SCIENTIFIC
DENS EVAGINATUS: ODONTOGENESIS ANOMALY CASE REPORTS
Robert Warren, DDS; Elizabeth Berry, DDS, MPH, MSD; John Unkel, MD, DDS, MPA; William Piscitelli, DDS, MS; Dennis Reinhartz, PhD; Judy Reinhartz, PhD
Introduction
Dental abscesses in the pediatric population are typically caused by dental caries or trauma, but some incidences are caused by unusual conditions that can lead to complexities in diagnoses and treatment.1 Dens Evaginatus (DE) is one of these development anomalies in teeth. It frequently goes undiagnosed and results in complicated sequela. DE is characterized by a supernumerary tubercle protruding on the occlusal surface of the affected tooth. The tubercle is at high risk for pulpal exposure from attrition forces due to its elevation above the occlusal plane. This condition has also been described as an accessory cusp, Leong’s premolar, occlusal pearl, evaginatus odontoma, and talon cusp (only if it is present in anterior teeth), but the most commonly accepted term is DE.2 DE is uncommon, but has been well documented since 1925. Studies have found a higher prevalence among individuals of Asian descent (ranges from 0.5 to 4.3%) compared to Caucasians (0%).3 Higher incidences have also been reported in Alaskan Natives and North American Indians, providing reasonable evidence for a genetic component.3 For a conclusive diagnosis of DE, this anomaly must project higher than the adjacent tooth structure and contain enamel, dentin, and a pulp horn.3 The etiology suggests exfolding of epithelium, which creates the tubercle during the bell stage of tooth development and progresses through maturation.4 Due to the protrusion of pulpal tissue on the occlusal surface, these teeth are at a higher risk of pulpal exposure than adjacent teeth. While this is generally attributable to physiological wear, the pulp may also accede to bacterial assaults through patent dentinal tubules.5
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If untreated, patients with one or more DE teeth are likely candidates for root canal treatment (RCT) or extraction of the affected teeth. RCT is a difficult and expensive option before the apex is fully closed because these teeth are prone to fracture.5, 6 Treatment options for a tooth with DE are monitoring, pulpotomy, RCT, extraction, and equilibration. All factors must be taken into consideration for proper treatment planning: root length, general alignment of teeth, occlusion, and overall arch length. Only minimal structure can be removed before a possible pulp exposure occurs leading to pulpal necrosis and/or apical periodontitis.7 A pulpotomy with mineral trioxide aggregate (MTA) or calcium hydroxide (Ca(OH)2) at the most coronal portion to continue induction of hard-tissue formation is an option if there is a pulp exposure. This report presents two cases of DE, an uncommon condition in pediatric patients, and discusses the importance of early recognition as well as recommended treatment options. Both cases were 11-year-old females who presented to Bon Secours Health System, Inc. hospital-based clinic with pain. Both patients were noted to have facial cellulitis, and they were subsequently diagnosed with DE.
Cases
One of the cases was of an 11 year old Asian female who presented to the emergency department with right side facial cellulitis in her mandibular premolar region. The patient indicated the pain was in her lower right second premolar (#29). She reported the onset of pain was initiated upon chipping her tooth on the previous day. Her medical history was noncontributory. The patient had limited opening due to increased pain. Because
of the facial cellulitis, the patient was placed on antibiotics and instructed to come to the clinic the next day. Figure 1 shows the clinical representation in the emergency department of #29. Swelling and inflammation can be seen on the gingiva buccal to and interproximal to #29. A shallow vestibule is observed indicating infection has spread into the sub masseteric space. The next day, a periapical film was obtained in the clinic. Radiographic examination showed tooth #29 had periapical radiolucency, immature apex, and no caries. Because of the ALARA radiographic principle, and that this was not the patient’s primary dental home, the other premolars were not imaged. Figure 2 shows a large periapical radiolucency to #29 and open apex. Pulpal testing in the clinic of #29 yielded a positive response to cold, and a heightened sensitivity to palpation and percussion; therefore, #29 was diagnosed with irreversible pulpitis and symptomatic periapical periodontitis. As a consequence of the size of the radiolucency, it was reasonable to assume the pulp had been exposed for quite some time. All of the patient’s mandibular premolars presented clinically with DE, as seen in Figure 3. The patient’s premolars had prominent DE, resulting in an open bite on all teeth except her premolars. Pulp tests were performed on all of them and exhibited normal responses. The patient was referred to an endodontist. There she received a root canal on #29 using MTA (apexification). The endodontist additionally completed apexogenesis using MTA on her remaining mandibular premolars along with gross occlusal reduction. The endodontist reasoned a substantial risk or
