Pulp calcification

Pulp stones are primarily a physiological manifestation (as are most other pulpal calcifications) and may increase in number and/or size due to local or systemic pathology.

The aetiological factors involved in their formation are still not fully apparent.

AGE CHANGES IN PULP

Pulp spaces of teeth decrease in size through the deposition of secondary and tertiary dentine.

Increase in the number of collagenous bundles in old coronal pulps occur

As a result of calcification of the blood vessels and nerves in the pulp, their numbers decrease

As part of the pulp ageing process there is also a considerable decrease in the number of cells -fibroblasts, odontoblasts and mesenchymal cells

Fat deposits occur in the pulp with age

ETIOLOGY Etiological factors for pulp stone formation are not

well understoodPulp degeneration Inductive interactions between epithelium and pulp tissueAgeCirculatory disturbances in pulpOrthodontic tooth movementIdiopathic factorsGenetic predisposition

Most possible factors are•Periodontal disease•Carious teeth•Restorative procedures•Fluoride prophylaxsis•Cardiac disease•Kidney stones

Systemic or genetic diseases such as dentine dysplasia,

Dentinogenesis imperfecta

Certain syndromes such as Van der Woude syndrome

Types of calcified bodies

• Central cavity filled with epithelial remnants and surrounded peripherally by odontoblasts

DENTICLES

• Compact degenerative masses of calcified tissuesPULP

STONES

Diffuse calcifications- amorphous and un organized linear strands of calcification They appear as amorphous irregular calcific deposits in the pulp tissue, usually following collagen fiber bundles or blood vessels. They are usually found in root canals and less often in the coronal area.

Based on morphology

TRUE DENTICLES Localized masses of

calcified tissue that resembles dentin

Resembles more of secondary dentin

More common in pulp chamber than in root canal

Seldom larger than a fraction of millimeter

usually located near the apical foramen.

FALSE DENTICLES Do not exhibit dentinal

tubules Appear as lamellae

deposited around a central nidus

Larger than true denticles May fill entire pulp

chamber

Based on location

Embedded stones are formed in the pulp but with ongoing physiological dentine formation they become enclosed (sometimes fully) within the canal wallsAdherent pulp stones are simply less attached to dentine than embedded pulp stones

Free pulp stones are found within the pulp tissue proper and are the most commonly seen type on radiographs

How pulp stone forms

Growth with timePulp stone

fibrosis

Mineralization Nidus formation

Local metabolic dysfunction

Hyalinization of injured cellsTrauma leads to vascular

damage-calcification of thrombi phleboliths form

What does stone contain

The stones were composed of two major elements: calcium and phosphorus. The average concentrations were 32.1% and 14.7%, respectively, resulting in a calcium/phosphorus weight ratio of 2.19

Other elements included fluorine (0.88%), sodium (0.75%) and magnesium (0.51%). Potassium, chlorine, manganese, zinc and iron in trace concentrations.

Clinical implications

May block access to canal orifices and alter the internal anatomy

Attached stones may deflect or engage the tip of exploring instruments

Ultrasonic instrumentation with the use of special tips makes their removal far easier

Should a stone be attached to the canal wall and a file can be passed alongside the stone, it may be removed by careful instrumentation

Pulp stones present little clinical difficulty during root canal treatment when magnification, good access and appropriate instruments are employed.