Case #6

A 63-year-old male visited a dentist for a checkup. Radiographic examination revealed two small, round radiopacities attached to the roots of the right maxillary molars.

A 63-year-old male visited a dentist for a checkup. Radiographic examination revealed two small, round radiopacities attached to the roots of the right maxillary molars.

Joen Iannucci Haring, DDS, MS

History

The patient denied any history of signs or symptoms associated with the right maxillary molar region and appeared to be in a general good state of health. The patient`s only significant past medical history included prostate and knee replacement surgeries.

The patient`s past dental history included sporadic dental examinations and routine restorative, periodontic, and prosthetic treatment. At the time of the dental appointment, the patient was not taking medications of any kind.

Examinations

The patient`s blood pressure was recorded at 135/80 and all other vital signs were found to be within normal limits. Examination of the head and neck region revealed no enlarged or palpable lymph nodes. No significant extraoral findings were noted. Examination of the oral soft tissues revealed no unusual findings.

After a thorough clinical examination, periapical radiographs were ordered of all existing teeth in order to evaluate the periodontal condition. Examination of the right maxillary molar radiograph revealed the presence of two small round radiopacities - one attached to the root surface of tooth #2 and one attached to the root surface of tooth #3 (see radiograph). No bony expansion was noted in the area of the involved molars, and no additional radiopacities were noted on the other periapical films.

Clinical diagnosis

Based on the clinical and radiographic information presented, which of the following is the most likely clinical diagnosis?

- enamel pearls

- calculus

- cusps of Carabelli

- concrescence

- dens invaginatus

Diagnosis

__ enamel pearls

Discussion

Enamel is sometimes found in ectopic locations, such as on the root of a tooth. The most widely recognized form of enamel in an ectopic location is the enamel pearl (also known as the "enameloma"). This developmental anomaly typically presents as a small globule of enamel attached to a tooth root. As the name suggests, the globule of enamel resembles the shape of a pearl.

The enamel pearl may be comprised of enamel only, or, a combination of enamel, dentin and pulp tissue. The enamel pearl is fairly common. Depending on the population studied, the prevalence of the enamel pearl ranges from 1.1 to 9.7 percent of all patients, and Asian populations are the most often affected.

Clinical Features

Clinically, the enamel pearl appears as a small, white, and dome-shaped mass attached to a root surface. The roots of the maxillary molars are most often involved. The root surfaces of the mandibular molars are the second most frequent site of involvement. Most enamel pearls develop near the furcation area of a tooth or near the cemento-enamel junction.

The enamel pearl may occur singly or in multiples. In most instances, one pearl occurs; however, up to four pearls have been identified on a single tooth. On a dental radiograph, the enamel pearl appears as a small round radiopacity attached to a root surface.

Diagnosis

The diagnosis of an enamel pearl is based on its characteristic radiographic appearance. If an enamel pearl is suspected as the result of a clinical examination, a radiograph of the area must be exposed. Occasionally, the enamel pearl may be mistaken for calculus during a clinical exam.

Treatment

If an enamel pearl is detected, the involved root area must be carefully followed (clinically and radiographically) and observed for periodontal attachment problems. Scrupulous oral hygiene must be maintained in an effort to prevent loss of periodontal attachment.

In some instances, the removal of the enamel pearl may be desired. In such cases, if pulp tissue is present within the enamel pearl, a pulp exposure may take place.

Joen Iannucci Haring, DDS, MS, is an associate professor of clinical dentistry, Section of Diagnostic Services, The Ohio State University College of Dentistry.

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