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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/ formation so upregulates ( by binding to receptor RANK on osteoclast)
  • OPG inhibits osteoclast development - down regulates ( by binding to RANKL)
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3
Q

RANKL stimulation

A
  • parathyroid hormone, integrin B3 and IL-1B (interleukin)
  • 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 of tooth 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 - in external cervical resorption

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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 (external replacements resorption)

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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

all positive except external inflammatory resorption

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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 of canal - parallel lines of root canal 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

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25
Q

internal inflammatory resorption - prevalence

A

<1%

26
Q

internal inflammatory resorption - vague clinical findings & radiograph findings

A
  • no PD pocketing unless lesion has perforated root surface
  • mostly found incidentally on radiograph
  • radiolucency central in canal, not move with parallax
  • ballooning of canal
  • tramlines of RC indistinct
  • Root surface intace
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 more common in M/F?

A

Male

30
Q

internal inflammatory resorption - tx

A

orthograde endo only

  • active irrigation and disinfection,
  • intervisit 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
    • ns CaOH for 4-6 weeks
  • thermal obturation e.g. warm vertical compaction

possible haemorrhage

31
Q

internal replacement resorption - diagnosis

A

no clinical indications

incidental finding radiographically - trabecular pattern in pulp - ossified

32
Q

Internal replacement resorption radiographic findings

A
  • irregular enlargement of the pulp space
  • bone-like and extends into the dentin towards the cementum
    -resemble cancellous bone (trabecular)
33
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
34
Q

external surface resorption - clinical features

A

can be unrestored
increased physiological mobility
+ve to sensibility tests

35
Q

external surface resorption - radiographic features

A

PDL space and lamina dura intact
no obvious periapical radiolucency

36
Q

external surface resorption - aetiology

A
  • Damage to PDL which subsequently heals.
  • Non-progressive

orthodontics

  • 90% of teeth have some form of ESR
  • 2-5% severe ESR
  • 15% moderate
  • usually teeth for anchorage are the worst affected ( max canine/ lats)

ectopic teeth - pressure from erupting tooth

pathological lesions - pressure from adjacent pathological lesion e.g. odontogenic keratocyst

idiopathic

37
Q

external surface resorption - tx

A

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

38
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

39
Q

external inflammatory resorption - radiographic findings

A
  • moth-eaten appearance
  • loss of lamina dura, PDL sapce
  • radiolucency in the adjacent alveolar bone
  • periapical radiolucency
  • indistinct root surface
  • intact RC tramlines
40
Q

external inflammatory resorption - aetiology

A
  • progressive
  • pulp is necrotic - bacterial or dental trauma in origin
  • periapical inflammatory lesion (damage to PDL initially ) precipitates the resorption process
  • Propagated by RC toxins reaching external root surface - via dentinal tubules
  • majority (81%) of teeth with periapical lesions will have microscopic areas of RR
  • only 7% of these are detectable radiographically
41
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

42
Q

External cervical resorption classification 2 types

A
  • Heithersay 1999
  • Patel 2016
43
Q

external cervical resorption - clinical findings

A

can be unrestored

  • pink spot on crown
  • 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
  • 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

= won’t always have these S and S

normal or no mobility
positive to sensitivity testing

44
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
resorption radiolucency is superimposed on the pulp

45
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)
46
Q

Name of layer in predentine that protects pulp from resorption

A

Pericanalar Resorption Resistant Sheet (PRRS)

47
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

48
Q

external cervical resorption - tx options - surgical repair

A

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

49
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

50
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
51
Q

which tooth more at risk of external cervical resorption

A

max canine > max incisor > mand molar

52
Q

external replacement resorption - clinical findings

A
  • infraoccluded
  • possibly erythematous
  • high-pitched note
  • ankylosed - no physiologicla mobility
53
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

54
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
  • bone cells faster than PDL fibroblasts
  • bone directly fused to dentine
  • Progressive.
    • Tooth gradually resorbed as it is now part of bone remodelling.
55
Q

external replacement resorption - tx options

A
  • decoronation : growing pt
  • monitor + Incisal comp build up : non growing pt
  • endo will not stop resorption - no RCT
56
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

57
Q

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

A

alveolus growing around it

  • avoid further recession of gingival margin - infra-occlusion
  • need height of bone for implant
  • also adjacent teeth tip into prosthetic space
58
Q

Which resorption to use :

primary tx strategies for resorption - orthograde endo

A

external inflammatory

internal inflammatory

59
Q

primary tx strategies for resorption - surgical endo

A

external cervical

60
Q

primary tx strategies for resorption - no endo

A

external surface

external replacement

61
Q

ECR - Heithersay 1999 classification

A
  • 2 dimensional
  • 1
  • 2 : little or no root dentine involvement
  • 3: coronal 1/3 of root dentine
  • 4: Beyond coronal 1/3 of root dentine
62
Q

ECR - Patel 2016 classification

A
  • 3 dimensional
  • 3 parts : apico-coronal / circumferential/ pulp involvement
  • eg. 2Bp

perio (8 decks)

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