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Case Report

Immune periapical granuloma with Mott cells: Endodontic

significance and need for identification
Uma Vasant Datar, Aarti Mahendra Mahajan1, Vishakha Chaudhari2, Rahul B. Patil3
Department of Oral Pathology and Microbiology, Bharati Vidyapeeth (Deemed to be University) Dental College and Hospital, Sangli,
1
Department of Oral Pathology and Microbiology, Mahatma Gandhi Vidyamandir’s Karmaveer Bhaurao Hire Dental College, Nashik,
2
Expedent Dental Clinic, Navi Mumbai, 3Department of Oral Pathology and Microbiology, Rural Dental College, Pravara Institute of
Medical Sciences, Loni, Maharashtra, India

ABSTRACT
Periapical granulomas (PGs) respond well to endodontic treatment. In case of refractory response to the treatment apicectomy and finally,
extraction is the treatment of choice. Herein, we present a case of endodontically failed PG with an excessive amount of Mott cells (MCs).
MCs are plasma cells with spherical aggregates in their cytoplasm. The extensive accumulation of MCs in a periapical lesion is hitherto
underreported and might elucidate the cause of refractory treatment outcomes of certain periapical lesions. The lesion was diagnosed with
immune PG with multiple MCs. To the best of our literature search, there have been only two similar reports till date. Additional case reports
and long‑term follow‑up are necessary to understand the nature and significance of such lesions. This article aspires to further the awareness
regarding such unique presentation to aid appropriate diagnosis and also highlights the importance of subjecting apicectomy specimen to
histopathological examination.

Keywords: Endodontics, histopathological examination, Mott cell, periapical granuloma, Russell bodies

INTRODUCTION
Nonsurgical endodontic treatment is often the treatment of choice
for nonhealing or persistent Periapical granulomas (PGs).[1,2] PG
are histologically of two types, nonimmune granulomas, which
predominantly show macrophages and giant cells, and immune
granulomas that are rich in lymphocytes and plasma cells.[3]
Mott cells (MCs) are plasma cells that produce large amounts of
immunoglobulin, which are contained mainly in large vesicles.[3]
Russell body (RBs) are eosinophilic, multiple, variable‑sized,
spherical inclusions of immunoglobulins within the MCs.[4,5]
MCs are observed in various pulpitis,[6,7] chronic inflammatory
lesions,[7‑9] and benign and malignant neoplasms.[5,10] Abundant
MCs are noted in malignancies like plasmacytoma/multiple
myeloma,[10] which may occur in the periapical region. However,
Submitted: 30‑Aug‑2021 Revised: 09-Nov-2021
Accepted: 24‑Dec‑2021 Available Online: 25-Mar-2022
till date, to the best of our knowledge, only two cases of
abundant MCs in periapical lesions have been reported.[3,8]
Their presence in abundant numbers in the periapical area is
not only perplexing but also a plausible indication of refractory
treatment outcome in certain periapical lesions. Herein, we
report a rare case of PG rich in MCs with emphasis on its
histopathological features, differential diagnosis and treatment
outcome.
CASE REPORT
A 35‑year‑old female presented with a complaint of pain and
swelling in the anterior region of the upper jaw. Intraoral
Address for correspondence: Dr. Uma Vasant Datar,
Department of Oral Pathology and Microbiology, Bharati
Vidyapeeth (Deemed to be University) Dental College and Hospital,
Sangli, Maharashtra, India.
E‑mail: dataruv@gmail.com

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DOI:
How to cite this article: Datar UV, Mahajan AM, Chaudhari V, Patil RB.
10.4103/endo.endo_163_21 Immune periapical granuloma with Mott cells: Endodontic significance and
need for identification. Endodontology 2022;34:66-8.

66 © 2022 Endodontology | Published by Wolters Kluwer - Medknow

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Datar, et al.: Immune periapical granuloma with Mott cells

examination revealed a discrete swelling in relation to

maxillary right central and lateral incisors and a draining sinus
in relation to maxillary right central incisor. The patient had
undergone root canal treatment for the same tooth elsewhere
3 years ago. On the intraoral periapical radiograph, it was
evident that incisors were endodontically treated and a
diffuse, ill circumscribed radiolucency of two centimeters in
diameter was noted in relation to the root of the maxillary
right central incisor [Figure 1]. Patient’s medical history
and general physical examination were noncontributory.
Provisional diagnosis of the radicular cyst was considered. On
the patient’s request, the tooth was extracted and the tissue
was sent for histopathological examination. On microscopic
examination, loosely arranged fibrocellular connective tissue
Figure 1: Intraoral periapical radiograph showing unilocular radiolucency
stroma with the fibrous wall in the periphery was noted. associated with root apex of maxillary right central incisor
Diffuse dense chronic inflammatory cell infiltrates rich in
plasma cells and numerous MCs showing Russell bodies (RBs)
and few mitotic figures were noted [Figure 2]. Variation in the
size and number of RBs within the (MCs) was noted. To rule
out malignancy, immune histochemical analysis was done
using kappa and lambda light chain [Figure 3]. The plasma cells
and MCs showed positivity for both and kappa: lamda ratio
was approximately 2:1, thus suggesting their polyclonality a b
and reactive nature of the lesion ruling out malignancy. The
lesion was diagnosed with immune PG with multiple MCs.

DISCUSSION

MCs have acquired their name from F. W. Mott, who first c d

identified these cells. He called these cells as Morular
cells (from the Latin morus meaning, mulberry) and identified
them to be plasma cells.[5] RBs present within MCs are believed
to be the result of cellular indigestion in the endoplasmic
reticulum. RBs represent mutated immunoglobulin which
are neither secreted nor degraded, resulting in excessive
accumulation of immunoglobulins in the endoplasmic
reticulum, thus greatly distending it and manifesting as
homogenous eosinophilic inclusions.[5] Researchers have
also put forth a possible role of type I proinflammatory
cytokines in the over‑production of immunoglobulins
in pulp and periapical areas.[9] Moreover finally, the root
canal microorganisms have been implicated to trigger the
overproduction of RB in plasma cells of periapical lesions.[9]
Subsequently, it may be presumed that MCs are aberrant
responses to a certain antigenic stimulus. The exuberant host
immune response to an elusive stimulant and subsequent
accumulation of immunoglobulin might be the reason why
few PGs are refractory to nonsurgical endodontic treatment.
Nonhealing lesions can be treated with or without surgery,
but surgical endodontic treatment will marginally have better
treatment outcomes in such lesions.[11,12]
Endodontology / Volume 34 / Issue 1 / January‑March 2022
Figure 2: (a) Sheets of plasma cells and dispersed Mott cells (H and E, ×40).
(b) Arrowhead pointing at Mott cell containing multiple variable
sized RBs (H and E, ×40). (c) Mott cell at higher magnification
(H and E, ×100). (d) Illustration showing immune profile of Mott cell
a b
Figure 3: (a) Mott cells showing strong immunoreactivity for kappa light
chain. (b). Mott cells showing immune‑reactivity for lambda light chain (×40)
In the present case, clinical and radiographic findings
were indicative of a periapical lesion. Histopathological
findings were also supportive of the same. However, striking
features noted were sheets of mature plasma cells, few
lymphocytes, and other inflammatory cells. In addition,
abundant, evenly dispersed MCs were noted throughout
the lesional tissue. These features indicated the possibility
of plasmacytoma which are known to occur periapically.[10]
Mature plasma cells of plasmacytoma are monoclonal and
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Datar, et al.: Immune periapical granuloma with Mott cells
show kappa or lambda chain restriction. In the present case,
immune‑expression of both kappa and lambda chain by the
plasma cells ruled out plasmacytoma, in addition, the ratio
of kappa‑positive cells to lambda‑positive cells was studied
to confirm the reactive nature of the lesion. Moreover,
destructive infiltrative growth, nuclear atypia, pleomorphism,
and mitotic activity, which are hallmarks of malignancy, were
lacking.
Over‑diagnosing these lesions as malignancy should be
avoided, especially in the absence of other clinical or
histological indicators of malignancy. Immunohistochemical
markers may be beneficial. MCs show expression for
CD11b, CD43, CD5, CS45, CD138, CD78 and kappa and
gamma [Figure 2d].[5,8,9]
Till date, two cases[3,8] of abundant MCs accumulation in
periapical lesions have been reported. The age of the patients
was nineteen and twenty‑four and the patients were female
and male, respectively.[3,8] In both cases, the lesion was reported
in the maxillary anterior region, similar to the present case.
Interesting finding was that both the lesions had a history of
trauma. In both cases, the lesion was excised, but the details
about the fate of the involved teeth are not available.[3,8] Due to
the paucity of literature, it is unclear whether the occurrence
of MCs in the periapical lesion is a chance finding or indicative
of chronicity of the lesion or an altered immune response.
CONCLUSION
The actual occurrence of MT‑rich periapical lesions is obscure
since not all the surgically removed tissues are sent for
histopathological examination. Hence, this case highlights the
necessity of subjecting all surgically removed tissue from the
periapical lesions to histopathological examination. Moreover,
if these cases are unique; it remains to be seen whether their
clinical outcomes different than other PG and if endodontic
treatment with periapical surgery is remedial in such cases. The
significance of their occurrence, their nature and the diagnostic
implication is unexplored and warrants further research.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form, the patient has given her
68 Endodontology / Volume 34 / Issue 1 / January‑March 2022
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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