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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 3  |  Page : 212-215

A rare case report of focal cement osseous dysplasia associated with recurrent periodontal abscess


1 Department of Periodontology, Christian Dental College, Ludhiana, Punjab, India
2 Department of Oral Pathology, Christian Dental College, Ludhiana, Punjab, India

Date of Submission24-Oct-2020
Date of Acceptance29-Jul-2021
Date of Web Publication04-Mar-2022

Correspondence Address:
Anushi Mahajan
Department of Periodontology, Christian Dental College, Ludhiana, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_148_20

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  Abstract 


Focal cemento-osseous dysplasia (FocCOD) is a fibro-osseous lesion of the jaw, which is usually asymptomatic. We report the case of FocCOD in association with recurrent periodontal abscess. A 58-year-old female reported a chief complaint of swelling of gums for 2 months. Periodontal abscess with respect to 35 and 36 tooth regions was noted with no associated tooth mobility. Panoramic view showed extensive generalized horizontal bone loss suggestive of generalized chronic periodontitis. There was a characteristic radio-opaque lesion in relation to apices of 34 and 35. The periodontal abscess was recurrently formed even after repeated scaling, curettage, and antibiotic coverage. The associated teeth were extracted along with the hard tissue mass, and the histopathological examination of the latter revealed FocCOD. This case report intends to highlight the diagnostic dilemma and management of a rare, symptomatic FocCOD associated with recurrent periodontal abscess.

Keywords: Focal cemento-osseous dysplasia, generalized periodontitis, recurrent periodontal abscess


How to cite this article:
Mahajan A, Grover S. A rare case report of focal cement osseous dysplasia associated with recurrent periodontal abscess. CHRISMED J Health Res 2021;8:212-5

How to cite this URL:
Mahajan A, Grover S. A rare case report of focal cement osseous dysplasia associated with recurrent periodontal abscess. CHRISMED J Health Res [serial online] 2021 [cited 2022 May 28];8:212-5. Available from: https://www.cjhr.org/text.asp?2021/8/3/212/339043




  Background Top


According to the World Health Organization's histological classification of tumors, focal cemento-osseous dysplasia (FocCOD) has been recognized as a form of COD.[1] COD consists of three variations of a single entity, all with the same unknown etiology. The origin of the entity may be from the periodontium, in medullary bone, or may result from the simultaneous involvement of both tissues.[2] The three types of CODs are periapical cemental dysplasia (PCOD, common in blacks), FocCOD (Caucasians), and FCOD (blacks). The common location of PCOD is in the mandibular anterior region while that of FocCOD appears to be in the mandibular posterior region. FCOD occurs both in the maxilla and mandible in multiple quadrants.

FocCOD is usually a painless, inadvertently diagnosed, mixed radiolucent/radiopaque lesion of tooth-bearing jaws of the oral cavity. It has a greater predilection for women (88%), especially around 41 years of age, in the posterior mandible (77%). These lesions intraoperatively were found to be multiple, hemorrhagic, granular, and firmly bound to the surrounding bone which is a diagnostic landmark. Histologically, “a cellular connective tissue stroma with irregular, osseous, and/or cementum-like calcifications is seen. FocCOD is thought to be of periodontal ligament origin and to be nonneoplastic in nature. It is considered to be evolved into three stages: osteolytic, cementoblastic, and mature.”[3] However, Langlais et al. believed that “there would be two additional stages: a more early osteoporotic stage in all cases and a later florid stage in some cases.”[4] In initial stages, the fibrous tissue that has replaced the osseous structure presents as a radiolucent image at the tooth apexes. With increase in cementoblastic activity and cementum spicules deposition, the lesion assumes a mixed pattern. As the maturation progresses, PCOD presents “as a solid opaque mass, frequently surrounded by a radiolucent halo” which may take months or years to evolve.[5] The evolution and asymptomatic nature of the lesion usually does not necessitate any intervention.


  Case Report Top


A 58- year old female reported to the Department of Periodontology with a chief complaint of swelling of gums for 2 months. A written consent was taken from the patient. Medical history revealed was nonsignificant. Intraoral examination showed the presence of local deposits. On probing, generalized deep periodontal pockets were present. Grade III mobility with upper teeth and lower third molars was seen. Generalized loss of clinical attachment was seen. Periodontal abscess with respect to 35 and 36 tooth regions was noted with no associated mobility [Figure 1]. A provisional diagnosis of generalized chronic periodontitis was made.
Figure 1: Periodontal abscess with respect to #35 and 36

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Complete blood count, thyroid function tests, fasting blood sugar, and glycosylated hemoglobin tests were carried out. All the tests were within normal limits which ruled out any systemic etiology. Panoramic view showed extensive generalized horizontal bone loss. There was a characteristic radio-opaque lesion in relation to apices of 34, 35. On the basis of the radiographic appearance, differential diagnosis of ossifying fibroma, FocCOD, condensing osteitis, and odontome was made [Figure 2].
Figure 2: Panoramic view – radio-opaque mass at apex of #35 and 36

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All upper teeth and lower third molars (tooth no. 38 and 48) had hopeless prognosis and hence were extracted. Phase I therapy was initiated with thorough scaling and root planing, followed by splinting of lower anteriors. Phase II therapy was initiated in the fourth quadrant with modified flap operation done under local anesthesia. In the third quadrant, there was recurrent periodontal abscess formation with respect to 35 and 36 regions even after repeated scaling, curettage, and antibiotic coverage. Vitality test revealed that 34, 35, and 36 were all vital, hence endodontic origin was excluded. Hence, it was suggested that the hard tissue mass was probably causing the recurrence of periodontal abscess. The decision was made to extract the teeth numbers 35 and 36 with the removal of radiopaque mass. The hard tissue specimen was then sent for histopathological examination.

Histopathologic report

Gross examination

A hard tissue mass along with soft tissue at the periphery was received. The hard tissue measured 2 cm × 1.3 cm × 1 cm [Figure 3].
Figure 3: Hard tissue mass removed from the site #35 and 36

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Soft tissue specimen detached from the hard tissue mass

Sections reveal stratified squamous epithelium associated with underlying fibrovascular connective tissue. The epithelium is hyperplastic with proliferating rete ridges exhibiting pseudoepitheliomatous hyperplasia. Areas of hyalinization can also be seen. An intense inflammatory infiltrate can be seen composed of lymphocytes, plasma cells, and some neutrophils. A few bony trabeculae can also be seen. Dystrophic calcifications and areas of hemorrhage can be seen.

Hard tissue specimen

Grounded and decalcified sections reveal sheets of calcified material exhibiting lacunae with canaliculi and cellular inclusions [Figure 4]a. Prominent reversal lines can be appreciated throughout the calcified mass [Figure 4]b. The periphery shows globular masses appearing to be coalescing, in the mid of the fibrous connective tissue. Small areas of vascular connective tissue are seen interspersed [Figure 4]c. Correlating with the clinical and radiographic findings, the histopathological features are suggestive of focal COD.
Figure 4: (a) Decalcified sections showing sheets of calcified mass with lacunae and canaliculi. (b) Decalcified sections showing prominent reversal line. (c) Decalcified sections showing fusion of globular masses and vascular channels interspersed

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  Discussion Top


COD is a commonly encountered fibro-osseous lesion of the oral cavity. Some investigators have suggested that COD originates from the periodontal ligament, because of microscopic similarity and lesion proximity to this structure. Or contrary, it may be a sequela of extraligamentary bone remodeling in response to local injury or some hormonal imbalance.

FocCOD usually presents in posterior mandibular region around tooth apices, predominant in females, usually with a mean age of 41 years. It is a benign lesion, usually lesser than 1.5 cm in diameter, asymptomatic, and may be discovered incidentally by radiographic examination. Radiographically, it is radiopaque with a thin peripheral radiolucent rim, with well-defined but irregular borders.

In our case, a 58-year-old female patient had periodontal abscess without any significant bony swelling. When OPG was taken to assess the periodontal status of the involved teeth, a radiopaque mass in relation to apices of teeth no. 34 and 35 was seen. Radiographically, a differential diagnosis of ossifying fibroma, FocCOD, condensing osteitis, and odontome was made.

The clinical varieties of COD present with similar histopathologic features. There are typically fragments of cellular fibrovascular connective tissue with scattered hemorrhage. It may consist of the immature woven bone, lamellar bone, and cementum-like particles. On maturation, the fibrous connective tissue is replaced by the mineralized tissue. Over time, the bony trabeculae thicken and assume curvilinear shapes in resemblance to ginger roots. In the last radiopaque stage, the individual trabeculae fuse to form sheet-like or globular masses of sclerotic, disorganized cemento-osseous material. A similar kind of histopathological findings was evident in our case as well. FocCOD can be found anywhere whereas the PCOD is found exclusively in relation to the apex of the tooth.[6],[7],[8]

In the present case, the radiopaque mass was fused laterally to the apex of the tooth and was seen in posterior mandible, hence the diagnosis of FocCOD was made.

Other than this, the most common differential diagnosis for FocCOD includes ossifying fibroma. This can be differentiated during the surgical removal of the lesion where FocCOD is a gritty, irregularly shaped cementum-like spicule that needs to be curetted into small fragments from adjacent stroma during biopsy. In contrast, ossifying fibromas separate out as a single large mass. It also exhibits brush border association with the adjacent stroma. Histopathologically, the latter has thin bony trabeculae with prominent rim of osteoblastic activity compared to those in COD.[9],[10]

Condensing osteitis or focal sclerosing osteomyelitis is another important periapical radiopacity that may mimic FocCOD. It can be distinguished by the fact that it does not exhibit a radiolucent border and is usually associated with nonvital teeth, contrary to the latter.[11] In our present case, teeth involved were vital.

In cases, wherein the radiopaque mass resembles crown, a differential diagnosis of compound odontoma should be considered. In case of no resemblance with the crown, complex odontoma cannot be ruled out radiographically. Although odontomas are usually seen in younger age, asymptomatic ones can be diagnosed coincidentally later in adult age group as well, as seen in our case. The differentiation can be confirmed upon histopathological examination.


  Conclusion Top


In most cases, no surgical intervention is required for FocCOD. A periodic follow up is recommended.[3] However, in our case, as the FocCOD was involved with recurrent periodontal abscess, hence the decision to extract the teeth along with hard tissue mass was made. The patient was put on regular follow-up and maintenance phase since then. Hence, this case highlights a rare type of symptomatic FocCOD that needed surgical intervention.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Cho BH, Jung YH, Nah KS. The prevalence, clinical and radiographic characteristics of cemento-osseous dysplasia in Korea. Korean J Oral Maxillofac Radiol 2007;37:185-9.  Back to cited text no. 1
    
2.
Kawai T, Hiranuma H, Kishino M, Jikko A, Sakuda M. Cemento-osseous dysplasia of the jaws in 54 Japanese patients: A radiographic study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:107-14.  Back to cited text no. 2
    
3.
Summerlin DJ, Tomich CE. Focal cemento-osseous dysplasia: A clinicopathologic study of 221 cases. Oral Surg Oral Med Oral Pathol 1994;78:611-20.  Back to cited text no. 3
    
4.
Langlais RP, Langland OE, Nortjé CJ. Diagnostic Imaging of the Jaws. Malver: Williams and Wilkins; 1995. p. 540-6.  Back to cited text no. 4
    
5.
Melrose RJ. The clinicopathologic spectrum of cemento-osseous dysplasia. Oral Maxillofac Surg Clin North Am 1997;9:643-53.  Back to cited text no. 5
    
6.
Macdonald-Jankowski DS. Focal cemento-osseous dysplasia: A systematic review. Dentomaxillofac Radiol 2008;37:350-60.  Back to cited text no. 6
    
7.
Melrose RJ. The clinico-pathologic spectrum of cemento-osseous dysplasia. Oral Maxillofac Clin North Am 1997;9:643-53.  Back to cited text no. 7
    
8.
Waldron CA, Giansanti JS. Benign fibro-osseous lesions of the jaws: A clinical-radiologic-histologic review of sixty-five cases. II. Benign fibro-osseous lesions of periodontal ligament origin. Oral Surg Oral Med Oral Pathol 1973;35:340-50.  Back to cited text no. 8
    
9.
Su L, Weathers DR, Waldron CA. Distinguishing features of focal cemento-osseous dysplasias and cemento-ossifying fibromas: I. A pathologic spectrum of 316 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:301-9.  Back to cited text no. 9
    
10.
Triantafillidou K, Venetis G, Karakinaris G, Iordanidis F. Ossifying fibroma of the jaws: A clinical study of 14 cases and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol 2012;114:193-9.  Back to cited text no. 10
    
11.
El-Beialy AR, Mostafa YA. Focal sclerosing osteomyelitis and orthodontic treatment planning. J Clin Orthod 2009;43:269-71.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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