|Year : 2015 | Volume
| Issue : 3 | Page : 150-154
Correlation between prevalence of pulp stones and renal stones in Panchkula region of India
Tarun Kumar1, Gagan Puri1, Konidena Aravinda1, Sanjeev Laller2, Deepa Jatti1, Rajesh Gupta1
1 Department of Oral Medicine and Radiology, Swami Devi Dyal Hospital and Dental College, Panchkula, Haryana, India
2 Department of Oral Medicine and Radiology, PDM Dental College and Hospital, Bahadurgarh, Haryana, India
|Date of Web Publication||4-Aug-2015|
Department of Oral Medicine and Radiology, Swami Devi Dyal Hospital and Dental College, Panchkula, Haryana
Aim: Pulp stones are discrete calcified bodies found in the dental pulp. The aim of the present study was to determine the prevalence of pulp stones in patients with renal stones and to determine the relationship between the pulp stones and renal stones. Materials and Methods: A total of 240 patients participated in the study. Group A consisted of 120 patients who had renal calculi, and Group B had 120 randomly selected controls for the study. The periapical radiographs for all patients were evaluated for the presence or absence of the narrowing of dental pulp chambers and pulp canals. The radiographs were also evaluated to determine the presence or absence of pulp stones. The results were compared and analyzed using the Chi-square test (P < 0.001). Results: A total of 163 patients had pulp narrowing, and 112 patients had pulp stones, which included 55 controls and 57 renal calculi patients. There was no statistical correlation between pulp narrowing and renal stones (P > 0.001) and also between pulp stones and renal stones (P > 0.001). Conclusion: However, there was no significant correlation between the presence of pulp stones and renal stones, the incidental findings of pulp stones on periapical radiographs can provide useful information in the early diagnosis of the systemic calcifications.
Keywords: Periapical radiograph, pulp stone, renal stone
|How to cite this article:|
Kumar T, Puri G, Aravinda K, Laller S, Jatti D, Gupta R. Correlation between prevalence of pulp stones and renal stones in Panchkula region of India. SRM J Res Dent Sci 2015;6:150-4
|How to cite this URL:|
Kumar T, Puri G, Aravinda K, Laller S, Jatti D, Gupta R. Correlation between prevalence of pulp stones and renal stones in Panchkula region of India. SRM J Res Dent Sci [serial online] 2015 [cited 2020 Jul 13];6:150-4. Available from: http://www.srmjrds.in/text.asp?2015/6/3/150/162156
| Introduction|| |
Calcified bodies in the dental pulps of healthy, diseased, and even unerupted teeth in the primary and permanent dentition are known as pulp stones.  They may be located in the coronal or radicular portion of the pulp. Based on the location, pulp stones can be classified as embedded, adherent and free. The embedded stones are formed in the pulp but become enclosed within the canal walls due to the deposition of physiological dentin and are usually located at the apical portion of the root.  Odontoblasts and a calcified tissue resembling the dentine may be present on the peripheral aspect of these stones.  The adherent pulp stones are less attached to the dentine, and they are never fully enclosed by the dentine when compared to embedded pulp stones. Both the types of pulp stones can cause significant obstruction of the canals and may be located at a curve which may interfere with the root canal treatment.  Kronfeld and Boyle  classified pulp stones histologically into "true" or "false" forms. The true pulp stones are more irregular in shape and are lined by odontoblasts. They are composed of dentine, whereas the degenerating cells of the pulp which mineralize, form false pulp stones. , A third type of pulp stones, "diffuse" or "amorphous" type is also seen in close association with the blood vessels. 
Pulp stones have been described as the symptoms of the changes in the pulp tissue rather than their cause. The exact mechanism and the etiology of pulp calcification is not known, however, various factors such as pulp degeneration, age, epithelium rests in the pulp tissue, operative procedures, impaired blood supply of the pulp, periodontal disease, orthodontic treatment, long-standing irritants such as caries, deep fillings, or abrasion, genetic factors, and certain syndromes such as the van der Woude syndrome have been implicated in their formation. , It has also been noted that an irritated pulp, when attempts to repair itself, may lead to pulpal stone formation. The carious teeth of children and young adults have a 5 times higher incidence of calcifications of the pulp than in the noncarious teeth. 
The pulp calcifications usually occur throughout the dentition in patients with systemic or genetic diseases like dentin dysplasia and dentinogenesis imperfecta.  The conditions which are like hypercalcemia, gout and renal lithiasis that are secondary to the calcium metabolism have been noted as the predisposing factors. Pulpal calcification has been commonly observed in patients with end-stage renal disease and transplanted patients and a strong correlation between the chronicity of the renal disease and the pulp narrowing has been observed in the premolar and molar teeth of such patients.  A number of studies have suggested pulp stones to be a manifestation of systemic illnesses leading to pathological biomineralization in many parts of the body. , While, a few authors have suggested that complex biomechanical and physiologic changes occurring in systemic diseases do not affect the dentin and pulp and hence, no correlation exists between the pulpal calcifications and calcifications in other parts of the body. 
The aim of the present study was to determine the prevalence of pulp stones in patients with renal stones and healthy adults and to determine the relationship between the pulp stones and renal stones.
| Materials and Methods|| |
The present study included a total of 240 patients to study the prevalence of pulp stones in patients with renal stones and to determine if any relationship exists between the pulp stones and renal stones. All the patients were divided into two groups. Group A consisted of 120 randomly selected renal calculi patients from the General Hospital of the institution and Group B had 120 randomly selected controls from the patients visiting the outpatient Department of Oral Medicine and Radiology of the Dental College. Ethical clearance was obtained from the Institutional Ethical Committee. A detailed medical and dental history of all the patients was recorded. Patients with any history of cardiovascular diseases, gout, gallstones or any other systemic diseases were excluded from the study. Patients with any attrition or abrasion, presence of radiographically observable periodontal diseases and presence of Class V restorations were also excluded from the study. A total of 3452 periapical radiographs of the posterior and anterior teeth were evaluated for the presence of pulp stones. The radiographs with poor angulations, improper exposures or faulty processing, which could lead to scoring difficulties and the radiographs with carious and restored teeth were excluded from the study. The periapical radiographs for all patients were evaluated for the presence or absence of the narrowing of dental pulp chambers and pulp canals. All the radiographs were interpreted by two examiners (oral radiologists) in a dark room using a standard viewing box under the ×2 magnification and with the peripheral light being blocked out to ensure the accuracy of the diagnosis. Narrowing was defined as a notable reduction in the size of the pulp chamber and the pulp canals [Figure 1]. The definite radiopaque masses inside the pulp chambers were identified as pulp stones and scored as present or absent [Figure 2]. The data were entered using computer software SPSS 12.0 (SPSS Inc., Chicago, IL, USA) and analyzed using the Chi-square test. P < 0.001 was considered to be statistically significant.
|Figure 1: Intra-oral periapical radiograph depicting pulp stone in maxillary molar region|
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|Figure 2: Intra-oral periapical radiograph depicting pulp narrowing in mandibular molar region|
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| Results|| |
A total of 6939 teeth from 240 patients were evaluated in the present study. The mean age of the patients in Group A was 33.9 ± 10.6 years and 34.8 ± 11.2 years for Group B. There were 68 (56.67%) males and 52 (43.33%) females in Group A and 63 (52.5%) males and 57 (47.5%) females in Group B. 75 renal calculi patients and 88 controls had pulp narrowing [Table 1]. There was no statistical correlation between pulp narrowing and renal stones (P > 0.001). 112 patients in total had pulp stones, which included 55 controls and 57 renal calculi patients [Table 2]. There was no statistically significant relation between the presence of pulp stones and renal stones (P > 0.001).
| Discussion|| |
Pulp stones are calcifications found in the pulp chamber or pulp canals of deciduous and permanent teeth. They are often incidental findings on dental radiographs, and the incidence of pulp stones has been investigated in many radiological studies as mentioned in the literature. A wide discrepancy in the prevalence of pulp stones has been observed in various population. ,,,, The prevalence varies from 8% to 90%, depending on the study type, design, and radiographic technique employed. This difference results from the variation in sample and sample size in previous studies. Furthermore, the presentations of prevalence were also different in the literature. Some investigations presented the prevalence based on person and teeth numbers, and the others reported only the prevalence based on teeth number.  Histological method of evaluation is reported to yield higher values than radiographic method. The prevalence based on radiographic examinations has been reported to be around 20-25% , while histological examinations have shown higher prevalence.  Recently, Al-Hadi Hamasha and Darwazeh  identified pulp the prevalence in Jordanian adults to be 51.4% in a radiographic study and Ranjitkar et al.,  reported a prevalence of 46.1% in Australian adults population.
The frequency of pulp stones has been reported to increase with age. The size of the pulp chamber may be decreased due to the secondary dentin deposition with increasing age.  A decrease in the size of the pulp chamber due to the deposition of the secondary dentin and due to the deposition of calcified masses in the root has been reported by Bernick and Nedelman.  Some studies have reported that there exists no difference in the occurrence between genders while others have reported a higher prevalence of pulp stones in females. , They have been reported to occur more frequently in coronal pulp than in radicular pulp. Pulp stones have been noted to vary in number from 1 to 12 or more in a single tooth, with size varying from small microscopic particles to large masses that may occlude the pulpal space. 
Urinary stone disease is common and is reported to be increasing across the globe and it has been reported that almost 5% of American females and 12% males will develop a kidney stone at some point during their lifetime. The renal stone disease has shown to affect approximately 5% of the general population in the US.  It affects approximately 1.2 million people every year, accounting for approximately 1% of all hospital admissions. In certain parts of the world, as in the Middle East, the lifetime risk appears to be even higher. It poses a significant health care burden in a working-age population.  Kidney stone formation is usually due to genetic and environmental factors. Genetic factors are unlikely to be the driving force to influence stone risk since the changes in the gene pool occur at a slow pace. The influence of the varied and complex environmental factors is more apparent as changes occur over a shorter time interval. Changes in diet and climate, the 2 most important environmental factors have the most significant impact on the increasing prevalence. 
The 16 th century reported the first documented increase in stone disease when European Stein-Schneiders (stone cutters) found an increased demand in their services. Improvements in food production and corn becoming a popular staple food occurred during the same time.  This promoted obesity, which is currently a known risk factor for stone formation, due to increased consumption of corn-derived starchy foods. Other dietary risk factors have also been identified. High fructose consumption, increased oxalate, diminished fluid, and calcium consumption are also considered to be a risk factor for renal stone formation. , Epidemiologic studies have demonstrated increased sodium and animal protein intake to have an equivocal impact on stone risk. However, reduction of sodium and animal protein and maintenance of normal dietary calcium intake, demonstrated attenuated stone activity in recurrent hypercalciuric stone formers. The consumption of animal protein has increased in a number of countries, along with the increase of stone disease. , While certain studies have demonstrated a decrease in stone prevalence among older age groups with increased intake of sodium and sodium-rich foods.  These differences could be attributed to differences in sampling methods, study design or renal calculi patients dying at a younger age. Renal stone formation has been associated with a number of medical co-morbidities such as obesity, hypertension, cardiovascular ailments, diabetes mellitus, and chronic kidney disease. 
Pulp calcifications are not clinically discernible and appear on intraoral radiographs such as bitewing and periapical radiographs, as radiopaque structures within the pulp chamber and root canal. Since so many calcifications are not of the sufficient size to be identified on radiographs, the incidence studies based on radiographic examination would be not be accurate. However, they are the only means of examining pulp stones noninvasively in such studies. The periapical and bitewing radiographs when compared for their efficacy in the diagnosis of the pulp calcification showed no significant difference. Thus, periapical radiographs were used to determine pulp stones in the present study.
A total of 88 patients in Group A and 75 patients from Group B showed narrowing of the pulp space. No statistically significant relation (P < 0.001) was found between the pulp narrowing in both the groups. A total of 46.67% patients showed the presence of pulp stones. 45.84% patients from Group A and 47.5% patients from Group B showed pulp stones. The results were higher when compared to the findings of Malhotra et al.  who showed 18.1% prevalence of pulp stones in healthy adults and 25.4% prevalence in patients with renal stones and Ciftcioglu et al.  who showed a prevalence of 28% pulp stones in renal patients. There was no statistically significant relation between the presence of pulp stones and renal stones (P > 0.001) in the present study, as opposed to the findings of Malhotra et al.  who demonstrated a statistically significant relation between the presence of renal stones and pulp stones.
However, recent immunohistochemical study by Ninomiya et al.  found an even distribution of Type I collagen throughout the pulp stones, which indicated that it is a major matrix component of free pulp stones, whereas osteopontin was found to play an integral part in the calcification front as it was found in the peripheral area of the pulp stones. Hirota et al.  and Kohri et al.  found similar occurrence of osteopontin in their immunohistochemical study on atherosclerotic plaques and urinary stones. These findings suggest that a relationship occurs between the incidence of pulp stones and kidney stones contrary to the findings of the present study.
| Conclusion|| |
The present study, however, did not report any significant association between pulp stones and renal stones, but it seems to be of significant clinical importance. Further large-scale, multi-institutional studies are encouraged to establish any positive correlation between pulp and renal calcifications along with other systemic diseases. It is thus suggested that routine dental radiographs could serve as a significant prognostic tool for early identification of potential renal stones. This screening method could easily be employed as a tool in public health programs for early identification of possible renal calculi symptoms, since it requires minimal radiation, with the advanced imaging techniques.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]
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