Gold & Hasselgren

JCP 1992

Resorption

Peripheral inflammatory root resorption: A review of the literature with case reports.
- External resorptions: physiological or pathological. A recent classification (Andreasen 1985): surface, inflammatory and replacement-ankyiosis resorption - Idiopathic external resorptions: may be genetically linked,since they have been found in members of the same families (Liedberg 1990). - 2 main forms of external resorption associated with inflammation in the periodontal tissues (Andreasen 1985): 1) Extemal inflammatory resorption: triggered by the destruction of cementoblasts and cementoid, and continued by necrotic, and infected pulp tissue 2)a communication with the periodontal pocket and does not have any pulpal involvement - It has been given many names. Subosseous resorption, Supraosseous extracanal invasive resorption, the most commonly cervical resorption. However, even if the location is often cervical, this is not always the case. The location is related to the level of the marginal tissues and the pocket depth. - This paper will review the changing histopathologic and therapeutic concepts associated with this type of external dental resorption. A revised name, peripheral inflammatory root resorption (PIRR), is proposed. Clinical Features - The majority of root surface resorptions: self limiting and reversible, in 82% of young males and 91% of females, Identifiable etiologic factor case-about 3% of those teeth. Asymptomatic, most frequently detected during routine radiographic or clinical examination, redder in color than the surrounding gingiva and bleeds freely on probing, detectable by probing. - Radiographs: smallest lesions were never detected. - Conditions favoring radiographic visibility of PIRR lesions: proximal location of the lesion, diameter of lesion greater than 1.2 mm and high contrast X-ray technique.

- To follow the continuity of the pulp canal and to distinguish internal resorption from external resorption: varying X-ray angles (Tube shift) - Tangential X-rays: helpful in locating the site of entry. - Radiographically: a mottled appearance (Seward 1963). - The continuity of the pulp canal in radiograph: important in the differential diagnosis of PIRR. - knife-edged border: It has been described as appearing caries-like or as gingival inflammation - Electric and thermal pulp tests remain positive. - PIRR lesions have been reported associated with cysts and tumors. Mechanisms of Resorption - Osteoclasts: responsible for bone resorption as well as the resorption of other hard tissues. Usually large and with multiple nuclei. filled with vacuoles and 2 kinds of membranes: the clear zone and the ruffled border - Possible source of osteoclasts: Cells from capillaries, undifferentiated mesenchyme cells, and transformed osteogenic cells, recently the fusing of extraskeletal mononuclear precursor cells. - The presence of a highly vascularized tissue adjacent to an unprotected root surface has been postulated as the necessary condition for root resorplion (Sognnaes 1963). - The resistance to resorption of uncalcified, newly formed tissue on cemental surfaces has been observed (Gottlieb 1942), also in osteoid and predentin. - Cementum may have a resorption preventing function on the root surface (Lindskog et al. 1985, Hammarstrom et al. 1986). - The removal of the organic matrix of bone will make it possible for phagocytic cells to recognize the mineral component (Chambers 1981): a hard tissue matrix is a barrier that has to be broken to trigger osteoclastic activity (trauma or excessive scaling). - An inflammatory stimulus is also necessary for the continuation of the resorption process(Andreasen 1985): infection in the root canal, orthodontic forces, or, in the case of PIRR, inflammation in the marginal periodontal tissues.

- An occasional feature of the PIRR lesion: replacement or healing of resorbed tooth structure by a calcified bone-like tissue which is not well organized (Goldman 1954, SulMvan & Jolly 1957). This phenomenon differs from the type of replacement resorption which results in bony ankylosis. Animal Models - Resorption of the PIRR type in the domestic cat (Hopewell-Smith 1930): differentiated from caries and associated with granulation tissue which destroyed the adjacent "osseous and dental tissues." Foreign body giant cells and plasma cells - A detailed description of periodontal disease in the domestic cat (Reichart et al. 1984): extemal root resorption was seen and was associated with periodontal disease. most frequently seen in the region of the cemento-enamel junction. The pulp tissue has a normal appearance. - Tooth transplantation, replantations and implantations in monkeys (Nyman et al. 1985): The dental and supporting tissues, histological study with both the light and electron microscopic levels after varying periods of time. The common findings of ankylosis and resorption have been analyzed. It has been noted that the sequence of events following replantation is dependent upon the cell type repopulating the wound following destruction of the periodontai ligament. - In a study designed to evaluate the effectiveness of various tissues to promote cementogenesis following dental autotransplantations, the investigators concluded that only periodontal ligament tissues have this potential (Andreasen & Kristerson 1981), Case Reports (1-5) Discussion - The conditions necessary to initiate peripheral inflammatory root resorption (PIRR): the absence of cementoblasts, cementoid and healthy periodontal attachment on the root surface as well as an inflammatory process in the adjacent marginal tissues capable of providing a source of monocytic cells

- The organic phase of the predentin contains a resorptioninhibitor (Wedenberg 1987a). - The exposure of dentinal collagen by acid decalcification provides a good environment for periodontal repair (Cole et al. 1981. Claffey et al. 1987) - By creating a "predentin-like" surface, resorption is prevented. (Colyer 1910). - The newly formed incompletely mineralized cementum is most resistant to resorption (Colyer 1910. Gottlieb 1942) and in severe external resorptions a thin layer of dentin remains protecting the pulp (Makkes & Thoden van Velzen 1975) - After bleaching resorptions can occur in the cervical area of root filled teeth (Harrington & Natkin 1979, Montgomery 1984, Friedman et al. 1988). The reason why the cemento-enamel junction is a vulnerable locus might be a result of the gap between the enamel and cementum. Bleaching agents can leak through dentin and cementum. This could damage the soft tissue attachment to the tooth. Conceivably, bacteria could also later colonize the empty tubules causing inflammation and root resorption (Cvek & Lindvall 1985). The PIRR that is occasionally found after bleaching of a non-vital tooth is often extensive, as it can rapidly progress through the root without being hindered by pulp and predentin. - Intemal resorption only occurs under conditions in which pulpal connective tissue has been convened to a periodontal ligament-like tissue in contact with dentin deprived of its predentin protection (Wedenberg 1987a). The treatment of root resorptions: root resections (Partsch 1899), extraction (Oran 1913). endodontic treatment (Sullivan & Jolly 1957) endodontic therapy with surgical debridement or endodontic treatment, surgical-chemical debridement and orthodontic extrusion (Heithersay 1985), surgical debridement and amalgam or composite restoration without endodontic treatment (Frank & Bakland 1987). - It is necessary to localize the site of the resorption by means of radiographic and clinical examination and after that make a diagnosis and treatment plan.