Endod Dent Traumatot 1997; 13; 75-81 Copyright © Munksgaard 1997

Printed in Denmark . Alt rights reserved

Endodontics &
Dental Traumatology
ISSN 0109-2502

Prognosis of permanent teeth with internai

resorption: a clinical review
^ali§kan MK, Tiirkun M. Prognosis of permanent teeth with iVI. K. Qali§i(an, M. Furkun
internal resorption: a clinical review. Endod Dent Traumatol 1997; Department of Endodontics, Ege University,
13: 75-81. © Munksgaard, 1997. Bornova-izmir, Turkey

Abstract - This study was performed in order to report the clinical

features of internal resorption cases and evaluate their prognosis
after endodontic treatment. Twenty-seven patients with 28 teeth
with internal resorption were referred to our clinic and 20 teeth were
treated endodontically. Sixteen teeth had non-perforating internal
resorption and were treated by conventional root canal therapy.
The remaining 4 teeth had perforating internal resorption and were
initially treated by remineralization therapy with calcium hydrox-
ide. The teeth treated by conventional root canal therapy showed
Key words: internal resorption; endodontic
clinical and radiographic e\ddence of healing. However, the re- treatment
mineralization therapy was successful in only one case. The three M. Kemal Qali§kan, Ege universitesi,
failed cases were subsequently treated by endodontic surgery. The Di§ Hekimligi Fakultesi, Bornova Kampusu 35100,
surgical therapy was unsuccessful in one case due to extensive loss izmir, Tijrkiye
of marginal alveolar bone and increased tooth mobility. Accepted September 14, 1996

A case report on internal resorption was presented by
Bell as early as in 1830 (1). Since then there have
been numerous reports in the literature. Traditionally,
internal resorption has been associated with a long-
standing chronic inflammation in the pulp. The re-
sorptive process is sustained by infection of necrotic
pulp tissue in the root canal coronal to the area where
the resorption takes place (2). Trauma, caries and
periodontal infections, iatrogenic procedures such as
restorative preparation, improper restoration place-
ment, calcium hydroxide procedures such as vital
pulpotomy and pulp capping, vital root resections, or-
thodontics, bruxism, diathermy, anachoresis, and
radioactive material are suggested as contributory fac-

Table 1. Details of the history and the first examination of the patients

Frequency of code allocations Coding key

Variables 0 (%) 1 (%) 2 (%) 3 (%) 0 1 2 3

1. Age 11 (41) 1 (4) 6 (22) 9 (33) 24-30 3-35 36-40 40 and over
2. Sex 17 (63) 10 (37) men women
3. Number of teeth 13 (46) 7 (25) 3 (11) 5 (18) max.ant.teeth max.post.teeth mand.ant.teeth mand.post.teeth
4. Presumed etiology 12 (43) 7 (25) 4 (14) 5 (18) trauma carious lesion carious-period.lesion unknown
5. Location of resorption 4 (14) 17 (61) 6 (21) 1 (4) apical third middle third coronal third crown
6. Perforation 20 (71) 8 (29) absent present
7. Periradicular pathosis 14 (50) 14 (50) absent present
8. Pain 18 (64) 10 (36) no yes
9. Mobility 20 (71) 3 (11) 5 (18 none slight marked
10. Discoloration 15 (54) 6 (21) 7 (25) none slight marked
11. Percussion 20 (71) 8 (29) absent present
12. Sinus tract 21 (75) 7 (25) absent present
13. Vitality 12 (43) 16 (57) positive negative

75
Qaii§i(an & riiricun
Table 2. Success of endodontic treatment in teeth with internal resorption
Various endodontic treatments Number of teeth Failure
Root canal treatment 16
Recalcification 4 3
Surgical treatment* 3 1
* All of the three surgically treated teeth were subjected to remineralization
treatment prior to the surgical intervention.
tors by different researchers (3^11). It is believed that
internal resorption may occur as an idiopathic dis-
trophic change in cases of unrestored or non-carious
teeth (12-14). Systemic diseases are not considered to
be etiological factors of internal resorption (15).
Internal resorption can be either transient or pro-
gressive (2, 16). It can affect one tooth or many teeth.
Incisors show the highest incidence (9, 17). According
to Gorlin & Goldman (16), its occurrence is more
common in men than women in the fourth and fifth
decades of life and most frequently occurs in the
middle or apical third of the root.
Internal resorption is usually asymptomatic and
first recognized clinically through routine full mouth
radiographs. Pain may occur depending on the pulpal
condition or perforation of the root resulting in a peri-
odontal lesion (8, 9). When the resorption in the
Fig. I. A. Preoperative radiograph oi mandibular left lateral incisor with non-perforating internal resorption and large periapical lesion. B.
Follow-up 2 years after completion of endodontic treatment. Decrease of periapical lesion is evident.
76
crown reaches the enamel, the patient may notice a
pink spot (5, 9).
The devastation rate of internal resorption may be
rapid or slow (9, 15). Spontaneous repair is extremely
rare (18-20). Therefore, "a wait and see" approach
is not appropriate. Prompt endodontic treatment is
recommended in all diagnosed cases, because re-
moval of pulp tissue halts the process (4, 9). Preven-
tion of internal resorption can, to a certain degree, be
accomplished by careful observation of teeth follow-
ing traumatic injuries (5). Most of our knowledge of
internal resorption derives from observations on indi-
vidual cases (3, 7, 12, 21, 22).
The aim of this study was to describe clinical find-
ings in internal resorption cases and evaluate the
prognosis of endodontic treatment of teeth with inter-
nal resorption.
iVIateriai and methods
The study included 28 teeth with internal resorption
of 27 patients who attended the Department of Endo-
dontics, School of Dentistry, Ege University between
1980 and 1993. Supplemental radiographs were
taken from different angles in order to make a defini-
tive diagnosis and to examine the extent of tooth de-
struction. Details of the history and first examinations
M

Fig. 2. A. Preoperative radiograph of maxillar)' right lateral incisor with non-perforating internal resorption and periapicai lesion. B.
Radiograph taken at follow-up examination 4 years after endodontic treatment. Complete healing of periapicai lesion is evident.
in each case were noted. Age and sex of the patient,
number of teeth, possible etiology^, location of internal
resorption lacuna, presence or absence of root perfor-
ation, periradicular radiolucency, pain, mobility and
discoloration of the crown, tenderness to percussion,
sinus tract and response to an electric pulp tester were
recorded (Table 1). The patients' medical histories
were non-contributory.
Two patients with 3 teeth did not accept endodon-
tic therapy since their teeth were asymptomatic. Five
teeth were planned to be extracted due to extensive
root destruction or intra-or periradicular lesions.
The remaining 20 teeth were treated endodont-
ieally by the same operator using a standardized tech-
nique. After local anaesthetic infiltration, except for
necrotic teeth, a standard endodontic access cavity
was prepared under rubber dam isolation. The work-
ing length was established at 1 mm short of the radio-
graphic apex, and the root canal preparation was ac-
complished using 2.5% sodium hypochlorite irri-
gation and hand instrumentation. In vital teeth,
considerable bleeding was encountered from the root
canal. Irrigation with 2.5% sodium hypochlorite and
saline solution aided in controling the bleeding. After
the completion of the chemo-mechanical root canal
preparation, the canals were finally irrigated with 10
Internal resorption
ml 2.5% sodium hypochlorite solution, dried with
sterile paper points, and filled with calcium hydroxide
paste (calcium hydroxide and barium sulfate powder
(Merck, Darmstadt, Germany) in ratio of 8:1 mixed
with glycerine as a medium) by means of a lentulo
spiral filler in a slow-speed handpiece and packed
with the blunted end of a paper point.
In non-perforating cases of internal resorption, the
calcium hydroxide paste was removed one week after
its placement and the apical portion of the root canal
was obturated using gutta-percha (Hygenic, Akron,
OH, USA) and Calcibiotic Root Canal Sealer (Hyg-
enic) as a sealer by a single cone technique. The re-
sorption space was filled with gutta-percha and sealer
by vertical and thermatic condensation via the cor-
onal access cavity.
In perforating cases of internal resorption , the cal-
cium hydroxide paste was changed 3 weeks after the
initial treatment and the paste was checked and re-
placed again two or three times at 3-month intervals.
If a fistulous tract was present, calcium hydroxide
paste was expressed through the fistula. When the re-
mineralization treatment was found to be successful,
the calcium hydroxide paste was replaced with a per-
manent root canal filling using gutta-percha and
sealer as described above.
77
Qali§kan & Fiirkun

Fig. 3. A. Preoperative radiograph of maxillary left lateral incisor

with non-perforating internal resorption. B. Radiograph taken im-
mediately after the obturation of the root canal. C. Radiograph
taken at follow-up examination 3 years after connpletion of endo-
dontic treatment. Periapicai bone pattern was norrnal.

78

Fig. 4. A. Periapicai radiograph of maxillary^ left central incisor with a perforation at the buccal surface of a root caused by internal
resorption. B. Follow-up 4 years after completion of remineralization treatment with calcitim hydroxide and prosthetic restoration. Buccal
perforation was healed and periapicai bone pattern is normal.
A surgical approach was required in 3 cases where
the remineralization treatment was not successful.
The root canal obturation was completed before the
surgical intervention. A triangular buccal or lingual
flap was raised to reveal the perforation area. Re-
moval of the granulation tissue allowed the exposure
of the resorption lacuna. This lacuna was filled with
zinc-free amalgam (Standalloy F, Degussa, Frankfurt,
Germany). The operation site was thoroughly rinsed
with saline solution and the flap was replaced and
sutured.
The patients were examined clinically and radio-
graphically 3 months after the treatment and there-
after at 3- or 6-month intervals for up to 1 year and
then at longer inter\'als. The observation period
varied from 2 to 4 years. The treatment was con-
sidered to be successful if the following criteria were
met: absence of clinical symptoms, absence of peri-
radicular lesions, disappearance or decrease in size of
pre-existing periradicular radiolueeneies, presence of
calcific barrier at the site of perforative defects, and
absence of abnormal mobility and sinus tracts.
Internal resorption
Results
Of the 27 patients, 17 were men (63%) and 10 were
women (37%). Trauma (43%) was the most common
etiologieal factor, followed by carious lesions (25%).
Maxillary anterior teeth showed the highest percen-
tage of involved teeth (46%). The most frequent loca-
tion of internal resorption was the middle third of the
root (61%) (Table 1). Clinical examinations carried
out between 2 and 4 years after the root canal therapy
revealed that all cases with non-perforating internal
resorption (16 cases) were asymptomatic. Of the 7
teeth with periapicai lesions, resolution of the lesions
was observ'ed radiographically at the 6- or 12-month
recall examinations (Fig. lA, B; 2A, B). The remain-
ing 9 teeth without periapicai lesions showed radio-
graphically normal periapicai bone patterns (Fig. 3A"
C).
Of the 4 teeth with perforating internal resorption
exposed to remineralization treatment with calcium
hydroxide, only one tooth with the perforation was
on the buccal surface of a root, showed clinical and
79
 & rurkun

Fig. 5. A. Preoperativc radiograph showing lingual perforating internal resorption associated with mandibular right second pretnolar.
Recalcification treatment with calcium hydroxide failed. B. Radiograph taken during the obturation of the apical portion using gutta-percha
and sealer by a single cone technicjue. Note the margins of resolution space. C. Radiograph taken after completion of the filling of the
resorption space with gutta-percha and sealer by vertical and thermatic condensation. D. Radiograph taken at follow-up examination 3
years after eompletion of surgical endodontic treatment. No evidence of periradicular pathology.

radiographic evidence of healing (Fig. 4A, B). The Discussion

draining sinus tract closed after the initial calcium hy-
droxide application. At the 9-month recall examin-
ation, a calcified barrier could be detected and the
calcium hydroxide paste was dr^,. The process of heal-
ing was followed both elinically and radiographically
at subsequent recall appointments as well as after the
completion of the endodontic treatment.
The 3 teeth that did not respond to recalcification
treatment were later treated by endodontic surgery.
Two of these teeth remained asymptomatic and no
radiographic changes were evident at the follow-up
examinations (Fig. 5A-D). However, these teeth
showed increasing gingival probing depths and loss
of marginal alveolar bone to the apical level of the
restoration of the resorption lacuna. The surgical
therapy was found to be unsuccessful in one tooth
due to extensive loss of marginal alveolar bone and
severe tooth mobility. This tooth was extracted.
This study did not aim to analyze the prevalence of
teeth with internal resoiption statistically because it
was felt that the number of cases was inadequate.
However, our clinical findings that it was more fre-
quent in males, that the most affected teeth were the
maxillary incisors, and that it occurred most fre-
quently in the middle third of the root corroborated
the findings of earlier reports (9, 10). Kerr et al. (23)
claim that occurrence of internal resorption is most
frequently seen in women in the second and third
decades of life. In the present study, it was more com-
mon in persons in their twenties. Also, trauma was
the most common contributory factor which causes
the internal resorption via the infection of necrotic
pulp. This finding also agrees with previous reports
(3, 6, 9).
Treatment of internal resorption is quite predict-

80

able. Root canal therapy will interrupt the resorptive
process. If the resorptive defect does not perforate the
canal wall, root canal therapy should be the choice of
treatment. In teeth with perforating defects, remin-
eralization of the defect may occur following calcium
hydroxide treatment, but often a surgical approach
will be necessary, and some eases may require extrac-
tion (8, 9, 21). In the present study, different examples
related to all these treatment approaehes were in-
cluded.
Conventional root canal therapy resulted in a high
degree of success in the treatment of non-perforating
internal resorption, which was in accordance with
previously reported results (3, 7, 12).
The prognosis of remineralization of root perfor-
ations is poor (8). Multiple appointments in which re-
peated applications of calcium hydroxide for a long
period of time are required in order to create hard
tissue closure of root perforations (24). Of the 4 teeth
with perforating internal resorption which were treated
with calcium hydroxide, in spite of repeated appli-
cation, 3 teeth failed. A possible explanation for the
failure is the presenee of periodontal pocket even
though, clinically, a pocket could not be probed. The
periodontal pocket causes the communication of per-
foration with oral fluids and washing out of the calcium
hydroxyde, because the perforation is coronal to the
epithelial attachment. When these teeth were treated
surgically, increasing gingival probing depths and loss
of marginal alveolar bone were obser\'ed, but they were
symptomless and in function except for one case.
References
1. BELL T . The anatomy, physiology, and disease of the teeth.
Philadelphia: Carey and Lee Publishing, 1830; 171-2.
2. TRONSTAD L . Root resorption - etiology, terminology and clin-
ical manifestations. Fndod Dent Traumatol 1988; 4: 241-52.
3. MORSE DR. Internal root resorption obturated by the gutta-
percha-eupercha endodontic method; Report of a case. Tlie
Compendium of Continuing Fducation 1985; 6/414-23.
4. SMULSON M H , SIERASKI S M . Histophysiolog}' and diseases of
Internal resorption
the dental pulp. In; WEINE FS, ed. Fndodontic therapy. 4th ed. St.
Louis; CV Mosby, 1989; 150.
5. BAKLAND L K . Root resoqation. In; HOVLAND E J , ed. The Dental
Climes of North America Fndodontics. Philadelphia; WB Saunders
Co. 1992; 36(2): 491-507.
6. RABINOVVTTCH B Z . Internal resorption. Oral Surg Oral Med Oral
Pathol 1972; 33: 263-82.
7. MANDOR R B . A tooth with internal resorption treated with a
hydrophylic plastic material; a case report. J Fndod 1981; 7:
430-2.
8. WEBBER RT. Traumatie injuries and the expanded endodontic
role of calcium hydroxide. In; GERSTEIN H , ed. Teelmique.s in
elinieal endodonties. Philadelphia; Saunders Co, 1983; 181-4.
9. CHIVIAN N . Root resorption. In; COHEN S, BURNS RC, eds.
Pathways of the pulp. 3rd ed. St. Louis; C \ ' Mosby, 1984; 543-
84.
10. CoRLiN J K , CoLDMAN MH. Thoma's oral pathology: Volume 1.
St. Louis; CV Mosby, 1970; 210-2.
11. PENIDO R S , CARREL R , CHIALASTRI A]. The anachoretic effect
in root resorption; report of a case. J Pedod 1980; 5: 85-9.
12. SAMIMY B . Idiopathic internal resorption - a case report. J Br
Fndod Soe 1978; //.• 11-2.
13. L\T^GH EJ, AHLBERG KR Bilateral idiopathic tooth resorption
of upper first premolars. Int Fndod J 1984; 17: 218 20.
14. BROOKS K J . An unusual case of idiopathic internal resolution
beginning in an unerupted permanent tooth. J Fndod 1986; 12:
309-11.
15. BROWTJ CE. A case indicative of rapid, destructive internal re-
sorption. J ^H^fo^ 1987; 19: 516-8.
16. W^EDENBERG C, LiNDSKOG S. Experimental internal resorption
in monkey teeth. Fndod Dent Traumatol 1985; /.- 221-7.
17 GouLTSCHN J, NiTZAN D, .\zAZ B. Root resorption - review
and discussion. Oral Surg Oral Med Oral Pathol 1982; 54: 586-
91.
18. WEISMAN M I , RAGKLEY R H . Recalcification of internal resorp-
tion. A rare case. J Ga Dent Assoe 1968; 41: 15.
19. HARTNESS DJ. Fraetured root with internal resorption repair
and formation of callus. J £'n//o(/ 1975; /.• 73-5.
20. QALI§KAN M K , PI§KIN B . Internal resorption occurring after
accidental extrusion of iodoform paste into the mandibular ca-
nal. Fndod Dent Traumatol 1993; 9: 81-4.
21. FRANK AL, WEINE FS. Nonsurgical therapy for the perforative
defect of internal resorption. J .4m Dent Assoc 1973; 87: 863-8.
22. QALI§K.AN MK, TURKUN M . Root canal treatment of a root-
fractured incisor tooth with internal resorption; a case report.
Int Fndod J 1996 (In press).
23. KERR DA, COURTNEY RM, BI^RKES EJ. Multiple idiopathic
root resorption. Oral Surg Oral Med Oral Pcithol 1970; 29: 552-
63.
24. E L DEBB ME, EL DEBB M , TABIBI A, JENSEN JR. An evaluation
of the use of amalgam, ca\it, and calcium hydroxide in the
repair of furcation perforations. J'£'?Z(/ort' 1982; 8: 459-60.
81