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iutiut th'iil t)(iuniiilnt t<>'>fK t2: tTT-t t'rhilrit ill thiimiirti Atl iii^tiis irsrrvcit

(:ol>\rigtit i\iiniti\j;nnrd 1996

Endodontics & Dental Traumatology

Management of dens evaginatus: evaluation of two prophylactic treatment methods

Sim Tf^C. Management of d e n s exaginattis: e\afnatieiii of two pre)jihylactic treatment methods. Etidod Dent liatitnatol 1996; 12: 137-140. Muuk.sgaarcf, 1996 Abslracl - Dens evaginaltis (DE) is an ode)nlogenic aneinialy characteri/.ed fiy au enamef covered tufiercfe, eucfosiug dentin aucf jjulpal lissue. It most coninionly affects premolar teelfi of ])eoj3le of lnoiigoloid etliuicil). fhe piexalence of DE in Siiigajjore is 2.1%. Fracture or attrition of the ttibercle may lead to puljDal necrosis. Thtis, j^ropbylactic inauagemeut of DE is preferred. A retrospeclive cofiort stucfy couipariug two ce:)nime)n jjrojjhyhictic restorative nietbods was condticled. This involved 817 children, aged 10 years at the outset, having I .'i9f DE. Tfie teeth were oliserxcd for 2 \ears. The results showed that significantly less teetli cfevefoped jitiljial j^atholog-) when an enaniojDfasly-preventive resin restoration method was tised (0.52%) as compared to an amalgam ca\'it)' restoration (5.37%) and the control (3.65%) [X" = 9.595 (p<().01) df = 2]. Knowledge of tfie various treatment ojitions and pre\alenc-e data is iniporlanl as ifiere is au increasing gfof)af liiigration of jjeopfe of niongoloid etlmicitv.

T. P. C. Sim
School Dental Service, Ministry ot Health, Singapore, Repuhlic of Singapore

Key words: dens-evaginatus: dental abnormality: dental anatomy Timothy P. C. Sim. Lillian Penson Hall (Room 233), Talbot Square, London W2 ITT, United Kingdom Accepted October 3, 1995

Detis e\agitiatits (l^E) is ati odoutogeuic anomaly cfiaracterized by an cMianic^f covered conicaf tufjercle, enclo.sing dentin and pitljDaf tisstie, tnost coiiimoiify fcjuiid on tfie occlusaf surface of permanent premolats (Fig. 1). Althotigh rare, similar tufoercufated strtictures fiave been reported in ifie molars atid anterior teeth (1). DE is thought to be formed as an abnormal profiferatic^n c:)f ifie internal enamel ejDithelitun leading to an invagiiiatioii of the internal enamel epithelium and dental papilla into the stellate retictiluni of the enamel organ (4). T h e tubercle averages f.5 mm in diameter and 3.0 mm in length (5). Histologic studies bv Oefilers (2) fiave sfiown tfie pre.sence of a sfencfer pulp horn which extends within the dentin of lhe tuf)ercfe. Tfie pufpaf extension may vary from f .f5 to 3.2 mm in length and 0.03 to 0.18 nnn in diameter (3). Tfie tnfiercle may be large enougfi lo catise occhisal interferences, incomplete erujjliou, displacement, rotation and lifting of opposing

teeth (2), and fractute of the tuf)ercle itself. Eracture or alirilion e)f the tuf^ercle may lead to pulpal necrosis, periapical inflammatory responses and loss of vitality in caries free teeth (2). This will necessitate endodonlic proceditres stich as apexificatiejn e)f immalnre apices and snfiseqtient ofittnation, or renunal of the offending tootfi. Tfierefore lhe prophylactic restoration c> these teeth would :f be the preferred treatment cfioice. f{\agiuated teetfi occur predoniinautf) iu persons of mongoloid ethnicity. T h e pathogenesis of DE is uncertain, fjut e\icfence suggest a familial or hereditary pattetti (6-7). T h e teporled differences iu iucidence amongst tfie niongofoid sufjgroups, lietween 1.01 % (8) and 4.3% (6), niavsuggest varying degrees of penetrance (6) allhougfi this is disputed by Yip (5). The management of DE is based mainly on empirical evidence. A fiieiattire search fVoin 1936 show a paucity of coutreiffcnf cfiuicaf trials to CNalii-

137

Sim
fhe children were seen every six months b)' lhe denial nurse aud all patients with ertijDting premolars with DE were referred to the dental officer for tnanagetnent. Information from tfie tieatment cards of these 8f 7 cliildreu was used for the study. De])ending on the lype oi' treatment instituted, lhe Df''. were divided inlo 3 lreatment groups: TreMvtcitt Grottp A - The tubercle was removed and an occlusal amalgam cavity prejjaralion was created, tfie floor of the cavity was lined witfi hardsetting calcium hydroxide, based with zinc-oxideeugene)l cement and restored with amalgam (after Ycmg-''). Treatment Group B - Each tubercle was trimmed, the cavity extending only into cfentin. The cavity was lined with calcitim hydroxide, cleaned and etched. A composite resin was placed to fill tfie cavity and to seal tfie surrouncfing fissures (after Hill and Bellis"). For very large tubercles, a two stage jDrocedure was emjDloyed. fn tfie first stage, only enotigh e)f the ttibercle was trimmed to prevent occhisaf tratima. The second stage was completed 3 months later as described abcive. Treatment (jToup C - (Used as tfie control): No treatment instiluted. This groujD was confhied mainly lo jDiemolai's with very small tubercles which did uot appear to interfere with the occlusion. Tfie jaatients were reviewed f y the dental nurse ^ evei-y six months for two years fbr every f^E. Any teelh that develojDed signs a n d / o r .symptoms of jjtilpal e)r periapicaf patfieisis was referred to tfie dental cjfflcer for management and was counted as a faifure of tfiat form of treatment. The data was tabtilated by treatment grotips and the ])resence or absence of pufpaf signs ancf syni|> tonis (Table f). The chi-square test for iudejiendence for tfnee or more variables was nsed to compare statistically the observed projDortions dc^velo|5ing ptiljDal signs and symptoms, and as lo whether the outcome was depeudeul u|)on lhe treatment.

Fig. I. A typical c-\amplc- ol ;i ma\illat-y ptc-molat widi dens e-vaginatus (ai row).

ale the effectiveness ofclifferenl types e)f treatment fc5r tfiis anomafy. The literature has lieeu mainly confined to single case reports (9-12) and the occasional report cjf several cases (3, 13). The ctirricttlum of dental schools in this region also show differing treatment pfiilosophies in the management of Df^. Flowever, most of the scliools advocate identical or variations of the two treatment jjroec-dures evaftiated in this study. Follc:)wing is a report of a rc-li-e)S]3ective cohort study evaltiatiug two common prophylactic restorative procecfures used to treat DE, with respect to the rate of occurrence of j^tilpal and/or periaj^ical signs and symptoms caused by eaeh lreatment. Material and method f-'iglit hundred and seventeen (HI 7) students out of lhe lotal participating jDoptilation of 39,125 children, aged 10 years from the otitset, from 3() primary schools, wete fbtuid to have at least e)ne DE. Only DE which were asymptomatic and vital were included in the study. A total of 1591 premolar teeth which met the selection criteria were included iu the sttidy; oul of 1605 DE present. Six hundred and seventy-nine (679) leetfi were included in the study althotigh they had tubetcles which wc-re worn or attritecl as these teeth were vital and asyinpiomatir. There were 14 teelh which exhibited se)nie fejrm e)r|Dulpal and/or periapical pathe)sis and were excluded. However, dtie te) the lack of iadie)graphie equipment at tfie school dental clinics, periapical ladiogiaphs cottld not he taken. Denial care was provided by denfal ntuses ("New Zeafancf" lype) and dentists tcj aff primary and secondary school children aged 6-18. As sucfi, tfiere were no prololems with rc'S])onse.

Table 1. Obseryed Values in the 3 Treatmeiit Groups Treatment A Treatment B Treatment C (Control) Totals (Rows)

Symptomatic'
Asymptomatic** Totals (Cotutntis)

59

11

71
1520 1591

[5.37%] [0.52%] [3.65%] 1039 191 290 1098 192 301 X'- = 9.595 (p<0,01)d1=2

Teeth which developed pulpal signs/symptoms during the observation period of 24 inonths ** Teetli which remained free of any pulpal signs/sympfoms during the observation period

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Management of dens evaginatus Results

O f l h e total jjarticipating popttlation of 39125,817 students witfi a total e)f 1591 l^E were incfticfed in tfie sltidy. Thus the prevalence e f DE in this series > was 2 . 1 % . The prevaleMiee e)f DE in Chinese Siugaporeaus was 2.6% aud iu Mahns, 0.5%). Tliere were no DV. ofoserved in fndians and other races. The results were- similar lo that rejjorted by Yip". The projieirtioii e)f the elilfere-nt races seen was similar te) the national figure (f4) oi'11.1% (Chinese, 14.1% Malay, 7.1%'Indian aud 1.1% other races. There was no sex iiredilection. E\ag-iualie)ii was eibsei-\-ed meist frecjiieutly in niaiicfibular preuiolars (81.(i%) and were generally preseul f)ifaterally. The mode was 2 DE per child (42.7%) and the range betwe-e'ii f and S DE per cfiifd. The results e)f the stuch- she)wed lhat 5.37%) iu Ciroup A developed pulpal sigus ancf symplonis within 24 months wliile lhe figure was only 0.52% for Cirouj) B and 3.65%) for Group C ((',outre>l). Talofe f shows the actual observed values. Iu the chi-square tesl with 2 degrees e)f fieeele)iii, the calculaled observed value \vas 9.595 wliie h is greater than the critical value 9,210 (a= 0.01). Tfierefbre, there appears to he a siguificaiu difference f^etween treatment grotips A, B and i\ wiifi respects to tlie proportions developing pul|)al sigus and .syniptcMiis. Equivafentlv, tbete appears to f^e a relaliouship between tlie choice of tieatment and development of pttlpal pathology. the tubercle- to abrade sle)wfy witfi time encouraging foi nialiou of seccjiidary deiiliu; aftfiougfi this has been shown by Oehlers to he itnieliafile (16). fiazan, in tfie same paper, fater reconiniended tfie tise of a ceMiiposite resin instead of a fisstne sealant for improNed sireiiglh. This method ajajieais to he impractical es]:)ecially in leetfi witfi large tubercles as tfic" occftisal build-np of couijiosite resin would create occlusal iuterferences with opposing teeth. A survey h\ fiedi (f 7) shows that 27% of dentists in H o n g Kong tise the nielfiod desc rified h\ ^c)ng (3). A fufl 67% of ifieni prefer ifie nielfiod of "judicious grinding of the tubercles" (16) at periodic iutervafs soon after tootli eriqjtion lo enconrage secondary cleiuin foruialion aiie;l obliteration of the pulpal chamber within the tul^ercle (17). The lilerattire appears to be against lliis lecfinic]tie (f), (17, 18, 19). Otlier niethods stufi as efective root canal ireatlneiit iiia\- be coiiiplicaied b\ immature apices and itieeinipfete root foruialion necessitating apexification i)rocediu-es wilfi calcium fiycfroxicfe. filecli\e reincnaf of ifie affected tootli sliould otih- he considered in conjuuciiou with orihodontic lhera|j\-. 1 he results of this sttid\' sfiottld encotirage the wider acfoptiou of the selective euamopfast\--pre\-eiiti\-e resin resloratixc uielliod as a viafife wa\' lo manage cfens exaginaUis. f\.iie)\vledge of ifie Narious treatineiU modalities and prc'Nalence data for dens evaginatus is iiiiportanl as there is an iticreasing global niigratiein of j)cH)|ife e)l inoiig<)le)id c-tliiiicit)\ f he more recent case reports afiont dens evaginaltis have originated fi-om the West. .Aff of these fia\e fjeeii on the uianageinent of this anouialy in Asian iiniiiigrant populations (9-12).

Discussion
It would a])|:)eai- ihal the more coiisei-\'ati\-e a|5|)rc)ach towards the management of Df\ h\ a loreveutive resiu testoration (Crottp B) tnay be the more appre)i5riate choice when coinj^arecl lo a lined, aiiialgani occlusal cax'ity reste)ratioii (C.reiuii A). However it must he noted that the j5i'c^|:)orlie)ns devele)|3iug puf]:)al signs aucf syiii|)toiiis are smafl for either Irealnienl greiu]). The lenver value of)served for the control (Ciroup C) |3.t)5%] as coui]Dared to the jjiojihylaclic ainalgaiii method (Group A) [5.37%)| may be altribuleel te) the fad thai oiil\' small Itibercles whicli did not appear to cause occfusal iiUerrereuces WCMC (iut iu this category. Moreover, the proj:ilt\laclic amalgani restoraticjii (Group A) was prefc-rred by operators h\ a ratio of 2.2: 1 conijjared to the olher two gi-oiij)s and this may fiave fiacl an inllueuce ou ifie result. There have been many alteinalixe trealittenl nietfiods prope)sed to niauagc DE. f^a/.an (f5) lias altein]3ted to stippori the tubercle with a li.ssurcsealant. This was to alfo\v l)oth the- material and

Summary and conclusions

fleus e\-agiuatus w.is found in 2.f % of chilcfreii in Singapore. There was a racial predilection fe)i- j^erse)ns eif iiU)iigofoid etliuicilv-. A retrospective coluirt stuch' cotujjariiig two ce)iiinu)u pre)plnlaclie- reste)i-ati\-e liiethods fbr iiiaiiagiiig cfens cwagitiattts was d o n e involving 817 children, aged 10 vears at ifie e)utset, with a te)tal e)f 1591 leelh having tliis aitoinal\-. The leeth vvet-e e)bser\-eel leii 2 ^-c'ars. Tlie restilts sliowed lltat sigiiificanlh' less teelli cfc-vefopecf pulpal signs aud SNniptoiiis when a sc-lec'lixe euaiiioj)lasty-pre\-enli\-e resin resloratixe uu-thod was used (().52%i) as compared to the anialgatti cavilv restorative method (5.37%) and the control (3.65%), [x" = 9.595 (p < 0.01) df = 2] Knowledge of the vaiiotis treattnent options and [irevaleMice data le)r clcMis eNagiiiatus is impor-

139

Sim tant as tfiere is an increasing migration of peojjle with a predilection for tliis anomaly to many parts of the world. Aeknowledgements -The author would like te) thank tfie cfentaf therapists and ntirses fre)in tfie Jtiroug/ Cifementi and Hotigang/Serangoon/Aiig Mo Kio groups of school dental clinics feir tfieir help in collecting the data and reviewing the patients involved in the study. References
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(Iliuical aud radiological stttely of deus evagiuattts. Dmtomaxillofae Radiol 1975; ,S'.- 78-83

140