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Management of Internal Root Resorption with Bioceramic Material on Permanent Tooth-A Case Report | Lupine Publishers

Lupine Publishers | Journal of Pediatric Dentistry

Abstract

Internal root resorption (IRR) is a category of pulp disease characterized by the loss of dentine as a result of the action of clastic cells stimulated by pulpal inflammation. The objective of this case report was to account for the diagnosis and management of an internal root resorption without perforation. The patient, a 26-year-old male, came to Guru Nanak Institute of Dental Sciences and Research, West Bengal, without having symptoms in the tooth. Endodontic treatment was performed using the following methods: irrigation of the root canal with 2.5% of sodium hypochlorite, then calcium hydroxide (CH) was applied as intracanal medicament for one month. Complete instrumentation was done with Hyflex One File (Coltene) and obturation with corresponding guta-percha and Roeko Guttaflow Bio seal sealer (Coltene). The patient was checked after one week and then after six months. He did not have any symptoms and IOPA radiograph did not show any further progression of the lesion.

Introduction

The Glossary of the American Association of Endodontists defines internal root resorption (IRR) as a condition associated with a physiological or pathological process that results in the loss of dentin, cement and bone [1]. Most teeth with internal root resorption are symptom free and are first clinically recognized through routine radiographs. However, when resorption actively progresses, the tooth is only partially vital and may present typical symptoms of pulpitis. Bell (1830) first reported about IRR. Mummery (1920) called it “pink tooth of Mummery” due to the presence of pink discoloration on the crown [2]. This condition, although rare, is more frequent in the male population. The IRR is more common in the presence of a periapical lesion. Its prevalence was estimated between 0.01% and 1% depending on the inflammatory condition of the pulp [3]. The IRR could be caused by several stimuli: trauma, chronic inflammation of pulp/periodontal ligament, heat created by the friction of drills during the preparation of cavities, cracked tooth syndrome, tooth reimplantation and orthodontic treatment [4]. There have also been reported cases of internal reabsorption caused by Herpes Zoster virus [5]. The IRR is caused by inflammatory stimuli which produce an alteration of the odontoclast inhibitory mechanism resulting in an alteration of the pre-dentine layer. The vascular change in the pulp produces hyperemia increasing oxygen tension and causing an acidic pH level that attracts multinucleated cells, odontoclasts and dentin clasts. Dominance of inhibitory substances such as OPG (osteoprotegerin) as activators of RANKL (receptor activator of factor kappa B ligand) followed by swelling, results in the rupture of protective coatings allowing the invasion of odontoclasts and initiating resorptive patterns. Connective, post-resorptive activity tissue transforms into metaplastic granulation tissue [6]. Generally, IRR detection is done by X-rays, however, the use of cone beams computed tomography (CBCT) has been reported to be highly useful for diagnosis in endodontics, since it shows the lesion in detail and includes information about adjacent anatomy, which X-rays does not provide [7]. The periapical radiography is limited because it provides a twodimensional image [8], whereas diagnosis by CBCT shows images in all their dimensions through tomographic slices, without image overlay [9]. Also, diagnosis by CBCT may improve the accuracy and efficiency in the prognosis of the tooth [10]. Therapeutically, the biomaterial employed can influence the prognosis of the nonsurgical endodontic treatment done for extensive internal root resorption [11]. MTA is most commonly used in these cases because of its sealing ability, biocompatibility and potential induction of osteogenesis and cement genesis and it can be used in a humid environment [12]. Another study using an experimental immature tooth model, demonstrated that the MTA also increased the fracture resistance of bovine incisors when submitted to different reinforcement treatments Recently bioceramics are widely used in endodontics. Roeko Guttaflow Bio seal (COLTENE) is a bioceramic endodontic sealer which claims to avoid shrinkage upon setting as it has Zirconium oxide is used as the radiopacifier, and the material is claimed to be aluminum-free, non-soluble and does not shrink during setting. It gives advantage of flow of material as well as sealing ability which better bond with the corresponding gutta percha used for obturation [13]. The purpose of this case report is to describe the diagnosis and clinical management of an internal root resorption with bioceramic material.

Case Report

Male patient, 26 years old, treated at the post graduate department in Guru Nanak Institute of Dental Sciences and Research. The patient reported no pain at the time of appointment the chief complaint was discoloration of the front tooth which was traumatized 5 year back. Vitality tests using Endo-Ice (Coltene, Switzerland) were performed in [11]; the tooth gave negative response. The patient did not present tooth mobility and periodontal pockets. IOPA radiograph of the affected tooth#11 showed an oval enlargement (ballooning out) of the root canal space (Figure 1). The pulp chamber and canal cannot be followed throughout the lesion. Radiograph performed at different angulation to confirm the resorptive lacunae is a continuation of the distorted border of the root canal. Endodontic treatment was suggested; therefore, isolation protocol was performed to make the cavity opening later (Figure 2). Working length of the tooth was determined by IOPA radiograph using #15K file (Figure 3) and the result was confirmed with apex locator Canal Pro (COLTENE). After removing the pulp tissue properly chemical-mechanical instrumentation was performed with Hyflex One File (COLTENE) and irrigation was done with 1ml of 2.5% of sodium hypochlorite between each time instrumentation with 30-gauge side vented needle. This was followed by irrigation with normal saline to remove any remnants of hypochlorite, later canal was dried with absorbent points. Ca (OH)2 dressing was given for 1month and the medicament was changed weekly. After one month, temporary restoration was removed with [4] round diamond bur, canal was irrigated with 5 mL of 2.5% sodium hypochlorite (NaOCl) and 5 mL of 17% of ethylenediaminetetraacetic acid for removing the Ca (OH) dressing and then the canal was flushed with normal saline and dried.

Figure 1: .

Figure 2:

Figure 3:

Figure 4:

Figure 5: .

After removing the medication, obturation was done with Hyflex corresponding Gutta Percha and the remaining pulp chamber was obturated with Guttaflow Bio seal sealer (Figure 4). Access cavity restoration was done with light cure composite resin. The patient was recalled after 6 and 12 months (Figure 5, 6) for clinical and radiographic follow up. Clinical examination of tooth was functional without sensitivity to percussion or palpation [11].

Figure 6: .

Discussion

There is always a dilemma of whether to treat a tooth with a questionable prognosis endodontically or extract it and subsequently place an implant. Bell first reported a case on internal resorption in 1830. Since then there have been numerous reports in the literature [14]. Two types of internal root resorption are generally described: the internal root canal inflammatory resorption and the internal root canal replacement resorption. In the inflammatory resorption, the resorptive process of the intraradicular dentin progresses without adjunctive deposition of hard tissues adjacent to the resorptive sites. The phenomenon is associated with the presence of granulation tissues in the resorbed area and identifiable with routine radiographs as are radiolucent zone centered on the root canal. In the replacement resorption, the resorptive activity cause defects in the dentin adjacent to the root canal, with concomitant deposition of bone like tissue in some regions of the defect. It results in an irregular enlargement of the pulp space with partially or fully obliterated area of the pulp chamber. Internal resorption is the result of an inflamed pulp and the clastic precursor cells recruiting through the blood vessels. Treatment of internal resorption is quite predictable as it is easy to control the process of internal root resorption via severing the blood supply to the resorbing tissues with conventional root canal therapy. Intraoral X-ray of IRR is characterized by the radiographic appearance of an oval shape enlargement within the pulp chamber or the root canal. However, the early diagnosis of the IRR is difficult by examination of a conventional X-ray. If IRR is suspected, several shots under different angles of incidence are recommended. In the treatment of internal resorption, the use of calcium hydroxide also has two other important goals: to control bleeding, and to necrotize residual pulp tissue and to make the necrotic tissue more soluble to sodium hypochlorite. Because of the limited access by instruments to all areas of the resorption cavity, chemical means are needed to completely clean the canal. Studies on the effectiveness of sodium hypochlorite and calcium hydroxide to remove the resorptive and other tissues from the root canal indicate that they have an additive or even synergistic effect [15]. In cases where the resorption has not perforated, it is usually enough to use calcium hydroxide paste in the canal once from 1 to 2 weeks. This allows removal of the residual tissue at the next appointment by irrigation and instrumentation. In our treatment protocol, we choose Guttaflow Bio seal (COLTENE) sealer due to its versatile property of Bioceramic component & gutta-percha particles. Upon contact with fluids, this material provides natural repair constituents, such as silicates and calcium, which contribute to the activation of biochemical processes, providing additional support to the root canal regeneration. A novel material for root canal filling that combines gutta-percha in a powder form with a particle size of less than 30 μm and a sealer. The sealer has also showed least cytotoxicity as well as inflammatory reaction [15].

Conclusion

It is puzzling in diagnosing and treating a root resorption case, therefore a suitable management is perilous. Thorough investigations and discussion are required for the management especially when the prognosis of the tooth is poor upon consultation. Absence of periapical lesion and no signs and symptoms at the 12-months review provided a favorable outcome to once a tooth of hopeless prognosis.

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Analysis of Reasons for Extraction of Permanent Teeth in Children in Senegal: A Retrospective Study | Lupine Publishes

Lupine Publishers - Journal of Pediatric Dentistry

Abstract

Background: Loss of permanent teeth can have negative functional, psychological and social consequences, especially for children and adolescents with growing bone structures. Knowledge of their causes is of interest in the development of comprehensive dental public health programs. The objective of this study was to evaluate the reasons for extractions of permanent teeth in children in public oral structures in Dakar.
Material and method: A retrospective descriptive study, based on consultation registers and patient records, was performed. Patients between the ages of 6 and 15 who had permanent tooth extractions between January 2014 and August 2018 were included. A questionnaire including socio-demographic data, reason for consultation, reason for extraction and extracted teeth was included allowed to collect the data.
Results: A total of 321 patients aged 6 to 15 years received 375 permanent tooth extractions (1.16 teeth / child). Dental caries and its complications were the main reasons for extractions (94.7%).
Conclusion: Dental caries remains a real public health problem in developing countries. Decision-makers need to focus on strategies for the prevention and management of early childhood oral conditions to avoid the extraction of permanent teeth.
Keywords: Reasons for Extraction; Permanent Teeth; Child, Tooth Decay; Senegal

Introduction

The extraction of permanent teeth should not be an insignificant act, especially in children, because of the negative repercussions on eruption phenomena, the harmony of the arches, the primary functions of chewing, swallowing, breathing and phonation. Indeed, the first permanent molar, which is the first permanent tooth to erupt, is the keystone of the occlusion; it determines the shape of the lower part of the face and conditions the position and health of the other permanent teeth [1]. The decision to extract permanent teeth must be reasoned and integrated into a global treatment plan that often requires collaboration with other dental specialties. The analysis of the causes of permanent tooth loss is of interest to practitioners and decision-makers in order to develop control strategies to be integrated into overall dental public health programs. It is from this perspective that an indirect method based on the search for reasons for these permanent tooth losses by extraction has been developed and used in many countries. Numerous studies on the causes of permanent tooth extraction in children, adolescents and adults have been conducted in industrialized countries [2-5] and caries and periodontal disease have been the main causes of extractions. In Africa, studies are rare. The main objective of this study was to evaluate the reasons for extractions of permanent teeth in children in public oral structures in Dakar.

Materials and Methods

This was a descriptive retrospective study of patients consulting the oral structures of Aristide Dantec Hospital (HALD), Albert Royer National Children’s Hospital of Fann (CHNEAR), Dakar Institute of Odonto-Stomatology (IOS) and Grand Yoff General Hospital (HOGGY). Patient selection was based on consultation records. All records of patients aged 6 to 15 years who received permanent tooth extractions were included in the study. A “reasoned choice” sampling was conducted. A data sheet was used to collect information on socio-demographic data, the reason for consultation, the reasons for extraction, and the type of teeth extracted. The collected data were analysed with the SPSS 20.0 IBM software. The quantitative variables were described by their means and standard deviations. The qualitative variables were described by their numbers and percentages.

Results

Among 26362 children consulted, 321 patients (1.21%) aged 6 to 15 years had received permanent tooth extractions. The number of permanent teeth extracted was 375 (1.16 teeth/child). Girls had received 55.2% of extractions. The number of permanent teeth extracted was 375 (1.16 teeth / child). Girls had received 55.2% of extractions. The 12-15 age group had benefited from 77.88% (Table 1). The distribution of extractions by health centre was 33.64% in the CHNEAR and 31.77% in HOGGY (Table 2). The first molars accounted for 76.94% of the extracted teeth (Table 3). Dental caries and its complications were the main reasons for extracting permanent teeth in 94.16% of cases (Table 4). Pain was the reason for consultation for 74.8% of extracted teeth (Figure 1).

Figure 1: Breakdown by reasons for consultation.

Table 1: Distribution of extractions by age group.

Table 2: Distribution of extractions according to the host structure.

Table 3: Distribution of extractions according to tooth type.

Table 4: Distribution by extraction reasons.

Discussions

The health structures selected in this study have the particularity of being centres receiving many patients for general health and oral health care. In addition, the CHNEAR and the IOS have services exclusively oriented towards the oral care of children and adolescents. The prevalence of permanent tooth extractions seems low but not negligible given the key role played by these teeth and in particular the first permanent molar. This result is lower than that reported by Murray et al [6] and Johansen et al [7]. This could be explained by the difference in the study population, which was made up of adults and elderly subjects (20-50 years and >70 years). Children in the 12-15 age group received more extractions than others. This shows that the number of permanent teeth extracted increases with age. Pain was the main reason for consultation and concerned the majority of patients. Studies by several authors [8,9] have produced similar results. This is linked to an economic situation and/or a lifestyle that is not compatible with a “preventive-conscious” approach. Difficulties in access to dental care, lack of dental facilities, lack of financial resources or lack of information and education on oral health may constitute a barrier to systematic visits or consultations as soon as the first signs of dental problems appear [10]. Dental caries and its complications were the most common reasons for extraction of permanent teeth. The first permanent molars were the most frequently extracted teeth. These data support the results of Shammari et al [11] who reported that dental caries was the leading cause of permanent tooth extractions in patients under 40 years of age and that the first permanent molars were the most affected teeth. Other studies [12-17] have shown that the first permanent molar was the most extracted tooth with prevalence ranging from 11.7% to 86.2%. A study by Safadi et al [18] in subjects aged 13 to 20 years showed that the prevalence of extractions of the first permanent molars was 31.3%, of which 76.5% concerned the first lower molars and that dental caries and its consequences were the main reasons for extraction. The greater susceptibility of the first molars to extraction can be explained by several factors. Their eruption, usually around 6 years of age, is silent and usually goes unnoticed, resulting in defective brushing. They have an occlusal surface whose morphology is more favourable to the retention of soft cariogenic deposits [19]. However, given their important roles, especially in children and adolescents, their extraction should be the ultimate therapeutic choice.

Conclusion

It should be noted that dental caries and its complications are the main reasons for the extraction of permanent teeth in children. It is important to implement a policy of promotion, prevention and early management of oral diseases in children aged 12 to 15 years in order to reduce dental loss.

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Lupine Publishers - Journal of Pediatric Dentistry

Management of Mesiodens In Mixed Dentition- Molariform and Tuberculate: A Case Report by Reena Augustine in Interventions in Pediatric Dentistry Open Access Journal - Lupinepublishers

Timely intervention is the key to any setback in the mixed dentition. Teeth which are supplemental to the normal dentition are supernumeraries, the most common being mesiodens, present in the premaxillary region. Certain pathological consequences may arise due to mesiodens like unaesthetic midline diastema, rotation, displacement, root resorption and cyst formation. The current case report presents the management of developing malocclusion in the anterior region due to the presence of mesiodentes- a molariform and a tuberculate. The molariform mesiodens was impeding the eruption of the maxillary right central incisor, thus the surgical removal of both mesiodentes was planned and executed. In addition to this soft tissue uncovering was done for the unerupted maxillary central incisor. On follow up, uneventful healing was observed successfully. Supernumerary teeth, or hyperdontia, is a term that describes teeth that are surplus in number when compared to the normal complement of teeth [1]. The etiology of supernumerary teeth remains unclear and not yet completely understood [2]. Among the various proposed theories that have attempted to explain the causes behind the development of supernumerary teeth, current literature favors the ‘lamina hyperactivity theory’ that states hyperdontia results from independent, locally conditioned hyperactivity of the dental lamina [1]. The most commonly occurring supernumerary tooth is the ‘mesiodens’, a term that was initially coined by Balk in 1917.As the name suggests, the mesiodens is usually located mesial to the central incisors in the premaxillary region [3].

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