Endod Dent Traumatot 1997; 13; 75-81 Printed in Denmark .

Alt rights reserved

Copyright Munksgaard

1997

Endodontics & Dental Traumatology

ISSN 0109-2502

Prognosis of permanent teeth with internai resorption: a clinical review

^alikan MK, Tiirkun M. Prognosis of permanent teeth with internal resorption: a clinical review. Endod Dent Traumatol 1997; 13: 75-81. Munksgaard, 1997. Abstract - This study was performed in order to report the clinical features of internal resorption cases and evaluate their prognosis after endodontic treatment. Twenty-seven patients with 28 teeth with internal resorption were referred to our clinic and 20 teeth were treated endodontically. Sixteen teeth had non-perforating internal resorption and were treated by conventional root canal therapy. The remaining 4 teeth had perforating internal resorption and were initially treated by remineralization therapy with calcium hydroxide. The teeth treated by conventional root canal therapy showed clinical and radiographic e\ddence of healing. However, the remineralization therapy was successful in only one case. The three failed cases were subsequently treated by endodontic surgery. The surgical therapy was unsuccessful in one case due to extensive loss of marginal alveolar bone and increased tooth mobility. iVI. K. Qalii(an, M. Furkun
Department of Endodontics, Ege University, Bornova-izmir, Turkey

Key words: internal resorption; endodontic treatment M. Kemal Qalikan, Ege universitesi, Di Hekimligi Fakultesi, Bornova Kampusu 35100, izmir, Tijrkiye Accepted September 14, 1996

A case report on internal resorption was presented by Bell as early as in 1830 (1). Since then there have been numerous reports in the literature. Traditionally, internal resorption has been associated with a longstanding chronic inflammation in the pulp. The resorptive process is sustained by infection of necrotic pulp tissue in the root canal coronal to the area where

the resorption takes place (2). Trauma, caries and periodontal infections, iatrogenic procedures such as restorative preparation, improper restoration placement, calcium hydroxide procedures such as vital pulpotomy and pulp capping, vital root resections, orthodontics, bruxism, diathermy, anachoresis, and radioactive material are suggested as contributory fac-

Table 1. Details of the history and the first examination of the patients Frequency of code allocations Variables 1. Age 2. Sex 3. Number of teeth 4. Presumed etiology 5. Location of resorption 6. Perforation 7. Periradicular pathosis 8. Pain 9. Mobility 10. Discoloration 11. Percussion 12. Sinus tract 13. Vitality Coding key

0 11 17 13 12 4 20 14 18 20 15 20 21 12

(%)
(41) (63) (46) (43) (14) (71) (50) (64) (71) (54) (71) (75) (43)

1 1 10 7 7 17 8 14 10 3 6 8 7 16

(%) (4)
(37) (25) (25) (61) (29) (50) (36) (11) (21) (29) (25) (57)

(%)

(%)

0
24-30

1
3-35 women max.post.teeth carious lesion middle third present present

2
36-40 mand.ant.teeth carious-period.lesion coronal third

3
40 and over mand.post.teeth unknown crown

6 (22) 3 (11) 4 (14) 6 (21)

9 (33) 5 (18) 5 (18) 1 (4)

men
max.ant.teeth trauma apical third absent absent

no 5 (18 7 (25)
none none absent absent positive

yes
slight slight present present negative marked marked

75

Qaiii(an & riiricun

Table 2. Success of endodontic treatment in teeth with internal resorption Various endodontic treatments Root canal treatment Recalcification Surgical treatment* Number of teeth Failure

16 4 3

3 1

* All of the three surgically treated teeth were subjected to remineralization treatment prior to the surgical intervention.

tors by different researchers (3^11). It is believed that internal resorption may occur as an idiopathic distrophic change in cases of unrestored or non-carious teeth (12-14). Systemic diseases are not considered to be etiological factors of internal resorption (15). Internal resorption can be either transient or progressive (2, 16). It can affect one tooth or many teeth. Incisors show the highest incidence (9, 17). According to Gorlin & Goldman (16), its occurrence is more common in men than women in the fourth and fifth decades of life and most frequently occurs in the middle or apical third of the root. Internal resorption is usually asymptomatic and first recognized clinically through routine full mouth radiographs. Pain may occur depending on the pulpal condition or perforation of the root resulting in a periodontal lesion (8, 9). When the resorption in the

crown reaches the enamel, the patient may notice a pink spot (5, 9). The devastation rate of internal resorption may be rapid or slow (9, 15). Spontaneous repair is extremely rare (18-20). Therefore, "a wait and see" approach is not appropriate. Prompt endodontic treatment is recommended in all diagnosed cases, because removal of pulp tissue halts the process (4, 9). Prevention of internal resorption can, to a certain degree, be accomplished by careful observation of teeth following traumatic injuries (5). Most of our knowledge of internal resorption derives from observations on individual cases (3, 7, 12, 21, 22). The aim of this study was to describe clinical findings in internal resorption cases and evaluate the prognosis of endodontic treatment of teeth with internal resorption. iVIateriai and methods The study included 28 teeth with internal resorption of 27 patients who attended the Department of Endodontics, School of Dentistry, Ege University between 1980 and 1993. Supplemental radiographs were taken from different angles in order to make a definitive diagnosis and to examine the extent of tooth destruction. Details of the history and first examinations

M
Fig. I. A. Preoperative radiograph oi mandibular left lateral incisor with non-perforating internal resorption and large periapical lesion. B. Follow-up 2 years after completion of endodontic treatment. Decrease of periapical lesion is evident.

76

Internal resorption

Fig. 2. A. Preoperative radiograph of maxillar)' right lateral incisor with non-perforating internal resorption and periapicai lesion. B. Radiograph taken at follow-up examination 4 years after endodontic treatment. Complete healing of periapicai lesion is evident.

in each case were noted. Age and sex of the patient, number of teeth, possible etiology^, location of internal resorption lacuna, presence or absence of root perforation, periradicular radiolucency, pain, mobility and discoloration of the crown, tenderness to percussion, sinus tract and response to an electric pulp tester were recorded (Table 1). The patients' medical histories were non-contributory. Two patients with 3 teeth did not accept endodontic therapy since their teeth were asymptomatic. Five teeth were planned to be extracted due to extensive root destruction or intra-or periradicular lesions. The remaining 20 teeth were treated endodontieally by the same operator using a standardized technique. After local anaesthetic infiltration, except for necrotic teeth, a standard endodontic access cavity was prepared under rubber dam isolation. The working length was established at 1 mm short of the radiographic apex, and the root canal preparation was accomplished using 2.5% sodium hypochlorite irrigation and hand instrumentation. In vital teeth, considerable bleeding was encountered from the root canal. Irrigation with 2.5% sodium hypochlorite and saline solution aided in controling the bleeding. After the completion of the chemo-mechanical root canal preparation, the canals were finally irrigated with 10

ml 2.5% sodium hypochlorite solution, dried with sterile paper points, and filled with calcium hydroxide paste (calcium hydroxide and barium sulfate powder (Merck, Darmstadt, Germany) in ratio of 8:1 mixed with glycerine as a medium) by means of a lentulo spiral filler in a slow-speed handpiece and packed with the blunted end of a paper point. In non-perforating cases of internal resorption, the calcium hydroxide paste was removed one week after its placement and the apical portion of the root canal was obturated using gutta-percha (Hygenic, Akron, OH, USA) and Calcibiotic Root Canal Sealer (Hygenic) as a sealer by a single cone technique. The resorption space was filled with gutta-percha and sealer by vertical and thermatic condensation via the coronal access cavity. In perforating cases of internal resorption , the calcium hydroxide paste was changed 3 weeks after the initial treatment and the paste was checked and replaced again two or three times at 3-month intervals. If a fistulous tract was present, calcium hydroxide paste was expressed through the fistula. When the remineralization treatment was found to be successful, the calcium hydroxide paste was replaced with a permanent root canal filling using gutta-percha and sealer as described above. 77

Qalikan & Fiirkun

Fig. 3. A. Preoperative radiograph of maxillary left lateral incisor with non-perforating internal resorption. B. Radiograph taken immediately after the obturation of the root canal. C. Radiograph taken at follow-up examination 3 years after connpletion of endodontic treatment. Periapicai bone pattern was norrnal.

78

Internal resorption

Fig. 4. A. Periapicai radiograph of maxillary^ left central incisor with a perforation at the buccal surface of a root caused by internal resorption. B. Follow-up 4 years after completion of remineralization treatment with calcitim hydroxide and prosthetic restoration. Buccal perforation was healed and periapicai bone pattern is normal.

A surgical approach was required in 3 cases where the remineralization treatment was not successful. The root canal obturation was completed before the surgical intervention. A triangular buccal or lingual flap was raised to reveal the perforation area. Removal of the granulation tissue allowed the exposure of the resorption lacuna. This lacuna was filled with zinc-free amalgam (Standalloy F, Degussa, Frankfurt, Germany). The operation site was thoroughly rinsed with saline solution and the flap was replaced and sutured. The patients were examined clinically and radiographically 3 months after the treatment and thereafter at 3- or 6-month intervals for up to 1 year and then at longer inter\'als. The observation period varied from 2 to 4 years. The treatment was considered to be successful if the following criteria were met: absence of clinical symptoms, absence of periradicular lesions, disappearance or decrease in size of pre-existing periradicular radiolueeneies, presence of calcific barrier at the site of perforative defects, and absence of abnormal mobility and sinus tracts.

Results Of the 27 patients, 17 were men (63%) and 10 were women (37%). Trauma (43%) was the most common etiologieal factor, followed by carious lesions (25%). Maxillary anterior teeth showed the highest percentage of involved teeth (46%). The most frequent location of internal resorption was the middle third of the root (61%) (Table 1). Clinical examinations carried out between 2 and 4 years after the root canal therapy revealed that all cases with non-perforating internal resorption (16 cases) were asymptomatic. Of the 7 teeth with periapicai lesions, resolution of the lesions was observ'ed radiographically at the 6- or 12-month recall examinations (Fig. lA, B; 2A, B). The remaining 9 teeth without periapicai lesions showed radiographically normal periapicai bone patterns (Fig. 3A" C). Of the 4 teeth with perforating internal resorption exposed to remineralization treatment with calcium hydroxide, only one tooth with the perforation was on the buccal surface of a root, showed clinical and 79

& rurkun

Fig. 5. A. Preoperativc radiograph showing lingual perforating internal resorption associated with mandibular right second pretnolar. Recalcification treatment with calcium hydroxide failed. B. Radiograph taken during the obturation of the apical portion using gutta-percha and sealer by a single cone technicjue. Note the margins of resolution space. C. Radiograph taken after completion of the filling of the resorption space with gutta-percha and sealer by vertical and thermatic condensation. D. Radiograph taken at follow-up examination 3 years after eompletion of surgical endodontic treatment. No evidence of periradicular pathology.

radiographic evidence of healing (Fig. 4A, B). The draining sinus tract closed after the initial calcium hydroxide application. At the 9-month recall examination, a calcified barrier could be detected and the calcium hydroxide paste was dr^,. The process of healing was followed both elinically and radiographically at subsequent recall appointments as well as after the completion of the endodontic treatment. The 3 teeth that did not respond to recalcification treatment were later treated by endodontic surgery. Two of these teeth remained asymptomatic and no radiographic changes were evident at the follow-up examinations (Fig. 5A-D). However, these teeth showed increasing gingival probing depths and loss of marginal alveolar bone to the apical level of the restoration of the resorption lacuna. The surgical therapy was found to be unsuccessful in one tooth due to extensive loss of marginal alveolar bone and severe tooth mobility. This tooth was extracted. 80

Discussion

This study did not aim to analyze the prevalence of teeth with internal resoiption statistically because it was felt that the number of cases was inadequate. However, our clinical findings that it was more frequent in males, that the most affected teeth were the maxillary incisors, and that it occurred most frequently in the middle third of the root corroborated the findings of earlier reports (9, 10). Kerr et al. (23) claim that occurrence of internal resorption is most frequently seen in women in the second and third decades of life. In the present study, it was more common in persons in their twenties. Also, trauma was the most common contributory factor which causes the internal resorption via the infection of necrotic pulp. This finding also agrees with previous reports (3, 6, 9). Treatment of internal resorption is quite predict-

Internal resorption able. Root canal therapy will interrupt the resorptive process. If the resorptive defect does not perforate the canal wall, root canal therapy should be the choice of treatment. In teeth with perforating defects, remineralization of the defect may occur following calcium hydroxide treatment, but often a surgical approach will be necessary, and some eases may require extraction (8, 9, 21). In the present study, different examples related to all these treatment approaehes were included. Conventional root canal therapy resulted in a high degree of success in the treatment of non-perforating internal resorption, which was in accordance with previously reported results (3, 7, 12). The prognosis of remineralization of root perforations is poor (8). Multiple appointments in which repeated applications of calcium hydroxide for a long period of time are required in order to create hard tissue closure of root perforations (24). Of the 4 teeth with perforating internal resorption which were treated with calcium hydroxide, in spite of repeated application, 3 teeth failed. A possible explanation for the failure is the presenee of periodontal pocket even though, clinically, a pocket could not be probed. The periodontal pocket causes the communication of perforation with oral fluids and washing out of the calcium hydroxyde, because the perforation is coronal to the epithelial attachment. When these teeth were treated surgically, increasing gingival probing depths and loss of marginal alveolar bone were obser\'ed, but they were symptomless and in function except for one case.
the dental pulp. In; WEINE FS, ed. Fndodontic therapy. 4th ed. St. Louis; CV Mosby, 1989; 150. BAKLAND L K . Root resoqation. In; HOVLAND E J , ed. The Dental Climes of North America Fndodontics. Philadelphia; WB Saunders Co. 1992; 36(2): 491-507. RABINOVVTTCH B Z . Internal resorption. Oral Surg Oral Med Oral Pathol 1972; 33: 263-82. MANDOR R B . A tooth with internal resorption treated with a hydrophylic plastic material; a case report. J Fndod 1981; 7: 430-2. WEBBER RT. Traumatie injuries and the expanded endodontic role of calcium hydroxide. In; GERSTEIN H , ed. Teelmique.s in elinieal endodonties. Philadelphia; Saunders Co, 1983; 181-4. CHIVIAN N . Root resorption. In; COHEN S, BURNS RC, eds. Pathways of the pulp. 3rd ed. St. Louis; C \ ' Mosby, 1984; 54384. CoRLiN J K , CoLDMAN MH. Thoma's oral pathology: Volume 1. St. Louis; CV Mosby, 1970; 210-2. PENIDO R S , CARREL R , CHIALASTRI A]. The anachoretic effect in root resorption; report of a case. J Pedod 1980; 5: 85-9. SAMIMY B . Idiopathic internal resorption - a case report. J Br Fndod Soe 1978; //. 11-2. L\T^GH EJ, AHLBERG KR Bilateral idiopathic tooth resorption of upper first premolars. Int Fndod J 1984; 17: 218 20. BROOKS K J . An unusual case of idiopathic internal resolution beginning in an unerupted permanent tooth. J Fndod 1986; 12: 309-11. BROWTJ CE. A case indicative of rapid, destructive internal resorption. J ^H^fo^ 1987; 19: 516-8. W^EDENBERG C, LiNDSKOG S. Experimental internal resorption in monkey teeth. Fndod Dent Traumatol 1985; /.- 221-7. GouLTSCHN J, NiTZAN D, .\zAZ B. Root resorption - review and discussion. Oral Surg Oral Med Oral Pathol 1982; 54: 58691. WEISMAN M I , RAGKLEY R H . Recalcification of internal resorption. A rare case. J Ga Dent Assoe 1968; 41: 15. HARTNESS DJ. Fraetured root with internal resorption repair and formation of callus. J 'n//o(/ 1975; /. 73-5. QALIKAN M K , PIKIN B . Internal resorption occurring after accidental extrusion of iodoform paste into the mandibular canal. Fndod Dent Traumatol 1993; 9: 81-4. FRANK AL, WEINE FS. Nonsurgical therapy for the perforative defect of internal resorption. J .4m Dent Assoc 1973; 87: 863-8. QALIK.AN MK, TURKUN M . Root canal treatment of a rootfractured incisor tooth with internal resorption; a case report. Int Fndod J 1996 (In press). KERR DA, COURTNEY RM, BI^RKES EJ. Multiple idiopathic root resorption. Oral Surg Oral Med Oral Pcithol 1970; 29: 55263. E L DEBB ME, EL DEBB M , TABIBI A, JENSEN JR. An evaluation of the use of amalgam, ca\it, and calcium hydroxide in the repair of furcation perforations. J''?Z(/ort' 1982; 8: 459-60.

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