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Nupura, Vibhute, Daule, Bansal and Mahalle, J Pat Care 2016, 2:1
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DOI: 10.4172/2573-4598.1000105
ISSN: 2573-4598

Review Article Open Access

Hard Facts about Stones: Pulpal Calcifications: A Review

Nupura Aniket Vibhute1*, Vibhute Aniket H2, Daule RajendraT3, Bansal Puja P4 and Mahalle Aditi5
1Department of Oropathology and Microbiology, Kims University, Hyderabad, India
2Department of Orthodontia, Bharati Vidyapeeth Dental College And Hospital, Pune,Maharashtra, India
3Department of Conservative Dentistry, Bharati Vidyapeeth Dental College And Hospital, Pune,Maharashtra, India
4Department of Oral Pathology and Microbiology, Schiool of Dental Sciences, Sharda University, Greater Noida, India
5Department of Oral Pathology and Microbiology, Dr. D. Y. Patil Dental College and Hospital, Pimpri, Pune, India
*Corresponding author: Vibhute NK, Department of Oropathology and Microbiology, Kims University, Hyderabad, India, Tel: 919637689097; E-mail:
[email protected]
Received date: Nov 13, 2015, Accepted date: Dec 30, 2015, Published date: Jan 7, 2016
Copyright: © 2016 Vibhute NK, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Pulp calcifications stones are discrete calcifications within the pulps of teeth. They are a frequent finding on
bitewing and periapical radiographs. Johnson and Bevelander stated that 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. They
often develop in teeth that appear quite normal in other respects. They have been seen in both functional as well as
embedded teeth. Inspite of this frequent occurrence, they have received relatively little attention in textbooks. The
purpose of this review was to examine these pulp stones from all the aspects including their pathogenesis, clinical
aspects, histopathology, current perspectives and contemporary research on the same.

Keywords: Pulp stones; Denticles; Pulp calcifications In a radiographic assessment of the prevalence of pulp stones in a
group of Turkish dental patients by Gulsahi et al., [5], it was found that
Introduction as age increased, the prevalence of pulp stones increased (P<0.01).
Molars had statistically more pulp stones than premolars and incisors
Pulp calcifications stones are nodular, calcified masses appearing in (P<0.001).
either or both the coronal or root portions of the pulp organ. They
often develop in teeth that appear quite normal in other respects. They Hamasha and Darwazeh [6] assumed that molars are the largest
have been seen in both functional as well as embedded teeth. They are teeth in the arch and have a better supply of blood to pulp tissue, which
usually asymptomatic unless they impinge on the nerves or blood may precipitate more calcification.
vessels. Johnson and Bevelander [1] stated that a single tooth may have In the study by Nayak et al., [7], frequency of pulp stone on the right
stones ranging from 1 to 12 or even more, with sizes varying from side was higher than left side, which is in contrast to findings by
minute particle to large masses that occlude the pulp space. Despite a Ranjitkar [8]. Higher frequency of pulp stones were reported in
number of microscopic and histochemical studies, the exact cause of maxillary arch compared to mandibular arch by Nayak et al., [7], but
such pulp calcifications remains largely unknown. Thus, the purpose of similar frequency in both arches [9] or higher occurrence in
this review is to examine these pulp stones from all the aspects mandibular arch have also been reported [10].
including their pathogenesis, clinical aspects, histopathology, current
perspectives and contemporary research on the same. Pulp stones extending to the entire dentition are infrequent.
Radiographic diagnosis and a multidisciplinary approach are of
paramount importance for successful treatment in cases of generalized
Incidence pulp stones.
A number of studies have been carried out to determine the actual Donta et al., [11] presented a mildly mentally retarded patient with
incidence of pulp calcifications, and the results of these investigations generalized pulp stone formation with a six-year follow-up in whom
are in essential agreement. For example Wilman [2] reported that of a pulp stones were radiographically detected in the pulp chamber of all
series of 164 teeth picked at random and examined histologically, 143 permanent teeth. They advocated that such patients should be referred
(or 87%) exhibited calcification ins the pulp. Interestingly only 15% of for genetic evaluation because pulp stones are mostly associated with
the areas of calcification were large enough to be seen on the dental genetic dentine defects.
radiograph. These findings confirm the investigations of Hill [3], who
reported calcifications in 66% of all teeth examined in young persons Ozkalayci et al., [12] presented a report of an unusual case of a 13-
between ages of 50 and 70 years. There is no apparent difference in the year-old girl with generalized pulp stones with clinically normal
frequency of occurrence either between genders or among teeth in the crowns. Orthodontic treatment, gingivoplasty, and esthetic restorations
dental arch. were performed, thus using a multidisciplinary approach to establish
functionally and esthetically sound dentition.
According to one estimate, 66% of teeth in persons 10 to 30 years of
age, 80% in those between 30 and 50 years and 90% in those over 50
years contain calcifications of some type [4].

J Pat Care, an open access journal Volume 2 • Issue 1 • 1000105

ISSN:2573-4598
Citation: Nupura Aniket Vibhute, Vibhute Aniket H, Daule RajendraT, Bansal Puja P and Mahalle Aditi (2016) Hard Facts about Stones: Pulpal
Calcifications: A Review. J Pat Care 2: 105. doi:10.4172/2573-4598.1000105

Page 2 of 4

Etiology False denticles are composed of localized masses of calcified

material and unlike true denticles do not exhibit tubules. Instead the
The etiology of various types of pulp calcifications is unknown. nodules appear to be made up of concentric lamellae or layers
Although the incidence appears to increase with age of the persons, deposited around a central nidus. The exact nature of this nidus is
there is no definite association with pulpal irritation or inflammation unknown, although Johnson and Bevelander believe it is composed of
such as that arising from caries or trauma. Since pulp calcifications cells , as yet unidentified, around which is laid down a layer of reticular
have been reported from unerupted teeth, it is doubtful whether pulpal fibers that subsequently calcify [16].
disease such as inflammation is of any significance.
False denticles may be also further classified into free or attached.
Kretschmer and Seybold [13] reported that an extremely high Sometimes as the concentric deposition of calcified material continues,
percentage of pulp stones yield a pure streptococci upon culture. On it approximates and finally is in apposition with the dentinal wall. Here
this basis it has been suggested that microorganisms are the cause of it may eventually become surrounded by secondary dentin, and is
pulp calcifications. Since the pulps of affected teeth were reportedly referred to as interstitial denticle. False denticles, which occur more
normal, aside from the calcification, and since it is well recognized that commonly in the pulp chamber than in the root canal, are generally
bacteria may be forced into the pulp tissue at the time of tooth somewhat larger than true denticles. They may fill nearly the entire
extraction, it is most unlikely that bacteria are of any significance in pulp than true denticles which are seldom larger than a fraction of a
the development of these pulp nodules. millimeter in diameter [16].
Stafne and Szabo [14] attempted to correlate pulp nodules with Johnson and Bevelander concluded from their studies that a
various local or systemic diseases including cholelithiasis, renal differentiation between true and false denticles should not be drawn,
lithiasis, arteriosclerosis, gout, acromegaly, osteitis deformans, since all denticles originally show no tubules even though subsequently
hypercementosis, and torus mandibularis or palatinus. Their data may become surrounded by tissue containing dentinal tubules [1].
indicates that no clear-cut relation exists between any of these
conditions and pulp calcification. Diffuse Calcifications are most commonly seen in the root canals of
teeth and resemble the calcification seen in other tissues of the body
Sundell et al., [15] and his associates attempted to determine following degeneration. This type of calcification is frequently termed
whether the degree of pulp response elicited by cutting procedures and calcific degeneration. Its usual pattern is amorphous, unorganized
restorative materials was capable of increasing the incidence of pulp linear strands or columns paralleling the blood vessels and nerves of
stone nidi and pulp stones. They found no significant correlation pulp [16].
between pulp stones or nidi and the age and gender of the patient, the
thickness of remaining dentin, beneath the cavity preparation, the
preparation time, or the traumatic potential of the operative
Histopathology
procedure. In addition, these workers proposed a combination of Denticles consist of tubular dentin surrounding a central nest of
several hypotheses from literature including thrombosis or vascular epithelium. With time, the central epithelium degenerates and the
wall injury or both, leading to pulp stone formation. tubules undergo sclerosis, making their detection difficult [17].
A theory has been advanced that the development of true denticle is Pulp stones demonstrate a central amorphous mass of irregular
caused by inclusion of remnant s of epithelial root sheath within the calcification surrounded by concentric lamellar rings of regular
pulp. These remnants induce the cells of the pulp to differentiate into calcified material. Occasionally, a peripheral layer of tubular dentin
odontoblasts, which form dentin masses called pulp stones [4]. may be applied by odontoblasts, which arise from the surrounding
pulp tissue in response to the presence of the pulp stone; in addition
Types/Classification fibrillar irregular calcified material may also be evident on the
periphery of pulp stones [17].
The two chief morphologic forms of pulp calcifications are discrete
pulp stones (pulp nodules, denticles) and diffuse calcifications. Pulp Diffuse linear calcifications consist entirely of fine, fibrillar and
stones are classified as per their structure into true denticles and false irregular calcifications that develop in pulp chambers and canals. This
denticles. material is often deposited in a linear fashion along the course of blood
vessel or nerve [17].
True denticles are made up of localized masses of calcified tissue
that resemble dentin because of their tubular nature. Actually these
tubules bear greater resemblance to secondary dentin than to primary
Primary Teeth and Pulp Stones
dentin, since the tubules are few and irregular. They are considerably In recent times, there have been many studies dealing with pulp
more common in pulp chamber than in root canal [16]. stones in the deciduous dentition. One hundred and twenty primary
True denticles may be further classified into free or attached. maxillary and mandibular extracted teeth were collected to study the
Denticles lying entirely within the pulp tissue and not attached to the occurrence and nature of pulp calcifications by Kumar et al., [18] The
dentinal walls are called free denticles, while those continuous with the teeth were serially sectioned, stained with hematoxylin and eosin,
dentinal wall are referred to as attached denticles. examined by light microscope. Pulp calcifications were observed in 31
(25.8%) teeth. Two types of pulp calcifications were noticed i.e., diffuse
Attached denticles are thought to be more common than the free calcifications and free/attached type denticles. They concluded that the
denticles. However it should be remembered that though a denticle low prevalence of pulp calcifications in the primary teeth supported
may appear free in one plane of section in which it is visualized it may the view that pulp calcification increases as the age advances.
be attached in another plane. Thus, without serial sections on an entire
tooth pulp, one cannot state with any degree of assurance that a given Similar findings were stated by Yaacob and Hamid [19] who
denticle is free or attached. examined 120 primary teeth and found that only 6.7% of the teeth had

J Pat Care, an open access journal Volume 2 • Issue 1 • 1000105

ISSN:2573-4598
Citation: Nupura Aniket Vibhute, Vibhute Aniket H, Daule RajendraT, Bansal Puja P and Mahalle Aditi (2016) Hard Facts about Stones: Pulpal
Calcifications: A Review. J Pat Care 2: 105. doi:10.4172/2573-4598.1000105

Page 3 of 4

pulp stones, with 11.7% having some diffuse calcification. Given that dentin formation, results in a decrease in the size of pulp chamber, and
the size of the pulp stones ranged from 0.05 to 3.3 mm, it is likely that degenerative diffuse calcification might result in reduced ability to
the radiographic prevalence of pulp stones would be very low. detect pulp stones in these teeth during radiographic examination [8].
In contrast, Arys et al., [20] found that age did not have any
influence on the occurrence of pulpal calcifications. They examined 42 Clinical Significance
primary molars and their results revealed that pulp stones were present The clinical significance of pulpal calcification is not completely
in 78% of the molars, with 95% of the material showing some form of understood. It has been reported upon numerous occasions that pulp
pulpal calcification. There was a lower incidence of pulp stones in stones are a cause of pain, varying from mild to severe excruciating
treated and carious molars, which might be related to tertiary dentine pain [16]. Given the association between pulp stones and nerve tissue,
formation or the low number of caries-free teeth. Further, in contrast both in terms of pulp stone formation and nerve fibre entrapment, it
to the Yaacob and Hamid [19] study, free or attached pulp stones were has been suggested that some pain of an idiopathic nature may be
the most common type of calcification (as opposed to diffuse). caused by pulp stones [28].
Holtgrave et al., [21] found a correlation between extensive pulp The consensus is that though denticles may seem to impinge on the
calcification and post-natally initiated fluoride prophylaxis, although nerves of the pulp, they probably do not. Therefore the extraction of
the duration of tablet fluoridation (1-10 years) had no statistically teeth with radiographically demonstrable pulp stones in the hope of
significant influence on pulp calcification. pain relief cannot be defended [16].
Thus even though there are contrasting findings regarding Along similar lines, pulp stones have been compared to kidney and
occurrence of pulpal calcifications in primary teeth, the dominant gall bladder stones [29], but a much higher incidence of unexplained
results conclude that the prevalence and complexity of pulpal dental pain would be expected, given the high prevalence of pulp
calcification increases with age and has a large physiological stones and pulp calcifications. Pulp stones have been described as
component [22]. symptoms of changes in the pulp tissue, rather than their cause [30].
The presence of pulp stones or diffuse calcifications does not affect
Association with Systemic Conditions
the threshold of electric pulp testing [31].
Pulp stones have been noted in patients with systemic or genetic
However difficulty is frequently encountered in extirpating the pulp
disease such as dentin dysplasia, dentinogenesis imperfecta and in
during root canal therapy if calcifications are present.
certain diseases such as Vander Woude syndrome [23].
Attached stones may deflect or engage the tip of exploring
There is also evidence that hypercalcemia, gout and renal lithiasis
instruments, preventing their easy passage down the canal [32].
are pre-disposing factors to pulpal calcification [24].
Sometimes a large pulp stone can be dissected out of an access cavity
Edds et al., suggested that 74% of patients with reported using burs, but ultrasonic instrumentation with the use of special tips
cardiovascular disease had detectable pulp stone, while only 39% of makes their removal far easier [33,34].
patients without a history of cardiovascular disease had pulp stones.
Should a stone be attached to the canal wall and a file can be passed
This finding suggests the usefulness of dental radiographs to identify
alongside the stone, it may be removed by careful instrumentation
patients with cardiovascular disease for further screening and
[35].
evaluation [25].
Generally speaking however, pulp stones present little clinical
Bernick found calcification and lumen narrowing within extirpated
difficulty during root canal treatment when magnification, good access
dental pulp vessels, in both medium and small precapillary arteriole of
and appropriate instruments are employed.
cardiovascular patients [22].
Russell had investigated human pulp histologically on non-carious Conclusions
extracted teeth of seven patients suffering from diabetes for a long-
term duration and control group of 13 non-diabetics. He concluded Thus, pulp stones are mainly a sign of ageing of human pulp. They
that calcification in angiopathies and thickened basement membrane appear to be a part of normal physiological age changes in the body.
were noted in both large and small blood vessels, and vascular changes This review has examined the various aspects of pulp stones including
seemed more pronounced in the central area of the pulp. Calcifications its types, etiology, incidence, relationship with primary dentition,
in diabetics were frequent and often sickle-shaped. In another correlation with systemic conditions and its clinical implications.
histopathological study, conducted by Bissada and Sharawy's on 21 However further research is still required, especially in the treatment
human dental pulps of diabetics and 20 matched controls, no vascular point of view to enable increased success rate of endodontic therapy.
changes groups were found in the dental pulp of both. However,
amorphous calcified bodies in the pulp of diabetics were found. Dental References
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J Pat Care, an open access journal Volume 2 • Issue 1 • 1000105

ISSN:2573-4598
Citation: Nupura Aniket Vibhute, Vibhute Aniket H, Daule RajendraT, Bansal Puja P and Mahalle Aditi (2016) Hard Facts about Stones: Pulpal
Calcifications: A Review. J Pat Care 2: 105. doi:10.4172/2573-4598.1000105

Page 4 of 4

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J Pat Care, an open access journal Volume 2 • Issue 1 • 1000105

ISSN:2573-4598