0099-2399/92/1810-0515/$03.00/0 JOURNAL OF ENDODONTICS Copyright © 1992 by The American Association of Endodontists

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VOL. 18, NO. 10, OCTOBER1992

Symmetrical Pulp Obliteration in Mandibular First Molars Adriano Piattelli, MD

left mandibular molars, and an occlusal composite restoration on the first right mandibular molar. The periodontal tissues appeared to be normal. An orthopantomogram revealed a complete calcification of the pulp chamber and of the root canals of both first mandibular molars (Fig. 1). A periapical film of both teeth showed a complete disappearance of the pulp chamber with a small radiolucent line in the distal root canal indicating remnants of pulp tissue (Fig. 2). Moreover, a small distal interproximal carious lesion was detected on both teeth. All of the blood values of the patient were within normal limits. The teeth were completely asymptomatic. It was decided to carry out only a restoration of the carious lesions.

Pulp obliteration is an extremely rare morphological type of pulp calcification, with calcified material completely occupying the pulp chamber and root canal spaces. The etiology of pulp obliteration may be trauma or systemic diseases such as secondary hyperparathyroidism. Pulp obliteration may also be seen in dental anomalies such as dentinogenesis imperfecta and dentinal dysplasia. In cases of pulp obliteration with periapical disease, the preferred treatment is surgery, while calcified canals without symptoms or periapical lesions are best left untreated.

DISCUSSION Calcifications in the dental pulp may be found in two morphological forms: discrete calcifications that appear as denticles, nodules and stones, and diffuse calcifications (1-3). Pulp stones occur most frequently in the coronal pulp (4). Diffuse calcifications are generally observed in root canals in older persons but they may also be present in the pulp chamber (1, 3, 5). These calcifications are usually formed as amorphous unorganized linear columns lying parallel to the blood vessels of pulp (1) and they are similar to the calcifications seen in other tissues of the body following degeneration (calcific degeneration) (3). Fibrillar calcifications are one of the manifestations of the regressive changes that the pulp undergoes (2). The incidence of pulp calcifications seems to be relatively high, especially on the basis of microscopic examination because many of the calcifications are not of sufficient size to be discernible in radiographs (2). Calcifications seem to increase with age, with about 90% of those of 50 yr or older being reported as affected (5, 6). Moreover, Seltzer (7) states that pulp stones are present in the apical third of the root in approximately 15% of the teeth and that usually more than one stone is found.

Pulp stones are calcified bodies with an organic matrix. They are usually divided into true pulp stones that contain tubules and may have an outer layer ofpredentin and adjacent odontoblasts and false pulp stones that are composed of concentric layers of calcified material with no tubular structure (4). The latter are by far the most common and they are formed by deposition of consecutive layers of calcium salts around a central nucleus (2). According to Seltzer (7) pulp stones may form around foci of mineralizing pulp tissue components such as collagen, nerve fibers, blood vessels, ground substance, and inflammatory or necrotic cells. The mineralization resembles that of bone rather than that of dentin with regard to crystallinity and inorganic content (2, 8). Fusion of the deposits around these may form a solid calcified mass (2).

CASE R E P O R T An 18-yr-old patient was referred for a routine check-up. Previous medical history was noncontributory; in particular there was no history of trauma to the teeth or jaws. Clinical examination showed the presence of occlusal amalgam restorations on the first right maxillary molar, first and second

FiG 1. Orthopantomogram.Complete obliteration of the pulp chamber and root canal space of the first mandibular molars.

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FIG 2. A and B, Periapical film of right and left mandibular molars. Complete disappearance of the pulp chamber with a small radiolucent line in the distal root canal.

The etiology of pulp calcifications is unknown. Their incidence appears to increase with age and it has been postulated that local irritants of long-standing could be causative factors, such as pulpal irritation or inflammation arising from caries or trauma (3), dental restorations, abrasion, erosion, gingival recession, and periodontal disease (2). Such a view must however be questioned in view of the large number of calcifications that occur in normal teeth where such irritants are not present (2). Pulp calcifications have even been described in unerupted teeth (3) and so perhaps it is doubtful whether pulpal disease or inflammation can be of any significance (3). It has also been suggested that their formation is a local manifestation of systemic disturbances (2), but it has been found that there appears to be no clear-cut relationship be-

tween systemic conditions and pulp calcification with the possible exception of arteriosclerosis (2, 3). Pulp calcifications appear as radiopaque structures within the pulp chamber and the root canal. They may be round or oval bodies of various size that may appear singly but more often appear in multiple numbers. Others are solid opaque bodies that tend to conform in shape to the outline of the pulp chamber and root canal (2). An extremely rare morphological form of pulp calcification is the so-called pulp obliteration, in which calcified material occupies completely the coronal and radicular pulp spaces. Pulp obliteration may be found in two forms, generalized and localized (1). In the absence of other tooth deformities the generalized form is probably a part of the aging process and is usually seen in older individuals (i). The occurrence of pulp obliteration in only one tooth, especially in a younger individual, is usually connected to an altered vitality of the pulp (1). A mechanical injury to the apical blood vessels could be insufficient to cause pulp necrosis and the injured pulp could form large quantities of irregular dentin at an accelerated rate with a complete obliteration of the pulp chamber and the root canals (1, 4). In such a way the tooth could attempt "self' or natural endodontia (1). Generalized pulp chamber obliteration with an enlarged root canal space in a younger individual, along with a ground glass trabecular pattern in bone and loss of lamina dura, could be suggestive of secondary hyperparathyroidism (1). Pulp obliteration is also seen in dentinogenesis imperfecta and dentinal dysplasia (4, 6). In dentinogenesis imperfecta the whole pulp chamber and much of the root canal become obliterated within a few years of tooth eruption: all teeth are usually affected (6). Large pulp stones in the coronal pulp of molars are characteristic of Ehlers-Danlos syndrome and of calcinosis (6). In pulpal calcifications following trauma histology shows the presence of pulp tissue, which may undergo necrosis and give rise to a periapical infection (6). In the present case it was not possible to find a correlation between systemic disturbances and the pulp obliteration of the two teeth. Even traumatic factors could be excluded in relation to the history of the patient and to the unlikely possibility for a traumatic factor to exert its influence in such a symmetrical way. It could be therefore suggested that this unusual case may be of idiopathic origin. This work was partially supported by grants from MURST (60%) and from Regione Abruzzo, Italy. Dr. Piattelli is associate professor of oral pathology, Department of Dentistry, University of Chieti, Chieti, Italy. Address requests for reprints to Dr. Adriano Piattelli, via F. Sciucchi 63, 66100 Chieti, italy.

References 1. Langland OE, Langlais RP, Morris CR. Principles and practice of panoramic radiology. Philadelphia: WB Saunders, 1982:187. 2. Gibilisco JA. Stafne's oral radiographic diagnosis. 5th ed. Philadelphia: WB Saunders, 1985:71-3. 3. Shafer WG, Hine MK, Levy BM. A textbook of oral pathology. 4th ed. Philadelphia: WB Saunders, 1983:325-8. 4. Soames JV, Southam JC. Oral pathology. Oxford: Oxford University Press, 1985:49-50. 5. Weine FS. Endodontic therapy. 4th ed. St. Louis: CV Mosby, 1989:14850. 6. Rowe AHR. Clinical dentistry. Oxford: Blackwell Scientific Publications, 1987:101. 7. Seltzer S. Endodontology. 2nd ed. Philadelphia: Lea & Febiger, 1988:23. 8. Siskos GJ, Georgopoulou M. Unusual case of general pulp calcification (pulp stones) in a young Greek gid. Endod Dent Traumato11990;6:282-4.

Symmetrical pulp obliteration in mandibular first molars.

Pulp obliteration is an extremely rare morphological type of pulp calcification, with calcified material completely occupying the pulp chamber and roo...
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