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root resorption Flashcards

1
Q

definition

A

the non-bacterial destruction of the dental hard and soft tissue due to the interaction of clastic cells

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2
Q

stimulation of osteoclast activity

A

signals can up/down regulate osteoclast activity

  • RANKL promotes development so upregulates
  • OPG inhibits RANKL and so the development so down regulates
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3
Q

RANKL stimulation

A

parathyroid hormone, B3 and IL-1B
bacterial lipopolysaccharides
trauma (physical, chemical)
chronic inflammation

  • apart from trauma can be hard to identify cause
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4
Q

the cell

A

multinucleate giant cells
e.g. osteoclast - when attached to dentine sometimes called dentinoclast as attacking dentine
highly specific and effective
key features
- v motile
- ruffled border (large SA so can resorb v quickly)
- in contact with dentine

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5
Q

aspects of OC/dentinoclast

A 
sit in Howships lacunae
intracellular vesicles
release proteolytic enzymes
ruffled border
integrins to attach
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6
Q

surfaces which act to prevent resorption

A

PDL (external)
- e.g. trauma - PDL necrosis = intimate contact between OCs and dentine

cementum (external)
- particularly the non-mineralised layer

predentine (internal)
- non-collagenous component, closest to pulp

but when damaged the resorption process can begin

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7
Q

types of internal resorption

A

inflammatory

replacement

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8
Q

types of external resorption

A

inflammatory
replacement
cervical
surface

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9
Q

EO exam - smile line

A

if there is a consideration for endo microsurgery

- post-surgical recession or scarring (aesthetics)

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10
Q

IO exam - tooth in question

A 
coronal integrity of remaining tooth and Rx quality
colour
PD pocketing
sinus inc location in relation to mucogingival jct
swelling
apical tenderness
TTP
mobility
occlusal contact in ICP and guidance
integrity of adjacent teeth
sensitivity test
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11
Q

IO exam - coronal integrity of remaining tooth and Rx quality

A

can tooth be predictably restored after tx?

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12
Q

IO exam - colour

A

pink spot

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13
Q

IO exam - PD pocketing

A

with a PCP12 probe both horizontally and vertically (BPE not small enough)
- is there a PD communication with the resorption?

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14
Q

IO exam - sinus inc location in relation to mucogingival jct

A

has the internal resorption perforated the RC?

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15
Q

IO exam - swelling

A

associated with periradicular disease

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16
Q

IO exam - apical tenderness

A

associated with PR disease

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17
Q

IO exam - TTP

A

a test of the PDL not necessarily PR disease

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18
Q

IO exam - mobility

A

no physiological mobility and high pitched percussion

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19
Q

IO exam - occlusal contact in ICP and guidance

A

is the tooth in fct and prudent to retain?

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20
Q

IO exam - integrity of adjacent teeth

A

alternative replacement options e.g. bridge

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21
Q

IO exam - sensitivity test

A

pulp response

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22
Q

radiographic examination

A

absolute minimum is an up to date PA subsequent to any tx
- need 2 from different angles for parallax (SLOB)
- 30 degree mesial or distal beam shift
CBCT (not always needed)

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23
Q

radiographic appearance - internal resorption

A

ballooning out - parallel lines of RC disappear

parallax - doesn’t move - stays centred in canal

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24
Q

radiographic appearance - external resorption

A

can just make out parallel lines of RC system - superimposed on resorption
parallax - appears to change position

25
Q

internal inflammatory resorption - prevalence

A

<1%

26
Q

internal inflammatory resorption - vague clinical findings

A

can be unrestored
no PD pocketing unless lesion has perforated root surface
colour and mobility normal
no sinus unless PR disease
sensitivity testing positive
= mostly found incidentally on radiograph

27
Q

internal inflammatory resorption - pathogenesis

A

coronal pulp is necrotic
lesion includes inflammatory and vascular tissue - if perforated will communicate with PDL
apical pulp is vital (need vital pulp to allow it to progress and keep nibbling)
lesion will continue to progress until apical pulp goes completely necrotic - until PA radiolucency - indicates complete necrosis
- RR likely stopped by this point

can happen in any part of root
- in apical region a consequence can be root perforation

28
Q

internal inflammatory resorption - likely cause

A

trauma

29
Q

internal inflammatory resorption - tx

A

orthograde endo
possible haemorrhage
active irrigation and disinfection, internist medicament (disperse and agitate CaOH e.g. endoactivator) - won’t be able to mechanically clear all the D of OCs
can be hard to find apical canal beyond lesion
thermal obturation e.g. warm vertical compaction

30
Q

internal replacement resorption - diagnosis

A

no clinical indications

incidental finding radiographically - trabecular pattern in pulp - ossified

31
Q

internal replacement resorption - tx

A 
RCT nearly impossible:
 - ossified 
 - thin root dentine in walls
 - perforation risk
if can't RCT often let it run course then when symptomatic look at replacement options
32
Q

external surface resorption - clinical features

A

can be unrestored
increased physiological mobility
+ to sensibility tests

33
Q

external surface resorption - radiographic features

A

PDL intact

no obvious periapical radiolucency

34
Q

external surface resorption - aetiology

A

orthodontics

  • 90% of teeth have some form of ESR
  • 2-5% severe ESR
  • 15% moderate
  • usually teeth for anchorage are the worst affected

ectopic teeth - pressure from erupting tooth

pathological lesions - pressure from adjacent pathological lesion e.g. OK

idiopathic

35
Q

external surface resorption - tx

A

pulp healthy - DON’T RCT
remove the source to stop the resorption
splint if mobile

36
Q

external inflammatory resorption - clinical findings

A

usually restored
no PD pocketing, colour normal
may have sinus, swelling, apical tenderness, TTP
mobility may be increased depending on extent
sensitivity negative - pulp is necrotic

37
Q

external inflammatory resorption - radiographic findings

A

POLL

periapical radiolucency

38
Q

external inflammatory resorption - aetiology

A

pulp is necrotic - bacterial or dental trauma in origin
periapical inflammatory lesion precipitates the resorption process
majority (81%) of teeth with periapical lesions will have microscopic areas of RR
- only 7% of these are detectable radiographically

39
Q

external inflammatory resorption - tx

A

remove the cause of the inflammation
usually orthograde endo (re) tx, possibly surgical endo, or extraction
if apex significantly resorbed may not be able to control GP - need to alter technique

arrests RR
only external RR that benefits from endo

40
Q

classification: Heithersay and Patel

A 
class 1
class 2
class 3
class 4
3D imaging
apico-coronal direction
1 crestal
2 coronal 1/3
3 middle 1/3
4 apical 1/3
circumferential
1 1/4
2 1/2
3 3/4
4 >3/4
41
Q

external cervical resorption - clinical findings

A

can be unrestored
PD pocketing: yes if extensive and profuse BOP
- probe may drop into a hard cavity when you probe margin
- can misdiagnose as caries - but will be hard to probe
pink spot
- lesion has good blood supply - don’t always see e.g. if small or in particular position may not see it until get to a critical stage
normal or no mobility
positive to sensitivity testing

= won’t always have these S and S

42
Q

external cervical resorption - radiographic findings

A

radiolucency at level of CEJ
can still see parallel RC lines, changes in position with parallax
CBCT can show apical coronal spread

43
Q

external cervical resorption - aetiology

A 
orthodontics
trauma - avulsion and luxation 
 - don't traumatise CEJ with forceps when repositioning traumatised tooth
historical non-vital whitening when heat was applied
 - vvv rare with modern bleaching
wind instruments
viral infection (from cats)
systemic disturbance (thyroid)
44
Q

external cervical resorption - pathogenesis

A

portal of entry
bone-like tissue
PRRS: predentine, also called Pericanalar Resorption Resistant Sheet (PRRSP) protects the pulp

45
Q

external cervical resorption - tx options

A 
monitor
 - the resorption will v likely continue - significant number are progressive
extraction and prosthetic replacement
surgical repair
leave root in situ 
 - preserve ST and bone
surgical repair and orthograde endo
internal repair and orthograde endo
 - if can't access surgically

need clean and frosted dentine otherwise RR will continue - keep going with chemical disinfection

46
Q

external cervical resorption - tx options - surgical repair

A

flap to expose
NaOCl - coagulation necrosis
can’t get rid of all lacunae with handpiece as can’t see them and would remove too much tooth

47
Q

external cervical resorption - tx options - surgical repair and orthograde endo

A

1/3 pulp exposed/after pulp becomes necrotic

do endo first to avoid periapical radiolucency

48
Q

external cervical/replacement resorption - healing?

A 
v rarely does it cease and allow healing
lesion has a trabecular pattern
bone rather than ST
the PDL is present
no tx
49
Q

external replacement resorption - clinical findings

A 
can be unrestored but infraoccluded
 - also gingival margin level 
no PD pocketing, possibly erythematous
not TTP but high-pitched note
no physiological mobility - ankylosed
positive to sensitivity tests
50
Q

external replacement resorption - radiographic findings

A

loss of obvious PDL
cotton wool appearance
root surface replaced by trabecular pattern - bone
affects a lot of root surface

51
Q

external replacement resorption - aetiology

A

trauma

  • significant injuries to there periodontium such that bone (OCs) are then in contact with external root dentine to begin resorption
    e. g. avulsion or lateral luxation
52
Q

external replacement resorption - tx options

A

decoronation

monitor

53
Q

external replacement resorption - tx options - decoronation

A

if infra occlusion is >1mm in a growing pt
remove crown to alveolar level and allow root to resorb - root replaced by bone
this preserves bone volume
adjacent teeth and periodontium develop normally
tooth replacement with denture or RBB

54
Q

external replacement resorption - who do you need to intervene early in a growing pt?

A

alveolus growing around it

  • need height of bone for implant
  • also adjacent teeth tip into prosthetic space
  • MD and vertical problem
55
Q

external replacement resorption - tx options - monitor

A

if pt has stoped growing
endo will not stop resorption - no RCT
because of infra occlusion can add composite incisally

56
Q

primary tx strategies for resorption - orthograde endo

A

external inflammatory

internal inflammatory

57
Q

primary tx strategies for resorption - surgical endo

A

external cervical

58
Q

primary tx strategies for resorption - no endo

A

external surface

external replacement

perio (8 decks)

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