witcop C, Yamane G. Pulpal dysplasia. Oral Surg Oral Med Oral Pathol 1970;30:682-9.  Back to cited text no. 16
    
17.Tsatsas B. An unusual general pulp calcification (pulp stones). Report of a case. Odont Progr 1971;6:314-9.  Back to cited text no. 17
    
18.Klein H, Orent E, McCollum EV. The effects of magnesium deficiency on the teeth and their supporting structures in rats. Am J Phsiol 1935;112:256.  Back to cited text no. 18
    
19.Ninomiya M, Ohishi M, Kido J, Ohsaki Y, Nagata T. Immunohistochemical localization of osteopontin in human pulp stones. J Endod 2001;27:269-72.  Back to cited text no. 19
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20.Schroeder HE. Crystal morphology and gross structures of mineralizing plaque and of calculus. Helv Odontol Acta 1965;9:73-86.  Back to cited text no. 20
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Correspondence Address:
S K Bahetwar
Department of Pedodontics with Preventive Dentistry, Faculty of Dental Sciences, CSM Medical University, Lucknow, Uttar Pradesh
India
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