Case Report Enamel Pearls Implications on Periodontal...

Case ReportEnamel Pearls Implications on Periodontal Disease

Elton Gonçalves Zenóbio,1 Thaís Ribeiral Vieira,2 Roberta Paula Colen Bustamante,3

Hayder Egg Gomes,4 Jamil Awad Shibli,5 and Rodrigo Villamarin Soares1

1Department of Dentistry, PUC Minas Master Program of Implantology and Periodontology, 500 Dom Jose Gaspar Avenida,46 Hall, 30535-610 Belo Horizonte, MG, Brazil2Department of Dentistry, PUC Minas Master Program of Periodontology, Belo Horizonte, MG, Brazil3Department of Dentistry, PUC Minas Master Program of Implantology, Belo Horizonte, MG, Brazil4Department of Dentistry, PUC Minas, Belo Horizonte, MG, Brazil5Dental Research Division, Department of Implantology and Periodontology, School of Dentistry, UNG, Guarulhos, SP, Brazil

Correspondence should be addressed to Elton Goncalves Zenobio; [email protected]

Received 21 June 2015; Revised 24 August 2015; Accepted 26 August 2015

Academic Editor: Samir Nammour

Copyright © 2015 Elton Goncalves Zenobio et al. This is an open access article distributed under the Creative CommonsAttribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work isproperly cited.

Dental anatomy is quite complex and diverse factors must be taken into account in its analysis. Teeth with anatomical variationspresent an increase in the rate of severity periodontal tissue destruction and therefore a higher risk of developing periodontaldisease. In this context, this paper reviews the literature regarding enamel pearls and their implications in the development ofsevere localized periodontal disease as well as in the prognosis of periodontal therapy. Radiographic examination of a patientcomplaining of pain in the right side of the mandible revealed the presence of a radiopaque structure around the cervical regionof lower right first premolar. Periodontal examination revealed extensive bone loss since probing depths ranged from 7.0mm to9.0mm and additionally intense bleeding and suppuration. Surgical exploration detected the presence of an enamel pearl, whichwas removed. Assessment of the remaining supporting tissues led to the extraction of tooth 44. Local factors such as enamel pearlscan lead to inadequate removal of the subgingival biofilm, thus favoring the establishment and progression of periodontal diseases.

1. Introduction

Inflammatory periodontal diseases present an etiologicalcause which is primarily determined by a bacterial biofilmand its subproducts. Multiple factors influence the qualityof this biofilm as well as its pathogenic potential. The basisof periodontal therapy can most commonly be found in themaintenance of a specific microbiota through the control ofthe dental biofilm and decontamination of the root surface[1, 2].

Root anatomy has been reported in the literature asa highly relevant predisposing factor in the installationand perpetuation of periodontal diseases. In this context, anumber of authors have given priority to in-depth knowledgeof root morphology [3–6]. In particular, the presence ofenamel pearls can affect mechanical control of dental biofilm,since they serve as niches which retain bacterial biofilm anddental calculus [7].

Ectopic globules of enamel, or the so-called enamel pearls(EP), can be either internal or external, with the formerbeing more common and usually found at a cervical orcoronary location on the root surface. These globules aremost frequently located near the enamel-cementum junction.EP origin is probably related to a localized developmentalactivity of Hertwig’s epithelial root sheath (HERS) cells thatremained adherent to the root surface as the root devel-opment proceeds. HERS cells differentiate into functioningameloblasts which deposit an enamel organic matrix on theroot surface [7–9].Additionally, a recent report discussing thepresence of multiple EP in two siblings raised the possibilityof a hereditary association in the formation of EP [10].

These deposits predominantly consist of enamel andrarely present pulp tissue in their composition. They aremost frequently located in bifurcations or trifurcations ofmultiradicular teeth but can also appear in uniradicular

Hindawi Publishing CorporationCase Reports in DentistryVolume 2015, Article ID 236462, 3 pageshttp://dx.doi.org/10.1155/2015/236462

2 Case Reports in Dentistry

teeth.Themaxillary molars are affectedmore frequently thanmandibular molars [8, 11]. Nearly three-fourths of the EPmight be found in the maxillary third molars, although theirappearance in mandibular third and second molars may alsobe observed [6]. These circular formations can achieve 0.3to 2.0mm in diameter, in the majority of the cases onlyone EP incidence can be detected in each tooth, and two ormore pearls located on the surface of a single tooth are rarelyobserved [6, 9, 12].

Theprevalence of EPmaydiffer depending on themethodused to detect them. In a clinical exam performed by Kerr[13], EP were found in at least 1% of all extracted teeth andin 2% of the maxillary molars. In another report histologicalexam of extracted teeth revealed that nearly 15% of all teethand 54% of maxillary molars presented EP [7]. Moskow andCanut [6] demonstrated that these globules can be diagnosedby radiographic examination. Their study reported a meanincidence of 2.6% and a variation of 1.1% to 9.7% dependingon tooth type and location.

There is evidence suggesting that the clinical significanceof EP may be related to periodontal disease. These nodulescontribute to local deepening of periodontal pockets because,in their presence, the attachment of the periodontal ligamentdoes not occur properly [14]. The periodontal pocket, whenpresent, extends apically to the EP generating difficulty onbiofilm control and restricting access for scaling and rootplanning. In this context, the presence of EP in various peri-odontal lesions has been previously described [6]. EP mustbe removed or undergo intervention to allow access to thearea for proper biofilm control by patients and professionalsin order to prevent future attachment loss [5].

2. Case Description and Results

A 18-year-old female patient complaining of pain in theright mandibular region was examined at Department ofDentistry, PUCMinas. During the clinical examination, pulpvitality and absence of mobility were shown, probing depthsof 8.0mm at the mesiobuccal, 7.0mm at the distobuccal,and 9.0mm at the midbuccal sites were encountered, and,additionally, intense bleeding, suppuration, and the presenceof a gingival abscess could also be observed (Figure 1). Radio-graphic examination of lower right first premolar revealed thepresence of a radiopaque structure around its cervical region(Figure 2). Surgical exploration was performed by means ofa conventional gingivoperiosteal flap and the presence of EPassociated with extensive bone loss was observed (Figure 3).After removal of anatomical alterations and assessment ofthe remaining supporting tissues (Figure 4), the extraction oftooth 44 was indicated and conducted.

3. Discussion

Mechanical factors which favor the retention and growthof the dental biofilm act as secondary etiological factorsof periodontal diseases [15]. They are usually derived fromabnormal anatomical characteristics of the roots and/or

Figure 1: Gingival abscess and suppuration in the premolar area.

Figure 2: Radiograph of tooth 44. The presence of a radiopaquestructure can be observed around the cervical region.

Figure 3: Surgical exploration. The presence of EP associated withextensive bone loss can be observed.

restorative interventions (i.e., inadequate or excessive mar-gins of subgingival restorations) that might increase bacterialadhesion and growth on dental surfaces and on pocketepithelium [3] leading to periodontal diseases [4].

The presence of EP associated with a number of peri-odontal lesions has been reported [5, 7, 16] and althoughsmall EP can be inadvertently removed during scaling androot planning, larger ones may be an obstacle to appropriateroot instrumentation and additionally and clinically and at

Case Reports in Dentistry 3

Figure 4: Assessment of the remaining supporting tissues.

radiographic exam incorrectly diagnosed as dental calculus[6].

There is scientific consensus that EP favor the installationor at least an increase in the severity of isolated periodontalproblems [5–7, 11, 14]. Therefore, this anatomical anomalydemands a more careful approach and a precise diagnosissince unidentified EP can possibly initiate or aggravateperiodontal diseases leading to unfavorable tooth prognosis.

4. Conclusions

Many failures in periodontal treatments are related to inad-equate evaluation of the teeth with distinct anatomicalcharacteristics and incorrect diagnosis. Therefore, a detailedassessment of variations on teeth anatomy is important toobtain a correct diagnosis, more predictable and reliableprognosis to select the appropriate periodontal therapy.

Disclosure

Hayder Egg Gomes would like to disclose that he is anundergraduate student at Department of Dentistry, PUCMinas, Belo Horizonte, MG, Brazil.

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper.

Acknowledgment

The present work was supported by Department of Dentistryof PUCMinas.

References

[1] H. Loe, E. Theiland, and S. B. Jensen, “Experimental gingivitisin man,” Journal of Periodontology, vol. 36, pp. 177–186, 1965.

[2] P. D. Marsh, “Dental plaque: biological significance of a biofilmand community life-style,” Journal of Clinical Periodontology,vol. 32, no. 6, pp. 7–15, 2005.

[3] R. C. Bower, “Furcation morphology relative to periodontaltreatment: furcation root surface anatomy,” Journal of Periodon-tology, vol. 50, no. 7, pp. 366–374, 1979.

[4] M. E. Gher and A. R. Vernino, “Root anatomy: a local factor ininflammatory periodontal disease,”The International Journal ofPeriodontics &Restorative Dentistry, vol. 1, no. 5, pp. 53–63, 1981.

[5] G. L. Hou and C. C. Tsai, “Relationship between periodontalfurcation involvement and molar cervical enamel projections,”Journal of Periodontology, vol. 58, no. 10, pp. 715–721, 1987.

[6] B. S. Moskow and P. M. Canut, “Studies on root enamel. (2)Enamel pearls. A review of their morphology, localization,nomenclature, occurrence, classification, histogenesis and inci-dence,” Journal of Clinical Periodontology, vol. 17, no. 5, pp. 275–281, 1990.

[7] A. O. Cavanha, “Enamel pearls,” Oral Surgery, Oral Medicine,Oral Pathology, vol. 19, no. 3, pp. 373–382, 1965.

[8] B. R. Chrcanovic, M. H. N. G. Abreu, and A. L. N. Custodio,“Prevalence of enamel pearls in teeth from a human teeth bank,”Journal of Oral Science, vol. 52, no. 2, pp. 257–260, 2010.

[9] X.-Q. Mao, “Root-like enamel pearl: a case report,” Journal ofMedical Case Reports, vol. 8, no. 1, article 248, 2014.

[10] T. Saini, A. Ogunleye, N. Levering, N. S. Norton, and P.Edwards, “Multiple enamel pearls in two siblings detected byvolumetric computed tomography,” Dentomaxillofacial Radiol-ogy, vol. 37, no. 4, pp. 240–244, 2008.

[11] N. H. Andrews, “Periodontal significance of cervical enamelprojections,” Journal of the Canadian Dental Association, vol. 41,no. 1, pp. 50–52, 1975.

[12] A. Sehic, R. Peterkova, H. Lesot, and S. Risnes, “P32-distribution and structure of the initial dental enamel formedin incisors of young wild-type and Tabby mice,” Bulletin duGroupement International Pour la Recherche Scientifique enSstomatologie & Odontologie, vol. 49, no. 3, pp. 104–106, 2010.

[13] D. A. Kerr, “The cementum: its role in periodontal health anddisease,” Journal of Periodontology, vol. 32, pp. 183–189, 1971.

[14] R. H. Swan and W. C. Hurt, “Cervical enamel projections asan etiologic factor in furcation involvement,”The Journal of theAmerican Dental Association, vol. 93, no. 2, pp. 342–345, 1976.

[15] D. C. Matthews and M. Tabesh, “Detection of localized tooth-related factors that predispose to periodontal infections,” Peri-odontology 2000, vol. 34, pp. 136–150, 2004.

[16] S. Risnes, J. J. Segura, A. Casado, and A. Jimenez-Rubio,“Enamel pearls and cervical enamel projections on 2 maxillarymolars with localized periodontal disease: case report andhistologic study,” Oral Surgery, Oral Medicine, Oral Pathology,Oral Radiology, and Endodontics, vol. 89, no. 4, pp. 493–497,2000.

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