Australian Dental Journal 1998;43:(5):328-30
Dens evaginatus on a wisdom tooth: A diagnostic
dilemma. Case report
Wei Cheong Ngeow, BDS*
Wen Lin Chai, BDS†
Abstract
Pericoronitis is the most common odontogenic
problem associated with the wisdom tooth in young
men and women. Patients may present with
problems associated with infection, swelling and
pain. However, other associated pathology such as
caries, periodontal disease and referred pain from
the temporomandibular joint must be investigated
when treating pain from the wisdom tooth. The
authors wish to present a case in which the pain
from a wisdom tooth was due to a fractured dens
evaginatus. The importance of this dental anomaly
should not be overlooked.
Key words: Wisdom tooth, dens evaginatus, rheumatic
heart disease, mitral valve replacement, warfarin therapy,
case report.
(Received for publication July 1995. Accepted August
1995.)
Introduction
Dens evaginatus is a developmental anomaly
which is found most frequently in premolars. It
occurs almost exclusively among people of
Mongoloid racial stock such as the Chinese,
Japanese, Eskimos and to a lesser extent, the Malays,
Filipinos, American Indians 1 and the Thai. 2 Isolated
cases of dens evaginatus have also been documented
in Caucasians.3,4
In Malaysia and Singapore, this anomaly is
popularly referred to as 'Leong's premolar', after M.
O. Leong who first drew attention to the anomalous
premolar at a meeting of the Malayan Dental
Association in 1946.5 Leong did not realize that the
premolars were not the only teeth affected.
Occasionally the molar,2 canine and incisor teeth
were also affected. 6
Dens evaginatus appears as an accessory cusp or
tubercle located between the buccal and lingual
*Former Tutor, Department of Oral and Maxillofacial Surgery,
Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia.
†Former Dental Officer, Ipoh General Hospital, Perak, Malaysia.
328
cusps of premolars. It is composed of an enamel
covering over a dentine core with a fine extension of
pulpal tissue.7 Dens eva gi n atus has practical
significance because of its morphology and extension
of pulpal tissue. If the tubercle fractures, the pulpal
extension into the tubercle may be exposed to the
oral environment. This can result in early pulpal
inflammation (pulpitis), necrosis, periapical infection
and even osteomyelitis.8
This paper presents the diagnosis and treatment
of a case in which the toothache from a functioning
wisdom tooth was actually a result of a fractured
dens evaginatus. It is believed that such a case has
never been presented in the English literature. The
choice of treatment was limited by the patient's past
medical history of chronic rheumatic heart disease
with mitral valve replacement. He was also on
warfarin therapy.
Case repor t
An 18 year old Malay man presented with
toothache in his lower right mandibular third molar
(48) area. He complained of pain for the past week,
initiated every time he took hot and cold foods and
drinks. The pain was not very sharp and was
localized. He tried taking paracetamol tablets but
this failed to relieve his pain.
He had a medical history of chronic rheumatic
heart disease with mitral valve replacement. He was
also on warfarin. Otherwise, he looked like any fit
young man.
No abnormality was detected extra-orally. His
temporomandibular joints were normal. Intra-orally,
he had a good permanent dentition. No signs of
pericoronitis could be detected in the mandibular
right third molar (48) area. Tooth 48 looked sound
and was in contact with the opposing second molar
(17). Only the distal aspect of 48 was covered with
operculum. There was no traumatic occlusion from
the maxillary right second molar (17) onto the
Australian Dental Journal 1998;43:5.
 18347819, 1998, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1834-7819.1998.tb00183.x by Cochrane Romania, Wiley Online Library on [02/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Fig. 1. – Right side of the panoramic radiograph showing 48 slightly mesially angulated but still having an
occlusion with the opposite tooth. The arrow shows the dens evaginatus.

operculum. The patient was dismissed with found to be a three-rooted tooth. The patient made
reassurance that he may only have atypical an uneventful recovery and was no longer in pain.
odontalgia, as he admitted to being stressed because
his examinations were coming up. Discussion
He returned a week later with the same complaint. Dens eva gi n atus, also known as eva gi n at e d
The toothache was getting worse and it was odontome, odontome of the axial core type6,9 or
disturbing his sleep. This time, examination was occlusal tuberculated premolar, is clinically
carried out more meticulously and an additional significant because the tubercle that fractures easily
tubercle was found on the mandibular right third exposes the pulp.
molar (48). Its appearance was identical with those It is thought to form from the proliferation and
described as dens evaginatus normally found in the evagination of an area of the inner enamel epithelium
premolars. The tubercle seemed to have fractured and its subjacent odontogenic mesenchyme into the
and it was painful to probing. The tooth itself was dental organ during early tooth development.6,9
tender to percussion. Since the tubercle is usually at a level higher than
A panoramic radiograph (Fig. 1) and a periapical that of the normal tooth cusps, it invariably fractures
radiograph were taken. Tooth 48 had erupted into when the tooth comes into contact with the
occlusion. No periapical lesion was demonstrated yet opposing tooth. It has also been reported to cause
on the radiograph. An extra tubercle could be incomplete eruption, displacement of teeth and
identified. The tooth seemed to have two roots. traumatic occlusion because of the size and location
The 48 was very sensitive to heat, cold and of the tubercle. 7
electrical stimuli. Based on the clinical findings, a
diagnosis of fractured dens evaginatus causing
pulpitis was made. The patient was given a choice of
either trying to save the tooth by undergoing
endodontic treatment or having it removed. He
opted to have it removed, saying that he could not
spend too much time attending clinics.
He was hospitalized for prophylactic care prior to
extraction of the tooth 48. He was given 12 000 units
of subcutaneous heparin in order to achieve an
International Normalized Ratio (INR) of 1.4.
Prophylactic antibiotics vancomycin 1 g and
gentamicin 80 mg were given intravenously one hour
before the operation. Tooth 48 was elevated out with
Fig. 2. – Photograph showing the fractured dens evaginatus (arrow)
the patient under local anaesthesia (Fig. 2). It was on the occlusal surface of 48.
Australian Dental Journal 1998;43:5. 329

In the present case, the wisdom tooth was almost
fully erupted, with only its distal aspect covered by
operculum. The tooth was in contact with the
opposing second molar with a premature contact of
the tubercle, leading to its fracture and exposure of
the dentine and perhaps pulpal tissue. The authors
missed the fractured tubercle during the first visit
and dismissed the patient by informing him that he
may have stress-related orofacial pain. Only on
closer examination at the second visit was the
fractured tubercle detected.
Early delivery of appropriate treatment was
mandatory to prevent complication in this case, with
regards to the patient's medical condition. Two
options were open for discussion with the patient;
either to remove the tooth by extraction/minor
surgery, or to initiate endodontic treatment. The
endodontic treatment may have been either direct
pulp capping after removal of the cusp or a complete
root canal treatment.
It has been demonstrated that early removal of the
dens evaginatus, accompanied by immediate direct
or indirect calcium hydroxide pulp capping and
restoration, is effective in maintaining pulp vitality.10
However, there is no reported case of such a treat-
ment option on a molar tooth. In addition, the
success of root canal treatment on a third molar is
unpredictable, given the nature of its complicated
pulpal and canal systems.11,12
The patient's medical condition itself also did not
permit any risk of endodontic misadventure or
complication. A possible complication is bleeding
from the canal following endodontic instrumenta-
tion, which may pose serious problems for a patient
with a heart valve replacement and undergoing
warfarin therapy. Injury of the inferior dental nerve
during the administration of local anaesthesia,
during instrumentation, following seepage of excess
irritant medicament from the root canal, or as a
result of excess root filling material which has passed
through the apices also is possible. This root filling
material may cause pressure on the nerve in the infe-
rior dental canal or produce a neurotoxic effect on
the ner ve trunk causing dysaesthesia of the inferior
330
18347819, 1998, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1834-7819.1998.tb00183.x by Cochrane Romania, Wiley Online Library on [02/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
dental nerve.13 A surgical procedure is then neces-
sary to remove the excessive overfilled material, a
procedure that must be avoided in a patient with
such a medical condition.
The authors agreed with the patient's request to
remove the affected tooth after considering his
medical condition and all the possible complications
of root canal treatment.
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Address for correspondence/reprints:
Mr Wei Cheong Ngeow,
Lecturer, Department of Oral
and Maxillofacial Surger y,
Faculty of Dentistr y,
Universiti Kebangsaan Malaysia (UKM),
Jalan Raja Abdul Aziz,
50300 Kuala Lumpur, Malaysia.
Australian Dental Journal 1998;43:5.