Interventions for the management of external root resorption
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:
The objective of this review is to evaluate the effectiveness of any interventions that can be used in the management of external root resorption in permanent teeth.
Background
Resorption of the root of a permanent tooth is a pathological process that can occur inside the tooth (internal resorption), or on the outer surface of the tooth (external root resorption) and can ultimately lead to loosening of the tooth and its early loss. External root resorption (ERR) occurs when the cementoblastic layer or other tooth tissue on the root surface are either damaged or removed (Leach 2001).
Classification
There is some uncertainty over the most appropriate way of classifying ERR and several methods have been proposed and used. The classical approach divides ERR into three subgroups: surface resorption; inflammatory resorption and replacement (ankylosis) resorption but this classification was based on root resorption following traumatic injuries (Andreasen 1985). Classification of ERR by its clinical and histological appearance i.e. external surface resorption, external inflammatory root resorption, replacement resorption, and ankylosis has also been recommended (Ne 1999).
A further classification, which is based on factors that may act as a stimulus for resorption, has been shown to be useful in helping clinicians to diagnose and treat ERR. It classifies root resorption due to: pulpal (tooth nerve) or periodontal (gum) infection; orthodontic tooth movement; impacted tooth or tumour pressure and as result of tooth ankylosis (Fuss 2003). More over a recent review has proposed a new category of tooth resorption entitled hyperplastic invasive cervical resorption which is said to have either an internal or external origin and the potential predisposing factors to this condition include trauma, orthodontic treatment and intracoronal bleaching. There are also some rare tooth resorptions of unknown cause that do not fit into any of the above categories and they are usually labelled 'idiopathic' (Heithersay 2007).
Diagnosis
Whichever classification is used, early diagnosis is a critical factor in the management of ERR because the sooner treatment is initiated the less severe the long‐term consequences of resorption (da Silveira 2007). Diagnosis should be based on a combination of radiographic and clinical examination. Intraoral radiographs of the lesion usually show an uneven root surface outline, and radiographs obtained at different angles may be useful to determine which surface is affected (Bergmans 2002). Vitality testing may also be helpful in detecting the type of ERR (Fuss 2003; Nance 2000).
Recent studies have indicated that computed tomography, with its higher sensitivity and specificity may be a useful diagnostic tool particularly in detecting small and less accessible root resorption (da Silveira 2007).
Diagnosis should also seek to differentiate between ERR and internal root resorption (IRR) (Carrotte 2004).
Description of the condition
External root resorption tends to occur more frequently in patients aged between 21 and 30 years (28.40%) and is more common in females (59.04%) than males (Opacic 2004). Trauma, previous periodontal surgery, pressure from adjacent unerupted teeth and pathological conditions such as tumours as well as tooth re‐implantation have all been implicated as aetiological factors (Opacic 2004; St George 2006). Orthodontic tooth movement may also play a role in ERR especially where the forces applied to induce tooth movement are not controlled and in these situations the resorption usually occurs in the apical third of the root (Abuabara 2007). Root resorption may also occur as a result of systemic disease and endocrine disorders i.e. hyperparathyroidism, Paget's disease, calcinosis, Gaucher's disease and in Turner's syndrome as well as after radiation therapy (Carrotte 2004).
However, it is generally accepted that in the majority of cases two factors, injury and stimulation, are required to initiate root resorption (Fuss 2003).
Description of the intervention
Treatment alternatives will depend on the type and extent of resorption and may include symptomatic treatment for relief of pain and swelling and the stabilisation of any mobile teeth if appropriate (Trope 2000).
If there is pulpal involvement, endodontic therapy together with surgery to remove the granulation tissue and filling of the resorptive defect may be required (Fuss 2003). Root canal medications and intracanal cements, such as MTA, have also been used in an attempt to arrest the resorptive process and provide an apical seal for the tooth (Gulsahi 2007).
If the root resorption is extensive and the cervical margin (adjacent to the gum) is involved with the most apical parts of the root, the treatment is usually more complicated and not infrequently extraction may be the only option (Fuss 2003; Gulsahi 2007; Trope 2002).
If it has occurred as a result of pressure from an unerupted tooth or erupting teeth or during orthodontic treatment and there is no sign of infection, removal of the tooth or pressure will usually stop further root resorption (Heithersay 2007). However, if teeth are severely mobile after completion of orthodontic treatment splinting may be required.
In case of hyperplastic invasive cervical resorption, due to its invasive nature, total removal or inactivation of the resorptive tissue via chemical approach or surgical modalities is essential (Heithersay 2007).
As for replacement resorption (ankylosis), the treatment will depend on the stage of tooth development, the severity of trauma and the extent of periodontal ligament necrosis. In younger patients, there is a greater chance of early tooth loss followed by ridge resorption, and therefore a need for the clinician to consider timely and appropriate management of the resorptive process. This may involve regenerative treatments, orthodontic space closure, or ultimately extraction of the ankylosed tooth followed by bone augmentation (Sapir 2008).
Currently there is no consensus on the management of the different forms of external root resorption (Fuss 2003; Majorana 2003).
Objectives
The objective of this review is to evaluate the effectiveness of any interventions that can be used in the management of external root resorption in permanent teeth.
Methods
Criteria for considering studies for this review
Types of studies
Only randomised controlled clinical trials (RCTs) will be considered in this review.
Types of participants
Participants with single and multiple permanent teeth with evidence of any type of external root resorption irrespective of its aetiology, and confirmed by clinical and radiological examination.
Types of interventions
Root canal medications and canal filling, splinting or extraction of teeth or the surgical removal of any relevant pathology, in comparison with each other, or placebo or no treatment.
Types of outcome measures
Primary outcomes
(1) Change in the amount of root resorption visible on radiological examination.
(2) The number of teeth extracted at any follow‐up period.
These additional primary outcomes will be considered: if studies included patients with acute symptoms:
(1) Pain/discomfort: patient‐assessed using any recognized validated pain scale
(2) Tooth mobility
(3) Infection (abscess, inflammation, fistulae).
Secondary outcomes
(1) Number of visits.
(2) Any self assessed quality of life or patient satisfaction evaluated with a validated questionnaire.
Adverse effects
We will also report on any adverse effects related to any of the interventions or control.
Search methods for identification of studies
Electronic searches
For the identification of studies included or considered for this review, detailed search strategies will be developed for each database to be searched.
The MEDLINE search strategy will combine the subject search with the Cochrane Highly Sensitive Search Strategy for identifying reports of randomised controlled trials in MEDLINE: sensitivity maximising version (2008 revision) as referenced in Chapter 6.4.11.1 and detailed in box 6.4.c of the Cochrane Handbook for Systematic Reviews of Interventions version 5.0.1, updated September 2008) (Higgins 2008).
The following databases will be searched:
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The Cochrane Oral Health Group's Trials Register
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The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, current issue)
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MEDLINE (from 1950 to the present)
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EMBASE (from 1980 to the present).
Detailed search strategies for all databases are provided in Appendix 1, Appendix 2, Appendix 3 and Appendix 4.
Searching other resources
Handsearches
We will conduct handsearching of any journals considered appropriate for this review. The reference lists of any clinical trials identified will be cross‐checked for additional trials published outside the handsearched journals. A search for existing meta‐analyses and non‐Cochrane systematic reviews will be performed and their reference lists scanned for additional trials.
Language
There will be no language restriction on the inclusion of studies and we will arrange to translate any relevant non‐English papers.
We will search the reference lists of relevant articles and the review authors' personal database of trial reports and attempt to contact investigators of included studies by electronic mail to ask for details of additional published and unpublished trials.
Data collection and analysis
Selection of studies
Two review authors, Mina Mahdian (MM) and Melissa Marchesan (MAM), will independently and in duplicate assess the titles and the abstracts of trials identified from the searches. Full copies of all relevant and potentially relevant trials, those appearing to meet the inclusion criteria, or for which there were insufficient data in the title and abstract to make a clear decision, will be obtained. The full text papers will be assessed independently and any disagreement on the eligibility of trials will be resolved through discussion and consensus, or if necessary through a third party, Mona Nasser (MN). All potentially relevant studies that fail to meet the eligibility criteria will be excluded and the reasons for their exclusion will be noted in the 'Characteristics of excluded studies' table.
Data extraction and management
Study details will be collected using a pre‐determined form designed for this purpose and entered into the 'Characteristics of included studies' table. Two review authors (MN and Zbys Fedorowicz (ZF)) will independently and in duplicate extract all data. Any disagreements will be resolved by consulting with a third author (Zohreh Ahangari (ZA)).
The following details will be extracted for included studies.
(1) Trial methods:
(a) method of allocation
(b) masking of participants and outcome assessors
(c) exclusion of participants after randomisation and proportion of losses at follow up.
(2) Participants:
(a) demographic characteristics including symptoms of external root resorption
(b) source of recruitment
(c) country of origin
(d) sample size
(e) age
(f) sex
(g) inclusion and exclusion criteria as described in the 'Criteria for considering studies for this review' section of this protocol.
(3) Intervention:
(a) type of intervention
(b) duration and length of time in follow up.
(4) Control:
(a) type of control or placebo or no treatment
(b) duration and length of time in follow up in the control group.
(5) Outcomes:
(a) primary and secondary outcomes as described in the outcome measures section of this protocol.
We will also record any sources of funding reported in the included trials.
This information will be used to assess heterogeneity and the external validity of the trials.
Assessment of risk of bias in included studies
Two review authors (MN and ZA) will grade the selected trials using a simple contingency form following the domain‐based evaluation described in the Cochrane Handbook for Systematic Reviews of Interventions 5.0.1 (Higgins 2008). The evaluations will be compared and any disagreements between the review authors will be discussed and resolved.
The following domains will be assessed as 'Yes' (i.e. low risk of bias), 'Unclear' (i.e. uncertain risk of bias) or 'No' (i.e. high risk of bias):
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sequence generation;
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allocation concealment;
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blinding (of participants, personnel and outcome assessors);
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incomplete outcome data;
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selective outcome reporting;
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other sources of bias.
These assessments will be reported for each individual study in the 'Risk of bias' table.
After assessment the included studies will be grouped accordingly.
(A) Low risk of bias (plausible bias unlikely to seriously alter the results): if all criteria are met.
(B) Unclear risk of bias (plausible bias that raises some doubt about the results): if all criteria are at least partly met or are unclear.
(C) High risk of bias (plausible bias that seriously weakens confidence in the results): if one or more criteria were not met as described in Section 8.7 of the Cochrane Handbook for Systematic Reviews of Interventions 5.0.1 (Higgins 2008).
Measures of treatment effect
The data will be analysed by MN and ZF using Review Manager (RevMan) 5 and reported as suggested in Chapter 9 of the Cochrane Handbook for Systematic Reviews of Interventions 5.0.1 (Higgins 2008).
In general, for continuous data, we will calculate the mean difference and 95% confidence intervals. Risk ratios and their 95% confidence intervals will be calculated for all dichotomous data.
Assessment of heterogeneity
We plan to assess clinical heterogeneity by examining the characteristics of the studies: the similarity between the types of participants, the interventions and the outcomes as specified in the criteria for included studies. Statistical heterogeneity will be assessed using a Chi2 test and the I2 statistic where I2 values over 50% indicate moderate to high heterogeneity (Higgins 2003).
Assessment of reporting biases
Whilst recognising its limitations, if a sufficient number of randomised controlled trials are identified, an attempt will be made to assess publication bias using a funnel plot (Egger 1997).
Data synthesis
We will pool the results of clinically and statistically homogeneous trials to provide estimates of the effects of the interventions. If the studies have similar interventions received by similar participants, the fixed‐effect model will be used.
In the event that there are insufficient clinically homogeneous trials for any specific intervention or insufficient study data that can be pooled, a narrative synthesis will be presented.
Subgroup analysis and investigation of heterogeneity
In case of substantial heterogeneity between the studies, we will use the random‐effects model.
If sufficient data are available we will conduct the following subgroup analyses: categorising and subsequent analysis of participants by age group and severity of external root resorption.
Sensitivity analysis
If there are sufficient included trials we plan to conduct sensitivity analyses to assess the robustness of our review results by repeating the analysis with the following adjustments: exclusion of studies with unclear or inadequate allocation concealment, unclear or inadequate blinding of outcomes assessment and completeness of follow up.
