·Idiopathic Cervical Resorption: A Diagnostic...
Transcript of ·Idiopathic Cervical Resorption: A Diagnostic...
Aparna Aggarwal
Manoj Vengal, AuswafAhsan and Keerthilatha M Pai
·Idiopathic Cervical Resorption: A Diagnostic Di-lemma Abstract: Idiopathic cervical resorption is a rare form of external resorption, usually with no external signs, and can be misdiagnosed as
dental caries or other types of tooth resorption. Here we report a case in which, during routine radiography, an asymptomatic lower rig hr molar presented with a radiolucPncy at the cervical region, with no obvious aetiologic factor identified.
Clinical Relevance: This paper emphasizes the aetiopathogenesis and differential diagnosis of this rare and asymptomatic form of
pathologic resorption, which can be encountered in dental practice.
Dent Update 2007; 34: 646-648
Case report
A 22-year-old female, final
year engineering student reported with
a complaint of repeated food lodgement in relation to her partly erupted lower left
third molar for the past 5 months. This was
associated with discomfort in the form of a continuous, pricking type of non
radiating pain, which was relieved only on
removal of the lodged food particles. Her
medical history and family history were
non-contributory and she reported having
undergone scaling of her teeth one year
previously.
molar and lower right third molar were
partially erupted, with food debris beneath
the pericoronal soft tissue on the lower left
third molar with minimal inflammation. No
other abnormalities were evident on the
clinical examination.
Intra-oral periapical radiographs
(IOPAs) of the lower third molars werP taken to assess their eruption status. Radiograph1
revealed horizontal impaction of the
lower left third molar and mesioangular
impaction of the lower right third molar. An
Intra-oral examination revealed
satisfactory oral hygiene, dental and
gingival condition. Her lower left.third
Aparna Aggarwal, BOS, MOS, Associate Professor, Department of Oral Medicine
and Radiology, Manoj Vengal, BOS,
MOS, Associate Professor, Department
of Oral Medicine and Radiology, Auswaf Ahsan, BOS, MOS, Associate Professor, Department of Oral Medicine and
Radiology, Keerthilatha M Pai, BOS, MOS, Professor and Head, Department of Oral
Medicine and Radiology, MCODS, Manipal, India.
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Figure l. IOPA of lower right first molar showing a radiolucent defect along the cervical region (see black arrows).
December 2007
Figure 2. Panoramic radiogra ph showing localized area of cervical resorption with respect to lower right
first molar (see black arrows).
periapical or periodontal inflammation,
herpes zoster infection, dental trauma,
cyst, tumour, and excessive mechanical
or occlusal forces.' Pathologic resorption
can be either external or internal. External
resorption can be either the inflammatory
or replacement type.'
ICR is considered as a type of external inflammatory resorption,' which
was first reported by Mueller and Rony as
mentioned by Liang et a/.' ICR is a process
whereby an unprotected, locally destroyed
or altered root surface becomes susceptible
to resorbing elastic cells during an
inflammatory response of the periodontal
ligament (PDL) to a 'stimulus' and a bowl
shaped invasion of cementum and dentine
in the cervical region of a root by resorptive
fibrovascular tissue.'·'.. It has been
suggested that the potential for resorption
is inherent within the periodontal tissues of
each patient, based mainly upon the tooth morphology (dentine defects at cemento
enamel junction);'" individual susceptibility
to resorption being the most important • /OPA for the lower right third molar showed
IS an unusual irregular radiolucency extending •r. • along the cervical region of the lower right
first molar from the mesial to the distal
aspect, separating the crown from the roots
and shifting it slightly distally (Figure 1 ).
Lamina dura of the mesial root seemed to
be slightly thickened, but that of the distal
root was disrupted. The only discernible
outline was that of the mesial root canal.
Radiographic artefacts were
out, and a panoramic radiograph
(Figure 2) cancelled out the possibility of
multiple teeth involvement.To eliminate any
factors, a detailed history of
t trauma, orthodontic treatment, bleaching aggressive periodontal
discomfort on chewing from the
. right side, sensitivity, and pain in relation to
lower right first molar was obtained but
was non-contributory.
The patient was clinically re
examined to exclude cervical abrasion,
root caries, radiolucent restoration, crown
racture or pathologic resorption. The
ingiva in relation to the lower right first
olar was non-inflamed, non-tender and
adherent, with a periodonial pth� 2-
3-mmmfall fhe tooth surfaces. mobility
or cavitations were detected
and there was no tenderness on percussion
change in the normal resonant sound.
Electric pulp testing showed slightly
delayed response.
Considering the above
mentioned facts, the only possibility that
could not be ruled out was of a pathologic
resorption, which might have been initiated
by periodontal tissue trauma during
oral prophylaxis done a year previously.
However, as the panoramic radiograph
showed good generalized bone levels, it
was unlikely that any aggressive periodontal
treatment was carried out. As the lesion
was typically at the cervical region and no
factor could be contributed to its cause, a
diagnosis of'idiopathic cervical resorption'
(ICR) was made. In view of the extensive
nature of the lesion and poor long term
prognosis, extraction was advised. But, as
the tooth was asymptomatic, the patient
did not give her consent for the same.
Follow-up after 3 months was advised, but
the patient relocated after completing her
college education and was lost to follow-up.
Discussion
Tooth resorption i_s a
multifactorial process.' Resorption can be • Physiologic, which is associated with
shedding of the primary teeth; or
• Pathologic, which can be due to chronic
factor.• Pre-dentine possesses resistance
to resorption owing to its organic phase,
which contains an enzyme inhibitor against
resorption.' But, in the case discussed, it was
considered to be of the replacement type,
as for inflammation to occur there should
have been an exposure of resorptive lesion
to the oral cavity.
Although knowledge of
the exact mechanism causing cervical
resorption is limited, factots implicated in
the aetiology are trauma, bleaching with
hydrogen peroxide,'0 periodontal treatment,
orthodontic treatment, dento-alveolar or
orthognathic surgery, idiopathic, etc.1.J·'·"·"
Generalized cervical resorption has been
reported in a patient with periodontal
disease and maintaining a high acidic
diet-" It has also been associated with
many systemic disorders, like hereditary
haemorrhagic telangiectasia,"and
endocrine disorders, as is a known fact
that periodontal tissues are sensitive to
hormonal fluctuations.• Multiple ICR has
been observed in young females.• In this
case, only a single tooth was involved,
whereas in systemic problems, usually
multiple teeth would be involved. Studies
have identified deep scaling and root
planing as a major potential predisposing
factor.'
/CR is a relatively uncommon
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condition with no external-Signs and radiographic examination.
Coyle M, Toner M, Barry H. Multiple
observed as an incidental finding on The management of ICR is teeth showing invasive cervical
a routine radiograph, as in this case.• based on many factors: resorption - an entity with little
It usually preserves a layer of dentine • Identification and elimination of the known histologic features. J Oral immediately around the pulp, whereas known accelerating factors.' Pathol Med 2006; 35: 55-57.
internal resorption starts from the In case gingival tissue inflammation is the Rodd HD, Naik S, Craig GT. Exterrial
pulp and extends towards the external cause, periodontal care (debridement of cervical resorption of a primary canine. surface.' The radio-opaque layer around plaque and calculus) and mainteriance is Int J Paediat Dent 2005; 15: 375-379.
the pulp helps in differentiating external indicated.' Periodontal curettage done 8. Neville BW, Damm DD, Allen CM,
from internal resorption.' ICR may alone has led to failures.• Bouquot JE. Oral and Maxillofacial
involve a single tooth, multiple teeth or: • Knowledge of the prognosis for success Pathology. Pennsylvania: Elsevier
rarely, the entire dentition.' It is slightly of specific treatment regimen." (Saunders). 2004.
more prevalent in lower teeth than in • Complete removal of the fibrovascular Berg mans L, Cleynenbreuge JV,
the upper teeth and primarily involves tissue and restoration of the lost tooth Verbeken E, Wevers M, Meerbeek BV,
central incisors, followed by canines structure.' Lambrechts P. Cervical external
and premolars.' Deciduous dentition • The extent of involvement. root resorption in vital teeth.JC/in
involvement has been reported in only Periodontol 2002; 29: 580-585.
two cases so far.' Clinically, even after a 10. Tredwin CJ, Naik S, Lewis NJ, Scully C. considerable loss of the tooth structure, Conclusion Hydrogen peroxide tooth-whitening
the tooth in question is frequently firm in ICR, although a rare occurrence, (bleaching) products: review of the dental arch.' On probing, the exposed poses a diagnostic challenge and may be adverse effects and safety issues.
dentine is hard, which distinguishes it from difficult to treat for the dental practitioner. Br Dent J 2006; 200: 371-376.
caries;' the vascular tissue may bleed on 11. Heithersay GS. Clinical, radiologic, and
probing.' Electric and thermal pulp tests
remain positive till the later stages.'
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