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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
internal inflammatory resorption - prevalence
<1%
26
internal inflammatory resorption - vague clinical findings & radiograph findings
- 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
internal inflammatory resorption - pathogenesis
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
internal inflammatory resorption - likely cause
trauma
29
Internal inflammatory resorption more common in M/F?
Male
30
internal inflammatory resorption - tx
**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 ## Footnote possible haemorrhage
31
internal replacement resorption - diagnosis
no clinical indications incidental finding radiographically - trabecular pattern in pulp - ossified
32
Internal replacement resorption radiographic findings
- irregular **enlargement** of the pulp space - bone-like and extends into the dentin towards the cementum -resemble **cancellous bone (trabecular)**
33
internal replacement resorption - tx
``` 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
external surface resorption - clinical features
can be unrestored increased physiological mobility +ve to sensibility tests
35
external surface resorption - radiographic features
PDL space and lamina dura intact no obvious periapical radiolucency
36
external surface resorption - aetiology
* 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
external surface resorption - tx
pulp healthy - DON'T RCT remove the source to stop the resorption splint if mobile
38
external inflammatory resorption - clinical findings
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
external inflammatory resorption - radiographic findings
* **moth-eaten appearance** * loss of **lamina dura, PDL sapce** * radiolucency in the adjacent alveolar bone * periapical radiolucency * indistinct root surface * intact RC tramlines
40
external inflammatory resorption - aetiology
* 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
external inflammatory resorption - tx
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
External cervical resorption classification 2 types
- Heithersay 1999 - Patel 2016
43
external cervical resorption - clinical findings
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 ## Footnote normal or no mobility positive to sensitivity testing
44
external cervical resorption - radiographic findings
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
external cervical resorption - aetiology
- **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
Name of layer in predentine that protects pulp from resorption
Pericanalar Resorption Resistant Sheet (PRRS)
47
external cervical resorption - tx options
- 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
external cervical resorption - tx options - surgical repair
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
external cervical resorption - tx options - surgical repair and orthograde endo
1/3 pulp exposed/after pulp becomes necrotic | do endo first to avoid periapical radiolucency
50
external cervical/replacement resorption - healing?
``` v rarely does it cease and allow healing lesion has a trabecular pattern bone rather than ST the PDL is present no tx ```
51
which tooth more at risk of external cervical resorption
max canine > max incisor > mand molar
52
external replacement resorption - clinical findings
- infraoccluded - possibly erythematous - **high-pitched note** - ankylosed - no physiologicla mobility
53
external replacement resorption - radiographic findings
loss of obvious PDL cotton wool appearance root surface replaced by trabecular pattern - bone affects a lot of root surface
54
external replacement resorption - aetiology
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
external replacement resorption - tx options
- decoronation : growing pt - monitor + Incisal comp build up : non growing pt - endo will not stop resorption - no RCT
56
external replacement resorption - tx options - decoronation
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
external replacement resorption - why do you need to intervene early in a growing pt?
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
Which resorption to use : primary tx strategies for resorption - orthograde endo
external inflammatory | internal inflammatory
59
primary tx strategies for resorption - surgical endo
external cervical
60
primary tx strategies for resorption - no endo
external surface | external replacement
61
ECR - Heithersay 1999 classification
- 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
ECR - Patel 2016 classification
- 3 dimensional - 3 parts : apico-coronal / circumferential/ pulp involvement - eg. 2Bp

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