Idiopathic tooth resorption in association with metaplasia

Ural IDIOPATHIC

WILLIAM

cr.

Pathology

TOOTH RESORPTION IN ASSOCIATION WITH MJZTAPLASI@ BROWNK,

H.D.l).R..F.P.S.(:.,

k’.D.S.R.C.S.&., (-:LASGOW,

SCOTI.AXI,

T

WO types of idiopat.hic rcbsorl)tion of the teeth are recognized : peripheral (from the periodontal membrane or connective tissue), and central (from within the tooth). Either of t.hesc:may be associated with met.aplasia. By metaplasia is meant the replaccmcnt. of one tissue by another, usually as a result of inflammation, disease, or dama#e severe anough to prevent reconstitution by the original tissue. A IUON: highly specializetl t,ixsue is always replaced by a less specia.Iized on(l, never the ~+cvct‘se. In dental pathology. melnl~lusia nlay accompany the condition of idiopathic tooth resorption, t.issue of osseous-like structure I)cing laitl tlowii withill the resorbed area. The calcified t.issue which rrplacon or repairs the ~esorbetl dental tissue(s) is identical to bone with lil~lll~at~. ciln;lliCllli, illltl lIaversia.n systems. Some observers, however, prefer 10 (~111this t&such (*iIIcifiv repail material. Pathogenesis Many causes have bexll iltl\-2l,ll~!Ctl to esl)l;tiii those ii\:0 co~itlitiolis. Of esiet*ll;ll rcsclrptic~ri which An early observer, Salter,’ tlcscribrs il This condition w;~s asso&tttvl wit.h lt~&l)l:lsii~. had almost involved the pulp. Ot.her early observers were Tomeq2 I~‘c~t.hc?r~ill,” iUltl MUll1111eYy.4 In an article on the hislopathology of the embedded treth of ;I. dog! Wormati discusses several cases where peripheral resorption (that is, from the periodontal membrane) has occurred. In some of these, bone and marrow spaces occupy those areas frown which rellientunl sntl dentine h:tvc been resorbed. The process of rcSOrldi(Jli has reached the pulp tissue in ON instance. and here the communication is lijled ou eitltcr sit’le by bone deposited on the resorbed surfaces of the dentine. c'ilS('

*From

the

Glasgow

Dental

Hospital

muI

School.

1 ?!M

IDICI’ATHIC

TOOTH

RESORPTION

ASSOCWTli:D

\VITEI

MMETQI’LASL~

1299

Leriche and I’olicard’s theory on bone resorption is used by C!a.hn” to explain the sequence of events following the initial \rasoul;lr disturbance. He states that following this disturbance of unknown causation 6he inorganic* constituents of the dentine are resorbed, leaving a collagenous base which later reverts to embryonic tissue. In t.his area tissue then is laid down in the form of bone with lacunae: Haversian systems, ant1 n1;1rrow. Five cases of internal resorption, in one of which mctaplasia has oc(~urrcd, are shown 1)~ A4pplebaum.7 He shows clearly that in these ca.sesthe “int ernal ’ ’ resorption had commenced from without. SoifeP reviews the literature and adds ;I cilS(f history of generalized idiopathic resorpt.ion involvin g three teeth in one patient. An csamination of the patient’s blood for any variation in the nortnal ralcium and alkaline l)hosphatase reading was negative. Colyer and Sprawson9 draw attention t.0 a chronic pulpitis resulting from infection reaching the pulp via an aberrant root canal. They also note that. aberrant root. ~nals sometimes are seen bilat.erally and synimetricall~ ant1 suggest t.hat a caria.tion in development may be an ctiological factor. Fish’” considers that idiopathic resorption of the pnlp wall can c!ommencc either from within the pulp or from the periodontal membrane, that is, that there are two types of resorpt.ion: centxal and peripheral. As the central type does not give rise to any clinieal symptoms, it is rarely discovered until infection has supervened from without. Fish :llso st.ates that b0t.h types of resorption are really neoplastic and he has given the name i‘iendoc~ontoma” to the central type and “oclontoclaston~” to the peripheral type. KronfeW1 shows an example of t.he peripheral type with bone deposition in the resorbed area. It is his opinion t,ha.t resorption of central origin is due initially to a chronic inflammatory procacssof the ~)ulp tissue. According to Thornal’ t.wo distinct types of resorption occur : central ancl peripheral. lie states, “Pathologicr examination shows that we ilye tl(~nling with localized resorpt.ion of the t.ooth. a process of acxtc*leration brought ahouf by vascnlar granulation tissue. It. may 1~ induced 11;\-an acvzeleration of the circ~ulat.ion in the pulp or the periodontal memlrra ne. caused by I)r-olongrtl cffrcts of a local inflammation. a.nrl greatlv., filcilitaterl by Pollateral c*ir(!iil;it ion. ” Discussion One of the greatest dificulties experienced by anyone trying to con10 to any conclusion on the foregoing views is t.hat, while many cases arc mentionrd. not many photomicrographs are available in the older articles and these articles, bherefore, must be viewed with suspicion. Radiographic evidence alone is useless, as central resorption may have taken place following death of the pulp. The final diagnosis must be microscopic, aud photonlicrographs should be provided if any reliance at all is to be plseetl on future reports of? idiopathic resorption with metaplasia. The following might be said to represent the present-clay viewpoint : the resorpt,ion is brought about by a local increase in t.he 1~100~1 supply in the

t.issue adjacent to? or withill. ihc tooth. ‘I’llis I(biltlS lo ;h wsoqtl.it~tl ot’ vilr.vitlc rit.pidity of the adjacent tlent al tissues. This. ill 1~11. niily 01’ Itlily Ilot be followed by metaplasia in th(I resorbetl arcq ; that is, bone map IW laid tlow II within the dental t.issnc. 111 t.he case of central rt:surption, this loct;tl itlerewe of bl~~otl supply is aided greatly by the existence of il large apical foramen 01’fOl~ilnli~l;l. AhHxllt root canals also tllily help by l)roviiling COllat.~IX.l Grculntic~~i illl~l prclventiiip the rapitl lleiith or tlegenetxtion of the I)uIp thal inv;tri;lbly OWIII’S in UNtreated i~(~l~tehyl)eremin. The ;~l~~iiw of paili, which is il feaiure of central resorption in it,s early stitges l~Eol*c it I);it,hologic el~il~l~lel is est.aIdishccl xilh the esterior, illtio is ileeoll~lt(~tl for Iby itI1 t~l)sr~~cc OII p;lssiVr mmgc!stion (Iu~ lo t,he utlusllill and s;ltisf:tet 01.y 1)lootl snpply to tllc pulp t.issur. Peripheral resorption HI;I~ IW aitlt~cl in iis I)etlrtr;~tion of the rlcdinc 01’ If IlIe Ctl.llill is Vt’t’y l!lOSe t0 the Sl1lC.W. C~tIlt~Ilt~Utt1 11y ill1 ILlN?lTilllt, IYlClt (filllill. however, infection may easil\: pzlss illOllR this chatlnrl and Ieat1 to n~croxis 0.f t.he pulp. In those cilses whrrr only the! (~llilll~t~l i11l(l underlying dentine htlve heen resorbed, iIs in ullt~~upi WI I theth, ittt iIl)et.~tt~lt I’oa)t V;LIIR~, of WIIII’SCL. (a;lrlll~~t. be considered, even in this ;lccessory rc~le. I>ealing with the local Cilllses OEIKII~C resorpbion. ~oilget*s at~tl \Veidnlatin’.’ “ Onr knowledge of the local procc~sses involved in the rt!sorption of statn, bonc~ is negligible ant1 tllOSl. hypothetical asplanntions dept~cl ul)011 systt’rnie effects such as cha.nges of ionic c*oncentrut.ion in the 1~1.00~1.” As reg;n~ls general C;LIISW,llone of the bonr (lystrophies have ilIly bearing I3\-cn in extreme c.;ises of llypcrparatliy~oidiali. on t.hese two conditions. such as cm he arranged in ;Irlirn:~l experiments, IIO I’(~~lO\‘iII of’ c:ilvinn~ from the t.eeth takes place. The alveolar bone is Ilot iI fisetl structuI.1~. It is subject to il caontinuous I)l’oc’ess (II’ tTtI~OV;ll ;l.ti(l I,(~-I’o~l~i:ltioli, o!’ resc~rptioll illId ileposition. The prriothe erupted tlOIltil1 memhn(: :lcts ns iI 1):1rril>l* ;lgilinst ihis ~IVW~SS involving teeth.

‘I’hc functions of the ])t’ric,(Iont;lI membri~tle are given succinctly lay Orl~ii~i” as formative, supportive. sensory! rinil tndritire. WidclowsotilS holds :I siaiilar viewpoint. Any snggestic~tt of the protective c*hat*acter of the Iwt*iotlotltal tttctnltt*ilne is always Iitnitrtl to its ;I.(!t.ing ils :I l)nffr~*: for es:~~plr, slight ~IIOV~*ment of the tooth on mastication is nllm~rl and swl(l(~n taild stressw ilI’P ill~sorheil safely. As Stiltf31 l)reviously, however, tlll! I~e1~iotloiltnl ttlt~~lllJ~~i~tlt~ illSO acts as :I barrier. Damage t.0 the perioclontal niemI)rane, leatling lo Iiecrosis, thrombosis, or rupture of t,he vessels, invariably results in active resorption of the adjoining cementum (and bone), according to Henry ant1 Wc~iunlann. I’/ So long as the periodontal membrane is intact, the i~I\~colar bonr is not allowetl to come in contact with the eement.um ant7 (lenfitltl. Should thtl cc)ittitmily of the perioc1ont.d membrane he destrnyecl, then resorption of the cemrtt~.urtt ant1 adjoining bone takes place. This may be followed by ankylosis. The cliffprence l)et.ween nnkylosis and peripheral resorption associated with tnetapla.si;i is Iwssiltly

oniy

i)lle

of

clfyrw.

Similarly, the crown of an uneruptetl tooth is protedetl frotu resorption Bhoultl this cuticle be ~la~uaged or so long ilS the eIl~l1ncl cuticle is intact. lose its continuity, then the connecti~~e tissue comes in contact with the enamel. I tt tinto, Ihis may lend to the deposition of cetttetttutI1 itt the fissures of the tooth or, iE resorptiott of the etl;uttel has prececlerl the tlcl)ositiott. tltetl 1-ltc c:en~ttlutt~ (,or Itone) may be laid clown wit.hin t.he crown. KU Itrtavious reporter itietitions any difficulty itt retno\-ittg il spccitttett with peripheral resorption associated with metaplasia. This is possibly tlue to fwo t*etts()tts. h’irst, t.he ttttt.jot*it.y of material t*(~pctrtctl t*ecettt.ly is post-tttorietjt INterial. Second, where the conclitiou was oltservetl preopet*:ttirely. the MI*rounding ttlveolus and the tooth were out out in n ltlock. A stu(ly of SOI~I~of the pllotomiero~ri~Iths of post-tnortt~ttt tttaterittl, where the dceolitr hone is continuous with the botle rcl)l;tGttg t.he detltitle, shows t.httt I)ct*iphrra.l resorption associat.etl with tttettt.plttsitt c;ttl Ite it ~~ttudt more severe type of ltony union that1 that which is cottttttonly citll~~(l ankylosis. When au operator has seen perilthersl root. rcsorptiott with metaplasia (luring ratliographic examination, he must uot ottly perfortn tk surgical est.r:tction, but also delil~eratclp rerttovtl the ntljneettt portion o-f 1t011r itlong wit& the tooth.

Case Report The patient, a man aged 59 years, attended the Glasgow Deutal School in February, of his mouth revealed a partly erupted lower thirfl molar with caries 1953. kkmination On the right sifle there was x llulge in thr itlrt:oluz; in the nlolar nrcn. in the crown.

position. The lkliogrnphs showed a completely buried third molar hertr, in vertical The lower half of the root was intooth on t.he left side was in mesio-oblique position. distinct and appeared to merge with the surrounding bone (Fig. 1).

1:w"

I?.

lDIOI’ATHI(:

TOOTH

RES0RPTIOiK

ASSOCIATED

WI’LW

BI~ETAI’LASIA

1308

LSorgical removal was indicated, and this was performed under regional anesthesia. After the bone investing the crown had been removed, an unsuccessful attempt was made to elevate the tooth. No movement was detected. The walls of the socket on the distal and In~ccal aspects then were removed with a surgical drill almost to the apcis of thn tooth. A further unsuccessful attempt at removal was made. The bone on the wholo of the mesial aspect and part of the lingual aspect was then removeal. This lime the tooth came away with a slight crunching sound. The patient was given penicillin iutra muscaularly postoperatively. Healing was uneventful. HistopatholoQly.-From the radiographic report and operative Andings, a true union or ankylosis was anticipated in the histologic findings. Even after examination of the r;oc!tions. a long at.udy of the radiographs did not show :III~ peripheral resorption. This

undoubtedly was due to t,he fact that thu resorbed area had bc~c~nrepaired 11y calcified tissue of equal density. Serial sections were cut aftrr the tissue had I~c!u lisetl in 10 per cent formalin and then decalcified. Altogether, more than 160 sections n’erc examined. These sections demonstrate excellently the const.ant and unceasing changes of llstt.ern so characteristic of bone. The different trabeculat!? surrounding either fatty or

Dental 8urgery ana1 Pathology, 1. Salter, J. A.: T.on~lon, 1874, I.ongmans, Grcon $ (!o., D. 79. 2. Tom&j 0. 8.: Absorption Arounrl thu Pulp antI Krplsc~rnent I)y Serondar~ Dentinr, Tr. Odont. Sot. 5: 194, 1872. 3 Fothergill, .J. A.: Pink Spots Appearing in the Teeth, Tr. Odont. Sot. 32: 213, I#!). 4. Mummery, J. H.: The Pathology of “Pink Spots” on Teeth, Brit. I). J. 41: 301), 1920.

7. 3. !I. IO. 1 I. ., .I 13: 14. 15. 1Ii.