TITLE: ASSESSMENT OF PULP STONES AND ITS CORRELATION WITH LOCAL FACTORS AND SYSTEMIC DISEASES- A CONE BEAM COMPUTED TOMOGRAPHIC STUDY.

PRINCIPAL INVESTIGATOR: PEETHA KRUPAVATHI

DEPARTMENT: ORAL MEDICINE AND RADIOLOGY

                                 SIBAR INSTITUTE OF DENTAL SCIENCES, GUNTUR

INTRODUCTION:

                   Pulp stones are calcified bodies in the dental pulp of the teeth, which may occur in health or disease, deciduous or permanent, one or multiple teeth, and in unerupted or impacted teeth¹. They are classified based on their location as free, adherent, and embedded pulp stones².

                  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 originating in the root. Although the exact cause for the formation of pulp stones is not clear, multiple factors such as aging, periodontal disease, various systemic diseases, genetic predisposition, bacterial infection, deep caries, restorations and orthodontic tooth movement can lead to pulp stones³.Carious lesion or irritation to the pulp stimulates inflammatory changes within pulp, leading to reparative dentin formation and increased calcification³. The presence of pulp stones and their significance with systemic diseases is still inconclusive in literature.

                   CBCT offers a sensitive diagnostic system to detect pulp stones as compared to 2-dimensional radiographic techniques⁴. Pulp stones appear radiographically as round or ovoid opacities within the pulp⁵.The prevalence of pulp stones in teeth, based on radiographic examination, has been reported to be around 20–25%.

REVIEW OF LITERATURE:

 1.Chen G et al (2022): conducted a study to assess the pulp stones in subjects with periodontal diseases using digital panoramic and periapical radiographs. They retrospectively reviewed radiological records of 465 subjects [(12,407 teeth) (271 male,194 female)] who received full mouth periodontal treatment for chronic generalized periodontitis. They concluded that pulp stones were more often seen in maxillary molar teeth and in subjects greater than 40 years of age with periodontal conditions.

 2.Gowthami Jawahar et al (2021): conducted a study to evaluate the radiological and histological features of pulp stones with clinical parameters such as age, gender, tooth involved, dental caries, trauma and also histological correlation with occurrence of pulp stones in systemic hypertension and hyperlipidemia. A total of 70 subjects (9-65 years of age) with periapical radiographs were analyzed. The results showed that there is significant association between age, trauma and caries with the presence of pulp stones and also concluded that there is a positive correlation between pulp stones and hypertension & hyperlipidemia.

 3.Kumar Chandan Srivastava et al (2020): conducted a retrospective, observational study to assess the prevalence of pulp stones with cardiovascular disease and diabetes mellitus. In this study, 3 groups were involved. Group 1, including cardiovascular diseases, group 2 including diabetes mellitus and group 3, involving the healthy control groups. A total of 229 CBCT scans (4807 teeth) were screened for pulp stones. They concluded that the prevalence of pulp stones is higher in subjects with cardiovascular diseases and older age groups (>50 years).

4.Guzide Pelin Sezgin et al (2020): conducted a retrospective study to assess the presence of pulp stones through CBCT images and to correlate their prevalence with age, sex, dental arch and side, tooth type, restoration type and depth. In this study, CBCT images were obtained from 673 subjects who had subsequently underwent diagnostic CBCT imaging. Total 11,494 teeth were examined. They concluded that the maxillary dental arches, molar teeth, medium depth restorations and individuals of age 30-39 years have higher risk of pulp stone formation.

5.Ertas ET et al (2017): conducted a retrospective clinical follow up study to assess the incidence of pulp stone formation during orthodontic treatment. A total of 545 subjects of 12-22 years of age who had undergone non extraction orthodontic treatment was selected. Pre and post treatment panoramic radiographs were collected,8442 teeth from pretreatment radiographs and 8410 teeth from post treatment panoramic radiographs were evaluated. They concluded that orthodontic treatment triggers the formation of dental pulp stones.

6.Nayak M et al (2010): conducted a prospective study to determine the radiographic association between pulp stones and systemic disorders. A total of 1432 teeth from 150 subjects of 20-55 years of age with various systemic disorders were selected. The 150 subjects were equally divided into 5 groups. Group 1, subjects with h/o cardiovascular disorders, group 2, type 2 diabetes mellitus, group 3, autoimmune disorders, group 4, dental wear defects, group 5, control group. Subjects periapical radiograph with conventional film and radio visiograph (RVG) from full mouth series were recorded. Presence or absence of pulp stones was recorded. The results showed that occurrence of pulp stones was significantly higher in subjects with cardiovascular disorders.

AIM:

To assess the presence of pulp stones and its correlation with local factors and systemic diseases.

OBJECTIVES:

1. To assess the presence of pulp stones in subjects with systemic diseases. 

2. To assess the presence of pulp stones in teeth with local factors.

3. To assess the presence of pulp stones in subjects without local factors and systemic diseases.

4. To compare the presence of pulp stones in subjects with and without local factors/ systemic diseases.

MATERIALS AND METHODS:

Source of Data:  CBCT scans of subjects taken in OMR department

Study Design: Prospective Study

Study Period: June 2022 to November 2023

INCLUSION CRITERIA:

1.Subjects >14 years of age will be included in this study.

2.Subjects who are willing to give their consent for the study.

EXCLUSION CRITERIA:

1.Systemic diseases impacting calcium levels in the body.

2.Patients under long term calcium supplements

3.Retained deciduous teeth

4.Tooth with developmental anomalies.

5.Tooth with resorbed roots.

6.Fractured teeth.

7.Teeth with metal crowns.

8. Teeth with previous root canal treatment.

9. Unerupted teeth and third molars.

Procedure:

               A structured case history will be taken of the study subjects prior to CBCT scan. All the subjects will be explained about the importance of study and a written consent form will be obtained prior to the participation of the study. All the patients will be subjected to random blood sugar level estimation. CBCT scans of subjects will be taken using Carestream CS 9300-3D machine and images will be stored in DICOM format and will be evaluated with CS Imaging software.

                Radiographic CBCT scans of study subjects will be interpreted by two maxillofacial radiologists independently to avoid inter observer variations. Individual teeth in the CBCT scan will be assessed for the presence of pulp stones and also its site, size, number and type will be recorded. Local factors such as attrition, dental caries, restoration and bone loss will also be noted.

Based on the history and CBCT scan, all the subjects will be categorized into 3 groups:

GROUP 1-Teeth (CBCT scan) of subjects with systemic diseases.

                a) Subjects with history of cardiovascular disorders such as angina pectoris,     myocardial infarction, heart surgery, hypertension, congestive heart failure, cerebrovascular accident, hypercholesterolemia or arrhythmia.

                 b)  Subjects with a history of diabetes mellitus, diagnosed according to WHO criteria – RBS ≥200 mg/dl (or) FBS ≥ 126 mg/dl (or) glycosylated Hb (HbA1 C) > 7% will be selected.

GROUP 2- Teeth (CBCT scan) of subjects with local factors such as attrition, dental caries, restoration and bone loss.

GROUP 3 – Control groups (without any local or systemic factors).

CATEGORIZATION OF TYPES OF PULP STONES ⁽²⁾:

Free pulp stone: lies freely and it is surrounded by pulp.

Embedded pulp stone: It is fully embedded in dentin and most commonly found in the apical portion of the root.

Adherent pulp stone: attached to the wall of pulp space but not fully enclosed by dentin.              

POTENTIAL RISKS: There are no significant risks associated with the study.

POTENTIAL BENEFITS:

1.As dental radiographs are taken very frequently; presence of pulp stones could be a diagnostic factor for systemic diseases.

2. Knowledge of pulp stones distribution can aid dentists in clinical procedures like root canal treatment.

STATISTICAL ANALYSIS:

            The analysis will be performed using SPSS version 20.0. The frequency of distribution of pulp stones in all the three groups will be calculated by descriptive statistics. Pearson’s chi-square test will be used to investigate the significant correlation between the incidence of pulp stones with study parameters. ANOVA test will be performed to compare the size of pulp stones in between the groups.                

REFERENCES:

1. Gin Chen , Liang-Gie Huang , Pei-Cheng Yeh . Detecting calcified pulp stones in patients with periodontal diseases using digital panoramic and periapical radiographies. J. Dent. Sci.2022 ISSN 1991-7902

2.Gowthami Jawahar et al. Clinicopathological Correlation of Pulp Stones and Its Association with Hypertension and Hyperlipidemia: An Hospital-based Prevalence Study. J Pharm Bioallied Sci. 2021;13(2: S1274.

3.Kumar Chandan Srivastava et al. Assessing the Prevalence and Association of Pulp Stones with Cardiovascular Diseases and Diabetes Mellitus in the Saudi Arabian Population-A CBCT Based Study. Int J Environ Res Public Health. 2020;17(24):9293.

4. Sezgin GP, Sönmez Kaplan S, Kaplan T. Evaluation of the relation between the pulp stones and direct restorations using cone beam computed tomography in a Turkish subpopulation. Restor Dent Endod. 2021;46(3): e34.

5. Ertas E T, Veli I, Akin M, Ertas H, Atici M Y. Dental pulp stone formation during orthodontic treatment: A retrospective clinical follow-up study. Niger J Clin Pract 2017; 20:42.

6.Nayak M, Kumar J, Prasad LK. A radiographic correlation between systemic disorders and pulp stones. IJDR. 2010;21(3):369.