INTERNAL ROOT RESORPTION AND ITS CLINICAL MANAGEMENT

INTERNAL ROOT RESORPTION AND ITS CLINICAL MANAGEMENT
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1. INTERNAL ROOT RESORPTIONAND ITS CLINICAL MANAGEMENT Dr BASIL JOSE

2. Root resorption (RR) is either a physiologic or a pathological condition that is associated with tooth structure loss caused by clastic cells. The process of resorption in permanent dentition is usually pathological and may occur after various injuries, including mechanical, chemical, or thermal injury. Root resorption can be classified into either internal or external according to the damaged protective layer. If pathologic resorption is untreated it will result in the premature loss of the teeth . INTRODUCTION

3. INTERNAL ROOT RESORPTION Definition: Internal resorption is an unusual form of tooth resorption that begins centrally within the tooth, apparently initiated in most cases by a peculiar inflammation of the pulp . (Ingle) Internal resorption is an idiopathic, slow or fast progressive resorptive process, occurring in the dentin of the pulp chamber or root canals of teeth .(Grossman) Internal surface resorption Internal infection related root resorption Internal replacement resorption

4. ETIOLOGICAL FACTORS Trauma; Caries; Periodontal infections; Excessive heat generated during restorative procedures on vital teeth; Calcium hydroxide procedures Vital root resections Anachoresis Orthodontic treatment; Cracked teeth; Idiopathic dystrophic changes in normal pulps

5. CLINICAL FEATURES: Asymptomatic until it has perforated and become necrotic Pain : lesion perforates and tissue exposed to oral fluids Can be found in all areas of root but most commonly found in cervical region Common in maxillary central incisors Usually single tooth but can involve multiple teeth Detected through routine radiographs Granulation tissue manifests as a “Pink Spot” The response to vitality tests, thermal and electrical, is positive until the lesion grows significantly in size resulting in a perforation [ Ingle ]

6. Radiographic Diagnosis Intraoral X-ray: oval shape enlargement within the pulp chamber or the root canal CBCT has been successfully used to evaluate the true nature and severity of resorption lesions in isolated case reports

7. Therapeutic Decision ( i ) location, size, and shape of the lesion (ii) presence of root perforations, (iii) root wall thickness, (iv) presence of an apical bone lesion, (v) localization of anatomical structures: (v) resorption location and wideness (vi) presence or not of root perforations and their wideness, (vii) resistance/weakness of the remaining root hard tissue, (viii) periodontal status, (ix) ability to realize a restorative treatment on the concerned tooth

8. Conservative Dental Treatments of Resorbed Teeth Root canal treatment remains the treatment of choice access cavity preparation must be as conservative as possible A great emphasis must be placed on the chemical dissolution of the vital and necrotic pulp tissue with sodium hypochlorite. The use of ultrasonic devices activates and facilitates the penetration of the irrigation solution of hypochlorite to all the areas of the root canal system . The nontraumatic plastic tips of EndoActivator are particularly indicated to achieve a complete chemomechanical debridement calcium hydroxide as an interappointment dressing maximizes the effect of disinfection procedures Thermoplastic guttapercha techniques seem to give the best results when the canal walls are respected

9. Surgical Treatment of Internal Root Resorption Following local anesthesia a mucoperiosteal flap is raised. The cortical bone plate is removed to provide access to the root area. The softtissue lesion is curetted and the intraradicular dentin cavity is prepared with the aid of an operative microscope, cleaned, and dried. The filling materials (like MTA or Biodentine ) are placed and smoothed on its external surface.

10. Internal Surface Resorption Etiology: Found in areas where revascularisation occurs Fracture lines of root . Apical part of root canal of luxated teeth undergoing revascularisation Pathogenesis: O st eocla s tic activi t y is p a rt o f the p r ocess al o n g with f orm a tion o f g r anu l a tion tissue . [ Ingle ]

11. Radiographic Findings: Appears to be a temporary widening of root canal Endodontic Implications: Resorption process is a sign of progressing pulp healing and that a ny endodontic intervention may arrest this process. Treatment: No treatment except periodic observation [ Ingle ]

12. Transient Apical Internal Resorption Another form of trauma induced non-infective root resorption identified by Andreasen in 1986. Resorption follow luxation injuries Recognized by a confined periapical radiolucency which resolves within a few months. There may be associated colour change due to intra-pulpal haemorrhage. This resolve spontaneously if revascularisation to the coronal pulp chamber occurs . Heithersay GS. Management of tooth resorption. Australian Dental Journal. 2007 Mar;52:S105-21.

13. In the longer term, (transient process), the internally resorbed apex will close uneventfully. Radiograph taken 1 year after the original trauma shows resolution of the apical internal resorption and no other signs of periradicular pathosis Radiograph taken 1 month after the luxation injury shows evidence of transient apical internal resorption Heithersay GS. Management of tooth resorption. Australian Dental Journal. 2007 Mar;52:S105-21.

14. •It involves a progressive loss of intraradicular dentin without adjunctive deposition of hard tissue adjacent to the resorptive sites. •The coronal pulp is usually necrotic, whereas the apical pulp must remain vital. 2. Internal Infection Related Root Resorption Nilsson, E., Bonte , E., Bayet, F., & Lasfargues , J.-J. (2013).  Management of Internal Root Resorption on Permanent Teeth. International Journal of Dentistry, 2013, 1–7.

15. • One hypothesis suggest that the necrotic coronal part of the infected pulp provides a stimulus for inflammation in the apical part of the pulp. • Second hypothesis is based on the recent understanding that osteocytes participate in bone homeostatis by inhibiting osteoclasteogenesis . The symptoms of acute or chronic apical periodontitis may be seen after the entire pulp has undergone necrosis and the pulp space has become infected.

16. Apical : Study showed that 74.7 % of teeth with periapical lesions had varying degrees of apical internal resorption. Heithersay GS. Management of tooth resorption. Australian Dental Journal. 2007 Mar;52:S105-21. Intraradicular : Internal resorption fully contained as round or oval shaped radiolucencies within an intact root

17. Treatment: Defect not perforated the root to the periodontal ligament Profuse bleeding from the granulomatous tissue within the root canal system. As a result of the irregular anatomy of internal root resorption lesions, techniques such as passive ultrasonic irrigation or the use of a three-dimensionally adaptive file system such as the xp -endo finisher have been advocated to facilitate cleaning of the inaccessible regions of the resorptive defect. Inter-appointment dressing such as calcium hydroxide Thermoplasticised technique to ensure optimum adaptation and compaction

18. Defect perforated the root below bone level : A hard tissue barrier can be produced with long-term calcium hydroxide treatment, after which obturation is carried out. Root canal filling is best performed with a bioceramic material such as mineral trioxide aggregate ( mta ) or biodentine Defect perforates coronal to the epithelial attachment or if an extremely large perforation is present : A surgical approach is required to seal the perforation.

19. Treatment : Apical Extend instrumentation only to the position of the resorption. With the removal of micro-organisms followed by root canal filling, hard tissue repair will occur in the resorbed apical region. Treatment to the position of the resorption help in achieving biological repair of the resorbed apex.

20. Intraradicular Preparation of the canal to the apical foramen. Particular emphasis on irrigation and ultrasonication ( resorbed area is cleansed thoroughly ). Thermoplastic obturation of canal.

21. Umashetty G, Hoshing U, Patil S, Ajgaonkar N. Management of inflammatory internal root resorption with Biodentine and thermoplasticised Gutta-Percha. Case reports in dentistry. 2015;2015.

22. Thermafil , JS Quick-Fill, Soft Core, System B and Microseal , and by LC  Warm gutta-percha compaction techniques filled the resorption areas with more gutta-percha than sealer ( Microseal 68%, System B 62%) compared to the other techniques (LC 48%, Quick Fill 41%, Soft Core 34%, Thermafil 35%) Gencoglu N, Yildirim TA, Garip Y, Karagenc B, Yilmaz H. Effectiveness of different gutta‐percha techniques when filling experimental internal resorptive cavities. International endodontic journal. 2008 Oct;41(10):836-42.

23. 3. Internal Replacement Resorption Etiology: The d amage to pulp tissue is usually related to trauma. When damaged pulp tissue replaced as a part of healing process – tissue metaplasia occurs – formation of bone tissue in pulp canal . Damaged pulp tissue – replaced with an ingrowth of new tissue, includes bone derived cells.

24. H ypothesis I T he metaplastic tissues are produced by postnatal dental pulp stem cells present in the apical, vital part of the root canal as a reparative response to the resorptive insult. H ypothesis II B oth the granulation tissues and metaplastic hard tissues are derived from the vascular compartments or originated from the periodontium . Appears to be caused by low grade inflammatory process of the pulpal tissue such as chronic irreversible pulpitis or partial necrosis.

25. Clinical Findings: Teeth asymptomatic If ankylosis develop – teeth gradually develop infraocclusion Radiographic Findings: A dissecting resorptive area- seen in root canal initially Root canal appears intact R esorption of the intraradicular dentin is accompanied by subsequent deposition of a metaplastic hard tissue that resembles bone or cementum instead of dentin . Histological Features

26. Treatment : Root canal therapy , curettage of the resorptive defect and root filling Generally control the resorptive process as soon as possible

27. In extensive cases: Resorptive tissue may communicate with the periodontal ligament Pulpe c t o m y supple m e nt e d b y the c a r e fu l t opi c al app l i c a tion of 90% aqueous trichloracetic acid to the defect . This inactivate any communicating resorptive tissue Insert conventional root filling In communi c ating lesions - MTA may be used to seal the defect prior to the placement of a root filling. Heboyan A, Avetisyan A, Karobari MI, Marya A, Khurshid Z, Rokaya D, Zafar MS, Fernandes GV. Tooth root resorption: A review. Science Progress. 2022 Jul;105(3):00368504221109217.

28. Materials used to manage root resorption Drugs that affects osteoclasts present at the site of resorption : Tetracyclines Anti-resorptive properties Sustained antimicrobial effect Direct inhibitory effect on osteoclasts and collagenase Significantly more cemental healing . Terranova showed that tetracyclines promote fibroblast and connective tissue attachment and enhance regeneration of lost periodontal attachment to pathologic processes. Mohammadi Z, Cehreli ZC, Shalavi S, Giardino L, Palazzi F, Asgary S. Management of root resorption using chemical agents: a review. Iranian endodontic journal. 2017;11(1):1.

29. Drugs that affect the recruitment of osteoclasts to the injury site : Glucocorticoids Topical dexamethasone was found to be useful while systemic usage was not . Bisph o sh o n a t es Alend r o n a t e Pereira et al. indicated that sodium alendronate was able to reduce the incidence of radicular resorption, but did not reduce dental ankylosis. Amino acids Taurine

30. BIOCERAMICS These materials offer improved handling and setting properties, high pH, potential bioactivity, chemical stability, good radiopacity, increased root fracture resistance, and resistance to resorption. They interact with periapical tissue stem cells to encourage biological sealing and trigger the healing process . Bhopatkar J, Ikhar A, Nikhade P, Chandak M, Agrawal P. Emerging Paradigms in Internal Root Resorption Management: Harnessing the Power of Bioceramics . Cureus . 2023 Sep 13;15(9)

31. Combination of the two types of drugs Ledermix t etracycline + demeclocycline HCl + corticosteroid (1% triamcinolone acetonide), in a polyethylene glycol base . Ledermix are capable of diffusing through dentinal tubules and cementum to reach the periodontal and periapical tissues. Ledermix paste had no damaging effects and was an effective medication for the treatment of progressive RR in traumatically injured teeth.

32. ART - Antiresorptive Regenerative Therapy (Pohl et al 2005) Comprises a combination of different treatment strategies for a synergistic effect : Local application of a glucocorticoid Systemic and local application of Tetracyclines Use of Enamel Matrix Derivative (EMD) e.g. Emdogain Emdogain (Enamel Matrix Protein)

33. Treatment approaches of IRR using endodontic regenerative treatment protocols In RET procedures, the most commonly used intracanal antibiotic combinations are triple (metronidazole, ciprofloxacin, and minocycline) or double (metronidazole, ciprofloxacin). Although antibiotic combinations have been linked to positive outcomes in RET procedures. Revascularization was successful in all of the treatments. All previous symptoms vanished, existing root resorption was stopped, and the root canal walls thickened after treatment, reducing the risk of a root fracture. As a result, revascularization should be considered as an alternative to traditional root canal treatment for IRR cases Heboyan A, Avetisyan A, Karobari MI, Marya A, Khurshid Z, Rokaya D, Zafar MS, Fernandes GV. Tooth root resorption: A review. Science Progress. 2022 Jul;105(3):00368504221109217.

34. Nageh , M., Ibrahim, L. A., AbuNaeem , F. M., & Salam, E. (2021).  Management of internal inflammatory root resorption using injectable platelet-rich fibrin revascularization technique: a clinical study with cone-beam computed tomography evaluation

35. Favourable Small/medium defect A small lesion in the apical or mid-root area AAE Guidelines (Management of Internal Root Resorption) Unfavourable A large defect that perforates the external root surface Questionable Larger defect that does not perforate the root Treatment Options for the Compromised Tooth: A Decision Guide : AAE 2014

36. Conclusion The diagnosis of dental resorptions and an understanding of the underlying pathosis is critical to clinical management. With the advent of newer technologies like CBCT, Light microscopy and Electron microscopy; the early detection of resorptive lesion has been made easier . Most infection related resorption respond well to endodontic treatment. Highlighting the importance of correct type of resorption, early diagnosis, adequate management with most appropriate material may lead successful outcome of the resorptive defect.

37. references Ingle’s Endodontics, 7th edition Cohen's Pathways of the Pulp, 9th Edition Heithersay GS. Management of tooth resorption. Australian Dental Journal. 2007 Mar;52:S105-21. Nilsson, E., Bonte , E., Bayet, F., & Lasfargues , J.-J. (2013).  Management of Internal Root Resorption on Permanent Teeth. International Journal of Dentistry, 2013, 1–7. Gencoglu N, Yildirim TA, Garip Y, Karagenc B, Yilmaz H. Effectiveness of different gutta‐percha techniques when filling experimental internal resorptive cavities. International endodontic journal. 2008 Oct;41(10):836-42. Treatment Options for the Compromised Tooth: A Decision Guide : AAE 2014 Nageh , M., Ibrahim, L. A., AbuNaeem , F. M., & Salam, E. (2021).  Management of internal inflammatory root resorption using injectable platelet-rich fibrin revascularization technique: a clinical study with cone-beam computed tomography evaluation Heboyan A, Avetisyan A, Karobari MI, Marya A, Khurshid Z, Rokaya D, Zafar MS, Fernandes GV. Tooth root resorption: A review. Science Progress. 2022 Jul;105(3):00368504221109217.