Incidence of pulp necrosis subsequent to pulp canal obliteration from trauma of permanent incisors

Post-traumatic complications of severe luxations and replanted teeth

AIM

The aim of this study was to evaluate the main post-traumatic complications of severe luxation and replanted teeth using clinical and radiographic analyses.

MATERIALS AND METHODS

Eighty-three patients aged between 7 and 55 years old presenting 180 traumatized teeth that suffered extrusive luxation (n=67), lateral luxation (n=69), intrusive luxation (n=10) and tooth avulsion (n=34) followed by replantation were evaluated. The follow-up period was 24 months. The complications examined were: pulp canal obliteration, pulp necrosis and root resorption (infammatory and replacement). Furthermore, the relationship between time elapsed before receiving dental attendance and development of infammatory resorption was observed.

RESULTS

Pulp necrosis was the main complication, occurring in 147 teeth (82.7%). All of the teeth that suffered intrusive luxation and tooth avulsion were diagnosed with pulp necrosis, with significant difference in comparison with another traumas (p<0.001/Fisher's exact test). Infammatory root resorption was observed in 20.5% of the cases and replacement resorption was more related to tooth replantation (94.1%), showing significant prevalence among tooth luxations (p<0.001/Fisher's exact test). In addition, it was noted that patients who seek treatment 9 weeks after the trauma episode presented 10 times more chance of developing infammatory resorption when compared with patients who seek treatment soon after dental trauma (Odds ratio test).

CONCLUSION

It may be concluded that pulp necrosis was the main post-traumatic complication observed in traumatized teeth and that delay in seeking treatment may damage the prognosis of severe luxation and replanted teeth.

CLINICAL SIGNIFICANCE

Clinical studies describing the main complications that may affect traumatized teeth present great relevance to make the population aware of the importance of seeking immediate treatment and to alert the professional to the need for follow-up. When traumatic injuries are diagnosed and treated early, post-traumatic complications may be controlled, allowing conservation of the tooth in oral cavity.

Bleaching options for pulp-calcified teeth: case history reports

The aim of this article is to review some essential aspects of anterior tooth calcification and its esthetic treatment. Furthermore, three cases including different and successful bleaching strategies are reported.

Distinctive genetic activity pattern of the human dental pulp between deciduous and permanent teeth

Human deciduous and permanent teeth exhibit different developmental processes, morphologies, histological characteristics and life cycles. In addition, their pulp tissues react differently to external stimuli, such as the pulp sensitivity test, dental trauma and pulp therapy materials. These suggest differences in gene expression and regulation, and in this study we compared gene-expression profiles of the human dental pulp from deciduous and permanent teeth. Pulp tissues from permanent premolars and deciduous molars aged 11–14 years were extirpated and mRNA was isolated for cDNA microarray analysis, and quantitative real-time PCR (qPCR). Other teeth were used for immunohistochemical analysis (IHC). Microarray analysis identified 263 genes with a twofold or greater difference in expression level between the two types of pulp tissue, 43 and 220 of which were more abundant in deciduous and permanent pulp tissues, respectively. qPCR analysis was conducted for eight randomly selected genes, and the findings were consistent with the cDNA microarray results. IHC confirmed that insulin-like growth factor 2 mRNA-binding protein 1 (IGF2BP1) was broadly expressed in deciduous dental pulp tissue, but minimally expressed in permanent dental pulp tissue. Immunohistochemical analysis showed that calbindin 1 (CALB1), leucine-rich repeat-containing G-protein-coupled receptor 5 (LGR5), and gamma-aminobutyric acid A receptor beta 1 (GABRB1) were abundantly expressed in permanent predentin/odontoblasts, but only minimally expressed in deciduous dental pulp tissue. These results show that deciduous and permanent pulp tissues have different characteristics and gene expression, suggesting that they may have different functions and responses to therapies focused on pulp or dentin regeneration.

Pulp canal obliteration: an endodontic diagnosis and treatment challenge

AIM

To review the literature on pulp chamber and root canal obliteration in anterior teeth and to establish a clear protocol for managing teeth with fine, tortuous canal systems.

SUMMARY

Pulp canal obliteration (PCO) occurs commonly following traumatic injuries to teeth. Approximately 4-24% of traumatized teeth develop varying degrees of pulpal obliteration that is characterized by the apparent loss of the pulp space radiographically and a yellow discoloration of the clinical crown. These teeth provide an endodontic treatment challenge; the critical management decision being whether to treat these teeth endodontically immediately upon detection of the pulpal obliteration or to wait until symptoms or signs of pulp and or periapical disease occur. The inevitable lack of responses to normal sensibility tests and the crown discoloration add uncertainty to the management; however, only approximately 7-27% of teeth with PCO will develop pulp necrosis with radiographic signs of periapical disease. Root canal treatment of teeth with pulpal obliteration is often challenging. This article discusses the various management approaches and highlights treatment strategies for overcoming potential complications.

KEY LEARNING POINTS

Up to 25% of traumatized anterior teeth can develop pulp canal obliteration; Discolouration is a common clinical finding in teeth with pulp canal obliteration; Up to 75% of teeth with pulp canal obliterations are symptom-free and require no treatment other than radiographic monitoring; Routine pulp sensibility tests are unreliable in the presence of pulp canal obliteration; Teeth with pulp canal obliteration in need of root canal treatment pose particular diagnostic and treatment challenges.

A retrospective study of 889 injured permanent teeth

The aim of this study was to investigate pre-injury factors, causes of dental injuries and healing complications after traumatic injuries to permanent teeth. The analysed sample comprised 889 permanent teeth of 384 patients, who were treated in the Dentistry Department in Faculty Hospital in Pilsen. Enamel-dentin fractures [233 teeth (26.2%)] and lateral luxations [207 teeth (23.3%)] were the most frequent injuries. The age of the patients at the time of injury varied between 7 and 65 years. Predominantly, children were affected [587 injured teeth (66.0%)]. The most frequent causes of injuries in patients older than 11 years were various sport activities, predominantly bicycling. Pulp necrosis was observed in 239 teeth (26.9%). It was the most frequent post-traumatic complication in all types of dental traumas. Teeth with a completed root formation demonstrated a higher prevalence of pulp necrosis than teeth with an incomplete root formation in all types of luxation injuries. External root resorption was observed in 144 teeth. The rate of inflammatory resorption differed between the various types of luxation injuries (extrusive luxation 5.6%, lateral luxation 11.6%, intrusive luxation 33.3%). Following avulsion and replantation, active inflammatory resorptions were diagnosed in 13 (26.5%) of 49 replanted teeth and ankylosis/replacement resorptions were observed in 21 (42.9%) of 49 replanted teeth. After avulsion, primarily, immature teeth were affected by these complications. Within the observation period of 5 years, 39 teeth (4.4%) had to be removed (16 teeth with root fractures, 19 avulsed and replanted teeth, 3 luxated teeth, 1 tooth with crown-root fracture).

Evaluation of radiographs, clinical signs and symptoms associated with pulp canal obliteration: an aid to treatment decision

Pulp canal obliteration (PCO) is a sequela of tooth trauma. The dental clinician faced with this condition has to make a difficult decision. The aim of this study was to evaluate the clinical signs and symptoms associated with teeth with PCO and to assess the status of the periapical tissues using the periapical index (PAI) as an aid in making a treatment decision. The study included teeth diagnosed with PCO in patients with a history of traumatic injury to the involved teeth. Histories of associated signs and symptoms including pain, swelling and drainage from a sinus tract were elicited. Tooth color, sensibility to electric pulp testing, mobility and percussion tenderness were recorded. The periapical status was assessed using the PAI. Two hundred and seventy-six teeth were diagnosed with PCO. One hundred and fifty-seven (56.9%) and 119 (43.1%) demonstrated partial or total PCO, respectively. Yellow discoloration presented most frequently, occurring in 186 (67.4%) teeth. Sixty-two (33.3%) of these had developed periapical lesions and reacted negatively to sensibility testing. Fifty-seven (30.7%) of these teeth presented radiographically with a normal periapical appearance and reacted normally to sensibility testing, whereas 67 (36.0%) presented with small changes in the periapical bone pattern and reacted in the high normal range to sensibility testing. Teeth with PAI scores < or =2 presented with occasional spontaneous pain. Teeth with PAI scores > or =3 presented with clinical symptoms and signs ranging from pain on percussion to spontaneous pain, and slight swelling to sinus tract drainage. Based on the findings of this study, endodontic treatment should be initiated in teeth with tenderness to percussion, PAI scores > or =3 and a negative response to sensibility testing.

Endodontic management of horizontally placed molars after gunshot injury to mandible: a case report

A 37-year-old man reported to our department with the history of gunshot injury to the mandible 15 years before. His anterior mandible had been resected earlier and bone graft was seen. Intraoral examination of lower jaw revealed 4 remaining mandibular molars. These teeth were severely rotated such that they lay horizontal with respect to the mandibular base. Preoperative Dentascan spiral computerized tomography (CT) of the patient revealed obliteration of the mesial canals of the mandibular right first molar and pear-shaped internal resorption defect in the distal canal of the same tooth. This paper reports the challenging endodontic management of a rare case of severely angulated teeth also exhibiting traumatic sequelae in both roots of the impact tooth. It also highlights the usefulness of spiral CT scan in diagnosis of traumatic sequelae such as pulp canal obliteration and internal resorption.

Pulp Vitality in Teeth Suffering Trauma during Orthodontic Therapy

Objective: To examine pulpal vitality in teeth suffering dental trauma during orthodontic therapy with fixed appliances.

Materials and Methods: Pulpal condition was evaluated in 59 teeth that had suffered dental trauma during orthodontic treatment (TO-group), in 800 orthodontically treated teeth without previous dental trauma (O-group), and in 193 orthodontically untreated teeth with previous dental trauma (T-group). Pulpal vitality was examined clinically and with radiographs. Degree of pulp obliteration was rated as absent, partial, or total. All teeth in the TO-group showed a positive sensibility test prior to resumption of orthodontic therapy.

Results: Teeth in the TO-group revealed a significantly higher frequency of pulp necrosis than teeth in the O-group or teeth in the T-group (P &lt; .001, respectively). In the TO-group, teeth with extrusive or lateral luxation (P = .031) and teeth with intrusive luxation (P = .015) injuries showed a significantly higher rate of pulp necrosis than teeth with fracture of enamel. In addition, teeth with total pulp obliteration showed a significantly higher frequency of pulp necrosis than teeth without pulp obliteration (P = .013).

Conclusion: Teeth with severe periodontal injury during orthodontic therapy and subsequent total pulp obliteration have an increased risk of pulp necrosis during additional orthodontic treatment stages.

Pulpal sequelae after trauma to anterior teeth among adult Nigerian dental patients

Background

Epidemiological studies show that about 11.6% to 33.0% of all boys and about 3.6% to 19.3% of all girls suffer dental trauma of varying severity before the age of 12 years. Moderate injuries to the periodontium such as concussion and subluxation are usually associated with relatively minor symptoms and hence may go unnoticed by the patient or the dentist, if consulted. Patients with these kinds of injuries present years after a traumatic accident most of the time with a single discoloured tooth. This study sets out to document the incidence of various posttraumatic sequelae of discoloured anterior teeth among adult Nigerian dental patients.

Methods

One hundred and sixty eight (168) traumatized discoloured anterior teeth in 165 patients were studied. Teeth with root canal treatment were excluded from the study. Partial obliteration was recorded when the pulp chamber or root canal was not discernible or reduced in size on radiographs, total obliteration was recorded when pulp chamber and root canal were not discernible. A retrospective diagnosis of concussion was made from patient's history of trauma to the tooth without abnormal loosening, while subluxation was made from patient's history of trauma to the tooth with abnormal loosening.

Results

Of the 168 traumatized discoloured anterior teeth, 47.6% and 31.6% had partial and total obliteration of the pulp canal spaces respectively, 20.8% had pulpal necrosis. Concussion and subluxation injuries resulted more in obliteration of the pulp canal space, while fracture of the teeth resulted in more pulpal necrosis (p < 0.001). Injuries sustained during the 1^st and 2^nd decade of life resulted more in obliteration of the pulp canal space, while injuries sustained in the 3^rd decade resulted in more pulpal necrosis.

Conclusion

Calcific metamorphosis developed more in teeth with concussion and subluxation injuries. Pulpal necrosis occurred more often in traumatized teeth including fractures.

Management of an unerupted dilacerated maxillary central incisor: a case report

A case with a dilacerated maxillary permanent central incisor, treated with forced eruption technique is illustrated and the results of the 4-year follow up are presented. After the successful eruption of the tooth, the root development was completed and the root canal was obliterated. The 4-year follow-up results revealed the tooth to be still functional and the radiographic evaluation showed that the periodontal and periapical tissues were intact and healthy. In conclusion, the impacted dilacerated incisor diagnosed in the early mixed dentition should be treated with the aid of orthodontic traction. The long-term follow up showed that once the tooth is placed in the occlusion properly, it may function well esthetically and preserve its periodontal and periapical health.

Delayed multidisciplinary management of an extrusively luxated maxillary central incisor

This paper reports a case of delayed (1 month after the injury) multidisciplinary management of an extrusively luxated permanent central incisor. The extruded tooth was diagnosed as necrotic without coronal discoloration. Upon completion of root canal treatment, the tooth was repositioned orthodontically and finally restored for esthetic purposes with a composite resin. The tooth was diagnosed as normal in the 1 year check-up.

Apical surgery with calcium hydroxide capping of the exposed dentine: a case report

Among a variety of biomaterials that have been reported to be ideal for dental repair, calcium hydroxide has been shown to have excellent long-term biocompatibility in the pulp and periapical areas. Here we report an alternative method employing calcium hydroxide for periapical surgery in a patient who developed internal apical resorption after traumatic injury, which negatively affected the quality of the cleaning, shaping and filling of the root canal. Obturation of the root canal as far as the middle third was followed by apicoectomy and ultrasonic retropreparation, and then retrograde root filling with resin cement sealer (Sealer 26) and zinc oxide powder. Calcium hydroxide paste was applied over the exposed dentinal surface, forming a barrier over the root apex. Radiographic follow-up after 24 months showed absence of apical resorption and complete periapical bone repair associated with a continuous apical lamina dura.

The endodontic management of traumatized permanent anterior teeth: a review

Despite the many journal articles and reviews that have been published regarding the treatment of trauma to teeth, the endodontic management of these injuries is often still not fully understood. The purpose of this review is to establish clear and up-to-date guidelines for practitioners who are faced with treating dental injuries on a day-to-day basis, based on an assessment of current available scientific information relating to the endodontic management of these injuries. Treatment is discussed under the headings: infractions, uncomplicated crown fractures, complicated crown fractures, crown-root fractures, root fractures, luxation injuries, avulsion, root resorption, pulp canal obliteration and open-apex teeth. Emphasis is placed on the treatment of traumatized immature teeth where maintenance of pulp blood supply is important to encourage continued development of the root system. Only the treatment of traumatized permanent anterior teeth is reviewed. Information contained in this article is based on a review of the literature on dental trauma which involved a MEDLINE search using the key words "dental trauma" and the individual topics listed above. The guidelines produced by the International Association of Dental Traumatology, the American Academy of Pediatric Dentistry and the American Association of Endodontists were also reviewed and the recommendations contained in this paper are in concert with the major recommendations of these bodies.

Pulp canal obliteration in an unerupted permanent incisor following trauma to its primary predecessor: a case report

Trauma to a primary tooth may result in damage to the underlying developing permanent tooth bud because of the close proximity between the root of the primary tooth and its permanent successor. We report an unusual case where injury to the primary dentition resulted in pulp canal obliteration (PCO) of a permanent maxillary central incisor prior to its eruption. The other permanent maxillary central incisor was diagnosed as malformed because of trauma to the primary dentition at an earlier age. The occurrences of PCO or crown malformation dose not routinely disrupt the eruption of those teeth. Periodic assessment is required to determine the need for endodontic intervention.

Clinical outcomes for permanent incisor luxations in a pediatric population. I. Intrusions

A longitudinal outcome study was undertaken to identify variables that significantly influenced tooth survival as well as pulpal and periodontal outcomes for intruded permanent maxillary incisors of children and adolescents. All cases were treated between June 1988 and June 1998 in a teaching hospital clinic. Clinical and radiographic data were collected for 26 patients (19 males, 7 females) that represented 31 permanent maxillary incisors. Mean age at the time of injury was 9.3 years (range = 5.5-17.8 years). Mean time elapsed to follow up was 1380 days (range = 65-3394 days). Survival analysis was used to identify variables significantly related to the survival and pulp necrosis (PN) for these incisors. Proportional hazards regression yielded significant prognostic models for tooth survival and the diagnosis of PN (P < 0.05). Incisors intruded > 6 mm had significantly decreased survival compared with incisors intruded < 3 mm (5-year survival, 0.45 and 1.0, respectively, (P < 0.05)). Complex crown fractures were significantly related to the development of PN (P < 0.05). Logistic regression analysis showed that treatment method and severity of intrusion were related to the presence of replacement root resorption (P < 0.05). This study represents the largest sample of intruded permanent incisors examined in an outcome study of children and adolescents exclusively.

Clinical outcomes for permanent incisor luxations in a pediatric population. III. Lateral luxations

A longitudinal outcome study was designed to identify variables that influenced tooth survival as well as pulpal and periodontal outcomes of laterally luxated permanent maxillary incisors of children and adolescents. All cases were treated between June 1988 and June 1998 in a teaching hospital clinic. Clinical and radiographic data were collected for 42 patients (26 males, 16 females) that represented 58 permanent maxillary incisors. Mean age at the time of injury was 11.4 years (range: 6.3-17.8 years). Mean follow-up time was 1460 days (range: 183-3905 days). In the entire sample (n = 58), no incisors required extraction. Survival analysis and logistic regression were used to identify variables significantly related to the survival and healing outcomes of these incisors. Pulp necrosis (PN) (40%) and pulp canal obliteration (PCO) (40%) were common healing complications. Proportional hazards (Cox) regression showed that PN develops within the first year. Logistic regression demonstrated that root development (P = 0.3, PN; P = 0.8, PCO) and extent of lateral luxation (P = 0.5, PN; P = 0.9, PCO) were not significantly related to PN and PCO. This study provides the first report of incisor survival in children and adolescents following lateral luxation injuries.

Monitoring pulp vitality after transplantation of teeth with mature roots: a case report

AIM

To initiate discussion on the value of routine root canal treatment for transplanted teeth.

SUMMARY

Autotransplantation is an accepted treatment option to replace missing teeth. It is generally considered that revascularization of the pulp following such a procedure is more favourable in teeth with immature roots. In teeth with closed apices root canal treatment is considered necessary. This paper presents a case of pulp revascularization in a transplanted tooth with mature roots and casts doubt on whether root canal treatment is essential in such situations. An alternative treatment protocol is proposed.

KEY LEARNING POINTS

* Following transplantation original pulp tissue may survive the operation. * Teeth with obliterated pulp space do not become necrotic more often than those without obliteration. * Monitoring the tooth is an acceptable alternative to automatic root canal treatment for transplanted teeth. * Root canal treatment should be undertaken only upon occurrence of pathological signs.

Histopathological evaluation of the dental pulps in crown-fractured teeth

Trauma is a common cause of pulpal damage. In traumatic injuries, the first priority is to protect the vitality of pulps. But the time between the trauma and treatment must be short to preserve vital, noninflamed pulps. The aim of this study was to investigate the histopathological changes in pulpal tissues at different time periods after crown fractures. Twenty-three teeth with enamel and dentin fractures, with and without pulp exposure were evaluated. The reasons for seeking dental treatment were aesthetic consideration, pain, or discomfort. The extirpated pulps were histologically prepared for microscopical evaluation. There was myelin degeneration surrounding the axons and edema in the early posttraumatic stages (17 h). In the later stages (4 to 20 days), the tissues showed varying degrees of inflammation, and neuronal degeneration such as intramyelin edema, aberrant myelin synthesis, and axonal swelling.