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Idiopathic external root resorption – A case report

Article · April 2011

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CASE REPORT
Idiopathic External Root Resorption – A Case Report
Madhuri Sawai,1 Pravesh Mehra2
ABSTRACT
Generalized external root resorption is a rare condition. As the
condition is non-symptomatic, a case is usually diagnosed during
routine dental radiographic examination. Though many etiologies
have been associated with external root resorption, a single
causative factor is difficult to determine, more so in the case of
generalized external root resorption. Hence, most of these cases
are labeled as Idiopathic external root resorption.
Being a rare entity, this case report is an addition to the existing
literature.
Key Words: Idiopathic, root resorption, external.
Introduction
Human tooth is composed of enamel, dentin and
cementum i.e. the hard tissues and pulp and periodontal
ligament i.e. the soft tissues. Resorption of roots of
primary teeth is a normal physiologic process leading to
exfoliation of the tooth. However, a permanent tooth
root resorption is not a normal condition.
Pathologic root resorption has been broadly classified
based on the site of occurrence into:
 External Root Resorption
 Internal Root Resorption
Andreasen1 (1985) classified root resorption as:
 Surface
 Inflammatory
 Replacement – ankylosis
Heithersay2 (1999) classified tooth resorptions as:
 Internal
o Internal Replacement Resorption
o Internal Inflammatory Resorption
 External
o External Surface Resorption
o External Inflammatory Root Resorption
(cervical resorption)
51  With Vital Pulp IJCD • JUNE,explained
 With Non Vital Pulp © 2011 Int. Journal of Contemporary
 With Vital Pulp
 With Non Vital Pulp
 External Apical Resorption
o External Replacement Resorption
o Ankylosis
Over the years, various authors associated external root
resorption with different etiologies like:
 Periapical inflammation
 Reimplantation of teeth
 Tumours and Cysts
 Excessive Mechanical and Occlusal Forces
 Idiopathic
But for internal root resorption, the most likely causes
cannot be determined, hence, it is mostly Idiopathic.
Some other rare etiologies have been associated with
external root resorption like frequent scaling and root
planing, late orthodontic correction, systemic conditions
like hypophosphatasia, Paget’s disease, Calcium-
phosphorous metabolic alterations, calciuria and genetic
susceptibility3. A number of cases have been observed
after the intracoronal bleaching. A strong suspicion
exists that bleaching agents such as 30% H2O2 were able
to penetrate the dentin, alter the root surface and
irritate the periodontal ligament and surrounding
tissues; although there is no scientific study to prove this
effect4.
Though several etiologic factors have been advocated,
but the prediction and prevention are still impossible
and an exact diagnosis and treatment is often far from
easy, depending upon the severity and localization of the
defect5.
External root resorption occurs immediately
below/apical to the epithelial attachment of the tooth.
As a result, the location is not always cervical but related
to the level of marginal tissues and the pocket depth.
Clinically, external root resorption is associated with
inflammation of the periodontal tissues and does not
have any pulpal involvement6. It has been postulated
that bacteria in the sulcus sustain the inflammatory
response in the periodontium2, 7. The pulp does not play
any role in external root resorption. It always remains
protected by a thin later of predentin. This could be
2011 • 2(3)by the fact that predentin possess a resistance
8.
to resorptionDentistryas demonstrated by Stenvik and Mjor It
 CASE REPORT

Fig.1: OPG – Showing Extraction Sockets of 14, 15 along with External Root Resorption in 12 and 13

Fig.2: OPG – Showing Extraction Sockets of 12, 13 along with External Root Resorption of 11, 21, 22, 23 and 24.

Fig.3: Clinical Photo – Showing the Present Intraoral Condition Fig.4: Clinical Photo – Showing the Present Intraoral Condition with
the Removable Partial Denture in Place.

IJCD • JUNE, 2011 • 2(3) 52

© 2011 Int. Journal of Contemporary Dentistry
 CASE REPORT
Fig.5: Recent OPG – Showing Generalized Root Resorption except in teeth number 36, 37 and 38
protected by a thin later of predentin. This could be
explained by the fact that predentin possess a
resistance to resorption as demonstrated by Stenvik
and Mjor8. It has been stated that the organic phase of
the predentin contains an enzyme-inhibitor against
resorption9.
Researchers have reported cases of external root
resorption, showing localized and some generalized
involvement of teeth along with different theories for
the occurrence of external root resorption.
A rare form of multiple idiopathic root resorption have
been reported which involved all or nearly all teeth10.
The resorption in this case began at the cementoenamel
junction or nearer to the root apex. The authors have
pointed out that these patients have no medical
problem and have no past history of orthodontic
treatment or radiation.
Gold and Hasselgren11 in their case reported the
presence of an unprotected, locally destroyed or altered
root surface. They suggested that the root surface
became susceptible to their resorbing clastic cells
during inflammatory response of the periodontal
ligament to traumatic (injury) or bacterial (irritation)
stimulus, which was maintained by infection in the
adjacent marginal tissues.
Lindskog and Hammarstrom12 reported that the
intermediate cementum had resorption preventing
function, whereas, Wedenberg and Lindskog9 suggested
that predentin layer had an inhibitory action against
resorption. Along with different theories for external
root resorption, different authors suggested different
approaches to the treatment of such cases.
Some suggested the procedure of subgingival curettage
to arrest resorption. Others suggested use of calcium
hydroxide to neutralize resorption, or exposure of
resorption defects for purpose of restoration with glass
ionomer cement or light cure composite resin13.
IJCD • JUNE, 2011 • 2(3)
53 © 2011 Int. Journal of Contemporary Dentistry
Extraction of involved teeth was also suggested by some
researchers.
The case reported here is one such rare case where
multiple teeth show external root resorption and the
use of different treatment plans to arrest resorption.
Case Report
A female patient, aged 40 years, reported to the
department of Dental and Oral Surgery, Lady Hardinge
Medical College and S. K. Hospital, New Delhi, India,
with a complaint of two adjacent painless mobile teeth.
The patient was healthy, with non-contributory medical
history, family history and no history of any previous
dental treatment.
Intraoral examination of the patient revealed a full
complement of permanent erupted teeth in good
occlusion and without any carious teeth. The
periodontal condition was also excellent without any
plaque or calculus deposit. The crowns of 14,15 showed
grade II mobility. There was no history of trauma with
relation to 14,15 in the past. As the prognosis of these
teeth was poor, they were extracted and the patient
was kept on observation and implant treatment was
suggested for their replacement.
The patient then reported 2 months later for the
replacement of teeth. An OPG was advised which
revealed severe external root resorption in tooth
number 12, 13 (fig. 1). As the patient was considered
for implants, tooth 12, 13 were also extracted so that all
4 teeth could be replaced together. The patient was
then recalled after 2 months for further treatment.
Two months later a new OPG was taken which revealed
external root resorption with teeth number 11, 21, 22,
23, 24 (fig. 2). Routine blood investigations,
investigations relating to hormonal imbalance and
investigations related to bony changes like AST, ALP etc.
were done and found to be within normal range. This
time, a periodontal flap surgery with restoration with

glass ionomer cement was done with teeth number 11,
21, 22, 23, 24. The patient was kept on follow up.
However, the treatment procedure did not succeed and
ultimately all these teeth were extracted (fig. 3). The
patient was then advised the use of a removable partial
denture.
Since then, the patient is using a removable partial
denture with the teeth number 15, 14, 13, 12, 11, 21,
22, 23, 24 and uses topical application of GC tooth
mousse to help in remineralization of teeth (fig. 4).
Almost 2 years later, the patient reported now with a
similar complaint of a single mobile tooth. On intraoral
examination, tooth number 16 was grade II mobile and
had a pink hue. Tooth number 44 also had a pink hue.
Cervical abrasion was seen with teeth number 33, 34
and 43. The patient was advised a new OPG. The OPG
revealed that all the teeth except 35, 36, 37 and 38 had
external root resorption (fig. 5). The resorption was
more severe with tooth number 16. All blood
investigations along with investigations to determine
hormonal imbalance or any other systemic pathology
were repeated again. The reports were non suggestive
of any such systemic abnormality. Thus the case can be
classified into the category of generalized idiopathic
external root resorption.
The patient is still been followed up and periodically
OPG is taken to monitor the radicular changes.
Discussion
The patient in this case was medically fit and did not
give history of any past dental treatment. Knowing the
nature of disease and its spread, the case was thus
diagnosed as ‘Idiopathic Generalized External Root
Resorption’.
Different treatments suggested in the literature were
tried in this case like extractions; subgingival curettage
with restoration with glass ionomer cement was tried
but did not succeed. As the disease kept on extending
to earlier uninvolved teeth and at present has become
extensive that is involving most of the teeth of the
dentition, other treatments like exposing root surfaces
by ostectomy was not considered as it would
compromise the aesthetics. Hence the patient still
maintains a recall visit and is under treatment of topical
application of GC tooth mousse.
References
1. Andreasen J O. External Root Resorption: Its
Implications in Dental Traumatology, Pedodontics,
Periodontics, Orthodontics and Endodontics.
International Journal of Endodontics 1985:8; 109-
118
2. Heithersay G.S. Clinical, Radiographic and
Histopathologic Features of Invasive Cervical
Resorption. Quintessence International 1999:30;
27-37
IJCD • JUNE, 2011 • 2(3)
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© 2011 Int. Journal of ContemporarySenior
CASE REPORT
3. Llena-Puy M C, Amengual-Lorenza J and Forner-
Navarro L. Idiopathic External Root Resorption
Associated to Hypercalciuria. Med Oral 2002 : May
– June 7(3); 192-199
4. Friedman S, Rotstein I, Libfeld H, Stabholz A and
Heling I. Incidence of External Root Resorption and
Esthetic Results in 58 Bleached Pulpless Teeth.
Endodontics and Dental Traumatology 1988; 4:23-
26
5. Bergman L, Van Cleynenbreugel J, Verbeken E,
Wevers M, Van Meerbeek B, and Lambrechts P.
Cervical External Root Resorption in Vital Teeth – X-
ray Microfocus – Tomographical &
Histopathological Case Study. J Clin Periodontol
2002:29; 580-585.
6. Frank A.L, and Torabinejad M. Diagnosis and
Treatment of Extracanal Invasive Resorption.
Journal of Endodontics 1998:7; 500-504
7. Tronstad L. Root Resorption, Etiology, Terminology
and Clinical Manifestations. Endodontics and Dental
Traumatology 1998:4; 241-252
8. Stenvik A and Mjor I. Pulp and Dentine Reaction to
Experimental Tooth Intrusion. Americal Journal of
Orthodontics 1970:57; 370-385
9. Wedenberg C and Lindskog S. Experimental Internal
Resorption in Monkey Teeth. Endodontics and
Dental Traumatology 1985:1; 221-227
10. Kerr D. A, Courtney R M, Burkes J E. Multiple
Idiopathic Root Resorption. Oral Sur 1970:29; 552-
565
11. Gold S I and Hasselgren S. Peripheral Inflammatory
Root Resorption. A Review of Literature with Case
Reports. J Clin Periodontol 1992:19; 523–534
12. Lindskog S and Hammarstrom L E. General
Morphological Aspects of Resorption of Teeth and
Alveolar Bone. International Endodontic Journal
1985:18; 93-108
13. Heithersay G.S. Clinical Endodontic and Surgical
Management of Tooth and Associated Bone
Resorption. International Endodontic Journal
1985:18; 72-92
About the Authors
1. Dr. Madhuri Sawai
Associate Professor, Department of
Periodontology, Faculty of Dentistry,
Jamia Millia Islamia, New Delhi
2. Dr. Pravesh Mehra
Professor and Head of the Department,
Department of Oral and Maxillofacial
Surgery, Lady Hardinge and S K Hospital,
New Delhi
mehra_who@yahoo.com
Address for correspondence:
Dr. Madhuri Sawai
Associate Professor, Department of Periodontology, Faculty
of Dentistry, Jamia Millia Islamia, New Delhi
Email: madhuri@sawai.in
54
Dentistry Lecturer,