Continuing Education Florid Cemento

Continuing Education
Course Number: 143.2
Florid Cemento-Osseous
Dysplasia and a
Dental Abscess
Authored by Alison Glascoe, DDS, MS; Ronald Brown, DDS, MS;
Michael Goode, DDS; and Gustavo Mongelos, DDS
Upon successful completion of this CE activity 1 CE credit hour may be awarded
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Continuing Education
Recommendations for Fluoride Varnish Use in Caries Management
INTRODUCTION
Florid Cemento-Osseous Dysplasia
and a Dental Abscess
Effective Date: 11/1/2011
A fibro-osseous lesion is a generic term used to
characterize a lesion where bone is replaced by a benign
connective tissue matrix. This matrix has varying degrees of
mineralization, from woven immature bone to round
cementumlike structures. The term fibro-osseous lesion in
the maxillofacial region of the jaw is applied to cementoosseous dysplasia, fibrous dysplasia, and cementoossifying fibroma and their subtypes.1,2 Florid cementoosseous dysplasia (FCOD), periapical cemento-osseous
dysplasia, and focal cemento-osseous dysplasia
collectively have been designated by the WHO as cementoosseous dysplasias.1-3 FCOD, also known as florid
osseous dysplasia, is related to (focal benign) periapical
cemental dysplasia, a relatively benign mixed density
lesion of the jawbones.4-8 This article discusses the
etiology, symptoms, and histological and clinical
presentation of FCOD. A case of FCOD in combination
with an abscessed tooth with a sinus tract is presented.
FCOD affects multiple areas of the jaw and is more
extensive in its presentation, exhibiting the same lesions
present in periapical and focal cemento-osseous dysplasia.1,2 Periapical and focal cemento-osseous dysplasia
are similar terms for the same syndrome previously
distinguished by the anatomical location of the lesions.1,9
The initial appearance of this group of lesions is
radiolucent. Over time, however, the lesions tend to become
mixed density and then radiopaque. Therefore, the
appearance of these lesions tends to change with time.10
FCOD is most commonly seen in women of African and
Asian decent and in white females, approximately aged 30
years or older.1,10 The classic presentation is middle-aged,
African-American females; this is the case approximately
90% of the time.1,11 The etiology of FCOD is unknown. It is
generally believed that it originates from the periodontal
ligament.12,13 Other possible contributing factors that have
been suggested include hormonal imbalance and familial
association.12,14,15 The condition tends to be totally
asymptomatic and is therefore usually detected with routine
dental radiographs. However, symptoms such as dull pain
or drainage may be present and tend to be associated with
exposure of sclerotic calcified masses within the oral cavity.
With regard to painful symptoms, extraction of teeth within
Expiration Date: 11/1/2013
LEARNING OBJECTIVES
After reading this article, the individual will learn:
• A basic understanding of how florid cemento-osseous
dysplasia (FCOD) is characterized.
• A basic understanding of the diagnosis, radiographic
presentation, and management of FCOD.
ABOUT THE AUTHORS
Dr. Glascoe is an assistant professor in
the department of Preventive Services at
Howard University College of Dentistry in
Washington, DC. She is a Diplomate of the
American Board of Periodontology and
practices periodontics in a private practice in
Baltimore, Md. She can be reached at [email protected].
Dr. Brown is a professor in the department of Diagnostic
Services at Howard University College of Dentistry, a
clinical associate professor of otolaryngology at
Georgetown University Medical Center in Washington,
DC, and a research associate at National Heart, Lung,
and Blood Institute/NIH Division of Hematology in
Bethesda, Md. He practices oral medicine in a private
practice in Washington, DC. He can be reached at
[email protected].
Dr. Goode is an assistant professor in the department of
endodontics at Howard University College of Dentistry in
Washington, DC. He practices endodontics in a private
practice in College Park, Md. He can be reached at
[email protected].
Dr. Mongelos practices general dentistry in a private
practice in Washington, DC. He can be reached at
[email protected].
Disclosures: The Authors report no disclosures.
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Continuing Education
Florid Cemento-Osseous Dysplasia and a Dental Abscess
the area of sclerotic bone may be a precipitating factor.4
Radiographically, the lesions appear as progressing
from radiolucent to radiopaque masses. They may also
appear as multiple sclerotic masses located in 2 or more
quadrants (may be found in all 4 quadrants), usually within
tooth-bearing regions, and tend to be bilateral.10,16 The
lesions appear in either the maxilla or mandible or
both.10,17,18 The borders vary from well-defined to poorlydefined and tend to be round to lobulated to irregular in
shape.10,16 These lesions are usually located within the
alveolar bone. In the anterior mandible, the lesions usually
have the more classic appearance of periapical cemental
dysplasia.1,11 Occasionally, the lesions may exhibit
expansile characteristics and patients may report
experiencing pain.10,17
Histologically, the lesions are described as
anastomosing bone trabeculae and layers of osteoid and
cementumlike calcifications embedded within a fibroblastic
background.4,10 The histological appearance has also been
described as mature bone replaced with woven bone in a
matrix of fibrous connective tissue.10,18 Bone cysts and
inflammatory cells may also be associated with FCOD.1,11
Usually, patients with FCOD are asymptomatic;
however, intraorally, if a yellowish bonelike material
perforates the oral mucosa and thus communicates with the
oral cavity, this may result in a low-grade infection.1 Unless
an infection is otherwise noted, management typically
involves only clinical-radiographic follow-up. If an infection is
noted, treatment may be difficult because antibiotics are
often ineffective.1,11 Endodontic therapy is not advised prior
to a definitive diagnosis. This is especially so when the
diagnosis is solely based on radiographic findings with no
other signs and symptoms.4,19
Figure 1.
Panoramic radiograph demonstrating multiple periapical radiolucencies.
Figure 2.
Erythema and a sinus
tract of the right maxillary
bicuspid region.
was a family history of cancer and diabetes. The patient was
referred due to radiographic periapical findings that noted
multiple apical radiolucencies. The patient reported
tingling/paresthesia of the maxillary right posterior. The
radiographic examination was taken during a routine dental
examination. There was no lymphadenopathy noted. The
periapical radiographs taken in late July 2008 revealed
relative periapical radiolucencies below the mandibular left
lateral incisor, left canine, left first and second bicuspids, and
left first and second molars. Also, relative periapical
radiolucencies were noted above the maxillary right and
second molar, first bicuspid, lateral incisor, left central and
lateral incisor, and left canine. These periapical radiographs
appeared to demonstrate failing restorations of the maxillary
right lateral incisor (mesial), left central incisor (distal), lateral
incisor (mesial), and left canine (mesial). The radiographic
appearance was also consistent for caries of the maxillary
right canine (mesial). The appearance of the maxillary right
central incisor (distal) was questionable. The bite-wing
radiographs appeared to demonstrate caries of the maxillary
CASE REPORT
A 38-year-old Asian woman was referred by her general
dentist with multiquadrant periapical radiolucencies (Figure 1)
and a draining sinus tract of the right maxillary posterior buccal
gingiva (Figure 2). The chief complaint was “consultation
because of the x-rays.”
The medical history did not appear to be contributory to
the chief complaint. The patient was not on any medical drug
therapy. The patient noted no known drug allergies. There
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Continuing Education
Florid Cemento-Osseous Dysplasia and a Dental Abscess
Figure 3. Periapical radiographic series demonstrating multiple periapical radiolucencies.
right first molar (distal) (Figure 3). Clinically, a red and white
area was noted above the maxillary second bicuspid which
was consistent with a sinus tract infection, probably
emanating from the maxillary second bicuspid (Figure 2).
Other clinical findings were unremarkable. A panoramic
radiograph was taken and radiolucencies were much less
obvious (Figure 1). The remaining oral tissues appeared to
be within normal limits.
The diagnoses consisted of FCOD, multiple failed or
failing restorations, an abscessed maxillary right bicuspid,
and dental caries. The suggested treatment was to refer the
patient back to her general dentist for treatment of the
abscessed tooth, failed restorations, and dental caries. The
suggested therapy for the presumptive diagnosis of FCOD
was continued observation clinically and radiographically.
which may be difficult to control.
The management of FCOD involves an emphasis on
preventive, conservative treatments since these patients are
very susceptible to chronic osteomyelitis, and biopsy may increase the risk for infection and/or jaw fracture. Additionally,
these patients should avoid extractions and surgical removal of
the lesions.12,25,26 If chronic osteomyelitis results from
impaired blood circulation in the lesion, then antibiotics should
be used.7,12,27 When these patients present with a sinus tract,
the practitioner must assess the pulpal status because its development may be associated not with periapical pathosis but
with a chronic low-grade infection of the osseous lesion.1
SUMMARY
In most cases, FCOD is diagnosed by reviewing clinical and
radiographic information and data. Multiple quadrants and a
mixture of sclerotic radiopaque lesions with radiolucent
borders facilitate radiographic interpretation. FCOD is a selflimiting condition that requires no further treatment once a
diagnosis has been made. Prognosis is excellent. Follow-up
is needed to assess for progression and any possible
complications. This should include periodic radiographic
evaluation. If endodontic therapy is required, it should not be
initiated until a thorough clinical and radiographic evaluation
has been completed.
DISCUSSION
In this asymptomatic case, the diagnosis of FCOD was
based on radiographic presentation and the patient’s age,
gender, and ethnicity. The radiographic examination noted
multiple apical radiolucencies on the periapical
radiographs, with less obvious radiolucencies noted on the
panoramic radiograph.
FCOD should be differentiated from other benign fibroosseous lesions such as fibrous dysplasia, ossifying
fibroma, Paget’s disease of the bone, and chronic sclerosing
osteomyelitis by utilizing a combination of clinical,
radiographic, and histologic assessments, and in some
cases blood chemistry analysis.2,5,6,8,11,20-24 Biopsy might
facilitate diagnosis, but it may also precipitate infection,
3
Continuing Education
Florid Cemento-Osseous Dysplasia and a Dental Abscess
14. Zegarelli EV, Kutscher AH, Napoli N, et al. The cementoma.
A study of 230 patients with 435 cementomas. Oral Surg
Oral Med Oral Pathol. 1964;17:219-224.
REFERENCES
1.
Tonioli MB, Schindler WG. Treatment of a maxillary molar in
a patient presenting with florid cemento-osseous dysplasia:
a case report. J Endod. 2004;30:665-667.
2.
Waldron CA. Fibro-osseous lesions of the jaws. J Oral
Maxillofac Surg. 1993;51:828-835.
3.
Kawai T, Hiranuma H, Kishino M, et al. Cemento-osseous
dysplasia of the jaws in 54 Japanese patients: a
radiographic study. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod. 1999;87:107-114.
4.
5.
15. Thakkar NS, Horner K, Sloan P. Familial occurrence of
periapical cemental dysplasia. Virchows Arch A Pathol Anat
Histopathol. 1993;423:233-236.
16. Schneider LC, Mesa ML. Differences between florid osseous
dysplasia and chronic diffuse sclerosing osteomyelitis. Oral
Surg Oral Med Oral Pathol. 1990;70:308-312.
17. White SC, Pharoah MJ. Oral Radiology: Principles and
Interpretation. 5th ed. St. Louis, MO: Mosby; 2003:485-498.
Gonçalves M, Píspico R, Alves Fde A, et al. Clinical,
radiographic, biochemical and histological findings of florid
cemento-osseous dysplasia and a report of a case. Braz
Dent J. 2005;16:247-250.
18. Beylouni I, Farge P, Mazoyer JF, et al. Florid cementoosseous dyplasia: Report of a case documented with
computed tomography and 3D imaging. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod. 1998;85:707-711.
Young SK, Markowitz NR, Sullivan S, et al. Familial gigantiform
cementoma: classification and presentation of a large pedigree.
Oral Surg Oral Med Oral Pathol. 1989;68:740-747.
19. Smith S, Patel K, Hoskinson AE. Periapical cemental dysplasia:
a case of misdiagnosis. Br Dent J. 1998;185:122-123.
6.
Melrose RJ, Abrams AM, Mills BG. Florid osseous
dysplasia. A clinical-pathologic study of thirty-four cases.
Oral Surg Oral Med Oral Pathol. 1976;41:62-82.
20. Cavalcante AS, Sgarbi FC, Agapito Lda C, et al. Florid
cemento-osseous dysplasia: a report of three cases. Gen
Dent. 2008;56:186-190.
7.
Waldron CA, Giansanti JS, Browand BC. Sclerotic cemental
masses of the jaws (so-called chronic sclerosing
osteomyelitis, sclerosing osteitis, multiple enostosis, and
gigantiform cementoma). Oral Surg Oral Med Oral Pathol.
1975;39:590-604.
21. Slootweg PJ. Maxillofacial fibro-osseous lesions:
classification and differential diagnosis. Semin Diagn Pathol.
1996;13:104-112.
22. Ellis GL, Lewis DM, Carleton AS. Multiple osteosclerotic
masses of the jaw. J Am Dent Assoc. 1987;114:678-680.
8.
Kramer IRH, Pindborg JJ, Shear M. Neoplasms and other
lesions related to bone. In: Histological Typing of
Odontogenic Tumors. Berlin, Germany: Springer-Verlag;
1992:28-31.
23. Ariji Y, Ariji E, Higuchi Y, et al. Florid cemento-osseous
dysplasia. Radiographic study with special emphasis on
computed tomography. Oral Surg Oral Med Oral Pathol.
1994;78:391-396.
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;84:301-309.
24. Waldron CA. Fibro-osseous lesions of the jaws. J Oral
Maxillofac Surg. 1985;43:249-262.
25. Marx RE, Stern D. Oral and Maxillofacial Pathology: A
Rationale for Diagnosis and Treatment. Chicago, IL:
Quintessence Publishing; 2003:57-63.
10. Singer SR, Mupparapu M, Rinaggio J. Florid cementoosseous dysplasia and chronic diffuse osteomyelitis: Report
of a simultaneous presentation and review of the literature. J
Am Dent Assoc. 2005;136:927-931.
26. Eversole LR, Stone CE, Strub D. Focal sclerosing
osteomyelitis/focal periapical osteopetrosis: radiographic
patterns. Oral Surg Oral Med Oral Pathol. 1984;58:456-460.
11. Neville B, Damm DD, Allen CM, et al. Oral and Maxillofacial
Pathology. Philadelphia, PA: WB Saunders; 1995:464-468.
27. Schneider LC, Mesa ML, Brickman JH. Complications of
endodontic therapy in florid osseous dysplasia. Oral Surg
Oral Med Oral Pathol. 1987;64:114-116.
12. Islam MN, Cohen DM, Kanter KG, et al. Florid cementoosseous dysplasia mimicking multiple periapical pathology—
an endodontic dilemma. Gen Dent. 2008;56:559-562.
13. Neville BW, Albenesius RJ. The prevalence of benign fibroosseous lesions of periodontal ligament origin in black
women: a radiographic survey. Oral Surg Oral Med Oral
Pathol. 1986;62:340-344.
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Continuing Education
Florid Cemento-Osseous Dysplasia and a Dental Abscess
2. The classic presentation of FCOD is:
POST EXAMINATION INFORMATION
a.
b.
c.
d.
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3. The etiology of FCOD is:
a.
b.
c.
d.
Unknown.
Bacterial.
Traumatic.
Genetic.
4. It is generally believed that the lesion of FCOD
originates from the:
a.
b.
c.
d.
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Use this page to review the questions and mark your
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Cementum.
Alveolar bone.
Gingiva.
Periodontal ligament.
5. FCOD is usually detected:
a.
b.
c.
d.
On clinical examination.
Based on symptoms.
On radiographic examination.
On review of medical history.
6. The histologic appearance of the FCOD lesion has been
described as:
a. Immature bone layered by Sharpey’s fibers.
b. Mature bone replaced by benign connective tissue
matrix.
c. Immature bone replaced by fibrous connective tissue
matrix.
d. None of the above.
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7. Management of FCOD typically involves:
a.
b.
c.
d.
POST EXAMINATION QUESTIONS
Resection of lesion.
Systemic antifungal therapy.
Irradiation of the jaw.
Clinical and radiographic follow-up.
8. The presence of a sinus tract associated with a FCOD
lesion may not be always due to pulpal pathology but is
most likely due to:
1. The initial appearance of FCOD is:
a.
b.
c.
d.
Asian teenage females.
White women in the eighth and ninth decade.
African-American middle-aged women.
Mediterranean women in their second and third decade.
Radiopaque.
Radiolucent.
Mixed density.
None of the above.
a.
b.
c.
d.
5
Root fracture.
Furcation involvement.
Chronic infection from osseous lesion.
None of the above.
Continuing Education
Florid Cemento-Osseous Dysplasia and a Dental Abscess
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6