Endodontics

Invasive cervical rsorption: An analysis of potential predisposing factors

Geoffrey S, Heithersay, MDS (Adel). FDS, RCS (Edin), FRACDS
Objective: An investigation was undertaken to assess potentiai predisposing factors to invasive cervicai resorpi/on. Method and materials: A group of 222 patients with a totai of 257 teeth displaying varying degrees of invasive cervical rsorption were analyzed. Fotentiai predisposing factors, induding trauma, intracoronal bleaching, surgery orthodontics, periodontal root scaling or pianing, bruxism. deiayed eruption, developmental defects, and restorations were assessed from the patients'history and orai examination. Results: Ot the potentiai predisposing factors identified, orthodontics was the most common sole factor, constituting 21.2% of patients and 24.1 % of teeth examined. Other factors were present in an additionai 5.0% of orthodonticaiiy treated patients (4.3% of teeth), and these consisted principatiy ot trauma and/or intracoronai bieaching. Trauma was the second most frequent soie factor (14.0% of patients and 15.1% ot teeth). Trauma in combination with intracoronai bleaching, orthodontics, or delayed eruption constituted an additionai 11.2% ot patients (10.6% ot teeth), intracoronai bieaching was found to be the sole potential predisposing factor in 4.5% of patients and 3.3% ot teeth, and an additionai 10 4% ot patients and 9.7% of teeth showed a combination of intracoronai bieaching with trauma and/or orthodontics. Surgery particularly invoiving the cementoenamel unction area, was a sole potential predisposing factor in 6.3% of patients and 5.4% of teeth. Periodontai therapy induding deep root scaiing and pianing. showed a low incidence, as did other factors, such as bruxism and developmental defects. The presence of an intracoronai restoration was the oniy identifiabie factor in 15.3% of patients and 14.4% of teeth, while 15.0% of patients and 16.4% of teeth showed no identifiabie potentiai predisposing factors. Conclusion: These resuits indicated a strong association between invasive cervical rsorption and orthodontic treatment, trauma, and intracoronai bieaching. either alone or in combination. (Quintessence int 1999:30:83-95) Key words: externai rsorption, invasive cervical rsorption

CLINICAL RELEVANCE: Ciinicians should be alert to the possibility of invasive cervicai rsorption, especiaiiy fciiowing trauma, intracoronai bleaching, or orthodontic treatment aione or in combination. Periodic radiographie checks are necessary for those teeth that might be considered to be at risk.

nvasive cei^ical rsorption is an insidious and often aggressively destructive form of external root rsorption that is characterized by invasion of the cervical region of the root by fibrovascular tissue derived from the periodontal ligament. This pathologic process progressively resorbs cementum, enamel, and dentin, to eventually involve the pulp space late in the process.

Clinical Associate Professor, Department of Dentistry, University of Adelaide. Adelaide, South Australia, Australia. Reprint requests: Dr Geoffrey S. Heithersay, Gawler Chambers, IBS Nortti Terrace, Adelaide, South Austraiia 5000, Australia. Fax: 61-8-8410-0709.

Ectopic calcifications can also be obset^ed in advanced lesions, both within the invading fibrous tissue and deposited on the resorbed dentin surface. The clinical and histopathologic features of this condition have been outlined in a previous publication.' The etiology of invasive cervical rsorption is unknown, but several potential predisposing factors have been suggested. Of these, intracoronai bleachingreiated rsorption has heen the most widely documented factor, following the initial report by Harrington and Natldn in 1979^ (for a review, see Heithersay et aP). Trauma has also been recognized as a potential cause of "late external root rsorption," the clinical description of invasive cervicai rsorption adopted by Cvek in 1981.'' Other potential predisposing factors that have also been explored include orthodontics, orthognathic and other dentoalveolar surgery, and periodontai treatment.^-^ The present investigation was undertaken to assess various potential predisposing factors in a relatively large group of patients presenting with varying degrees of invasive cervical rsorption.
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Class 4
Fig 1 Clinical classilicalion ol invasive cervical rsorption.

METHOD AND MATERIALS

The subject material consisted of 257 teeth displaying invasive cervical rsorption in 222 patients who had been referred to the specialist endodontic practice of the author. Patients underwent a clinical and radiologie examination, and photographic records were taken
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where appropriate. Specific details of age, sex, and medical and dental history were recorded. Completemouth radiographie surveys were taken whenever multiple rsorptions were deemed a possibility. The potential predisposing factors were assessed from the patients' history and oral examination. Dates of specific incidents or treatments were also recorded.
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60-64 55-59 5G 54 45-49 OJ 40-44 m 35-39 30-34

Q.

'

a Female Male

25-29 ^ K 20-24 15-19 tO-14 0 5 10 15 No. ol patients 0 25 5 10 15 20 25 30

No. o patients Fig 3 Invasive cervical rsorption: Tiie number o( patients according to age group and severity of rsorption.

Fig 2 Invasive cervioal rsorption: Sex and age distribution al time ol diagnosis.

The following factors were caiegorized and described: 1. Trauma. The age at the time of trauma along with severity of trauma. Details of tionsurgical root canal treatment or adjunctive treatment, eg, intracoronal bleaching. 2. Intracoronal bleaching. In patients with a history of intracoronal bleaching, details of previous injuries or treatment, and the number and timing of intracoronal bleaching treatments. 3. Surgery. The type of surgerj' in the related area, eg, surgical removal of unerupted or partially erupted teeth, or transplantation. 4. Orthodontic treatment. The ages at the commencement and completion of orthodontics, and the orthodontic method employed. 5. Periodontal root scaling or planing. The severity of periodontal involvement and the duration of treatment. 6. Bruxism. The approximate duration of bruxing and the degree of tooth wear. 7. Delayed eruption. 8. Developmental defects. 9. Other potential factors. Any other treatments or incidences that may he considered to be related to this condition. 10. Intracoronal restorations. When no other potential predisposing factor was identifiable, the presence of coronal restoration was recorded. The degree of invasive cervical rsorption for each tooth was recorded according to the following clinical classification (Fig 1):
Quintessence internationai

1. Class 1. Denotes a small invasive resorptive lesion near the cervical area with shallow penetration into dentin. 2. Class 2. Denotes a well-defined invasive resorptive lesion that has penetrated close to the coronal pulp chamber but shows little or no extension into the radicular dentin. 3. Class 3. Denotes a deeper invasion of dentin by resorbing tissue, not only involving the coronal dentin but also extending at least to the coronal third of the root. 4. Class 4. Denotes a large invasive resorptive process that has extended beyond the coronal third of the root canal. The data were subjected to frequency analysis, which was the only statistical method deemed applicable to this study.
RESULTS

Of the 222 patients, 114 were females and 108 were males. The sex and age distribution at the time of diagnosis is shown in Fig 2. The ages varied from 11 to 75 years; the mean age was 37 years. Figure 3 indicates the severity of invasive cervical rsorption, as defined in Fig 1. by age group. The total number of teeth from this patient sample was 257, and their distribution is outlined in Table 1. The analysis of potential predisposing factors for the patients is sutnmarized in Fig 4.

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TABLE 1 Distribution of teeth showing invasive cervical rsorption Tooth Central incrsor Lateral incisor Canine First premolar Second premolar First molar Second molar Third molar Maxillary 75 23 34 2 3 20 7 2 Mandibular 12 13 13 4 7 26 13 3

TABLE 2 Distribution of patietits and teeth associated with trauma aione or in cotnbination with other factors Polential predisposing factors Trauma as a sole factor Trauma and bleaching Trauma and orlbodontics Trauma, bleaching, and orthodontics Trauma and delayed eruption Total No, of patients (%) 31 (14.0%) 17 (7.7%) 3 (1.4%) 4 (1.8%) 1 (0,5%) 56 (25,2%) No,ot teeth (%) 39(15,1%) 19 (7,4%) 3 (1.2%) 4 (1,6%) 1 (0,4%) 66 (25,7%]

Trauma Intracoronalbleacbing Surgery Orthodontics Penodoniics Bruxism Delayed eruption Developmental defects Interproximal stripping Restoration Unknown

5b). A radiograph (Fig 5c) showed a large, irregular radiolucent area extending to the crown and root. The rsorption was classified as class 3, Intracoronal bleaching
Sole factors D Additional factors

10 20 30 40 50 60 70 No ol patients Fig 4 Invasive cervical rsorption. Distribution of potential predisposing factors lor patients.

Trauma

The distribution of teeth and patients showing trauma and related factors is shown in Table 2, The teeth most frequently affected by a sole history of trauma were the (1) maxillary central incisors {7.8/ii), (2) mandibuiar lateral incisors (2,3%), (3) mandibular central incisors fl,6"/o), and (4) maxillary canines (1,2%). Illustrative case report. A 45-year-old man presented for a routine examination. His maxillary left central incisor had been luxated palatally 21 years earlier, repositioned, and splinted. The tooth was asymptomatic but showed a pink discoloration near the gingival margin on the palatal aspect (Fig 5a), and the labial surface showed a small, dark surface defect (Fig

The distribution of patients and teeth showing intracoronal bleaching and related factors is shown in Tabie 3, The teeth most frequently affected by a sole history of intracoronal bleaching were the (1) maxillary central incisors (3,1%) and (2) maxillary lateral incisors (0,3%), Illustrative case report. The patient, a 42-year-old man, noticed an irregularity on the palatal aspect o his maxillary left lateral incisor. Examination revealed an erosive defect containing soft tissue on the palatal surface of the incisor (Fig 6a); the labial surface was intact (Fig 6b). No symptoms were associated with this lesion. The patient had received fixed orthodontic treatment at 20 years of age, when he was a dental student. When he was 23 years old, his lateral incisor was luxated palatally while playing soccer. It was repositioned within 30 minutes and splinted, Nonsurgical root canal treatment proved necessary. This was followed by intracoronal bleaching with 30% hydrogen peroxide activated thcrniocatalytically by an ultraviolet lamp applied intermittently for 5 minutes. This was followed by a "walking bleaeh," in which a cofton pellet, saturated with 30% hydrogen peroxide, was sealed into the pulp chamber with Cavit (ESPE) for 6 days. The procedure was repeated, and 8 days later the access cavity was restored. The tooth was reassessed 2 and 7 years later, at which times there was no radiographie evidence of invasive eervical rsorption or periapical pathosis (Fig 6c),
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Fig 5a Palatal view of the anterior teeth of a 45-year-olcl man ,vnose maxillary left central incisor had been palatally luxaled 21 years previously. Note the pink discoloration in tfie gingival third of the crown

Fig 5b "The enamel of Ihe labial surface of the maxillary left central incisor displays a defect resulting from the trauma thai had occurred 21 years earlier

Fig 5c (lefi) The radiograph of the maxillary left centrai incisor reveals a large radiolucency superimposed over the outline ol the root canal

TABLE 3

Distribution of patients and teeth

associated with intracoronal bleaching alone or in combination with other factors

Potential predisposing faetcrs Bleaching as a sole faetor Bleaching and trauma Bieaching and orthodcntics Bleaching, trauma, and orthodontics Tolal No. of patients (%) 10 17 2 4 (4.5%) (7.7%) (0.9%] (1.8%) No. cf teeth (%) 10 19 2 4 (3.9%) (7,4%) (0.8%) (1 6%)

33(14.9%.)

35(13.6%)

lntracoronai bleaching using the same procedure was repeated at the 7-year recall. The subsequent radiographie records suggest that, during the rehleaching procedure, additional gutta-percha had been removed and replaced with another material within the canal, presumably as an additional seal. The patient presented 12 years after the second ntraeoronal bleaching procedure, when he noticed an irregularity on the palatal aspect of the same left lateral ineisor. Evidence of an extensive resorptive process in :he previously root-filled incisor was shown adiographically by the presence of a radiolucent area it the mesiocervical region of the left lateral incisor, exLjintessence International

tending 3 to 4 mm into radicular dentin and cementum (Fig 6d). In addition, a periapical radiolucency could be observed, indicative of a periapical inflammatory response probably resulting from microbial leakage of the root canal filling via the resorptive defect. The lesion was classified as a class 3 invasive cervical rsorption.
Surgery

The distribution of patients and teeth showing surgery and related factors is shown in Table 4. The type of surgery varied. The removal of adjacent partially or fully unerupted third molars or superntimerary teeth
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Fig 6a Palatal view ot the anterior eetii of a 42-year-oid man whose maxillary left incisor tooth had been luxated 19 years earlier, 2 years after reoeiving orlhodohtic treatmeht. Nonsurgicai root cahal treatment and intraooronal bleaohing proved neoessary, and intraooronal bleaohing was repeated 7 years later Note the erosive defect at the mesiogirgivai surface, evident 12 years after the second intracoronai bieaching procedure.

Fig 6b The abiai surface o the maxiiiary left lateral incisor shows some discoloration near the gingival margin but is otherwise intact.

Fig 6c A radiograph taken 7 years after trauma, nonsurgical root canai treatment, and intracoronai bieaching shows no evidence of rsorption or periapicai pathosis.

Fig 6d A radiograph of the ma^iiiary left iaterai incisor taken 12 years after a second inlracoronai bleaching procedure shows evidence of e>;tensive invasive cervical rsorption extending into the radicuiar and ccronai looth structure. A periapicai radiolucency, indicative of periapicai patfiosis. is aiso evident.

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Fig 7a Labial surface ot the maxillary lefi canine of a 28-year-old woman wtio had surgery to expose an unerupted canine at the age ot 14 years. Protracted orthodontic treatment followed. Note the irregularity at the distogingival surface with an associated soft tissue ulcration.

Fig 7b The palatai surtace of the maxillary left canine is intact and shows no clinical signs of rsorption.

Fig 7c (left) The radiographie appearance at the maxiilary ielt canine reveis an irregular ladioiucency extending to the radicuiar Ihird of the tooth and to the ccronai tooth structure in a crescentai patlern.

TABLE 4

Distribution of patients and teeth

associated with surgery alone or in combination with other factors

Potential predisposing factors Surgery as a soie factor Surgery and orthodontics Surgery and periodontai therapy Totai No. of patients (%) 13 (5,9%] 1 (0,5%) 1 (0.5%) t5(6.8%) No. Ot teeth (%| 13(5.1%) 1 (0.4%) 1 (0.4%) 15(5 8%)

occurred in eight patients (eight teeth). Transplantation of canine teeth had been carried out in three patients (three teeth) and the surgical exposure of an unenipted canine was performed in one patient {one tooth). Periodontal surgery involving root amputation had been performed in one patient (one tooth). Illustrative case report. A 28-year-old woman presented with localized swelling of the gingival tissues associated with her maxillary left canine, which disQuintessenceinternational

played a resorptive defect near the distogingival margin [Figs 7a and 7b), Her dental history indicated that the previously unerupted canine had been surgically exposed when she was 14 years old, prior to orthodontic treatment. Records indicated that orthodontic movement of this tooth was difficult and protracted. The radiograph (Fig 7c) indicated a class 3 rsorption defect, with extensions both eoronally and apically for at least a third of its depth.

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Fig 8a Labial view o( tiie anterior teeth of a 2e-year-old woman who haa received li\ed orthodontic treatment 14 years eariier. Tiie maxiilary right centrai incisor shows a pink disco i oration near the gingivai margin.

Fig 8b The paiaiai surface of the maxiiiary righ\ centrai incisor appears normai

Fig 8c (ieft) The radiograph of the maxillary right central incisor reveals an irregular radioiucency overlying the rool canai outline.

TABLE 5

Distribution of patients and teeth

associated with orthodontics alone or in combination with other factors

Potential predisposing factors Orthodontics as a sole factor Orthodontics and trauma Orthodontics and bleaching Orthodontics, trauma, and bieaching Orthodontics and surgery Orthodontics and periodontal therapy Total No. of patients (%) 47(21.2%) 3 (1.4%) 2 (0.9%l 4 (1.8%) 1 1 (0.5%) (0.5%) No. of teeth (%) 62(24.1%) 3 (1.2%) 2 (0.8%) 4 (1.6%) 1 (0-4% 1 (0.4%) 73 (28-4%)

58 (26.2%]

Orthodontics The distribution of patients and teeth showing orthodontics and related factors is shown in Tahle 5. The teeth tnost frequently affected by orthodontics were (Ij maxillary canines (6.2%), (2) maxillary central incisors (4.3%), (3) mandibular molars (2.3'>/o), and (4) maxillary and mandibular incisors (\.9%). In those patients with a history of orthodontics alone, multiple rsorptions were recorded in six patients (2.7%). Of these patients, one had seven teeth involved, two patients had four teeth 90

involved, and three patients had two teeth involved. Illustrative case report. A 28-year-old woman presented with a pink discoloration of the crown of her asymptotTiatic maxillary right central incisor (Figs 8a and 8b). The patient had received fixed appliance orthodontic therapy 14 years earlier, apparently uneventful both during and after the 2-year treatment period. The radiograph revealed an irregular radioiucency extending from the cervical area into the crown (Fig 8c). This lesion was classified as class 2 invasive cervical rsorption.
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Periodontal therapy The distribution of patients and teeth showing periodontal therapy and related factors is shown in Table 6, Bruxism Six patients (2,8%) with SL\ teeth (2,4%) showed a history of bruxism, Deiayed eruption Delayed eruption resulting from tooth impaction was found in three patients (1,4%) with four teeth (1,6%), One other patient had an additional history of trauma, which resulted in a total of four patients (1,8%) with five teeth (1,9%) where delayed eruption was involved. Illustrative case report. The mandibular right canine of a 35-year-old man had been submerged until the patient was in his early 20s, at which stage its full eruption was still impeded by crowding in the mandibular arch (Fig 9a), Radiographic evidence of invasive cervical rsorption could be observed in both the mandibular right canine (Fig 9b) and the first premolar (Fig 9c), The lesions were classified as class 3, Developmental defects Developmental defects were recorded in two lateral incisors (0,8%) of one patient (0,5%), Other factors Interproximal stripping was the only other potential predisposing factor identified. Illustrative case report. A 22-year-old woman's maxillary anterior teeth had been treated 3 years earlier by a general dental practitioner who performed interproximal stripping in an attempt to reduce anterior crowding. Advanced invasive cervical rsorption was present in the maxillary right canine tooth, as was evident clinically (Fig 10a), Radiographie examinafion revealed evidence of a deeply infiltrating resorptive process surrounding an apparently intact ruot canal (Fig 10b). The lesion was classified as class 3, intracoronal restorations The presence of an intracoronal restoration was the only identifiable factor in 34 patients (15,3%) with 37 teeth (14,4%), In 33 patients (14,9%) with 36 teeth (16.4%), no predisposing factors could be identified.
Quintessence International

TABLE 6 Distribution ot patients and teeth associated with periodontal therapy alone or in combitiation with other factors
Polential ptedisposing factors Periodontal therapy as a sole lactor Periodontal therapy and orthodontics Periodontal therapy and surgery Total No, of patients (%) 4(1.8%) 1 (0 57c) 1 (0,5%) 6 (2,8% No.ol teeth (%) 4(1,6%] 1 (0,4%) 1 (0.4%) 6 (2,4%)

DISCUSSION

To date, there do not appear to have been any previous epidemiologic studies that specifically indicate the proportion of a population group that may develop invasive cervical rsorption. The present sample of patients referred to the author, a specialist endodontist with a special interest in the condifion, represents approximately 0,02''.'o of the population of Adelaide, a city of approximately 1,2 million people, Several statistical tests were considered for this study, including analysis of variance, but the nonrandomized nature of subjects indicated that the only valid statistical method applicable was that of frequency analysis. There was little overall difference between males and females in the incidence of invasive cervical rsorption, but there were some interesting age group variations. In the 35- to 39-year-old group, the majority were males, which contrasted with the 45- to 49year-old group, where the sex distribution was reversed. While an analysis of potential predisposing factors for the two groups gave no indication for the predominance of females in the 45- to 49-year-old group, males in the 35-year-old group had a predictably greater history of dental trauma than females, no doubt resulfing from a greater participafion in contact sports. Surprisingly, males in this group also had a greater history of orthodonfic treatment. For invasive cervical rsorption to be inifiated, tbe normally protective cementum-eementoid layer must be deficient or damaged,' This may have occurred developmentally or can be caused by physical or chemical trauma. Chemical trauma may be involved in the initiation of invasive cervical rsorption associated with intracoronal bleaching with hydrogen peroxide, Intracoronal bleach-related cervical rsorption has received the attention of the dental profession since the first case reports in 1979,' 91

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Fig 9a Delayed eruption of the mandibular right canine in a 35year-oid man because of arch crowding.

Fig 9b Tine radiograph cf the mandibular right canine reveals an extensive radiolucency extending principally into the crown.

Fig 9c An irregular radiolucency indicative of Invasive cervicai rsorption is also evident in the adjacent mandibuiar premoiar. The pulp outiine is demarcated from the radiolucency by a radiopaque line.

The results of the present study show that ntraeoronal bleaching was the sole potential predisposing factor in 4,5% of patients (3.9''/o of teeth). When combined with other potential predisposing factors, 14.9% of the patients surveyed, or 13.6"/o of the teeth, showed a history, at some stage, of intracoronal bleaching with hydrogen peroxide. The intracoronal bleaching method varied between a thenitocatalytic technique with hydrogen peroxide and the walking bleaching method using hydrogen peroxide alone or mixed with sodium perborate. A combination of the two methods had also been used.
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Two studies have assessed the incidence of intracoronal bleaching-related rsorption. Friedman et a\' found an incidence of 6.8"/o in a sample of 58 teeth treated by either a thermocatalytic or a walking bleaching technique. None of the teeth had a history of trauma, A more recent study of 202 patients treated with a comhination of thermocatalytic and walking bleaching reported an incidence of 1.96%.' All teeth with rsorption in this study had a history of tratima. This was also the case in each of the seven cases of invasive cervical rsorption reported by Harrington
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Fig 10a Pdlatal view of the maxiliary right canine ol a 22-year-old patient who had a history ot interproximal stripping. The palatal surface of the maxillary right canine shews extensive tooth loss; (he cavity contains reddish-pink soft tissue.

Fig 10b A radiograpn of Ihe maxiliary right canine shows evidence of an extensive iesion extending coronaily and deeply into the radicular dentin. Nole the retained outline ot the root canal surrounded by the irreguiar radiolucency.

and Natkin in 1979.- These authors suggested that leakage of bleaching agent from the pulp chamber through patent dentinal tubules into the cervical periodontal tissues may he sufficient to initiate the resorptive process. Furthermore, a passage of hydrogen peroxide from the pulp chamber of root-filled teeth to the externai surface during intracoronai bleaching with 30% hydrogen peroxide was demonstrated by Rotstein in 1991* and found to be facilitated by the presence of cmentai defects at the cementoenamel junction."^ Further information regarding the possible pathogenesis of intracoronai bleaching-related rsorption has been provided by recent studies that demonstrated hydroxyl radical activity at the external root surface following the thermocatalytic intracoronai bleaching of root-filled teeth." The hydroxyl radical is one of a number of oxygen-derived free radicals that can destroy components of connective tissue, inciuding the periodontal ligament. These hydroxyl radicals could be involved in the initiation of postbleaching invasive cervical rsorption, particularly if a tbermocatalytic method has been employed. Invasive cervical rsorption has been identified as a long-term eomplication of luxation and exarticulation injuries,-* and the relatively high incidence of 25.2% of patients (or 25.7% of teeth) in this study confirms trauma as a potential predisposing factor. It suggests that the injury has left the cementum surface damaged, deficient, or altered in character, thereby allowQuintessence Internationai

ing the possibiiity of ingrowth of potentially resorbing cells from the periodontal ligament. Maxillary central incisors were those predominant recorded in this study, and this observation is consistent with their strategic vulnerability to dental trauma. The present study also showed that more than one factor may be involved in the same patient, and this was particularly significant when there had been a history of trauma and bleaching. Surgical procedures involving the sensitive cementoenamei junction were identified as potential predisposing factors in 6.80/0 of patients (5.8% of teeth). This represents a comparatively low incidence, considering the frequency of such treatment procedures. The removal of unerupted third molars has the potential for damage to the cementoenamel junction of the adjacent second molar, while the exposure of unerupted canines for orthodontic purposes may cause similar damage, especially if a cervical wire ligature is used rather than a bonded bracket. Similar damage to the cementoenamel junction also occurred in one patient who had a history of interproximal stripping. There were three patients with a history of orthognathic surgery who displayed root rsorption with similarities to invasive cervical rsorption. However, these patients were excluded from this study, because the predominating type of rsorption was replacement rsorption resulting from loss of the periodontal ligament and progressive root replacement by bone. 93

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The highest incidence of invasive cervical rsorption was found in patients with a history of orthodontic treatment; the rsorption was detected as early as 18 months after tbe removal of appliances or as late as 33 years. There was no correlation between the orthodontic technique employed and the development of this type of rsorption. Some degree of surface rsorption can occur during orthodonric treatment,'^ This rsorption is usually transitory and wili undergo repair after the removal of orthodontie fores,'^ However, if surface rsorption of eementum exposes the underlying dentin, then a potential will exist for rsorption to be initiated by mononuclear precursor cells from tbe periodontal ligament, sbould tbey be stimulated by otber factors. For example, pressure caused by excessive orthodontic forces may result in localized tissue necrosis adjacent to denuded eementum. The resulting tissue metabolites may stimulate mononuclear precursor cells to differentiate into specific clastic cells, which couid cause active rsorption. It is of interest to note that, of the teeth with a history of ortbodontics, maxillary canines were the most commonly recorded in this study, occurring as multiples in two patients. Recause of their position, tooth lengtb, and bone support, canines often are more resistant to ortbodontic movement tban other teeth in the dental arch. Furthermore, if class 2 elastics are used in treatment, they are attached to the maxillary canines and the mandibular first molars. This may translate into greater forces on one root surface, whieh could predispose the area to invasive cervical rsorption. Maxillary central incisors were tbe next most frequently affected teeth. This bigh incidence may be due to tbe position of the maxillary central incisors at the apex of the dental areh, where they couid be subjected to greater tooth movement tban other teetb in the dentition. Mandibular molars were tbe third most frequently affected teeth. These teeth are often used as anchor teeth, and the orthodontie treatment may subject some root surfaces to localized and perhaps excessive pressure during treatment. Multiple rsorptions were present in six patients witb a history of ortbodontics, the number varying from two to seven teeth per patient. This suggests a need for a complete-mouth radiographie examination for any patient with a history of orthodontic treatment who develops invasive cervical rsorption. The apparent association between invasive cervical rsorption and orthodontic treatment must be viewed within the context of the frequency of orthodontic treatment within tbe community. There has been a significant inerease in the use of orthodontic services within South Australia since 1973, when a study indicated that only 7% of patients to the age of 14 years were using specialist orthodontic services.'"^ However, 94

that study did not assess the extent of orthodontic treatment provided by the State School Dental Service and general dental practitioners at tbat rime. A more recent study of the use of orthodontic services by a cobort of adolescents enrolled in tbe South Australian School Dental Service program'^ showed that, by age 15 years, 27,30/o of young patients had received fixed orthodontic treatment, and 15.3% had also been treated by removable appliances. An association between invasive cervical rsorption and orthodontics has been reported previously,^* The endodontic implications of orthodontic treatment have been studied in 87 patients, aged 20 to 25 years, who had received ortbodontic treatment earlier in tbeir lives. The authors recorded only one case of cervical rsorption in an incisor, representing 1.5% of the group,'* A control group of a similar age range showed no evidence of cervical rsorption. It should be noted that oniy anterior teeth were examined in tbat study. In addition, tbe lag time between ortbodontic treatment to the diagnosis of invasive cervical rsorption can vary, and tbis sbould be taken into consideration in atiy comparative study. In the present study, the average age of detection of invasive cervical rsorption in patients with a history of orthodontic treatment was 31,5 years. Despite the opinion that cmentai defects appear to predispose teeth to this type of rsorption,' periodontai therapy with deep scaling or root planing was not identified in this study as a major potential predisposing factor, being recorded as a sole factor in only four patients (1,8%) witb four teetb (1.6%), When combined with other factors, namely, surgery or orthodontics, the incidence was still low (2,8% of patients; 2,4% of teeth}, Tbis may be due to the fact that in chronic periodontal disease there may be inhibition or destruction of the precursor resorbing cells in the periodontai ligament in the area of denuded eementum, or rapid epithelial downgrowth may effectively prevent contact of connective tissue eells with that surface,= Of the six patients with invasive cervical rsorption associated with bruxism, it was perhaps significant to the occupational stress of our profession that two were dentists and one a medical practitioner The presence of intracoronal restorations may have little significance in anterior teeth, but in posterior teeth they can be associated with the development of dcntinai and cmentai cracks, especially if the restorations are supplemented with pins. Such cracks often extend into the periodontal ligament and, accordingly, may ailow invasion of resorbing tissue. Delayed eruption resulting from tooth impaction, observed in four patients (1.8%) and five teeth (LWo), tends to leave a tooth crown partially surrounded by attached gingival tissues. This may result in eonditions similar to those obtained experimentally when gingival
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flaps are coronally repositioned.'' In these experiments, invasive cervical rsorption was observed in association with a high proportion of root surfaces. While 14.9% of patients (16.4% of teeth) did not have a registrable potential predisposing factor, it is possible tbat some may have had undetectable developmental defects, such as hypoplasia or hypomineralization of cementum. In 28.90.0 of patients, there was more than one potential predisposing factor (for example, 7.5% of patients had a history of trauma and intracoronal bleaching). These observations confirm a need for careful follow-up examinations for such patients. The present analysis shows that the majority of cases referred for treatment were classified as class 3 severity (see Fig 3)- In lesions with this classification, there has been invasion of resorptive tissue into the crown and at least one third the length of the root. Rsorptions of this magnitude usually have a complicated structure.' Not only is there invasion hy fibrovascular tissue, but ectopic calcifications both occur within the fibrovascular tissue and are deposited on the resorbed dentin. A series of channels containing resorptive tissue are present, and they usually have connections furtber apically with the periodontal ligament. The pulp space is surrounded by tbe resorbing tissue, but generally this is walled off by a thin layer of intact dentin and predentin. Detection of invasive cervical rsorption at an early stage is important, because it provides a clinician with the possibility of treating such lesions with a satisfactory degree of success. While several methods of treatment can be employed, a technique involving the topical application of trichloracetic acid, curettage, nonsurgicai root canal treatment, where necessary, and restoration with glass-ionomer cement will he outlined in a further report, along witb the long-term results of such a treatment regimen for each of the four classes of invasive cervical rsorption as defined in this study.
CONCLUSION

REFERENCES 1. Heithersay GS. Clinical, radiologie, and histopathologic features of invasive cervical rsorption. Quintessence Int 1999;30:27-37. 2. Harrington GW, Natkin E. Esternal rsorption associated with the bieiitliing of pulpless teeth. | Endod 1979;5344-348. 3. Heithersay GS, Dahlstrom SW, Marin PD. Incidence of invasive tervical rsorption in bleached root-filled teeth. Aust Dent I 1994 ;39:82-87. 4. Cvek M. Endodontic treatment of traumatiscd teeth. In; Andreasen )0 (ed). Ttaumatic Injuries of the Teeth, ed 2. Copenhagen: Munksgaard, 1981:362-363. 5. Tronstad L. Root resorption-Etiologi', terminology and elinicai manifestations. Endod Dent Traumatoi 1988;4: 241-252. 6. Trope M, Chivan N. Root rsorption. In: Cohen S, Burns RC (eds). Pathways of the Pulp, ed 6. St Louis: Mosby, 1994:493-503. 7. Hammarstrom L, Lindskog S. Factors regulating and modifying dental root rsorption. Pri>c Finn Dent Soc 1992; 88(suppll):115-123. 8. Friedman S, Rotstein I, Libfield H, Stabliolz A, Heling T Incidence of external root rsorption and esthetic results in 58 bleached pulpless teeth. Endod Dent Traumatoi 1988;4: 23-26. 9. Rotstein I. In-vitro determination and quantification of 30% hydrogen peroxide penetration through dentin and cementum during bleaching. Oral Surg Oral Med Oral Fathol 1991:72:602-506. 10. Rotstein 1, Torek Y, Misgav R. Effect of cementum defects on radicular penetration of 30"'' H^O^during intracoronal bleaching. I Endod 1991;17:230-233. 11. Dahlstrom SW, Bridges TE, Heithersay GS. Hydroxyl radical activity in thermocatalytically bleached root filled teeth. Endod Dent Traumatoi 1997:13:119-125. 12. Barber AF, Sims MR. Rapid maxillary expansion and external root rsorption in man: An SEM study. Am ) Orthod 1981:79 630-652. 13. Langford SR, Sims MR Root rsorption, repair, and periodontal attachment following rapid maxillary expansion in man. Am J Orthod 1982:81:108-115 14. Bajada S. Ulilisation of Orthodontic Services in South Australia |thcsis|. University of Adelaide, 1973. 15. Allister JH, Spencer AJ, Brennan DS Provision of orthodontic care to adolescents in South Australia: The type, the provider, and the place of treatment. Aust Dent J 1996: 41:405-410. 15. Cwyk F, Saint-Perre F, Tronstad L. Endodontic implications of orthodontic tooth movement [abstract 1039]. J Dent Res 1984:63. 17. Bogle G, Claffey N, Egelberg |. Healing of horizontal circumferential periodontal defects following regenerative surgery in beagle dogs. J Clin Pcriodontol 1985:12:837-849.

This study has attempted to identify potential predisposing factors in the development of invasive cervical rsorption. There appear to be strong associations between the incidence of invasive cervical rsorption and orthodontic treatment, intracoronal bleaching, and dental trauma, alone and in cotnbination, but further investigations with randomized samples are warranted.

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