Endodontic Challenges in the Management of Multiple Pulp Stones and Root Canal Calcification - A Case Report

Abstract

Root canal calcification is currently a challenging and interesting case for endodontists. Removing microorganisms and their by-products from the root canal system is the goal of root canal treatment. Worse outcomes from root canal procedures can occur due to root canal calcification, as it can block access to the root canal and hinder cleaning and shaping. Iatrogenic errors may occur in the treatment of such cases which will lead to failure of endodontic treatment. This case report describes a 20-year-old woman with multiple pulp stones in the pulp chamber of the mandibular left first molar. In addition, there were also calcified root canals in the mesiolingual and mesiobuccal canals. The patient had asymptomatic irreversible pulpitis and had to undergo endodontic treatment. Several challenges were faced in this case. The initial challenge was to determine the location of the pulp stone in the pulp chamber. Radiographs taken from multiple angles, as well as a direct assessment of the cavity during access preparation, addressed this initial challenge. Retrieval of the pulp stone which in this case is the embedded type that was carried out by grinding it with the help of an ultrasonic tip. Other difficult challenges were avoiding perforation of the pulp chamber floor during treatment, especially when removing the pulp stone, and identifying the location of the orifice. With clinical knowledge, magnification aids and ultrasonic tips, successful treatment in this challenging case was achieved.
 Calcific metamorphosis, sometimes known as pulp canal obliteration (PCO), is the extensive formation of tertiary dentin in the pulp chamber leading to circumferential narrowing of the pulp chamber and root canal.[1] According to the AAE (American Academy of Endodontics), PCO is radiographic evidence of increased dentin production mainly in response to trauma. The result is a calcified canal and does not necessarily indicate pulp disease.[2] Pulp calcification is a common occurrence. The incidence varies, but overall it can be estimated that 50 % of teeth have one or more calcifications.[3]
 There is no evidence to explain whether pulp calcification is a pathological process associated with various forms of injury or natural phenomena.[3] In general, the pulp chamber becomes progressively smaller and often very small, a phenomenon known as calcified metamorphosis or obliteration of the pulp canal. Dentin can be accelerated by caries, trauma, abrasion, restoration, and periodontal disease and is not uniform.[1]
 Calcifications are divided into denticle (pulp stones) and diffuse (linear) calcifications. Pulp stones are divided into free, attached, and embedded types. Pulp stones tend to be found in the coronal pulp, and diffuse calcifications are found in the radicular pulp. It has been speculated that the nidi of calcification arise from degenerating nerves or blood vessels, but this has not been proven.[1