Generealized cervical resorption case present

Case conference
Boondarick Niyatiwatchanchai,DDS

Patient History
ผู้ป่วยหญิงไทยอายุ 31
ปี
อาชีพ ผู้ช่วยทันตแพทย์
ปฎิเสธการมีโรคประจำ
ตัวและการแพ้ยา
อาการสำคัญ
ถูกส่งตัวมาจากคลินิก
เพื่ออุดฟันหน้าล่างที่พบ
รอยโรคจากภาพรังสี

Dental history and
present illness
ผู้ป่วยรู้สึกว่าฟันหน้ามีลักษณะสั้นลงในช่วงเวลา 1 ปี
ที่ผ่านมา และพบฟันผุบริเวณคอฟันของฟันหน้าล่าง
จากฟิล์ม x-ray จึงได้รับคำแนะนำให้มารักษาที่
คณะทันตแพทยศาสตร์ จุฬาลงกรณ์มหาวิทยาลัย

ไม่พบ 11,21,25 ในช่องปาก

ไม่พบฟันซี่ 36,37
ในช่องปาก

Radiographic
finding
พบรอยโรคโปร่งรังสีที่บริเวณคอฟัน ฟันซี่
12MD,13M,22MD,23M,31MD,32MD,33MD,
41MD,42MD,43MD,34MD,35MD,36MD,
48M

Differential
diagnosis
dental caries
root resorption

dental caries
after radiation multiple invasive
cervical resorption
Eisbruch, A., Ten Haken, R.K., Kim, H.M., Marsh, L.H., Ship, J.A. (1999) Dose, volume, and
function relationships in parotid salivary glands following conformal and intensity-modulated
irradiation of head and neck cancer. Int J Radiation Oncol Biol Phys, 45, 577-587

ซักประวัติและตรวจเพิ่มเติม
ไม่เคยได้รับการฉายรังสี
ไม่เคยประสบอุบัติเหตุ
ไม่เคยจัดฟัน
ไม่เคยฟอกสีฟัน
ไม่เคยเจ็บป่วยรุนแรงจนต้องนอนโรงพยาบาล
เท่าที่ทราบบุคคลในครอบครัวไม่เคยมีอาการเช่นเดียวกัน
EPT : 31= 33 , 32=40 , 33=35 , 41=30 , 42=33 ,43=33

Radiologist
consultation
ลักษณะรอยโรคไม่เหมือนกับโรคฟันผุ แต่มีลักษณะ
คล้ายกับการ resorption เนื่องมาจากการเห็น
ขอบเขตที่ชัด และตำแหน่งของการเกิดโรค
impression for multiple cervical
resorption

tooth resorption
- the loss of hard dental tissue (i.e. cementum and dentin)
as a result of odontoclastic action.
- classified by its location in relation to the root surface
- may be physiological and pathological
- External resorption can be divided into three broad
groups:
(a) trauma-induced tooth resorption
(b) infection-induced tooth resorption
(c) hyperplastic invasive tooth resorption
Heithersay,2007

hyperplastic invasive
tooth resorption
!
insidious in nature and generally present complex therapeutic
challenges
resorbing tissue invades the hard tissues of the tooth in a
destructive, and apparently uncontrolled fashion,
akin to the nature of some fibro-osseous lesions such as fibrous
dysplasia.
An important distinguishing factor for this third group of
resorptions is that, unlike the first two types of resorption, simple
elimination of the cause of the lesion is ineffective in arresting
their progress
Heithersay,2007

tooth resorption
Total removal or inactivation of the
resorptive tissue is essential
The reason for recurrence or concurrence is
probably due to the invasive nature of the
resorptive tissue whereby small infiltrative
channels are created within the dentine and
these may interconnect with the
periodontal ligament
Heithersay,2007

tooth resorption
pulpal origin or periodontal origin
may be subdivided into
internal replacement (invasive) resorption
invasive coronal resorption
invasive cervical resorption
invasive radicular resorption.
Heithersay,2007

Cervical external
resorption
Invasive cervical resorption is not a
common occurrence, is insidious and often
an aggressive form of external tooth
resorption, and can occur in any tooth in
the permanent dentition.
Heithersay,2007

In the absence of treatment, invasive
cervical resorption leads to progressive and
usually destructive replacement of tooth
structure.
pinkish colour in the tooth crown
may be no obvious outward sign
its detection may be by routine radiographs.
usually painless unless there is superimposed
secondary infection when pulpal or
periodontal symptoms may arise.
Heithersay,2007

results in the loss of cementum and dentine
by an odontoclastic type of action.
begins just apical of the epithelial
attachment of the gingiva at the cervical area
of the tooth but can be found anywhere on
the root.
ICR is still not clearly understood.
Heithersay,2007

Diagnosis
!
usually found at cervical region
pink spot in the cervical region
hard and mineralised on probing
EPT usually positive
usually no symptoms
outline of root canal should be visible and intact
cone beam CT is useful to assess the lesion
Heithersay,2007

Etiology and
pathogenesis
Microscopic analysis of the cervical region of teeth
has shown that there appear to be frequent gaps in the
cementum in this area, leaving the underlying mineralised
dentine exposed and vulnerable to osteoclastic root
resorption.
Heithersay,2007

Etiology and
pathogenesis
damage or deficiency of the protective
layer of cementum apical to the
gingival epithelial attachment exposes
the root surface to osteoclasts, which
then resorbs the dentine.
Heithersay,2007

Histopathology
similar to any other inflammatory root resorption
resorption cavity contained granulomatous
fibrovascular tissue
Thin layer of predentin is always present
free of acute inflammatory
Clasting resorbing cells and Howship’s lacunae
In advanced lesion ectopic calcification may be
observed
Patel,2009

3 Conditions
blood supply, breakdown or absence of the
protective layer, and a stimulus
In the case of ICR, the external protective
layer is the cementum, and the internal layer is
the predentine of the pulp.
Heithersay,2007

Protective layer
The exposure of pulp is prevented by
the predentin layer
predentin contains an anti-invasion
factor and resorption inhibitor
Shilpa ,2013

Predisposing factor
Physical
-orthodontic treatment
—segmental orthonathic surgery
-transplant teeth
-bruxism
-guided tissue regeneration
Chemical agents
-intracoronal bleaching
-secondary bone grafting in
unilateral complete cleft palate patient
-tetracycline conditioning of root
Heithersay GS. Invasive cervical resorption:
An analysis of potential predisposing factors.
Quint Int 1999;30(2):83-95.

classification
Class 1: Small invasive resorptive
lesion with shallow penetration into
dentine.
_Class 2: Well-defined invasive
resorptive lesion close to the
coronal pulp chamber.
_Class 3: Deeper invasion extending
into the coronal third of radicular
dentine.
_Class 4: A large invasive lesion
extending beyond the coronal third
of the root.
Heithersay,1999

Traditional method
of treatment
!
Curetting the active tissue from the
resorption cavity and restoring the defect
with a suitable restorative material.
Heithersay GS. Treatment of invasive cervical resorption: an analysis of results using topical application of trichloracetic acid,
curettage, and restoration. Quintessence Int 1999:30;96-110.

Alternative
treatment method
the topical application of 90%
aqueous trichloracetic acid,
curettage and restoration, has been
outlined and clinically assessed

trichloracetic acid
(TCA)
is an analogue of acetic acid , It is
widely used in biochemistry for the
precipitation of macromolecules, such
as proteins, DNA, and RNA.
used for cosmetic treatments, such as
chemical peels, tattoo removal, and the
treatment of warts, including genital
warts. It can kill normal cells as well.

One advantage of this approach
is haemorrhage control
As the effect of trichloroacetic
acid is to cause coagulation
necrosis, the resorptive tissue is
rendered avascular.

Monsel’s solution
another option in case that TCA is
not available
a 72% solution of ferric sulphate
with sulphuric acid
John J,2012

Consideration
in bonding
Dentin that has been treated with TCA is
severely demineralized and is not suitable
for bonding with either dentin-bonding
agents or glass ionomer materials. It must be
‘‘refreshed’’ with a bur before bonding
procedures
Schwartz,2010

Multiple invasive
cervical resorption
First reported by Mueller and Rony
in 1930
since then numerous other cases
have been documented where none
of the common initiating factors
appears to have been involved
Liang,

Multiple invasive
cervical resorption

Although mICR is rare in humans, a
similar disease known as feline
odontoclastic resorptive lesions
(FORL) is common in cats.
FORL has been associated with feline
viruses
all patients reported having had direct
(2 cases) or indirect (2 cases) contact

blood samples were taken from all patients
for neutralization testing of feline herpes virus
type 1 (FeHV-1).
Indeed, the sera obtained were able to
neutralize (2 cases) or partly inhibit (2 cases)
replication of FeHV-1, indicating transmission
of feline viruses to humans.
Thomas , 2012

The patient was questioned about
possible contact with cats.
She confirmed that she lives
with several cats and reported that
one (a 6-year-old female) had had
severe drooling, and that 2 teeth
had had to be removed by the
veterinarian in April 2008.
The veterinarian was contacted
by telephone and confirmed that
both teeth had presented with neck
lesions, presumably feline
odontoclastic resorptive lesions
Thomas , 2012

Case report
A 36-year-old woman presented with pain in
her maxillary left canine and first premolar
that had persisted for 15 day
!
!!

Patient history
The patient’s history failed to reveal any incidence of
trauma, orthodontic treatment,bleaching,periodontal
treatment or other relevant information.
!
There was no family history of any similar condition,
and she had no pets or any contact with cats.
!

Further investigate
Relevant ionic(calcium and phosphorus) ,
enzymatic(alkaline phosphatase) and endocrine
investigation (T3,T4 and parathyroid hormone) report
were normal
A diagnosis of multiple idiopathic cervical resorption
was made

Treatment
Endodontic treatment for the canine and
second premolar, followed by surgical
exposure and restoration for the canine,
second premolar, and first molar, was
planned.

treatment plan
consult oral medicine for further investigation
and rule out the systemic disease
consult periodontist for periodontal surgery
consult endodontist for TCA application and
root canal therapy if need
consult radiology for cone beam CT
consult occlusion to assessment the occlusion
abnormally

Endodontic
treatment
Endodontic treatment might be necessary with some
class 2 and usually class 3 lesions when pulpal
involvement has occurred or is very close to occurring.

The use of RMGI
The use of adhesive restorative materials has
been proved a biocompatible alternative for
restoration of deep lesion or cervical abrasion
prior to surgical root coverage.
The response of periodontal tissue to adhesive
restorative materials has been studied by a
number of investigators

Konradsson and Van Dijken,analyzed interleukin-1
levels in the gingival crevicular fluid adjacent to
subgingival restorations of resin modified glass
ionomer cement and concluded that the restorations
did not alter gingival health nor did they significantly
affect interleukin-1 levels or induce gingival
inflammation
!
Martins et al, analyzed the histological response of
periodontal tissues to subgingival class V resin-modified
glass ionomer cement restorations and
observed biocompatibility of tested restorative
materials.

treatment plan
Periodontal surgery , TCA ,
curettage , restoration with
RMGI wih/without endodontic
treatment
do nothing

Prognosis
smaller lesions offer the most
favorable long-term outcome.
Heithersay has reported a 100%
success rate in the treatment of class
I and II ECR lesions The success
rate in class 3 lesions was 77.8% and
only 12.5% of teeth in class 4 cases.
Heithersay,1999

Generealized cervical resorption case present

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Generealized cervical resorption case present