Endod Dent Traumatot 1997; 13; 75-81Printed in Denmark . Alt rights reserved

Copyright © Munksgaard 1997

Endodontics &Dental Traumatology

ISSN 0109-2502

Prognosis of permanent teeth with internairesorption: a clinical review^ali§kan MK, Tiirkun M. Prognosis of permanent teeth withinternal resorption: a clinical review. Endod Dent Traumatol 1997;13: 75-81. © Munksgaard, 1997.

Abstract - This study was performed in order to report the clinicalfeatures of internal resorption cases and evaluate their prognosisafter endodontic treatment. Twenty-seven patients with 28 teethwith internal resorption were referred to our clinic and 20 teeth weretreated endodontically. Sixteen teeth had non-perforating internalresorption and were treated by conventional root canal therapy.The remaining 4 teeth had perforating internal resorption and wereinitially treated by remineralization therapy with calcium hydrox-ide. The teeth treated by conventional root canal therapy showedclinical and radiographic e\ddence of healing. However, the re-mineralization therapy was successful in only one case. The threefailed cases were subsequently treated by endodontic surgery. Thesurgical therapy was unsuccessful in one case due to extensive lossof marginal alveolar bone and increased tooth mobility.

iVI. K. Qali§i(an, M. FurkunDepartment of Endodontics, Ege University,Bornova-izmir, Turkey

Key words: internal resorption; endodontictreatment

M. Kemal Qali§kan, Ege universitesi,Di§ Hekimligi Fakultesi, Bornova Kampusu 35100,izmir, Tijrkiye

Accepted September 14, 1996

A case report on internal resorption was presented byBell as early as in 1830 (1). Since then there havebeen numerous reports in the literature. Traditionally,internal resorption has been associated with a long-standing chronic inflammation in the pulp. The re-sorptive process is sustained by infection of necroticpulp tissue in the root canal coronal to the area where

the resorption takes place (2). Trauma, caries andperiodontal infections, iatrogenic procedures such asrestorative preparation, improper restoration place-ment, calcium hydroxide procedures such as vitalpulpotomy and pulp capping, vital root resections, or-thodontics, bruxism, diathermy, anachoresis, andradioactive material are suggested as contributory fac-

Table 1. Details of the history and the first examination of the patients

Frequency of code allocations Coding key

Variables

1. Age2. Sex3. Number of teeth4. Presumed etiology5. Location of resorption6. Perforation7. Periradicular pathosis8. Pain9. Mobility

10. Discoloration11. Percussion12. Sinus tract13. Vitality

0

111713124

2014182015202112

(%)

(41)(63)(46)(43)(14)

(71)(50)(64)

(71)(54)

(71)(75)(43)

1

11077

178

14103687

16

(%)

(4)(37)(25)(25)(61)(29)(50)(36)

(11)(21)(29)(25)(57)

2

6

346

57

(%)

(22)

(11)(14)(21)

(18(25)

3

9

551

(%)

(33)

(18)(18)

(4)

0

24-30men

max.ant.teethtrauma

apical thirdabsentabsent

nononenone

absentabsentpositive

1

3-35women

max.post.teethcarious lesionmiddle third

presentpresent

yesslightslight

presentpresentnegative

2

36-40

mand.ant.teethcarious-period.lesion

coronal third

markedmarked

3

40 and over

mand.post.teethunknown

crown

75

Qaii§i(an & riiricun

Table 2. Success of endodontic treatment in teeth with internal resorption

Various endodontic treatments Number of teeth Failure

Root canal treatmentRecalcificationSurgical treatment*

1643

31

* All of the three surgically treated teeth were subjected to remineralizationtreatment prior to the surgical intervention.

tors by different researchers (3^11). It is believed thatinternal resorption may occur as an idiopathic dis-trophic change in cases of unrestored or non-cariousteeth (12-14). Systemic diseases are not considered tobe etiological factors of internal resorption (15).

Internal resorption can be either transient or pro-gressive (2, 16). It can affect one tooth or many teeth.Incisors show the highest incidence (9, 17). Accordingto Gorlin & Goldman (16), its occurrence is morecommon in men than women in the fourth and fifthdecades of life and most frequently occurs in themiddle or apical third of the root.

Internal resorption is usually asymptomatic andfirst recognized clinically through routine full mouthradiographs. Pain may occur depending on the pulpalcondition or perforation of the root resulting in a peri-odontal lesion (8, 9). When the resorption in the

crown reaches the enamel, the patient may notice apink spot (5, 9).

The devastation rate of internal resorption may berapid or slow (9, 15). Spontaneous repair is extremelyrare (18-20). Therefore, "a wait and see" approachis not appropriate. Prompt endodontic treatment isrecommended in all diagnosed cases, because re-moval of pulp tissue halts the process (4, 9). Preven-tion of internal resorption can, to a certain degree, beaccomplished by careful observation of teeth follow-ing traumatic injuries (5). Most of our knowledge ofinternal resorption derives from observations on indi-vidual cases (3, 7, 12, 21, 22).

The aim of this study was to describe clinical find-ings in internal resorption cases and evaluate theprognosis of endodontic treatment of teeth with inter-nal resorption.

iVIateriai and methods

The study included 28 teeth with internal resorptionof 27 patients who attended the Department of Endo-dontics, School of Dentistry, Ege University between1980 and 1993. Supplemental radiographs weretaken from different angles in order to make a defini-tive diagnosis and to examine the extent of tooth de-struction. Details of the history and first examinations

M

Fig. I. A. Preoperative radiograph oi mandibular left lateral incisor with non-perforating internal resorption and large periapical lesion. B.Follow-up 2 years after completion of endodontic treatment. Decrease of periapical lesion is evident.

76

Internal resorption

Fig. 2. A. Preoperative radiograph of maxillar)' right lateral incisor with non-perforating internal resorption and periapicai lesion. B.Radiograph taken at follow-up examination 4 years after endodontic treatment. Complete healing of periapicai lesion is evident.

in each case were noted. Age and sex of the patient,number of teeth, possible etiology , location of internalresorption lacuna, presence or absence of root perfor-ation, periradicular radiolucency, pain, mobility anddiscoloration of the crown, tenderness to percussion,sinus tract and response to an electric pulp tester wererecorded (Table 1). The patients' medical historieswere non-contributory.

Two patients with 3 teeth did not accept endodon-tic therapy since their teeth were asymptomatic. Fiveteeth were planned to be extracted due to extensiveroot destruction or intra-or periradicular lesions.

The remaining 20 teeth were treated endodont-ieally by the same operator using a standardized tech-nique. After local anaesthetic infiltration, except fornecrotic teeth, a standard endodontic access cavitywas prepared under rubber dam isolation. The work-ing length was established at 1 mm short of the radio-graphic apex, and the root canal preparation was ac-complished using 2.5% sodium hypochlorite irri-gation and hand instrumentation. In vital teeth,considerable bleeding was encountered from the rootcanal. Irrigation with 2.5% sodium hypochlorite andsaline solution aided in controling the bleeding. Afterthe completion of the chemo-mechanical root canalpreparation, the canals were finally irrigated with 10

ml 2.5% sodium hypochlorite solution, dried withsterile paper points, and filled with calcium hydroxidepaste (calcium hydroxide and barium sulfate powder(Merck, Darmstadt, Germany) in ratio of 8:1 mixedwith glycerine as a medium) by means of a lentulospiral filler in a slow-speed handpiece and packedwith the blunted end of a paper point.

In non-perforating cases of internal resorption, thecalcium hydroxide paste was removed one week afterits placement and the apical portion of the root canalwas obturated using gutta-percha (Hygenic, Akron,OH, USA) and Calcibiotic Root Canal Sealer (Hyg-enic) as a sealer by a single cone technique. The re-sorption space was filled with gutta-percha and sealerby vertical and thermatic condensation via the cor-onal access cavity.

In perforating cases of internal resorption , the cal-cium hydroxide paste was changed 3 weeks after theinitial treatment and the paste was checked and re-placed again two or three times at 3-month intervals.If a fistulous tract was present, calcium hydroxidepaste was expressed through the fistula. When the re-mineralization treatment was found to be successful,the calcium hydroxide paste was replaced with a per-manent root canal filling using gutta-percha andsealer as described above.

77

Qali§kan & Fiirkun

Fig. 3. A. Preoperative radiograph of maxillary left lateral incisorwith non-perforating internal resorption. B. Radiograph taken im-mediately after the obturation of the root canal. C. Radiographtaken at follow-up examination 3 years after connpletion of endo-dontic treatment. Periapicai bone pattern was norrnal.

78

Internal resorption

Fig. 4. A. Periapicai radiograph of maxillary^ left central incisor with a perforation at the buccal surface of a root caused by internalresorption. B. Follow-up 4 years after completion of remineralization treatment with calcitim hydroxide and prosthetic restoration. Buccalperforation was healed and periapicai bone pattern is normal.

A surgical approach was required in 3 cases wherethe remineralization treatment was not successful.The root canal obturation was completed before thesurgical intervention. A triangular buccal or lingualflap was raised to reveal the perforation area. Re-moval of the granulation tissue allowed the exposureof the resorption lacuna. This lacuna was filled withzinc-free amalgam (Standalloy F, Degussa, Frankfurt,Germany). The operation site was thoroughly rinsedwith saline solution and the flap was replaced andsutured.

The patients were examined clinically and radio-graphically 3 months after the treatment and there-after at 3- or 6-month intervals for up to 1 year andthen at longer inter\'als. The observation periodvaried from 2 to 4 years. The treatment was con-sidered to be successful if the following criteria weremet: absence of clinical symptoms, absence of peri-radicular lesions, disappearance or decrease in size ofpre-existing periradicular radiolueeneies, presence ofcalcific barrier at the site of perforative defects, andabsence of abnormal mobility and sinus tracts.

Results

Of the 27 patients, 17 were men (63%) and 10 werewomen (37%). Trauma (43%) was the most commonetiologieal factor, followed by carious lesions (25%).Maxillary anterior teeth showed the highest percen-tage of involved teeth (46%). The most frequent loca-tion of internal resorption was the middle third of theroot (61%) (Table 1). Clinical examinations carriedout between 2 and 4 years after the root canal therapyrevealed that all cases with non-perforating internalresorption (16 cases) were asymptomatic. Of the 7teeth with periapicai lesions, resolution of the lesionswas observ'ed radiographically at the 6- or 12-monthrecall examinations (Fig. lA, B; 2A, B). The remain-ing 9 teeth without periapicai lesions showed radio-graphically normal periapicai bone patterns (Fig. 3A"C).

Of the 4 teeth with perforating internal resorptionexposed to remineralization treatment with calciumhydroxide, only one tooth with the perforation wason the buccal surface of a root, showed clinical and

79

& rurkun

Fig. 5. A. Preoperativc radiograph showing lingual perforating internal resorption associated with mandibular right second pretnolar.Recalcification treatment with calcium hydroxide failed. B. Radiograph taken during the obturation of the apical portion using gutta-perchaand sealer by a single cone technicjue. Note the margins of resolution space. C. Radiograph taken after completion of the filling of theresorption space with gutta-percha and sealer by vertical and thermatic condensation. D. Radiograph taken at follow-up examination 3years after eompletion of surgical endodontic treatment. No evidence of periradicular pathology.

radiographic evidence of healing (Fig. 4A, B). Thedraining sinus tract closed after the initial calcium hy-droxide application. At the 9-month recall examin-ation, a calcified barrier could be detected and thecalcium hydroxide paste was dr ,. The process of heal-ing was followed both elinically and radiographicallyat subsequent recall appointments as well as after thecompletion of the endodontic treatment.

The 3 teeth that did not respond to recalcificationtreatment were later treated by endodontic surgery.Two of these teeth remained asymptomatic and noradiographic changes were evident at the follow-upexaminations (Fig. 5A-D). However, these teethshowed increasing gingival probing depths and lossof marginal alveolar bone to the apical level of therestoration of the resorption lacuna. The surgicaltherapy was found to be unsuccessful in one toothdue to extensive loss of marginal alveolar bone andsevere tooth mobility. This tooth was extracted.

Discussion

This study did not aim to analyze the prevalence ofteeth with internal resoiption statistically because itwas felt that the number of cases was inadequate.However, our clinical findings that it was more fre-quent in males, that the most affected teeth were themaxillary incisors, and that it occurred most fre-quently in the middle third of the root corroboratedthe findings of earlier reports (9, 10). Kerr et al. (23)claim that occurrence of internal resorption is mostfrequently seen in women in the second and thirddecades of life. In the present study, it was more com-mon in persons in their twenties. Also, trauma wasthe most common contributory factor which causesthe internal resorption via the infection of necroticpulp. This finding also agrees with previous reports(3, 6, 9).

Treatment of internal resorption is quite predict-

80

Internal resorption

able. Root canal therapy will interrupt the resorptiveprocess. If the resorptive defect does not perforate thecanal wall, root canal therapy should be the choice oftreatment. In teeth with perforating defects, remin-eralization of the defect may occur following calciumhydroxide treatment, but often a surgical approachwill be necessary, and some eases may require extrac-tion (8, 9, 21). In the present study, different examplesrelated to all these treatment approaehes were in-cluded.

Conventional root canal therapy resulted in a highdegree of success in the treatment of non-perforatinginternal resorption, which was in accordance withpreviously reported results (3, 7, 12).

The prognosis of remineralization of root perfor-ations is poor (8). Multiple appointments in which re-peated applications of calcium hydroxide for a longperiod of time are required in order to create hardtissue closure of root perforations (24). Of the 4 teethwith perforating internal resorption which were treatedwith calcium hydroxide, in spite of repeated appli-cation, 3 teeth failed. A possible explanation for thefailure is the presenee of periodontal pocket eventhough, clinically, a pocket could not be probed. Theperiodontal pocket causes the communication of per-foration with oral fluids and washing out of the calciumhydroxyde, because the perforation is coronal to theepithelial attachment. When these teeth were treatedsurgically, increasing gingival probing depths and lossof marginal alveolar bone were obser\'ed, but they weresymptomless and in function except for one case.

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