MANAGEMENT OF CALCIFIED PULP CANAL

Overview of management of a calcified pulp chamber and canal endodontically

1. MANAGEMENT OF CALCIFIED PULP CANAL OGUNLADE.T

2. OUTLINE INTRODUCTION CAUSES OF PULP CALCIFICATION CLINICAL FEATURES MANAGEMENT CONCLUSION REFERENCES

3. INTRODUCTION Pulp calcifications stones are nodular, calcified masses appearing in either or both the coronal or root portions of the pulp organ Pulp stones are primarily a physiological manifestation and may increase in number and/or size due to local or systemic pathology. Other names; Calcific metamorphosis (CM ), pulp canal obliteration, Pulp stones

4. INTRODUCTION Calcification is a process involving the reduction in size of the intra-dental cavities as a result of hard-tissue formation by the cells of the vital pulp. It may ends in complete calcification as a result of dentin deposition inside the tooth Stones may exist freely within the pulp tissue or be attached to or embedded in dentine

5. INTRODUCTION Calcification of the dental pulp may be discrete or diffuse in its form. Discrete calcification results in the formation of pulp stones, denticles , or nodules. Diffuse calcification results in a symmetric reduction in the size of the pulp chamber and the radicular pulp space, which is more commonly observed in older patients.

6. INTRODUCTION A single tooth may have from 1 to 12 or even more stones , with sizes varying from minute particles to large masses which occlude the pulp space Their large size in the pulp chamber may block access to canal orifices and alter the internal anatomy . Attached stones may deflect or engage the tip of exploring instruments, preventing their easy passage down the canal

7. INTRODUCTION Two types of calcified bodies in the dental pulp have been described; Denticles possessing a central cavity filled with epithelial remnants surrounded peripherally by odontoblasts A nd pulp stones being compact degenerative masses of calcified tissues

8. INTRODUCTION O ccur more often in the coronal region but are also found in the radicular pulp They have been seen in both functional as well as embedded teeth Common in molars than premolars and incisors They have also been noted in patients with systemic or genetic diseases such as dentine dysplasia, dentinogenesis imperfect and in certain syndromes such as Van der Woude syndrome

9. 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 T he collagen bundles of vascular and neural sheaths of old pulps were the loci for calcification 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 such as fibroblasts, odontoblasts and mesenchymal cells with the cell density decreasing by half from 20 to 70 years Fat deposits occur in the pulp with age

10. CONTENT OF PULP STONES The stones were composed of two major elements: C alcium and phosphorus. The average concentrations were 32.1% and 14.7%, respectively Other elements included fluorine (0.88%), sodium (0.75 %) and magnesium (0.51%). Potassium, chlorine, manganese , zinc and iron in trace concentrations.

11. TYPES PULP STONES Pulp stones can be structurally classified and based on location Structurally, there are T rue and F alse pulp stones; the distinction being morphological A third type, ‘diffuse’ or ‘amorphous ’ pulp stones, is more irregular in shape than false pulp stones, occurring in close association with blood vessels

12. TYPES PULP STONES True pulp stones are made of dentine and lined by odontoblasts F alse pulp stones are formed from degenerating cells of the pulp that mineralize

13. TYPES PULP STONES Based on location, pulp stones can be embedded, adherent and free Embedded stones are formed in the pulp but with ongoing physiological dentine formation they become enclosed (sometimes fully) within the canal walls They are found most frequently in the apical portion of the root, and the presence of odontoblasts and calcified tissue resembling dentine can occur on the peripheral aspect of these stones

14. TYPES PULP STONES Adherent pulp stones are simply less attached to dentine than embedded pulp stones The difference between adherent and embedded can be subjective, but adherent stones are never fully enclosed by dentine. Adherent and embedded pulp stones can interfere with root canal treatment if they cause significant occlusion of canals or are located at a curve They may also become dislodged

15. TYPES PULP STONES Free pulp stones are found within the pulp tissue proper and are the most commonly seen type on radiographs They are very common and vary in size from 50µm in diameter to several millimetres when they may occlude the entire pulp chamber

16. TYPES PULP STONES Stones can be further subdivided into those with distinct concentric laminations and those without distinct laminations. Laminated pulp stones are not usually associated with smaller pulp stones , whereas nonlaminated stones are rougher and may have smaller stones attached to their surfaces This is in agreement with Pashley & Liewehr (2006) who histologically recognized two types of stones: those that are round or ovoid, with smooth surfaces and concentric laminations And those that assume no particular shape, lack laminations and have rough surfaces.

17. CAUSES Dental pulp calcification may occur in response to both local as well as systemic factors. Local factors include caries, cavity preparation, the presence of restorations, and excessive forces caused by clenching and trauma Pulpal calcification is a common phenomenon that occurs in young patients’ teeth following calcium hydroxide ( Ca (OH)2 ) pulpotomy therapy The increased number of calcium ions leads to the reduction in capillary permeability, which will fail to operate the pyrophosphatase enzyme leading to uncontrolled mineralization

18. CAUSES Ca (OH)2 is characterized by its ability to induce reparative bridge formation when applied to vital pulpal tissues However, the pulp chamber and the pulp canal entrances can be subjected to dystrophic calcification after being exposed to Ca (OH)2 for a long period It was suggested that the high alkaline pH level of Ca (OH)2 irritates the pulp cells and activates the release of bioactive molecules, which stimulate pulpal repair and therefore induce mineralization

19. CAUSES Systemic factors include hypercalcemia , gout, and end-stage renal diseases have also been linked with pulp calcification

20. CAUSES Etiological factors for pulp stone formation are not well understood Pulp degeneration Age Prolonged infection Non Vital tooth without Endodontic treatment for many years Circulatory disturbances in pulp Orthodontic tooth movement Idiopathic factors Genetic predisposition dentine dysplasia, Dentinogenesis imperfect, Van derWoude syndrome

21. CLINICAL FEATURES Generally, pulp calcification has no symptoms and may be noted via tooth discoloration or routine examination visible yellowish discoloration due to a decrease in tissue transparency Also the response to thermal stimuli and electric pulp tests can be diminished or even absent which may lead to difficulties to make a diagnosis

22. MANAGEMENT There is controversy regarding whether endodontic treatment is indicated for teeth with pulpal calcification Some authors recommend treatment only after appearance of symptoms and radiography shows apical bone rarefaction. However , others believe that immediate endodontic treatment is indicated because pulpal calcification may develop into an infection

23. EVALUATION Conventional radiographs ( periapical , bitewings) The use of conventional radiographs often do not give a clear picture of the actual root canal anatomy because of its inherent limitations Since the conventional radiographs are the representation of a three dimensional structure by a two-dimensional (2D ) image I t does not provide an accurate depiction of the internal anatomy of the root canal

24. EVALUATION Cone beam computer tomography (CBCT ) This is an accurate diagnostic tool in endodontics as it eliminates the superimposition of anatomic structures Can aid in evaluating the extent and nature of calcification, depth of calcification and can guide the clinician to access the patent portion of the canal It can reveal the internal morphology of the root canal better

25. EVALUATION CBCT can be a valuable tool in the diagnosis, treatment and prognosis of teeth with pulpal calcification Despite the advantages offered by CBCT when compared with conventional radiographs, it should be used carefully, to gain most useful information for diagnosis and the radiation exposure to patient should be at the least possible level

26. EVALUATION W ith CBCT scan we can scroll through the entire volume and simultaneously view axial, coronal , and sagittal 2-D sections that range from 0.125–2.0 mm thick. The axial and proximal areas which are generally not seen with conventional periapical radiography can be revealed by CBCT .

27. EVALUATION CBCT scanning provides an excellent imaging method to detect differences in external and internal dental anatomy. The ability to visualize the area of interest in thin sections eliminates the superimposition of surrounding structures, like dentin and surrounding bone to better understand the root canal morphology

28. TREATMENT The various treatment approaches in teeth with pulp calcification are as follows; Wait and watch Nonsurgical approach S urgical approach N on-surgical followed by surgical approach T he choice of treatment is mainly dependant on the periapical status and canal patency of the affected teeth Depending on critical information revealed by CBCT clinician can decide whether to go for a surgical or non-surgical treatment

29. T he patients’ aesthetic requirement also plays a key role in the choice of the treatment. The different options to address the aesthetic concerns of patients associated with pulp calcification are ; E xternal bleaching E ndodontic treatment followed by internal bleaching I nternal and external bleaching without root canal treatment F ull/partial coverage restorations (crown/veneer)

30. External bleaching is slow and less predictable due to the nature of discoloration. I nternal bleaching without root canal therapy has been mentioned as a likely treatment option It has not gained much support due to the possibility of secondary intraradicular infection.

31. The difficulty in obtaining the accurate shade and removal of intact tooth structure are the drawbacks of extra-coronal restoration (full coverage crowns/veneers) in masking the discoloration. Intra-coronal bleaching after root canal therapy not only provides seal thus prevent secondary root canal infection, but also removes tertiary dentin from the pulp chamber thus contributing to the faster action of the bleaching agent

32. TREATMENT contd WAIT AND WATCH Since more than three-fourth of the teeth with pulp canal obliteration are asymptomatic , no therapeutic intervention is usually indicated, except for periodic radiographic monitoring In the absence of any additional signs or symptoms, pulp stones should not be interpreted as a disorder requiring endodontic therapy

33. TREATMENT contd NONSURGICAL APPROACH Teeth that are symptomatic (tender on percussion) and/or have associated periapical lesion requires active therapeutic intervention Conventional non-surgical endodontic therapy is the treatment of choice as it is can eliminate the foci of infection from the root canal space

34. TREATMENT contd SURGICAL APPROACH In cases where the canal cannot be located , a surgical intervention is required as it offers direct access to the periradicular area This include Apicectomy , curettage or retrograde filling.

35. TREATMENT contd NON-SURGICAL FOLLOWED BY SURGICAL APPROACH In cases where there is persistence of infection even after non-surgical treatment a surgical approach is necessitated

36. NONSURGICAL APPROACH The management of teeth with obliterated pulp chamber and calcified canals, which require root canal treatment, is a challenging therapy

37. STAGES OF TREATMENT Preparation of an adequate access cavity I dentification of the canal orifices Biomechanical preparation Obturation

38. ACCESS CAVITY PREPARATION After initial clinical and radiographic examination, the quality of the coronal restoration if present should be checked and insufficient restorations should be removed, decayed hard tissue completely excavated Access cavity preparation should be performed parallel to long axis of the tooth using diamond burs in a high-speed contra angle hand-piece with water cooling under rubber dam isolation Calcifications in the pulp chamber can be gently removed with a round diamond-coated high-speed bur or diamond-coated ultrasound tips

39. IDENTIFICATION OF THE CANAL ORIFICES After gaining access to the pulp chamber, its roof must be completely removed The pulp chamber floor must be dried by air stream and carefully inspected in order to localise colour changes that may indicate the way to the orifice of the root canal. Locate the canal orifices This can be achieved with the aid of the following; D ental operating microscopy (DOM) U ltrasonic tips (US ) Dental probe

40. IDENTIFICATION OF THE CANAL ORIFICES Dental operating microscopy (DOM )/endodontic microscope offers magnification and lighting U ltrasonic tips allow working at greater depth within the pulp chamber safely, with a low risk of iatrogenic injury In contrast to drills, it provide a more conservative approach to conventional treatment US tips do not rotate inside the canal, ensuring greater security and control while maintaining their cutting efficiency

41. IDENTIFICATION OF THE CANAL ORIFICES It help in breaking up calcifications covering the canal opening, which allows safe access to deeper areas , with enough safety and minimal wear, and the identification of dental structures By scouting the pulp floor gently with stainless steel hand instruments, canal orifice can be localized

42. IDENTIFICATION OF THE CANAL ORIFICES However, in some situations, despite all of these resources and the skills and expertise of the operator, ( CBCT) is necessary and allows 3D images without overlapping adjacent structures This facilitates the identification of the canals, their directions, degrees of obstruction and dimensions

43. BIOMECHANICAL PREPARATION This involves removal of debri from the root canal and shaping of the canal for final obturation This can be achieved with the use of the following; Files and Reamers Chelating agent Root canal irrigants

44. CHELATING AGENTS Chelating agents were introduced into endodontics as an aid for the preparation of narrow and calcified root canals in 1957 by Nygaard-Ostby A liquid solution of ethylene- diamine -tetra-acetic acid (EDTA) was thought to chemically soften the root canal dentine and dissolve the smear layer, as well as to increase dentine permeability Irrigation of the RC with 15-17% EDTA solution to dissolve the smear layer is recommended by many authors

45. CHELATING AGENTS Chelators bind to and inactivate metallic ions Chelator preparations include the following; LIQUID CHELATORS Calcinase contains 17% sodium edetate , sodium hydroxide as a stabilizor and purified water EDTAC and DTPAC are produced when 100 mL of EDTA (15%) and diethyl- triamine - penta acetic acid (DTPA) at pH 8 are added to 0.75g of the detergent Cetyl -tri-methyl ammonium bromide ( Cetrimide ) EDTA-T consists of 17% EDTA + sodium lauryl ether sulfate ( Tergentol ) as a detergent EGTA main component is ethylene glycol bis (β-amino- ethylether )-N.N.N’.N'-tetra acetic acid. It is reported to bind Ca ions more specifically than EDTA

46. CHELATING AGENTS PASTE-TYPE CHELATORS : Literature reports the mode of action of liquid chelator solutions for root canal irrigation is predominant T he chelators recommended for use during rotary root canal preparation must have a paste or gel consistency RC-Prep 10 % urea peroxide + 15% EDTA and glycol in an aqueous ointment base Glyde file Composed of 15% EDTA and 10% urea peroxide in aqueous solution. Developed for use with NaOCl irrigants , because it causes effervescence

47. CHELATING AGENTS When using 17 % EDTA always ensure to irrigate 1.5 % NaOCl used during recapitulation

48. After cleaning and shaping of the root canal and irrigation, dry the canal with paper points Obturate canals with appropriate size gutta percha Restore the tooth Postoperative radiograph

49. CONCLUSION Calcified Roots are an enigma in Dentistry for the Endodontist , treating such cases is a challenge but it sure brings in a lot of satisfaction after completing the case successfully

50. REFERENCES Oginni AO, Adekoya-Sofowora CA, Kolawole KA. Evaluation of radiographs, clinical signs and symptoms associated with pulp canal obliteration: an aid to treatment decision . Endod Dent Traumatol . 2009 Dec; 25(6 ): 620-625 . Goga R, Chandler NP, Oginni AO. Pulp stones: a review. International Endodontic Journal, 41, 457–468, 2008. doi:10.1111/j.1365-2591.2008.01374.x McCabe PS, Dummer PM. Pulp canal obliteration: an endodontic diagnosis and treatment challenge . Int Endod J. 2012;45(2):177-97 . Abdul Majid. et al., Int J Dent Health Sci 2015; 2(1): 225-229 Prasad Koli , Madhu Pujar , Viraj Yalgi , Veerendra Uppin , Hemant Vagarali , and Namrata Hosmani , “Ultrasonic Management of Calcified Canal: A Case Report.” Oral Surgery, Oral Medicine, Oral Radiology , vol. 2, no. 2 (2014): 11-13. doi : 10.12691/oral-2-2-1. de Toubes KMPS, Oliveira PAD, Machado SN , Pelosi V, Nunes E, Silveira FF. Clinical Approach to Pulp Canal Obliteration : A Case Series. Iran Endod J. 2017;12(4):527-33. Doi : 10.22037/iej.v12i4.18006 . Other online materials and pictures

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