Seminal paper regarding the protocol of pulp necrosis before, during and after orthodontic treatment

• This is the strongest paper to cite for the position that orthodontic treatment itself does not normally induce pulp necrosis or calcific metamorphosis .
• The paper explains this using pulp physiology, microscopy, pathology, and the biology of induced tooth movement .

Suggested protocol framework

Before orthodontic treatment

• Take a detailed history of dental trauma, luxation, avulsion, crown fracture, caries, restorations, periodontal disease, discoloration, pain, swelling, or previous endodontic treatment, especially because trauma history is central to pulpal risk assessment before orthodontic tooth movement .
• Teeth with previous trauma need special attention because loss of pulp vitality, root resorption, and pulp canal calcification are recognized risks during orthodontic tooth movement .
• Consider recording baseline pulp sensibility tests and periapical radiographs for teeth with trauma history, discoloration, symptoms, or suspicious restorations, as these teeth are the group emphasized as higher risk in the orthodontic-endodontic interface literature .
• Explain to the patient that orthodontic treatment is not generally considered a direct cause of pulp necrosis, but previously traumatized or compromised teeth may show pulpal complications during treatment .

During orthodontic treatment

• Monitor teeth with previous trauma, discoloration, abnormal pulp tests, symptoms, or radiographic changes more closely because traumatized teeth are reported to be at higher risk for loss of pulp vitality, root resorption, and pulp canal calcification during orthodontic tooth movement .
• If a tooth becomes painful, discolored, develops swelling, sinus tract, periapical radiolucency, or repeated negative sensibility tests, suspect pulpal pathology rather than assuming it is a normal orthodontic response .
• Consider pausing orthodontic force on the affected tooth and referring for endodontic evaluation if necrosis is suspected, particularly in teeth with previous trauma or other signs of pulpal compromise .
• Rare pulpal complications during orthodontic treatment have been described, including pulp necrosis and pulp obliteration by secondary dentin .

After orthodontic treatment

• Reassess any tooth that changed color, became symptomatic, or showed abnormal radiographic or pulp-test findings, because post-orthodontic necrotic pulp with crown discoloration has been described in case-report evidence .
• Confirm suspected pulp necrosis with combined clinical signs, sensibility testing, and radiographic findings rather than relying on a single finding alone, especially in teeth with prior trauma or other risk factors .
• Treat confirmed pulp necrosis with endodontic therapy before cosmetic procedures such as internal bleaching, as illustrated in the post-orthodontic necrotic pulp case report .

Evidence note

• The evidence is somewhat mixed in emphasis: Consolaro & Bianco argue that orthodontic treatment itself does not induce pulp necrosis , while clinical reviews emphasize that teeth with prior trauma are at higher pulpal risk during orthodontic movement .
• The most defensible interpretation is: routine orthodontic forces do not usually cause pulp necrosis, but orthodontic treatment can coincide with or reveal pulpal necrosis in teeth with prior trauma or other pre-existing risk factors .