Conditions,  Health

Dens in Dente Tooth – Radiograph, Treatment, Classification, Causes

Dens in dente, also known as dens invaginatus, is a developmental anomaly that results in an abnormally shaped tooth. Dens in dente is a result of an invagination in the dental papilla during tooth development, which can occur in various teeth but is most commonly seen in the maxillary lateral incisors but can also involve other anterior teeth. This article explores the complexities of dens in dente, focusing on its clinical examination, diagnosis, and treatment options. Dens invaginatus originates from an invagination of the enamel organ into the dental papilla during tooth development. This can lead to a variety of associated anterior crown forms, often resulting in complex tooth morphology.

Key Facts

  • Dens in dente, also known as dens invaginatus, is a rare dental condition that involves the invagination of the tooth crown or root before the calcification phase.
  • It primarily affects the permanent lateral incisors but can occur in any tooth.
  • This condition can predispose the tooth to dental issues such as caries (tooth decay), periodontal disease, infection, and abscess formation.
  • It occurs in 0.3% to 10% of the population, with a higher prevalence in the permanent dentition compared to the primary dentition.
  • Dens in dente is typically diagnosed through dental radiography.
  • The exact cause is not clear but it’s thought to occur during tooth development.
  • There are no known prevention methods as it’s a developmental anomaly.
  • Depending on the severity (categorized according to Oehlers’ classification), treatment ranges from regular monitoring to restorative procedures or, in severe cases, extraction.
  • Home care involves maintaining good oral hygiene and regular dental check-ups.

What is Dens In Dente?

Dens in dente, literally translated as tooth within a tooth, is a developmental dental anomaly that occurs when the enamel and dentin layers of the tooth crown invaginate or fold into the interior of the tooth. This creates a pocket or groove that resembles a smaller tooth within the affected tooth. The condition can vary in severity, with some teeth exhibiting minor form invaginations that only affect the crown of the tooth, known as anterior crown forms, to more severe forms where the invagination extends deeper into the root canal and potentially the apical region of the tooth.
This condition is mostly asymptomatic and may be discovered incidentally during routine dental X-rays. However, if left untreated and depending on its severity, dens in dente can lead to complications such as cavities and infections due to the accumulation of bacteria in the invaginated area.

Risk Factors of Dens In Dente

Dens in dente can affect anyone, but certain factors might increase the likelihood of developing this condition:

  • Genetics: There appears to be a genetic component, as it often runs in families.
  • Tooth Development Issues: Problems during the early stages of tooth development could lead to dens in dente.
  • Gender and Age: It is slightly more common in males, and usually becomes apparent during adolescence when the permanent teeth are developing.

It is important to note that while these factors might increase the risk, dens in dente can occur without any known risk factors.

Causes of Dens In Dente

The exact cause of dens in dente is not definitively known. However, it is believed to be a result of a distortion occurring during the development of the tooth. During tooth development, the enamel organ, which helps to shape the tooth, invaginates or folds in on itself. This folding can cause the enamel and dentin to grow inward, leading to the characteristic appearance of a tooth within a tooth.
Some theories suggest that trauma, infection, or genetic factors during tooth development could influence the occurrence of dens in dente. However, more research is needed to fully understand the underlying causes of this condition.

Symptoms of Dens In Dente

In many cases, dens in dente is asymptomatic, meaning that there are no obvious symptoms.
However, when complications arise due to the anomaly, symptoms can include:

  • Tooth Sensitivity: The invagination may allow for easier access of hot, cold, or sweet substances to the nerves, causing sensitivity.
  • Discoloration or Spotting: The affected tooth may have a dark spot or may become discolored.
  • Pain or Discomfort: If a cavity or infection develops in the invagination, this can cause pain or discomfort.
  • Swelling: In case of infection, swelling of the gum around the affected tooth might occur.
  • Abscess Formation: Severe infections can lead to the formation of an abscess (a swollen area containing pus) around the affected tooth.

What Does Dens In Dente Look Like?

Commonly affected teeth include the maxillary lateral incisor, though cases in maxillary central incisors and mandibular lateral incisors are documented. Dens invaginatus can appear as a lingual pit or a more bulbous root and can occur bilaterally in cases of bilateral maxillary dens invaginatus. Dens in dente, or dens invaginatus, may not always be visible to the naked eye, especially if the invagination is minor.
However, in more pronounced cases, the affected tooth may display certain features:

  • Groove or Depression: The most common visual indication is a groove, pit, or depression on the crown of the tooth, often towards the inside surface.
  • Irregular Shape: The tooth may appear to have an irregular shape compared to normal teeth, possibly appearing as though a smaller tooth is embedded within it.
  • Discoloration: Dens in dente can sometimes cause discoloration or a dark spot on the affected tooth, especially if there is decay or infection associated with it.

In many cases, the invagination is detected through dental X-rays, which can reveal the inner structure of the tooth.

What Are The Complications Of Dens In Dente?

Dens in dente can be associated with various complications, particularly when the invagination is deep or if proper oral hygiene is not maintained.
These complications include:

  • Tooth Decay and Cavities: The invagination creates a space that is hard to clean, which can lead to the accumulation of bacteria and food particles, resulting in tooth decay and cavities.
  • Infection and Abscess Formation: The accumulation of bacteria can lead to infections within the tooth, and in severe cases, an abscess may form due to the infection.
  • Increased Sensitivity: The invagination can make the tooth more sensitive to temperature and pressure changes because it may place the enamel and dentin closer to the tooth’s pulp.
  • Periodontal Disease: The invagination may harbor bacteria that can affect the gums and bone surrounding the tooth, leading to periodontal (gum) disease.
  • Loss of Tooth Structure: In severe cases, the tooth may lose structural integrity, making it weak and more susceptible to fractures or breakage.

Diagnosis: How is Dens In Dente diagnosed?

Dens in dente is usually diagnosed through dental X-rays, which can reveal the invagination in the tooth. The condition might also be spotted during a routine dental examination, especially if the invagination is deep and causes a visible groove or pit on the surface of the tooth.
The diagnosis often involves:

  • Dental Examination: A dentist might notice an irregularity in the shape or appearance of the tooth during a regular check-up.
  • Dental X-rays: This is the most definitive way to diagnose dens in dente, as X-rays can show the structure of the teeth and the extent of the invagination.
  • Assessment of Symptoms: If a patient experiences symptoms such as tooth sensitivity or pain, this might lead to further investigation and the diagnosis of dens in dente.

Treatment of Dens In Dente

Treatment for dens in dente depends on the severity of the invagination and whether or not there are any complications such as cavities or infections.

  • Observation and Monitoring: For mild cases with no symptoms, the dentist may choose to monitor the tooth regularly to ensure that no complications develop.
  • Dental Cleaning and Sealing: The dentist might clean the invaginated area and apply a sealant to prevent the accumulation of bacteria and debris.
  • Filling or Restoration: If a cavity has developed in the invagination, a filling or restoration might be needed to repair the tooth.
  • Root Canal Therapy: In cases where the invagination is very deep and has affected the pulp of the tooth, root canal therapy might be necessary.
  • Antibiotics: If there’s an infection, antibiotics may be prescribed to deal with it.
  • Tooth Extraction: In very severe cases, where the tooth’s structure is significantly compromised, extraction might be the only option.

Treatment is customized for each individual case. It is essential to consult a dentist for proper evaluation and management of dens in dente.

How Does Dens In Dente Present on a Radiograph?

On a dental radiograph or X-ray, dens in dente appears as an invagination (inward curvature) within the crown or root of the tooth. It typically presents as a radiolucent line or area within the tooth, signifying the presence of a hollow or cavity within the tooth structure. The degree and location of this invagination vary and may be limited to the crown or extend deeper towards the root.

Dens In Dente Oehlers’ Classification

Oehlers’ classification is a system used to categorize the severity and extent of the dens in dente based on radiographic findings. The condition is classified into types, with Type III dens invaginatus being the most severe. This type often involves both the crown and root of the tooth, extending beyond the apical foramen.
The classification is divided into three types:

  • Class I: The invagination is confined to the crown of the tooth and does not extend beyond the cemento-enamel junction (the junction between the crown and root of the tooth). This type usually presents as a small pit or groove on the surface of the tooth.
  • Class II: The invagination extends beyond the cemento-enamel junction and into the root but remains confined as a blind sac; it may or may not communicate with the dental pulp.
  • Class III: The invagination extends through the root and may or may not have an additional opening at the root apex. This type can be associated with a higher risk of complications, as it is often in communication with the pulp and periapical tissues.

Oehlers’ classification helps in understanding the complexity and potential risks associated with dens in dente, and aids the dental professional in deciding the best course of treatment.

Preventive Measures for Dens In Dente

Preventing Dens in Dente itself may not be possible since it is a developmental anomaly.
However, there are measures that can be taken to prevent complications associated with it:

  • Regular Dental Check-ups: Regular dental check-ups are essential in early detection and management of dens in dente, preventing the occurrence of complications.
  • Good Oral Hygiene: Maintaining good oral hygiene by regular brushing and flossing helps to reduce the risk of tooth decay and infection.
  • Sealants: Dental sealants can sometimes be applied to the surface of a tooth with dens in dente, particularly if there is a pit or groove, to prevent food and bacteria from accumulating.
  • Early Intervention: If dens in dente is diagnosed, early treatment to address the anomaly can help in preventing further complications.

Dens In Dente Dental Care

The primary goal of dental care for dens in dente is to prevent complications such as tooth decay and infection, and to maintain the integrity and health of the affected tooth.
Dental care for dens in dente may include:

  • Regular Monitoring: Mild cases of dens in dente might not require immediate treatment. However, the dentist will monitor the tooth closely during regular check-ups to make sure no complications arise.
  • Cleaning and Sealing: In some cases, the dentist might clean the invaginated area thoroughly and apply a sealant to prevent bacteria and debris from accumulating.
  • Restorative Treatment: If the tooth has developed a cavity, the dentist might perform restorative procedures like placing a filling to repair the tooth.
  • Endodontic Therapy: For deep invaginations that have affected the pulp of the tooth, root canal treatment may be necessary to remove infected tissue and seal the tooth. Endodontic treatment is often necessary for dens invaginatus, particularly in cases of pulpal disease or apical periodontitis. Root canal treatment, considering the unique anatomy of the affected teeth, is challenging yet crucial.
  • Restorative Approaches: Post-endodontic treatment, restorative procedures such as the use of composite resin to rebuild the tooth structure are essential. This helps in restoring the normal anatomy and function of the tooth.
  • Nonsurgical and Surgical Treatment: In severe cases, where the tooth structure is extensively compromised, extraction might be considered. While nonsurgical endodontic treatment is preferred, surgical treatment like periapical surgery may be needed in complicated cases. Treatment modalities depend on factors like the extent of invagination and presence of pulp disease or abscess formation.

What Are Dens In Dente Other Names?

Dens in dente is also known as dens invaginatus, invaginated odontome, dilated gestant odontome, tooth inclusion, and dens telescopicus.

Dens in Dente Histology

Histology involves the study of the microscopic structure of tissues. In the context of dens in dente, histology examines the microscopic characteristics of the tooth affected by this condition.

  • Enamel and Dentin: The invagination in dens in dente is lined by enamel, which is invaginated into the dentin. The enamel lining can be thinner than usual.
  • Pulp Connection: In deeper invaginations, the enamel lining may be in close proximity to or even in communication with the dental pulp.
  • Collagen and Cellular Structures: The invaginated area may show irregularities in the distribution of collagen fibers and other cellular structures due to the altered development of the tooth.

Dens In Dente vs. Talon Cusp

While both dens in dente and talon cusp are developmental dental anomalies, they are distinct in their appearance and location.

  • Dens in Dente: As discussed previously, dens in dente is characterized by an invagination or inward folding of the enamel and dentin, creating a pocket or groove within the tooth, often in the crown.
  • Talon Cusp: Talon cusp, on the other hand, is characterized by an additional cusp or projection of enamel and dentin that extends from the chewing surface of a tooth. It is called a “talon” cusp because it often resembles an eagle’s talon in shape.

Dens in dente primarily creates an inward pocket, whereas talon cusp is an outward projection. Both anomalies can cause difficulties in cleaning the tooth and can lead to an increased risk of decay if not managed properly.

Home Remedies for Dens in Dente

While dens in dente is a structural anomaly and cannot be corrected through home remedies, there are some practices that can help in managing oral hygiene and preventing complications associated with it:

  • Regular Brushing and Flossing: Regularly brushing with fluoride toothpaste and flossing can help in cleaning the invaginated area and reducing the risk of cavities and infections.
  • Use of Mouthwash: Antiseptic mouthwash can help in killing bacteria and should be used as part of your oral hygiene routine, especially if you have dens in dente.
  • Dental Picks or Interdental Brushes: These tools can help in cleaning the hard-to-reach invaginated area.
  • Saltwater Rinses: Gargling with a saltwater solution can help in reducing bacteria and inflammation in the mouth.

When Should I See My Healthcare Provider?

You should consider seeing a dentist in the following scenarios:

  • If you notice an abnormal shape or depression in one of your teeth.
  • If you experience pain, sensitivity, or swelling around a tooth that may have dens in dente.
  • If you have difficulty in cleaning a particular area of a tooth.
  • If the tooth with dens in dente changes color, which may indicate tooth decay.

Bottom Line

Dens in dente is a unique and challenging developmental anomaly that requires specialized treatment approaches, and careful management to prevent complications such as tooth decay and infection. While there are home remedies that can assist in maintaining oral hygiene, they are not substitutes for professional dental care. Understanding its varied presentations and adopting appropriate treatment modalities, ranging from nonsurgical endodontic treatment to surgical intervention, is essential for effective management. Early diagnosis and intervention are crucial in preventing complications like internal resorption, apical periodontitis, and abscess formation. With advancements in dental technology and clinical research, managing dens in dente has become more predictable and successful. If you suspect you have dens in dente or are experiencing symptoms such as pain or sensitivity in the affected tooth, it is advisable to consult a dentist for a comprehensive examination and appropriate treatment.

This article is complete and was published on June 7, 2023, and last updated on December 29, 2023.

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