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