History and Physical Examination Findings
A 2-year-old 26-kg castrated male Labrador Retriever was presented to a veterinary dental hospital for oral examination, diagnostic imaging, periodontal treatment, and evaluation of a fractured right maxillary fourth premolar tooth. The conscious oral examination confirmed fracture of the right maxillary fourth premolar tooth and revealed clinically normal occlusion, rotated right and left maxillary third premolar teeth, and a supernumerary right maxillary premolar tooth as well as a calculus index of 1, gingival index of 1, and plaque index of 1 on the buccal surfaces of the teeth. No additional abnormalities were noted on physical examination, and results of a preanesthetic CBC and serum biochemical analyses were within reference limits. The dog underwent anesthesia and a complete oral examination, including full-mouth digital dental radiography with the use of a No. 4 phosphor plate and a bisecting-angle technique (Figure 1). Findings were consistent with those in the awake patient, and the right maxillary fourth premolar tooth had 1-mm gingival recession.
Dental im-ages of an anesthetized 2-year-old 26-kg castrated male Labrador Retriever that was referred to a veterinary dental practice for the evaluation of a fractured right maxillary fourth premolar tooth. A—The right maxillary third premolar tooth is rotated, there is a supernumerary maxillary premolar tooth, and the right maxillary fourth premolar tooth has an uncomplicated crown fracture. B—Close-up image of the right maxillary fourth premolar tooth and adjacent teeth after dental prophylaxis. C—Intraoral radiographic image (obtained with a bisecting-angle technique) of the right maxillary fourth premolar tooth and adjacent teeth.
Citation: Journal of the American Veterinary Medical Association 261, 1; 10.2460/javma.22.03.0114
Diagnostic Imaging Findings and Interpretation
The right maxillary fourth premolar tooth had an uncomplicated crown fracture and a round, well-defined radiodensity in the pulp cavity (Figure 2). Additionally, the dog’s supernumerary right maxillary first premolar tooth and rotated right and left maxillary third premolar teeth were evident. To better evaluate the abnormal radiodensity identified in the pulp cavity of the right maxillary fourth premolar tooth, cone-beam CT (CBCT; VetCAT cone beam computed tomography; Xoran Technologies LLC) of the skull was performed (0.3-mm slice thickness, 120 kVp, 57.6 mAs, and 16 X 16-cm field of view; Figure 3). All digital images were evaluated with commercially available software (VetCAT cone beam computed tomography; Xoran Technologies LLC). The CBCT revealed round, well-defined radiodensities of the pulp cavity of the right maxillary fourth premolar tooth. There was no evidence of bone loss in the periapical space, and the pulp cavity of the right maxillary fourth premolar tooth was comparable in size to pulp cavities of adjacent teeth and the contralateral maxillary fourth premolar tooth. Findings were consistent with pulp stones or endoliths.
Same radiographic image as in Figure 1. There is a supernumerary right maxillary first premolar tooth (star), a rotated right maxillary third premolar tooth (black arrow), and a radiodense opacity in the root canal space of the right maxillary fourth premolar tooth (white arrow).
Citation: Journal of the American Veterinary Medical Association 261, 1; 10.2460/javma.22.03.0114
Transverse (A), sagittal (B), and dorsal (C) plane volume reconstruction cone-beam CT images of the skull of the same dog in Figure 1 that were obtained at the level of the right maxillary fourth premolar tooth. Round, well-defined radiodensity is present in the pulp cavity of the right maxillary fourth premolar tooth (arrows). The pulp cavity of the right maxillary fourth premolar tooth (arrows) is comparable in size to the pulp cavities of the adjacent teeth. The images are displayed in a bone window (window width, 3,400 HU; window level, 950 HU) with a 0.3-mm slice thickness.
Citation: Journal of the American Veterinary Medical Association 261, 1; 10.2460/javma.22.03.0114
Treatment and Outcome
The patient received a complete professional dental cleaning procedure performed by means of a piezoelectric scaler and hand scaling of the supragingival tooth and subgingival space, followed by polishing with a fine-grit fluoride pumice. The uncomplicated crown fracture did not require any additional treatment. The patient was discharged from the hospital, and the client was educated on daily dental home care and appropriate chewing behavior. Recommendations were made to return in 12 months for full oral evaluation under anesthesia including digital dental radiography and CBCT.
Comments
Full-mouth dental radiology is beneficial in veterinary patients when evaluating periodontal health, tooth injuries, and tooth vitality.1 Furthermore, in a feline study2 of dentoalveolar lesions, CBCT provided more clinically relevant diagnostic information regarding periapical disease, tooth resorption, and vertical bone loss than did digital dental radiography. The dog of the present report was referred for evaluation of a fractured tooth. In most cases, it is impossible to determine the best treatment option for damaged teeth without a thorough examination under anesthesia and evaluation of diagnostic imaging. Radiographic signs of endodontic disease can be numerous and include a loss of the radiopaque lamina dura, widening of the periodontal ligament space at the apex, diffuse or clearly evident radiolucency pattern in the periapical space, sclerosing osteitis, changes in the trabecular bone pattern, apical root resorption, internal root resorption, external root resorption, arrested tooth maturation, or accelerated tooth maturation, as compared with adjacent teeth and the same tooth on the contralateral side.3 For the dog of the present report, the right maxillary fourth premolar tooth had a crown fracture without pulp exposure (uncomplicated) and there was no evidence of endodontic disease upon evaluation of diagnostic images; therefore, only close future monitoring was needed. In contrast, tooth fractures with pulp exposure or evidence of endodontic disease on diagnostic imaging require root canal treatment or extraction. The use of CBCT for this dog played a crucial role in evaluating the endodontic health of the affected tooth and aided in directing treatment recommendations. A discussion with the patient’s owner regarding appropriate chewing behaviors and daily dental home care was conducted to help prevent further tooth trauma and maintain periodontal health. It was recommended to perform a follow-up comprehensive oral health assessment and treatment to reassess the periodontal and endodontic health of the affected tooth.
Pulp stones or endoliths, as seen in the dog of the present report, are calcifications that can be found within the pulp cavity of teeth.4 They do not appear to be associated with a pathologic change but can present a challenge when performing a root canal procedure due to difficulty in instrumentation to the apex.4,5 In human patients, long-term pulpal irritation, which can occur with deep caries lesions, has been shown to be a potential factor in the development of pulp stones.5 Conversely, another study6 of humans concluded that pulpal pathology is unlikely to be a contributing factor as pulp stones have been identified in very immature teeth and unerupted teeth, and no relationship between pulp stones and caries lesions in the crown has been identified in humans. Additionally, a human dental case study7 suggested that genetics could be a contributing factor as pulp stones could be associated with a genetic dentine defect. This same study7 tracked a patient with multiple pulp stones over a period of 6 years and concluded that the pulp stones and endodontic health remained unchanged over time. The exact etiology of pulp stone formation remains undetermined.5
Pulp stones with a diameter of < 200 µm cannot be detected on routine dental radiography, and the use of CBCT has greatly improved the identification of calcifications of the pulp cavity.5 Pulp stones have been identified freely in the pulpal tissue or adhered to the dentin. The most commonly identified location is the coronal pulp chamber.8 In human patients, pulp stones do not appear to negatively affect pulpal pain testing and are not considered a condition that requires treatment.8 In human endodontic patients, removal of the pulp stones with ultrasonic instruments has been utilized but carries a high failure rate. Micro-guided endodontics that use CBCT scans to map the endodontic system may be the future of endodontics.5
When pulp stones are diagnosed on diagnostic imaging, notation of the abnormality should be made in the patient’s medical record. If there is no radiographic or examination evidence of endodontic disease, no additional treatment is warranted. Recommendations of reevaluation with diagnostic imaging in 1 year should be suggested to screen for pathology or endodontic disease.
References
- 1. ↑
Verstraete FJM, Kass PH, Terpak CH. Diagnostic value of full-mouth radiography in dogs. Am J Vet Res. 1998;59(6):686–691.
- 2. ↑
Heney CM, Arzi B, Kass PH, Hatcher DC, Verstraete FJM. The diagnostic yield of dental radiography and cone-beam computed tomography for the identification of dentoalveolar lesions in cats. Front Vet Sci. 2019;6:42. doi:10.3389/fvets.2019.00042
- 4. ↑
Wiggs RB, Lobprise HB. Veterinary Dentistry: Principles and Practice. Lippincott-Raven Publishers; 1997:161.
- 5. ↑
Pietrzycka K, Pawlicka H. Clinical aspects of pulp stones: a case report series. Dent Med Probl. 2020;57(2):213–220. doi:10.17219/dmp/117944
- 6. ↑
Ravanshad S, Khayat S, Freidonpour N. The prevalence of pulp stones in adult patients of Shiraz Dental School, a radiographic assessment. J Dent (Shiraz). 2015;16(4):356–361.
- 7. ↑
Donta C, Kavvadia K, Panopoulos P, Douzgou S. Generalized pulp stones: report of a case with 6-year follow-up. Int Endod J. 2011;44(10):976–982. doi:10.1111/j.1365-2591.2011.01903.x
- 8. ↑
Goga R, Chandler NP, Oginni AO. Pulp stones: a review. Int Endod J. 2008;41(6):457–468. doi:10.1111/j.1365-2591.2008.01374.x
