Page 22 - GP Spring 2025

External Replacement Resorption with Remaining Silver Points

Authors: Emily Silman, Gal Sahar, Paul R. Baker, DDS, and Kim Phung T. Hoang, DDS

Abstract: replacement resorption is a process when cementum and dentin are
Tooth resorption is mainly attributed to odontoclasts, which are resorbed and replaced by bone, following injury to PDL and cemen-
the cells that resorb dental hard tissues - dentin and cementum. tum. PDL necrosis leads to ankylosis as response of osseous healing.
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Root resorption can be classified into either internal or external root Once the tooth loses its PDL, clastic cells resorb the cementum and
resorption. External root resorption is a result of the body’s own dentin followed by osteoblasts forming bone in the area of resorp-
immune system dissolving the tooth root structure. It is initiated tion. This process is often progressive, ultimately leading to resorp-
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by trauma to the periodontal ligament and affects the external or tion of the entire root and
lateral surfaces of a tooth. The types of external root resorption loss of the tooth. The
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include surface, inflammatory, replacement, invasive, pressure, diagnosis of root resorp-
orthodontic, physiologic, and idiopathic. Root resorptions can be tion can be made based
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further classified according to stimulation factors including pulpal on clinical, radiographic,
infection, periodontal infection, orthodontic pressure, impacted and histological findings.
tooth, tumor and ankylosis. Most of the time, cases of root resorp- Cone beam computed to-
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tion are asymptomatic. However, symptoms can present as tooth mography (CBCT) can
pain, tooth mobility, swollen and erythematous gingivae, or shifting be used as an adjunct in
teeth. Endodontic root canal treatment is the main method to treat formulating the final di-
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pulpal and periapical disease. This procedure aims to eliminate in- agnosis. 10
fected pulp and bacteria of the root canal system, which is then Figure 1. Periapical radiograph taken
cleaned, shaped, and filled. Silver points is a method of endodontic Case Presentation: in 2011.
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obturation that was introduced in the 1930s. In the past, they gained An 81-year-old male
popularity from their ease of handling and placement, ductility, ra- presents with moderate
diopacity, and some antibacterial properties, however the use of sil- to severe periodontitis
ver points has greatly diminished over the past few decades. This and previously treated
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paper presents a case of what appears to be external replacement root canal therapy. The
resorption with remaining silver points embedded in bone. patient visited an endo-
dontist in Russia over ten
Current Literature: years ago and received
Root resorption is a pathologic condition when it occurs in per- root canal treatment on
manent teeth. It is initiated by injury to either the non-mineralized tooth #31 and a three unit
tissues covering the external root surface (precementum) or the bridge on teeth #29-31.
internal surface of the root canal (pre-dentin), triggering the in- Radiographs were taken Figure 2. Periapical radiograph taken
teraction between inflammatory cells, resorbing cells (osteoclasts, in the years 2011 (Figure in 2016.
odontoclasts, or dentinoclasts), and hard tissues. This process is 1), 2016 (Figure 2), 2023
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multifactorial, leading to progressive destruction and eventual loss (Figure 3), with none
of tooth root dentin and/or cementum. Additionally, resorption can taken in between as the
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be a product of ankylosis, which is defined as loss of PDL in which patient refused addition-
the bone and tooth root seem fused together through direct contact al imaging. Radiograph-
with each other. In other cases, the root itself is fully resorbed and ic imaging in 2023 (Fig-
replaced by bone, known as external replacement resorption. 4 ure 4) revealed complete
root resorption in tooth
Current literature also addresses the concern of the high failure #31, but the treatment
rate when using silver points in root canal therapy. Failure of silver material of silver points
points is due to their inability to seal the apical foramen and their was left undamaged and
corrosion over time which allows for high levels of leakage into the appears to be integrat- Figure 3. Periapical radiograph taken in
root canal system. 8 ed into the mandibular 2023 showing complete root resorption
bone. The patient is as-
Differential Diagnosis: ymptomatic, with no mo- of tooth #31.
The following proposed classifications of root resorption by Abbott bility, pain, or inflamma-
and Lin (2022) may assist dentists in the formulation of a differential tion noted in the affected
diagnosis. External surface resorption is best defined as small ar- tooth. His medical history
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eas of resorption of the cementum. It is caused by local injury to the was significant only for
cementum and PDL, but is self-limiting provided injury is removed the use of Nexium to treat
and devoid of bacterial contamination. External inflammatory re- GERD. There are no in-
sorption occurs when bacteria infects the root canal system during terferences present in the
injury. Endotoxins released by the invading bacteria either induce patient’s occlusion with
an inflammatory reaction or exacerbate an inflammation that’s al- the opposing porcelain
ready present following an injury. The resorption will continue for implant-supported resto-
as long as the tooth remains untreated and injury persists. External ration. Treatment plans Figure 4. Periapical radiograph taken
in 2023 showing the other side of the
www.nysagd.org l Spring 2025 l GP 22 three unit bridge.