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Endodontic therapy on a dentition exhibiting multiple periapical radiolucencies
Shohreh Ravanshad, DMD, MScD and Akbar Khayat, DMD, MScD
School of Dental Medicine, Shiraz University
of Medical Sciences, Shiraz, Iran
hereditary disturbance, pulp calcification. Dentinal dysplasia (DD) Type I, is a hereditary disturbance in
dentine formation. In this anomaly, teeth in both primary and secondary
dentitions are affected,
Correspondence
and radiographically show short and blunted
roots with obliterated root canals
Dr Akbar Khayat, School of Dental Medicine,
and periapical pathosis. Management of
patients with DD has presented dentists
Shiraz University of Medical Sciences,
Shiraz,
with problems. Extraction has been suggested
as a treatment alternative for
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teeth with pulp necrosis and periapical
abscess. Follow-up and routine conser
doi: 10.1111/j.1747-4477.2006.00008.x vative treatment is another choice of treatment
plan in DD. Another approach for the treatment of teeth with DD has included
periapical surgery and retrograde filling, which is recommended
in the teeth with long roots. The purpose of this report is to present an
unusual case of dentinal dysplasia Type I in a 22year-old woman showing upper
and lower teeth with obliterated root canals and periapical radiolucencies. In
this case, conventional endodontic treatment was performed. Postoperative
radiographs and clinical evaluation demonstrated periapical healing and
successful results. Based on the results of this case report, conventional
endodontic treatment for cases with pulp necrosis and periapical radiolucencies
in dentinal dysplasia is highly recommended.
and the pulp chambers are completely obliterated, but
Introduction
these findings are not present in permanent teeth. No
Dentinal dysplasia (DD) is a rare hereditary disease, trans-multiple periapical
radiolucencies associated with denmitted as an autosomal dominant character
gene. Rushton tinal dysplasia Type II have been reported (3). used this term in
1939 (1) and characterised it as abnormal In patients with dentinal dysplasia
Type I, the pulps of dentine that contains an enormous number of spherical the
affected teeth tend to become necrotic following calcibodies. In dentinal
dysplasia, both the deciduous and per-fication, probably as a result of a
deficiency in the nourishmanent dentitions are affected and the teeth become
loose ment and oxygen supply to the pulp. Periapical pathosis and are exfoliated
prematurely. may then develop and result in apical resorption and tooth
Witkop (2) in 1972 classified dentinal dysplasia into two exfoliation.
Management of patients with DD has pre-types, radicular DD for Type I and
coronal DD for Type II. sented dentists with problems. Extraction has been
sug-In Type I DD, both the deciduous and permanent denti-gested as the treatment
of choice for teeth with pulp tions are affected. The crowns of the teeth appear
clinically necrosis and periapical abscess (5). Follow-up and routine normal in
morphology. Defects in dentine formation and conservation is an alternative
treatment plan in order to pulp obliteration are present. In Type I DD,
obliteration of retain the teeth as long as possible (6). root canals occurs
much earlier by deposition of amor-Tidwell and Cunningham (7) reported a case of
Type II phous dentine or pulp stones (3). Radiography shows DD with relatively
long roots treated by conventional short, pointed or blunted roots and
periapical radiolucen-endodontic therapy with short-term success. Coke et al. cies despite the absence of dental caries (4–6). In Type II (8) managed a
case of Type I DD with periapical curettage DD, the primary teeth are brown or
opalescent blue in and retrograde root filling with 2 months of follow-up.
colour, similar to those seen in dentinogenesis imperfecta, Our report is of is
an unusual case that presented with
S. Ravanshad and A. Khayat Endodontic
Therapy on a Dentition
obliterated root canals and multiple periapical
radiolucencies that was managed by conventional endodontic treatment resulting
in a high degree of clinical success.
Case report
A 22-year-old woman was referred to Shiraz
Dental School Department of Endodontics for endodontic evaluation of her teeth.
The medical history of the patient was unremarkable. Clinical examination
revealed an anterior open bite. The teeth exhibited normal shaped crowns but a
slightly yellow-grey colour was observed. The teeth revealed no signs of
attrition and no response to thermal and electrical stimuli were exhibited.
Teeth 36 and 46 exhibited extensive carious lesions.
An orthopantomogram and periapical radiographs were taken, and
they revealed that all the permanent teeth were present; obliterated pulp
chambers were evident in all the teeth, even in unerupted third molars.
Short, spindly roots were present on all permanent teeth. The
anterior, premolar and molar teeth (11, 12, 14, 15, 16, 17, 22, 25, 26, 27, 31,
34, 35, 37, 45 and 47) were asymptomatic but showed periapical radiolucencies
and no apparent caries.
Teeth 36 and 46 showed extensive carious lesions with
periapical pathosis (Fig. 1).
On the basis of the clinical and radiographic appearance, a
diagnosis of dentinal dysplasia Type I was made. Systemic findings were
unremarkable and the family history revealed no previous cases of such a
problem. The patient was considered to be the first-generation sufferer.
The treatment approach that was planned in this case was
conventional endodontic therapy. The untreatable teeth 36 and 46 were extracted
because of extensive carious lesions. Each involved and savable tooth displaying
periapical pathosis was scheduled for treatment. Rubber dam isolation was
placed, access cavities were prepared, and the root canals were instrumented
with step-back preparation technique and copious amounts of 2.5% sodium
hypochlorite solution for irrigation. Obturation was accomplished with a warm
lateral condensation gutta-percha technique and Roth’s 801 sealer (Roth
International Drug. Co., Chicago, IL, USA). Coronal restoration was performed
using amalgam or composite resin.
In the upper left lateral incisor (tooth 22), following a
conventional access cavity, no sign of a canal system was found despite
considerable penetration, and the canal was obturated to the mid-root level as a
last resort.
Postoperative reviews of endodontically treated teeth at 3 and
6 months and from 1 to 4 years revealed that the teeth were asymptomatic.
Radiographic examination showed complete resolution of the periapical lesions.
Discussion
The most extensive review of dentinal
dysplasia was done by Ansari et al. in 1997 (6). This paper reviewed 52
cases taken from the literature and reported that endodontic therapy was
attempted in only two cases. One was reported as a case of DD Type II with
relatively long roots, which was treated by conventional endodontic therapy. The
other was a case of DD Type I which was treated surgically with 2 months of
follow-up.
In dentinal dysplasia, calcified pulp chambers, unfavourable
crown-root ratio, periapical radiolucent areas and the nature of the periapical
lesion are the characteristic findings that present the dentist with problems in
the management of this condition. The exact mechanism responsible for the
abnormal tooth development and obliteration of the pulp space in DD is unknown.
Rushton (1), Logan et al. (9), proposed that multiple degenerative foci
in the dental papillae became calcified, leading to reduced growth and final
obliteration of the pulp space. Sauk et al. (4) suggested that it was not
the dental papillae, but the epithelial root sheath that was responsible for the
root development and that this invaginated too early, which then induced ectopic
dentine formation in the pulp space. Wesley et al. (10) disagreed with
these theories and proposed that the condition is caused by an abnormal
interaction of odontoblasts with ameloblasts leading to abnormal differentiation
and/or function of these odontoblasts. In dentinal dysplasia Type I, pulp
necrosis and periapical pathosis are common findings present in the affected
teeth. The authors of the present study believe that the pulp necrosis found in
this condition occurs because of impairment in pulpal circulation and
nourishment deficiency of the dental pulp, which renders the pulp susceptible to
bacteraemia. Other authors attribute this finding to pulp contamination through
the tunnels present in the defective dentine (11).
Histopathologically, the periapical radiolucent
areas seen in most cases of dentinal dysplasia have been interpreted as
radicular cysts; however, in some cases a diagnosis of periapical granuloma has
been reported (8–10).
According to some reports, treatment of symptomatic teeth in
Type I dentinal dysplasia that have undergone pulpal necrosis and periapical
pathosis is extraction (12). Endodontic treatment has been recommended on the
teeth with relatively long roots (7). Periapical surgery and retrograde root
filling is another approach for the treatment of teeth with dentinal dysplasia
(8). Another management strategy suggested by Steidler et al. is
prevention (11). They recommended routine conservation and follow-up to prevent
periodontal problems and dental caries in order to retain the teeth as long as
possible. Our case report is unusual in that multiple periapical pathoses were
associated with non-carious asymptomatic teeth. This case was also interesting
because of the successful result following conventional endodontic treatment. At
the 3-year
S. Ravanshad and A. Khayat
recall (Fig. 2), healing was complete, and the patient was
delighted.
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