Denosumab Use as a Predictor Variable for External Cervical Resorption: A Case-Control Study

Potential predisposing features of external cervical resorption: An observational study

AIM

To assess the occurrence of external cervical resorption (ECR) in relation to patient characteristics and potential predisposing factors.

METHODOLOGY

In total, 215 ECR lesions (194 patients) referred to the Endodontic postgraduate Unit at King's College London or Specialist Endodontic practice (London, UK) between September 2017 and January 2022. The clinical records were readily accessible for evaluation. At the time of initial presentation, patients diagnosed with ECR were interviewed regarding potential predisposing factors using a checklist based on existing literature of reported predisposing factors. Absolute and relative frequencies for all variables were computed. Inferential analysis was carried out to determine if there was any potential association between the type and location of tooth in the jaw as well as sex, age of the patient and potential predisposing factors.

RESULTS

No identifiable predisposing factor were detected in 22.3% (48/215 teeth) of the cases, 57.7% (124/215 teeth) had a sole, identifiable predisposing factor and 20% (43/215 teeth) had combined (several) factors. The most common (sole or combined) potential predisposing factors were previous/existing history of orthodontic treatment (25.6%, 55/215 teeth), dental trauma injury (DTI) (20.9%, 45/215 teeth), domestic cat ownership (15.8%, 34/215 teeth) and parafunctional habits (10.2%, 22/215 teeth). The highest occurrence of sole predisposing factors was recorded for males (62%, 75/121 teeth), all other ethnic groups combined (non-white) patients (58.5%, 24/41 teeth), incisor teeth (64.4%, 56/87 teeth) and maxillary teeth (62.4%, 68/109 teeth). While the highest occurrence of combined predisposing factors was found in females (22.3%, 21/94 teeth), white patients (20.1%, 35/174 teeth), premolars (29%, 9/31 teeth) and mandibular teeth (21.7%, 23/106 teeth). There were significant associations between tooth type and trauma (p < .001), cat ownership (p = .003) and parafunctional habits (p = .017). The association between trauma (p < .001), cat ownership (p = .002) and jaw location were found to be significant. Concerning parafunctional habits, female patients had significantly (p = .015) more ECR occurrence than male patients.

CONCLUSION

Most cases had 1 (sole) identified predisposing factor; orthodontic treatment, dental trauma history and (previous) cat ownership were the most identified factors. The information may be helpful in diagnosing early stage ECR.

Molecular Profiling of Odontoclasts during Physiological Tooth Replacement

The odontoclast is a rarely studied cell type that is overly active in many dental pathologies, leading to tooth loss. It is difficult to find diphyodont mammals in which either physiological or pathological root resorption can be studied. Here we use the adult leopard gecko, which has repeated cycles of physiological tooth resorption and shedding. RNA-seq was carried out to compare gene expression profiles of functional teeth to developing teeth. Genes more highly expressed in bell-stage developing teeth were related to morphogenesis (PTHLH, SFRP2, SHH, EDAR). Some genes expressed in osteoclasts (ACP5, CTSK, CSF1R) were relatively more abundant in functional teeth compared with developing teeth. There was, however, no differential expression of RANKL (TNFSF11) in the 2 tooth types. In addition, functional teeth expressed proteolysis genes not found in osteoclasts (ADAMTS2, 3, 4, 14; CTSA, CTSH, CTSS). We used tartrate acid resistant phosphatase and cathepsin K (CTSK) staining to identify odontoclasts in and around the gecko dentition. There were 3 populations of CTSK cells: (1) large, functional multinucleated odontoclasts in the crown of the tooth with a ruffled border inside resorption pits; (2) smaller, precursor cells in the pulp with fewer nuclei; and (3) flattened external precursor cells next to the root and bone of attachment. We found a positive relationship between developing teeth and the population of CTSK+ cells on the root surface. We tested a candidate signal that may be involved in CTSK+ cell presence. An antagonist of CSF1R was delivered to developing teeth in vivo, which resulted in a significant decrease in CTSK and CSF1R compared with DMSO controls. Thus, the CSF1 signaling pathway is upstream of CTSK in teeth. This is the first work to detail the molecular characteristics of odontoclasts during physiological tooth shedding and to demonstrate that in vivo, local drug delivery is possible in the gecko model.

Invasive cervical root resorption in a cancer patient: A rare case report with 2 years of follow-up and literature review

INTRODUCTION

Cases involving invasive cervical root resorption (ICRR) in oncological patients are rare, in addition, follow-up of these patients has not yet been reported in the literature.

OBJECTIVE

This study aims to present a literature review and report a case of denosumab as a possible cause of ICRR in a patient with breast cancer with 2 years of follow-up.

CASE REPORT

A 39-year-old female with a history of luminal breast cancer was treated with denosumab semiannually for osteopenia with discontinuation 1 year ago. Oral examination revealed areas of ICRR lesions on two mandibular teeth. The patient presented irreversible pulpitis on the lower left first molar (#19). The lower right first premolar (#28) was asymptomatic, and the resorption cavity was restricted to the tooth crown. Cone-beam computed tomography (CBCT) established the ICRR 2Bp and 2Ad diagnosis in teeth #19 and #28, respectively. Periodontal surgery and a nonsurgical root canal were performed in the molar and restorative treatment was performed in the premolar. Two years after treatment, both teeth were functional and asymptomatic, and probing was within normal limits (< 3 mm) without bleeding. Periapical radiographic examination revealed no progression of resorption nor new lesions.

CONCLUSIONS

This article highlights a rare adverse effect of an antiresorptive therapy, unfamiliar to most clinicians and specialists. In addition, it emphasizes that the early diagnosis and follow-up of ICRR are relevant and can provide successful treatment, avoiding infections and extractions.

Laser Technology in Dentistry: From Clinical Applications to Future Innovations

This narrative review comprehensively synthesizes laser technology's clinical applications, advantages, and limitations in modern dentistry. The review of 67 articles published between 2018 and 2023 highlights the latest advancements, including photobiomodulation (PBM) for enhanced tissue healing and inflammation control, alongside innovative uses in implantology, endodontics, and teeth whitening. The findings underscore the transformative potential of lasers in improving dental treatment precision and patient outcomes while addressing the barriers to their widespread adoption, such as costs and training needs. This review emphasizes the integration of laser technology into routine clinical practice and identifies pathways for future innovations in dentistry.

The prevalence, characteristics, and risk factors of external cervical resorption: a retrospective practice-based study

OBJECTIVES

External cervical root resorption (ECR) is a poorly understood and aggressive form of resorption. The purpose of this study was to examine the prevalence, characteristics, and risk factors associated with the occurrence of ECR in patients seeking endodontic care from private practice settings.

MATERIALS AND METHODS

Records of 343 patients with 390 teeth diagnosed with ECR were identified from 3 private endodontic practices from 2008 to 2022. The patients' demographic information, systemic conditions, and dental history were recorded. The characteristics of the cases including Heithersay classification, pulpal and periapical status, and their management were documented. The association between case severity and potential predisposing factors was examined using chi-square analysis.

RESULTS

The overall prevalence of ECR among patients seeking endodontic care was low (< 1%). However, there was a greater than twofold increase in the pooled prevalence from 2016 to 2021 (0.99%) compared to the data from 2010 to 2015 (0.46%). The most commonly affected teeth were anterior teeth (48.7%). Class II (30.0%) and class III (45.4%) defects were the most often identified. Patients with a history of trauma or orthodontic treatment were significantly more likely to be diagnosed with severe cervical resorption (class III or IV) (p < 0.05).

CONCLUSIONS

There has been an increase in the prevalence of ECR in patients seeking endodontic care. A history of orthodontic treatment and traumatic dental mechanical injuries may predict the severity of resorption.

CLINICAL RELEVANCE

The upward trend in the occurrence of ECR warrants close monitoring of the patients at high risk of developing the condition to facilitate early detection and management.

Multiple idiopathic cervical root resorption: A systematic review

The current literature on multiple idiopathic cervical root resorption (MICRR), a rare and aggressive form of external root resorption, is limited to case reports and series. Therefore, we performed a systematic review of this condition. A comprehensive search of PubMed, Embase, Web of science, Cochrane Library, CNKI, and WANFANG was conducted using key terms relevant to MICRR, supplemented by a grey literature search. Risk of bias was assessed using Cochrane's and Joanna Briggs Institute's tools. A total of 36 studies with 47 cases were included. MICRR is more common among younger females and may be related to hormonal changes and denosumab use. Initially, the premolars are usually affected but all permanent teeth may eventually be involved. Cone-beam computed tomography is recommended for diagnosis and assessment of resorptive lesions. The management is focused on complete removal and restoration of the resorptive tissue to maintain the tooth's structural integrity. However, MICRR usually has a poor prognosis. Due to its invasive and aggressive behavior, MICRR requires greater attention.

External Cervical Resorption: Relationships Between Classification, Treatment, and One-Year Outcome with Evaluation of the Heithersay and Patel Classification Systems

INTRO

The purpose of this study was to identify possible associations between classification, treatment, and one-year outcome of external cervical resorption (ECR) lesions using the Heithersay and Patel systems. Performance of the Patel 3-dimensional classification system was also evaluated.

METHODS

A chart review identified 142 cases of ECR over a twelve-year period. Information regarding demographics, predisposing factors, lesion classification, treatment, and outcomes were collected and analyzed. Inter- and intra-observer reliability analyses were conducted for both classification systems.

RESULTS

There were 72 cases with at least one year of follow up. 70% of these cases survived. Treatment recommendations were correlated with both Heithersay and Patel classification. There were no correlations found between one-year outcome and either classification or treatment done. The weighted reliability analysis showed substantial agreement in both classification systems for both inter- and intra-observer agreement. There was a significant association between the two systems, however the Heithersay system tended to underestimate the apical extent of the lesion.

CONCLUSIONS

Periodic review of ECR lesions presents as a viable treatment option, at least for one year after diagnosis. The Patel 3-D classification system is at least as effective as the Heithersay system and should be used in future ECR prognosis studies. Further long-term outcome assessments are still needed.

PROBE 2023 guidelines for reporting observational studies in endodontics: Explanation and elaboration

Observational studies play a critical role in evaluating the prevalence and incidence of conditions or diseases in populations as well as in defining the benefits and potential hazards of health-related interventions. There are currently no reporting guidelines for observational studies in the field of Endodontics. The Preferred Reporting Items for study Designs in Endodontology (PRIDE) team has developed and published new reporting guidelines for observational-based studies called the 'Preferred Reporting items for OBservational studies in Endodontics (PROBE) 2023' guidelines. The PROBE 2023 guidelines were developed exclusively for the speciality of Endodontics by integrating and adapting the 'STrengthening the Reporting of OBservational studies in Epidemiology (STROBE)' checklist and the 'Clinical and Laboratory Images in Publications (CLIP)' principles. The recommendations of the Guidance for Developers of Health Research Reporting Guidelines were adhered to throughout the process of developing the guidelines. The purpose of this document is to serve as a guide for authors by providing an explanation for each of the items in the PROBE 2023 checklist along with relevant examples from the literature. The document also offers advice to authors on how they can address each item in their manuscript before submission to a journal. The PROBE 2023 checklist is freely accessible and downloadable from the PRIDE website (http://pride-endodonticguidelines.org/probe/).

Multiple idiopathic external cervical root resorption in patient treated continuously with denosumab: a case report

Background

External root resorption is an irreversible loss of dental hard tissue as a result of odontoclastic action. Multiple external cervical root resorptions in permanent teeth are rare. The exact cause of external cervical root resorption is unclear. It is currently well established that RANK/RANKL signaling is essential for osteoclastogenesis and osteoclast-mediated bone resorption. Denosumab is an anti-RANKL antibody used for the treatment of postmenopausal osteoporosis. RANK/RANKL pathway suppression by denosumab is expected to suppress the activity of clastic cells responsible for hard tissue resorption involving both osteoclasts and odontoclasts.

Case presentation

This case report demonstrates aggressive and generalized idiopathic external cervical root resorption that started and advanced during ongoing antiresorptive therapy with the human monoclonal RANKL-blocking antibody denosumab without discontinuation of therapy in a 74-year-old female patient treated for postmenopausal osteoporosis. The extent of resorptive defects was too large and progressively led to fractures of the teeth. The number of teeth involved and the extend of destruction excluded conservative treatment. The affected teeth had to be extracted for functional prosthetic reconstruction.

Conclusions

This finding suggests that treatment with denosumab may be associated with severe and aggressive odontoclastic resorption of multiple dental roots despite an adequate inhibitory effect on osteoclasts in the treatment of osteoporosis. The RANKL-independent pathways of clastic cell formation are likely to be involved in this pathological process.

Denosumab and invasive cervical root resorption: a case report

This case report describes an adverse side-effect from long-term denosumab therapy in a patient with metastatic breast cancer. The patient presented with extensive external root resorption affecting most of her dentition. There were no other identified risk factors. As the treatment of breast cancer evolves leading to improved survival, and the number of cancer survivors increases, it is expected that dental practitioners will see a growing number of patients who are on long-term denosumab. Comprehensive dental examinations including radiographs, are warranted to identify unusual or unexpected findings such as invasive cervical root resorption. © 2022 Australian Dental Association.

A Bioinformatics Systems Biology Analysis of the Current Oral Proteomic Biomarkers and Implications for Diagnosis and Treatment of External Root Resorption

External root resorption (ERR) is a silent destructive phenomenon detrimental to dental health. ERR may have multiple etiologies such as infection, inflammation, traumatic injuries, pressure, mechanical stimulations, neoplastic conditions, systemic disorders, or idiopathic causes. Often, if undiagnosed and untreated, ERR can lead to the loss of the tooth or multiple teeth. Traditionally, clinicians have relied on radiographs and cone beam computed tomography (CBCT) images for the diagnosis of ERR; however, these techniques are not often precise or definitive and may require exposure of patients to more ionizing radiation than necessary. To overcome these shortcomings, there is an immense need to develop non-invasive approaches such as biomarker screening methods for rapid and precise diagnosis for ERR. In this review, we performed a literature survey for potential salivary or gingival crevicular fluid (GCF) proteomic biomarkers associated with ERR and analyzed the potential pathways leading to ERR. To the best of our knowledge, this is the first proteomics biomarker survey that connects ERR to body biofluids which represents a novel approach to diagnose and even monitor treatment progress for ERR.