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Denticles. a Literature Review Prog Health Sci 2015, Vol 5, No2 Denticles – literature review Denticles. A literature review Kisiel M, Laszewicz J, Frątczak P, Dąbrowska B, Pietruska M, Dąbrowska E. Department of Social and Preventive Dentistry Medical University of Bialystok, Poland Social and Preventive Dentistry Research Club under the supervision of Ewa Dąbrowska ABSTRACT __________________________________________________________________________________________ Denticles are pulp degenerations in the form of obtain proper access to the pulp chamber bottom and calcified deposits of mineral salts, usually found in the canal orifices. There is also the increased risk of molars and lower incisors, as well as in impacted bending or breaking the endodontic instruments. teeth and deciduous molars. Denticles may come in Sometimes, denticles fill the entire space of the tooth various sizes, from microscopic particles to larger chamber and pushing the pulp to the edges of the mass that almost obliterate the pulp chamber and are chamber. Denticles can cause pain due to the visible only on X-ray images. Denticles form as a pressure on the nerves and blood vessels supplying result of chronic inflammatory lesions, but may also the internal tissue of the tooth. The presence of large be caused by injuries and conservative treatment. denticles might eventually lead to necrosis of the They are most frequently found in necrotic foci. pulp. Denticles accompany certain diseases, such as Denticles may cause problems for root canal dentin dysplasia, odontodysplasia or Albright treatment, as their presence might make it difficult to hereditary dystrophy. Key wards: teeth, denticles, _________________________________________________________________________________________ *Corresponding author: Ewa Dąbrowska Department of Social and Preventive Dentistry Medical University of Bialystok ul. Akademicka 3, 15-280 Białystok, Poland e-mail: [email protected] Received: 02.11. 2015 Accepted: 13.12. 2015 Progress in Health Sciences Vol. 5(2) 2015 pp 200-204 © Medical University of Białystok, Poland 200 Prog Health Sci 2015, Vol 5, No2 Denticles – literature review LITERATURE REVIEW be the dentinoma, most frequently located in the incisors [7]. However, according to Allen, dentinoma The tooth pulp is a dentin-forming tissue. is a very rare condition [8]. Furthermore, Cuevas- Initially, the pulp is responsible for the formation of Nunez reports that the nature of the dentinoma the primary dentin, and in the fully formed tooth for remains largely unknown. Dentinoma is probably the the formation of secondary dentin. Denticles may be effect of an epithelio-mesenchymal interaction caused by fibroblasts by differentiation of secondary during the tooth development [9]. The enamel lining fibroblasts into cells producing hard tissue [1]. Also, the invagination of the crown is usually thin, the aging of the organism reduces the size of the deficient and often does not form at all. The tooth chamber due to the formation of the tertiary invagination of the root develops as a result of the dentin and dental pulp atrophy. It starts with the protrusion of the Hertwig epithelial root sheath and apoptosis of odontoblasts and fibroblasts, and the ac- is most frequently found in mandibular first cumulation of hydroxyapatite crystals. This is ac- premolars and second molars. In most cases, tooth in companies by the reduction of the perfusion due to tooth does not give any clinical symptoms. The the narrowing of the apical foramina caused by ce- crown morphology is usually normal, sometimes a ment depositions. Furthermore, the number and di- sulcus forms on the incisal margin, or a particularly ameter of nerve fibers is reduced and the blood ves- deep and wide foramen cecum with prominent sels become calcified. Dental pulp inflammation also lingual cusp [7,10]. causes deposits of impaired secondary dentin and the The structure of alleged denticles is not formation of denticles or deposits of mineral salts, similar to dentine. Alleged denticles consist usually either loose or connected to hard tissue, called denti- of concentric running lines of calcification, with cles or pulp stones [1,2,3]. Pulp stones also accom- dead or calcified pulp cells in the central parts. The pany a number of diseases, among others: end-stage calcifying clots in the dental pulp blood vessels renal failure, dental dysplasia, Ehlers-Danlos syn- might also result in the formation of alleged denticles drome, Ellis-van Creveld syndrome, dentinogenesis [2]. imperfecta, van der Woude syndrome or Marfan syn- Another classification of denticles is based drome. A correlation has been determined between on their position with respect to dentin. In terms of the presence of denticles and the enamel pearls, tau- the ratio of pulp stones to the dentin wall, the rodontism, dilaceratio and crooked roots [5]. Komor- following types of denticles are distinguished: owska and Bany report that physiological or patho- • free denticles (interstitial denticles) - logical stimuli to the pulp may result in the formation surrounded completely by the pulp, of increased mineralization sites usually referred to • adjacent denticles (parietal denticles) - as denticles. Various reasons of the formation of in- partially connected to the dentin, creased mineralization sites in the pulp have been re- • intradentinal denticles (intratissular ported [6]. denticles) - fused with canal wall and There is a number of classifications of denticles. One completely surrounded by dentin [2]. of the most popular classifications is based on the In terms of dimensions, the denticles are structure of denticles. According to Kmieć, the classified as: following types are distinguished: • compact denticles - visible on an X-ray • genuine denticles - highly shaped image, • scattered denticles - not visible on X-ray • alleged denticles - low formed [4]. A characteristic feature of genuine denticles image and detected by histopathological is their similarity to dentin [4]. They have more or examination [11]. less regular dentinal tubules extending from the Furthermore, Bargholz also distinguishes: Tomes fibers. They are usually found around the • fibrous denticles - formed from the remains apical foramina, but are less frequent than alleged of the epithelial cells of the Hertwig denticles [2]. According to Bargholz, all genuine epithelial root sheath, with odontoblasts denticles are anomalies related to the protrusion of arranged concentrically around, dentine structures into chamber [1]. Bargholz defines • radial denticles - reticulin fibers surround genuine denticles as anomalies related to the the denticle, penetrate its structure and invagination caused by the protrusion of the dentine connect with the surrounding tissue, structures into the chamber. Furthermore, Bargholz • lamellar denticles - with loose connection writes that the total protrusion may take the form of of individual dentin layers. They are dens invaginatus. This claim is supported by connected to the pulp blood vessels, often numerous authors of English-speaking reports. located in the center of the pulp stone [1]. According to White, the invagination in the crown is The main cause of formation of the pulp formed due to the incorrect protrusion of the enamel stones is difficult to determine. Pulp stones often organ into the dental papilla, which results in the appear in teeth that appear normal in every respect formation of a fold of the hard tissues of the tooth, [2]. According to Barańska-Gachowska, denticles lined with enamel. The final form of the defect may might form in the course of chronic pulp 201 Prog Health Sci 2015, Vol 5, No2 Denticles – literature review inflammation and after conservative treatment [2]. A mineralization process. They also observed that large number of histopathological tests confirm that TWIST1 acted in protective capacity, preventing the the presence of pulp stones is not necessarily related formation of denticles [14]. to the pathological symptoms of the pulp. The Pulp stones usually form without symptoms formation of pulp stones is affected by a number of and are detected by chance on X-ray images. On the factors and the exact cause remains unclear [1]. The X-ray image, a denticle might appear as a tooth set Department Of Histology of the Jagiellonian in another tooth, hence the name "tooth in tooth" University Medical College examined the [15]. Denticles may form in the vicinity of nerve ultrastructure of the denticle using electron fibers which, when pressed by the developing microscopy. In the denticle, collagen fibers were denticle, can induce spontaneous dental pain observed, both individual and in bundles following imitating trigeminal neuralgia or dental pulp different directions. The collagen fibers were not inflammation. The diagnosis is posted on the basis of arranged uniformly and did not run perpendicular to the X-ray image on which isolated shading is visible, dentinal tubules. Such arranged results in the less after excluding other possible causes [2]. compacted tissue of the tubular space as compared to On the X-ray image, denticles take the form normal dentin. The authors hypothesized that the of round or oval shades in the tooth cavity. Digital structure and the formation of the denticle were radiography provides high quality images [16]. determined by the disorder of the layout and Denticles vary in size, from microscopic particles arrangement of collagen fibers in the tooth bud [12]. not visible on traditional X-ray images, to well- One of the factors
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