multiple idiopathic external and internal resorption- dr sanjana ravindra
TRANSCRIPT
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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
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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
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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
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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
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BASED ON ETIOLOGY
PHYSIOLOGIC
PATHOLOGIC
IDIOPATHIC
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BASED ON LOCAL CAUSES
INFLAMMATION-EXTERNAL-INTERNAL
PRESSURE-ORTHODONTIC
TOOTH MOVEMENT-TUMOURS OR
CYST
REPLACEMENT OR
DENTOALVEOLARANKYLOSIS
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Inflammatory
•Internal •External
Non inflammatory•Pressure •Replacement
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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
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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
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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.
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PATHOLOGICAL RESORPTION
Any resorption of teeth which is not related to shedding of
primary teeth.
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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
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EXTERNAL ROOT RESORPTION
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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
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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.
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TYPES
CervicalLateralapical
BASED ON LOCATION
Acc to Cohen
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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
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ETIOPATHOGENESIS
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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
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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
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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
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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
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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
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Hypoparathyroidism
Calcinosis
Gauchers disease
Hyperparathyroidism
Turners syndrome
Pagets disease
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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
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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
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histologically
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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.
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DIFFERENTIAL DIAGNOSIS
Internal resorption
Incomplete root
formation
Short root
Apicectomy
Foreshortening of root
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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
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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)
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MANAGEMENT
Removal of cause
Apicoectomy
Curettage and filling
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INTERNAL RESORPTION
Chronic perforating hyperplasia of the Pulp
Internal granuloma
Odontoclastoma
Pink tooth of mummery
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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
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MECHANISM
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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
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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
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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
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HISTOLOGICALLY
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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
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DIFFERENTIAL DIAGNOSIS
Dental caries Internal resorption
More diffused margins Sharp and clearly defined
Enamel - involved Enamel- not necessary
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IDIOPATHIC ROOT RESORPTION
By definition, if an etiological factor cannot be identified for root resorption, the term “idiopathic” is applied.
(Belanger & Coke-1985)
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• 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)
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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.
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CASE REPOR
T
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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.
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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
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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
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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.
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CASE REPORT
Cross-sectional cone-beam computed tomographic images show external resorption in molar teeth (arrows).
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Three-dimensional conebeam computed tomographic volume rendering images clearly show external and internal resorption (arrows).
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No treatment was performed
because the patient refused
treatment
CASE REPORT
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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
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REASON FOR CHOOSING THIS ARTICLE?
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R E F E R E N C ES
1. Grossman LI, Oliet S, Del Rio CE. Endodontic Practice.11th edition.2. Chandra BS, krishna VG. Grossman’s endodontic practice. 12th ed. New delhi: wolters
kluwer pvt. Ltd; 2010.3. Nisha garg, amit garg. Textbook of endodontics. Jaypee publications. 2nd edition.4. Neville, Damm, Allen CM, Bouquot JE. Oral and maxillofacial pathology. 2nd ed. India:
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