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JOURNAL OF ENDOOONT~CS
Copyright9 1986 by The AmehcanAssociationofEndodontists

Printed in U.S.A.
MOL. 12, NO. 7, JULY 1986

A New Treatment Modality for Internal Resorption


David Eugene Stamos, DDS, and Daniel George Stamos, DDS, MS

A new treatment modality is offered for internal


resorption. Two case reports are described. The
Cavi-Endo ultrasonic unit with 2.6% sodium hypochlorite was used for canal preparation and preflaring. After final canal preparation, a # 2 0 ultrasonic
file was placed back into the canal and activated
with intermittent irrigation for an additional 3 min.
The Obtura injection-molded thermoplasticized
gutta-percha delivery system was used to obturate
the canal. Vertical condensation was used to compact the gutta-percha.

evaluation of root canal debridement comparing conventional instrumentation and ultrasonic instrumentation, found that canals debrided by the ultrasonic technique were significantly cleaner at all canal levels studied. This was supported by a scanning electron microscopic study which reported that canals instrumented
by ultrasonics were significantly cleaner than those
instrumented conventionally (8).
Obturation of canals with internal resorption has been
achieved with semisolid materials, with the warm guttapercha method being used most frequently (9). Yee et
al. (10) studied the obturation of root canals using
injection-molded thermoplasticized gutta-percha in
1977. He found that the injection-molded technique
leads to a seal comparable to that of conventional
techniques. Torabinejad et al. (11), in a scanning electron microscopic study, further supported this finding.
Marlin et al. (12), in a preliminary report, described
clinical success rates comparable to the rate achieved
with conventional gutta-percha obturation techniques.
The purpose of this article is to report two cases of
internal resorption that were treated with ultrasonics
and injection-molded thermoplasticized gutta-percha.

Bell (1) first described a tooth having internal resorption


in 1830. Since that time, there have been numerous
reports in the literature concerning various aspects of
treatment but there has been very little change. Now
with the recent introduction of the ultrasound instrumentation and injection-molded thermoplasticized
gutta-percha obturation techniques, a new treatment
modality is offered.
Instrumentation of canals with internal resorption has
consisted of mechanical and chemical debridement.
Morphologically, these root canals exhibit many complex irregularities (i.e. fins and cul-de-sacs). It has been
shown by Gutierrez and Garcia (2) that prolongation of
the root canals, resembling fins, were never touched
by root canal instrumentation. Shih et al. (3) reported
that irregularities in the main canal may contain organic
tissue not mechanically removed. Chemical debridement of these canals has been relied on exclusively.
However, Senia et al. (4) found that 5.2% sodium
hypochlorite, when combined with usual hand instrumentation, was not effective in removing debris from
the apical third of the canal.
Richman (5) in 1957 first described a root canal
preparation technique utilizing ultrasonic energy. Some
20 yr later, Martin (6) further investigated the use of
ultrasound for the disinfection of the root canal system
in combination with a bactericidal irrigant. He concluded
that ultrasound in conjunction with a bactericidal irrigant
was effective in achieving a greater reduction in organic
debris and microorganisms than ultrasound alone with
a neutral buffer solution. Cunningham et al. (7), in an

CASE 1

A 37-yr-old white male was referred to the graduate


department at Marquette University for endodontic
therapy. The medical history was noncontributory. A
past history of trauma to the maxillary anterior region
was reported by the patient. No response could be
elicited from tooth 7 using the electric pulp tester or a
carbon dioxide cold test. The remaining anterior teeth
all responded within normal limits. Radiographic examination revealed internal resorption in tooth 7 (Fig.
1). A diagnosis of pulpal necrosis with a normal periapical region was established and the patient consented to endodontic therapy.
Standard endodontic access was prepared under
rubber dam isolation. A #15 file was the first instrument
felt to bind and a working length of 27.0 mm was
established. Canal preparation and preflaring was accomplished using a 2.6% solution of sodium hypochlorite and the Cavi-Endo (Dentsply International, Inc.,
York, PA) ultrasonic unit as described by Stamos et al.
315

316

Stamos and Stamos

FIG 1. Maxillary right lateral incisor, preoperative radiograph. Note


internal resorption. Maxillary central incisor has unusually wide pulp
chamber. Defective distal and facial resins are present.

Journal of Endodontics

FIG 2. Postoperative radiograph. Canal obturated using Obtura gun.

(13). After final canal preparation, a #20 ultrasonic file


was placed back into the canal and activated with
intermittent irrigation for an additional 3 min. The canal
was obturated during the same visit using a zinc oxideeugenol sealer and an injection-molded thermoplasticized gutta-percha delivery system (Obtura, Unitek Corporation, Monrovia, CA). Vertical condensation was
used to compact the gutta-percha firmly. Cotton and
Cavit were placed in the access opening and a postoperative radiograph was taken (Fig. 2). The patient
returned in 1 yr for a recall examination and reported
no symptoms. Radiographic examination showed a
normal periapical bone pattern (Fig. 3).
CASE 2

A 32-yr-old white male was referred to the graduate


department at Marquette University for endodOntic
therapy. This medical history was noncontributory.
Eight years previously the patient had a bicycle accident
with a resulting crown fracture of tooth 7. A porcelain
veneer crown was placed and the patient remembers
no further problems. For the past year the patient has
noticed a raised area over tooth 7 with an occasional
discharge. Clinical examination revealed a draining
sinus tract over tooth 7. The tooth responded to carbon
dioxide cold testing. A radiograph was made with the

FIG 3. Radiograph 1-yr posttreatment.

Vol. 12, No. 7, July 1986

Internal Resorption Treatment

317

the paste, and the canal was sealed with Cavit and the
crown was replaced (Fig. 5).
The patient was seen 7 wk later, at which time a
radiograph was made and the crown removed to check
the condition of the Ca(OH)2. The sinus tract over tooth
7 had disappeared and the Ca(OH)2 was dry. The
radiograph showed that some of the Ca(OH)2 had been
absorbed on the mesial surface. It was decided to
replace the crown without changing the Ca(OH)2.
Six months after the initial appointment, the Ca(OH)2
dressing was removed. Paper points showed the canal
to be dry. The Neosono-D (American Medical & Dental
Corp., Cherry Hill, NJ) was used to check for leakage
from the resorbed area on the mesial surface of the
root. This was accomplished by bending the tip of a
#15 file and gently exploring the perforated area while
connected to the Neosono-D. The digital read-out indicated leakage present from the perforation even though
a slight resistance was felt. Ca(OH)2 was repacked into
the canal and the crown was replaced.
The patient returned 4 months later, at which time
the crown was removed and the Ca(OH)2 taken out.
Paper points again were dry and use of the NeosonoD indicated minor leakage from the mesial surface. It
was decided to obturate the canal at this visit. Obtur-

FIG 4. Maxillary right lateral incisor, preoperative radiograph. Sinus


tract traced to mesial surface using gutta-percha. Note area of
perforated internal resorption.

sinus tract being traced with a gutta-percha cone (Fig.


4). The radiograph revealed considerable internal resporption, with lateral root perforation on the mesial
surface. A diagnosis of irreversible pulpitis with suppurative periodontitis was established, and the patient
consented to endodontic therapy.
The area was infiltrated with local anesthetic and the
crown was removed for easier access. Standard endodontic access was made under rubber dam isolation.
Profuse hemorrhage from the canal was encountered.
A #20 file was the first file to bind at a working length
of 19.0 mm. The canal was hand instrumented to a
#25 and closed with cotton and Cavit. The crown was
replaced with temporary cement.
One week later the patient returned. The Cavi-Endo
ultrasonic unit with 2.6% sodium hypochlorite was used
for canal preparation and preflaring. A #20 ultrasonic
file was placed into the canal and activated for an
additional 3 min with intermittent irrigation. The last
hand file to reach working length was a #50 file. A
thick paste of Ca(OH)2 (Lilly, Indianapolis, IN), barium
sulfate (10%), and 2% lidocaine with 1:100,000 epinephrine was packed into the canal with an amalgam
carrier and various condensers. Cotton was placed over

FIG 5. Working radiograph with canal packed with calcium hydroxide


and barium sulfate.

318

Stamos and Stamos

FIG 6. Postoperative radiograph. Canal obturated using Obtura gun.


Note second area of resorption on distal.

ation consisted of a Ca(OH)2 sealer (Sealapex; Kerr,


Romulus, MI) and an injection-molded thermoplasticized gutta-percha delivery system. Vertical condensation was used. Cotton and Cavit were placed in the
access and the crown replaced with temporary cement.
A postoperative radiograph was made (Fig. 6). The
patient returned in 7 months for evaluation, at which
time he was asymptomatic. Radiographic examination
revealed good periapical healing (Fig. 7).
DISCUSSION
A multiplicity of uses for ultrasonics has been previously described by Stamos et al. (13). Internal resorption was not discussed and only Chivian (14) has made
any reference to ultrasonics for use in such cases.
Ultrasonics is effective because of a synergistic action
involving both physical and chemical activity. Physical
activities associated with ultrasonics include cavitation
and acoustic streaming. Cavitation refers to the growth
and collapse of small bubbles in a fluid medium causing
radiating shock waves. These waves produce a very
effective cleansing mechanism in irregular canal spaces.
Acoustic streaming is the harmonic motion of the irrigant around the energized file enhancing removal of
debris. Chemical activity is associ'&ted with ultrasonic

Journal of Endodontics

FIG 7. Radiograph 7 months posttreatment.

activation of a bactericidal irrigant. It has been shown


that ultrasonic activation of 2.6% sodium hypochlorite
warms the solution, an action that will improve its tissue
dissolving ability (15). Ultrasonic activation also will
enhance the disinfecting capability of sodium hypochlorite in root canals (6). These synergistic effects enable
the irrigant to cleanse and penetrate the canal space.
In the cases presented, an additional 3 min of intermittent irrigation was used to maximize the chemical effect
of the energized irrigant. In a study comparing conventional and serial instrumentation, the results showed
the canal to be clean only where instrumentation had
occurred (16). It has recently been shown that canals
prepared with the step-back/ultrasonic technique are
significantly cleaner than canals treated with the conventional step-back technique (17). This was attributed
to the action of the ultrasonically activated irrigant
within the canal system.
Obturation of canals with internal resorption has been
quite a challenge in the past. The warm gutta-percha
method has proven to be the most effective technique
in producing a three-dimensional root fill. Thermoplasticized injection-molded gutta-percha has. been shown
to given an impression-like reproduction of the irregularities of the root canal space (10). Vertical condensation was used in both cases to ensure a dense root fill.
Sealer is advocated not only for a hermetic seal but

Internal Resorption Treatment

Vol. 12, No. 7, July 1986

also to act as a lubricant for the gutta-percha. Longterm follow-up is necessary to determine endodontic
Success.

SUMMARY
Two cases were presented involving internal root
resorption. A new treatment modality involving ultrasonics and injection-molded thermoplasticized guttapercha was described.
We are grateful to our late father, James A. Stamos, for his enthusiasm and
support in our endeavors. We wish to thank Kathryn Scheets for her assistance
in preparation of this article.
Dr. David Stamos is currently a second-year endodontic graduate student
at Marquette University School of Dentistry. Dr. Daniel Stamos is a recent
graduate and is currently in private practice in Kansas City North, MO.

References
1. Bell T. The anatomy, physiology, and disease of the teeth. Philadelphia:
Carey and Lee Publishing, 1830:171.
2. Gutierrez JH, Garcia J. Microscopic and macroscopic investigation on
results of mechanical preparation of root canals. Oral Surg 1968;25:108-16.
3. Shih M, Marshall FJ, Rosen S. The bactericidal efficiency of sodium
hypochlorite as an endodontic irrigant. Oral Surg 1970;29:613-9.

319

4. Senia ES, Marshall FJ, Rosen S. The solvent action of sodium hypochlorite on pulp tissue of extracted teeth. Oral Surg 1971 ;31:96-103.
5. Richman MJ. Use of ultrasonics in root canal therapy and root resections.
J Dent Meal 1957;12:12-18.
6. Martin H. Ultrasonic disinfection of the root canal. Oral Surg 1976;42:929.
7. Cunningham WT, Martin H, Forrest WR. Evaluation of root canal debridement by the endosonic ultrasonic synergistic system. Oral Surg 1982;53:4014.
8. Cunningham WT, Martin H. A scanning electron microscope evaluation
of root canal debridement with the endosonic ultrasonic synergistic system.
Oral Surg 1982;53:527-31.
9. Weine FS. Endodontic therapy. 3rd ed. St. Louis: CV Mosby, 1982.
10. Yee FS, Marlin J, Krakow AA, Gron P. 3-dimensional obturation of the
root canal using injection-molded thermoplasticized dental gutta-percha. J
Endedon 1977;3:168.
11. Torabinejad M, Skobe Z, Trombly PL, Krakow hA, Gron P, Marlin J.
Scanning electron microscopic study on root canal obturation using thermoplasticized gutta-percha. J Endedon 1978;4:245.
12. Marlin J, Krakow AA, Desilets RP, Gron P. Clinical use of injectionmolded thermoplasticized gutta-percha for obturation of the root canal system:
a preliminary report. J Endedon 1981 ;7:277.
13. Stamos DG, Haasch GC, Chenail B, Gerstein H. Endosonics: clinical
impressions. J Endedon 1985;11:181-7.
14. Chivian N. Root resorption. In: Cohen S, Bums RC, eds. Pathways of
the pulp. St. Louis: CV Mosby Co., 1984.
15. Cunningham WT, Balekjian BA. Effect of temperature on collagendissolving ability of sodium hypochlodte endodontic irrigant. Oral Surg
1980;49:175-7.
16. Coffee KP, Brilliant JD. The effect of serial preparation on tissue removal
on the root canals of extracted mandibular human molars. J Endodon
1975;1:211-4.
17. Goodman A, Reader A, Beck M, Melfi R, Meyers W. An in vitro
comparison of the efficacy of the step-back technique versus a step-back/
ultrasonic technique in human mandibular molars. J Endedon 1985;11:249-56.

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