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

i-.iutiut th'iil t)(iuniiilnt t<>'>fK t2: tTT-t

t'rhilrit ill thiimiirti Atl iii^tiis irsrrvcit

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.

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

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

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:>f these teeth would
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

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.

138

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.

Table 1. Obseryed Values in the 3 Treatmeiit Groups

Symptomatic'
Asymptomatic**
Totals (Cotutntis)

Treatment

Treatment

Treatment

Totals

C (Control)

(Rows)

59

11

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

71
1520
1591

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

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.

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

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).

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.

8. Ri:ic:iiARi P. TWIINIRW I). l)e-us c-vaginaltis in Ihe- Thai. An

e-valiiation ol liriyone- casc-s. Orat Sing Oral Med Oiiit Pathot

1975; J9.-()1.5-2r
9. M< ALLAN l . I l , n i K i i nos PA. D e n s E v a g i n a l t t s . C^asc- Re-port.

Anst Dent I \989\ 34: V.W-\

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.
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