The Periapex » Resorption

“Expert” Opinion.

Ameloblast — Tue, 13 Nov 2007 23:23:00 +0000

An hour later and this is what I ended up with. I usually don’t charge for lawyer letters, but this one took me away from Heroes so I think I’ll send the lawyer a bill.

As I wrote this I was thinking that the exam candidates could probably quote literature like crazy back at me with respect to dental trauma while here I am slowly forgetting even the classic Andreasen stuff. Oh well, such is life in the fast lane.

Dear Mr. Lawyer,

Thank you for your inquiries regarding XXX (your file No. XXX).

Dental trauma generally leaves involved teeth with a guarded long-term prognosis. This is especially true in luxation injuries (injuries where the tooth is physically displaced in one direction or another and requires repositioning). Delayed sequela of trauma such as internal or external resorption (reduction of root structure), root canal infection, or ankylosis (loss of the tooth’s physiologic attachment apparatus to the jawbone) can become obvious and problematic many years later.

XXX’s tooth 12 currently appears to be in a stable situation and does not demonstrate obvious signs or symptoms associated with infection. This is subsequent to trauma that occurred over three years ago. My testing, however, does provide some evidence consistent with a necrotic (dead) pulp (nerve) within the tooth.

Endodontic (root canal) treatment of a tooth with a necrotic pulp is not essential as a therapeutic measure. Should the pulp become infected, however, endodontic treatment then becomes necessary. The period of time between pulpal necrosis and infection varies from case to case. Generally, the easier it is for bacteria to penetrate into the canal space of the tooth, the faster necrosis will convert to infection.

Because tooth 12 is intact, has no decay, and no pre-existing fillings, the chance of infection developing within the near future is slim. The elective option of pursuing root canal treatment of this tooth for prevention of future potential infection does have some risk associated with it and could actually potentiate other issues with the tooth. I am of the opinion that the tooth should be monitored for problems (through the usual dental recall visits) and any future problems be addressed as needed.

The root canal space within this tooth has become significantly restricted. This is a reactive response of the pulp to the injury before it died off. The more restricted the canal space is, the more complicated root canal therapy becomes and the greater risk of irreparable damage to the tooth whilst searching for an opening into the canal.

At this point the best indicator of retentive potential of the tooth is the external resorption that I observe radiographically. The tip of the root is shorter and more blunted than it should be. This occurred as part of the biologic repair process in the area subsequent to the accident. I have no historic radiographs to compare current ones to, so I am working under the assumption that the resorptive process is currently arrested. If this is not the case and the resorption is in fact progressive, the tooth will be lost once the root is completely resorbed. This is the other reason the tooth needs to be monitored for some time longer at regular recall intervals.

Should this tooth be lost, an osseointegrated dental implant would be the ideal way to replace it. Permanent tooth replacement is best done once jaw growth is complete (generally between 18 and 21 years). Because my expertise lies within the bounds of retaining this tooth, replacement options, costs, and timeline are best discussed with the dentist who would actually perform the replacement procedures.

I hope this information is of value to you. Should you wish to further discuss this case, please feel free to email me at XXX.

Sincerely,

Ameloblast

Is Nothing Up?

Ameloblast — Tue, 13 Nov 2007 21:35:00 +0000

Hmm. A blank window to post in—and nothing to post. Nothing interesting anyway.

Am I too busy, not busy enough, was life more interesting a few months ago when I was posting like mad to the blog?
It’s a combination of all of the above, but most importantly, it’s because of Facebook.

I’ve recognised my problem, admitted it, now I have to change. I’ll waste less time on Facebook, and waste more time posting to the blog. Now I only have to find things to post about…

I’ll think about that once I finish this dento-legal letter to a lawyer asking for a translation to lay terms of a case about a boy who suffered an intrusive luxation injury a few years ago and presented to me for exam a couple of months ago. The lawyer needs to know what the terms ankylosis, calcific canal obliteration, and apical external resorption mean.

Internal Resorption Update.

Ameloblast — Thu, 26 Jul 2007 18:23:00 +0000

Here’s a month and a half recall film of the internal resorption case I did a short time ago. I just finished a retreatment of 11. Looks like healing is progressing apical to 21. The tooth has remained comfortable.

Crazy Internal Resorption.

Ameloblast — Wed, 06 Jun 2007 16:15:00 +0000

Internal resorption cases that are as advanced as this are difficult to manage, especially if they are more coronal and compromise the integrity of the clinical crown.

The complication with this case was that the resorption had perforated the root. Every time I tried to regain the true canal beyond the level of the defect, my instruments would slip out the perforation. Because of this I decided to limit obturation to the level of the defect.

The prognosis of the case is fair at best and could require surgery to address the apical area and perforation better. Surgery isn’t a great option either though because if I end up having to resect the root to the coronal aspect of the defect, the tooth might become very unstable.

Ankylosis.

Ameloblast — Tue, 16 Jan 2007 18:38:00 +0000

This guy was asymptomatic. A removable partial denture hooks onto the 13 and the endo in 12 was done 1.5-2 years ago. His current dentist was a little concerned with the resorptive defect on the root of the 3.

Percussion produced a higher pitched sound on the 3 than the other teeth, and when I checked mobility, there wasn’t even any physiologic movement.

I diagnosed ankylosis, replacement/external resorption, and told the patient to consider replacement options. He’ll probably be ok leaving the tooth alone for now, but if the replacement resorption is still active, he will lose the tooth sooner than later.

These are all things we see with teeth that have been traumatised (avulsed in particular). The only history of “trauma” to this tooth is the RPD…

Conversation With an Orthodontist.

Ameloblast — Wed, 10 Jan 2007 05:10:00 +0000

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.

Recall of the Week.

Periapex — Thu, 04 Jan 2007 00:30:00 +0000

Here’s a case I finished last February. Apical external resorption of the distal root had eaten away into the canal so I had to obturate very short of the radiographic apex to stay within the root.

The endo was done over two appointments using calcium hydroxide paste as a therapeutic intracanal medicament.

This is a 3 month recall:

And this is a 10 month recall:

Hopefully that’s not a void above one of the mesial canals.

A Case of Internal Resorption

Periapex — Mon, 11 Sep 2006 13:24:00 +0000

Here’s a case I finished today. The left central was done many years ago (post-trauma). The right central was done today; the diagnosis was a necrotic-infected pulp.

The canal was instrumented apically to a #55 and vertical compaction of gutta-percha was used to obturate. The internal resorptive defect and lateral canal show up well. The apical sealer puff will disappear with time.

Recall of the Week.

Ameloblast — Wed, 30 Aug 2006 17:23:00 +0000

Not that I do one every week…

Here’s a case that was finished last year. Previous endo, post and crown. The tooth was symptomatic and demonstrated either apical external resorption, or more likely, some sort of apical surgery (the patient didn’t recall any surgery but that doesn’t always mean it was not done).

Anyway, the retreatment was started, the canal was medicated, the patient forgot to come back for a few months, xray then showed washout of the calcium hydroxide, but some degree of apical healing. Endo was finished; some apical sealer puffs can be seen.

The recall today shows progressive apical healing and resorption of the extra sealer.

Perforation Repair Recall Exam.

Ameloblast — Mon, 01 May 2006 21:04:00 +0000

I was referred this patient over a year ago. His dentist had inherited the root canal situation from a previous dentist (the patient had recently switched GP’s). The current dentist did a couple of pulpectomies and placed calcium hydroxide in the canals. He found a perforation in the root of the central incisor.

This is after I finished the root canals and sealed up the perf in the central. I was not able to go any further apically because of excessive bleeding. Electronic apex locator readings consistently indicated periodontal ligament at the level of obturation.

This is a one year recall film that shows significant signs of osseous healing. Looks like some apical resorption has occurred at the tip of the lateral incisor.