A 41-year-old female visited a dentist for a routine checkup. Radiographic examination revealed a lesion in the mandibular incisor area.
Joen Iannucci Haring, DDS, MS
When questioned about the lesion in the mandibular anterior region, the patient denied any history of signs or symptoms associated with this region. The patient also denied any history of trauma to the involved area.
The patient appeared to be in a general good state of health, with no significant past medical history. The patient`s dental history included regular examinations and routine treatment. At the time of the appointment, the patient was not taking medications of any kind.
The patient`s vital signs were all found to be within normal limits. Examination of the head and neck region revealed no enlarged or palpable lymph nodes. Examination of the soft tissues of the oral cavity revealed no unusual findings. No bony abnormalities were noted.
Radiographic examination revealed mixed lucent-opaque lesions around the apices of teeth #24 and #25 (see radiograph). No caries were noted on the radiograph, and the pulp chambers and pulp canals appeared to be of normal size and shape. No other abnormalities were noted on the remaining films in the complete series. The mandibular incisors were tested for vitality; all tested vital and no clinical evidence of caries was noted.
Based on the clinical and radiographic examination available, which one of the following is the most likely diagnosis?
- Periapical cemento-osseous dysplasia
- Florid cemento-osseous dysplasia
- Fibrous dysplasia
- Complex odontoma
- Ossifying fibroma
Periapical cemento-osseous dysplasia
Cemento-osseous dysplasias are the most common fibro-osseous lesions encountered in dental clinical practice. On the basis of their clinical and radiologic features, the cemento-osseous dysplasias can be divided into three groups: periapical, focal, and florid.
Periapical cemento-osseous dysplasia (formerly known as the cementoma) is a common lesion found in the tooth-bearing areas of the jaws. The term periapical cemento-osseous dysplasia (PCD) is truly descriptive of the lesion. Periapical refers to the location, cemento-osseous refers to the microscopic features, and dysplasia refers to the abnormal alteration of bone and cementum that occurs. The cause of PCD is unknown.
PCD occurs most often in middle-aged black females. Females are affected far more frequently than males (14:1). The reason for the race and gender predilections is unclear. PCD most often involves the mandibular anterior periapical regions, although other periapical areas occasionally may be involved. Solitary or multiple lesions may be seen. Frequently, the apical regions of more than one to two teeth are involved. Lesions are rarely larger than one centimeter in diameter.
No symptoms are associated with PCD. The adjacent teeth are vital, and there is no history of pain, sensitivity, or bony expansion. Lesions are typically discovered during routine radiographic examination.
Radiographically, PCD appears in one of three stages: radiolucent, mixed lucent-opaque, or radiopaque. Initially, PCD appears as a small periapical radiolucency continuous with the periodontal ligament space. For unknown reasons, a small area of periapical bone is replaced with fibrous connective tissue. The fibrous connective tissue is what gives the lesion a radiolucent appearance.
With time, the small radiolucency progresses on to appear as a mixed lucent-opaque lesion. This stage represents the deposition of bone and cementum (radiopaque) in the fibrous connective tissue (radiolucent). As the lesion progresses, tiny radiopacities are seen within the periapical radiolucency. The lesion becomes progressively more radiopaque.
In the final stage of PCD, the lesion undergoes a complete calcification. An excessive amount of calcified material is deposited in the area once occupied by fibrous connective tissue. A thin, radiolucent rim that surrounds the opacity may appear to separate the lesion from normal bone. The progression of PCD from radiolucent to radiopaque may take months or years.
The diagnosis of PCD is made based on the clinical and radiographic findings; no biopsy is necessary. The age and gender of the patient, the radiographic appearance and location of the lesion, and the associated tooth vitality are all diagnostic for PCD.
If one or more of these factors are atypical, further investigation is warranted and other lesions should be considered in the differential diagnosis.
PCD in its radiolucent form may be confused with a periapical lesion caused by a necrotic pulp (periapical cyst, granuloma, or abscess, for example). Therefore, pulp testing for vitality is critical; a vital pulp rules out the possibility of lesions such as a periapical cyst, granuloma, or abscess. Failure to differentiate between PCD and lesions associated with pulpal necrosis may result in unnecessary endodontic treatment or extractions on the assumption that the tooth is nonvital.
No treatment for PCD is indicated. Once a clinical and radiographic diagnosis has been established, periodic radiographic follow-up is all that is necessary to ensure that the lesion is not a proliferative one. Should expansion be observed clinically or radiographically, a biopsy is indicated. The teeth associated with PCD are vital and do not require treatment.
Joen Iannucci Haring, DDS, MS, is an associate professor of clinical dentistry, Section of Primary Care, The Ohio State University College of Dentistry.