Case Report

Enamel Pearl Diagnosed by Cone Beam Computed Tomography:

A Clinical Case Report

Abstract Beatriz De Carvalho

Little research has been performed on tomographic observations of the dental development anomaly Silva Rocha,
known as enamel pearl. This article presents a clinical case report in which enamel pearl was Johne Andrade,
detected through cone beam computed tomography  (CBCT). In this study, a patient was referred
to undergo a CBCT of the left maxillary molar region, due to the patient’s pain symptoms in this Claudia Scigliano
region. The CBCT showed the existence of an enamel pearl in tooth 27. A  precise diagnosis made Valerio,
it possible for the patient to begin the preventive treatment against periodontal disease in tooth 27. Flávio Ricardo
Manzi
Keywords: Cone beam computed tomography, dental enamel, dental radiography, periodontal
Department of Dentistry,
diseases
Pontifical Catholic University of
Minas Gerais, Belo Horizonte,
Minas Gerais, Brazil
Introduction molar teeth). These authors also observed
that there was no statistically significant
Enamel pearls, described for the first time
association between the prevalence of
in 1841 as a “pin’s head,”[1] are enamel
enamel pearls and the patient’s gender.
deposits in the bifurcation areas or on
the root surface near the cementoenamel In general, the enamel pearl is more
junction.[2] The average diameter of an frequently observed in molars, especially
enamel pearl is 0.96 mm, varying from 0.3 to in the second and third maxillary molars.[2]
0.4 mm.[3] Regarding the structure, the enamel In the maxillary molars, enamel pearls are
pearl can be classified into three groups: true more commonly located in the bifurcation
or simple, composite, and composite with area between the distobuccal and palatal
pulp chamber.[1,4] The first consists only of roots.[5]
enamel; the second consists of dentine and Few studies in prior literature have
enamel; and the third is a pearl consisting evaluated enamel pearls through CBCT
of enamel, dentine, and the pulp chamber, examinations. Thus, the presentation of
which can be an extension of the coronary or this clinical case seeks to describe the
root pulp. The majority of the enamel pearls tomographic characteristics of enamel
contain a tubular dentine core.[1] pearls in such a way as to contribute to
The prevalence of the enamel pearls varies correct diagnostic of this dental anomaly.
between 0.83% and 9.7% and are uncommon
in single‑rooted teeth.[1,2,5,6] However, this Case Report
prevalence can vary depending on the A 35 year old female patient searched Address for correspondence:
evaluated population, group of studied teeth, Dr. Flávio Ricardo Manzi,
for a dentist, complaining of pain in the Pontifícia Universidade Católica
and method used in the diagnosis of these maxillary posterior teeth on the left side. In De Minas Gerais, Av. Dom
structures. Akgul et  al.,[2] who investigated the anamnesis, the patient reported having José Gaspar, 500 ‑ Coração
the prevalence of enamel pearls in cone submitted to endodontic treatment in teeth Eucarístico, CEP 30535610,
beam computed tomography (CBCT) images Belo Horizonte, Minas Gerais,
26 and 27. The extraoral examination Brazil.
of 768 individuals, found a prevalence showed no abnormality. The intraoral E‑mail: manzi@pucminas.br
of 4.69%  (36 individuals). All of enamel examination showed the presence of
pearls of the 36 individuals were detected in restoration in teeth 24, 25, 26, and 27, as
molar teeth. By contrast, when considering well as the absence of tooth 28. No intraoral Access this article online
only the molars of the 768 individuals, fistula was found. The dentition appeared Website: www.ijdr.in
the prevalence was of 0.83%  (36 of 4334 to be in good condition, and the patient’s DOI: 10.4103/ijdr.IJDR_751_16
medical history proved to be negative. Quick Response Code:
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identical terms. Valerio CS, Manzi FR. Enamel pearl diagnosed by
cone beam computed tomography: A clinical case
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 Rocha, et al.: Enamel pearl diagnosed by computed tomography

A periapical radiograph was requested to evaluate the

affected region through symptomatology, where the
presence of a round, radiopaque, well‑defined image
was observed in tooth 27  [Figure  1]. As the periapical
radiograph showed no image that justified the presence
of pain symptoms, a CBCT examination, with a more
well‑defined field of view, was requested to better evaluate
the area and search for possible cracks or fractures.
A  CBCT of the region was therefore performed using a
Kodak 9000C 3D Extraoral Imaging System  (Eastman
Kodak Company, Rochester, NY, USA), with the following
exposure factors: 74 Kv, 10 mA, 10.8 s exposure time, and
a resolution of 76 µm × 76 µm × 76 µm voxel size.
In the CBCT, a hyperdense round structure on the
outside and a hypodense structure on the inside were Figure 1: Periapical radiograph. White arrow shows a round structure,
observed in the furcation area, adherent to the roots of radiopaque on the outside and radiolucent in the center, projected over
tooth 27, between the mesiopalatal and distopalatal roots, the furcation area of tooth 27. The borders of the sphere are well defined,
and there is a thin radiolucent line at the periphery. This image does not
measuring 0.2  mm, suggesting the diagnosis of an enamel show the adherence between the sphere and tooth
pearl  [Figures  2 and 3]. A  hypodense line was observed at
the apex of the mesiobuccal root of tooth 26, presenting
an increase in the adjacent periodontal space, which is
compatible with an inflammatory and infectious osteolytic
lesion  [Figure  4]. Also observed was a hypodense line
in the palatal root of tooth 26, near the metallic nucleus,
which is compatible with a crack [Figure 5].
The treatment plan included the extraction of tooth 26 and
the periodontal control of tooth 27, given that enamel pearls
facilitate the progression of periodontal breakdown.[5,7] a b
Figure 2: Cone beam computed tomography reconstruction. White arrow
Discussion shows the enamel pearl fusion with the root dentin of tooth 27, located in
the furcation area, between mesiopalatal and distopalatal roots. (a) Axial
The majority of studies on enamel pearls were performed view. (b) Buccopalatal sectional view. P  = Palatal, MP = Mesiopalatal,
using either extracted teeth[4,5,8,9] or conventional DP = Distopalatal

radiography.[7,10] Few studies in prior literature have

evaluated enamel pearls using CBCT,[2,3] and only one
study was carried out using a micro‑CT.[6] Thus, this article
seeks to describe the tomographic aspects of enamel pearls
through the presentation of a clinical case study.
The etiology of enamel pearls has yet to be fully clarified.
The more accepted theory affirms that its development is
due to the adherence of Hertwig’s epithelial root sheath
cells to the tooth’s root surface during root development,
differentiating into functioning ameloblasts that are apical to
the cementoenamel junction.[1,3,6,9] What is still not understood
are the necessary conditions through which this differentiation
of the ameloblast can occur in an ectopic location.[9]
Microscopically, the enamel pearl located in tooth roots is
similar to immature enamel, presenting irregular areas and
enamel prisms that are generally twisted and wavy.[1,9] By Figure 3: Three‑dimensional volumetric view of enamel pearl. Palatal view.
White arrow shows an enamel pearl between mesiopalatal and distopalatal
contrast, the dentine presented a normal morphology with roots of tooth 27. MP = Mesiopalatal, DP = Distopalatal
aligned dentinal tubules. Many times, there is a thin layer
of afibrillar cementum covering the enamel pearl.[1] or worsen preexisting periodontal diseases, leading the
The existence of an enamel pearl requires careful affected tooth to an unfavorable prognosis.[5,7] This fact is
treatment, given that an improper diagnosis can trigger due to the greater facility of accumulating biofilms in the

518 Indian Journal of Dental Research | Volume 29 | Issue 4 | July-August 2018

 Rocha, et al.: Enamel pearl diagnosed by computed tomography

a b
Figure 4: Cone beam computed tomography reconstruction. (a) Buccopalatal
sectional view. (b) Yellow arrow shows a hypodense line at the apex of the
mesiobuccal root of tooth 26. MB = Mesiobuccal, DB = Distobuccal

regions in which enamel pearls are present. In this sense,
there is a greater probability of the occurrence of clinical
cases of gingivitis or periodontitis that can lead to tooth
loss.[8] Because the enamel pearl is a predisposing factor
for periodontal lesion, the patient described in this clinical
case study was referred for periodontal control in tooth 27.
Figure 5: Cone beam computed tomography reconstruction. Buccopalatal
sectional view. Red arrow shows a hypodense line at the palatal root of tooth
26 compatible with a crack. P = Palatal, MP = Mesiopalatal, DP = Distopalatal
prevent the appearance of periodontal disease due to the
presence of an enamel pearl.

Enamel pearls may also be related to the lack of success in Conclusion

endodontic treatments. In an attempt to aid in the diagnosis
of complications stemming from the presence of enamel
pearls, it is essential for dentists to perform a complete
examination, including radiographic examinations and pulp
vitality tests, in order, in certain situations, to be able to
drain the lesion through gingival sulcus and swelling, in
turn simulating an endodontic‑periodontal lesion.[6]
For the dental professional to make the correct diagnosis of
a dental anomaly, knowledge about anatomical variations
and the help of imagery examinations, such as radiographs
and CBCTs, are imperative. Radiographically speaking, the
enamel pearl, associated with the periodontal or periapical
lesion, reveals an angular bone loss along the root
surface.[6] This is depicted as a radiopaque, dense, smooth
image, overlapping the crown or affected tooth root.
However, in the radiographic examination, the enamel pearl
is often confused with a dental calculus, hindering correct
diagnosis.[7] Hence, the CBCT is useful in identifying these
anatomic structures.[6]
When the enamel pearl is exposed to the oral environment,
surgical treatment is recommended since its elimination
facilitates the patient’s access to oral hygiene, allowing
for the control of biofilms. Other procedures are often
commonly recommended, such as odontoplasty, tunneling,
root separation, resection, or extraction.[6,10]
In the clinical case presented in this study, it could be
observed that the pain symptoms were caused by the
presence of cracks in the root of tooth 26. Tooth 27, which
presented an enamel pearl, proved to be asymptomatic.
Thus, the extraction of tooth 26 was recommended in an
attempt to resolve the pain symptoms. The patient was also
advised to undergo periodontal follow‑up of tooth 27 to
In the literature, there are few studies demonstrating the use of
CBCT in the diagnosis of enamel pearls. Hence, this clinical
case describes the tomographic characteristics of enamel
pearls and highlights the importance of CBCT examinations
in attaining more precise diagnoses of lesions associated
with this dental anomaly since conventional radiographs do
not provide the information about surrounding structures.
Through the proper diagnosis of enamel pearls, preventive
measures can be adopted to preserve the affected tooth.
Acknowledgments
Dr  C.S. Valerio’s studies were supported by the
Coordination for the Improvement of Higher Education
Personnel (CAPES Foundation).
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form, the patient has given
her consent for her images and other clinical information
to be reported in the journal. The patient understands that
name and initials will not be published and due efforts
will be made to conceal identity, but anonymity cannot be
guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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