Internal resorption: A brief review

and case report

September 15, 2014
ByStacey L. Simmons, DDS
Resorption is a condition associated with either physiologic or a pathologic
process resulting in a loss of dentin, cementum, and/or bone. 1 The
etiology for resorption initiates from various injuries to the tooth, including
thermal, mechanical, and chemical.2 There are two different kinds of
resorption external and internal. External resorption is resorption
initiated in the periodontium and initially affecting the external surfaces of
a tooth may be further classified as surface, inflammatory, or
replacement, or by location as cervical, lateral, or apical; may or may not
invade the dental pulp space. 1 Internal resorption is an inflammation
process initiated within the pulp space with loss of dentin and possible
invasion of cementum.1 This review will focus on internal resorption.

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The pathology of internal root resorption (IRR) is caused by transformation
of normal pulp tissue into granulomatous tissues with giant cells, which
resorb dentin. 3 This, in turn, resorbs the dentinal walls, advancing from
the center to the periphery. There are two classifications of internal
resorption: internal root canal inflammatory resorption and internal root
canal replacement resorption.2

1. In the inflammatory resorption, the resorptive process if the

intraradicular dentin progresses without adjunctive deposition of
hard tissues adjacent to the resorptive sites. The phenomenon is
associated with the presence of granulation tissues in the resorbed
area and identifiable with routine radiographs as a radio clear zone
centered on the root canal.

2. In the replacement resorption, the resorptive activity causes defects

in the dentin adjacent to the root canal, with concomitant deposition
of bone-like tissue in some regions of the defect. It results in an
irregular enlargement of the pulp space with partially or fully
obliterated area of the pulp chamber.

Trauma and pulpal inflammation/infection are two of the major

contributory factors in the initiation of internal resorption. (2) Caliskan et
al. reported that in a study done on patients diagnosed with IRR, 43% of
the patients had trauma as a common etiological factor, followed by
carious lesions at 25%. (2,4)

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Internal root resorption is typically detected clinically via routine
radiographs. It is observed in all areas of the root canal, but it is most
commonly discovered in the cervical region of the tooth. (3) One of the
key ways to diagnose internal resorption (vs. external resorption) is to
observe whether or not there is a defined outline of the pulp chamber. If
the pulp chamber outline is within the lesion itself, it is likely internal
resorption. If the pulp chamber outline is recognizable within a radiolucent
halo, then it is likely external resorption. The use of CBCT has allowed for
more accurate and complete diagnosis of IRR (and external root
resorption) and is highly recommended in early presentations of potential
resorption. (2,3)
IRR is usually asymptomatic, but pain or discomfort may be the chief
complaint if the granulation tissue has been exposed to oral fluids. (3) The
granulation tissue can clinically manifest itself as a pink spot where the
crown dentin destruction is severe. (3) The pink shade is related to the
highly vascularized connective tissue adjacent to the resorbing cells and
when the pulp becomes necrotic, it turns grey/dark grey. (2)
Teeth with IRR typically respond normally to pulpal and periapical tests
until the lesion grows significantly in size, which then results in
perforation. (2,5) Once necrosis of the pulpal tissue takes place, then the
typical signs/symptoms of an abscessing tooth occur. Vital pulp tissue is
required for IRR to take place; therefore, when there is complete pulpal
necrosis, the growth of the resorption ceases because the resorbing cells
are cut off from the blood supply and nutriments. (2,3)
Once diagnosed, treatment considerations and prognosis must be
rendered. Since removal of vital tissue ceases progression of the lesion,
then initiation of root canal therapy is recommended. However, the
prognosis for the long-term form and function of the tooth is dependent on
the size of the lesion. The American Association of Endodontics (AEE)
offers this as a general guide: (6)

More detailed management protocols and resources can be found at the

AAE website (6) and in the literature. (2,3)
Case report
A healthy 36-year-old male presents to the office with a chief complaint of
a loose front tooth. A radiograph revealed significant bone loss around
tooth No. 10 in addition to the focalized loss of internal tooth structure in
the apical one-third of the root. Obvious perforation of the root was
observed. Clinical exam revealed a lack of recession, probing depths of 8+
mm with a Class III mobility. No drainage point or fistula were noted. The
patient indicated that he had the crowns placed in the anterior area eight
years ago and has not had any complications since then. He furthermore
admits to lack frequent dental visits during this time.
Differential diagnoses of internal and external resorption were given.
Earlier radiographs would definitely aid in a more accurate and definitive
diagnosis, but ultimately, internal resorption was given due to the focal
point of radiolucency within the pulp chamber area. While there could be
debate on this, the ultimate fate of the tooth did not change. Due to the
extent of the defect (perforation through external root surface) and the
advanced bone loss and periodontal disease, it was recommended that
that tooth be removed and other restorative options be assessed. Upon
removal of the tooth, there was very little root structure left as it came out
in a multitude of pieces.

Internal root resorption is observed daily in practice (although more rare

than external resorption) and with early detection (especially with the use
of technology and CBCT scans), diagnosis, and management, the
prognosis for rendered treatment can be favorable. The numerous
resources available offer significant aid in the diagnosis and treatment of
such lesions.
Stacey L. Simmons, DDS, is in private practice in Hamilton, Montana.
She is a graduate of Marquette University School of Dentistry. Dr.
Simmons is a guest lecturer at the University of Montana in the Anatomy
and Physiology Department and is a contributing author for DentistryIQ,
Surgical-Restorative Resource, and Dental Economics. She can be
reached at ssimmonsdds@gmail.com.
References
1. American Association of Endodontics, Glossary of
endodontic terms, 2014. www.aae.org/glossary
2. Nilsson E, Bonte E, Bayet F, Lasfargues J. Management
of internal root resorption on permanent teeth.
International Journal of Dentistry. Volume 2013. Article ID
929486, 7 pages.
3. Maria R, Mantri V, Koolwal S. Internal resorption: A review and case
report. medind.nic.in/eaa/t10/i1/eaat10i1p98.pdf
4. Caliskan MK, Turkun M. Prognosis of permanent teeth with internal
resorption: A clinial review. Dental Traumatology. 1997;13(2):75-81.
5. Principals and Practice of Endodontics. 2nd Edition. Walton &
Torabinejad. WB Saunders Company. 1996. 36.
6. American Association of Endodontics
website. www.aae.org/treatmentoptions. Internal Resorption.