Tooth resorption part I - pathogenesis and case series of internal resorption
A 31-year-old male patient reported to the department of Conservative Dentistry and Endodontics for esthetic rehabilitation of his anterior teeth. The patient complained of occasional pain in tooth #10. The medical history was non-contributory. Clinically, unsightly restorations were present on teeth #7, 8, 9 and 10. A periapical radiograph revealed radiolucent lesions in relation to the apices of teeth #7, 8, 9 and 10. An oval radiolucency indicative of internal resorption was evident in the middle third of the radicular portion of tooth #10 []. The radiolucency appeared to be continuous with the distal radicular surface, suggestive of a perforating resorptive defect. Teeth #7, 8, 9, 10 failed to respond to thermal and electric pulp testing. The diagnosis was inflammatory perforating internal resorption.\nFollowing access cavity preparation, the coronal pulp in tooth #10 was nonvital while profuse bleeding was induced on probing the middle third of the canal space. Coronal flaring of the canal was done with Gates Glidden drills to facilitate entry of an endodontic spoon excavator to remove granulation tissue from the resorption site under copious 5.25% NaOCl irrigation. The apical third of canal space was negotiated to the working length with hand K- files and debridement of the canal system was carried out. Ultrasonic activation of the resorptive defect was carried out with NaOCl. The canal was dried with paper points and Ca(OH)2 paste was placed as an intracanal medicament. After 1 week, Ca(OH)2 was flushed out of the canal with NaOCl. Residual Ca(OH)2 from the resorptive defect was removed out with the help of the endodontic spoon excavator. The canal was dried and sectional cone obturation with gutta- percha was carried out in the apical third of canal []. The resorptive defect was then repaired with Mineral trioxide Aggregate (MTA) []. Post endodontic restoration was then carried out with composite resin. The patient was asymptomatic for a period of 3 months following which he has failed to report for a follow up.\nIn contrast to the case 1, the resorption was active in case 2 evident by the presence of granulation tissue in the resorption site and vital apical tissue. The progress of resorption laterally possibly led to the distal perforation. Numerous studies have proven the superior sealing ability of MTA as a perforation repair material.[–] MTA when placed in direct contact with human tissues forms Ca(OH)2 that releases calcium ions for cell attachment and proliferation, creates an antibacterial environment by its alkaline pH, modulates cytokine production, encourages differentiation and migration of hard tissue producing cells and forms hydroxyapatite on the MTA surface and provides a biologic seal.[] Reparative tissue barrier formation through use of Ca(OH)2 has been tried[] but this method is time consuming, requiring several months. It has also been reported that the tissue barrier that forms is usually incomplete, displaying voids or porosity.[] Surgical repair of the defect may also be considered[] but if the resorption is extensive or occurs on the proximal or lingual surface of the root, it is often impossible.[] If the resorption is quite extensive, the first presentation may be root fracture, which may manifest as a sudden increase in mobility of the tooth.[]