Enamel Pearl (enameloma)

A small nodule of enamel can form on the root surface near the amelocemental junction, particulary on maxillary molars; mandibular molars are the second most frequent site (Figure 1-1). This may result from cells of Hertwing’s sheath which have become differentiated into ameloblast. It consist of a circumscribed nodule of otherwise normal enamel, occasionally with a core of dentine and rarely containing a minute horn of pulp. Small lesions may become coated with cementum.


Figure 1.1 - Enamel Pearl on Buccal
of Lower Right Second Molar

Buccal Exostosis

Buccal exostosis ocurr as a bilateral row of bony hard nodules along the facial aspect of the maxillary (Figure 1-1) and/or mandible (Figure 1-2). They are usually asymtomatic, unless the thin overlying mucosa becomes ulcerated from trauma. One study reported that buccal exostoses were found in 1 of every 1000 adults, although the prevalence could be even higher. They ocurr equally in males and females.

Figure 1.1 - Maxillary Buccal Exostosis







Figure 1.1 - Mandible Buccal Exostosis









SHOVEL-SHAPED INCISORS

 This alteration occurs predominantly in Asians, with a prevalence of approximately 15% in whites but close to 100% in native Americans and Alaskans. Affected incisors demonstrate prominent lateral margins, creating a hollowed lingual surface that resembles the scoop of a shovel (figure 1-1). Typically, the thickened marginal ridges converge at the cingulum; not uncommonly there is a deep pit, fissure, or dens invaginatus at this junction. Maxillary lateral and central incisors most frequently are affected, with mandibular incisors and canines less commonly reported. Frequently, shovel-shaped incisors is seen in association with another variation of coronal anatomy, dens evaginatus.

Figure 1-1 Maxillary central incisors exhibiting prominent lateral margins.

   If shovel-shaped incisors are present, the affected teeth should be inspected for surface defects at the point where the marginal ridges converge. Any deep fissures or invaginations should be restored shortly after eruption to prevent carious exposure of the adjacent pulp.

 

CHRONIC HYPERPLASTIC PULPITIS (PULP POLIP)

Clinical Features
This condition occurs in children and young adults who have large exposures of the pulp in which the entire dentinal roof often is missing. The most frequently involved teeth are the deciduous or succedaneous molars, which have large pulp chambers in these age groups.

   Mechanical irritation and bacterial invasion result in a level of chronic inflammation that produces hyperplastic granulation tissue that extrudes from the chamber and often fills the associated dentinal defect (figure 1-1). The apex may be open and reduces the chance of pulpal necrosis secondary to venous compression. The tooth is asymptomatic except for a possible feeling of pressure when it is placed into masticatory function.

Figure 1.1 - Pulp Polip on Mandible Left First Molar

 Histopathologic Features

Chronic hyperplastic pulpitis demonstrates a cap of subacutely inflamed granulation tissue resembling that seen in a pyogenic granuloma. The surface of the polyp may or may not be covered with stratified squamous epithelium, which migrates from the adjacent gingival or arises from sloughed epithelium  within the oral fluids. The deeper pulp tissue demonstrates a chronic inflammatory infiltrate.

Treatment and Prognosis

Chronic hyperplastic pulpitis is treated by extraction of the tooth or by root canal therapy.

LINEA ALBA (WHITE LINE)

Linea alba is a common alteration of the buccal mucosa that is most likely associated with pressure, frictional irritation, or sucking trauma from the facial surfaces of the teeth. In one study of 256 young men, the alteration was present in 13%. No other associated problem, such as insufficient horizontal overlap or rough restorations of the teeth, is necessary for the development of linea alba.

Clinical Features

As the name implies, the alteration consists of a white line that is usually bilateral. It may be scalloped and is located on the buccal mucosa at the level of the occlusal plane of the adjacent teeth (figure 1-1). The line varies in prominence and is usually restricted to edentulous areas. It often is more pronounced adjacent to the posterior teeth.

Figure 1-1 Linea Alba on both Buccal Mucosa

 

Histopathologic Features

Biopsy is rarely indicated. If a biopsy is performed, hyperorthokeratosis is seen overlying otherwise normal oral mucosa. On occasion, intracellular edema of the underlying connective tissue may be noted.

Treatment and Prognosis

No treatment is required for patients with linea alba, and no difficulties are documented as a result of its development. Spontaneous regression may occur.

Ankyloglossia (tongue-tie)

Ankyloglossia is a developmental anomaly of the tongue characterized by a short, thick lingual frenum resulting in limitation of tongue movement. It has been reported to occur in 1.7% to 4.4% of neonates and is four times more common in boys than in girls. In adults, mild forms are not unusual, but severe ankyloglossia is a relatively uncommon condition that has been estimated to occur in about 2 to 3 of every 10,000 people.

Clinical Features
Ankyloglossia can range in severity from mild cases with little clinical significance to rare examples of complete ankyloglossia in which the tongue is actually fused to the floor of the mouth. Sometimes the frenum extends forward and attaches to the tip of the tongue, (Figure 1.1) and there may be slight clefting of the tip.



Figure 1-1 Ankiloglossia in 9 year old girl

Some investigators have speculated that ankyloglossia may contribute to the developmental of an anterior open bite because the inability to raise the tongue to the roof of the mouth prevents developmental of the normal adult swallowing pattern. However, others have questioned this theory. It also is possible that a high mucogingival attachment of the lingual frenum may lead to periodontal problems.
It has been suggested that tongue- tie may result in speech defects. Usually, however, the shortened frenum results in only minor difficulties because most people can compensate for the limitation in tongue movement. Yet there are rare examples of patients who have experienced an immediate noticeable improvement in speech after surgical correction of ankyloglossia. Recent reports from Japan have theorized that some ankyloglossia cases can be associated with an upward and forward displacement of the epiglottis and larynx, resulting in various degrees of dyspnea.


Treatment and Prognosis
Because most cases of ankyloglossia results in few or no clinical problems, treatment is often unnecessary. If there are functional or periodontal difficulties, a frenectomy may allow greater freedom of tongue movement. In young children it often is recommended that surgery be postponed until age 4 to 5. Because the tongue is always short at birth, it is difficult in the infant’s early life to assess the degree of tongue limitation caused by ankyloglossia. As the infant grows, the tongue becomes longer and thinner at the tip, often decreasing the severity of the tongue-tie. The condition probably is self-correcting in many cases because it is less common in adults.

Fibroma (irritation fibroma; traumatic fibroma; focal fibrous hyperplasia; fibrous nodule)

The fibroma is the most common “tumor” of the oral cavity. However, it is doubtful that it represents a true neoplasm in most instances; rather, it is a reactive hyperplasia of fibrous connective tissue in response to local irritation or trauma.

Clinical Features

Although the irritation fibroma can occur anywhere in the mouth, the most common location is the buccal mucosa along the bite line. This site is more prone to irritation due to cusps of the teeth or improper dental restoration leading to tissue injury. The labial mucosa, tongue (figure 1-1) , and gingival also are common sites. It is likely that many gingival fibromas represent fibrous maturation of a preexisting pyogenic granuloma. The lesion typically appears as a smooth-surfaced pink nodule that is similar in color to the surrounding mucosa. In black patients, the mass may demonstrate grayish brown pigmentation.

 

In some cases, the surfaces may appear white as a result of hyperkeratosis from continued irritation. Most fibromas are sessile, although some are pedunculated. They range in size from tiny lesions that are only a couple of millimeters in diameter across; however, most fibromas are 1.5cm or less in diameter. The lesion usually produces no symptoms, unless secondary traumatic ulceration of the surface has occurred. Irritation fibromas are most common in the fourth to sixth decades of life, and the male-to-female ratio is almost 1:2 for cases submitted for biopsy.
 




Figure 1-1 Small fibroma on the tip of the tongue 

Histopathologic Features

Microscopic examination of the irritation fibroma shows a nodular mass of fibrous connective tissue covered by stratified squamous epithelium. This connective tissue is usually dense and collagenized, although in some cases it is looser in nature. The lesion is not encapsulated; the fibrous tissue instead blends gradually into the surrounding connective tissues.

 

The collagen bundles may be arranged in a radiating, circular, or haphazard fashion. The covering epithelium often demonstrates atrophy of the rete ridges because of the underlying fibrous mass. However, the surface may exhibit hyperkeratosis from secondary trauma. Scattered inflammation may be seen, most often beneath the epithelial surface. Usually this inflammation is chronic and consists mostly of lymphocytes and plasma cells.

 

Treatment and Prognosis  

The irritation fibroma is treated by conservative surgical excision; recurrence is extremely rare. However, it is important to submit the excised tissue for microscopic examination because other benign or malignant tumors may mimic the clinical appearance of a fibroma. 

Hypercementosis

Hypercementosis is a nonneoplastic deposition of excessive secondary cementum on the root surface.

Clinical and Radiographic features

Radiographically, affected teeth demonstrate a thickening or blunting of the root, but the exact amount of increased cementum often is difficult to ascertain because cementum and dentin demonstrate similar radiodensities (figure 1-1). It may occur on any part of the root, but the apical two-thirds are most commonly affected. The enlarged root is surrounded by the radiolucent periodontal ligament space and the adjacent intact lamina dura. Hypercementosis may be isolated, may involve multiple teeth, or may appear as a generalized process. Premolar teeth are involved most frequently (figure 1-2). In some cases on the x-rays there are similarities between atypical hypercementosis and cementoblastoma. Cementoblastoma must be included in the differential diagnosis.

Figure 1.1  Premolar and Molar with
Hypercementosis in a patient with arthritis.

Hypercementosis occurs predominantly in adulthood, and the frequency increases with age. Its occurrence has been reported in younger patients, and many of these cases demonstrate a familial clustering, suggesting hereditary influence. Apart from the idiopathic nature of hypercementosis, this condition is associated with local and systemic factors (Box 1-1).

Of these factors, Paget’s disease of bone has received the most attention. Numerous authors have reported significant hypercementosis in patients with Paget’s disease, and this disorder should be considered whenever generalized hypercementosis is discovered in a patient of the appropriate age.

In spite of the association with a number of disorders, most localized cases of hypercementosis are not related to any systemic disturbance.

Figure 1.2 Hypercementosis. Maxillary second premolars exhibiting
 thickening and blunting of the roots.

Histopathologic Features

The periphery of the root exhibits deposition of an excessive amount of cementum over the original layer of primary cementum. The excessive cementum may be hypocellular or exhibit areas of cellular cementum that resemble bone (osteocementum). Often the material is arranged in concentric layers and may be applied over the entire root or be limited to the apical portion. On routine light microscopy, the distinction between dentin and cementum often is difficult, but the use of polarized light clearly separates the two different layers.

Treatment and Prognosis

Patients with hypercementosis  require no treatment. Because of a thickened root, occasional problems have been reported during the extraction of an affected tooth. Sectioning of the tooth or surgically removing significant amounts of the surrounding bone may be necessary in certain cases to aid in removal.

Box 1-1 Factors associated with Hypercementosis.

Local factors

Abnormal occlusal trauma

Periapical inflammatory processes

Unopposed teeth (e.g., impacted, embedded, without antagonist) ( figure 1-3)

Systemic factors

Acromegaly and pituitary gigantism

Arthritis

Calcinosis

Paget’s disease of bone

Rheumatic fever

Thyroid goiter

Vitamin A deficiency

Figure 1.3 Hypercementosis. Mandibular canines showing
thickening and blunting of the roots in a complete upper
edentulous patient.

By:  Noslen De Lapuente, DDS