Multiple idiopathic external and internal resorption: Case report with cBCT

findings

Berkan Celikten, Ceren Feriha Uzuntas, Hakan KurtImaging Science in Dentistry 2014; 44: 315-320

Journal club : 06

INTRODUCTION

RESORPTION- A condition associated with

either a physiologic or a pathologic process

that results in loss of substance from a tissue

such as dentin, cementum or alveolar bone.

Glossary of the american association of endodontists

TOOTH RESORPTION

DEFINITION:

A chronic progressive damage or loss of tooth structure due to the action of cells called odontoclasts

Langlais rp, langland op, nortje’ cj. Diagnostic imaging of the jaws. Usa:williams & wilkins

TYPES

Resorption can occur from the internal

surface of tooth i.e. the pulpal surface

INTERNAL RESORPTION

From the external surface of tooth i.e.

enamel or cementum surface

EXTERNAL RESORPTION

BASED ON ANATOMICAL LOCATION:

Apical Lateral

Cervical

BASED ON ETIOLOGY

PHYSIOLOGIC

PATHOLOGIC

IDIOPATHIC

BASED ON LOCAL CAUSES

INFLAMMATION-EXTERNAL-INTERNAL

PRESSURE-ORTHODONTIC

TOOTH MOVEMENT-TUMOURS OR

CYST

REPLACEMENT OR

DENTOALVEOLARANKYLOSIS

Inflammatory

•Internal •External

Non inflammatory•Pressure •Replacement

PATHOGENESIS

Resorption of root surfaces, whether internal or external, occurs by the action of clastic cells. These cells are multinucleated giant cells with cytoplasmic vacuoles originating from bloodborne leucocytes from the bone marrow; the precursor cell is from the monocyte cell line.Cellular components in a resorptive complex include:1. Clast cells- odontoclast, dentinoclast,

osteoclast, cementoclast2. Monocysts and macrophages

MECHANISM OF TOOTH RESORPTION

• Initiated by creation of acidic pH(3 – 4.5) at the site of resorption- created by polarized proton pump- produced within the ruffled border of clast cells- below pH of 5, dissolution of hydroxyapatite occurs

Degradation of inorganic crystal structure- hydroxyapatite

• Enzymes: collagenase, MMP, cysteine proteinase

Degradation of organic matrix

PHYSIOLOGICAL RESORPTION

Physiological resorption occurs when the roots of deciduous tooth undergo resorption before tooth exfoliation.

This occurs with or without presence of permanent successor tooth.

There is no infectious (microbiological) component involved in physiological resorption.

PATHOLOGICAL RESORPTION

Any resorption of teeth which is not related to shedding of

primary teeth.

PATHOLOGICAL RESORPTION

Orthodontic therapy

Trauma

Periapical or periodontal

inflammation

TumorsCysts

Occlusal stress

Impacted and supernumerary

teeth

Hyperparathyroidism, Hypoparathyroidism

Hypophosphatemia

Hyperphosphatemi

a

Gaucher’s disease

Paget’s disease of the bone

Goltz syndrome

Turner syndrome

LOCAL CAUSES ENDOCRINE

DISTURBANCES SYSTEMIC CAUSES

EXTERNAL ROOT RESORPTION

Loss of tooth material from the

outer surface of the tooth, arising from a

tissue reaction in the periodontal or pericoronal tissue.

Langlais rp, langland op, nortje’ cj. Diagnostic imaging of the jaws. Usa:williams & wilkins

definition

Is a lytic process occurring in the cementum or

cementum and dentin of the roots of teeth

Grossman LI, Oliet S, Del Rio CE. Endodontic Practice.11th edition.

definition

It is initiated in the periodontium and often results in significant loss

of hard tooth structure.

Histologically: scalloped border

lined with osteoclasts.

TYPES

CervicalLateralapical

BASED ON LOCATION

Acc to Cohen

ACCORDING TO SEVERITY

SURFACE RESORPTION occurs commonly periapically as microdefects on the root

surface and stops when the instigating agent is removed and there is repair of cementum.

INFLAMMATORY RESORPTION Occurs when root resorption progresses into the dentinal

tubules to reach the pulpal tissue.

REPLACEMENT RESORPTION Produces ankylosis of a tooth because bone replaces the resorbed bone substance. Ie osseous ingrowth into resorbed areas of the root

TYPES

Acc to Guttman et al as given in Quintessence International 1999

ETIOPATHOGENESIS

Injury to the precementum or predentin, infected dentinal tubules may stimulate the inflammatory process with osteoclastic activity in the periradicular tissues or in pulpal tissues, consequently initiating external or internal root resorption. On radiograph, it appears as slight raggedness or blunting of the root apex in the early stages.

ROOT RESORPTION DUE TO PULPAL INFECTION

Infrequently, external root resorption may occur after injury to the pre-cementum, apical to the epithelial attachment, followed by bacterial stimulation originating from the periodontal sulcus

ROOT RESORPTION DUE TO PERIODONTAL INFECTION

Pressure root resorption can be observed during the eruption of the permanent dentition, especially of maxillary canines ( affecting lateral incisors ) and mandibular third molar ( affecting madiubular second molars ). Tumors and osteosclerosis impingning on the root of the tooth could also be an etiological factor for pressure resorption

ROOT RESORPTION DUE TO IMPACTED TOOTH , TUMOR PRESSURE

In severe traumatic injuries ( intrusive luxation or avulsion with extended dry time ), injury to the root surface may be so large that the healing with cementum is not possible, and one may come into contact with the root surface without an intermediate attachment apparatus. This phenomena is termed dentoalveolar ankylosis

ANKYLOTIC ROOT RESORPTION

The injury originating in the orthodontic root resorption is from the pressure applied to the roots during tooth movement. Continuous pressure stimulates the resorbing cells in the apical third of the roots, a possibility of significant shortening of the root. Teeth are asymptomatic and the pulp is usually vital unless the pressure of the operative procedure is high, which disturbs the apical blood supply

ROOT RESORPTION DUE TO ORTHODONTIC PRESSURE

Hypoparathyroidism

Calcinosis

Gauchers disease

Hyperparathyroidism

Turners syndrome

Pagets disease

CLINICAL FEATURES SITES

Upper incisors, upper and lower bicuspids

SYMPTOMS

Usually asymptomatic

SIGNS

When root is completely resorbed- tooth becomes mobileRoot resorption is followed by ankylosis- tooth is immobile, in infraocclusion and with high percussion sound

APICAL LATERAL CERVICALCAUSES Mainly trauma Occur after all

luxation injuries (except the most minor) & avulsions

Injury to attachment apparatus immediately below the epithelial attachment of the root eg in ortho tooth movement, trauma,non vital bleaching with inflammation of periodontal origin

FEATURES -Commonly seen-

-Root loses its cemnetal protection--bacterial toxins can pass thru dentinal tubules & stmulate inflamatory response in the pdl

-slowly progressive-characterized by invasion of the root by fibrovascular tissue derived frm pdl-often aggressively destructive

Clinical evaluation Symtoms associated with apical periodontitis

-Usually asymptomatic-H/o trauma- +/- of pain on percusion-in adv stages tooth mobility & tenderness on percussion

-Ususally asymptomatic-probing may result in profuse bleeding-+ of inflamed tissue-Pink spot when the resorption is long standing which can b misdiagnsed as int resorption

histologically

RADIOGRAPHIC FEATURES APPEARANCE

When the lesion begins at the apex, it causes smooth resorption of the root surface.The conical end is removed and replaced by more or less blunt or square apex

BONE AND

LAMI

NA DURA

Show normal appearance.Appears as concave and ragged area on the root surface

EXTERNAL- INTERNAL RESORPTION

Appears eccentrically shaped notch with areas of resorption which are uneven and appears like trabeculae.The resorptions extend apically into the pulp/ coronally under the enamel.Also called as invasive cervical resorption.

DIFFERENTIAL DIAGNOSIS

Internal resorption

Incomplete root

formation

Short root

Apicectomy

Foreshortening of root

INTERNAL RESORPTION EXTERNAL RESORPTIONRADIOGRAPHIC FEATURES-The margins are smooth & clearly defined-the walls of the root canal may appear to balloon out

- The borders may be irregular & ill defined

- Outline of canal is distorted - Outline of root canal is mormal

- Lesion appears close to the canal even if angulations of radiograph changes

-Lesion moves away from the canal as angulation changes

-does not involve bone so radiolucency is confined to root .bone resorption is seen only if the lesion perforates the root

-almost always accompanied by resorption of bone so radiolucency appears in root & adj bone

-Root canal & resorptive defect appears contiguous

-root canal can be seen running through the defect

PULP TESTING- Commonly occurs in teeth with vital pulp so gives positive response to pulp tests but negative response is seen when pulp gets involved

- Involves commonly infected pulp space so negative response to pulp tests

PINK SPOT-seen- Represents hyperplastic vascular pulp tissue filling resorption bed showing off through the tooth

- Pulp is nonvital , granulation tissue which produces pink spot is not seen

ORDINAL SCALE DATA

• Visually assessed grades of resorption assigned

RATIO SCALE DATA• Measurements

with calipers or some computer aided device

QUANTIFICATION OF ROOT RESORPTION

Goldson and Hendrikson(1975)

MANAGEMENT

Removal of cause

Apicoectomy

Curettage and filling

INTERNAL RESORPTION

Chronic perforating hyperplasia of the Pulp

Internal granuloma

Odontoclastoma

Pink tooth of mummery

Process that begins centrally within the tooth, wherein the pulp chamber or the rootcanals or both expand by resorption of the surrounding dentin

Definition

“unusual form of tooth resorption that begins centrally within the

tooth, apparently initiated in most cases by a peculiar inflammation of

the pulp” – Shafer

MECHANISM

ETIOLOGY

Etiology

Idiopathic

Inflammatory

Pulpal treatment

Others

Inflammatory

hyperplasis of pulp (pulp

polyps)

Direct and indirect pulp capping and pulpotomy

(CaOH2) may stimulate the odontoclasts

formation

Other causes like

enamel invagination and acute trauma to

teeth

TYPES

Occurs due to intense inflammatory reaction within the pulp tissueHere, resorbed dentin is replaced by inflamed granulation tissue

Occurs due to absence of any inflammatory reaction within the pulp.Here, pulpal and dentinal walls are resorbed and replaced by bone or cementum like bone

INTERNAL INFLAMMATORY RESORPTION

INTERNAL REPLACEMENT/ METAPLASTIC RESORPTION

CLINICAL FEATURE

4th – 5th decade Males

Primary and secondary dentition Cental and lateral incisors, premolar, canine, 3rd molar

Asymptomatic until root has become perforated and necrotic

Appearance of pink hued area on the crown, which represents the hyperplastic pulp tissue filling the resorbed area

Crown- lesion may expand to such an extent that crown shows dark shadow due to necrosis of the pulp tissueRoot- weaken the tooth and results in fracture

It may perforate the crown with hemorrhagic tissue projecting from the perforation and results in infectious pulpitis

AGE AND GENDER

SITESSYMPTOMS

PINK TOOTH OF MUMMERY

SIGNS

INFECTIOUS PULPITIS

HISTOLOGICALLY

RADIOGRAPHIC FEATURES Location:

Destruction may be symmetrical around the

original canal or it may be eccentric, so that it is

situated entirely on one side of the root

Appearance:Radiolucency is

homogenous without bony trabeculae or radiopaque

foci

Pulp canal:Enlargement of canal which is symmetrical or irregular

Shape: Tooth substance which is destroyed in the root may

assume any shape, rounded oval , inverted, pear or

irregular

Margins:Margins of enlarged

chamber are sharp and clearly defined

DIFFERENTIAL DIAGNOSIS

Dental caries Internal resorption

More diffused margins Sharp and clearly defined

Enamel - involved Enamel- not necessary

IDIOPATHIC ROOT RESORPTION

By definition, if an etiological factor cannot be identified for root resorption, the term “idiopathic” is applied.

(Belanger & Coke-1985)

• Cervical type starts in the cervical area of the teeth and progresses toward the pulp.

• In the Apical type the resorption starts apically and progresses coronally causing a gradual shortening and rounding of the remaining root.

1ST REPORTED BY (Lydiatt et al. 1989, Yusof & Ghazali 1989)

Minimal apical external root resorption may be present in all permanent teeth and has been attributed to a variety of causes.

However, upto now only numerated cases of idiopathic apical root resorption have been reported in the literature.

This article describes a rare case of multiple idiopathic external and internal resorption in the permanent maxillary and mandibular teeth of an otherwise healthy 36-year-old male patient in which no cause could be identified or no reason could be determined for its occurrence and was evaluated using periapical/panoramic radiography and CBCT.

CASE REPOR

T

CASE REPORT

A 36-year-old male was referred to our outpatient clinic for discomfort in the left mandibular second molar under a crown bridge restoration; he experienced slight discomfort while chewing.

There was no history of trauma, hospitalization, or medical, endocrine, or systemic disease.

Hematological investigations, including a complete blood count and measurement of the calcium, phosphorus, and alkaline phosphatase levels, revealed values within the normal range.

There was no evidence of adenopathy, paresthesia, or motor nerve deficiency in the head and neck area.

A clinical examination showed no tenderness upon palpation of the labial tissues over the periapical region of any toothThere was no tenderness to percussion; however, the patient felt discomfort while chewing with the left mandibular second molar

A clinical examination revealed moderate oral hygiene and healthy gingival tissues.

An intraoral examination also revealed that the patient was caries-free and had four amalgam restorations and a fixed bridge to replace lost mandibular premolars and molars.

Periodontal probing was consistently 3 mm or less, and no bleeding on probing was detected.

CASE REPORT

Initially, a panoramic radiograph was taken.

The radiograph showed evidence of resorption

in several teeth, including the 11, 14,15, 21,

22, 25, 26 and the unerupted left maxillary

canine (23)

CASE REPORT

CASE REPORT

A. Axial cone-beam computed tomographic images show sites of idiopathic resorption of the teeth.

B. B. Panoramic reconstructed Image clearly demonstrates the resorptive areas.

CASE REPORT

Cross-sectional cone-beam computed tomographic images show external resorption in molar teeth (arrows).

Three-dimensional conebeam computed tomographic volume rendering images clearly show external and internal resorption (arrows).

No treatment was performed

because the patient refused

treatment

CASE REPORT

Early detection can lead to timely interventionand better treatment outcomes.

• Apical shortening, lateral or cervical root gaps, enlargement of the root canal, and external root radiolucencies are typically not detectable on radiographs in the early stages when they are small or because of the limitations of this two-dimensional methodwhich is most frequently used.

An alternative diagnostic tool for the early detection of root resorption is CBCT

• Root resorption extension is identified by analyzing all lesion dimensions; axial, transverse, and cross-sectional slices can be obtained using CBCT.

CBCT should not necessarily replace panoramic images due to radiation risk

• The decision to select an imaging modality for diagnostic purposes should be based on the expected diagnostic yield and in accordance with the “as low as reasonably achievable” principle

CONCLUSION

REASON FOR CHOOSING THIS ARTICLE?

R E F E R E N C ES

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