A 22-year-old male with pain and tooth surface loss on multiple teeth

Dr. Sageer Ahmed (MS Resident): A 22-year-old male reported to the outpatient department with the complaints of occasional pain and tingling sensation on his maxillary left posterior teeth and mandibular anterior teeth for 3 to 4 months with slight mobility of mandibular anterior teeth. He had no significant medical history as well as no history of trauma and familial history of similar disease. He also stated that he went to Dhaka Dental College where he received clinical and radiological investigations and diagnosed as a case of external tooth resorption. In the Dhaka Dental College, upper left 1st and 2nd premolar, mandibular right central and lateral incisor teeth were extracted. Root canal treatment was started on the maxillary left central and lateral incisor, canine and 1st molar teeth and in the lower jaw, right canine and left central incisor teeth were subjected to root canal treatment. As the patient’s chief complain did not subside, he was referred to our outpatient department. On clinical observation, the periodontal condition was found fairly well with control of the dental plaque and the teeth looked normal in appearance. There was no sinus tract but the affected teeth were slightly tender to percussion and vital to pulp vitality test.


Radiological Findings
Dr. Mozammal Hossain (Associate Professor): The intraoral periapical and orthopantogram radio-graph revealed that the cervical radiolucency was seen on the cervical areas of upper left central and lateral incisor, canine, and 1 st molar tooth. In the lower jaw, the affected teeth were right canine and left central incisor teeth. The lamina dura was intact and the width of periodontal ligament was also intact ( Figure 1).

Dr. Asaduzzaman Misha (Dental Pathologist):
Histological examination was performed on the extracted upper left third molar tooth as it was also affected later on and it disclosed the presence of multinucleated giant osteoclast-like cells and infiltration of chronic inflammatory cells in the resorptive tissue.

Treatment Procedure
Dr. Shegufta Tabassum (FCPS Trainee): Following discussion with the patient, surgical exposure, debridement and restoration of defects by mineral trioxide aggregate along with endodontic treatment were planned. After preparation of the access cavity, a temporary barrier was made at the resorption sites by glass ionomer cement for the purpose of isolation. Root canal treatment was performed on the upper left central and lateral incisors, canine, first molar and lower right canine and left central incisor tooth according to the conventional method. As the tooth become symptomless, the labial flap was then reflected to expose the lesion. The lesion was then dry and leathery in texture with no bleeding present. It had a honeycomb-like appearance. The lesion was debrided first with spoon excavator and then slow speed hand piece with carbide round bur. The bleeding in the operative field was controlled by the pressure of moisten cotton pack and irrigated with normal saline. The cavities were then restored with mineral trioxide aggregate (Pro-root, Dentsply, USA). Mineral trioxide aggregate was mixed according to the manufacturer's instruction and it was then placed at the resorption site using a carrier and condensed with a moistened cotton pellet. A radiograph was taken to check proper place-ment. After 10 min when the initial setting of mineral trioxide aggregate was completed, the flap was sutured back with 3-0 black silk suture. The patient was called for the removal of stitch and evaluation after 1 week. Finally, the patient was advised to come for follow-up visit at 3, 6, 9, 12 months, yearly and throughout the life.

Provisional Diagnosis
External tooth resorption

Aggressive periodontitis
Dr. Md. Joynal Abdin (Assistant Professor): In case of aggressive periodontitis, there is rapid destruction of the clinical periodontal attachment and the bone as well as surrounding tissues of the affected teeth. 1-2 Furthermore, it can occur localized or generalized based on patient health condition especially due to selective immune dysfunction. 3-4 Patient with aggressive periodontitis usually presents with chronic inflammation of gingival tissue and deep periodontal pockets with or without bacterial plaques and complaints of deep dull pain during mastication. In the radiograph, vertical loss of alveolar bone in multiple teeth is evident. 5 Microbial activities and systemic disease may also associate with aggressive periodontitis. 6-8

External inflammatory root resorption
Dr. Md. Mujibur Rahman Howlader (Associate Professor): In the histological examination, external inflammatory root resorption is characterized by resorption gaps in the cementum and dentin. 9-10 It usually occurs due to infection, occlusal trauma or systemic factors as well as a sequel of orthodontic tooth movement. 11-12 Multinucleated osteoclast-like giant cell activity can also be the source of root and cervical resorption of the tooth which is evident in histopathological examination of this case.

Cervical caries
Dr. Abdin: Cervical carious lesions are smooth surface lesions which morphology and extent are similar to carious smooth surface lesions of the tooth. The lesions may present with variable morphology and therefore not detected in the routine clinical examination but could be detected in routine radiograph. Among the etiological factors, high sugar diet, poor oral hygiene, xerostomia and orthodontic brackets are common. On clinical examinations, gingival recession and exposed root surfaces may be found. 13-14 A saucer-like appearance on the roots of the affected teeth that involves cementum could be recognized by radiological examination. It is also common among the elderly patient. 13

Osteoporosis
Dr. Howlader: Osteoporosis is a complex and multifactorial chronic disease. It can progress silently until fracture of tooth and bone appears late in life. 15 -16 It is associated with demineralization of bones as well as deformities and bone fracture. The patient usually complains of pain. Previous studies have indicated that the rate of loss of bone minerals is twice higher in women than in men due to lack of estrogen in women in post-menopausal period. 17-19 A significant correlation between periodontitis and osteoporosis have been reported in female. 20 A possible correlation between systemic osteoporosis and alveolar bone loss in periodontal disease is also reported by some of the previous studies. 21 -22

Clinical Diagnosis
Cervical tooth resorption

Dr. Ahmed's Diagnosis
External tooth resorption

Discussion
Dr. Ahmed: Multiple external resorption of permanent teeth is not common. A study indicated that maxillary teeth were more commonly involved than the mandibular teeth. 23 This is also similar to the present case.

Radiographic discussion
Dr. Hossain: Investigation of cervical external resorption is difficult by conventional radiography. In the present case, intraoral radiograph, Orthopantogram and histological examinations were performed for diagnosis. It is possible to use other techniques such as X-ray microfocus computed tomography for further analysis. 24-25

Discussion on treatment options
Dr. Tabassum: There are several options prescribed by some of the previous studies that include: a) The resorptive defects could be restored with an ''open sandwich'' technique where the dentin is conditioned with 10% polyacrylic acid for 15 sec and then a resin-modified glass ionomer cement is used to restore the majority of the preparation. The remaining of tooth structure (above the crest of alveolar bone) is restored with a bonded com-posite resin. [26][27] The problem in this procedure is the difficulty to achieve isolation i.e. moisture control.
b) Debridement of the resorptive lesion. 28 In this technique, the lesion is accessed, whether internally or externally, and debrided with a carbide round bur in a slow-speed handpiece. The dentin is then scrubbed for 1 min with 90% aqueous trichloroacetic acid on a cotton ball. 28 However, trichloroacetic acid cauterizes the residual resorptive tissue. If any of the invading resorptive tissue remains viable, the resorptive process is likely to continue. The trichloroacetic acid is also harmful to the gingival tissue if it comes in contact with the tissues. Furthermore, dentin that has been treated with trichloroacetic acid is severely demineralized and is not suitable for bonding with either dentin-bonding agents or glass ionomer materials. c) Dental implants following the extraction of symptomatic teeth with idiopathic resorption. 29 However, placing implants in alveolar bone require adequate bony supports. In such patient, there may be involvement of alveolar bone which will finally lead to the loss of bony supports and failure of the implant. d) Repair with biodentin. 30-31 It has been proposed as a favorable repair material as it can be placed in permanent and close contact with periodontal tissue due to its bioactivity and biocompatibility. e) Periodontal flap reflection, curettage, restoration of the defect either with mineral trioxide aggregate, amalgam, composite resin, or glass ionomer cement, and repositioning the flap to its original position is also another treatment option for treatment of cervical resorption. 32 However, periodontal reattachment cannot be expected with amalgam or composite resin and is unlikely with glass ionomer cement but there is experimental evidence to suggest that this might be possible if mineral trioxide aggregate is used in this situation. Therefore, in the present study, mineral trioxide aggregate was used to repair the resorption area.

Repair with mineral trioxide aggregate
Dr. Ahmed: Mineral trioxide aggregate was chosen as the filling material for its biocompatibility and for its sealing ability even in presence of moisture.
In previous studies, mineral trioxide aggregate was successfully used to repair communication between the pulp canal space and the periodontal tissue that occurs in cases of root perforation in dogs and

Discussion on the location of defects
Dr. Ahmed: The use of chemical agents, such as trichloroacetic acid also eliminates resorbing cells, which penetrate into the deeper parts of the defect and enhance the visualization of the defect. 28 CBCT has a good role in three-dimensional evaluation of resorption defects. 36 Inflammatory cervical resorption occurs immediately below the epithelial attachment of the tooth. As a result, it must be noticed that the location is not always cervical but related to the level of the marginal tissues and the pocket depth.

Role of vitamin D on tooth resorption
Dr. Abdin: During development of enamel, vitamin D plays an important role by increasing the absorption of the calcium and phosphate from foods. [37][38] Therefore, in the case of vitamin D deficiency, enamel hypoplasia and dental caries is a prominent feature of tooth loss because it does not mineralize sufficiently and there is an increase of cavities of the tooth. 39-40 Furthermore, in the absence of sufficient vitamin D, the bone that forms in the jaw or skull isn't sufficiently mineralized so there is also the rapid progression of periodontal disease. 41-42

Comparison with previous studies
Dr. Hossain: A previous study indicated that localized invasive cervical lesions (class 1 or 2) could be successfully treated with mechanical and chemical debridement of the resorptive lesion followed by restoration. For the moderate-size lesions (class 3), the success rate was 77.8%. However, in the case of the extensive class 4 lesions, 12.5% success rate was found. 28 This condition is explained as extracanal invasive resorption or external cervical resorption. It could be assumed that at least one to two year follow up is necessary for the case.

Follow-up
Dr. Ahmed: After 3 months follow-up, it was found three more teeth were affected and after 6 month follow-up, it was found no further involvement of other teeth was seen. The patient is still on observation. So, the prognosis is doubtful. Dr. Ahmed: Teeth with inflammatory cervical resorption are often structurally compromised and may eventually fail even though the endodontic treatment is successful. The endodontic treatment is irrelevant if the resorption is not eliminated, and the restorative aspects are not managed properly. Longterm follow-up is needed to evaluate this case. After 3 months follow-up, it was found three more teeth were affected and after 6 month follow-up, it was found no further involvement of other teeth was seen. The patient is still on observation. So, prognosis is doubtful.

Final Diagnosis
Idiopathic invasive cervical resorption