e404
J Clin Exp Den . 2011;3(Suppl1):e404-7. C own discolo a ion and MTA.
Jou nal sec ion: Clinical and Expe imen al Den is y doi:10.4317/jced.3.e404
Publica ion Types: Case Repo
G een discolo a ion o he c own a e in e nal oo eso p ion ea men
wi h g ey mine al ioxide agg ega e (MTA).
Juan José Segu a-Egea 1, Lize Cas ellanos-Cosano 2, Jenni e Ma ín-González 2, Luis Osca Alonso-
Ezpele a 3, F. Ja ie López F ías 4
1 P o esso , Depa men o Endodon ics, School o Den is y, Uni e si y o Se illa, C/ A icena s/n, 41009-Se illa, Spain.
2 Doc o al ellow, Depa men o Endodon ics, School o Den is y, Uni e si y o Se illa, C/ A icena s/n, 41009-Se illa, Spain.
3 Assis an P o esso , Depa men o Endodon ics, School o Den is y, Uni e si y o Za agoza, 22006-Huesca, Spain.
4 Associa e P o esso , Depa men o Endodon ics, School o Den is y, Uni e si y o Se illa, C/ A icena s/n, 41009-Se illa,
Spain.
Co espondence:
Dp o. de Es oma ología,
Facul ad de Odon ología,
C/ A icena s/n,
41009-Se ille (SPAIN)
e-mail: [email p o ec ed]
Recei ed: 31/05/2011
Accep ed: 03/08/2011
Abs ac
Roo eso p ion (RR) is he loss o den al ha d issues as a esul o clas ic ac i i ies. In e nal in lamma o y oo e-
so p ion (IRR) is a ype o RR cha ac e ized by p og essi e loss o oo h subs ance s a ing om he oo canal wall.
IRR is usually asymp oma ic, slowly p og essing, and de ec able upon ou ine adiog aphic examina ion o by he
clinical sign o a ‘pink spo ’ when he IRR in ol es he c own o he co onal hi d o he oo canal. Mine al ioxide
agg ega e (MTA) is a biocompa ible cemen ha has been used success ully in pulp capping, pulpo omy, ea men
o auma ized ee h wi h imma u e apices, and o ea men o oo eso p ion. The ea men and ollow-up o a
maxilla y cen al inciso wi h pe o a ing IRR managed by oo canal ea men and g ey MTA epai is epo ed.
IRR a ec ed oo h 11 (FDI Wo ld Den al Fede a ion) in a 29-yea -old emale pa ien , wi h a his o y o p e ious
auma. Follow-up adiog aphs o e 24 mon hs demons a ed he main enance o a unc ional oo h. Howe e , he
oo h showed a g een discolo a ion o he c own a e MTA ea men .
Key wo ds: In e nal oo eso p ion, Mine al ioxide agg ega e, Roo canal ea men .
Segu a-Egea JJ, Cas ellanos-Cosano L, Ma ín-González J, Alonso-Ezpe-
le a LO, López F ías FJ. G een discolo a ion o he c own a e in e nal
oo eso p ion ea men wi h g ey mine al ioxide agg ega e (MTA). J
Clin Exp Den . 2011;3(Suppl1):e404-7.
h p://www.medicinao al.com/odo/ olumenes/ 3iSuppl1/jced 3iSu-
ppl1p404.pd
A icle Numbe : 50587 h p://www.medicinao al.com/odo/indice.h m
© Medicina O al S. L. C.I.F. B 96689336 - eISSN: 1989-5488
eMail: [email p o ec ed]
e405
J Clin Exp Den . 2011;3(Suppl1):e404-7. C own discolo a ion and MTA.
In oduc ion
Roo eso p ion (RR) is he loss o den al ha d issues
as a esul o clas ic ac i i ies (1). RR migh be b oadly
classi ied in o ex e nal o in e nal eso p ion by he lo-
ca ion o he eso p ion in ela ion o he oo su ace.
In e nal in lamma o y oo eso p ion (IRR) is cha ac-
e ized by p og essi e loss o oo h subs ance s a ing
om he oo canal wall (2). IRR is usually asymp oma-
ic, slowly p og essing, and de ec able upon ou ine a-
diog aphic examina ion o by he clinical sign o a ‘pink
spo ’ when he IRR in ol es he c own o he co onal
hi d o he oo canal (3).
Va ious e iologic ac o s ha e been implica ed, inclu-
ding auma, ca ies and pe iodon al in ec ions, excessi-
e hea gene a ed du ing es o a i e p ocedu es on i al
ee h, calcium hyd oxide p ocedu es, i al oo esec-
ions, anacho esis, o hodon ic ea men , c acked ee h,
o simply idiopa hic dys ophic changes wi hin no mal
pulps (2, 4).
Fo IRR o ake place, i al pulp issue is equi ed (5).
The e o e, nonsu gical oo canal he apy (pulp emo-
al) is he ea men o choice o a es he des uc i e
p ocess. T ea men o IRR mus aim a comple e emo-
al o he eso p i e issue om he oo canal sys em,
in an a emp o p e en u he loss o ha d issue. I
he p ocess has ex ended o he poin ha i eaches he
ex e nal oo su ace, oo in eg i y is los and des uc-
ion o he adjacen pe iodon al issues may occu (6).
Selec ing sui able es o a i e ma e ials o hese cases
emain a challenge, especially i oo h loss is ex ensi e;
ex ac ion is he only ealis ic op ion in some cases (5).
Mine al ioxide agg ega e (MTA) is a biocompa ible
cemen , ideal as o hog ade o e og ade illing ma e ial
(7), ha has been used success ully in pulp capping,
pulpo omy, ea men o auma ized ee h wi h imma-
u e apices, and o ea men o oo eso p ions (5,
6). MTA has good sealing p ope ies, biocompa ibili y,
bac e icidal e ec s, adiopaci y, and abili y o se in he
p esence o blood.
This case epo desc ibes he 24-mon h ollow-up o
pe o a ing in e nal oo eso p ion in a maxilla y cen-
al inciso , whe e g ay MTA we e employed o es o e
unc ion.
Case Repo
A 29-yea -old whi e woman because he p esence o
discolo a ion o he den al c own o he maxilla y igh
cen al inciso (11, FDI Wo ld Den al Fede a ion) wi h
ague pain. The medical his o y was non-con ibu o y.
She had a his o y o auma a ec ing bo h maxilla y
cen al inciso s wen y yea s ago. Clinical examina ion
showed he p esence o a sinus ac s oma on he buccal
gingi al mucosa (Fig. 1A). Radiog aphic examina ion
e ealed a well-ci cumsc ibed, ai ly o al adiolucency
in he middle hi d o he oo (Fig. 1B). No pe iapical
adiolucen lesion was de ec ed. The elec ic and hea
(hea ed gu a-pe cha) pulp es s we e nega i es. Pe io-
don al p obing dep hs we e physiological (<3 mm) a all
si es. Based on he clinical and adiog aphic indings,
he diagnosis was i e e sible pulpi is wi h pe o a ing
in e nal oo eso p ion ha had caused an abscess d ai-
ning h ough he is ulous ac .
The possibili y o conse ing oo h 11 was conside ed
h ough a combina ion o ea men s: non su gical oo
canal he apy o emo e he nec o ic pulp and disin ec
he oo canal sys em and su gical ea men o expose
he eso p i e de ec and o ill i up wi h MTA. Howe-
e , pa ien did no ag ee wi h su gical ea men . Thus,
consen was only ob ained o non su gical oo canal
ea men .
Anaes hesia was adminis e ed acco dingly, and he oo h
was isola ed wi h a ubbe dam. The access ca i y was
opened on he pala al su ace and he pulp issue was e-
mo ed. Leng h de e mina ion was pe o med elec oni-
cally using he Den aPo ZX (J. Mo i a, Kyo o, Japan)
and con i med adiog aphically (Fig. 1C). Du ing ins-
umen a ion a communica ion be ween he eso p ion
ca i y and he buccal pe iodon ium was obse ed as a
Fig. 1. (A) Clinical examina ion showed discolo a ion o he den al
c own o he maxilla y igh cen al inciso (11) and he p esence o
a sinus ac s oma on he buccal gingi al mucosa. (B) P eope a i e
adiog aph showing a well-ci cumsc ibed, ai ly o al adiolucency in
he middle hi d o he oo . (C) Leng h de e mina ion was pe o med
elec onically and con i med adiog aphically.
e406
J Clin Exp Den . 2011;3(Suppl1):e404-7. C own discolo a ion and MTA.
bleeding poin , in connexion wi h he is ulous ac .
The canal was p epa ed by he X-Sma (Den sply Mai-
lle e , Ballaigues, Swi ze land), which was cleaned and
shaped up o an F1 ins umen o he P o ape Sys em
(Den sply-Maille e , Ballaigues-Swi ze land). An api-
cal s op was c ea ed wi h a o a y nickel– i anium size
35.06 K3 (Syb onEndo Den al Special ies, O ange,
CA). In acanal i iga ion was pe o med wi h 5.25%
NaOCl (Fa macia Del Campo, Mad id, Spain). Then,
calcium hyd oxide pas e (Calcipulpe, Sep odon , Sain
Mau des Fosses, F ance) was placed o alkalinize he
en i onmen , emo e emaining pulp issue and con ol
bleeding a he pe o a ion and o assu e he comple e
elimina ion o he g anula ion issue (Fig. 2A).
A e 30 days, sinus ac s oma on he buccal gingi al
mucosa had disappea ed. Calcium hyd oxide pas e e-
mained illing he oo -canal (Fig. 2B). The d essing
ma e ial was emo ed wi h 5.25% sodium hypochlo i e
i iga ion and he oo canal was d ied wi h pape poin s.
A 35.06 au o i gu a-pe cha cone (Analy ic Endodon-
ics, O ange, CA) was used o ill he apical oo canal.
Then, g ay MTA powde was mixed acco ding o he
manu ac u e ’s ins uc ions and placed wi h an MTA ca-
ie . MTA was i mly condensed by using a plugge and
we co on pelle s. The access ca i y was sealed wi h
Ca i G (3 M ESPE, S Paul, MN). An immedia e pos o-
pe a i e adiog aph was aken, con i ming sa is ac o y
illing o he oo canal and eso p i e de ec (Fig. 2C).
A e 12 and 18 mon hs, he pa ien was ecalled and
he oo h was ound o be symp om ee. No pe cussion
sensi i i y was obse ed, and he pa ien had a heal hy
gingi a and no pe iodon al pocke s on p obing. Pe iapi-
Fig. 2. (A) Pe iapical adiog aph a e illing wi h calcium hyd oxide pas e. (B) Calcium hyd oxide pas e emained illing he oo -
canal a e 30 days. (C) Immedia e pos ope a i e adiog aph a e MTA illing o he eso p i e de ec . (D) Pe iapical adiog aph
a e 12 mon hs. (E) Pe iapical adiog aph a e 18 mon hs. (F) Pe iapical adiog aph showing sa is ac o y healing a e 24 mon hs
e407
J Clin Exp Den . 2011;3(Suppl1):e404-7. C own discolo a ion and MTA.
cal adiog aphs showed sa is ac o y healing o he dis al
adiolucen lesion in he al eola bone (Fig. 2D and 2E).
A e 24 mon hs, oo h emains asymp oma ic; howe e
a g een discolo a ion is e iden (Fig. 2F and Fig. 3).
ed o mula, Tulsa, OK) and by Angelus (MTA B anco,
Angelus Soluçöes Odon ológicas). The majo di e en-
ce appea s o be in he concen a ions o ca bo undum
(Al2O3) pe iclase (MgO), and especially FeO, wi h he
obse ed alues o each o hese oxides being conside-
ably lowe in he whi e MTA han in he g ay MTA. Di-
e ences in he obse ed FeO concen a ion a e hough
o be p ima ily esponsible o he a ia ion in colou o
he whi e MTA in compa ison wi h g ey MTA (9). This
colou change has b oadened he indica ions o MTA,
enabling i s applica ion in oo pe o a ions, pulpo o-
mies, and di ec pulp capping in an e io ee h. Whi e
MTA can be he ma e ial o choice o epai de ec s in
which di ec con ac wi h gingi al issues o oo h c own
implica ion is expec ed.
Re e ences
1. Pa el S, Ricucci D, Du ak C, Tay F. In e nal oo eso p ion: a e-
iew. J Endod. 2010;36:1107-21.
2. And easen JO, And easen FM. Roo eso p ion ollowing auma ic
den al inju ies. P oc Finn Den Soc. 1992;88 (Suppl 1):95-114..
3. Ga ne AH, Mack T, Some lo RG, Walsh LC. Di e en ial diagno-
sis o in e nal and ex e nal oo eso p ion. J Endod. 1976;2:329-34.
4. Wal on RE, Leona d LA. C acked oo h: an e iology o ‘idiopa hic’
in e nal eso p ion? J Endod. 1986;12:167–9.
5. Mei e M, De Moo R. Mine al ioxide agg ega e epai o a
pe o a ing in e nal eso p ion in a mandibula mola . J Endod.
2008;34:220-3.
6. Jacobo i z M, de Lima RKP. T ea men o in lamma o y in e nal
oo eso p ion wi h mine al ioxide agg ega e: a case epo . In En-
dod. J 2008;41:905–12.
7. Pa i okh M, To abinejad M. T ioxide Agg ega e: A Comp ehensi e
Li e a u e Re iew—Pa I: Chemical, Physical, and An ibac e ial P o-
pe ies. J Endod. 2010;36:16–27.
8. Gulabi ala K, Sea son LJ. Clinical diagnosis o in e nal eso p ion:
an excep ion o he ule. In Endod J. 1995;28:255– 60.
9. Bo oluzzi EA, A áujo GS, Gue ei o Tanoma u JM, Tanoma u-
Filho M. Ma ginal gingi a discolo a ion by g ay MTA: a case epo .
J Endod. 2007;33:325–7.
10. Sil ei a FF, Nunes E, Soa es JA, Fe ei a CL, Ro s ein I. Double
‘pink oo h’ associa ed wi h ex ensi e in e nal oo eso p ion a e o -
hodon ic ea men : a case epo . Den T auma ol. 2009;25:e43–7.
11. Hsien HC, Cheng YA, Lee YL, Lan WH, Lin CP. Repai o pe o a-
ing in e nal eso p ion wi h mine al ioxide agg ega e: a case epo .
J Endod. 2003;29:538–9.
12. To abinejad M, Hong CU, Pi Fo d TR, Kaiyawasam SP. Tissue
eac ion o implan ed Supe EBA and Mine al T ioxide Agg ega e in
he mandible o guinea pigs: a p elimina y. J Endod. 1995;21:569–71.
13. Regan JD, Gu mann JL, Wi he spoon DE. Compa ison o Diake
and MTA when used as oo -end illing ma e ials o suppo egene a-
ion o he pe i adicula issues. In Endod J. 2002;35:840–7.
14. Main C, Mi zayan N, Shabahang S, To abinejad M. Repai o oo
pe o a ions using mine al ioxide agg ega e: a long e m s udy. J En-
dod. 2004;30:80–3.
15. Jacobo i z M, Vianna ME, Pandol elli VC, Oli ei a IR, Rosse o
HL, Gomes BP. Roo canal illing wi h cemen s based on mine al ag-
g ega es: an in i o analysis o bac e ial mic oleakage. O al Su g O al
Med O al Pa hol O al Radiol Endod. 2009;108:140–4.
Discussion
In e nal oo eso p ion is an insidious pa hological p o-
cess, ini ia ed wi hin he pulp space and associa ed wi h
loss o den ine. I is o en desc ibed as an o al shaped,
symme ically dis ibu ed o e he oo , enla gemen o
he oo canal space and is usually asymp oma ic and
de ec able by adiog aphs (8). The p esen case demons-
a ed a success ul ea men o a pe o a ing in e nal
oo eso p ion wi h g ey MTA. Success ul su gical and
nonsu gical ea men o in e nal eso p ion in bo h p i-
ma y and pe manen ee h using MTA has been epo ed
p e iously in se e al case epo s (5, 9-11).
MTA is biocompa ible (12) and has been shown o be
e ec i e in epai ing u ca ion pe o a ions (13) and la-
e al oo pe o a ions (14). The ma e ial is well- ole a ed
by pe i adicula issues and has been shown o suppo
almos comple e egene a ion o he pe iodon ium (13).
In addi ion, MTA has supe io sealing p ope ies when
compa ed wi h o he ma e ials (15).
In he p esen case a hyb id echnique has been used o
ob u a e he canal. The po ion o he canal apical o he
eso p ion de ec was ob u a ed wi h gu a-pe cha, and
hen he eso p ion de ec and associa ed pe o a ion was
sealed wi h g ey MTA (6, 11).
One o he disad an ages o g ey MTA is ela ed o i s
colou . Discolo a ion o ma ginal gingi a a e pe o a-
ion epai wi h g ey MTA has been epo ed (9). The
po en ial o gingi al discolo a ion should be conside ed
in pe o a ions loca ed p oximal o he ma ginal a ea.
In he p esen case, a sligh gingi al discolo a ion was
obse ed a e 24 mon hs, bu a signi ican oo h c own
g een discolo a ion was e iden .
In an a emp o imp o e his aspec , oday whi e MTA is
manu ac u ed by Den sply (P oRoo MTA—new colo-
Fig. 3. A e 24 mon hs, oo h emains asymp oma ic, bu a g een
discolo a ion was e iden .