Pigmented lateral periodontal cyst: A case report and review of pigmented odontogenic cysts

Hardeep Kaur Chehal; Jasbir Deol Upadhyaya; Indraneel Bhattacharyya; Mohammed N Islam

doi:10.4103/jomfp.JOMFP_179_20



ONLINE ONLY ARTICLES - CASE REPORT

Year : 2020 \| Volume : 24 \| Issue : 3 \| Page : 592

Pigmented lateral periodontal cyst: A case report and review of pigmented odontogenic cysts

Hardeep Kaur Chehal¹, Jasbir Deol Upadhyaya², Indraneel Bhattacharyya³, Mohammed N Islam³
¹ Department of Oral Diagnostic Sciences, Creighton University School of Dentistry, Omaha, NE, USA
² Department of Applied Dental Medicine, Southern Illinois University School of Dental Medicine, Alton, IL, USA
³ Department of Oral and Maxillofacial Diagnostic Sciences, University of Florida College of Dentistry, Gainesville, FL, USA

Date of Submission	02-May-2020
Date of Decision	14-Oct-2020
Date of Acceptance	03-Nov-2020
Date of Web Publication	09-Jan-2021

Correspondence Address:
Jasbir Deol Upadhyaya
Department of Applied Dental Medicine, Southern Illinois University School of Dental Medicine, 2800 College Avenue, Alton, IL 62002
USA

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jomfp.JOMFP_179_20

Abstract

Pigmented odontogenic cysts are uncommon and to date, only 37 cases have been reported in the English literature. Here, we report a case of a pigmented lateral periodontal cyst (LPC) in the maxilla of a 48-year-old female. The patient presented with clinical swelling in the maxillary anterior region. Microscopic features of the biopsied specimen were consistent with a diagnosis of LPC. The epithelial cyst lining exhibited numerous coarse granules of melanin pigment, which was confirmed by S-100 immunohistochemistry and Fontana-Masson bleach histochemical method. Almost all documented cases of pigmented odontogenic cysts have occurred in Asians and African-Americans, with only three cases in white patients. Racial pigmentation may have a role in the pathogenesis of these lesions. Although the origin and pathologic significance of melanocytes in these pigmented intraosseous lesions cannot be explained, it may be something to consider for investigation in future.

Keywords: Fontana-Masson bleach, lateral periodontal cyst, melanin, pigmented odontogenic cysts

How to cite this article:
Chehal HK, Upadhyaya JD, Bhattacharyya I, Islam MN. Pigmented lateral periodontal cyst: A case report and review of pigmented odontogenic cysts. J Oral Maxillofac Pathol 2020;24:592

How to cite this URL:
Chehal HK, Upadhyaya JD, Bhattacharyya I, Islam MN. Pigmented lateral periodontal cyst: A case report and review of pigmented odontogenic cysts. J Oral Maxillofac Pathol [serial online] 2020 [cited 2021 Jan 27];24:592. Available from: https://www.jomfp.in/text.asp?2020/24/3/592/306634

Introduction

The lateral periodontal cyst (LPC) accounts for <1% of odontogenic cysts.^[1] The first well-documented case of LPC was presented in 1958.^[2] LPCs are considered noninflammatory developmental odontogenic cysts which may arise from the dental lamina, reduced enamel epithelium, or the rests of Malassez. They are typically seen on the lateral aspect or between the roots of erupted teeth, and most frequently arise in the mandibular incisor, canine and premolar region. Less than 20% may arise in the maxilla.^[1] A slight male predilection is noted with a peak incidence in the sixth and seventh decades of life. Radiographically, LPCs are well defined, often corticated unilocular radiolucencies which are approximately <1 cm in diameter. A larger multilocular variant known as botryoid odontogenic cyst (BOC) was first reported in 1973.^[3] Melanocytes, which are derived from the neural crest cells and are widely distributed throughout the skin, nervous system and certain types of the mucosa, are not a common finding in intraosseous gnathic lesions. Intraosseous pigmented lesions have often been reported to occur as metastatic lesions of malignant melanoma. Few cases of melanin pigmentation within the jaw bone in association with many gnathic tumors and cysts such as melanotic neuroectodermal tumor of infancy (MNTI), adenomatoid odontogenic tumor, calcifying odontogenic cyst (COC), ameloblastic fibroma, odontoma, ameloblastic fibro-odontoma, odontogenic keratocyst (OKC), LPC and dentigerous cyst (DC) have been documented. With the exception of MNTI, racial pigmentation may have an important role in the occurrence of such lesions as majority of these were reported in Asian and African-American patients. In this article, we present a rare pigmented variant of LPC which, to the best of our knowledge, is the second case of pigmented LPC documented in the English literature, and the first to occur in the maxilla.

Case Report

A 48-year-old African-American female presented with a clinically evident swelling in the anterior hard palate in the region of maxillary right central incisor. Past medical and dental histories revealed a congenitally missing tooth # 8 with no other significant contributory conditions. The patient was informed about the possibility of a cyst-like lesion by her previous dentist. Radiographic examination revealed a unilocular radiolucent lesion in the area of the maxillary right central incisor [Figure 1]. The borders of the radiolucency were well defined and corticated. An excisional biopsy was performed and revealed a gray cyst-like soft tissue measuring 1.5 cm × 1.3 cm × 0.8 cm. Histopathological evaluation revealed multiple sections of the specimen consisting of connective tissue and luminal odontogenic epithelium. A central lumen-like area was rimmed at the periphery by a band of epithelium that varied from one or three cells in thickness. Focal areas exhibiting nodular swirls of squamous cells were noted [Figure 2]a. The lining epithelium exhibited scattered melanocytes and fine granules of dark brown pigment which was interpreted as melanin [Figure 2]b and [Figure 3]a. Histochemical evaluation with Fontana-Masson bleach method confirmed the pigment to be melanin [Figure 3]b. Numerous melanin-containing cells were immunohistochemically positive for S-100 protein, and these were interpreted as melanocytes [Figure 4]a and [Figure 4]b. These spindle- and dendritic-shaped cells containing abundant cytoplasmic brown–black pigment were also seen in the superficial connective tissue subjacent to the cystic lining epithelium [Figure 4]b. In addition, numerous cholesterol clefts associated with foreign body type of giant cells were also noted within this specimen. A diagnosis of pigmented LPC was rendered. No recurrence has been noted till date.

Figure 1: Panoramic radiographic presentation of the pigmented lateral periodontal cyst shows a radiolucent lesion in the region of congenitally missing maxillary right central incisor (shown with red arrows). The cystic lesion grossly measured 1.5 cm × 1.3 cm × 0.8 cm

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Figure 2: Histopathologic examination shows a thin epithelial lining and numerous localized thickened nodular plaques (a, H&E stain, ×100 for ×10 magnification). Brown–black granules interpreted as melanin noted within the lining epithelium and thickened nodular plaques (b, H&E stain, ×400 for ×40 magnification)

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Figure 3: Histopathologic image shows a lining exhibiting numerous dark brown stained granules (a, H&E stain, ×400 for ×40 magnification). Fontana-Masson bleach shows the disappearance of brown granules in the tissue, confirming the pigment as melanin (b, H&E stain, ×400 for ×40 magnification)

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Figure 4: Immunohistochemistry with S-100 shows a few cells in the epithelial lining to be positive for S-100 protein (a, IHC stain, ×200 for ×20 magnification). Few S-100-positive cells are seen in the lining and in superficial connective tissue subjacent to the lining, marked with blue arrows (b, IHC stain, ×400 for ×40 magnification)

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Discussion

Pigmented odontogenic lesions of the jawbones are a rare phenomenon but not unusual. The existence of melanocytes in the oral mucosa, for example, gingiva and buccal mucosa, is not unusual and is often seen in patients of dark complexion. Majority of the physiological pigmentation in human tissues is a result of melanin production by the melanocytes. Melanocytes are derived from neural crest cells, and though the majority are present in the epidermis, nervous system, hair and iris, they are also seen in the inner ear, certain types of mucosa and other tissues.^[4] They produce melanin in intracellular granules called melanosomes which upon maturation release melanin into the surrounding keratinocytes or epithelial cells. However, the presence of melanocytes and melanin in intraosseous sites may suggest a pathological occurrence.

Reports of intraosseous odontogenic pigmentation as a primary lesion, other than metastases of malignant melanoma, are very few. Upon review of the English literature, 37 documented cases of pigmented odontogenic cysts were found [Table 1]. Melanin pigmentation has been reported most frequently in association with COC (21)^{[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21]} followed by OKC (9),^{[8],[22],[23],[24],[25]} DC (4),^{[26],[27],[28],[29]} LPC (1),^[30] gingival cyst (GC) (1)^[31] and BOC (1)^[32] [Table 1]. Buchner et al. were the first to report a pigmented LPC in the mandible of a 38-year-old African-American male.^[30] In a study of 20 cases of LPC, Altini and Shear found melanin pigment in the epithelium of one lesion which was classified as a BOC.^[32] To our knowledge, the present case is the second one to document melanocytes and melanin pigment in an LPC, and the first to report a pigmented LPC in the maxilla. When data from all known cases of pigmented odontogenic cysts were combined, no gender predilection was found (18 males, 19 females and one unreported). These cysts had an increased predisposition to occur in the mandible than the maxilla. The age range varied from 8 years to 68 years, with an average age of 23.4 ± 15.8 years at the time of diagnosis. Most lesions occurred mainly in the Asian and African-American ethnicities [Table 1]. The incidence of such lesions in Asians, specifically the Japanese population, exceeded others by far. Fourteen of the 38 (36.8%) lesions occurred in patients of Japanese ethnicity, seven each in males and females.

Table 1: Reported cases of pigmented odontogenic cysts

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The exact mechanism of the presence of melanin pigmentation in odontogenic cysts is still obscure. Most of the odontogenic cysts arise from the dental lamina which originates from the primitive oral ectoderm. In their study of facial skeletons of human fetuses, Lawson et al. found melanocytes within the dental lamina and outer enamel epithelium of 6 Negro fetuses and in 3 of the 11 Caucasian ones.^[33] This may justify the occasional presence of melanocytes in odontogenic lesions. However, this hypothesis fails to explain the presence of melanocytes and melanin pigment in lesions that do not originate from the rest of the dental lamina. Alternatively, it has been hypothesized that the presence of pigmentation may be attributed to either a close relationship between the oral epithelium and the cranial neural crest-derived ectomesenchyme during odontogenesis,^[34] and/or neuroectodermal differentiation of the odontogenic cells.^[35] Neural crest cells play an important role in odontogenesis as seen by the reciprocal induction between inner enamel epithelium and dental papilla, which arises from ectomesenchyme, a derivative of neural crest cells. As dentin is laid down, the odontoblasts and melanocytes retract, but the melanin pigment remains in the odontoblastic processes trapped between the new dentin formed. Thus, it might be considered that the presence of melanocytes in odontogenic lesions is developmental in nature. This hypothesis also explains the presence of melanocytes and melanin pigment in lesions that do not originate from the rest of the dental lamina. Interestingly, the propensity of pigmentation to be seen predominantly in Asians and African-Americans, and being almost nonexistent in white populations, points to a correlation with racial pigmentation. Although genetic factors have not been implicated in the occurrence of odontogenic lesions per se, the possible effects of genetic background on racial pigmentation cannot be neglected. Except for three cases, all patients were either African-American or Asian [Table 1]. This leads us to an understanding that the pigmentation is physiologic rather than pathologic and hence does not contribute to the outcome of the lesion. An additional explanation might be that under certain circumstances, few lesional odontogenic tissue cells have a potential for neuroectodermal differentiation. It is possible that odontogenic lesions contain inactive melanocytes which produce melanin after being activated by certain predisposing triggers that might be related to factors associated with racial pigmentation.^[30]

Conclusion

The exact etiopathogenesis of the pigmentation in intraosseous odontogenic lesions still remains unclear. More documented case studies and careful assessment may be necessary to derive an insight into the association between the cranial neural crest-derived ectomesenchyme and the odontogenic epithelium, as well as to understand the pathologic significance and prognostic implications if any.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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