Conversation With an Orthodontist.
Dentists, Resorption January 10th, 2007
She: Thanks for returning my call.
Me: No problem, how are you?
She: Good thanks. I wanted to ask you; remember that girl that I recently sent you with the internal resorption?
Me: Yeah, but I diagnosed it as invasive cervical resorption which isn’t really internal resorption. I sent you a report.
She: Yeah well after you worked on the tooth to try to save it and found that the internal resorption was too extensive I called her Mom.
Me: Uh huh.
She: Mom was very cool..ish.
Me: As in cold?
She: Well yeah. I got the sense while talking to her that someone had told her that the orthodontic treatment was responsible for the internal resorption.
Me: I’m pretty sure it wasn’t internal resorption. Internal resorption is a pulpal phenomenon, external resorption can become very invasive and sometimes resemble internal cervical resorption, but is actually an issue with periodontal cells.
She: Yeah, well I spoke to the oral radiologist that I know that works cases with me and I asked her if internal resorption can be caused by ortho and she said absolutely not.
Me: Well she’s probably right. External resorption, on the other hand, happens when osteoclasts get a little confused. Trauma and internal bleaching can do this. Ortho is controlled trauma, so it stands to reason that it could be responsible for cervical resorption.
She: Well in my 30 years of doing Ortho the only two cases of internal resorption I’ve seen have happened in the last year and I’ve sent both to you. Neither of them appear to be related to Ortho (the first one existed prior to my treatment) and the radiologist says that the second one isn’t related.
Editor’s note: The first case was diagnosed by the same radiologist as dens-in-dente. I confirmed this once I saw the patient and recommended no treatment. The second patient has been in retention for the last couple of years, the orthodontist didn’t see any problems with her teeth on a recent check, but a scheduled recall at the girl’s GP a short time after turned up a pretty bad case of pink tooth. The dentist really scared the girl and her mom about how the tooth would be lost, blah, blah. The upset mom called the orthodontist who then called me to give me the heads up and the referral. Turned out that the prognosis of the tooth was poor to hopeless.
Me: Well I told the Mom that these resorptive defects are often idiopathic, but orthodontics can be implicated in some of them. They happen rarely enough that their development is unpredictable however. I implied no negligence. I don’t know if her dentist did, however.
She: Ok, well, I just wanted to find out who told the Mom that the orthodontics caused the problem.
Me: Sounds like you’re worried she wants something?
She: No I’m not worried, I just don’t like people assigning guilt.
Me: Me neither. I’m not in that business, and doing that hurts my business. You know that, you get your patients from the same sources.
She: I’m sending the Mom a letter that shows the results of my research. I wasn’t able to find any implication between orthodontics and internal resorption. And I quote the radiologist as saying there’s no connection.
Me: Don’t you think that doing all of that makes it look like you’re worried about something?
She: No I asked the Mom if she wanted more information on resorption and she said yes.
Me: Ok then.
She: It’s really too bad so many of us have to boost our egos by blaming others for this and that. Don’t you think?
Me: Yup.
Editor’s note: Ok, I’m getting a little worked up now cuz she’s been wasting my time for the last 10 minutes and I’ve got lots of other people to blame for things.
She: Yeah, you know, when her mom told me that she was told that ortho could have caused the problem, I went to the library and looked and looked for that connection.
Me: Uh huh. Well anyway, seems like things are working out for you. I’ve told the family to speak to their dentist about replacement options for the tooth.
She: Ok then. Talk to you later.
Editor’s Note: I hope not.
Do you think it was bad of me to have faxed the following to her the next morning?
Invasive cervical resorption: an analysis of potential predisposing factors.Heithersay GS.
Department of Dentistry, University of Adelaide, Australia.
OBJECTIVE: An investigation was undertaken to assess potential predisposing factors to invasive cervical resorption.
METHOD AND MATERIALS: A group of 222 patients with a total of 257 teeth displaying varying degrees of invasive cervical resorption were analyzed. Potential predisposing factors, including trauma, intracoronal bleaching, surgery, orthodontics, periodontal root scaling or planing, bruxism, delayed eruption, developmental defects, and restorations were assessed from the patients’ history and oral examination.
RESULTS: Of the potential predisposing factors identified, orthodontics was the most common sole factor, constituting 21.2% of patients and 24.1% of teeth examined. Other factors were present in an additional 5.0% of orthodontically treated patients (4.3% of teeth), and these consisted principally of trauma and/or intracoronal bleaching. Trauma was the second most frequent sole factor (14.0% of patients and 15.1% of teeth). Trauma in combination with intracoronal bleaching, orthodontics, or delayed eruption constituted an additional 11.2% of patients (10.6% of teeth). Intracoronal bleaching was found to be the sole potential predisposing factor in 4.5% of patients and 3.9% of teeth, and an additional 10.4% of patients and 9.7% of teeth showed a combination of intracoronal bleaching with trauma and/or orthodontics. Surgery, particularly involving the cementoenamel junction area, was a sole potential predisposing factor in 6.3% of patients and 5.4% of teeth. Periodontal therapy, including deep root scaling and planing, showed a low incidence, as did other factors, such as bruxism and developmental defects. The presence of an intracoronal restoration was the only identifiable factor in 15.3% of patients and 14.4% of teeth, while 15.0% of patients and 16.4% of teeth showed no identifiable potential pedisposing factors.
CONCLUSION: These results indicated a strong association between invasive cervical resorption and orthodontic treatment, trauma, and intracoronal bleaching, either alone or in combination.
Quintessence Int. 1999 Feb;30(2):83-95
She hasn’t bothered to talk to me later as yet. She probably won’t send anymore patients either.
January 10th, 2007 at 12:16 am
I actually just read that paper for my Fellowship Final exams.
You’d think an orthodontist would know that that was a risk factor of treatment?
January 10th, 2007 at 6:04 am
The problem is that she’s been out for 30 years or so she says. Keeping up with the literature is not something that is a priority for most of us after we finish our programs and go exclusively into private practice.
January 10th, 2007 at 8:42 am
about a year ago a patient came in with pain in Q4, broken #48 with associated periapical lucency. it was fully erupted, but broken down and i had to section it and fish it out, i was sweating, let me tell you. i looked at the panoramic and the periapical, and it was about 2 mm superior to the IAN. i sutured him up and placed him on antibiotics.
three days later, he called back with paralysis of the right side of his face, inability to close his right eye. i told him to come in immediately, and at this point i was freaking out. sure enough, his right side was drooping, but all of his sensory function was intact. it was a classic case of bells palsey, but it couldn’t have been induced by my anesthesia because it presented itself two days after the extraction and he left my office with no apparent distress. it could have been brought on by the trauma of the extraction itself, compromised immune system, reaction to the antiobiotics, whatever (looking back, one of the prodromal signs of bells palsey is facial pain, and that could have been completely unrelated to the broken #48, the tooth just coincidently there) but of course, he blamed me because guess what, his cousin, who is an orthodontist, told him that numbness was a side effect of tooth extraction and that his paralysis was my fault.
umm, okay, do you have any knowlege of head or neck anatomy? do you know the difference between motor and sensory nerves? don’t you know that facial movement is regulated by the five branches of the facial nerve, which has no sensory function? did you bother to see that his IAN function was completely intact? i sent him bcak to his family physician for further evaluation and i never saw him again. at least, he never came back to complain to me again.
drives me crazy when people pull crap like that on me.
January 10th, 2007 at 9:22 am
Yeah, me too.
Actually, your case brings to mind a case that one of the endo exam candidates presented to the committee. Same sort of thing. Bell’s Palsy 2 days after a molar endo was done on this side. The candidate said it was idiopathic and we had to concur because none of us could logically link a dental cause to it.
Maybe one of the oral med people who read this has some ideas…
January 11th, 2007 at 3:01 am
Oo oo! Let me play!
Firstly to be horribly pedantic, the facial nerve DOES actually have sensory components. Via the greater petrosal nerve branch it provides taste to the palate and via the chorda tympani it provides taste to the anterior two thirds of the tongue. You are absolutely right, though, in saying that the five motor branches (zygomatic, buccal, mandibular, cervical…god I always forget the last one…temporal!) have no sensory component.
I’m sure everyone has considered that Bell’s Palsy could have been caused if anaesthetic solution was injected into the capsule of the parotid gland during administration of an inferior alveolar nerve block. The paralysis would have tended to be more immediate, as you said…I seriously doubt it would have taken two days to develop.
It is in the realm of conceivable possibility that if the gland capsule was punctured during a block, it may have caused inflammation (and/or oedema and haemorrhage) which may have caused compression of the nerve and *that* could take a day or two to manifest. That’s a lot of qualifiers though.
It’s more likely that the extraction had very little to do directly with the paralysis. Indirectly it could have caused something like a Ramsay Hunt Syndrome if he was stressed out and had that suppressed his immune system. But I’d be tending to agree that the palsy is most likely coincidental. He could suddenly be having symptoms from a parotid neoplasia. For all we know he could have had a stroke.
What gets me in cases like this is when people start making wild accusations about other peoples “mistakes” without actually knowing the particulars. Makes me want to grab the person and go “You weren’t there, you don’t know the case, please shut-the-f*ck-up!”.
January 11th, 2007 at 3:18 am
On a different but related noted, I actually *didn’t* know that orthodontics could cause invasive cervical resoprtion. Apical resorbtion yes, but cervical resorbtion no. Thanks for the info ameloblast!
January 11th, 2007 at 9:07 am
Looking_down: Thanks for the info! That was very informative. I remember learning about chorda tympani in anatomy. I can still see the diagram that our prof drew on the board, just before my eyes closed.
Gross anatomy was after lunch and as much as I tried I really had a hard time staying awake in that class. The lights would go lower, the slides would go on and I would be done…
January 11th, 2007 at 11:01 am
looking_down, i completely forgot about the chorda tympani and sensory functions of the facial nerve. thanks for the reminder! one thing was for sure, though, this guy hadn’t lost any hearing or taste sensation, his symptoms were purely motor. he was a little young IMHO for a stroke or a parotid neoplasm, no medical problems, nothing out of the ordinary. actually, he was the exact same age that my mother was when she developed bell’s palsey (late twenties). i know that doesn’t necessarily mean anything, but any of the other aforementioned ailments, as you stated before, would be a stretch because he just doesn’t fit the profile.
the motor components were always what were drilled into our skulls in anatomy class via the following neumonic Two Zebras Bit My Cookie (of course, that’s the PG version, we had lots of fun with that one) i have some really gross neumonics for the cranial nerves, too!
thanks for your insight!
October 11th, 2009 at 8:37 am
[...] cited in the post to learn more about what the endodontist is talking about. The irony when I saw a citation for invasive cervical resoprtion by Prof Heithersay. I remembered I barely skimmed through it while [...]