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Seeing the True Resorption Picture by Shawneen M. Gonzalez, DDS, MS

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Resorption is the loss of tooth structure due to odontoclastic processes. It may occur on either the external surface (external resorption) or the internal surface (internal resorption) of a tooth. Both external resorption and internal resorption can involve either the root or crown.

External resorption
External resorption starts from the external surface of a tooth and moves toward the pulp chamber and/or root- canal space. External resorption is more common than internal resorption and is frequently seen at the apices of the mandibular incisors, canines and premolars. It can occur on any portion of a tooth that is within bone. One subcategory of external resorption starts at the cervical region of a tooth and quickly moves throughout the root, sparing the pulp chamber and root-canal space until the final stages of resorption.

This subcategory is referred to as invasive cervical resorption. The etiology of external resorption has been attributed to many things, including but not limited to: local inflammatory lesions, trauma, re-implanted teeth, neoplasms, cysts, excessive mechanical and occlusal forces and adjacent impacted teeth—however, it is frequently idiopathic. External resorption typically does not present with any clinical signs or symptoms, as the affected tooth structure is surrounded by bone.

Radiographic appearances
External resorption that occurs at the apex of a tooth presents as a blunted root apex instead of nicely tapering to a point. If it occurs on the lateral root surface, it may present on a radiograph as a notching or concave defect on the mesial or distal root surface. If it occurs on the lateral root surface and is positioned over the pulp chamber and/or root-canal space, it presents as a well-defined, radiolucent area. To determine if the radiolucent area is coming from the lateral root surface or from the pulp chamber and/or root-canal space, another radiograph with a different horizontal angle should be taken. This will help determine if the resorption is continuous with the pulp chamber and/or root-canal space, or being superimposed over the tooth on a 2D radiograph. It may occur on a single tooth, multiple teeth or—in rare cases—every tooth in the oral cavity.

Differential interpretation and treatment
Differential interpretation includes lingual or facial caries when it presents on a lateral root surface superimposed over these areas. This can be evaluated clinically for the presence of caries. Sometimes external resorption can be confused with internal resorption, due to the radiolucent area appearing over the pulp chamber or root-canal space.

Again, another radiograph with a different horizontal angle will help in these cases. Treatment includes removing the etiologic factors, such as cessation of mechanical forces, removal of adjacent impacted teeth, or source of inflammation. Curettage of the defect and restoration placement usually stops the process. It may be self-limiting in some cases, and monitoring is recommended to see if it progresses or has stopped.

Internal resorption
Internal resorption starts from the internal surface of a tooth within the pulp chamber and/or root-canal space and moves toward the external surface of a tooth. The etiology of the internal resorption has been suggested as inflammation due to acute trauma, but is also frequently idiopathic.

It can occur in either the primary or permanent dentitions. There is a male predilection and most commonly involves permanent central incisors, first molars and second molars. If the resorption is located in the root-canal space, it is usually clinically silent. It can expand to the periodontal ligament space or perforating enamel, leading to pulpitis.

Radiographic appearance
It appears as a well-defined, radiolucent entity continuous with the pulp space (either from the pulp chamber and/or root-canal space) presenting as enlargement of the pulpal space. It may occur on a single tooth or within multiple teeth.

Differential interpretation and treatment
Differential interpretation includes facial and lingual caries. Facial or lingual caries will present as a radiolucent area that will not be continuous with the outline of the pulp space (pulp chamber and/or root-canal space). Clinical investigation can evaluate for facial and lingual caries.

Treatment of internal resorption is dependent on the tooth condition. If the tooth is stable in the bone, endodontic treatment may halt the resorption. However, if the tooth is mobile in the socket or perforation of the root has occurred, extraction may be necessary.

Conclusion
Both types of resorption are commonly clinically silent entities, making it prudent to be thorough when evaluating radiographs.

Shawneen M. Gonzalez, DDS, MS, Diplomate ABOMR, is the director of the Oral and Maxillofacial Radiology Clinic, and assistant professor and radiation safety officer at Oregon Health & Sciences University School of Dentistry in Portland, Oregon. She received her dental degree from the University of Washington School of Dentistry, in Seattle, and her oral and maxillofacial radiology certificate and M.S. in stomatology from the University of Iowa College of Dentistry, Iowa City, Iowa. Gonzalez is a diplomate of the American Board of Oral and Maxillofacial Radiology.

Gonzalez is the course director of several clinical and didactic oral-radiology courses for residents and dental students, and the creator of an informational oral radiology website (drgstoothpix.com). Gonzalez is a member of the American Association of Oral and Maxillofacial Radiology; American Board of Oral and Maxillofacial Radiology; American Dental Education Association; and the American Dental Association. She serves on the pre-doctoral and post-doctoral committees for the American Association of Oral and Maxillofacial Radiology.


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