A Case of Mistaken Identity_ Periapical Cemental Dysplasia in an ally Treated Tooth

8/3/2019 A Case of Mistaken Identity_ Periapical Cemental Dysplasia in an ally Treated Tooth

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C a s e r e

A c a s e o f m is t a k e n id e n t ity : p e r ia p

d y s p ia s ia in a n e n d o d o n tlc a ily t r e aWileox LR, Walton RE. A case of mistaken identity: periapicaicemental dyspiasia in an endodonticaliy treated tooth. EndodDent Traumatol 1989; 5:298-301.

Abstract - A case of a patient with a history of root canaltreatment and re-treatment and a persistent periapieal radio-lucency is reviewed. Following surgery, biopsy material was sub-mitted and diagnosed as periapieal eemental dyspiasia (PCD).

With careful diagnosis, PCD should be readily differentiatedfrom endodontic pathosis, thus avoiding unnecessary root canaltreatment. In this case, surgery was necessary to rule out otherinflammatory disease or benign odontogenie entities.

L is a R . W i ic o x , R i c h a r d E . WDepartment of Endodonfics, Collage of DentistryUniversify of Iowa, Iowa Cify, Iowa, USA

Key words: cementoma: apical granuloma: peri-

apicai lesion.Dr. Lisa R. Wilcox, College of Dentistry, Univerof Iowa, Iowa City, IA 52242, USA

Accepted tor ptiblication June 28, 1989.

Periapicai cemental dyspiasia (PCD) (eommonlyreferred to as eementoma) is estimated to occur in2-3 teeth per 1000 (1). It occurs most often in Blaekfemales, and in the fourth deeade of life (1, 2). It

predominates in the man dibula r anterior region andis usually an accidental (serendipitous) finding onroutine radiographs.

PCD is benign and represents the abnormalgrowth of mesenchymal elements of the periodontalligament. As both cementum and bone are pro-duced by ligamental eells, either of these mineral-ized tissues may be found in the lesion.

T he lesion is deseribed as having 3 develop men talstages, each with certain radiographie character-istics (3, 4). The first, or osteolytic stage, involves theproliferation of cementoblasts with aecompanyingresorption of alveolar bone. There is loss of perio-dontal ligament and lamina dura. In the secondstages droplets of eementum are deposited in thelesion and may give the lesion a mixed radiolucentand radiopaque appearance. In the third stage,calcification occurs and a definite radiopacity is evi-dent, which may be bordered by a thin radiolucentline.

Endodontic periapicai pathosis tends to have 3characteristie findings: a "hanging drop" appear-ance; a loss of lamina dura; and is centered over

the apex regardless of the angulation of the radio-graph (5). In addition, there should be an etiologyfor the necessary accompanying pulp necrosis. PCD


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n inap pro pria te trea tm ent. T he following case illus-rates such a situation.

Case report

T h e patient, a 26-year-old w hite female, presentedw i t h the chief com plaint of occasional mild pain

o ma stication associated with the m and ibula r leftcanine (tooth 22). The patient took no medicationa n d denied an y systemic illnesses, including cardio-vascular, renal, pulmonary, allergic, or infectiousdisease. Her dental history was unremarkable ex-cept for a history of root canal treatment 5 yearsearlier, in another city. At the time, she had experi-eneed one episode of brief sensitivity to cold in theower anterior region. The teeth were not carious,

restored, or traumatically injured. Apparently, aradiograph had been made, a radiolucency wasn ot e d, and no additional diagnosis was done. Basedo n radiographic appearance, root canal treatmentwas completed on tooth 22. The patient's reeordsw e r e unavailable for review.

Two years later, the periapicai radiolucency was

Fig. 3. Apparent heal ing at 2-NLai lecal l . Ihe lamina durpresent and the lesion has resolved.

Still present when she was examined on referraan endodontist. The tooth was re-treated convtionally because of the persistence of the lesion, wthe supposed etiology being an apparent undeling of the mesial canal. After re-treatment, patient had occasional twinges of mild pain. Ayear recall examination showed no change inradiographie appearanee of the lesion. It hadmained as a well-eireumseribed lesion approximly 10 mm in diam eter w ith peripheral hyperostborders. Th e periapicai lamina d ura was not inTwo roots were present and appeared adequaobturated, exeept that the mesial root appearebe filled well'short of the-radiographic apex.

Clinical exam ination was negative for swellinsinus tracts. There was slight tenderness to pation and percussion. There was no mobilityprobing depths greater than 2 mm. Clinical d

nosis was chronic apical periodontitis. Surgery recommended to the patient because of the proba bility of successful re-tre atm ent.


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lesion was easily removed. The consistency of thelesion was granular, and there was less hemorrhagethan is normally ereated in removing inflammatorylesions. Apicoectomies with retrograde amalgamrestorations were performed. Healing was un-eventful.

The biopsy report gave the diagnosis as a fibro-osseous lesion: periapieal eemental dyspiasia. Histo-ogically, the seetions showed cellular fibro-colla-

genous connective tissue containing numerous, vari-ably sized, rounded to irregularly shaped to oc-casionally linear masses of mineralized tissue. Thearger masses eontained cytes within lacunae. Areas

of peripheral blasts were also seen on the calcifiedmasses. The mineralized tissue had an irregularwoven app earance und er polarized light. Th ere wasno indieation of inflammation.

At 2-year recall, the patient was asymptomatic.There was no pain to percussion or palpation, nomobility or probing depths greater than 2 mm. Theesion had completely healed and the lamina dura

had regenerated in the apical area.

Fig. 5. High niagi i i l icat ion of his topa tholog ie specim en. Ce nti.s a mass of mine ral ized t issue. Not e ihe wov en ap pea ran eeene losed ey tes in l aeunae , and per iphera l b las t s. H & E (or imag nif icat ion: x 160).

D i s c u s s i e n

This case illustrates the importance of careful dnosis prior to root canal treatment. Many radgraphie entities mimic endodontic periapieal flammatory lesions, including normal anatomy, lignancies, and benign odontogenic and nodontogenie tumors (5). These non-endodoentities are usually diflerentiated by determinpulp responsiveness. In virtually all instances, pulp of a tooth must be necrotic in order to caenough apical bone resorption to be seen as a papieal inflammatory lesion. Therefore, if the toresponds to pulp testing, root canal treatment wnot be effective in resolving the lesion.

A case is presented in which the prineipal dnostic test (i.e., pulp vitality) could not be formed due to previous endodontic treatment laek of a reliable history While absence of rep


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findings alone. The periapicai entity that was HOFFMAN P The cemenloma. Oral Surg Oral Med Oral Pathol

treated originally was actually periapicai cemental {.JT?' ' , , , ,, - , , r , i ,. ' J r r 3 SHAFER WG, H I N E MK, LEVY BM. A textbook of orat pathology.

dyspia s i a . 3rd ed. Philadelphia: WB Saunders, 1974; 267-8.4. HOFFMAN S , JA CO WA Y JR, KROLLSSO. Intraosseous andparo-

RofOrOnCeS '' "' tumors of the jaws. Washington, DC: Armed Forces Insti-tute of Pathology, 1987; 133-5.

L CHAUDHRY AP, SPINK JH , GORLIN RH. Periapieal fibrous 5. TORABINEJAD M, WALTON RE. Pulp and periapicai pathosis.dyspiasia (cementoma). J Oral Surg 1958; 16: 483-8. In: WALTON RE, TORABINEJAD M , eds. Principles an d practic

2. ZEGARELLI EV, KUTSCHER AH, NAPOLI N, IURONO F, of endodontics. Philadelphia: WB Saunders, 1989; 53- 68.


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A Case of Mistaken Identity_ Periapical Cemental Dysplasia in an ally Treated Tooth