Tooth resorption

Last updated
Root resorption
External tooth resorption 9.jpg
Post traumatic External tooth resorption 9
Specialty Dentistry
Symptoms Dark tooth discoloration, swollen gums, chip tooth
Complications Tooth loss, infection [1]
TypesExternal (most common), internal [2]
CausesTrauma, idiopathic
Risk factors Trauma, orthodontics [3]
Diagnostic method Dental examination, X-rays
TreatmentDental crowns, tooth extraction, gum surgery

Resorption of the root of the tooth, or root resorption, is the progressive loss of dentin and cementum by the action of odontoclasts. [4] Root resorption is a normal physiological process that occurs in the exfoliation of the primary dentition. However, pathological root resorption occurs in the permanent or secondary dentition and sometimes in the primary dentition.

Contents

Causes

While resorption of bone is a normal physiological response to stimuli throughout the body, root resorption in permanent dentition and sometimes in the primary dentition is pathological. The root is protected internally (endodontium) by pre-dentin and externally on the root surface by cementum and the periodontal ligament. Chronic stimuli that damage these protective layers expose underlying dentin to the action of osteoclasts.

Root resorption most commonly occurs due to inflammation caused by pulp necrosis, trauma, periodontal treatment, orthodontic tooth movement and tooth whitening. [3] Less common causes include pressure from malpositioned ectopic teeth, cysts, and tumors. [4] [5] [6]

Pathophysiology

X-Ray of affected tooth (incisor 9, left). Tooth resorption x Ray 9.jpg
X-Ray of affected tooth (incisor 9, left).

The pathophysiology of root resorption is not completely understood. It is postulated that osteoclasts are the cells responsible for the resorption of the root surface. [7] Osteoclasts can break down bone, cartilage and dentin. [8]

Receptive activator of nuclear factor kappa-B ligand (RANKL), also called osteoclast differentiation factor (ODF) and osteoprotegerin ligand (OPGL), is a regulator of osteoclast function. [9] [10] In physiological bone turn over, osteoblasts and stromal cells release RANKL, this acts on macrophages and monocytes which fuse and become osteoclasts. [11] Osteoprotegerin (OPG) is also secreted by osteoclasts and stromal cells; this inhibits RANKL and therefore osteoclast activity.

One thought is that the presence of bacteria plays a role. Bacterial presence leads to pulpal or peri-periapical inflammation. These bacteria are not mediators of osteoclast activity but do cause leukocyte chemotaxis. Leukocytes differentiate into osteoclasts in the presence of lipopolysaccharide antigens found in Porphyromonas, Prevotella and Treponema species (these are all bacterial species associated with pulpal or periapical inflammation). [4] [12]

Osteoclasts are active during bone regulation, there is constant equilibrium between bone resorption and deposition. Damage to the periodontal ligament can lead to RANKL release activating osteoclasts. [13] Osteoclasts in close proximity to the root surface will resorb the root surface cementum and underlying root dentin. This can vary in severity from evidence of microscopic pits in the root surface to complete devastation of the root surface.

When there is insult leading to inflammation (trauma, bacteria, tooth whitening, orthodontic movement, periodontal treatment) in the root canal/s or beside the external surface of the root, cytokines are produced, the RANKL system is activated and osteoclasts are activated and resorb the root surface.

If the insult is transient, resorption will stop and healing will occur, this is known as transient inflammatory resorption. [14] If the insult is persistent, then resorption continues, and if the tooth tissue is irretrievably damaged, complete resorption may occur. [15]

Classifications

Resorptive lesions are categorized as internal or external and then further subdivided based on their etiology.

Internal root resorption

Internal resorption is defined by the loss of intraradicular dentin and tubular dentin from within the middle and apical thirds of the root canal(s).

It may also present as an incidental, radiographic finding. Radiographically, a radiolucent area of uniform density within the root canal may be visible with well-defined borders. Canal walls may appear sclerosed, thus the outline of pulp chambers or root canals may not be followed through the lesion. Lesions may also be oval radiolucencies that are continuous with the canal walls.

Chronic pulpal inflammation is thought to be a cause of internal resorption. The pulp must be vital below the area of resorption to provide osteoclasts with nutrients. If the pulp becomes totally necrosed the resorption will cease unless lateral canals are present to supply osteoclasts with nutrients.

If the condition is discovered before perforation of the root has occurred, endodontic therapy (root canal therapy) may be carried out with the expectation of a fairly high success rate. Removing the stimulus (inflamed pulp) results in cessation of the resorptive process.

External root resorption

external root resorption premolar 25. Wurzelresorption Zahn 25 und keilfoermiger Defekt PD 4.jpg
external root resorption premolar 25.

External resorption is the loss of tooth structure from the external surface of the tooth and is further subcategorized based on its etiology. [16]

External Inflammatory Root Resorption

External inflammatory root resorption may be caused by trauma to the root surface, due to damage to the periodontal ligament (PDL) and/or extended drying following tooth avulsion. Following trauma, dentinal tubules are exposed leading to communication with an infective or necrotic pulp. This leads to an inflammatory process that causes external root resorption. [16]

Alternatively, pressure may also cause external inflammatory root resorption. Specifically, application of heavy, continuous, and intrusive (i.e. directed toward the bone) forces during  orthodontic tooth movement are associated with external root resorption. [17]

External Surface Root Resorption

Occurs due to a localized and limited injury to the root surface or periodontium. It is a transient, self-limiting process of resorption that ceases after removal of the traumatic stimulus and is followed by healing of root surface, cementum, and periodontal ligament. [16]

External Cervical Root Resorption

External cervical resorption is a localised resorptive lesion in the cervical area of the tooth, below the epithelial attachment. It is distinguished from external inflammatory root resorption in that it rarely involves the pulp.  When at least 3 teeth are affected, it is referred to as multiple idiopathic cervical root resorption. The causes of external cervical root resorption are poorly understood but trauma, periodontal treatment, and/or tooth whitening may be predisposing factors. [16]

External Replacement Root Resorption

x-ray of external root resorption premolar 25. Wurzelresorption Zahn 25 und keilfoermiger Defekt PD 5.jpg
x-ray of external root resorption premolar 25.

External replacement root resorption (ERRR) occurs due to replacement of the root surface with bone, i.e. ankylosis. ERRR can be further categorized as transient or progressive depending on the extent of periodontal ligament damage with the latter resulting in complete root resorption. [16]

Clinical considerations

Orthodontically induced external root resorption (OIERR) may occur during orthodontic treatment. The use of heavy, continuous force increases the incidence and severity of OIERR. Additionally,  forces directed toward the bone (i.e. intrusive) or lingual torque may also cause OEIRR. Interestingly, previous root trauma and unusual root morphology do not predispose one to OEIRR. [17] Furthermore, endodontically treated teeth do not increase OIERR due to the absence of a vital pulp that can induce inflammation. [18] Thus, it is recommended to take screening radiographs to detect for OIERR as indicated, use light forces especially for intrusive movements, and perform endodontic treatment if needed.

However, due to the lack of robust evidence in treatment of other forms of external root resorption, there is currently no single recommended best treatment for the management of external root resorption. Treatments are case-dependent and dependent on clinical judgment and experience. Therefore, more research is needed in this area. [19]

See also

Related Research Articles

<span class="mw-page-title-main">Human tooth</span> Calcified whitish structure in humans mouths used to break down food

Human teeth function to mechanically break down items of food by cutting and crushing them in preparation for swallowing and digesting. As such, they are considered part of the human digestive system. Humans have four types of teeth: incisors, canines, premolars, and molars, which each have a specific function. The incisors cut the food, the canines tear the food and the molars and premolars crush the food. The roots of teeth are embedded in the maxilla or the mandible and are covered by gums. Teeth are made of multiple tissues of varying density and hardness.

<span class="mw-page-title-main">Cementum</span> Specialized calcified substance covering the root of a tooth

Cementum is a specialized calcified substance covering the root of a tooth. The cementum is the part of the periodontium that attaches the teeth to the alveolar bone by anchoring the periodontal ligament.

<span class="mw-page-title-main">Toothache</span> Medical condition of the teeth

Toothache, also known as dental pain or tooth pain, is pain in the teeth or their supporting structures, caused by dental diseases or pain referred to the teeth by non-dental diseases. When severe it may impact sleep, eating, and other daily activities.

<span class="mw-page-title-main">Cementoenamel junction</span>

Cementoenamel junction (CEJ) is defined as the area of the union of cementum and enamel at the cervical region of the tooth. It is a slightly visible anatomical border identified on a tooth. It is the location where the enamel, which covers the anatomical crown of a tooth, and the cementum, which covers the anatomical root of a tooth, meet. Informally it is known as the neck of the tooth. The border created by these two dental tissues has much significance as it is usually the location where the gingiva attaches to a healthy tooth by fibers called the gingival fibers.

<span class="mw-page-title-main">Periodontal fiber</span> Group of specialized connective tissue fibers

The periodontal ligament, commonly abbreviated as the PDL, are a group of specialized connective tissue fibers that essentially attach a tooth to the alveolar bone within which they sit. It inserts into root cementum on one side and onto alveolar bone on the other.

<span class="mw-page-title-main">Human tooth development</span> Process by which teeth form

Tooth development or odontogenesis is the complex process by which teeth form from embryonic cells, grow, and erupt into the mouth. For human teeth to have a healthy oral environment, all parts of the tooth must develop during appropriate stages of fetal development. Primary (baby) teeth start to form between the sixth and eighth week of prenatal development, and permanent teeth begin to form in the twentieth week. If teeth do not start to develop at or near these times, they will not develop at all, resulting in hypodontia or anodontia.

<span class="mw-page-title-main">Dental follicle</span> Anatomical entity

The dental follicle, also known as dental sac, is made up of mesenchymal cells and fibres surrounding the enamel organ and dental papilla of a developing tooth. It is a vascular fibrous sac containing the developing tooth and its odontogenic organ. The dental follicle (DF) differentiates into the periodontal ligament. In addition, it may be the precursor of other cells of the periodontium, including osteoblasts, cementoblasts and fibroblasts. They develop into the alveolar bone, the cementum with Sharpey's fibers and the periodontal ligament fibers respectively. Similar to dental papilla, the dental follicle provides nutrition to the enamel organ and dental papilla and also have an extremely rich blood supply.

<span class="mw-page-title-main">Alveolar process</span> Region of jaw bones containing tooth sockets

The alveolar process is the portion of bone containing the tooth sockets on the jaw bones. The alveolar process is covered by gums within the mouth, terminating roughly along the line of the mandibular canal. Partially comprising compact bone, it is penetrated by many small openings for blood vessels and connective fibres.

Cementogenesis is the formation of cementum, one of the three mineralized substances of a tooth. Cementum covers the roots of teeth and serves to anchor gingival and periodontal fibers of the periodontal ligament by the fibers to the alveolar bone.

<span class="mw-page-title-main">Feline odontoclastic resorptive lesion</span> Oral disease of cats

Feline odontoclastic resorption lesion (FORL) is a syndrome in cats characterized by resorption of the tooth by odontoclasts, cells similar to osteoclasts. FORL has also been called Feline tooth resorption (TR), neck lesion, cervical neck lesion, cervical line erosion, feline subgingival resorptive lesion, feline caries, or feline cavity. It is one of the most common diseases of domestic cats, affecting up to two-thirds. FORLs have been seen more recently in the history of feline medicine due to the advancing ages of cats, but 800-year-old cat skeletons have shown evidence of this disease. Purebred cats, especially Siamese and Persians, may be more susceptible.

<span class="mw-page-title-main">Pulpotomy</span> Dental procedure

Pulpotomy is a minimally invasive procedure performed in children on a primary tooth with extensive caries but without evidence of root pathology. The minimally invasive endodontic techniques of vital pulp therapy (VPT) are based on improved understanding of the capacity of pulp (nerve) tissues to heal and regenerate plus the availability of advanced endodontic materials. During caries (cavity) removal, this results in a carious or mechanical pulp exposure (bleeding) from the cavity. During pulpotomy, the inflamed/diseased pulp tissue is removed from the coronal pulp chamber of the tooth, leaving healthy pulp tissue which is dressed with a long-term clinically successful medicament that maintains the survival of the pulp and promotes repair. There are various types of medicament placed above the vital pulp such as Buckley's Solution of formocresol, ferric sulfate, calcium hydroxide or mineral trioxide aggregate (MTA). MTA is a more recent material used for pulpotomies with a high rate of success, better than formocresol or ferric sulfate. It is also recommended to be the preferred pulpotomy agent in the future. After the coronal pulp chamber is filled, the tooth is restored with a filling material that seals the tooth from microleakage, such as a stainless steel crown which is the most effective long-term restoration. However, if there is sufficient remaining supporting tooth structure, other filling materials such as amalgam or composite resin can provide a functional alternative when the primary tooth has a life span of two years or less. The medium- to long-term treatment outcomes of pulpotomy in symptomatic permanent teeth with caries, especially in young people, indicate that pulpotomy can be a potential alternative to root canal therapy (RCT).

Pulp necrosis is a clinical diagnostic category indicating the death of cells and tissues in the pulp chamber of a tooth with or without bacterial invasion. It is often the result of many cases of dental trauma, caries and irreversible pulpitis.

<span class="mw-page-title-main">Dental trauma</span> Medical condition

Dental trauma refers to trauma (injury) to the teeth and/or periodontium, and nearby soft tissues such as the lips, tongue, etc. The study of dental trauma is called dental traumatology.

<span class="mw-page-title-main">Dental avulsion</span> Medical condition

Dental avulsion is the complete displacement of a tooth from its socket in alveolar bone owing to trauma, such as can be caused by a fall, road traffic accident, assault, sports, or occupational injury. Typically, a tooth is held in place by the periodontal ligament, which becomes torn when the tooth is knocked out.

<span class="mw-page-title-main">Regenerative endodontics</span> Dental specialty

Regenerative endodontic procedures is defined as biologically based procedures designed to replace damaged structures such as dentin, root structures, and cells of the pulp-dentin complex. This new treatment modality aims to promote normal function of the pulp. It has become an alternative to heal apical periodontitis. Regenerative endodontics is the extension of root canal therapy. Conventional root canal therapy cleans and fills the pulp chamber with biologically inert material after destruction of the pulp due to dental caries, congenital deformity or trauma. Regenerative endodontics instead seeks to replace live tissue in the pulp chamber. The ultimate goal of regenerative endodontic procedures is to regenerate the tissues and the normal function of the dentin-pulp complex.

<span class="mw-page-title-main">Tooth mobility</span> Medical condition

Tooth mobility is the horizontal or vertical displacement of a tooth beyond its normal physiological boundaries around the gingival (gum) area, i.e. the medical term for a loose tooth.

Tooth ankylosis refers to a fusion between a tooth and underlying bony support tissues. In some species, this is a normal process that occurs during the formation or maintenance of the dentition. By contrast, in humans tooth ankylosis is pathological, whereby a fusion between alveolar bone and the cementum of a tooth occurs.

Dental intrusion is an apical displacement of the tooth into the alveolar bone. This injury is accompanied by extensive damage to periodontal ligament, cementum, disruption of the neurovascular supply to the pulp, and communication or fracture of the alveolar socket.

Periapical granuloma, also sometimes referred to as a radicular granuloma or apical granuloma, is an inflammation at the tip of a dead (nonvital) tooth. It is a lesion or mass that typically starts out as an epithelial lined cyst, and undergoes an inward curvature that results in inflammation of granulation tissue at the root tips of a dead tooth. This is usually due to dental caries or a bacterial infection of the dental pulp. Periapical granuloma is an infrequent disorder that has an occurrence rate between 9.3 to 87.1 percent. Periapical granuloma is not a true granuloma due to the fact that it does not contain granulomatous inflammation; however, periapical granuloma is a common term used.

Tooth replantation is a form of restorative dentistry in which an avulsed or luxated tooth is reinserted and secured into its socket through a combination of dental procedures. The purposes of tooth replantation is to resolve tooth loss and preserve the natural landscape of the teeth. Whilst variations of the procedure exist including, Allotransplantation, where a tooth is transferred from one individual to another individual of the same species. It is a largely defunct practice due to the improvements made within the field of dentistry and due to the risks and complications involved including the transmission of diseases such as syphilis, histocompatibility, as well as the low success rate of the procedure, has resulted in its practice being largely abandoned. Autotransplantation, otherwise known as intentional replantation in dentistry, is defined as the surgical movement of a tooth from one site on an individual to another location in the same individual. While rare, modern dentistry uses replantation as a form of proactive care to prevent future complications and protect the natural dentition in cases where root canal and surgical endodontic treatments are problematic. In the modern context, tooth replantation most often refers to reattachment of an avulsed or luxated permanent tooth into its original socket.

References

  1. ↑ Fernandes M, de Ataide I, Wagle R (January 2013). "Tooth resorption part I — pathogenesis and case series of internal resorption". J Conserv Dent. 16 (1): 4–8. doi: 10.4103/0972-0707.105290 . PMC   3548344 . PMID   23349568.
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  3. 1 2 Fuss, Zvi; Tsesis, Igor; Lin, Shaul (August 2003). "Root resorption - diagnosis, classification and treatment choices based on stimulation factors: Root resorption". Dental Traumatology. 19 (4): 175–182. doi:10.1034/j.1600-9657.2003.00192.x. PMID   12848710.
  4. 1 2 3 Galler, Kerstin M.; Grätz, Eva-Maria; Widbiller, Matthias; Buchalla, Wolfgang; Knüttel, Helge (2021-03-26). "Pathophysiological mechanisms of root resorption after dental trauma: a systematic scoping review". BMC Oral Health. 21 (1): 163. doi: 10.1186/s12903-021-01510-6 . ISSN   1472-6831. PMC   7995728 . PMID   33771147. S2CID   232376543.
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  6. ↑ Darcey, J.; Qualtrough, A. (2013). "Resorption: part 1. Pathology, classification and aetiology". British Dental Journal. 214 (9): 439–451. doi: 10.1038/sj.bdj.2013.431 . ISSN   0007-0610. PMID   23660900. S2CID   21870065.
  7. ↑ Boyle WJ, Simonet WS, Lacey DL (May 2003). "Osteoclast differentiation and activation". Nature. 423 (6937): 337–42. Bibcode:2003Natur.423..337B. doi:10.1038/nature01658. PMID   12748652. S2CID   4428121.
  8. ↑ Patel, Shanon; Saberi, Navid; Pimental, Tiago; Teng, Peng-Hui (2022-03-30). "Present status and future directions: Root resorption". International Endodontic Journal. 55 (Suppl 4): 892–921. doi:10.1111/iej.13715. ISSN   0143-2885. PMC   9790676 . PMID   35229320.
  9. ↑ Yasuda H, Shima N, Nakagawa N, Yamaguchi K, Kinosaki M, Mochizuki S, et al. (March 1998). "Osteoclast differentiation factor is a ligand for osteoprotegerin/osteoclastogenesis-inhibitory factor and is identical to TRANCE/RANKL". Proceedings of the National Academy of Sciences of the United States of America. 95 (7): 3597–602. Bibcode:1998PNAS...95.3597Y. doi: 10.1073/pnas.95.7.3597 . PMC   19881 . PMID   9520411.
  10. ↑ Mak TW, Saunders ME (2006). "Cytokines and Cytokine Receptors". The Immune Response. Elsevier: 463–516. doi:10.1016/b978-012088451-3.50019-3. ISBN   978-0-12-088451-3.
  11. ↑ Nakamura I, Takahashi N, Jimi E, Udagawa N, Suda T (April 2012). "Regulation of osteoclast function". Modern Rheumatology. 22 (2): 167–77. doi: 10.3109/s10165-011-0530-8 . PMID   21953286. S2CID   218989802.
  12. ↑ Choi BK, Moon SY, Cha JH, Kim KW, Yoo YJ (May 2005). "Prostaglandin E(2) is a main mediator in receptor activator of nuclear factor-kappaB ligand-dependent osteoclastogenesis induced by Porphyromonas gingivalis, Treponema denticola, and Treponema socranskii". Journal of Periodontology. 76 (5): 813–20. doi:10.1902/jop.2005.76.5.813. PMID   15898943.
  13. ↑ Trope M (2002). "Root resorption due to dental trauma". Endodontic Topics. 1: 79–100. doi:10.1034/j.1601-1546.2002.10106.x.
  14. ↑ Andreasen JO (1981). "Relationship between cell damage in the periodontal ligament after replantation and subsequent development of root resorption. A time-related study in monkeys". Acta Odontologica Scandinavica. 39 (1): 15–25. doi:10.3109/00016358109162254. PMID   6943905.
  15. ↑ Lossdörfer S, Götz W, Jäger A (July 2002). "Immunohistochemical localization of receptor activator of nuclear factor kappaB (RANK) and its ligand (RANKL) in human deciduous teeth". Calcified Tissue International. 71 (1): 45–52. doi:10.1007/s00223-001-2086-7. PMID   12043011. S2CID   20902759.
  16. 1 2 3 4 5 Darcey J, Qualtrough A (May 2013). "Resorption: part 1. Pathology, classification and aetiology". British Dental Journal. 214 (9): 439–51. doi: 10.1038/sj.bdj.2013.431 . PMID   23660900.
  17. 1 2 Weltman, Belinda; Vig, Katherine W.L.; Fields, Henry W.; Shanker, Shiva; Kaizar, Eloise E. (April 2010). "Root resorption associated with orthodontic tooth movement: A systematic review". American Journal of Orthodontics and Dentofacial Orthopedics. 137 (4): 462–476. doi:10.1016/j.ajodo.2009.06.021. PMID   20362905.
  18. ↑ Alhadainy, Hatem A.; Flores-Mir, Carlos; Abdel-Karim, Amany H.; Crossman, Jacqueline; El-Bialy, Tarek (May 2019). "Orthodontic-induced External Root Resorption of Endodontically Treated Teeth: A Meta-analysis". Journal of Endodontics. 45 (5): 483–9. doi:10.1016/j.joen.2019.02.001. ISSN   1878-3554. PMID   30904319. S2CID   85500512.
  19. ↑ Ahangari, Zohreh; Nasser, Mona; Mahdian, Mina; Fedorowicz, Zbys; Marchesan, Melissa A. (2015-11-24). "Interventions for the management of external root resorption". The Cochrane Database of Systematic Reviews. 2016 (11): CD008003. doi:10.1002/14651858.CD008003.pub3. ISSN   1469-493X. PMC   7185846 . PMID   26599212.
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