Case conference Boondarick Niyatiwatchanchai,DDS
Patient Historyผู้ป่วยหญิงไทยอายุ 31 ปี
อาชีพ ผู้ช่วยทันตแพทย์
ปฎิเสธการมีโรคประจำตัวและการแพ้ยา
อาการสำคัญ ถูกส่งตัวมาจากคลินิกเพ่ืออุดฟันหน้าล่างท่ีพบรอยโรคจากภาพรังสี
Dental history and present illness
ผู้ป่วยรู้สึกว่าฟันหน้ามีลักษณะสั้นลงในช่วงเวลา 1 ปีที่ผ่านมา และพบฟันผุบริเวณคอฟันของฟันหน้าล่างจากฟิล์ม x-ray จึงได้รับคำแนะนำให้มารักษาที่คณะทันตแพทยศาสตร์ จุฬาลงกรณ์มหาวิทยาลัย
Extra oral examination
Extra oral examination
Intra oral examination
Intra oral examination
ไม่พบ 11,21,25 ในช่องปาก
ไม่พบฟันซี่ 36,37 ในช่องปาก
Lower anterior
Lower right posterior
gr
group function
Radiographic examination
Upper anterior
Upper right posterior
Upper left posterior
Lower anterior
Lower right posterior
Lower left posterior
Posterior bitewing
Radiographic finding
พบรอยโรคโปร่งรังสีที่บริเวณคอฟัน ฟันซี่
12MD,13M,22MD,23M,31MD,32MD,33MD,41MD,42MD,43MD,34MD,35MD,36MD,48M
Panoramic
Differential diagnosis
dental caries
root resorption
dental caries after radiation multiple invasive
cervical resorptionEisbruch, A., Ten Haken, R.K., Kim, H.M., Marsh, L.H., Ship, J.A. (1999) Dose, volume, and function relationships in parotid salivary glands following conformal and intensity-modulated irradiation of head and neck cancer. Int J Radiation Oncol Biol Phys, 45, 577-587
ซักประวัติและตรวจเพิ่มเติมไม่เคยได้รับการฉายรังสี
ไม่เคยประสบอุบัติเหตุ
ไม่เคยจัดฟัน
ไม่เคยฟอกสีฟัน
ไม่เคยเจ็บป่วยรุนแรงจนต้องนอนโรงพยาบาล
เท่าที่ทราบบุคคลในครอบครัวไม่เคยมีอาการเช่นเดียวกัน
EPT : 31= 33 , 32=40 , 33=35 , 41=30 , 42=33 ,43=33
Radiologist consultation
ลักษณะรอยโรคไม่เหมือนกับโรคฟันผุ แต่มีลักษณะคล้ายกับการ resorption เนื่องมาจากการเห็นขอบเขตที่ชัด และตำแหน่งของการเกิดโรค
impression for multiple cervical resorption
Reviewtooth resorption
tooth resorption- the loss of hard dental tissue (i.e. cementum and dentin) as a result of odontoclastic action.
- classified by its location in relation to the root surface
- may be physiological and pathological
- External resorption can be divided into three broad groups:
(a) trauma-induced tooth resorption
(b) infection-induced tooth resorption
(c) hyperplastic invasive tooth resorption
Heithersay,2007
!
insidious in nature and generally present complex therapeutic challenges
resorbing tissue invades the hard tissues of the tooth in a destructive, and apparently uncontrolled fashion,
akin to the nature of some fibro-osseous lesions such as fibrous dysplasia.
An important distinguishing factor for this third group of resorptions is that, unlike the first two types of resorption, simple elimination of the cause of the lesion is ineffective in arresting their progress
hyperplastic invasive tooth resorption
Heithersay,2007
Total removal or inactivation of the resorptive tissue is essential
The reason for recurrence or concurrence is probably due to the invasive nature of the resorptive tissue whereby small infiltrative channels are created within the dentine and these may interconnect with the periodontal ligament
hyperplastic invasive tooth resorption
Heithersay,2007
Heithersay,2007
pulpal origin or periodontal origin
may be subdivided into
internal replacement (invasive) resorption
invasive coronal resorption
invasive cervical resorption
invasive radicular resorption.
hyperplastic invasive tooth resorption
Heithersay,2007
Cervical external resorption
Invasive cervical resorption is not a common occurrence, is insidious and often an aggressive form of external tooth resorption, and can occur in any tooth in the permanent dentition.
Heithersay,2007
In the absence of treatment, invasive cervical resorption leads to progressive and usually destructive replacement of tooth structure.
pinkish colour in the tooth crown
may be no obvious outward sign
its detection may be by routine radiographs.
usually painless unless there is superimposed secondary infection when pulpal or periodontal symptoms may arise.
Heithersay,2007
results in the loss of cementum and dentine by an odontoclastic type of action.
begins just apical of the epithelial attachment of the gingiva at the cervical area of the tooth but can be found anywhere on the root.
ICR is still not clearly understood.
Heithersay,2007
Diagnosis!
usually found at cervical region
pink spot in the cervical region
hard and mineralised on probing
EPT usually positive
usually no symptoms
outline of root canal should be visible and intact
cone beam CT is useful to assess the lesion
Heithersay,2007
Etiology and pathogenesis
Microscopic analysis of the cervical region of teeth has shown that there appear to be frequent gaps in the cementum in this area, leaving the underlying mineralised dentine exposed and vulnerable to osteoclastic root resorption.
Heithersay,2007
Etiology and pathogenesis
damage or deficiency of the protective layer of cementum apical to the gingival epithelial attachment exposes the root surface to osteoclasts, which then resorbs the dentine.
Heithersay,2007
Histopathologysimilar to any other inflammatory root resorption
resorption cavity contained granulomatous fibrovascular tissue
Thin layer of predentin is always present
free of acute inflammatory
Clasting resorbing cells and Howship’s lacunae
In advanced lesion ectopic calcification may be observed
Patel,2009
Thomas,2009
Bergmans,2002
John J,2012
3 Conditions
blood supply, breakdown or absence of the protective layer, and a stimulus In the case of ICR, the external protective layer is the cementum, and the internal layer is the predentine of the pulp.
Heithersay,2007
Protective layer
The exposure of pulp is prevented by the predentin layer
predentin contains an anti-invasion factor and resorption inhibitor
Shilpa ,2013
Predisposing factor
Physical-orthodontic treatment—segmental orthonathic surgery-transplant teeth-bruxism -guided tissue regeneration
Chemical agents-intracoronal bleaching -secondary bone grafting in unilateral complete cleft palate patient -tetracycline conditioning of root
Heithersay GS. Invasive cervical resorption: An analysis of potential predisposing factors.
Quint Int 1999;30(2):83-95.
classification
Heithersay,1999
Class 1: Small invasive resorptive lesion with shallow penetration into
dentine. _Class 2: Well-defined invasive resorptive lesion close to the
coronal pulp chamber. _Class 3: Deeper invasion extending into the coronal third of radicular
dentine. _Class 4: A large invasive lesion
extending beyond the coronal third of the root.
Heithersay,1999
Management
!
Curetting the active tissue from the resorption cavity and restoring the defect
with a suitable restorative material.
Traditional method of treatment
Heithersay GS. Treatment of invasive cervical resorption: an analysis of results using topical application of trichloracetic acid, curettage, and restoration. Quintessence Int 1999:30;96-110.
Alternative treatment method
the topical application of 90% aqueous trichloracetic acid, curettage and restoration, has been outlined and clinically assessed
Heithersay GS. Treatment of invasive cervical resorption: an analysis of results using topical application of trichloracetic acid, curettage, and restoration. Quintessence Int 1999:30;96-110.
trichloracetic acid (TCA)
is an analogue of acetic acid , It is widely used in biochemistry for the precipitation of macromolecules, such as proteins, DNA, and RNA.
used for cosmetic treatments, such as chemical peels, tattoo removal, and the treatment of warts, including genital warts. It can kill normal cells as well.
Heithersay GS. Treatment of invasive cervical resorption: an analysis of results using topical application of trichloracetic acid, curettage, and restoration. Quintessence Int 1999:30;96-110.
One advantage of this approach is haemorrhage control
As the effect of trichloroacetic acid is to cause coagulation necrosis, the resorptive tissue is rendered avascular.
Heithersay GS. Treatment of invasive cervical resorption: an analysis of results using topical application of trichloracetic acid, curettage, and restoration. Quintessence Int 1999:30;96-110.
Monsel’s solution
another option in case that TCA is not available
a 72% solution of ferric sulphate with sulphuric acid
John J,2012
Consideration in bonding
Dentin that has been treated with TCA is severely demineralized and is not suitable for bonding with either dentin-bonding agents or glass ionomer materials. It must be ‘‘refreshed’’ with a bur before bonding procedures
Schwartz,2010
Multiple invasive cervical resorptionFirst reported by Mueller and Rony in 1930
since then numerous other cases have been documented where none of the common initiating factors appears to have been involved
Liang,
Multiple invasive cervical resorption
Although mICR is rare in humans, a similar disease known as feline odontoclastic resorptive lesions (FORL) is common in cats. FORL has been associated with feline viruses all patients reported having had direct (2 cases) or indirect (2 cases) contact
blood samples were taken from all patients for neutralization testing of feline herpes virus type 1 (FeHV-1). Indeed, the sera obtained were able to neutralize (2 cases) or partly inhibit (2 cases) replication of FeHV-1, indicating transmission of feline viruses to humans.
Thomas , 2012
The patient was questioned about possible contact with cats. She confirmed that she lives with several cats and reported that one (a 6-year-old female) had had severe drooling, and that 2 teeth had had to be removed by the veterinarian in April 2008. The veterinarian was contacted by telephone and confirmed that both teeth had presented with neck lesions, presumably feline odontoclastic resorptive lesions
Thomas , 2012
Case report
A 36-year-old woman presented with pain in her maxillary left canine and first premolar that had persisted for 15 day !!!
Patient history
The patient’s history failed to reveal any incidence of trauma, orthodontic treatment,bleaching,periodontal treatment or other relevant information. !
There was no family history of any similar condition, and she had no pets or any contact with cats. !
Further investigate
Relevant ionic(calcium and phosphorus) , enzymatic(alkaline phosphatase) and endocrine investigation (T3,T4 and parathyroid hormone) report were normal A diagnosis of multiple idiopathic cervical resorption was made
Treatment
Endodontic treatment for the canine and second premolar, followed by surgical exposure and restoration for the canine, second premolar, and first molar, was planned.
treatment planconsult oral medicine for further investigation and rule out the systemic disease
consult periodontist for periodontal surgery
consult endodontist for TCA application and root canal therapy if need
consult radiology for cone beam CT
consult occlusion to assessment the occlusion abnormally
Cone beam CT
Cone beam CT
Cone beam CT
Endodontic treatment
Endodontic treatment might be necessary with some class 2 and usually class 3 lesions when pulpal involvement has occurred or is very close to occurring.
The use of RMGI
The use of adhesive restorative materials has been proved a biocompatible alternative for restoration of deep lesion or cervical abrasion prior to surgical root coverage. The response of periodontal tissue to adhesive restorative materials has been studied by a number of investigators
Konradsson and Van Dijken,analyzed interleukin-1 levels in the gingival crevicular fluid adjacent to subgingival restorations of resin modified glass ionomer cement and concluded that the restorations did not alter gingival health nor did they significantly affect interleukin-1 levels or induce gingival inflammation ! Martins et al, analyzed the histological response of periodontal tissues to subgingival class V resin-modified glass ionomer cement restorations and observed biocompatibility of tested restorative materials.
treatment plan
Periodontal surgery , TCA , curettage , restoration with RMGI wih/without endodontic treatment
do nothing
Prognosis
smaller lesions offer the most favorable long-term outcome.
Heithersay has reported a 100% success rate in the treatment of class I and II ECR lesions The success rate in class 3 lesions was 77.8% and only 12.5% of teeth in class 4 cases.
Heithersay,1999
Discussion
Thank you