A clinical approach strategy for the diagnosis, treatment and evaluation of external cervical resorption.

AIM: To propose a clinical approach strategy on the diagnosis, treatment and evaluation of external cervical tooth resorption (ECR) cases. To investigate and discuss the outcome of this approach. METHODOLOGY: A clinical approach strategy on ECR was developed based on a retrospective observation study of 542 teeth. Forty-seven teeth were excluded due to lack of clinical/radiographical information, and 182 were immediately extracted. This approach had three steps: diagnosis, treatment planning and evaluation. During diagnosis, the medical, dental history and clinical/radiographical characteristics were evaluated. Depending on the resorption extent, ECR cases were categorized into four classes according to Heithersay's classification. During treatment planning, a treatment decision flowchart was prepared based on four main decisive criteria: probing feasibility, pain, location and extent of resorption (class), and existence of bone-like tissue. Three treatment options were applied: (a) extraction, (b) monitoring or (c) conservative treatment by external, internal or combination of internal-external treatments. During evaluation, assessment of ECR progression, tooth survival and other factors like aesthetics and periodontal attachment were performed. Descriptive statistical analysis of the outcome for up to 10 years (for the overall clinical approach and for each individual treatment decision), was carried out with OriginLabs OriginPro 9 and Microsoft Excel 365. RESULTS: A three-step strategy was developed on how to deal with ECR cases. Indicative examples of each treatment decision were presented and discussed. The overall survival rate of this strategy was 84.6% (3 years), 70.3% (5 years), 42.7% (8 years) and 28.6% (10 years). Higher survival rate was observed for external treatment decision than for internal. The success of each treatment decision depended on the extent of the resorption (class). The success of a treatment decision should be based on the long-term outcome, as a different evolution can be observed with time. CONCLUSIONS: A clinical approach strategy was introduced on ECR pathosis. This strategy was not solely based on ECR class, as other important decisive criteria were considered. This step-wise approach, has a 70.3% survival rate with a mean of 5 years. This work will hopefully provide an incentive for a broader collaboration, to potentially establish a universally accepted ECR treatment strategy.

Is Hypoxia Related to External Cervical Resorption? A Case Report.

Despite the fact that external cervical resorption (ECR) is a well-known and rather frequently met condition, the driving force of this phenomenon still remains unclear. Recently, hypoxia has been linked to ECR. Thus, the aim of this work was to investigate the existence of hypoxia in ECR and hypothesize on its role at the time of extraction. This work is a case study of a tooth with ECR. ECR diagnosis was based on clinical and radiographic examination with cone-beam computed tomographic imaging. The extracted tooth was further analyzed by using nanofocus computed tomographic imaging and immunohistology. To investigate the 3-dimensional extent and pattern of ECR, in vivo cone-beam computed tomographic imaging and ex vivo nanofocus computed tomographic imaging were used. Different histologic stains were used to investigate the presence of a hypoxic environment and to gain a better insight into the involved cells, neuronal structures, and remodeling process during ECR. A higher distribution of hypoxia-inducible factor 1a-positive cells was found in the apical part of the resorption area when compared with the coronal area of the resorption. In addition, a similar distribution of hypoxia-inducible factor 1a-positive odontoblasts was observed in the pulp. Three-dimensional analysis of the calcification of the pulp revealed the formation of pulp stones in areas with higher hypoxia. Histology showed that remodeling during ECR can occur according to a layered pattern. This investigation confirms the presence of hypoxia in ECR and shows that there is a gradient of hypoxia within the ECR lesion and surrounding tooth structure. The hypoxic environment within the pulp is also indicated by the formation of pulp stones.

Descriptive Analysis of Factors Associated with External Cervical Resorption.

INTRODUCTION: The aim of this study was to perform a descriptive analysis of the occurrence of external cervical resorption (ECR) in relation to the patients' characteristics (sex, age, and tooth type) and the potentially involved predisposing factors. METHODS: This study includes data on 284 patients (337 teeth with evidence of ECR) referred to the University Hospital Leuven (Leuven, Belgium) and Endo Rotterdam (Rotterdam, the Netherlands) for diagnosis and treatment from 2010 to 2015. The medical history, existing radiographs, and dental records were available for evaluation. Each patient was then interviewed followed by a thorough clinical and radiographic examination. Intraoral pictures using a dental operating microscope and digital camera were taken during clinical examination. The radiographic examination consisted of digital periapical radiography and/or cone-beam computed tomographic imaging. A review of existing literature provided a potential predisposing factor checklist for ECR. The clinical data were correlated with the dental and medical history of each patient in an attempt to identify some potential predisposing factor(s) that could contribute to ECR. The frequency of the occurrence of ECR was correlated with tooth type, sex and age of the patient, and each 1 of the recorded potential predisposing factor(s). RESULTS: From the examined teeth (337) with ECR, 175 (54%) were found in male patients and 162 (46%) were found in female patients. In 59% of the cases, more than 1 potential predisposing factor was identified. Most ECR cases were observed on maxillary central incisors (29%) followed by maxillary canines (14%), mandibular molars (14%), and maxillary premolars (11%). In addition, most ECR cases were observed on maxillary teeth (72%). The most frequently appearing factor was orthodontics (45.7%). Other frequently observed factors were trauma (28.5%), parafunctional habits (23.2%), poor oral health (22.9%), malocclusion (17.5%), and extraction of a neighboring tooth (14%). CONCLUSIONS: The data indicate that ECR is not related to patient sex. ECR occurs most often in the maxillary central incisor. In the majority of the cases, more than 1 potential predisposing factor was identified, indicating that ECR may be mainly multifactorial. The most frequently appearing factors were orthodontics, iatrogenic or accidental trauma, and poor oral health. This information may be helpful in diagnosing ECR at an early stage when screening patients presenting with these predisposing factors.

Understanding External Cervical Resorption in Vital Teeth.

INTRODUCTION: The aim of this study was to investigate the 3-dimensional (3D) structure and the cellular and tissue characteristics of external cervical resorption (ECR) in vital teeth and to understand the phenomenon of ECR by combining histomorphological and radiographic findings. METHODS: Twenty-seven cases of vital permanent teeth displaying ECR were investigated. ECR diagnosis was based on clinical and radiographic examination with cone-beam computed tomographic imaging. The extracted teeth were further analyzed by using nanofocus computed tomographic imaging, hard tissue histology, and scanning electron microscopy. RESULTS: All examined teeth showed some common characteristics. Based on the clinical and experimental findings, a 3-stage mechanism of ECR was proposed. At the first stage (ie, the initiation stage), ECR was initiated at the cementum below the gingival epithelial attachment. At the second stage (ie, the resorption stage), the resorption invaded the tooth structure 3-dimensionally toward the pulp space. However, it did not penetrate the pulp space because of the presence of a pericanalar resorption-resistant sheet. This layer was observed to consist of predentin, dentin, and occasionally reparative mineralized (bonelike) tissue, having a fluctuating thickness averaging 210 µm. At the last advanced stage (ie, the repair stage), repair took place by an ingrowth and apposition of bonelike tissue into the resorption cavity. During the reparative stage, repair and remodeling phenomena evolve simultaneously, whereas both resorption and reparative stages progress in parallel at different areas of the tooth. CONCLUSIONS: ECR is a dynamic and complex condition that involves periodontal and endodontic tissues. Using clinical, histologic, radiographic, and scanning microscopic analysis, a better understanding of the evolution of ECR is possible. Based on the experimental findings, a 3-stage mechanism for the initiation and growth of ECR is proposed.

Evaluation of a preparation depth controlling device: a pilot study.

OBJECTIVE: To define the reproducibility and accuracy of the Prepometer device (Hager & Werken) and to correlate the measured electrical resistance with the remaining dentin thickness. METHOD AND MATERIALS: In vivo standardized cavities were made on the buccal side in the cervical region of 12 intact teeth. Measurements with the Prepometer were completed before tooth extraction. After extraction, in vitro measurements of the remaining dentin thickness were performed using a microfocus-computerized tomography scanner. These in vitro scan data were compared with the in vivo measurements, and correlation coefficients calculated. The intra- and interinvestigator variability were defined, using a paired 2-tailed Student t test. The level of significance was set at 5%. RESULTS: Although both the intra- and interinvestigator variability scored well, there was no clear correlation between the Prepometer measurements and the remaining dentin thickness. Because the device determines the electrical resistance of the dentin, which is related to dentin permeability, real remaining dentin thickness cannot be measured. A reasonable safety zone (3 of 12 teeth scored false negative and 1 of 12 teeth scored false positive) in terms of remaining dentin thickness was observed. CONCLUSIONS: The Prepometer, a device developed to screen dentin-surface permeability by measuring its electrical resistance, was shown to be reproducible in its use. However, electrical resistance was shown not to correlate with dentin thickness. Although the Prepometer might help to estimate the risk of pulp injury after tooth preparation, its effectiveness still remains to be proven in a randomized clinical trial.

Effect of polymerization shrinkage on the sealing capacity of resin fillers for endodontic use.

PURPOSE: Recently, highly flowable resin fillers have been proposed for filling root canals using a single-cone approach. The purpose of this study was to test the hypothesis that polymerization shrinkage, which is inherent to this type of filler, can break the close initial contact between the main core and the surrounding dentin even if root dentin infiltration has occurred. MATERIALS AND METHODS: Twenty roots of anterior teeth were prepared chemomechanically and divided into 4 groups of 5 samples each. Groups 1 and 2: hydrophilic resin filler injected and spread, roots sectioned after setting; group 3: hydrophilic resin filler injected and spread, dental substrate dissolved after setting; group 4: hydrophobic resin sealer lentulo-spiraled and spread, roots sectioned after setting (as control). In groups 1, 2, and 3 the material was used following manufacturer's instructions. The section surfaces of groups 1 and 4, and the resin components of group 3 were processed for conventional FE-SEM. The section surfaces of group 2 were observed successively under environmental and high-vacuum conditions. RESULTS: Microscopic examination of the resin-dentin interfaces of groups 1 and 2 showed the existence of resin-dentin interdiffusion zones (RDIZ); however, the close initial contact between the main core and the surrounding dentin was often lost. In group 3, resin tag morphology was well characterized. Identical morphological features were observed in the resin-dentin interfaces in group 4. CONCLUSION: Since the existence of resin tags did not exclude the existence of a gap between the main core and the adjacent RDIZ, our results confirmed the proposed hypothesis.

Age calculation using X-ray microfocus computed tomographical scanning of teeth: a pilot study.

To correlate dental age with an individual's chronological age based on the calculated volume ratio of pulp versus tooth volume measured, an X-ray microfocus computed tomography unit (microCT) with 25 microm spatial resolution was used to non-destructively scan 43 extracted single root teeth of 25 individuals with well-known chronological age. Custom-made analysis software was used by two examiners to obtain numerical values for pulpal and tooth volume. The ratio of both was calculated and statistically processed. No significant intra- or inter-examiner differences were found. In fact, a very strong concordance correlation coefficient was found. Linear regression analysis showed a coefficient of determination (r) of 0.31 which suggests that there is a rather weak correlation between the volume ratio of pulp versus tooth and biological age. Although rather time consuming, this technique shows promising results for dental age estimation in a non-destructive manner using X-ray microfocus computed tomography.