Continuing Education Activity
Epstein pearls are small, benign, self-resolving nodules commonly found in the oral cavities of newborns. This activity describes the evaluation and management of Epstein pearls. It highlights the role of the interprofessional team in the appropriate care of affected patients and the counseling of their families.
- Review the etiology of Epstein pearls.
- Describe the presentation of a patient with Epstein pearls.
- Outline the management options available for Epstein pearls.
- Explain interprofessional team strategies for improving care coordination and communication to advance the recognition and management of Epstein pearls.
Some transient benign oral mucosal conditions are often observed in newborns. These lesions exhibit a wide range of developmental abnormalities and morphologic variations. The identification and differentiation of the lesions remain crucial to guide clinicians in prioritizing the management of these problems as well as in the education to anxious parents.
In 1880, a Prague pediatrician Alois Epstein first described Epstein disease as the presence of small nodules in the oral cavity of newborns.
Multiple investigators reported a high rate of occurrence of palatal mucosal cysts in fetuses and infants. However, it was not until 1967 when Alfred Fromm studied and classified them according to their location and composition as Epstein pearls, Bohn nodules, and dental lamina cysts based on his comprehensive study of 1367 newborn infants. This was one of the first and largest studies done on oral cysts. Fromm concluded that these lesions were commonly found among infants and there were distinct types based on their histology and clinical presentation.
Some authors use these terms interchangeably. Epstein pearls have been labeled as epithelial debris of the tooth follicle, gingival glands of Serres, and as abortive enamel organs on the Palatine area. On the other hand, Bohn’s nodules are those found along the buccal and lingual aspects of the dental ridges. Dental lamina cysts are usually found on the crest of the alveolar mucosa. Currently, Palatal cysts of the newborn are the preferred term instead of Epstein’s pearls, Bohn’s nodules, or gingival cysts.
Keratin entrapment within the soft and hard palates causes Epstein pearls.
Epstein pearls are observed in nearly 60% to 85% of newborn infants. Among the different racial groups, Japanese newborns are most commonly affected (up to 92%), followed by Caucasians and African-Americans. No gender predilection has been observed through the years.
In one study, Epstein pearls were more common in infants born to multigravida mothers, also with those with higher birth weight. One study done in Turkey found that Epstein's pearls were less frequent in post-term babies in comparison with pre-term and term ones. A greater rate seen in term babies was reported. (Moosavi et al.).
Near the end of the 8 weeks in utero, the palate begins its development. Each maxillary process generates a lateral palatine process within the mouth. These processes are horizontal and shelf like, growing from the lateral aspect of the mouth toward the midline and downward. Between the 10 to the 11 weeks in utero, the lateral palatine processes meet and fuse with each side and with the much smaller premaxillary process and the nasal septum; palatal fusions normally are completed by the end of the 4 months of gestation.
In this stage, there is a theory that states that epithelium entrapped between the palatal shelves and the nasal process formed cysts called Epstein pearls. Another theory expressed that these cysts may come from epithelial remnants that have arisen from the formation of the minor salivary glands of the palate.
Epstein pearls are keratin-filled cysts with stratified squamous epithelium lining. Located on the mid-palatal raphe at the junction of the hard and soft palates.
History and Physical
They are small, opaque whitish-yellow lesions adjacent to the mid palatine raphe with no mucous glands in it Lesions are firm in consistency, size range from less than a millimeter to several millimeters in diameter. Size does not progress over time. They can be palpated during sucking by the examiner.
- Epstein pearls can be seen in cluster groups of 2 to 6 cysts, although they can present as an isolated lesion. Their distribution varied from mouth to mouth, barely being identical even in twins.
- Occasionally these cysts show communication with the mucosal surface.
- Cleft children appear to have cysts in the identical distribution pattern as non-cleft children except for those with a cleft palate which are located at the margins of the palatal shelves instead of the midline.
- Parents of newborn infants sometimes worriedly visit a dental surgeon or pediatrician, complaining of the presence of these abnormal structures in the mouth of their infants.
- The clinician should explain that Epstein pearls are benign and asymptomatic, with no interference with feedings or tooth eruption.
- Epstein pearls resemble the equivalent of milia (white papules produced by retention of sebum and keratin in the hair follicles), which are frequently seen on the faces of neonates.
Epstein pearls are a clinical diagnosis. No laboratory or imagining is needed.
Treatment / Management
No treatment or removal is required. Parental apprehension should be alleviated by reassurance.
After a lesion is found in the oral cavity, it is important to formulate a differential diagnosis since this will help lead any additional evaluation of the condition and managing the patient.
Some of the differential diagnosis for Epstein pearls include:
- Bohn nodules which are mucous gland cysts, frequently located on the buccal or lingual aspects of the alveolar ridges and rarely on the palate. Histologically consist of mucous glands and ducts. They are numerous, grayish white and firm in consistency.
- Dental lamina cysts are remnants of dental lamina epithelium found on the crest of the alveolar mucosa. They may be greater in size, more transparent, solitary lesion and fluctuant.
- Natal and Neonatal teeth are rare and usually located in the lower incisors region. They represent the early eruption of normal primary teeth. These are associated with developmental anomalies and recognized syndromes including Rubinstein-Taybi, Hallerman-Streiff, Ellis-van Creveld, Pierre-Robin, pachyonychia congenita, short rib-polydactyly type II, steatocystoma multiplex, cyclopia, Pallister-Hall, and many others. Therefore if the patient has any other dysmorphic features, genetic evaluation is indicated.
- Congenital epulis is pedunculated, soft nodule from 1 mm to several cms in diameter located on gingival margin.
- A congenital ranula is a translucent, firm papule or nodule found on the anterior floor of mouth, lateral to lingual frenulum.
- Alveolar lymphangioma is bluish fluid-filled lesions on the alveolar ridges. No seen in the palate. Predominant in black neonates. These lesions can be isolated or multiples.
Most of these cysts involute or spontaneously rupture eliminating their keratin contents into the oral cavity within the first few weeks to months of postnatal life.The lesions are hardly ever seen after three months of age. However, it has been suggested that part of the cystic epithelium may remain inactive even in the adult gingiva.
Enhancing Healthcare Team Outcomes
Epstein pearls may be encountered by many specialists including nurse practitioners. The key is to reassure the parent that the lesions are harmless and will disappear with time. No attempt should be made to remove them as this may cause more harm than good.