Florid Hypercementosis Synchronous with Periodontitis: a Case Report John K
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RADIOLOGY/IMAGING Florid hypercementosis synchronous with periodontitis: a case report John K. Brooks, DDS/Ioana Ghita, DDS/Evan M. Vallee, BS/Adrien L. Charles-Marcel, DDS/ Jeffery B. Price, DDS, MS Excessive cementum formation, referred to as hypercemento- ent the clinical, radiographic, and histopathologic findings of a sis (HC), is an uncommon nonneoplastic process that princi- 44-year-old female with moderate to severe periodontitis syn- pally occurs with permanent teeth. Widespread tooth involve- chronous with 22 HC-affected teeth. A list of other etiologies ment has been confined mostly to Paget disease of bone. Only associated with HC is provided. (Quintessence Int 2019;50: a limited number of reports of HC coincident with periodontitis 478–485; doi: 10.3290/j.qi.a42481) has appeared in the literature. The aim of this article is to pres- Key words: etiology, florid, hypercementosis, periodontitis Hypercementosis (HC) is characterized by an abnormal deposi- Case presentation tion of secondary radicular cementum, appearing as a spherical or irregularly shaped apical enlargement and typically found as An asymptomatic 44-year-old female sought comprehensive an incidental radiopaque finding.1 HC may be an isolated find- care at the University of Maryland School of Dentistry. The clin- ing or occur in more than one quadrant, predominately affect- ical examination was significant for generalized chronic, mod- ing posterior teeth.2 On rare occasions, HC may be symptom- erate to severe periodontitis and multiple caries lesions. Peri- atic and usually attributed to severe caries.3 The bulbous root odontal probing depths ranged from 2 to 7 mm. Tooth mobility configuration may pose increased difficulties when performing was restricted to the anterior teeth, mostly +2 grade, with only exodontia, orthodontic tooth movement, and endodontic ther- the maxillary right lateral incisor retained root tip (tooth 12 apy.4 In the earlier years of dentistry, some practitioners mistak- according to FDI notation) exhibiting a +3 mobility. HC was evi- enly believed that HC would promote an assortment of sys- dent radiographically with the maxillary right central incisor temic disorders, which prompted unnecessary extractions and and the left central and lateral incisor, canine, second premolar, the unfortunate persistence of the patient’s underlying illness.5 and third molar; the affected mandibular teeth were the left Although the primary cause for the majority of cases of HC first premolar, canine, and central incisor and the right canine, has been unclear, this dental malformation has been associated first premolar, and first molar (teeth 11, 21, 22, 23, 25, 28, 31, 33, with Paget disease of bone.6 There are only a scant number of 34, 43, 44, and 46) (Fig 1). The teeth with the most conspicuous published cases of HC concomitant with periodontitis.7-9 To involvement were 25, 28, 44, and 46 (Fig 2). Additionally, early increase awareness of their possible causal relationship, this signs of HC were seen with the maxillary right lateral incisor article describes the clinical, radiographic, and histopathologic and second premolar and the mandibular left lateral and right findings of a 44-year-old female with multiple teeth with HC and left central incisors (teeth 12, 15, 32, 41, and 42). Lesions and generalized chronic periodontitis. In addition, a list of consistent with focal osteosclerosis were visualized apical to other reported systemic, genetic, and dental comorbidities the mandibular left second premolar (tooth 35) and in the with HC is presented. edentulous left body of the mandible. 478 QUINTESSENCE INTERNATIONAL | volume 50 • number 6 • June 2019 Brooks et al 1 Fig 1 Multiple hypercementosis-affected teeth evident in the intraoral complete radiographic series. A panoramic radiograph taken 4.5 years previously was pro- bolic panel, ordered by the patient’s attending physician as cured and revealed five teeth with HC that had since been part of a routine physical examination, was obtained for ascer- extracted, namely the maxillary right first, second, and third tainment of HC and possible systemic correlation. These results molars and the maxillary left first and second molars (teeth 16, were significant for an elevated serum glucose of 164 mg/dl 17, 18, 26, and 27) (Fig 3). In total, the featured patient has had (normal 65 to 99 mg/dl) and vitamin D deficiency (25-hydroxy 22 teeth with radiographic manifestations of HC. It is unknown level 23.8 ng/ml [normal 30.0 to 100 ng/ml]). The serum calcium, whether any other previously extracted teeth displayed HC, as serum alkaline phosphatase, hepatic and renal function panel, the patient’s older dental records were not available. complete blood count, and platelets were within normal limits. The review of the medical history was salient for chronic The initial dental treatment plan consisted of extraction of all inactive hepatitis B, vitamin D deficiency, iron deficiency ane- remaining maxillary teeth (to be performed in separate quadrant mia, and headaches. Current medications included vitamin D, appointments) and construction of a conventional complete cyanocobalamin, and ibuprofen. A recent comprehensive meta- denture. All of the maxillary teeth were removed, with teeth 25 2a 2b 2c 2d Figs 2a to 2d Intraoral periapical radiographs of prominent examples of hypercementosis. (a) Maxillary left second premolar. (b) Maxillary left third molar. (c) Mandibular right first premolar. (d) Mandibular right first molar. QUINTESSENCE INTERNATIONAL | volume 50 • number 6 • June 2019 479 RADIOLOGY/IMAGING Fig 3 Panoramic radiograph taken 4.5 years previously revealed additional maxillary teeth with hypercementosis. 3 5 4b 4c Fig 5 Photomicrograph of the maxillary left third molar. Decalcified section showing Figs 4a to 4c Clinical views of two affected teeth. alternating layers of cellular and acellular (a) Maxillary left second premolar with adherent buccal plate. excessive cementum adjacent to root dentin (b) Maxillary left third molar (in toto). (hematoxylin and eosin stain, original 4a (c) Maxillary left third molar (hemisected, unstained). magnification ×10). and 28 being particularly laborious to extract, owing to their root specimen demonstrated excessive deposition of cementum malformations. Extraction of tooth 25 was facilitated by the use consistent with HC. There was a prominent line of demarcation of a high-speed surgical handpiece to remove surrounding between the radicular tubular dentin and osteocementum. Of bone, although a segment of the buccal plate remained adher- interest, the radicular overgrowth appeared with alternating ent to the root (Fig 4a). Images of tooth 28 illustrate the exagger- zones of cellular (containing scattered cementocytes within the ated degree of radicular alteration (Figs 4b and 4c). lacunae) and acellular cementum (Fig 5). Due to the added surgical difficulty extracting the maxillary Postoperatively, the patient experienced only mild discom- left teeth, the patient was prescribed 500 mg amoxicillin (three fort. The patient is treatment planned to undergo extraction of times/day for 7 days) as a precaution for possible infection, multiple mandibular teeth, construction of a partial denture, chlorhexidine gluconate 0.12% antimicrobial rinse, and 600 mg and periodontal scaling. ibuprofen (four times/day as needed) for analgesia and as an anti-inflammatory agent. The gingiva overlying the maxillary left Discussion extraction sites was sutured with 3-0 chromic gut for wound approximation. HC is a relatively uncommon root anomaly and its incidence has Tooth 28 was placed in neutral buffered 10% formalin solu- ranged from 1.3% to 4.8% in various subpopulations (> 600 tion for fixation. Microscopic assessment of the decalcified patients), representing 0.12% to 0.96% of the total number of per- 480 QUINTESSENCE INTERNATIONAL | volume 50 • number 6 • June 2019 Brooks et al manent teeth examined.10-13 Conversely, far fewer instances of HC of these patients had synchronous HC. Other manifestations of have been recognized in the primary dentition.13 The mean age Paget disease include radiographically radiopaque/radiolucent of affected patients is 47.3 years5 and noted with a slight gender osseous lesions, bowing of the long bones, deep-seated bone predilection, occurring in 54.2% of females and 45.8% of males.9 pain, neurologic deficits, and markedly elevated serum alkaline Radiographically, HC appears as a homogenous radiopacity, phosphatase. Widespread HC was also reported in a study of slightly more radiolucent than dentin, expanding predominately 55% (55/100) of cohorts who ostensibly developed systemic along the apical root and infrequently encompassing most of the fluorosis from industrial pollution.22 Moreover, some nonsyn- radicular complex; the lamina dura and periodontal ligament dromic pedigrees of familial HC have been noted.4,23 This article space usually may be visualized encircling the cemental mass.14 provides the most comprehensive listing of HC associated with HC may range from localized to extensive involvement, with any systemic and genetic diseases, although nearly all of these one affected patient averaging 3.8 hypercementosed teeth.5 pathologies coincident with HC have been reported too infre- The oral pathology literature typically utilizes the descriptor quently to establish any definitive correlation (Table 1). florid for widespread or generalized cases of cemento-osseous There is widespread belief that subsets of cases of HC arise dysplasia. As such, the term “florid hypercementosis”