|Year : 2013 | Volume
| Issue : 2 | Page : 120-124
Management of an endo-perio lesion due to invasive cervical resorption: Literature review and a clinical report
Ahmed Kulsoom Siddiqui, Ramya Raghu, Ashish Shetty, Chinmaya Kumar Samantaroy
Department of Conservative Dentistry and Endodontics, Bangalore Institute of Dental Sciences, Bengaluru, Karnataka, India
|Date of Web Publication||11-Feb-2014|
Department of Conservative Dentistry and Endodontics, Bangalore Institute of Dental Sciences, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Successful management of ICR relies on the location, size and accessibility of the lesion as well as the structural integrity of the tooth and periodontium after treatment is completed. The present case demonstrates that ICR can be arrested by the approach recommended by Heithersay. Here, a diode laser was used as an adjunct to aid in disinfecting the resorptive defect as well as the flap.
Clinical Relevance to Interdisciplinary Dentistry
- Invasive cervical resorption is a poorly understood and often misdiagnosed lesion.
- Careful clinical, radiographic and periodontal examinations hold the key to successful management.
- Teamwork by restorative dentists and periodontists is important for salvaging such damaged teeth.
Keywords: Cervical external resorption, endo-perio lesion, idiopathic external resorption, invasive cervical resorption
|How to cite this article:|
Siddiqui AK, Raghu R, Shetty A, Samantaroy CK. Management of an endo-perio lesion due to invasive cervical resorption: Literature review and a clinical report. J Interdiscip Dentistry 2013;3:120-4
|How to cite this URL:|
Siddiqui AK, Raghu R, Shetty A, Samantaroy CK. Management of an endo-perio lesion due to invasive cervical resorption: Literature review and a clinical report. J Interdiscip Dentistry [serial online] 2013 [cited 2021 May 16];3:120-4. Available from: https://www.jidonline.com/text.asp?2013/3/2/120/126876
| Introduction|| |
Tooth resorption is a common sequel following injuries to, or, irritation of the periodontal ligament and/or tooth pulp. The course of tooth resorption involves an elaborate interaction among inflammatory cells, resorbing cells and hard tissue structures.  Tooth resorption following dental trauma can be classified as: 
However, this classification does not include the resorptive processes identified in the last two decades. Of these, transient apical internal surface resorption and other types of hyperplastic tooth resorption should be added. 
Internal resorption is defined as an idiopathic slow or fast progressive resorption process occurring in the dentin of the pulp chamber or root canals of teeth.  External resorption may be physiological or pathological.  Of all its types, one of the least understood is external cervical resorption.  The first reported case of cervical root resorption was described by Mueller and Rony in 1930.  Invasive cervical resorption (ICR) is a form of external root resorption that is unusual and very aggressive.  Although common, it is often misdiagnosed as a form of internal resorption, ,, owing to common features, one of which is the "pinkish discoloration" of the tooth, a finding attributed to internal resorption, commonly known as " Pink tooth of Mummery." 
However, it should be noted that ICR is periodontally derived and generally begins at, or below the epithelial attachment , and above the ridge crest in the area of connective tissue insertion.  Thereby, the location is not always cervical, but related to the level of marginal tissues and pocket depth.  Once diagnosed, treatment should immediately follow since it can lead to extensive loss of tooth structure as it progresses.  ICR mainly occurs when the protective pre cementum layer is mechanically damaged or removed, which allows for denuded areas of the root to be colonized by clastic cells, which progressively resorb the root.
ICR is a termed coined by Heithersay.  It shares its nomenclature with "Odontoclastoma",  "Idiopathic external resorption",  "Fibrous dysplasia of teeth",  "Burrowing resorption",  "Peripheral cervical resorption",  "Late cervical resorption,  "Cervical external resorption",  Extra-canal invasive resorption",  "Supra osseous extra canal invasive resorption",  "Peripheral inflammatory root resorption",  "Sub epithelial inflammatory root resorption", , "Periodontal infection resorption",  or simply and commonly "Cervical resorption". 
| Etiology|| |
The etiology of ICR is debatable. It is theorized that natural cementum defects or physical injury predispose the root surface to sulcular invasion by micro-organisms.  However, it is uncertain whether these organisms activate the resorption process or are secondary invaders. ,, The main factor causing ICR remains obscure and its pathologic process still remains an enigma, judging by the diversity of opinion regarding its etiopathology. 
| Predisposing Factors|| |
Heithersay identified 11 predisposing factors to this condition.  These risk factors may occur alone or in combination.  The predisposing factors in order of their occurrences can be listed as orthodontic treatment, trauma, unsuccessful restorations, unknown reasons, intracoronal bleaching, surgery, compromised periodontal treatment, bruxisum, delayed eruption, developmental defects and interproximal stripping. 
| Clinical Presentation|| |
The clinical presentation of ICR differs depending upon the extent of resorption.  The condition is usually painless with the involved tooth presenting no clinical signs or symptoms; sometimes there may be "pinkish discoloration of the crown indicating underlying resorption. , In general, the condition goes unnoticed and is diagnosed only when the patient reports with pain due to pulpal and/or periodontal involvement.  Very often, ICR is identified by a chance radiographic examination. 
A clinical classification developed by Heithersay provides guidance in the assessment of ICR. 
Class 1 A small invasive resorptive lesion near the cervical area with shallow dentinal penetration. Radiographs may show small coronal radiolucencies in such instances
Class 2 A well-defined invasive resorptive lesion that has penetrated close to the pulp chamber, but not into the radicular dentin. Radiographically, as opposed to dental caries, an irregular, variable density lesion may appear to overlay the root canal, which may occur as a result of protective function of predentin. The pulp horns may appear "carved out" and the pitted root surface may resemble an "orange peel" microscopically
Class 3 A deeper invasion of dentin by resorbing tissue that not only involves coronal dentin but also extends into the coronal third of the root. Radiographically, these lesions often appear moth eaten with small finger like projections, and a radio opaque line may separate it from the root canal
Class 4 A larger invasion of the resorptive process extending far beyond the coronal third of the root.
ICR often may be confused with internal resorption, External resorption or root caries. However based on various factors a differential diagnosis can be easily made  [Table 1].
|Table 1: Differential diagnosis of ICR, internal resorption, root caries and external resorption |
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| Clinical Management|| |
The objective while treating ICR is aimed at debriding and inactivating the resorption tissue ,, followed by restoring the defect with a biologic, biomimetic or restorative material.  The treatment of ICR lesions are dictated by the extent of the lesion and its invasiveness. The treatment procedure entails non-surgical and surgical approaches based on the severity of the resorption.
It involves the topical application of a 90% aqueous solution of trichloracetic acid to the resorption tissue, curettage, endodontic treatment whenever necessary and restoration with glass ionomer cement.  Adjunctive orthodontic extrusion can be employed in advanced lesions. , The rationale behind the application of 90% aqueous solution of trichloracetic acid is that, it induces coagulation necrosis of the granulation tissue ,, and also infiltrates small channels and recesses of ICR that would otherwise be unreachable mechanically.  Furthermore, trichloracetic acid controls hemorrhage and eliminates possible chances of recurrence of the lesion. 
Reports also suggest that the use of Ledermix paste may prove beneficial when used as a dressing, during the course of non surgical management, due to its anticlastic activity.
It generally involves periodontal flap reflection, curettage, restoration of the defect with amalgam, composite resin or glass ionomer cement followed by flap repositioning to its original position. However, periodontal attachment cannot be expected to occur with amalgam or composite resin. Hence, the use of glass ionomer cement is advocated.  Use of mineral trioxide aggregate (MTA) in sub gingival areas has also been suggested to prove beneficial. 
An alternative surgical option is to apically position the flap to the base of the resorption site. Since this can prove to be aesthetically unacceptable, orthodontic extrusion can be utilized to improve the gingival contour. 
Use of "Rankow membrane" can also be used to correct such defects. It is an innovative method that utilizes a Gortex membrane for guided tissue regeneration in various forms of endodontic surgery including ICR. Its use in chemical trials has shown resorption control and no signs of periradicular pathology. 
Another possible avenue of treatment involves the application of Emdogain and Bio-Oss (bone graft material), which has been used to apparent advantage in regeneration of some localized periodontal lesions with bone loss. This technique has the advantage that a membrane is not required. 
| Case Report|| |
This was a case report of a 40-year-old male patient who presented with a complaint of food lodgment in a "cavity" on the backside of his upper front tooth, associated with no pain or discomfort. The patient gave dental history of orthodontic treatment done about 23 years ago.
During clinical examination, both maxillary central incisors appeared discolored [Figure 1]a. On tactile examination, the left maxillary central incisor appeared 'normal', but the right maxillary central incisor elicited a catch on its palatally cervical aspect [Figure 1]b, with presence of spontaneous bleeding on probing. The teeth were normal on percussion without any mobility. Radiographic examination revealed completely calcified root canals in both teeth. Furthermore, apically both teeth appeared to have blunt ends. The same radiograph demonstrated irregular radiolucency involving the cervical aspect of the right maxillary central incisor, extending about 3-4 mm apically [Figure 2]a. Hence, a diagnosis of "ICR" was made with respect to the right maxillary central incisor. Immediate treatment was planned to help arrest the invasive nature of the lesion and restore the defect efficiently. A surgical approach was planned and the defect was curetted, followed by restoration with glass ionomer cement. The patient was advised direct composite veneers to mask the discoloration of the maxillary central incisors.
|Figure 1: (a) Pre-operative view. (b) Probing elicits a 'catch' on the palatal surface. (c) Flap reflection. (d) Laser disinfection of resorptive lesion and flap. (e) GIC restoration. (f) Suture placement|
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| Discussion|| |
Treatment of ICR presents a challenge to the clinician.  The prognosis depends mainly on the extent of the resorptive process.  Orthodontic treatment leads as the most common predisposing factor for ICR.  Regarding the treatment of external root resorption, successful management of each case must be linked to the etiology.  The clinical classification of ICR proposed by Heithersay is effective for determining appropriate treatment based on the extent of the resorptive defect.  He advocated that the selection of case must be done carefully to achieve a favorable prognosis and recommended only treating defects ranging from Class 1 to 3. 
In the case presented, a diagnosis of Class 3 ICR was made, as the extent of the resorptive lesion was 3-4 mm apically, extending into the root, but not beyond the coronal third of the root. Arriving at the diagnosis was difficult, since the lesion communicated through a perforation. It's differentiation from a "grown out" internal resorptive lesion, or a "grown in" external resorptive lesion or a combination of both, was obscure. However, it was diagnosed as "ICR" based on its location, history (Orthodontic treatment), tactile examination (hard, sharp and smooth knife edges) and radiographic appearance (irregular margins). Internal resorption was ruled out since, for internal resorption to occur, vital pulp tissue is required, which was not a finding in the case presented. Furthermore, the need for endodontic therapy prior to restoration of the defect was not necessary since the canal was completely calcified.
A surgical approach was planned as the defect extended subgingivally, and was only partially accessible. A crevicular incision was made from #12 to #21 and a full thickness mucoperiostal flap was raised palatally [Figure 1]c, such that it provided complete access to the apical aspect of the defect. The defect was occupied by what seemed to be granulation tissue. It was curetted out and confirmed on histopathologic examination [Figure 3]a and b. On debridement of the granulation tissue, the "invasive course" of the lesion could be well appreciated. It seemed to have "burrowed in" into the tooth structure with smooth, knife edges. The defect was debrided and cleaned thoroughly. Following this the resorptive defect and the flap was disinfected using a diode laser KaVo GENTLEray 980, Germany (Power setting-1-1.5W. Motion-slow, circular, spiral forming movement, Time-four times for 5 s) each [Figure 1]d. Research has shown that Diode lasers can be a useful adjunct to mechanical flap debridement due to their bactericidal effects. 
Glass Ionomer Cement (GC Fuji II, Tokyo, Japan) was mixed and packed into the resorptive defect, conforming to the root anatomy [Figure 1]e. Glass ionomer cement was chosen over MTA in this case since the restoration was partly supragingival. After radiographic confirmation [Figure 2]b, the flap was repositioned and sutured in place [Figure 1]f.
On recall of the patient after 12 months, clinical and radiographic examination indicated a stable periodontal situation, without further deterioration of the cervical defect.
| Conclusion|| |
Early detection of ICR is important for its successful management, whenever there is a history of predisposing factors like orthodontic treatment or trauma. The patient should be periodically monitored. Successful management of ICR relies on the location, size and accessibility of the lesion as well as the structural integrity of the tooth and periodontium after treatment is completed. The present case demonstrates that ICR can be arrested by the approach recommended by Heithersay. Here, a diode laser was used as an adjunct to aid in disinfecting the resorptive defect as well as the flap. It is important for endodontists to have a combined interdisciplinary approach for the proper management of ICR.
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[Figure 1], [Figure 2], [Figure 3]