CLINICAL RESEARCH

Po-Yuan Jeng, DDS,* Li-Deh Lin,

Invasive Cervical DDS, PhD,*† Shu-Hui Chang,
PhD,‡ Yuan-Ling Lee, DDS,
Resorption—Distribution, PhD,*† Cheng-Ying Wang, DDS,
PhD,*† Jiiang-Huei Jeng, DDS,
Potential Predisposing Factors, PhD,*† and Yi-Ling Tsai, DDS,
PhD*†
and Clinical Characteristics

ABSTRACT
SIGNIFICANCE
Introduction: The purpose of this study was to investigate the distribution, predisposing
factors, and clinical characteristics of invasive cervical resorption (ICR). Methods: Cases with Understanding the age, sex,
ICR from 2009–2019 were collected. Clinical records and radiographs were reviewed. tooth distribution, single or
Descriptive analysis was performed in combination with univariate analysis and the Fisher multiple affected teeth,
exact test. Results: A total of 63 ICR teeth from 31 patients (14 men and 17 women) were predisposing factors, and
found. The patients’ ages ranged from 18–81 years, with a mean age of 45.77 years. Most clinical and radiographic
patients had a single ICR lesion. Among the 63 ICR teeth, maxillary anterior teeth (47.62%) characteristics of the invasive
were the most commonly affected followed by maxillary premolars (20.63%). Maxillary teeth cervical resorption in a
(76.19%) were more prone to ICR than mandibular teeth (23.81%). Most patients denied all Taiwanese population can be
major systemic diseases. The most common dental-related factors were dental/orofacial helpful for its clinical early
trauma (33.33%), periodontal treatment (26.98%), restoration/crown (17.46%), and ortho- diagnosis and further effective
dontic treatment (15.87%). Most teeth showed no percussion/palpation pain, probing depth treatment.
.3 mm, abscess formation, sinus tracts, or periapical lesions. The pulp status was mainly vital
(73.02%). The presence of percussion pain and probing depth differed significantly among
Heithersay ICR classification groups. Conclusions: ICR showed no difference in sex or age.
Maxillary anterior teeth were the most affected in a Taiwanese population. Traumatic injury,
periodontal treatment, and orthodontic treatment were the significant predisposing factors.
Furthermore, affected teeth typically lacked clinical signs and symptoms. Radiographic
examination is critical for early diagnosis. In advanced cases, deep pockets and abscess
formation were seen. These results are helpful for the diagnosis of ICR and further effective
treatment. (J Endod 2020;-:1–8.)

KEY WORDS
Dental traumatic injury; hyperparathyroidism; invasive cervical resorption; orthodontic treat-
ment; periodontal treatment; root resorption

Invasive cervical resorption (ICR) is a localized resorption process originating from the external cervical
root surface1,2. Cases of ICR have been noted after internal tooth bleaching3. The effect of bleaching on From the *School of Dentistry and
‡
periodontal tissue, dental tissue, and osteoclastic/odontoclastic cells has also been investigated. College of Public Health, National Taiwan
Although the mechanisms that trigger ICR are not entirely clear, bleaching procedures have been University, Taipei City, Taiwan; and
†
Department of Dentistry, National Taiwan
improved4; thus, ICR after bleaching is rarely reported5. However, cases with prior internal bleaching
University Hospital, Taipei City, Taiwan
account for only a low percentage of the total ICR cases6. This indicates that the etiology of ICR is
Address requests for reprints to Dr Yi-Ling
relatively complicated and requires further investigation.
Tsai, School of Dentistry and Department
The etiology of ICR remains unclear and is probably a multifactorial problem. It has been proposed of Dentistry, National Taiwan University
to be related to a developmental defect in the cementoenamel junction6. In approximately 10% of teeth, a and National Taiwan University Hospital,
gap is found between the enamel and cementum, leading to the exposure of dentin to oral soft tissue7. No 1, Changde Street, Zhongzheng Dist,
The presence of cementum and periodontal ligaments may protect the underlying dentin from root Taipei City 100, Taiwan.
E-mail address: tyl.endo@gmail.com
resorption7. Clastic cells may adhere to the exposed root dentin and initiate the resorption process. 0099-2399/$ - see front matter
Chemical or physical stimulations have also been hypothesized to damage the periodontium and trigger
Copyright © 2020 American Association
ICR. Dental trauma8, internal bleaching, orthodontic treatments9, and other surgical procedures10 are of Endodontists.
often related to ICR. Systemic diseases, such as autoimmune disorders11, varicella-zoster virus https://doi.org/10.1016/
infection12, hepatitis B virus infection13, and neuronal virus infection14, as well as the use of j.joen.2020.01.011

JOE  Volume -, Number -, - 2020 Invasive Cervical Resorption 1

bisphosphonates15 have also been reported in demographic information, potential Among the 31 patients, 14 (45.16%) were
the literature on ICR. However, the exact predisposing factors, and clinical men, whereas 17 (54.83%) were women. No
cause-and-effect association remains characteristics. significant difference was found in sex
uncertain. The demographic data of the patients distribution (P . .05, exact binomial test). The
At the early stage, ICR typically initiates included sex, age at which ICR was initially age of the patients ranged from 18–81 years,
below the epithelial attachment and has no diagnosed, position of the affected teeth, and with an average of 45.77 years (615.10 years).
visual signs. Therefore, ICR is detected at later case type. The case type was defined by the The peak age group was between 50 and 59
stages when destruction of the tooth structure cumulated incidence of ICR-affected teeth in years. The distribution among each age group
becomes evident. The radiographic patterns of the same patient at the latest follow-up. A showed a marginally significant difference (P .
ICR have been investigated, and several patient with a single ICR-affected tooth was .05, exact multinomial test). Regarding the
classifications have been established1,16. By classified as a “single ICR case,” whereas a case type, single ICR cases were more
contrast, the clinical features of ICR lack patient with more than 1 ICR-affected tooth common than multiple ICR cases (P , .05,
detailed investigation. A pink spot, vital pulp was classified as a “multiple ICR case.” exact binomial test). More female patients were
response, periodontal pockets, and bleeding The potential predisposing factors of the found in the single ICR group (61.54%),
on probing have been reported as common patients were assessed using both the clinical whereas more male patients were found in the
clinical signs of ICR17,18. However, limited records and radiographs. The medical and multiple ICR group (80.00%). However, no
studies have attempted to investigate whether dental history was reviewed to identify any significant difference was found between case
the symptoms and signs vary between stages relevant systemic diseases, history of dental type and patient sex (P . .05, Fisher exact
of ICR. Identifying the clinical features of ICR trauma, orthodontic treatment (Fig. 1), test) or between case type and patient age (P
could not only help clinicians in early diagnosis periodontal treatment, or bleaching . .05, Wilcoxon rank sum test).
but also help researchers to understand the procedures before the discovery of an ICR The most commonly affected teeth were
disease progression. lesion. Using the radiographic images, the maxillary canines (20.63%) and maxillary
Epidemiologic studies have estimated affected teeth were further assessed to identify central incisors (15.87%). Maxillary lateral
the prevalence of ICR as ranging from 0.02%– any prior restorations, root canal filling, incisors, maxillary first premolars, and
0.08%1,19. In previous studies, the disease attrition, or extraction of neighboring teeth. The mandibular first molars were equally affected
had a wide age distribution without sex number of missing teeth (excluding third (each 11.11%). This was followed by maxillary
difference, and the maxillary anterior teeth molars) was judged using the panoramic second premolars (9.52%), mandibular canine
were the most commonly affected6. However, radiographs with reference to the clinical and maxillary first molars (each 4.76%), and
limited studies have been conducted in Asian records. mandibular second molars (3.17%).
populations. This study had 2 objectives. The Clinical parameters including Mandibular central incisors, mandibular lateral
first objective was to assess the distribution percussion or palpation tenderness, incisors, mandibular first premolars, maxillary
and potential predisposing factors of ICR- periodontal probing depth, pulp vitality status, second molars, and maxillary third molars all
affected patients in a Taiwanese population. abscess formation, and sinus tract tracing contributed 1 tooth (1.59%). No mandibular
The second objective was to investigate the were recorded. The presence of periapical second premolar or mandibular third molar
clinical features of ICR to understand its lesions, Heithersay classification, and was affected by ICR in this study. The regional
evolution. combination with other types of resorption distribution of ICR-affected teeth is shown in
were also noted. Table 1. Maxillary anterior teeth were the most
commonly affected area followed by maxillary
MATERIALS AND METHODS
Statistical Analysis premolars and mandibular molars. In the
Case Collection The statistical analysis was performed with R maxilla, anterior teeth were the most
This study was approved by the Research studio version 3.6.1 (The R Foundation for commonly affected, whereas molars were the
Ethics Committee of National Taiwan Statistical Computing, Vienna, Austria). least commonly affected (P , .05, exact
University Hospital, Taipei City, Taiwan. Cases Descriptive analysis combined with univariate multinomial test). By contrast, in the mandible,
between July 2009 and June 2019 were analysis was used to assess the distribution, molars were the most commonly affected
collected at National Taiwan University potential predisposing factors, and the clinical teeth, whereas premolars were the least
Hospital. Patients over 10 years of age who features of ICR. The Fisher exact test was used commonly affected teeth (P , .05, exact
were diagnosed with ICR by the visiting staff to compare the clinical characteristics among multinomial test). Furthermore, anterior teeth
were included. The affected tooth was lesions with different Heithersay classes. A P (55.56%) were more commonly affected than
required to have radiographs taken at different value ,.05 was considered statistically premolars and molars (P , .05, exact
angulations to confirm the location and size of significant. multinomial test). Maxillary teeth (76.19%) were
the lesion. All collected cases were screened more commonly affected than mandibular
by 1 endodontic master student and 2 board- teeth (23.81%) (P , .05, exact binomial test).
certified endodontic specialists to confirm the RESULTS The potential predisposing factors of
presence of ICR. In cases of disagreement, the Initially, 67 teeth were retrospectively ICR were categorized into 2 groups: a
3 observers reached a consensus through diagnosed as being affected by ICR. Four teeth systemic condition and dental-related factors.
discussion. were excluded after screening by the 3 Hypertension was found in 4 patients
observers. Ultimately, 31 patients with a total (12.90%). Thyroid or parathyroid disorder was
Data Collection of 63 ICR-affected teeth were included in the found in 3 patients (9.68%) and 11 teeth
After screening, Excel 2016 (Microsoft, final analysis. An average of 2.03 teeth were (17.46%). Anemia was found in 2 patients
Redmond, WA) was used for data registration. affected by ICR per patient. (6.45%). Diabetes was reported in 1 patient
The clinical records and radiographs of the The demographic distribution of ICR- (3.23%). Hepatitis B infection was also found in
confirmed cases were reviewed to gather the affected patients is summarized in Table 1. 1 patient (3.23%). No ICR cases were related

2 Jeng et al. JOE  Volume -, Number -, - 2020

FIGURE 1 – A case of invasive cervical resorption related to orthodontic treatment. (A ) Soft tissue outgrowth over tooth 42 (black arrow ) was noted during dental scaling. (B ) A
periapical radiograph was taken. Cervical resorption combined with apical resorption was noted in tooth 42 (red arrow ). The tooth was asymptomatic and responded to an electric pulp
test and a cold test.

to herpes virus infection, arthritis, autoimmune Twenty-two patients (70.97%) and 42 teeth The more common dental-related
disease, or the use of bisphosphonates, (66.67%) were not related to any of the factors of ICR-affected teeth were a history of
although they were reported in the literature. systemic diseases under investigation. dental or orofacial trauma (33.33%), prior
periodontal treatment (26.98%), restoration/
crown (17.46%), orthodontic treatment
TABLE 1 - Demographic Distribution and Tooth Distribution among Patients and Teeth with Invasive Cervical Resorption
(15.87%), extraction of a neighboring tooth
(ICR)
(7.94%), more than 3 missing teeth (8.20%),
Classification Number of patients (%) Number of teeth (%) P value moderate to severe attrition (3.17%), external
tooth bleaching (1.59%), and root canal
Demographic distribution
perforation (1.59%). No tooth had a history of
of ICR patients
Sex distribution internal tooth bleaching. However, univariate
Male 14 (45.16) .720* analysis of dental-related factors found that
Female 17 (54.84) ICR-affected teeth occurred more often in
Age distribution teeth without a history of dental or orofacial
10–19 y 1 (3.23) .066† trauma, without previous periodontal
20–29 y 5 (16.13) treatment, without restoration/crown, without
30–39 y 6 (19.35) orthodontic treatment, without extraction of a
40–49 y 5 (16.13) neighboring tooth, without more than 3
50–59 y 8 (25.81)
missing teeth, without moderate to severe
60–69 y 4 (12.90)
attrition, and without external tooth bleaching
70–79 y 1 (3.23)
801 y 1 (3.23) (all P , .05).
Number of affected The main reasons for the discovery of
teeth per patient ICR among the 31 patients were a chief
Single ICR cases 5 (16.13) ,.001* complaint of symptoms (48.39%) and clinical/
Multiple ICR cases 26 (83.87) radiographic findings (51.61%). Further
Distribution of ICR-affected teeth univariate analysis of the clinical
Dental arch characteristics showed that ICR was more
Maxillary teeth 48 (76.19) .001* commonly noted in teeth without percussion
Mandibular teeth 15 (23.81)
pain, without palpation pain, with vital pulp
Tooth type
response, and without formation of an
Anterior teeth 35 (55.56) .002†
Premolars 14 (22.22) abscess and/or sinus tract (all P , .05)
Molars 14 (22.22) (Table 2). The ICR-affected teeth had probing
Maxillary teeth depths of both 3 mm and .3 mm (P . .05).
Maxillary anterior teeth 30 (62.50) ,.001† When sinus tracts were present, they were
Maxillary premolars 13 (27.08) most commonly traced toward the resorption
Maxillary molars 5 (10.42) cavity (75%, P . .05). Radiographically, ICR-
Mandibular teeth affected teeth mainly exhibited no periapical
Mandibular anterior teeth 5 (33.33) .043† lesions (88.89%, P , .05). Four teeth (6.35%)
Mandibular premolars 1 (6.67)
exhibited ICR in combination with other types
Mandibular molars 9 (60.00)
of resorption, including apical resorption,
*Exact binomial test. internal resorption, and replacement
†
Exact multinomial test. resorption.

JOE  Volume -, Number -, - 2020 Invasive Cervical Resorption 3

TABLE 2 - Clinical and Radiographic Findings among 63 Teeth Affected by Invasive Cervical Resorption completely healthy and denied all major
systemic diseases.
Clinical and radiographic findings Number (%) of affected teeth Hormones, cytokines, and growth
Clinical examination factors play a crucial role in osteoclast/
Tenderness to percussion 13 (20.63) odontoclast regulation including parathyroid
Tenderness to palpation 8 (12.70) hormone; thyroid hormone; 1,25-
Probing depth .3 mm 32 (50.79) dihydroxyvitamin D3; and estrogen21.
Pulp vitality status Orthodontic studies have shown that
Vital 46 (73.02) hyperparathyroidism22, hypophosphatemia23,
Necrotic 11 (17.46)
and the administration of thyroxine24 may
Previously initiated or treated 6 (9.52)
influence bone remodeling and root resorption.
Abscess formation 12 (19.05)
Sinus tract formation* 11 (17.46) A previous study reported a rare familial
Origin of sinus tract* pattern of multiple ICR in which most family
Around the resorption cavity 9 (75) members had hypothyroidism and received
Around the periapical area 3 (25) hormone replacement therapy when they were
Radiographic examination young25. In this study, 3 patients (9.68%) and
Presence of a periapical lesion 7 (11.11) 11 teeth (17.46%) had a history of thyroid or
Combined with apical resorption 2 (3.17) parathyroid disorder. One female patient with
Combined with internal resorption 1 (1.59) multiple ICR did not know that she had
Combined with ankylosis 1 (1.59)
hyperparathyroidism until her blood samples
*Eleven teeth exhibited sinus tract formation, 1 of which exhibited 2 sinus tracts simultaneously. One sinus tract was traced were analyzed. A prospective study can be
to the root apex, whereas the other was traced to the resorption cavity. Thus, 12 sinus tracts were analyzed to determine performed in the future to analyze the blood
their origin. samples of ICR-affected patients.
Dental and orofacial trauma was the
most prominent dental-related factor in the
Table 3 compares the clinical Regarding the distribution of affected
present study. Because it can damage the
characteristics among Heithersay classes of teeth, maxillary anterior teeth were the most
cementum, periodontal ligament, and the
ICR. Only a probing depth .3 mm differed commonly affected (30/63, 47.69%) in the
surrounding alveolar bone, dental trauma is a
significantly between Heithersay classes I and current study. However, this percentage was
common cause of transient apical breakdown,
II. The percussion test and probing depth slightly lower than in previous studies. A
external replacement resorption, external
differed significantly between Heithersay class I possible reason might be that the etiologic
inflammatory resorption, and internal
and classes III and IV. No significance factors of ICR differ according to population,
resorption26,27. Previous studies have shown
difference was found between class II and leading to various patterns of affected teeth. In
that 28.5% of ICR-affected teeth had a history
classes III and IV. addition, maxillary teeth were more commonly
of dental trauma6. Orofacial trauma was also
affected than mandibular teeth. This could be
included in our study, and we found that
explained by maxillary teeth being more prone
traumatic history was prominent regardless of
to dental trauma20.
DISCUSSION the tooth position. Anterior teeth were
Because the etiology of ICR was
commonly affected by dental trauma, whereas
To the best of our knowledge, this was the first unclear, a thorough investigation of the
posterior teeth were commonly affected by
epidemiologic study on ICR in an Asian systemic conditions and dental-related factors
population. The results showed that ICR has a orofacial trauma. These posterior teeth
of ICR was conducted in this study. Previous
probably suffered great mechanical impact,
wide age distribution without a significant sex case reports have suggested that autoimmune
although they typically showed no obvious
difference, which is in agreement with previous disorder11, varicella-zoster virus12, hepatitis B
studies1,6. Sex and age seemed to have little signs of tooth fracture or luxation. Because the
virus13, neuronal virus14, and the use of
cementoenamel junction is not always
effect on the development of this disease. bisphosphonates15 could be related to the
contiguous, cervical dentin is prone to
Notably, the multiple ICR cases were mainly development of ICR. However, our results
men, whereas single ICR cases were mainly colonization by activated clastic cells. Trauma
showed that patients with ICR rarely had these
women. may alter the microstructure of the tooth
diseases. In fact, many patients were
surface, which probably facilitates the
attachment of clastic cells.
TABLE 3 - Comparison of Clinical and Radiographic Features among Heithersay Classes Periodontal treatment was the second
most common dental-related factor in this
Class I (18 teeth), Class II (15 teeth), Classes III and IV study; however, whether it leads to ICR is
n (%) n (%) (30 teeth), n (%) unclear. Cementum is commonly regarded as
Tenderness to percussion* 1 (5.56) 3 (20.00) 9 (30.00) an antiresorptive barrier for dentin. Scaling and
Tenderness to palpation 0 (0.00) 1 (6.67) 7 (23.33) root planing result in the removal of cementum
Probing depth .3 mm*† 3 (16.67) 11 (73.33) 18 (60.00) regardless of the instrument used28,29, leading
Vital pulp response 15 (83.33) 8 (53.33) 23 (76.67) to the exposure of dentinal tubules. In severe
Abscess formation 1 (5.56) 4 (26.67) 7 (23.33) cases, pulpitis, tooth hypersensitivity, and
Presence of sinus tract 1 (5.56) 4 (26.67) 6 (20.00)
other complications have been reported30,31.
Presence of periapical lesion 0 (0.00) 3 (20.00) 4 (13.33)
In addition, the microbial stimulation and host
*Statistically significant difference between class I and classes III and IV (P , .05). inflammatory response in periodontitis may
†
Statistically significant difference between class I and class II (P , .05). promote osteoclast activity, resulting in

4 Jeng et al. JOE  Volume -, Number -, - 2020

FIGURE 2 – A case of multiple teeth affected by ICR with a history of dental trauma and new lesions that developed during and after treatment. (A ) A panoramic radiograph taken at the
initial visit (October 6, 2015). Multiple ICR lesions over teeth 15, 14, 13, 22, 23, 24, 27, 28, 46, and 47 were noted. (B ) On March 22, 2016, cone-beam computed tomographic
radiographs showed typical ICR lesions over teeth 14 distal, 14 mesial, 12 distal, and 28 mesial. (C ) A panoramic radiograph revealing new ICR lesions over teeth 11 and 13 (October
29, 2019). Some teeth with severe ICR involvement (teeth 21, 22, 23, 24, and 27) during this period were extracted and replaced using implant therapy.

JOE  Volume -, Number -, - 2020 Invasive Cervical Resorption 5

alveolar bone loss. A slight possibility exists wind instrument and malocclusion have also resorption, and ankylosis were detected.
that osteoclasts adhere to the exposed dentin been reported38,39. In addition, half of the These situations are related to the causes of
surface after periodontal treatment. cases had complaints of tissue swelling, pain resorption. In addition, multiple ICR-affected
Orthodontic treatment has been on biting, or tooth sensitivity. Another half had teeth in the same patient were not always
suggested as a potential cause of ICR. altered tooth appearance or random detected simultaneously; rather, new lesions
Heithersay1 stated that ICR was mainly radiographic findings. Most teeth appeared later developed in teeth that previously had no
detected after the completion of orthodontic normal, but occasionally pink cervical obvious signs of ICR. This successive
treatment. However, recent case reports have discoloration was noted. In 1 of our cases, the appearing phenomenon was found in 1 of our
shown signs of ICR development during the cervical third of the crown was resorbed and representative cases (Fig. 2) and also reports
treatment process32. The constant occupied by gingival tissue (Fig. 1). by other researchers25,40,41. We suggest that
orthodontic force may stimulate clastic cells, Limited studies have investigated the in patients with ICR, radiographs should be
particularly at the pressure side. In the present clinical signs and symptoms of ICR among taken periodically to ensure early detection of
study, 15.87% of teeth with ICR had a history different ICR classes. We found that most ICR- new ICR lesions and to improve treatment
of orthodontic treatment (Fig. 1), suggesting affected teeth showed no obvious symptoms outcomes. Periapical radiographs for anterior
orthodontic treatment as a possible factor of or signs. However, as the resorption advanced teeth and horizontal bitewings for posterior
ICR. Mavridou et al6 reported that 45.7% of to a later stage, pain on percussion and teeth can provide more accurate information.
ICR was related to orthodontics. These results palpation was observed. Regarding the Furthermore, because ICR is mainly
indicate that orthodontic treatment is the more probing depth, Heithersay class I lesions asymptomatic, clinicians should be familiar
critical predisposing factor of ICR in Europe, mostly showed a probing depth 3 mm, but with the radiographic patterns of ICR and be
whereas in a Taiwanese population trauma class II to IV lesions often had pockets .3 alert to any possible anomalies in routine
accounted for a greater portion. This difference mm1. The lesion causes localized bony practice.
may be affected by the popularity of destruction as it progresses apically.
orthodontics in different countries as well as Furthermore, most teeth with ICR showed a
the modality of treatment. Because craniofacial positive pulp response because a thin CONCLUSIONS
patterns differ between Asian and white resorption-resistant dentin layer typically
In a Taiwanese population, ICR had a wide age
patients33 and the perception of esthetics covers the outer surface of the pulp chamber2.
distribution, with the peak between 50 and 59
varies according to culture and race34, When ICR invades the dental pulp followed by
years. Maxillary anterior teeth were the most
treatment methods and needs vary on a case microorganisms, pulp vitality may diminish.
commonly affected. Traumatic injury,
by case basis. In the future, treatment details Abscess formation was detected in
periodontal treatment, and orthodontic
such as the movement method, movement approximately 25% of teeth with Heithersay
treatment were significant predisposing factors
distance, and treatment duration should be class II to IV lesions. These abscesses were
for teeth with ICR. Endocrine disorders are
investigated to determine their combined effect typically found at the gingival level, whereas
probably related to ICR. Furthermore, the
on the treatment outcome. sinus tracts were traced toward the resorbed
affected teeth were typically absent of clinical
Historically, ICR has occasionally cavity. The overlying mucosa appeared
signs and symptoms; thus, careful
developed after internal tooth bleaching3. erythematous, swollen, and with discomfort to
radiographic examination is critical for
Hydrogen peroxide is able to diffuse through palpation. Some patients reported a history of
diagnosis. Regular radiographic follow-up
the dentinal tubules35, producing free radicals, spontaneous, throbbing pain that later
should be performed for early detection of new
which react with the periodontal tissue and subsided. The reason for abscess formation is
ICR lesions in these patients.
participate in osteoclast differentiation and probably bacterial accumulation in the pocket
activation36. In this study, no tooth had inducing a severe inflammatory response. By
undergone internal bleaching; however, 1 contrast, without bacterial contamination,
tooth had a history of external bleaching. This abscesses might not be seen even in
ACKNOWLEDGMENTS
is probably because of the improvement of Heithersay class IV lesions. Supported by National Taiwan University
internal bleaching procedures. The extraction Radiographically, ICR-affected teeth Hospital, Taiwan (grant nos. 107-S003875,
of neighboring teeth has also been pointed out typically showed no periapical lesions, and 108-004156 and 109-S4632).
as a cause of ICR37, but in our study this was most teeth remained vital. Notably, in some The authors deny any conflicts of
the case for only 5 teeth (7.94%). Playing a affected teeth, apical resorption, internal interest related to this study.

REFERENCES
1. Heithersay GS. Invasive cervical resorption: an analysis of potential predisposing factors.
Quintessence Int 1999;30:83–95.

2. Mavridou AM, Hauben E, Wevers M, et al. Understanding external cervical resorption in vital
teeth. J Endod 2016;42:1737–51.
3. Madison S, Walton R. Cervical root resorption following bleaching of endodontically treated
teeth. J Endod 1990;16:570–4.

4. Plotino G, Buono L, Grande NM, et al. Nonvital tooth bleaching: a review of the literature and
clinical procedures. J Endod 2008;34:394–407.

6 Jeng et al. JOE  Volume -, Number -, - 2020

 5. Abbott P, Heah SY. Internal bleaching of teeth: an analysis of 255 teeth. Aust Dent J
2009;54:326–33.

6. Mavridou AM, Bergmans L, Barendregt D, Lambrechts P. Descriptive analysis of factors

associated with external cervical resorption. J Endod 2017;43:1602–10.
7. Nanci A. Ten Cate’s Oral Histology: Development, Structure, and Function. 8th ed. St Louis, MO:
Mosby Elsevier; 2013.
8. Dias C, Closs L, Barletta F, et al. Root resorption a 6-year follow-up case report. Open Dent J
2015;9:103–5.

9. Perlea P, Imre M, Nistor CC, et al. Occurrence of invasive cervical resorption after the completion
of orthodontic treatment. Rom J Morphol Embryol 2017;58:1561–7.
10. Diaz JA, Jans GA, Zaror CE. Long-term evaluation and clinical outcomes of children with dental
transplants in Temuco City, Chile. Eur J Paediatr Dent 2014;15:6–12.
11. Arroyo-Bote S, Bucchi C, Manzanares MC. External cervical resorption: a new oral manifestation
of systemic sclerosis. J Endod 2017;43:1740–3.

12. Patel K, Schirru E, Niazi S, et al. Multiple apical radiolucencies and external cervical resorption
associated with Varicella zoster virus: a case report. J Endod 2016;42:978–83.
13. Kumar V, Chawla A, Kaur A. Multiple idiopathic cervical root resorptions in patients with hepatitis
B virus infection. J Endod 2018;44:1575–7.
14. Kjaer I, Strom C, Worsaae N. Regional aggressive root resorption caused by neuronal virus
infection. Case Rep Dent 2012;2012:693240.

15. Patel S, Saberi N. External cervical resorption associated with the use of bisphosphonates: a case
series. J Endod 2015;41:742–8.
16. Patel S, Foschi F, Mannocci F, Patel K. External cervical resorption: a three-dimensional
classification. Int Endod J 2018;51:206–14.
17. Patel S, Kanagasingam S, Ford TP. External cervical resorption: a review. J Endod 2009;35:616–
25.

18. Patel S, Mavridou AM, Lambrechts P, Saberi N. External cervical resorption–part 1:

histopathology, distribution and presentation. Int Endod J 2018;51:1205–23.

19. Gulsahi A. Clinical and radiographic appearances of invasive cervical resorption. J Oral Health
Dent Manag 2014;13:934–9.
20. Atabek D, Alacam A, Aydintug I, Konakoglu G. A retrospective study of traumatic dental injuries.
Dent Traumatol 2014;30:154–61.

21. Lindskog SF, Dreyer CW, Pierce AM, et al. Osteoclastic activity. In: Andreasen JO,
Andreasen FM, Andersson L, editors. Textbook and Color Atlas of Traumatic Injuries to the Teeth.
4th ed. Oxford, UK: Blackwell Munksgaard; 2007. p. 137–71.

22. Midgetss RJ, Shaye R, Fruge JF. The effect of altered bone metabolism on orthodontic tooth
movement. Am J Orthod 1981;80:256–62.
23. Tangney NJ. Hypophosphatasia: a case report and literature review. Ir Med J 1979;72:530–1.

24. Poumpros E, Loberg E, Engstrom C. Thyroid function and root resorption. Angle Orthod
1994;64:389–94.

25. Neely AL, Thumbigere-Math V, Somerman MJ, Foster BL. A familial pattern of multiple idiopathic
cervical root resorption with a 30-year follow-up. J Periodontol 2016;87:426–33.
26. Andreason JO, Andreason FM. Root resorption following traumatic dental injuries. Proc Finn Dent
Soc 1992;88(Suppl 1):95–114.

27. Patel S, Durack C, Ricucci D. Root resorption. In: Hargreaves KM, Berman LH, Rotstein I, editors.
Cohen’s Pathways of the Pulp. 11th ed. St Louis, MO: Elsevier; 2016. p. 660–83.

28. Heo SR, Kim SA, Seo SR, Kim HS. A study on the loss of tooth substance and surface changes
following root planning. J Korean Acad Periodontol 1998;28:351–69.
29. Vastardis S, Yukna RA, Rice DA, Mercante D. Root surface removal and resultant surface texture
with diamond-coated ultrasonic inserts: an in vitro and SEM study. J Clin Periodontol
2005;32:467–73.
30. Corbet EF, Vaughan AJ, Kieser JB. The periodontally-involved root surface. J Clin Periodontol
1993;20:402–10.

31. Fischer C, Wennberg A, Fischer RG, Attstrom R. Clinical evaluation of pulp and dentine sensitivity
after supragingival and subgingival scaling. Endod Dent Traumatol 1991;7:259–65.

JOE  Volume -, Number -, - 2020 Invasive Cervical Resorption 7

32. Shemesh A, Birnhoim-Blau G, Zoizner R, et al. External invasive resorption: case report of a
rapidly progressive process in an impacted maxillary canine during orthodontic treatment. Aust
Endod J 2019;45:259–64.

33. Gu Y, McNamara JA Jr, Sigler LM, Baccetti T. Comparison of craniofacial characteristics of

typical Chinese and Caucasian young adults. Eur J Orthod 2011;33:205–11.

34. Chong HT, Thea KW, Descallar J, et al. Comparison of white and Chinese perception of esthetic
Chinese lip position. Angle Orthod 2014;84:246–53.
35. Wang JD, Hume WR. Diffusion of hydrogen ion and hydroxyl ion from various sources through
dentine. Int Endod J 1988;21:17–26.

36. Bax BE, Alam AS, Banerji B, et al. Stimulation of osteoclastic bone resorption by hydrogen
peroxide. Biochem Biophys Res Commun 1992;183:1153–8.

37. Gunst V, Mavridou A, Huybrechts B, et al. External cervical resorption: an analysis using cone
beam and microfocus computed tomography and scanning electron microscopy. Int Endod J
2013;46:877–87.

38. Gunst V, Huybrechts B, De Almeida Neves A, et al. Playing wind instruments as a potential
aetiologic cofactor in external cervical resorption: two case reports. Int Endod J 2011;44:268–
82.

39. Vossoughi R, Takei HH. External cervical resorption associated with traumatic occlusion and
pyogenic granuloma. J Can Dent Assoc 2007;73:625–8.
40. Jiang YH, Lin Y, Ge J, et al. Multiple idiopathic cervical root resorptions: report of one case with 8
teeth involved successively. Int J Clin Exp Med 2014;7:1155–9.

41. Macdonald-Jankowski D. Multiple idiopathic cervical root resorption most frequently seen in
younger females. Evid Based Dent 2005;6:20.

8 Jeng et al. JOE  Volume -, Number -, - 2020