Review article
Dens Evaginatus: Literature Review, Pathophysiology, and Comprehensive Treatment Regimen

https://doi.org/10.1016/j.joen.2005.10.009Get rights and content

Abstract

Dens evaginatus (DE) is an uncommon dental anomaly, having been well documented since 1925. It occurs primarily in people of Asian descent and is exhibited by protrusion of a tubercle from occlusal surfaces of posterior teeth, and lingual surfaces of anterior teeth. Tubercles have an enamel layer covering a dentin core containing a thin extension of pulp. These cusp-like protrusions are susceptible to pulp exposure from wear or fracture because of malocclusion, leading to pulpal complications soon after eruption. Endodontic intervention of permanent teeth with immature roots is unpredic for inflamed pulps, and leaves a tooth with compromised root structure when treating necrotic pulps. Efforts to ensure root maturity have involved preventive or prophylactic treatment with varying degrees of pulp invasiveness. Treatment options have changed as technology and materials have improved. The goal is to review the literature and pathophysiology regarding DE, and present a new comprehensive treatment regimen, including a truly prophylactic approach without pulpal invasiveness. A case study of a mestizo with DE is documented. Treatment of four affected mandibular premolars exhibiting three distinct diagnostic categories will illustrate various aspects of the treatment protocol presented, and tooth morphology of the anomaly is shown to aid clinical recognition.

Section snippets

Pathophysiology

DE is thought to develop from an abnormal proliferation and folding of a portion of the inner enamel epithelium and subjacent ectomesenchymal cells of the dental papilla into the stellate reticulum of the enamel organ during the bell stage of tooth formation (24, 25, 26). The resultant formation is defined as a tubercle, or supplemental solid elevation on some portion of the crown surface.

To establish a proposed embryologic etiology for this unusual entity, it is important to review the most

Morphology

The DE tubercles of posterior teeth average 2.0 mm in width (37) and up to 3.5 mm in length (9), and up to 3.5 mm in width and 6.0 mm in length for anterior teeth (17). Other than the cusp-like variable sized and shaped tubercle of teeth with DE, the remaining portion of the crown has a normal anatomy (6). This is an additional distinguishing characteristic from the accessory cusp of Carabelli, that when present, the associated teeth are often larger than normal mesiodistally (1). However,

Clinical Issues

Because the DE tubercle may extend above the occlusal surface up to 3.5 mm (6.0 mm for anterior teeth), malocclusion with the opposing tooth upon the cusp-like elevation occurs as involved teeth erupt into the dental arches. The resultant occlusal traumatic force causes abnormal wear or fracture of the tubercle, and is the usual manner of pulp exposure for this anomaly. Caries has historically not been a factor for consideration regarding pulpal involvement for this entity. A pathology report

Treatment of DE

Teeth presenting with a normal pulp and a mature apex (type I) should have the opposing occluding surface reduced to eliminate traumatic occlusion with the tubercle, followed by an application of topical fluoride to increase the enamel’s hydroxyapatite resistance to acid breakdown. Then, incremental layering of an acid-etched flowable light-cured resin (AEFLCR) is applied to the tubercle and surrounding surface (Fig. 2, tooth #21 and Fig. 6, tooth #28). Reevaluation at 6-month intervals is

Prophylaxis

Prevention of pulpal involvement in cases of DE is preferred over more invasive techniques. Because pulp exposure of the tubercle resulting from occlusal forces occurs soon after eruption, prophylactic intervention will prevent the need for treatment of teeth with immature apices and thin, weak roots. Even when pulp exposure is avoided past the period of complete root formation, the tubercles are still susceptible to fracture. Past treatment modalities suggested have had inconsistent results.

Case Study

The authors believe this to be a rare documented case of DE in a patient of Mestizo heritage. The earliest reported DE case in an individual with this familial heritage is by Priddy et al. in 1976 (37). However, early articles are devoid of the phraseology currently used to depict individuals of this heritage (14, 37, 78). In September 2003, a 13-year-old Mestizo female presented to the University of Tennessee College of Dentistry patient clinic. She presented with DE involving all four

Discussion

The treatment regimen for cases of type III through type VI can also be applied to traumatized teeth presenting with fractured crowns and pulp exposure. All of the considerations for evaluating the pulpal status and extent of root maturity when diagnosing these traumatized teeth are similar to patients who present with fractured tubercles as a complication of DE.

America’s largest minority, the Hispanic/Latino/mestizo people, constitutes 13.7% (40 million) of the US population. Since 1980, their

References (79)

  • J. Jernvall et al.

    Reiterative signaling and patterning in mammalian tooth morphogenesis

    Mech Dev

    (2000)
  • R. Chen et al.

    Talon cusp in primary dentition

    Oral Surg Oral Med Oral Pathol

    (1986)
  • W. Priddy et al.

    Dens evaginatus—an anomaly of clinical significance

    J Endod

    (1976)
  • S. Kakehashi et al.

    The effects of surgical exposure of dental pulps in germ-free and conventional laboratory rats

    Oral Surg

    (1965)
  • F. Banchs et al.

    Revascularization of immature permanent teeth with apical periodontitisnew treatment protocol?

    J Endod

    (2004)
  • T. Saito et al.

    Acceleration effect of human recombinant bone morphogenetic protein-2 on differentiation of human pulp cells into odontoblasts

    J Endod

    (2004)
  • E. Koh et al.

    Prophylactic treatment of dens evaginatus using mineral trioxide aggregate

    J Endod

    (2001)
  • M. Cvek et al.

    Histological appearance of pulps after exposure by a crown fracture, partial pulpotomy, and clinical diagnosis of healing

    J Endod

    (1983)
  • M. Nagayoshi et al.

    Antimicrobial effect of ozonated water on bacteria invading dentinal tubules

    J Endod

    (2004)
  • R. White et al.

    Residual antimicrobial activity after canal irrigation with chlorhexidine

    J Endod

    (1997)
  • M. Evans et al.

    Efficacy of calcium hydroxidechlorhexidine paste as an intracanal medication in bovine dentin

    J Endod

    (2003)
  • M. Torabinejad et al.

    The antimicrobial effect of MTADan in vitro investigation

    J Endod

    (2003)
  • S. Shabahang et al.

    Effect of MTAD on Enterococcus faecalis-contaminated root canals of extracted human teeth

    J Endod

    (2003)
  • B. Cohen et al.

    The effects of eugenol and epoxy-resin on the strength of a hybrid composite resin

    J Endod

    (2002)
  • S. Shabahang et al.

    Apexification in immature dog teeth using osteogenic protein-1, mineral trioxide aggregate, and calcium hydroxide

    J Endod

    (1999)
  • G. Lawley et al.

    Evaluation of ultrasonically placed MTA and fracture resistance with intracanal composite resin in a model of apexification

    J Endod

    (2004)
  • G. Matt et al.

    Comparative study of white and gray mineral trioxide aggregate (MTA) simulating a one- or two-step apical barrier technique

    J Endod

    (2004)
  • A. Al-Kahtani et al.

    In-vitro evaluation of microleakage of an orthograde apical plug of mineral trioxide aggregate in permanent teeth with simulated immature apices

    J Endod

    (2005)
  • A. Frank

    Therapy for the divergent pulpless tooth by continued apical formation

    J Am Dent Assoc

    (1966)
  • J. Schumacher et al.

    An alternative to apexification

    J Endod

    (1993)
  • J. Coviello et al.

    A preliminary clinical study on the use of tricalcium phosphate as an apical barrier

    J Endod

    (1979)
  • S. Shabahang

    State of the art and science of endodontics

    JADA

    (2005)
  • R. Augsburger et al.

    Pulp management in dens evaginatus

    J Endod

    (1996)
  • R. Chen

    Conservative management of dens evaginatus

    J Endod

    (1984)
  • H. Sedano et al.

    Clinical orodental abnormalities in Mexican children

    Oral Surg Oral Med Oral Pathol

    (1989)
  • M. Torabinejad et al.

    Physical and chemical properties of a new root-end filling material

    J Endod

    (1995)
  • B. Neville et al.
  • M. Ash
  • W. Mitchell

    Case report

    Dent Cosmos

    (1892)
  • Cited by (0)

    View full text