The enamel pearl is an ectopic accumulation of enamel that is firmly adherent to the tooth root surface. They are generally found on the root surface of molar teeth and as single. The most common site for enamel pearls is at the cementoenamel junction of maxillary molars. Enamel pearls are ectopic globules of enamel on the tooth root surface; they also may occur within dentin and are then referred to as intradentinal enamel pearls. Enamel pearls are classified as real enamel pearls (formed entirely of enamel), composite enamel pearls or enamel-dentin pearls (formed by enamel and dentin) and enamel-dentin-pulp pearls (formed by enamel, dentin, and pulpal tissue).
Etiology
The phenomenon of ectopic development of enamel on the root surface variedly referred to as enamel drop, enameloma, enamel pearl, or enamel nodule, is not well-understood. Enamel pearls occur mainly in permanent teeth, but
primary teeth can also be affected. Their cause remains obscure. Over the years theories have been developed. One of it suggests that they form because of residual Hertwig's epithelial root sheath. The term enameloma is discouraged as it connotes a neoplastic process for a lesion which can be said to be consistent with a form of heterotopic enamel development. What we know till now is that enamel pearls are a developmental anomaly of teeth. It has also been proposed in some research that the quiescent cells of the rests of Malassez may differentiate into ameloblasts and give rise to the formation of ectopic enamel within the periodontal ligament space.
Differential diagnosis
As enamel pearls mostly occur singularly, up to 4 enamel pearls have been observed on the same tooth. Depending on the study, enamel pearls on permanent molar teeth have an incidence rate of up to 1.1%-9.7% with distinct differences between nationalities and ethnics. They are varying in size from microscopic to a few millimeters. Some reported enamel pearl which was about 3 mm diameter on between roots of maxillary wisdom tooth was presented. Sometimes they are being confused with dental pulp stone.
Is there any need of treatment?
Enamel pearl was confirmed as a predisposing factor for the cause of localized periodontitis; it is crucial to recognize their radiographic aspect to make sure that proper treatment of involved teeth. Once detected should be surgically eliminated. Also,
odontoplasty, tunneling, root separation or resection are indicated. 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. Therefore, early recognition of enamel pearls is important in the prevention of periodontal disease and possibly in the prevention of tooth mal-positioning.
The difference between pulp stone and enamel pearl
Though both of those look the same to the untrained eye and may be confusing via clinical examination. Through radiographic tools, the dentist can confirm if that is a pulp stone of enamel pearl. It seems reasonable to suggest that enamel pearls represent developmental disturbances in position and timing. The structure of the enamel must be characterized as normal, but with considerable variations and irregular features which probably are related to its ectopic development.
How to recognize it?
The identification of enamel pearls is an incidental finding and usually requires no intervention. Still, selectively, one could perform odontoplasty to remove or recontour the enamel pearls. This rare case of enamel pearl present on apical third of mandibular teeth showed that it had facilitated the progression of periodontitis. It is well established that anatomical or iatrogenic factors can predispose it to periodontitis. Enamel pearls preclude connective tissue attachment. An early diagnosis of enamel pearls is important for better prognosis.