Journal of Indian Society of Periodontology
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Year : 2013  |  Volume : 17  |  Issue : 6  |  Page : 796-800  

Enamel pearl on an unusual location associated with localized periodontal disease: A clinical report

1 Department of Periodontics, Kalka Dental College, Meerut, Uttar Pradesh, India
2 Department of Periodontics, Sharad Pawar Dental College, Wardha, Maharashtra, India
3 Department of Endodontics, Vyas Dental College and Hospital, Jodhpur, Rajasthan, India

Date of Submission25-Jan-2013
Date of Acceptance29-Apr-2013
Date of Web Publication7-Jan-2014

Correspondence Address:
Shivani Sharma
Department of Periodontics, Kalka Dental College, Partapur By pass, Meerut 250 006, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-124X.124520

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Bacterial plaque has been implicated as the primary etiologic factor in the initiation and progression of periodontal disease. Anatomic factors (such as enamel pearls) are often associated with advanced localized periodontal destruction. The phenomenon of ectopic development of enamel on the root surface, variedly referred to as enameloma, enamel pearl, enamel drop or enamel nodule, is not well-understood. Such an anomaly may facilitate the progression of periodontal breakdown. A rare case of enamel pearl on the lingual aspect of mandibular central incisor associated with localized periodontal disease is presented. Removal and treatment of enamel pearl along with possible mechanisms to account for the pathogenesis of ectopic enamel formation are also discussed.

Keywords: Bacterial plaque, ectopic enamel, enamel pearl, enameloma, etiology, periodontal disease, tooth

How to cite this article:
Sharma S, Malhotra S, Baliga V, Hans M. Enamel pearl on an unusual location associated with localized periodontal disease: A clinical report. J Indian Soc Periodontol 2013;17:796-800

How to cite this URL:
Sharma S, Malhotra S, Baliga V, Hans M. Enamel pearl on an unusual location associated with localized periodontal disease: A clinical report. J Indian Soc Periodontol [serial online] 2013 [cited 2022 May 21];17:796-800. Available from:

   Introduction Top

The enamel pearl is a globule of enamel formation located on the root surface. [1] It is characterized by a core of dentin covered by enamel, and may contain a pulp chamber. [2] Histologically, the enamel pearl is often covered by a thin layer of cementum or reduced enamel epithelium. [3] The size of clinically recognizable enamel pearls may vary from 0.3 mm to 4 mm, with the mean diameter reportedly 0.96 ± 0.43 mm. The average distance of the enamel pearl from the cementoenamel junction (CEJ) was found to be 2.8 ± 1.00 mm. The distal proximal surfaces of the maxillary molars and the buccal or lingual surfaces of the mandibular molars are the preferred sites of occurrence. [2] Maxillary, second and third molars are more commonly involved than the first molars. [4] Among different populations, the prevalence of macroscopically detectable enamel pearls in molars ranges from 0% to 23.3%. [5] Enamel pearls rarely occur on premolars or anterior teeth. [6] The etiology of enamel pearls remains obscure. The formation of ectopic enamel requires the presence of differentiated ameloblasts apical to the CEJ. In humans, Hertwig's epithelial root sheath (HERS) or its residues, the epithelial rests of Malassez have been implicated as the likely sources of ectopic ameloblasts. [7]

Research has substantiated that bacterial dental plaque is the primary etiologic factor in gingivitis and periodontitis. It is also well-established that variations in tooth morphology and local anatomy can predispose an isolated area to inflammation by providing a niche for periodontopathogenic bacteria. [8] The precise nature of the junction between the periodontal ligament and enamel pearl has not yet been described. However, once breakdown occurs, a more rapid progression of disease is likely. The nature and location of such entities allow mechanical retention of plaque [1] and may also compromise the effective removal of plaque by both patients and health professionals. [2]

To the best of our knowledge, enamel pearl on mandibular central incisor has not been previously reported. The purpose of this paper is to report a rare case of enamel pearl on the lingual surface of mandibular central incisor as a likely cause of the chronic localized periodontitis.

   Case Report Top

A 21-year-old male patient presented to the Department of Periodontics for treatment, with a chief complaint of bleeding from gums. Intra-oral clinical examination of the patient revealed generalized pale pink gingiva with reddish pink interdental papilla and marginal gingiva in mandibular central incisors [Figure 1]. Notably, significant deposits of plaque and calculus were also present on the lingual surface of mandibular incisors. Bleeding on probing was noted. Grade II and grade I mobility was present in mandibular right and left central incisor respectively. A sinus opening was also seen at the apex of mandibular right central incisor [Figure 1]. Radiographic examination of mandibular anterior teeth showed severe bone loss in mandibular central incisors along with involvement of peri-apex in mandibular right central incisor. The sinus tract on the facial surface of mandibular right central incisor could be traced up to the apex of the tooth with gutta percha point [Figure 2]. Vitality testing of mandibular right central incisor showed the tooth to be non-vital. Patient gave no history of trauma to mandibular right central incisor and trauma from occlusion was absent. A diagnosis of chronic localized periodontitis was made on the basis of history, clinical, and radiographic examination.
Figure 1: The sinus tract opening (arrow) at the facial aspect of mandibular right central incisor

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Figure 2: Radiograph of the patient showing mandibular incisors with periapical lesion at the apex of mandibular right central incisor and gutta percha point traced up to the apex of mandibular right central incisor

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Initial periodontal treatment consisted of oral hygiene instructions and generalized scaling. Completion of phase I therapy led to an incidental finding of enamel pearl on the lingual surface of mandibular right central incisor at a distance of approx. 2.5 mm from the CEJ and about 2 mm × 3 mm in diameter [Figure 3]. Subsequently, root canal treatment was done in mandibular right central incisor [Figure 4] and the flap was raised in mandibular incisor region [Figure 5]. The area was completely debrided and odontoplasty was performed in mandibular right central incisor to remove the enamel pearl [Figure 6]. The flap was re-approximated and sutured [Figure 7]. The patient was recalled after 1 week for suture removal and showed uneventful healing [Figure 8]. Six month recall of the patient showed complete resolution of gingival inflammation [Figure 9], reduction in mobility and significant resolution of periapical lesion [Figure 10].
Figure 3: Clinical image depicting enamel pearl on the lingual aspect of mandibular right central incisor (arrow)

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Figure 4: Radiograph showing root canal treatment in mandibular right incisor

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Figure 5: Clinical image showing the enamel pearl (arrows) 2 mm 3 mm in diameter and at the distance of 2. 5 mm from the cement-enamel junction

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Figure 6: Lingual aspect of mandibular right central incisor after removal of enamel pearl

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Figure 7: Mandibular right central incisor after suturing

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Figure 8: Post-operative photograph of lingual aspect of mandibular right central incisor showing uneventful healing (1 week)

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Figure 9: Post-operative photograph of lingual aspect of mandibular right central incisor (6 month)

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Figure 10: Post-operative radiograph depicting significant resolution of peri-apical lesion (6 month)

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   Discussion Top

According to Kupietzky and Rozenfarb, [9] the enamel pearl anomaly was first described in 1842 by Linderer and Linderer. Since, then it has been referred to as an enameloma, enamel droplet, enamel nodule, enamel globule, enamel knot, and enamel exostoses. The use of the term enameloma is discouraged as it connotes a neoplastic process for a lesion that is more consistent with a form of heterotopic enamel development. [10] Shiloah and Kopczyk [11] defined enamel pearl as an ectopic globule of enamel, most often located on the root surface, often connected to the coronal enamel by Cemento-enamel projection. The enamel pearl is distinguished from enamel extensions, which are tongue-like linear continuations of cervical enamel over the root surface. The enamel extensions are structurally different from enamel pearls, although in some cases continuity may be identified between enamel pearls and the CEJ simulating an extension. [12] Enamel pearls occur more apically than enamel extensions. [13]

Structurally, enamel pearls generally exhibit a structure comparable with, although somewhat more irregular than, coronal enamel [14] with some variations in the direction of enamel rods, interprismatic substance, and the presence of Hunter-Shreger bands. [13] Single enamel pearl usually occurs on a tooth, but upto four enamel pearls have been observed on the same tooth. [15] Enamel pearls may consist entirely of enamel connected to cementum or root dentin or may show incorporation of a cone of dentin with or without pulpal extension; the last two are referred to as composite enamel pearls. [16] Free enamel pearls, consisting entirely of enamel may be found in the periodontal ligament space. An intra-dental variety has also been described, characterized by an enamel nodule that is totally surrounded by dentin. Although, the majority of enamel pearls are adherent to the external root surface of the tooth, on rare occasions they may be detected within the dentin as internal enamel pearl. [16] Enamel pearls may show a superficial covering of the enamel by acellular cementum [15] that may facilitate attachment of the periodontal ligament fibers and formation of a regular periodontal ligament space around the pearl. [17] The quality of the enamel in the enamel pearls has been studied, demonstrating areas of hypomineralization and the presence of superficial concavities filled with organic matter on the enamel surface. [18]

Different theories have been proposed to explain the ectopic presence of enamel pearls. One suggestion is that the inner cell layer of HERS fails to detach from the newly formed dentin matrix, resulting in ameloblastic differentiation and formation of ectopic enamel. [10] Stone postulated that enamel pearls develop from proliferating buds of epithelium that have become separated at the margin of enamel structure. [6] It has also been proposed that the quiescent cells of the rests of Malassez may differentiate into ameloblasts and give rise to ectopic enamel formation in the periodontal ligament space. [7] Some of these free enamel pearls may later form a cemental union with the root surface. [19] The intra-dental variety of the enamel pearl may form due to incorporation of epithelial cells into the dentin matrix of the papilla prior to the onset of mineralization. The cells may originate from the inner enamel epithelium or the transient enamel knot present during bell stage, the latter of which is responsible for the morphogenesis of the occlusal anatomy. [20] Possibly, composite enamel pearl may form in relation to a local bulging of the odontoblastic layer. This could favor prolonged contact between the epithelial root sheath and the developing dentin surface, thereby triggering the induction sequence leading to enamel secretion. The bulging would have to occur before dentin mineralization. [14]

Gaspersic [21] denied the role of heredity and stressed that local mechanical factors play the prime role in the genesis of enamel pearls. He further stated that the folding of HERS near root furrows, particularly in third molars, may occur due to lack of arch space, initiating amelogenesis and ectopic enamel formation. Saini et al., [17] however, did not consider the lack of arch space as a possible local etiological factor for enamel pearl formation in subjects examined. Pederson, [22] on the contrary, stated that the occurrence of multiple enamel pearls may be due to as yet undefined ''constitutional factors,'' implicating some unknown genetic factors.

The reported prevalence of enamel pearls varies in different studies. Risnes [5] observed enamel pearls on 2.28% molars of 8,854 teeth examined grossly, which were reported to occur more commonly on roots of maxillary molars, especially the third molar, followed by the roots of mandibular molars. Darwazeh and Hamasha, [23] reported enamel pearls occurred in 2.32% (48 of 2,064) of permanent molars when detected radiographically, with enamel pearls being more common on roots of mandibular, rather than maxillary teeth and third molars least affected with the anomaly. Sutalo et al., [24] studied a sample of 7,388 extracted teeth and detected enamel pearls in 1.6% of the sample. Chrcanovic et al., [25] observed similar findings of 1.71%, with the most prevalent anatomical location of enamel pearls for, the maxillary first and second molars, being the furcation between the distobuccal and palatal root. An even lower prevalence has been reported in primary teeth. [5],[15],[16] Nevertheless, a remarkably high prevalence of 33% has been reported in a microscopic study of 44 deciduous teeth. [26] This may suggest that the prevalence of enamel pearls could be higher if the specimens were examined histologically rather than macroscopically or radiographically. [24] Pederson [22] reported markedly higher occurrence in the Eskimo population (9.7%). The variation in the reported prevalence may reflect ethnic, racial or national variations in the prevalence of the condition. [15]

Enamel pearls are incidentally identified during routine radiography as hemispherical dense opacities projecting from the boundaries of root surface. [4],[6] This may result in deep pocket formation and therefore may be mistaken as dental calculus. A follow-up radiograph with a corrected angle projection will usually allow for accurate diagnosis. [4] The density, architecture, location of composite enamel pearls can be recognized by high-resolution volumetric computed tomography. This modality also helps in assessing the distance between the enamel pearl and the alveolar crest or the furcation areas for prognostic evaluation of the future risk of periodontal bone loss. [17]

Ectopic enamel is often associated with advanced localized periodontal destruction in molars. Both enamel pearls and cervical enamel projections in furcations predispose to attachment loss. [27] It has been shown that there is no attachment of connective tissue to enamel, but rather an adhesion of junctional epithelium. This may predispose an isolated area of subgingival enamel to the formation of increased pocket depth subsequent to gingival inflammation. [28] Further, Goldstein suggested that the enamel pearls have a weaker attachment to the periodontal ligament, therefore rendering these areas more prone to periodontal breakdown and pocket formation. [2] If the inflammatory infiltrate from the Gingiva reaches the enamel pearls, loss of periodontal attachment may be accelerated, as the anatomy of the pearl allows mechanical retention of plaque and prevents proper mechanical plaque removal.

Further, it could be observed that the smaller the distance between the cervical line of the enamel and the furcation vertex, the higher chance of periodontal disease, even with the presence of minor enamel pearls. [29] Thus, not only the enamel pearl size, but also its topographic relation with the furcation may well be a contributing factor to periodontal disease. [23] Enamel pearl in deciduous teeth may cause delayed exfoliation of primary teeth because of slower process of enamel resorption. This may lead to deviation of erupting permanent molars. [9] Therefore, early recognition of enamel pearls is important in the prevention of periodontal disease and possibly in the prevention of tooth mal-positioning. [23]

In the case described, the enamel pearl was of sufficient bulk and size to render the overlying gingiva susceptible to physical injury from routine toothbrushing or mastication and would also have made plaque control ineffective. This may have contributed to the development of inflammation in the gingival tissues. After the initial attachment loss had progressed to the enamel pearl level, accelerated breakdown occurred. This would have complicated the situation and lead to severe localized destruction. The identification of enamel pearls is an incidental finding and usually requires no intervention. However, in selective cases, one could perform odontoplasty to remove or recontour the enamel pearls. [2] In the present case, root canal treatment followed by flap surgery with odontoplasty was undertaken to remove the enamel pearl and other local factors such as plaque and subgingival calculus, with the aim to facilitate the attachment of the soft tissue to the tooth surface and healing in periapical area. This resulted in proper adaptation of soft tissue flap, allowed effective removal of plaque by the patient and the resolution of gingival inflammation.

   References Top

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2.Goldstein AR. Enamel pearls as contributing factor in periodontal breakdown. J Am Dent Assoc 1979;99:210-1.  Back to cited text no. 2
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4.Langlais R, Langland O, Nortje C. Development and acquired abnormalities of the teeth and jaws. In: Diagnostic Imaging of the Jaws. Baltimore, VA: Williams and Willkins; 1995. p. 124-6.  Back to cited text no. 4
5.Risnes S. The prevalence, location, and size of enamel pearls on human molars. Scand J Dent Res 1974;82:403-12.  Back to cited text no. 5
6.Farmer D, Lawton F. Odontogenic tumours: Odontomas. In: Stone's Oral and dental diseases. London: Livingstone; 1966. p. 905-7.  Back to cited text no. 6
7.Kalnins V. Origin of enamel drops and cementicles in the teeth of rodents. J Dent Res 1952;3:582-90.  Back to cited text no. 7
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12.Risnes S. The prevalence and distribution of cervical enamel projections reaching into the bifurcation on human molars. Scand J Dent Res 1974;82:413-9.  Back to cited text no. 12
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14.Risnes S, Segura JJ, Casado A, Jiménez-Rubio A. Enamel pearls and cervical enamel projections on 2 maxillary molars with localized periodontal disease: Case report and histologic study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:493-7.  Back to cited text no. 14
15.Moskow BS, Canut PM. Studies on root enamel (2). Enamel pearls. A review of their morphology, localization, nomenclature, occurrence, classification, histogenesis and incidence. J Clin Periodontol 1990;17:275-81.  Back to cited text no. 15
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18.Takiguchi R, Funaki T. Scanning electron microscopy of enamel drop. Bull Tokyo Dent Coll 1977;18:57-70.  Back to cited text no. 18
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21.Gaspersic D. Histogenetic aspects of the composition and structure of human ectopic enamel, studied by scanning electron microscopy. Arch Oral Biol 1992;37:603-11.  Back to cited text no. 21
22.Pederson PO. The East Greenland Eskimo dentition. Medd Gronl 1949;142:49-155.  Back to cited text no. 22
23.Darwazeh A, Hamasha AA. Radiographic evidence of enamel pearls in Jordanian dental patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:255-8.  Back to cited text no. 23
24.Sutalo J, Ciglar I, Bacic M. The incidence of enamel projections on the roots of the permanent teeth. Schweiz Monatsschr Zahnmed 1989;99:174-80.  Back to cited text no. 24
25.Chrcanovic BR, Abreu MH, Custódio AL. Prevalence of enamel pearls in teeth from a human teeth bank. J Oral Sci 2010;52:257-60.  Back to cited text no. 25
26.Arys A, Dourov N. Enamel pearls in the deciduous teeth. J Biol Buccale 1987;15:249-55.  Back to cited text no. 26
27.Hou GL, Tsai CC. Cervical enamel projection and intermediate bifurcational ridge correlated with molar furcation involvements. J Periodontol 1997;68:687-93.  Back to cited text no. 27
28.Newell DH. Current status of the management of teeth with furcation invasions. J Periodontol 1981;52:559-68.  Back to cited text no. 28
29.Lima AF, Nascimento A, Hebling E. Projection of cervical enamel and its relations to bifurcations. Odonto Mod 1991;18:9-15.  Back to cited text no. 29


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]


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