|Year : 2021 | Volume
| Issue : 3 | Page : 276-279
Association of pulp stones among patients with addictive habits – A descriptive cross-sectional study
Tapasya Karemore, Trushita Banubakode, Mukta Motwani, Apeksha Dhole, Rutuja Muneshwar
Department of Oral Medicine and Radiology, VSPM Dental College, Nagpur, Maharashtra, India
|Date of Submission||28-Jan-2021|
|Date of Decision||12-Aug-2021|
|Date of Acceptance||14-Aug-2021|
|Date of Web Publication||28-Sep-2021|
Dr. Trushita Banubakode
Lata Mangeshkar Hospital, Digdoh Hills, Nagpur - 440 019, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: The study aimed to determine the association of pulp stones among patients with addictive habits in comparison with healthy individuals without any addictive habits. Materials and Methods: A total of 240 patients were included in the study, i.e., 120 patients with addictive habits and 120 healthy individuals without addictive habits. Bite-wing projection of the intact or sound teeth of one side, i.e., either right or left side of the first and second molars of the upper and lower arch was obtained. The presence or absence of pulp stones was observed for the selected teeth. The Chi-square analysis was used to evaluate and compare the occurrence of pulp stones among patients with addictive habits and healthy individuals of a similar age group. Results: Of the 960 teeth examined from both groups, 111 (11.56%) teeth had pulp stones. Pulp stones were observed among 43 patients with addictive habits and in 30 healthy individuals. The occurrence of pulp stones was higher in the first molar followed by the second molar and in the maxillary than in the mandibular arch. Conclusions: No significant association was observed with the occurrence of pulp stones among patients with addictive habits, but a significant association was noted with respect to duration of habit.
Keywords: Addictive habits, bite-wing radiography, pulp stone
|How to cite this article:|
Karemore T, Banubakode T, Motwani M, Dhole A, Muneshwar R. Association of pulp stones among patients with addictive habits – A descriptive cross-sectional study. J Indian Acad Oral Med Radiol 2021;33:276-9
|How to cite this URL:|
Karemore T, Banubakode T, Motwani M, Dhole A, Muneshwar R. Association of pulp stones among patients with addictive habits – A descriptive cross-sectional study. J Indian Acad Oral Med Radiol [serial online] 2021 [cited 2021 Nov 29];33:276-9. Available from: https://www.jiaomr.in/text.asp?2021/33/3/276/326883
| Introduction|| |
In India, betel nut is consumed as a major constituent mixed with various tobacco products and it is among the most common addictions. It is present in several chewing products like paan, gutka, khaini, and paan masala. Its use is globally acceptable among all sections of society, including women and quite often in children. The reason for its use includes achieving euphoria, combating fatigue, increasing salivation, and attaining satiation. Betel nut chewing is an indigenous habit, which is more common in the inhabitants of Central, South, and Southeast Asia. Also, it is the fourth most commonly used psychoactive substance.
Pulp stones are discrete calcified bodies in the dental pulps of the teeth in the primary and permanent dentition., Their size ranges from a small microscopic particle to a large mass that almost obliterates the pulp chamber. They are located more commonly in the coronal than in the radicular portion of the pulp organ.,
Though the exact cause of pulp calcification is still unknown, several predisposing factors have been claimed for the formation of pulp stones such as pulp degeneration, age, caries, operative procedures, periodontal diseases, orthodontic tooth movement, circulatory disturbances in the pulp tissue, idiopathic factors, and genetic predisposition.,
Pulp stones are usually not a source of pain, but their evaluation is necessary because the concerned tooth undergoes endodontic treatment and the presence of large pulp stones may affect clinical management of the tooth. Large pulp stones in the pulp chamber might block the access to the canal orifices and may deflect or engage the tip of the exploring instruments, thereby, preventing its easy passage down the canal.
The hard fibrous nature of the betel nut can lead to fractured teeth and extensive attrition of the occlusal tooth surface among regular users. The loss of enamel may also expose the underlying dentine which may result in dentinal sensitivity. The degree of attrition is dependent upon several factors such as the consistency, i.e., hardness of the betel nut, frequency of chewing, and duration of the habit., It has been stated by several investigators that it has deleterious effects on the pulp.,,, A theory states that irritation to the pulp causes circulatory disturbances and thrombosis of the pulp, which initiates mineralization leading to pulp stone formation. Several studies have been carried out to assess the prevalence of pulp stones but only a countable number of studies have evaluated the occurrence of pulp stones among patients with addictive habits. This study emphasizes the type of habit, duration, frequency, and its association with the occurrence of pulp stones among patients with addictive habits.
| Materials and Methods|| |
A case history with details about the type of habit, duration, frequency, and other significant facts were procured. After the approval from the Institutional Ethical Committee vides Ref No IEC/VSPMDCRC/1/2020 dated 30/01/2020, the present study was undertaken at the Department of Oral Medicine and Radiology, in a Dental College at Nagpur, Maharashtra. Written informed consent was obtained from the patients for the study. Sample size was calculated by Epi Info software using following formula.
Sample size estimation
Zα – 1.96 at α error = 0.05
Zβ – 0.84 at β error = 0.2, i.e. 80% power
d = P1 – P2
P1: Prevalence of pulp stones among patients with addictive habits = 11%
P2: Prevalence of pulp stones among patients with non addictive habits = 2 %
Thus, the sample size was calculated to be 120 per group with the desired effect of a 95% confidence interval. Because of minimum exposure, digital imaging was preferred over to get radiographs of all 240 included patients. Also, proper radiation protection measures were taken by using a thyroid collar and lead apron. Group I included 120 patients with addictive habits and Group II included 120 healthy individuals.
Individuals with betel nut chewing habits for more than 3 years duration and healthy individuals below 50 years of age were included in the study.
Individuals with carious or hypoplastic teeth, parafunctional habits, history of cardiovascular disorders such as angina pectoris, myocardial infarction, heart surgery, hypertension, congestive cardiac failure, arrhythmia, diabetes mellitus, and individuals above 50 years of age and pregnant women were excluded from the study.
All the 240 patients were subjected to radiovisiograph with accurate radiation safety measures using a thyroid collar and lead apron. A digital Intraoral periapical radiograph (IOPAR) of the bite-wing projection of the first and second molars of the upper and lower arch was obtained using the Care stream RVG5200 Sensor with CS Imaging software version 7 with acquisition protocol of 70 Kvp, 8 mA, and 12-bit scale with the help of CNS—max 70 HF-DC IOPA machine.
The presence or absence of pulp stones was recorded in the first and second molars of one side, i.e., right or left side of the upper and lower arch [Figure 1] and [Figure 2]. A tooth was considered as having a pulp stone only when a definitive radiopaque mass was noticed in the pulp chamber. Radiovisiograph images with pulp stones were examined by an experienced second observer with more than 5 years of experience for accuracy and agreement.
|Figure 1: Showing presence of pulp stones in maxillary first and second molars|
Click here to view
Statistical analysis was carried out using Chi-square analysis to evaluate and compare the occurrence of pulp stones among patients with addictive habits and healthy individuals of similar age group.
| Results|| |
Out of the 240 patients, the pulp stones were observed in a total of 73 patients, out of which 43 were patients with addictive habits like kharra, gutka with betel nut being a major component and 30 were healthy individuals without any addictive habits. No significant association was observed among the patients with addictive habits and the occurrence of pulp stones as shown in [Table 1].
|Table 1: Presence and absence of pulp stones amongst patients with addictive habits and individuals without habit|
Click here to view
Of the total 960 teeth examined in both groups, 111 (11.56%) teeth had pulp stones. The pulp stones were present in 71 teeth of the addictive patients and 40 teeth of the healthy patients.
Of total 240 patients examined, 97 were females and 143 were males. Pulp stones were observed in 31 female and 42 male patients. The overall occurrence of pulp stones in males was higher than that of females. However, statistically no significant difference was found between the occurrence of pulp stones and gender of patients as shown in [Table 2].
|Table 2: Presence and absence of pulp stones with respect to gender of patient|
Click here to view
Pulp stones were found more commonly on right side as compared to that of the left side and were predominantly found in the maxillary arch especially in the first molar teeth.
A statistically significant difference was observed with occurrence of pulp stones and duration of habit as shown in [Table 3].
|Table 3: Prevalence of pulp stones among patients with addictive habits with respect to duration of habit|
Click here to view
| Discussion|| |
In India, betel nut chewing is among the most common addiction that can be due to a lack of awareness leading to compromised oral hygiene and esthetics.
Out of the total 240 patients, 73 patients showed pulp stones of which 43 individuals were consuming betel nut and 30 individuals had no addictive habits. No significant association was observed among the patients with addictive habits and the occurrence of pulp stones. However, in contrast to the present observations, Prasada et al. reported a positive correlation between the occurrence of pulp stone and tobacco chewers.
In comparison to the study conducted by Prasada et al., the present study evaluated the occurrence of pulp stones among patients with addictive habits concerning the type of habit, frequency, and duration which may stand as the major etiologic agent in the occurrence of pulp stones. Also, a significant association was observed for the duration of the habit.
The present study indicated a higher prevalence of pulp stones in patients of 30–40 years of age; however, no significant difference was observed between the occurrence of pulp stones and the age group. Similar results were reported by Kanan and Hamesha et al. which were in contrast with the results reported by Yacob et al. These variations in the results can be attributed to the fact that the inclusion criteria in the present study comprised patients less than 50 years of age. Conversely, this study does not suggest a true relationship between pulp stones and advancing age.
The observations of the present study regarding the occurrence of pulp stones showed no significant association for gender. Similar findings were reported by Nayak et al., Kanan et al., and Talla et al. However, in contrast with the present observations, Turkal et al. reported a high prevalence among the females and correlated it with bruxism. However, the habit of consuming betel nut may vary among genders from one geographic area to another along with the duration of exposure to betel nut products.
In the present study, the pulp stones were predominant in the maxillary arch, especially the first molar teeth. This finding is consistent with the findings reported by Turkal et al., Yosuf et al., Nayak et al., Sisman et al., and Ranjitkar et al. In contrast with the observations of the present study, Hamasha et al. reported occurrence of pulp stones frequently in the mandibular first molar. It has been reported that maxillary molars are prone to develop pulp stones and it is correlated to the fact that the molars are the largest teeth with a better blood supply to the pulp tissue and have the strongest chewing force which may contribute to a greater chance for calcification. However, this finding may not be fully justified as the above studies were not based on the habit of betel nut consumption.
The present study revealed the occurrence of pulp stones more frequently on the right side than on the left side. Similar observations were reported by Nayak et al. and Patil et al. which were in contrast with the results reported by Sisman et al. and Ranjitkar et al. These variations in the results may be attributed to the fact that all these studies were not related to the consumption of tobacco products. Also, the side affected with a carious and missing tooth was not considered for the study.
Limitations and Future Prospects
The limitation of the present study was based on the reliability of the case history provided by the patient for the duration of the habit and its association with the formation of pulp stones. So, to overcome this limitation, it is necessary to conduct trials on a large sample size to accurately analyze the association of occurrence of the pulp stones among patients with addictive habits.
Oral health awareness programs explaining the ill effects of betel nut and associated products to the general population are needed. De-addiction counseling conducted during this program can include information about the risk of cardiovascular disease and the association of pulp stones with it. It is observed that pulp stones are not only incidental radiographic findings but may also be an indicator of some serious underlying disease and may provide useful information to predict the susceptibility of patients for cardiovascular disorders. Therefore, the occurrence of pulp stones and their association with the cardiovascular disorder can be included in oral health awareness.
| Conclusion|| |
There is no significant association of the occurrence of pulp stones among patients with addictive habits. Although the significant association of occurrence of pulp stones among patients with addictive habits could not be proved but the study could correlate with duration of addictive habits and pulp stones. This significant association can generate awareness about the ill effects of prolonged betel but chewing habits and can prevent healthy teeth from pulp calcification.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Anand R, Dhingra C, Prasad S, Menon I. Betel nut chewing and its deleterious effects on oral cavity. J Cancer Res Ther 2014;10:499-505.
Nawaz MK, Sivaraman GS, Krishnamoorthy S, Balaji S. Temporomandibular joint dysfunction syndrome associated with betel nut chewing: A clinical study. J Orofac Res 2015;5:142-5.
Lan TY, Chang WC, Tsai YJ, Chuang YL, Lin HS, Tai TY. Areca nut chewing and mortality in an elderly cohort study. Am J Epidemiol 2007;165:677-83.
Turkal M, Tan E, Uzgur R, Hamidi MM, Çolak H, Uzgur Z. Incidence and distribution of pulp stones found in radiographic dental examination of adult Turkish dental patients. Ann Med Health Sci Res 2013;3:572-6.
] [Full text]
Harsh A, Harsh P, Jain DK, Kumawat R, Purohit S, Saify M. Correlation between pulp stones and serum calcium levels: A preliminary study. Int J Health Clin Res 2021;4:145-7.
Babu SJ, Swarnalatha C, Rao AP, Kumar BB, Tilak BP, Naidu RB, et al
. Pulp stones as risk predictors for coronary artery disease. Int J Prev Med 2020;11:1-7.
Ranjitkar S, Taylor JA, Townsend GC. A radiographic assessment of the prevalence of pulp stones in Australians. Aust Dent J 2002;47:36-40.
Patil SR, Abd Ghani H, Almuhaiza M, Al-Zoubi IA, Anil KN, Misra N, Raghuram PH. Prevalence of pulp stones in a Saudi Arabian subpopulation: A cone-beam computed tomography study. Saudi Endodontic Journal. 2018 May 1;8(2):93.
Talla HV, Kommineni NK, Yalamancheli S, Avula JS, Chillakuru D. A study on pulp stones in a group of the population in Andhra Pradesh, India: An institutional study. J Conserv Dent 2014;17:111-4.
] [Full text]
Hassan SA, Bheteja S, Arora G. Pulp stones associated with the renal calculi. IP J Urol Nephrol Hepatol Sci 2019;2:33-5.
Goga R, Chandler NP, Oginni AO. Pulp stones: A review. Int Endod J 2008;41:457-68.
Trivedy CR, Craig G, Warnakulasuriya S. The oral health consequences of chewing areca nut. Addict Biol 2002;7:115-25.
Prasada K, Issac E. A Radiographic co relation between smokeless tobacco and pulp stone. Int J Curr Adv Res 2017;6:8464-6.
Bains SK, Bhatia A, Singh HP, Biswal SS, Kanth S, Nalla S. Prevalence of coronal pulp stones and its relation with systemic disorders in northern Indian central punjabi population. ISRN Dent 2014; 1-5. doi: 10.1155/2014/617590.
Kannan S, Kannepady SK, Muthu K, Jeevan MB, Thapasum A. Radiographic assessment of the prevalence of pulp stones in Malaysians. J Endod 2015;41:333-7.
Hamasha AA, Darwazeh A. Prevalence of pulp stones in Jordanian adults. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:730-2.
Yacob HB, Hamid JA. Pulpal calcifications in primary teeth: A light microscope study. J Pedodontics 1986;10:254-64.
Nayak M, Kumar J, Prasad LK. A radiographic correlation between systemic disorders and pulp stones. Indian J Dent Res 2010;21:369.
] [Full text]
Yousuf MA, Antony S. Radiographic assessment of prevalence of pulp stones in South Indian population. Drug Invention Today 2018;10:3162-5.
Sisman Y, Aktan AM, Tarım-Ertas E, Çiftçi ME, Şekerci AE. The prevalence of pulp stones in a Turkish population. A radiographic survey. Med Oral Pathol Oral Cir Bucal 2012;17:e212-7.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]