Case report

A case of mistaken identity: periapicai cementai dyspiasia in an endodontlcaily treated tooth

Wileox LR, Walton RE. A case of mistaken identity: periapicai cemental dyspiasia in an endodonticaliy treated tooth. Endod Dent Traumatol 1989; 5: 298-301. Abstract - A case of a patient with a history of root canal treatment and re-treatment and a persistent periapieal radiolucency is reviewed. Following surgery, biopsy material was submitted and diagnosed as periapieal eemental dyspiasia (PCD). With careful diagnosis, PCD should be readily differentiated from endodontic pathosis, thus avoiding unnecessary root canal treatment. In this case, surgery was necessary to rule out other inflammatory disease or benign odontogenie entities. Lisa R. Wiicox, Richard E. Waiton
Department of Endodonfics, Collage of Dentistry, Universify of Iowa, Iowa Cify, Iowa, USA

Key words: cementoma: apical granuloma: periapicai lesion. Dr. Lisa R. Wilcox, College of Dentistry, University of Iowa, Iowa City, IA 52242, USA Accepted tor ptiblication June 28, 1989.

Periapicai cemental dyspiasia (PCD) (eommonly referred to as eementoma) is estimated to occur in 2-3 teeth per 1000 (1). It occurs most often in Blaek females, and in the fourth deeade of life (1, 2). It predominates in the mandibular anterior region and is usually an accidental (serendipitous) finding on routine radiographs. PCD is benign and represents the abnormal growth of mesenchymal elements of the periodontal ligament. As both cementum and bone are produced by ligamental eells, either of these mineralized tissues may be found in the lesion. The lesion is deseribed as having 3 developmental stages, each with certain radiographie characteristics (3, 4). The first, or osteolytic stage, involves the proliferation of cementoblasts with aecompanying resorption of alveolar bone. There is loss of periodontal ligament and lamina dura. In the second stages droplets of eementum are deposited in the lesion and may give the lesion a mixed radiolucent and radiopaque appearance. In the third stage, calcification occurs and a definite radiopacity is evident, which may be bordered by a thin radiolucent line. Endodontic periapicai pathosis tends to have 3 characteristie findings: a "hanging drop" appearance; a loss of lamina dura; and is centered over the apex regardless of the angulation of the radiograph (5). In addition, there should be an etiology for the necessary accompanying pulp necrosis. PCD can mimic radiographic endodontic pathosis; inaccurate or careless differential diagnosis may result 298

Fig. 1. Preoperative radiograph. Note apparently underftlled mesiaf canal.

Periapicai cementai dyspiasia i n inappropriate treatment. The following case illustrates such a situation. Case report T h e patient, a 26-year-old white female, presented with the chief complaint of occasional mild pain t o mastication associated with the mandibular left canine (tooth 22). The patient took no medication a n d denied any systemic illnesses, including cardiovascular, renal, pulmonary, allergic, or infectious disease. Her dental history was unremarkable except for a history of root canal treatment 5 years earlier, in another city. At the time, she had experieneed one episode of brief sensitivity to cold in the lower anterior region. The teeth were not carious, restored, or traumatically injured. Apparently, a radiograph had been made, a radiolucency was noted, and no additional diagnosis was done. Based o n radiographic appearance, root canal treatment was completed on tooth 22. The patient's reeords were unavailable for review. Two years later, the periapicai radiolucency was

Fig. 3. Apparent healing at 2-NLai lecall. Ihe lamina dura is present and the lesion has resolved.

I Fig. 2. Immediate postoperative radiograph, after apieoeetomies I" a n d retrograde amalgam restorations. The lesion was removed i; a n d submitted for biopsy.

Still present when she was examined on referral by an endodontist. The tooth was re-treated conventionally because of the persistence of the lesion, with the supposed etiology being an apparent underfilling of the mesial canal. After re-treatment, the patient had occasional twinges of mild pain. A 2year recall examination showed no change in the radiographie appearanee of the lesion. It had remained as a well-eireumseribed lesion approximately 10 mm in diameter with peripheral hyperostotic borders. The periapicai lamina dura was not intact. Two roots were present and appeared adequately obturated, exeept that the mesial root appeared to be filled well'short of the-radiographic apex. Clinical examination was negative for swelling or sinus tracts. There was slight tenderness to palpation and percussion. There was no mobility or probing depths greater than 2 mm. Clinical diagnosis was chronic apical periodontitis. Surgery was recommended to the patient because of the improbability of successful re-treatment. The area was anesthetized and a full thickness triangular flap reflected. The buecal cortical plate was intact so a bony window was created. The 299

Wiicox & Waiton lesion was easily removed. The consistency of the lesion was granular, and there was less hemorrhage than is normally ereated in removing inflammatory lesions. Apicoectomies with retrograde amalgam restorations were performed. Healing was uneventful. The biopsy report gave the diagnosis as a fibroosseous lesion: periapieal eemental dyspiasia. Histologically, the seetions showed cellular fibro-collagenous connective tissue containing numerous, variably sized, rounded to irregularly shaped to occasionally linear masses of mineralized tissue. The larger masses eontained cytes within lacunae. Areas of peripheral blasts were also seen on the calcified masses. The mineralized tissue had an irregular woven appearance under polarized light. There was no indieation of inflammation. At 2-year recall, the patient was asymptomatic. There was no pain to percussion or palpation, no mobility or probing depths greater than 2 mm. The lesion had completely healed and the lamina dura had regenerated in the apical area.

Fig. 5. High niagiiilication of histopathologie specimen. Centered i.s a mass of mineralized tissue. Note ihe woven appearanee, the enelosed eytes in laeunae, and peripheral blasts. H & E (original magnification: x 160).

Discussien This case illustrates the importance of careful diagnosis prior to root canal treatment. Many radiographie entities mimic endodontic periapieal inflammatory lesions, including normal anatomy, malignancies, and benign odontogenic and nonodontogenie tumors (5). These non-endodontie entities are usually diflerentiated by determining pulp responsiveness. In virtually all instances, the pulp of a tooth must be necrotic in order to cause enough apical bone resorption to be seen as a periapieal inflammatory lesion. Therefore, if the tooth responds to pulp testing, root canal treatment will not be effective in resolving the lesion. A case is presented in which the prineipal diagnostic test (i.e., pulp vitality) could not be performed due to previous endodontic treatment and laek of a reliable history. While absence of repair beeause of inadequate root canal treatment could not be ruled out as a factor, presumably root canal treatment had been initiated, based on radiographic

Fig. 4. Histopathologic speeimen. Note the masses of mineralized tissue (arrows) within a fibrous, uninOamed stroma. This is a charaeteristie appearance ofa fibro-osseous lesion. H & E (original magnification: x 6 0 ) .

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HOFFMAN P The cemenloma. Oral Surg Oral Med Oral Pathol {.J^T?'^' , , , ,, , , r , i ,
3 SHAFER WG, HINE MK, LEVY BM. A textbook of orat pathology.

treated originally was actually periapicai cemental dyspiasia. RofOrOnCeS

L CHAUDHRY AP, SPINK J H , GORLIN RH. Periapieal fibrous

3rd ed. Philadelphia: WB Saunders, 1974; 267-8. 4. HOFFMAN S,JACOWAYJR, KROLLS SO. Intraosseous andparo^''^"' tumors of the jaws. Washington, DC: Armed Forces Institute of Pathology, 1987; 133-5.
5. TORABINEJAD M, WALTON RE. Pulp and periapicai pathosis.

dyspiasia (cementoma). J Oral Surg 1958; 16: 483-8.

2. ZEGARELLI EV, KUTSCHER AH, NAPOLI N , IURONO F,

In: WALTON RE, TORABINEJAD M , eds. Principles and practice

of endodontics. Philadelphia: WB Saunders, 1989; 53-68.

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