Aparna Aggarwal

Manoj Vengal, AuswafAhsan and Keerthilatha M Pai

·Idiopathic Cervical Resorption: A Diagnostic Di-lemma Abstract: Idiopathic cervical resorption is a rare form of external resorption, usually with no external signs, and can be misdiagnosed as

dental caries or other types of tooth resorption. Here we report a case in which, during routine radiography, an asymptomatic lower rig hr molar presented with a radiolucPncy at the cervical region, with no obvious aetiologic factor identified.

Clinical Relevance: This paper emphasizes the aetiopathogenesis and differential diagnosis of this rare and asymptomatic form of

pathologic resorption, which can be encountered in dental practice.

Dent Update 2007; 34: 646-648

Case report

A 22-year-old female, final

year engineering student reported with

a complaint of repeated food lodgement in relation to her partly erupted lower left

third molar for the past 5 months. This was

associated with discomfort in the form of a continuous, pricking type of non­

radiating pain, which was relieved only on

removal of the lodged food particles. Her

medical history and family history were

non-contributory and she reported having

undergone scaling of her teeth one year

previously.

molar and lower right third molar were

partially erupted, with food debris beneath

the pericoronal soft tissue on the lower left

third molar with minimal inflammation. No

other abnormalities were evident on the

clinical examination.

Intra-oral periapical radiographs

(IOPAs) of the lower third molars werP taken to assess their eruption status. Radiograph1

revealed horizontal impaction of the

lower left third molar and mesioangular

impaction of the lower right third molar. An

Intra-oral examination revealed

satisfactory oral hygiene, dental and

gingival condition. Her lower left.third

Aparna Aggarwal, BOS, MOS, Associate Professor, Department of Oral Medicine

and Radiology, Manoj Vengal, BOS,

MOS, Associate Professor, Department

of Oral Medicine and Radiology, Auswaf Ahsan, BOS, MOS, Associate Professor, Department of Oral Medicine and

Radiology, Keerthilatha M Pai, BOS, MOS, Professor and Head, Department of Oral

Medicine and Radiology, MCODS, Manipal, India.

646 DentalUpdate

Figure l. IOPA of lower right first molar showing a radiolucent defect along the cervical region (see black arrows).

December 2007

Figure 2. Panoramic radiogra ph showing localized area of cervical resorption with respect to lower right

first molar (see black arrows).

periapical or periodontal inflammation,

herpes zoster infection, dental trauma,

cyst, tumour, and excessive mechanical

or occlusal forces.' Pathologic resorption

can be either external or internal. External

resorption can be either the inflammatory

or replacement type.'

ICR is considered as a type of external inflammatory resorption,' which

was first reported by Mueller and Rony as

mentioned by Liang et a/.' ICR is a process

whereby an unprotected, locally destroyed

or altered root surface becomes susceptible

to resorbing elastic cells during an

inflammatory response of the periodontal

ligament (PDL) to a 'stimulus' and a bowl­

shaped invasion of cementum and dentine

in the cervical region of a root by resorptive

fibrovascular tissue.'·'.. It has been

suggested that the potential for resorption

is inherent within the periodontal tissues of

each patient, based mainly upon the tooth morphology (dentine defects at cemento­

enamel junction);'" individual susceptibility

to resorption being the most important • /OPA for the lower right third molar showed

IS an unusual irregular radiolucency extending •r. • along the cervical region of the lower right

first molar from the mesial to the distal

aspect, separating the crown from the roots

and shifting it slightly distally (Figure 1 ).

Lamina dura of the mesial root seemed to

be slightly thickened, but that of the distal

root was disrupted. The only discernible

outline was that of the mesial root canal.

Radiographic artefacts were

out, and a panoramic radiograph

(Figure 2) cancelled out the possibility of

multiple teeth involvement.To eliminate any

factors, a detailed history of

t trauma, orthodontic treatment, bleaching aggressive periodontal

discomfort on chewing from the

. right side, sensitivity, and pain in relation to

lower right first molar was obtained but

was non-contributory.

The patient was clinically re­

examined to exclude cervical abrasion,

root caries, radiolucent restoration, crown

racture or pathologic resorption. The

ingiva in relation to the lower right first

olar was non-inflamed, non-tender and

adherent, with a periodonial pth� 2-

3-mmmfall fhe tooth surfaces. mobility

or cavitations were detected

and there was no tenderness on percussion

change in the normal resonant sound.

Electric pulp testing showed slightly

delayed response.

Considering the above

mentioned facts, the only possibility that

could not be ruled out was of a pathologic

resorption, which might have been initiated

by periodontal tissue trauma during

oral prophylaxis done a year previously.

However, as the panoramic radiograph

showed good generalized bone levels, it

was unlikely that any aggressive periodontal

treatment was carried out. As the lesion

was typically at the cervical region and no

factor could be contributed to its cause, a

diagnosis of'idiopathic cervical resorption'

(ICR) was made. In view of the extensive

nature of the lesion and poor long term

prognosis, extraction was advised. But, as

the tooth was asymptomatic, the patient

did not give her consent for the same.

Follow-up after 3 months was advised, but

the patient relocated after completing her

college education and was lost to follow-up.

Discussion

Tooth resorption i_s a

multifactorial process.' Resorption can be • Physiologic, which is associated with

shedding of the primary teeth; or

• Pathologic, which can be due to chronic

factor.• Pre-dentine possesses resistance

to resorption owing to its organic phase,

which contains an enzyme inhibitor against

resorption.' But, in the case discussed, it was

considered to be of the replacement type,

as for inflammation to occur there should

have been an exposure of resorptive lesion

to the oral cavity.

Although knowledge of

the exact mechanism causing cervical

resorption is limited, factots implicated in

the aetiology are trauma, bleaching with

hydrogen peroxide,'0 periodontal treatment,

orthodontic treatment, dento-alveolar or

orthognathic surgery, idiopathic, etc.1.J·'·"·"

Generalized cervical resorption has been

reported in a patient with periodontal

disease and maintaining a high acidic

diet-" It has also been associated with

many systemic disorders, like hereditary

haemorrhagic telangiectasia,"and

endocrine disorders, as is a known fact

that periodontal tissues are sensitive to

hormonal fluctuations.• Multiple ICR has

been observed in young females.• In this

case, only a single tooth was involved,

whereas in systemic problems, usually

multiple teeth would be involved. Studies

have identified deep scaling and root

planing as a major potential predisposing

factor.'

/CR is a relatively uncommon

DentalUpdate 647

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7.

condition with no external-Signs and radiographic examination.

Coyle M, Toner M, Barry H. Multiple

observed as an incidental finding on The management of ICR is teeth showing invasive cervical

a routine radiograph, as in this case.• based on many factors: resorption - an entity with little

It usually preserves a layer of dentine • Identification and elimination of the known histologic features. J Oral immediately around the pulp, whereas known accelerating factors.' Pathol Med 2006; 35: 55-57.

internal resorption starts from the In case gingival tissue inflammation is the Rodd HD, Naik S, Craig GT. Exterrial

pulp and extends towards the external cause, periodontal care (debridement of cervical resorption of a primary canine. surface.' The radio-opaque layer around plaque and calculus) and mainteriance is Int J Paediat Dent 2005; 15: 375-379.

the pulp helps in differentiating external indicated.' Periodontal curettage done 8. Neville BW, Damm DD, Allen CM,

from internal resorption.' ICR may alone has led to failures.• Bouquot JE. Oral and Maxillofacial

involve a single tooth, multiple teeth or: • Knowledge of the prognosis for success Pathology. Pennsylvania: Elsevier

rarely, the entire dentition.' It is slightly of specific treatment regimen." (Saunders). 2004.

more prevalent in lower teeth than in • Complete removal of the fibrovascular Berg mans L, Cleynenbreuge JV,

the upper teeth and primarily involves tissue and restoration of the lost tooth Verbeken E, Wevers M, Meerbeek BV,

central incisors, followed by canines structure.' Lambrechts P. Cervical external

and premolars.' Deciduous dentition • The extent of involvement. root resorption in vital teeth.JC/in

involvement has been reported in only Periodontol 2002; 29: 580-585.

two cases so far.' Clinically, even after a 10. Tredwin CJ, Naik S, Lewis NJ, Scully C. considerable loss of the tooth structure, Conclusion Hydrogen peroxide tooth-whitening

the tooth in question is frequently firm in ICR, although a rare occurrence, (bleaching) products: review of the dental arch.' On probing, the exposed poses a diagnostic challenge and may be adverse effects and safety issues.

dentine is hard, which distinguishes it from difficult to treat for the dental practitioner. Br Dent J 2006; 200: 371-376.

caries;' the vascular tissue may bleed on 11. Heithersay GS. Clinical, radiologic, and

probing.' Electric and thermal pulp tests

remain positive till the later stages.'

References

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