REVIEW ARTICLE

Filipe Colombo Vitali, DDS, MS,*

Ihan Vitor Cardoso, DDS, MS,* Association between
Fernanda Weber Mello, DDS,
MS,* Carlos Flores-Mir, DDS, Orthodontic Force and Dental
MS, PhD,†
Ana Cristina Andrada, DDS, Pulp Changes: A Systematic
DMSc,‡ Kamile Leonardi Dutra-
Horstmann, DDS, MS, PhD,* Review of Clinical and
and Thais Mageste Duque, DDS,
MS, PhD* Radiographic Outcomes

ABSTRACT
SIGNIFICANCE
Introduction: Orthodontic force triggers a sequence of biological responses that can affect
Orthodontically moved teeth dental pulp. The aim of this study was to systematically evaluate the clinical and radiographic
may present immediate findings of orthodontic force application on dental pulp. Methods: Two reviewers
reduction in pulpal blood flow, comprehensively and systematically searched 6 electronic databases (Latin American and
increased pulpal sensibility Caribbean Health Sciences [LILACS], Embase, Cochrane Library, MEDLINE/PubMed,
response to pulp tests, Scopus, and Web of Science) and the gray literature (Google Scholar, OpenGrey, and
increased incidence of pulp ProQuest) until April 2021. According to the PICOS criteria, randomized clinical trials and
stones, and changes in the observational studies that evaluated clinical or radiographic findings compatible with dental
pulp cavity dimensions. pulp changes due to orthodontic force were included. Studies in open apex or traumatized
teeth, case series or reports, and laboratory-based or animal studies were excluded. The
Newcastle-Ottawa Scale and Cochrane Risk of Bias 2.0 tool were used to determine the risk
of bias assessment. The overall certainty level was evaluated with the Grading of Recom-
mendations, Assessment, Development and Evaluations tool. Results: Twenty-six studies
were included. Among the clinical findings, orthodontic force promoted an increased pulp
sensibility response and decreased pulp blood flow. Changes in pulp cavity volume and
increased incidence of pulp stones were the radiographic findings observed. The studies
presented a moderate risk of bias for most of the domains. The certainty of the evidence was
considered very low. Conclusions: Orthodontic force promoted changes in the dental pulp,
generating clinical and radiographic findings. It is crucial to know these changes so that
orthodontic mechanics can be safely performed. The clinician has effective noninvasive
methods to assess the health and possible pulp changes during orthodontic
treatment. (J Endod 2022;48:298–311.)

KEY WORDS
From the *Department of Dentistry, Dental pulp; dental pulp calcification; dental pulp test; endodontics; orthodontics; systematic
Federal University of Santa Catarina,
Florianopolis, Santa Catarina, Brazil;
review
†
Department of Orthodontics, University
of Alberta, Edmonton, Alberta, Canada;
and ‡Department of Endodontics, Virgínia
Orthodontic force triggers a sequence of biological events in the dental complex, affecting dental support
Commonwealth University School of
Dentistry, Richmond, Virginia and pulp tissues1. The extent of dental pulp changes depends on many factors, such as the type or
direction of movement, distribution, intensity, and duration of the force2,3. Inherent characteristics of the
Address requests for reprints to Dr Filipe
Colombo Vitali, Department of Dentistry, tooth, such as age, previous orthodontic treatment, and trauma history, may also affect the pulp
Federal University of Santa Catarina, conditions2–4.
Delfino Conti, Trindade, Florianopolis, Noninvasive methods can be applied during orthodontic treatment to assess the condition of the
Santa Catarina, Brazil. pulp because they are simple tools for clinical use5. Laser Doppler flowmetry and electric/thermal pulp
E-mail address: fi[email protected]
0099-2399/$ - see front matter
tests can be used to monitor pulp vitality because they allow repeated clinical detection of blood flow and
pulp sensitivity response without tissue damage6. Therefore, clinicians need to know which clinical signs
Copyright © 2021 American Association
of Endodontists.
and symptoms may represent pulp changes due to orthodontic force.
https://doi.org/10.1016/ When the applied orthodontic force affects pulp tissue, it may concentrate inflammatory mediators,
j.joen.2021.11.018 stimulating resorptive or reparative responses to odontoblasts and odontoblastlike cells and leading to

298 Vitali et al. JOE
Volume 48, Number 3, March 2022

resorption processes or deposition of tertiary or animal studies, reviews, and studies that did studies) or outcome (in cohort studies)
dentin7,8. Such events can promote changes not investigate the association between the (maximum of 3 points). Studies that reached
in the pulp cavity’s internal dimensions, which application of orthodontic force and the up to 4 points were classified as “high risk of
can be detected by the clinician, who needs to occurrence of clinical or radiographic changes bias,” from 5 to 6 points as “moderate risk
have imaging tests for the diagnosis and in the dental pulp. of bias,” and more than 7 points as “low risk of
monitoring of the patient during orthodontic bias”17,18. The randomized clinical trials were
treatment7,8. Information Sources and Search examined using the Cochrane Collaboration
Previous studies have reported several Strategy Risk of Bias 2.0 tool19. The following domains
changes in the dental pulp tissue after Individual search strategies were developed for were evaluated: bias arising from the
orthodontic force9–12. Adequate knowledge the following databases: Latin American and randomization process, bias due to deviations
related to these changes is fundamental for Caribbean Health Sciences (LILACS), Embase, from intended interventions, bias due to
clinicians when applying orthodontic The Cochrane Library, MEDLINE-PubMed, missing outcome data, the bias in the
mechanics to control and minimize damage to Scopus, and Web of Science. Additionally, a measurement of the outcome, the bias in the
the pulp or supporting tissues9. Previous search of the gray literature was performed, selection of the reported result, and overall
reviews have evaluated the association including the databases Google Scholar, bias. Each domain was rated as “low risk,”
between orthodontic force application and OpenGrey, and ProQuest. No filters or “high risk,” or “some concerns.” Studies
dental pulp changes13,14; however, these restrictions were applied to the search. All judged to be low risk for all domains were
studies focus on verifying the alterations at the searches were conducted from the earliest classified as “low risk of bias,” studies
tissue morphology level. To date, no review date available until April 2, 2021. considered to have some concerns in at least
focused on the assessment of clinical and 1 domain were classified as “some concerns,”
radiographic changes. Thus, this systematic and studies judged to be at high risk in at least
Study Selection
review aimed to answer the following question: 1 domain or considered to have some
Study selection was performed in 2 phases. In
Does orthodontic force promote radiographic concerns for multiple domains were classified
phase 1, 2 independent authors reviewed the
or clinical changes in dental pulp tissues of as “high risk of bias.” To use these tools, the
titles and abstracts of all identified references.
permanent teeth? reviewers were previously trained and
In phase 2, the same reviewers separately
calibrated, discussing signaling questions
applied eligibility criteria to the full-text studies.
MATERIALS AND METHODS included to help them to judge the
The reviewers examined the selected studies’
methodological quality of the primary studies.
Protocol and Registration reference lists individually to identify potentially
This systematic review followed the Preferred relevant articles. Any disagreement was
Reporting Items for Systematic Reviews and resolved between them, and, if there was no Certainty of Evidence
Meta-Analyses Protocols statement15. A consensus, a third reviewer was consulted to The certainty of the evidence was assessed
protocol based on the Preferred Reporting make a final decision. using the GRADE approach. The following
Items for Systematic Reviews and Meta- parameters were evaluated: risk of bias, refers
analysis Protocols: elaboration and Data Collection Process and Data to judgments about the quality of individual
explanation16 was registered at the Items studies; inconsistency, refers to the presence
International Prospective Register of A data collection form was developed and of heterogeneity between the studies and the
Systematic Reviews (PROSPERO: tested in a pilot study. After training, 2 authors quality to produce consistent results;
CRD42020180542). collected critical data from the selected indirectness, refers to differences in
studies, and any disagreements were solved population, intervention, and outcome
Eligibility Criteria between them. Data collection consisted of measures; and imprecision, refers to the
The PICOS acronym was used to formulate study characteristics (author, year, country, presentation and extent of the confidence
the following focused question: Does and study design), sample characteristics interval and whether the sample size and
orthodontic force promote radiographic or (number, sex, and age of participants and characteristics were sufficient to be matched
clinical changes in dental pulp tissues of number and type of teeth on which orthodontic to the target population. The overall quality of
permanent teeth? force was applied), methodology details (type, the evidence was rated “very low,” “low,”
value, duration of the orthodontic force; follow- “moderate,” and “high” using GRADEpro

Population: permanent mature teeth of up period; and evaluation method), outcome software (McMaster University, Hamilton,
patients undergoing orthodontic treatment assessment, and main results. Ontario, Canada).

Intervention: any type of orthodontic force
vector and intensity
Risk of Bias Assessment

Comparison: none or studies comparing 2 RESULTS
Risk of bias assessment of the included
different orthodontic force vectors/
articles was independently performed by 3 Study Selection and Characteristics
intensities
authors according to the type of study. The The search strategy resulted in 3584

Outcomes: clinical and radiographic
Newcastle-Ottawa Scale was used17,18 for references after the duplicates were removed
findings compatible with changes in the
case-control and cohort studies (www.ohri. (Fig. 1). At the end of phase 1, 97 articles were
dental pulp after orthodontic force
ca/programs/clinical_epidemiology/oxford. included for evaluation of the full text. In phase
application
asp). This tool assigns a specific score to each 2, 71 articles were excluded, resulting in 26

Studies: randomized clinical trials or
study based on 3 domains: participant articles for the final evaluation. Of these, 24
observational studies
selection (maximum of 4 points), group were observational studies (18 case-control
The following exclusion criteria were comparability (maximum of 2 points), and studies and 6 cohort studies), and 2 were
applied: case series/reports, laboratory-based assessment of exposure (in case-control randomized clinical trials.

JOE
Volume 48, Number 3, March 2022 Orthodontic Force and Dental Pulp Changes 299
 the value of the applied force9–11. The return of
blood flow to baseline values varied according
to studies (ie, 3 weeks for maxillary incisors12
and 3 months for maxillary molars32. The
extrusion force was unable to reduce blood
flow9. For canine retraction, the pulpal blood
flow reduction occurred 10 minutes after the
force application and returned to baseline
values after 72 hours11.
For canine retraction and rapid maxillary
expansion, no significant changes were found
in the pulp cavity dimensions of the maxillary
canines and first molars, respectively39,40. For
maxillary incisors, the pulp chamber
dimensions were reduced in the
cementoenamel junction and increased in the
middle of the crown 1 year after rapid maxillary
expansion40. In addition, an increased
frequency of pulp canal narrowing and a
reduction in pulp cavity volume were observed
for fixed orthodontic after 5 years and 17–
18 months of treatment, respectively37,41. The
presence of pulp stones increased from
1.56%–6.5% after fixed orthodontic
treatment34–37.

Risk of Bias and Certainty of

Evidence Assessment
The interobserver agreement for the
assessment of the risk of bias using the
Newcastle-Ottawa Scale (kappa 5 0.816
[0.118]) and the Cochrane tool (kappa 5 0.858
[0.084]) was considered excellent42. Among
the case-control studies, 6 were classified as
low risk of bias24–27,30,40, 10 as moderate risk
of bias9,11,21–23,28,32,33,38,41, and 2 as high risk
FIGURE 1 – The PRISMA flow diagram. An overview of the search methodology used in the systematic review. of bias10,31. All the cohort studies were
classified as moderate risk of bias29,34–37,39.
Both randomized clinical trials were classified
as some concerns (12, 20). The certainty of the
Among the clinical outcomes, RESULTS OF INDIVIDUAL evidence was rated very low for all outcomes
orthodontic force application was associated STUDIES after evaluating the GRADE parameters. Very
with pulpal sensibility response changes and low-quality evidence indicates that the real
pulpal blood flow changes. Changes in the Detailed information about the included effect probably differs from the estimated
pulp cavity volume and the incidence of pulp studies’ results is available in Table 1. The effect43. Detailed information about the risk of
stone formation were the radiographic findings pulpal sensibility response to pulp tests varied bias and certainty of evidence assessment are
observed. between the studies. For the intrusion force, it available in Figure 2 and Table 2, respectively.
Eleven studies evaluated clinical was observed that the greater the applied
responses to pulpal sensibility when teeth force value, the more significant the electric
were subjected to different forces, including test response, and the response was greater in DISCUSSION
intrusion20–22, during canine traction23, after the group in which the force was applied in Orthodontic mechanics consists of applying an
conventional orthodontic treatment24–29, and comparison to the control group (without external force on teeth to stimulate their
after rapid maxillary expansion30. Seven force)20,22. For fixed orthodontic treatment, the movement within the alveolar bone2,3. When
studies evaluated pulpal blood flow in the response was also greater in the orthodontic forces are applied within the physiological
following situations: after intrusion9,10,12,31–33, group24,25,27. The number of negative limits, they tend to produce a physiological
extrusion9, or during canine retraction11. Five responses to the electric test increased in response in pulp and supporting tissues
studies evaluated pulp stone formation after groups where orthodontic force was applied, without causing long-term adverse
fixed orthodontic treatment34–38. Four studies but they started to respond positively over time reactions2,3. Clinicians must be attentive to the
evaluated internal dimensions of the pulp cavity (8.4–12 months)23–27. clinical signs of pulp changes because a direct
after canine retraction39, after rapid maxillary Pulpal blood flow decreased evaluation of tissue morphology would only be
expansion40, and after fixed orthodontic immediately after applying the intrusion force, possible after tooth extraction. This systematic
treatment37,41. and its decrease seemed to be proportional to review included 26 articles that evaluated the

300 Vitali et al. JOE
Volume 48, Number 3, March 2022

 TABLE 1 - Characteristics of the Included Studies
JOE
Volume 48, Number 3, March 2022

Test group
(n) patients, teeth Force type
age range value (g)
Authors (year), country (age mean ± SD) Control group Evaluated teeth Duration Assessment method Main results
Outcome: pulpal sensibility response
Alomari et al (2011)24, n 5 47 patients, n 5 23 patients, Maxillary canines, lateral and COT EPT and TPT 1. Negative responses both
Jordan 282 teeth 138 teeth central incisors 16.1 mo Times: (T0/baseline) before TPT and EPT: increased
12.1–17.3 y 13.7–18.1 y bonding, (T1) after 2 h, after T1, returned to
(15.1 y) (16.2 y) (T2) 30 d, (T3) 60 d, (T4) baseline value after T14;
No treatment 120 d, (T5) 180 d, (T6) 240 P , .001
d, (T7) 300 d, (T8) 360 d, 2. EPT response after T1 was
(T9) after debonding, (T10) higher in the orthodontic
after fitting the retainer, (43.05 u) than the control
(T11) after 3 mo, (T12) 6 group (30.62 u); P , .01
mo, (T13) 9 mo, (T14) 12 3. In the orthodontic group
mo (baseline 34.99 u), EPT
response increased at T1
(41.77 u) to T3 (50.12 u),
decreasing after T4 (48.42
u); P , .01
Cave et al (2002)25, n 5 33 patients, n 5 15 patients, Maxillary central and lateral COT EPT and TPT 1. Negative responses both
Australia 132 teeth 60 teeth incisors 28–252 d Times: (T0/baseline) before TPT and EPT: increased
9.8–29 y 14–27.3 y bonding, (T1) immediately after T1, returned to
(14.4 y) (21.7 y) after initial arch, (T2) after baseline value after T6;
No treatment 28 67 d, (T3) after 56 67 P , .05
d, (T4) after 100 6 14 d, 2. EPT response after T1 was
(T5) after 168 6 14 d, (T6) higher in the orthodontic
after 252 6 14 d (46.21 u) than the control
group (26.77 u); P , .01
3. In the orthodontic group
(baseline 37.96 u), EPT
response increased at T1
Orthodontic Force and Dental Pulp Changes

(42.32 u) to T3 (50.70 u),

decreasing after T4 (50.70
u); P , .05
4. EPT response of lateral
incisor was higher of
central incisor; P , .05
5. EPT response decreased
with increasing subject
age; P , .01
Cho et al (2010)30, USA n 5 25 patients, No group Maxillary premolars and first RME EPT and TPT 1. All teeth responded
no. of teeth varied molars Times: (T0/baseline) positively both EPT and
throughout the study immediately before TPT after T3.
10–16 y placement of the
separators, (T1) end of
301

(continued on next page )

 TABLE 1 - Continued
302
Vitali et al.

Test group
(n) patients, teeth Force type
age range value (g)
Authors (year), country (age mean ± SD) Control group Evaluated teeth Duration Assessment method Main results
RME (2 wk after T0), (T2)
2–4 w into retention, (T3)
3–9 mo after the force
stopped.
Ferreira et al (2013)23, n 5 24 patients, n 5 16 patients, Maxillary canines Canine traction TPT 1. Negative responses after
Brazil 32 teeth 32 teeth Time: before and after canine treatment was higher in
No treatment traction treatment the orthodontic (43.8%)
(no time information) than the control group
(3.1%); P , .01
Hall & Freer (1998)26, n 5 7 patients, n 5 2 patients, Maxillary canines, lateral and COT EPT and TPT 1. Negative responses for
Australia 41 teeth 12 teeth central incisors 4–8 w Times: (T0/baseline) before EPT (T0 and T1 5 9.76%):
14–18 y No treatment bonding, (T1) immediately all teeth responded
after initial arch, (T2) 4 wk negatively after T2 (100%).
after, (T3) 8 wk after 2. For TPT, all teeth
responded positively at all
times.
Han et al (2013)20, China n 5 24 patients, n 5 3 patients, Maxillary first premolars Intrusion EPT 1. In the 50-g force group,
48 teeth 6 teeth 50 and 300 g Times: before placement of response in relation to
14–24 y 14–24 y 1–12 wk the lingual button (T0/ baseline (3.44 u) was
(17.9 y) (17.9 y) baseline), (T1) after 1 wk, higher at T2 (5.20 u), T4
No treatment (T2) 2 wk, (T3) 3 wk, (T4) 4 (6.43 u), T5 (7.68 u), T6
wk, (T5) 5 wk, (T6) 6 wk, (8.35 u), and T7 (8.67 u);
(T7) 7 wk, (T8) 8 wk, (T9) 9 P , .05
wk, (T10) 10 wk, (T11) 11 2. In the 300-g force group,
wk, (T12) 12 wk no significant differences
were observed between
baseline and T1–T12
values; P . .05
3. Response at T1, T2, and
T3 was higher in the 300-g
force (6.63 u, 7.20 u, and
JOE
Volume 48, Number 3, March 2022

7.67 u) than the 50-g force

group (4.50 u, 5.20 u, and
4.29 u); P , .05
Khoshbin et al (2019)27, n 5 86 patients, n 5 43 patients, Maxillary central and lateral COT EPT 1. Negative responses (T0
Iran 344 teeth 172 teeth incisors Times: (T0/baseline) before and T1 5 0%): increased
12–44 y 14–39 y bonding, (T1) immediately at T2 (12%)
(23.8 6 9.1 y) after initial arch, (T2) 1 mo 2. Response at T1 and T2
No treatment after. In control group, (T0/ was higher in the
baseline), (T1) 5 min after orthodontic (40.83 u,
T0, (T2) 1 mo after T1. 38.08 u) than the control
group (23.49 u, 22.72 u);
(continued on next page )
 TABLE 1 - Continued
JOE
Volume 48, Number 3, March 2022

Test group
(n) patients, teeth Force type
age range value (g)
Authors (year), country (age mean ± SD) Control group Evaluated teeth Duration Assessment method Main results
P , .05
3. In the orthodontic group
(baseline 28.48 u),
response increased at T1
(40.83 u), decreasing at
T2 (38.08 u); P , .05
Leavitt et al (2002)28, USA n 5 9 patients, n 5 9 patients, Maxillary central incisors COT EPT 1. No significant differences
17 teeth 18 teeth 5 wk Times: (T0/baseline) after in the response were
13.3–33.8 y 14–37.8 y bracket placement, (T1) 1 observed between groups
(20.6 y) (20.5 y) h after initial arch, (T2) 1 and times; P . .05
No treatment d after T1, (T3) 1 wk after
T1, (T4) 1 mo after T1
Monardes Cort
es n 5 37 patients, No group Maxillary and mandibular Rotation (5.8–164.1 g) TPT 1. No significant differences
et al29(2018), Chile 136 teeth incisors and canines or sagittal movement Times: (T0/baseline) before in the response were
11.2–13.4 y (5.1–144.3 g) force, (T1) after 7 d observed between forces;
(12.6 y) 7d Force magnitude was P . .05
measured: extreme: 2. Maxillary central incisors
.100 g (n 5 98), high: 76– showed an increase
100 g (n 5 13), optimal: (38.1%) of response at T1
26–75 g (n 5 23), mild: 0– compared to the baseline;
25 g (n 5 2) P , .05
3. Sagittal movement
promoted greater
sensitivity (34% increased
of response) than the
rotation movement (11%
increased of response);
P , .05
Orthodontic Force and Dental Pulp Changes

Veberiene et al (2009)21, n 5 21 patients, Contralateral teeth Maxillary and mandibular Intrusion EPT 1. Response at T1 was
Lithuania 21 teeth No treatment premolars 61 g Time: (T0/baseline) before higher in the orthodontic
11–21 y 7d treatment, (T1) after (29.65 6 17.92 mA) than
(15.5 6 0.5 y) treatment the control group
(7.76 6 6.48 mA); P , .01
Veberiene et al (2010)22, n 5 13 patients, No group Maxillary premolars Intrusion EPT 1. No significant differences
Lithuania 13 teeth 82–97 g Time: (T1) 7 d after, (T2) 14 in the response were
14–22 y 7–14 d d after observed between times;
(16.5 6 2.7 y) P . .05
Outcome: pulpal blood flow
Barwick & n 5 8 patients, No group Maxillary central incisors Intrusion LDF 1. No significant differences
Ramsay(1996)31, 8 teeth 76–4400 g Times: (T0/baseline) 4 min in PBF between times;
Australia (38.4 6 9 y) 4 min before force, (T1) during P . .05
4 min of force, (T2) 12 min
303

after force
(continued on next page )
 TABLE 1 - Continued
304
Vitali et al.

Test group
(n) patients, teeth Force type
age range value (g)
Authors (year), country (age mean ± SD) Control group Evaluated teeth Duration Assessment method Main results
9
Brodin et al (1996) , n 5 6 patients, Contralateral teeth Maxillary lateral incisors Intrusion and extrusion LDF 1. No significant differences
Germany 10 teeth No treatment 204 g Times: (T0/baseline) before in PBF between times for
5 min forces, (T1) immediately extrusion force; P . .05
after forces 2. PBF reduction (80%) at T1
compared to the baseline
for intrusion force; P , .05
Ikawa et al (2001)10, n 5 17 patients, No group Maxillary central incisors Intrusion LDF 1. PBF reduction with the
Japan 17 teeth 51–510 g Times: (T0/baseline) before increase of force, baseline:
14–29 y intrusion, and after 11.23 6 5.62 PU, 51 g:
different forces: 51 g, 102 10.13 6 5.11 PU, 102 g:
g, 510 g (1-min intervals 9.92 6 4.83 PU, and 510
between applications) g: 9.71 6 5.17 PU;
P , .05
McDonald & Pitt Ford n 5 10 patients, Contralateral teeth Maxillary canines Canine retraction 50 g LDF 1. PBF reduction (baseline
(1994)11, England 10 teeth No treatment 2–5 wk Times: (T0/baseline) before 13.54 PU) at T1 (11 PU)
11.2–13.4 y retraction, (T1) 10 min and T2 (10.94 PU),
(12.6 y) after, (T2) 30 min, (T3) followed increase at T4
60 min, (T4) 24 h, (T5) 48 (15.43 PU) and T5 (15.75).
h, (T6) 72 h Returned to baseline value
at T6 (13.28); P , .05
Sabuncuoglu & Ersahan n 5 20 patients, Contralateral teeth Maxillary lateral and central Intrusion LDF 1. PBF reduction (baseline
(2014)12, Turkey 40 teeth No treatment incisors 40 g and 120 g Times: (T0/baseline) before 11.36 6 0.92 PU) at T1
18–25y 3 d to 3 wk intrusion, (T1) after 3 d, (7.72 6 0.50 PU), followed
(20.3 y) (T2) after 3 wk increase at T2
(10.37 6 0.58 PU) for 40-
g force group; P , .01
2. PBF reduction (baseline
11.47 6 0.89 PU) at T1
(7.72 6 0.52 PU), followed
increase at T2
(10.31 6 0.45 PU) for
JOE
Volume 48, Number 3, March 2022

120-g force group;

P , .01
3. No significant differences
in PBF between forces;
P . .05
Sabuncuoglu & Ersahan n 5 10 patients, n 5 6 patients, Maxillary molars Intrusion LDF 1. PBF reduction (baseline
(2014)32, Turkey 20 teeth 12 teeth 100 g Times: (T0/baseline) before 8.7 6 0.9 PU) at T1
18–25 y No treatment 6 mo intrusion, (T1) after 3 d, (6.1 6 0.6 PU) and T2
(21.7 y) (T2) 3 wk, (T3) 3 mo, (T4) 6 (6.0 6 0.6 PU). Returned
mo to baseline value at T3
(8.7 6 1.0 PU) and T4
(8.7 6 0.4 PU); P , .01
(continued on next page )
 TABLE 1 - Continued
JOE
Volume 48, Number 3, March 2022

Test group
(n) patients, teeth Force type
age range value (g)
Authors (year), country (age mean ± SD) Control group Evaluated teeth Duration Assessment method Main results
Sano et al (2002)33, Japan n 5 8 patients n 5 5 patients Maxillary central incisors Intrusion LDF 1. PBF reduction (baseline
27–31y 27–31 y 51 g Times: (T0/baseline) before 95.19 6 9.84 PU) at T1
No treatment 1–6 d intrusion, (T1) 1 d, (T2) 2 d, (74.68 6 19.09 PU), T2
(T3) 3 d, and (T4) 6 (70.98 6 16.23 PU), T3
d during force; (T5) 1 d, (68.08 6 20.58 PU), and
(T6) 3 d, and (T7) 5 d after T4 (67.29 6 23.37 PU).
force Returned to baseline value
at T5 (103.35 6 17.69
PU), T6 (107.11 6 15.10
PU), and T7
(103.56 6 21.31 PU).
P , .05
Outcome: internal dimensions of the pulp cavity
Abdel-Kader & Ammar n 5 5 patients, No group Maxillary canines Canine retraction CBCT 1. No significant differences
(2015)39, Egypt 10 teeth 150 g Times: (T1) before and (T2) in the internal vertical
14–18y 186 6 1.16 mo after retraction length of pulp chamber
(15.82 6 1.74 y) Evaluated changes: pulp between times (vertical
chamber dimensions and coronal); P . .05
Baratieri et al (2013)40, n 5 15 patients, n 5 15 patients, Maxillary central incisors and RME CBCT 1. No significant differences
Brazil 120 teeth 120 teeth first molars Times: (T1) before and (T2) 1 in molars between times;
7.8–11.6 y 7.6–11.4 y y after RME P . .05
(9.6 y) (9.4 y) Evaluated changes: pulp 2. In incisors, it reduced in
No treatment chamber dimensions the axial slices as it neared
the cementoenamel
junction (20.32, 20.36,
and 20.43 mm2), and on
the middle of the crown
Orthodontic Force and Dental Pulp Changes

(sagittal slice), there was

an increased (0.48 mm2);
P , .05
Popp et al (1992)37, USA n 5 75 patients n 5 53 patients Maxillary incisors and COT Periapical radiographs 1. Increased frequency of
9–17 y 10–14 y mandibular central Times: (T1) before treatment, pulp canal narrowing was
(12.81 6 2.06 y) (12.62 6 0.79 y) incisors (T2) after treatment, and observed at TI to T2
No treatment (T3) 5-year follow-up (79.06% of teeth) and at
Evaluated changes: pulp T2 to T3 (99.5% of teeth).
canal narrowing 2. Statistical difference in
pulp canal narrowing
frequency between
orthodontic (86.7%) and
control (66%) group only
in the right lateral incisor at
T1 to T2; P , .05
305

(continued on next page )

 TABLE 1 - Continued
306
Vitali et al.

Test group
(n) patients, teeth Force type
age range value (g)
Authors (year), country (age mean ± SD) Control group Evaluated teeth Duration Assessment method Main results
Venkatesh et al (2014) , 41
n 5 48 patients, n 5 39 patients Maxillary incisors and COT CBCT 1. Reduction of pulp cavity
India 288 teeth (234 teeth) canines 17–18 mo Times: (T0) before treatment volume for all anterior
(18.1 y) (17.5 y) and (T1) and after teeth between times; P ,
No treatment completion of space .05
closure 2. The highest volume
Evaluated changes: pulp reduction recorded was
cavity volume for the left lateral incisor
(3.86 mm3) and the least
for the right central incisor
(3.04 mm3).
Outcome: pulp stone formation
Delivanis & Sauer n 5 46 patients n 5 46 patients All teeth COT Periapical radiographs 1. No significant differences
(1982)38, USA 13–33 y 13–33y 8 mo to 4 y 7 mo Times: (T1) before and (T2) between orthodontic and
No treatment immediately after control group; P 5 .2
treatment 2. In orthodontic group,
Evaluated changes: canal complete and partial
calcification calcification was observed
in 2 (9.1%) maxillary lateral
incisors
Ertas et al (2017)34, n 5 545 patients, No group Maxillary and mandibular COT Panoramic radiographs 1. Pulp stone numbers
Turkey 16,852 teeth premolars and molars 16.48 mo (62.16 mo) Times: (T1) before and (T2) increased (2.2%) between
12–22 y immediately after times; P , .05
treatment
Evaluated changes: pulp
stone formation
Jena et al (2018)35, India n 5 200 patients, No group Maxillary and mandibular COT Panoramic radiographs 1. Pulp stone numbers
3200 teeth molars and premolars 15.23 mo (61.4 mo) Times: (T1) before and (T2) increased (4%) between
14–26 y immediately after times; P , .05
treatment
Korkmaz et al (2019)36, n 5 504 patients No group All teeth COT Panoramic radiographs 1. Pulp stone numbers
Turkey 12–32 y 24.5 mo (63.1 mo) Times: (T1) before and (T2) increased (6.5%) between
JOE
Volume 48, Number 3, March 2022

(18.7 6 2.9 y) immediately after times; P , .05

treatment
Popp et al (1992)37, USA n 5 75 patients n 5 53 patients Maxillary incisors and COT Periapical radiographs 1. Pulp stone numbers
9–17 y 10–14 y mandibular central Times: (T1) before treatment, increased at T1 to T2
(12.81 6 2.06 y) (12.62 6 0.79 y) incisors (T2) after treatment and (1.56%) and at T2 to T3
No treatment (T3) 5-year follow-up (0.9%).

CBCT, cone-beam computed tomography; COT, conventional orthodontic treatment; EPT, electric pulp test; LDF, laser Doppler flowmetry; PBF, pulpal blood flow; PU, perfusion units; RME, rapid maxillary expansion; SD, standard deviation; T, time;
TPT, thermal pulp test; u, EPT units.
FIGURE 2 – Risk of bias (RoB) assessment for case-control and cohort studies by the Newcastle-Ottawa Scale: a maximum of 4 points for selection, 2 points for comparability, and 3
points for exposure or outcome. Risk of bias for randomized clinical trials by Cochrane tool: (Q1) bias arising from the randomization process, (Q2) bias due to deviations from intended
interventions, (Q3) bias due to missing outcome data, (Q4) bias in measurement of the outcome, (Q5) bias in selection of the reported result, and (Q6) overall bias. Authors’ judgment:
low risk of bias or some concerns (SC).

pulp tissue changes due to orthodontic force have influenced the pulpal sensibility response in groups in which the orthodontic force was
using noninvasive methods. in addition to the orthodontic force, such as applied, there was an increase in the pulpal
Monitoring pulpal sensibility is essential sample age, evaluated tooth, conditions under sensibility response concerning baseline
during orthodontic treatment and may be which the study was performed, the number of values immediately after force application;
performed by several methods, such as laser repetitions of the measurement, and factors however, over time, these values tended
Doppler flowmetry and electric/thermal tests44. related to the patients themselves such as the toward baseline24,25,27. Therefore, the
To assess pulpal sensibility’s response, the concept that people have different pain or application of orthodontic force appeared to
electric test has high accuracy when testing prepain limits45. However, significant have a significant effect on pulpal neural
vital teeth, whereas thermal tests have differences among the measurements responsiveness, however, only immediately
moderate accuracy44. Of the included studies, obtained between the control and orthodontic with progressive normalization.
5 used only electric testing20–22,27,28, 4 used groups were observed and clouded the The increased pulpal sensibility
electric followed by thermal testing24–26,30, and certainty of the possible dental pulp changes response may result from the pressure or
2 only thermal testing23,29. Several factors may due to orthodontic force22,24,25,27. In addition, tension of the apical nerve fibers of the teeth

JOE
Volume 48, Number 3, March 2022 Orthodontic Force and Dental Pulp Changes 307
TABLE 2 - Grading of Recommendations, Assessment, Development and Evaluations (GRADE) Assessment

Quality assessment
Outcomes Studies (n) Risk of bias Inconsistency Indirectness Imprecision GRADE quality
Pulpal sensibility response 10 observational studies Serious* Very serious† Not serious Serious‡ 4BBB Very low
1 randomized trial Serious§ Not serious Not serious Serious‡ 4BBB Very low
Pulpal blood flow 6 observational studies Very seriousk Very serious† Not serious Serious‡ 4BBB Very low
1 randomized trial Serious§ Not serious Not serious Serious‡ 4BBB Very low
Internal dimensions 4 observational studies Serious¶ Very serious† Not serious Serious‡ 4BBB Very low
of the pulp cavity
Pulp stone formation 5 observational studies Serious# Very serious† Not serious Serious‡ 4BBB Very low

*Five studies were classified as moderate risk of bias.

†
The methodological heterogeneity between the included studies was considerably high.
‡
Absence or extended confidence interval.
§
The risk of bias was classified as “some concerns.”
k
Four studies were classified as moderate risk of bias, and 2 were classified as high risk of bias.
¶
Three studies were classified as moderate risk of bias.
#
All studies were classified as moderate risk of bias.

being orthodontically moved24. Another factor application of intrusion force, there was an maxillary expansion and fixed orthodontic
that may be related is the decrease in blood initial pulpal blood flow decrease, which may treatment. In rapid maxillary expansion,
flow to the dental pulp, mainly when the be the result of a significant compression of despite high forces being applied to the
intrusion force was applied10,32,33. Previous blood vessels caused by the apical anchorage teeth during the active phase of
studies suggested that orthodontic force has displacement of the tooth12,32,33. However, midpalatal suture expansion, minimal changes
an immediate effect on the blood supply of this was eventually followed by a gradual were observed in the internal dimensions of the
the pulp tissue, which can trigger recovery pattern over time, which varied incisors without changes in the molars40. The
hypoxia10–12,32,33. Hypoxia raises pulp between studies12,32,33. sample’s age seems to be a factor influencing
A-fibers’ response threshold, located Several factors may have influenced the results (mean age 5 9.6 years). In younger
peripherally in the pulp, whereas C-fibers are pulpal blood flow changes, such as force patients, the pulp cavity is wider and rich in
less affected20,22. Regarding the number of values, the time elapsed from the force applied blood vessels, which allows it to recover more
negative responses to pulp tests, there was an to the evaluation, and the sample’s quickly from injuries50. For fixed orthodontic
increase in the groups in which the orthodontic characteristics because the pulpal blood flow treatment, a reduction in pulp cavity volume for
force was applied. Still, it started to respond tends to decrease with the patient’s age47. anterior teeth was observed37,41. However, the
positively over time. Therefore, all teeth Histologic evaluation showed that not only did decrease in pulp cavity volume observed in
responded positively in most of the included the number of blood vessels decrease with these studies can result from the physiological
studies23–27. The number of negative age, but also the pulp area decreased due to process of deposition of secondary dentin
responses was only higher in a group in which increased calcified tissues14,47. Pulpal blood related to age because the follow-up period
canine traction was performed. However, flow rates also appear to have been affected varied from 17–60 months after treatment37,41.
there was no follow-up in this study; only a by the evaluated dental group. When the Based on the results of the included studies, it
thermal test was performed after the end of the intrusion force was applied to incisors and can be seen that the orthodontic force
traction23. This denotes that, although the premolars, the return to baseline values of promoted changes in the internal dimensions
pulpal sensibility increased, it was normally not blood flow occurred in 72 hours to 3 of the pulp cavity, and this may be indicative of
enough to trigger the loss of pulp vitality. In weeks11,12,33, whereas in molars it occurred some damage to the pulp tissue. However,
which patients this is likely to trigger this cutoff only after 3 months32. Molars have smaller these changes were considered mild, which
value is unknown at this time. Hopefully, in the apical foramen than incisors, canines, and suggests the pulp tissue’s ability to adapt to
future, we will be able to cluster this specific premolars; this smaller apical diameter may be the applied orthodontic force.
subgroup. Also, this is a rather infrequent responsible for a more significant restriction of The etiologic factors for the formation of
occurrence. blood flow in these teeth48,49. pulp calcifications are not fully understood51.
Laser Doppler flowmetry has high When the applied orthodontic force Factors such as sex, age, systemic diseases,
accuracy in detecting vital teeth and performs affects pulp tissue, it may concentrate chronic irritations, and degenerative lesions of
better than electric and thermal tests44,46. inflammatory mediators, stimulating resorptive the pulp are possible factors that can influence
Laser Doppler flowmetry was used to assess or reparative responses to odontoblasts and pulp stone development51. The included
pulpal blood flow in all included studies. The odontoblastlike cells and leading to resorption studies showed an increase in pulp stone
intrusion force was the most evaluated among processes or deposition of tertiary dentin7,8. formation from 1.56%–6.5% after fixed
the studies because, among the force vectors Such events can promote changes in the pulp orthodontic treatment34–37. However, all of
that can be applied to teeth during orthodontic cavity’s internal dimensions, which can be these studies were retrospective (ie, other
treatment, the intrusion is considered the detected by the clinician, who needs to have factors may have influenced the formation of
movement that promotes a more significant imaging tests for the diagnosis and monitoring pulp stones, such as the age of the patients,
impact on the apical region because it can of the patient during orthodontic treatment7,8. the occurrence of trauma, other dental
cause compression of apical blood Among the 4 studies included, changes in interventions, and the presence of bruxism,
vessels10,12,32,33. It was observed that in the internal dimensions were observed after rapid besides being subjected to the difference of

308 Vitali et al. JOE
Volume 48, Number 3, March 2022

interpretation by the evaluators)52. Also, all studies or the lack of presentation of these erroneous conclusions from being drawn and
assessments were performed using data. The studies assessing pulpal sensibility prevents the systematic review from pointing
radiographs, which provides less diagnostic clinical response, pulpal blood flow, and the to conclusions that are not well supported by
accuracy due to the possibility of distortions52. pulp cavity’s internal dimensions showed the literature in the area, which can harm the
However, based on the results of the included moderate heterogeneity, so the inconsistency clinician in making decisions.
studies, there is a possibility that orthodontic domain was classified as very serious. The main objective of this systematic
force accelerates pulp tissue calcification Regarding the studies that evaluated the review was to assess whether teeth moved
metabolism, which may increase the incidence formation of pulp stones, because they are orthodontically had pulp changes that could be
of pulp stone formation in teeth submitted to retrospective, the level of evidence generated clinically identified in order to contribute to the
orthodontic movement. Nevertheless, the was very low because other factors may be diagnosis of dental pulp status during
increase in frequency is relatively small and not involved in this outcome, in addition to the low orthodontic movement and to generate
likely of clinical importance. accuracy of the method of evaluating the parameters that could be analyzed clinically.
The selected studies were analyzed results. The identified evidence was considered to be
critically, and the risk of bias was determined The present systematic review has very low because most studies corresponded
with the aid of the Newcastle-Ottawa Scale for limitations that need to be discussed. The to nonrandomized and retrospective clinical
observational studies and the Cochrane tool methodological heterogeneity of the included studies. Based on the very low strength of
for randomized clinical trials. The risk of bias studies due to the lack of standardization of the evidence of the articles’ included outcomes, it
was considered moderate, and in no case did orthodontic force applied and the assessment is not possible to infer that regularly used
the study’s quality checklists meet all the method of the results and the limited number orthodontic force was able to promote
parameters evaluated. Most observational of studies made it difficult to compare the meaningful dental pulp changes. Nevertheless,
studies showed moderate risk of bias, mainly results. Therefore, a combined quantitative the included studies seem to suggest that
because of bias in the selection of the size synthesis was not considered adequate53. orthodontic force application could promote, in
and characteristics of the sample and Many included studies had small sample sizes an unidentified cluster of patients, an increase
heterogeneity between the exposed and and samples with heterogeneous in pulpal sensibility clinical response, an
nonexposed subjects. Several studies also characteristics; therefore, the results may have immediate decrease in pulpal blood flow,
failed to collect baseline information less statistical power and should be changes in pulp cavity volume, and an increase
concerning the pulpal sensibility response and interpreted with caution by the clinician. In in the incidence of pulp stone formation. Future
blood flow, thus failing to demonstrate that the addition, most of the included studies were research that investigates the effects of
outcome of interest was not present at the observational. In this study design, the orthodontic force on pulp tissue requires
start of the study. The method of assessment presence of confounding factors may have randomized clinical trials with larger samples
outcomes, the insufficient follow-up time for influenced the results. Such factors and appropriate length of follow-up and
the results to occur, and the follow-up time contributed negatively to the very low power of standardized evaluation methods to obtain
also contributed to the increase in the risk of evidence obtained from the primary studies. results with greater power of scientific
bias. For randomized clinical trials, the bias in Although limited by the very low quality evidence.
measuring and interpreting the outcome raises of the included studies, this review has
some concerns. This is explained by the fact important points to highlight. The wide data
that clinical trials collected the data in only 1 collection approach through multiple
CONCLUSIONS
moment without follow-up measurements. databases, including the gray literature, Within the limitations of this systematic review,
Some data collected are subjective, such as allowed the inclusion of a large number of it was possible to conclude that orthodontically
pulpal sensibility, so the patients’ perception articles related to the review topic. The moved teeth may present an immediate
can change the results if the tests were inclusion of studies of all languages and the reduction in pulpal blood flow, an increased
repeated. use of no filter also reinforce the search pulpal sensibility response to pulp tests, an
The quality of the evidence was process. These characteristics allow for a wide increased incidence of pulp stones, and
assessed using the GRADE tool and scope in the selection of articles, which changes in the pulp cavity dimensions. These
demonstrated very low strength overall increases the possibility of performing results suggest that the clinician has effective
performance after individual assessment of qualitative analysis of the data available in the noninvasive methods to assess health and
parameters. In the risk of bias domain, the literature. With the synthesis of the available possible pulp changes during orthodontic
reason for the downgrading of evidence was evidence, a baseline for future studies that can treatment.
due to the high number of moderate risk of benefit from the critical analysis of published
bias for observational studies and some data is established. Another advantage of this
concerns for randomized clinical trials. The review is the robust risk of bias assessment of
ACKNOWLEDGMENTS
imprecision of the results is mainly due to the the included studies by 3 reviewers The authors deny any conflicts of interest
broader confidence interval presented by the independently. This critical analysis prevents related to this study.

REFERENCES
1. Cattaneo PM, Dalstra M, Melsen B. Strains in periodontal ligament and alveolar bone associated
with orthodontic tooth movement analyzed by finite element. Orthod Craniofac Res
2009;12:120–8.

2. Henneman S, Von den Hoff JW, Maltha JC. Mechanobiology of tooth movement. Eur J Orthod
2008;30:299–306.

JOE
Volume 48, Number 3, March 2022 Orthodontic Force and Dental Pulp Changes 309
 3. Krishnan V, Davidovitch Z. Cellular, molecular, and tissue-level reactions to orthodontic force. Am
J Orthod Dentofacial Orthop 2006;129:e1–32.

4. Meikle MC. The tissue, cellular, and molecular regulation of orthodontic tooth movement: 100
years after Carl Sandstedt. Eur J Orthod 2006;28:221–40.
5. Alghaithy RA, Qualtrough AJ. Pulp sensibility and vitality tests for diagnosing pulpal health in
permanent teeth: a critical review. Int Endod J 2017;50:135–42.
6. Ghouth N, Duggal MS, BaniHani A, Nazzal H. The diagnostic accuracy of laser Doppler flowmetry
in assessing pulp blood flow in permanent teeth: a systematic review. Dent Traumatol
2018;34:311–9.

7. Inoue T, Shimono M. Repair dentinogenesis following transplantation into normal and germ-free
animals. Proc Finn Dent Soc 1992;88:183–94.

8. Patel S, Ricucci D, Durak C, Tay F. Internal root resorption: a review. J Endod 2010;36:1107–21.
9. Brodin P, Linge L, Aars H. Instant assessment of pulpal blood flow after orthodontic force
application. J Orofac Orthop 1996;57:306–9.

10. Ikawa M, Fujiwara M, Horiuchi H, Shimauchi H. The effect of short-term tooth intrusion on human
pulpal blood flow measured by laser Doppler flowmetry. Arch Oral Biol 2001;46:781–7.
11. McDonald F, Pitt Ford TR. Blood flow changes in permanent maxillary canines during retraction.
Eur J Orthod 1994;16:1–9.
12. Sabuncuoglu FA, Ersahan S. Changes in maxillary incisor dental pulp blood flow during intrusion
by mini-implants. Acta Odontol Scand 2014;72:489–96.

13. Weissheimer T, Silva E, Pinto KP, et al. Do orthodontic tooth movements induce pulp necrosis? A
systematic review. Int Endod J 2021;54:1246–62.
14. Vitali FC, Cardoso IV, Mello FW, et al. Effect of orthodontic force on dental pulp histomorphology
and tissue factor expression: a systematic review. Angle Orthod 2021;91:830–42.
15. Moher D, Shamseer L, Clarke M, et al. Preferred reporting items for systematic review and meta-
analysis protocols (PRISMA-P) 2015 statement. Syst Rev 2015;4:1.

16. Shamseer L, Moher D, Clarke M, et al. Preferred reporting items for systematic review and meta-
analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ 2015;350:g7647.

17. Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of
nonrandomized studies in meta-analyses. Eur J Epidemiol 2010;25:603–5.
18. Lo CK, Mertz D, Loeb M. Newcastle-Ottawa Scale: comparing reviewers’ to authors’
assessments. BMC Med Res Methodol 2014;14:45.

19. Sterne JA, Savovic
J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in
randomised trials. BMJ 2019;366:l4898.

20. Han G, Hu M, Zhang Y, Jiang H. Pulp vitality and histologic changes in human dental pulp after
the application of moderate and severe intrusive orthodontic forces. Am J Orthod Dentofacial
Orthop 2013;144:518–22.
21. Veberiene R, Smailiene D, Baseviciene N, et al. Change in dental pulp parameters in response to
different modes of orthodontic force application. Angle Orthod 2010;80:1018–22.
22. Veberiene R, Smailiene D, Danielyte J, et al. Effects of intrusive force on selected determinants of
pulp vitality. Angle Orthod 2009;79:1114–8.

23. Ferreira L, Macluf Filho E, Rodrigues CL, et al. Lack of pulp sensitivity in maxillary canines
submitted to orthodontic traction: a retrospective clinical study. RSBO 2013;10:29–33.

24. Alomari FA, Al-Habahbeh R, Alsakarna BK. Responses of pulp sensibility tests during
orthodontic treatment and retention. Int Endod J 2011;44:635–43.
25. Cave SG, Freer TJ, Podlich HM. Pulp-test responses in orthodontic patients. Aust Orthod J
2002;18:27–34.

26. Hall CJ, Freer TJ. The effects of early orthodontic force application on pulp test responses. Aust
Orthod J 1998;43:359–61.

27. Khoshbin E, Soheilifar S, Donyavi Z, Shahsavand N. Evaluation of sensibility threshold of dental

pulp to electric pulp test (EPT) in the teeth under fixed orthodontic treatment with 0.014 and
0.012 initial NiTi archwire. J Clin Diagn Res 2019;13:ZC16–9.
28. Leavitt AH, King GJ, Ramsay DS, Jackson DL. A longitudinal evaluation of pulpal pain during
orthodontic tooth movement. Orthod Craniofac Res 2002;5:29–37.

310 Vitali et al. JOE
Volume 48, Number 3, March 2022

 29. Monardes Cort

n
es H, Zu ~iga Caballero A, Bravo Mun
~oz C, et al. Reaccio

n pulpar frente a fuerzas

nticas: evaluacio
ortodo
n de la primera semana de tratamiento. Av Odontoestomatol
2018;34:237–44.

30. Cho JJ, Efstratiadis S, Hasselgren G. Pulp vitality after rapid palatal expansion. Am J Orthod
Dentofacial Orthop 2010;137:254–8.

31. Barwick PJ, Ramsay DS. Effect of brief intrusive force on human pulpal blood flow. Am J Orthod
Dentofacial Orthop 1996;110:273–9.
32. Sabuncuoglu FA, Ersahan S. Changes in maxillary molar pulp blood flow during orthodontic
intrusion. Aust Orthod J 2014;30:152–60.

33. Sano Y, Ikawa M, Sugawara J, et al. The effect of continuous intrusive force on human pulpal
blood flow. Eur J Orthod 2002;24:159–66.

34. Ertas ET, Veli I, Akin M, et al. Dental pulp stone formation during orthodontic treatment: a
retrospective clinical follow-up study. Niger J Clin Pract 2017;20:37–42.
35. Jena D, Balakrishna K, Singh S, et al. A retrospective analysis of pulp stones in patients following
orthodontic treatment. J Contemp Dent Pract 2018;19:1095–9.

36. Korkmaz YN, Aydin ZU, Sarioglu B. Orthodontic treatment and pulp stone formation: is there a
relationship? Clin Exp Health Sci 2019;9:340–4.

37. Popp TW, Artun J, Linge L. Pulpal response to orthodontic tooth movement in adolescents: a
radiographic study. Am J Orthod Dentofacial Orthop 1992;101:228–33.
38. Delivanis HP, Sauer GJ. Incidence of canal calcification in the orthodontic patient. Am J Orthod
Dentofacial Orthop 1982;82:58–61.

39. Abdel-Kader HM, Ammar AS. Maxillary canine internal root resorption concomitant to orthodontic
retraction: cone beam evaluation. Biomed J 2018;2:6.

40. Baratieri C, Alves M Jr, Mattos CT, et al. Changes of pulp-chamber dimensions 1 year after rapid
maxillary expansion. Am J Orthod Dentofacial Orthop 2013;143:471–8.
41. Venkatesh S, Ajmera S, Ganeshkar SV. Volumetric pulp changes after orthodontic treatment
determined by cone-beam computed tomography. J Endod 2014;40:1758–63.
42. Chmura Kraemer H, Periyakoil VS, Noda A. Kappa coefficients in medical research. Stat Med
2002;21:2109–29.

43. Schu€nemann HB, Guyatt G, Oxman A. GRADE handbook for grading quality of evidence and
strength of recommendations. The GRADE Working Group; 2013.
44. Mainkar A, Kim SG. Diagnostic accuracy of 5 dental pulp tests: a systematic review and meta-
analysis. J Endod 2018;44:694–702.
45. Bender IB, Landau MA, Fonsecca S, Trowbridge HO. The optimum placement-site of the
electrode in electric pulp testing of the 12 anterior teeth. J Am Dent Assoc 1989;118:305–10.

46. Brignardello-Petersen R. Laser Doppler flowmetry and pulse oximetry seem to have high
accuracy in detecting vital and nonvital teeth and perform better than cold, heat, and electric pulp
testing. J Am Dent Assoc 2018;149:e152.

47. Morse DR. Age-related changes of the dental pulp complex and their relationship to systemic
aging. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1991;72:721–45.
48. Ponce EH, Vilar Ferna
ndez JA. The cemento-dentino-canal junction, the apical foramen, and the
apical constriction: evaluation by optical microscopy. J Endod 2003;29:214–9.
49. Marroquín BB, El-Sayed MA, Willershausen-Zo €nnchen B. Morphology of the physiological
foramen: I. Maxillary and mandibular molars. J Endod 2004;30:321–8.

50. Ricucci D, Loghin S, Siqueira JF Jr. Correlation between clinical and histologic pulp diagnoses. J
Endod 2014;40:1932–9.
51. Sener S, Cobankara FK, Akgu €nlu
€ F. Calcifications of the pulp chamber: prevalence and implicated
factors. Clin Oral Investig 2009;13:209–15.
52. da Silva E, Prado MC, Queiroz PM, et al. Assessing pulp stones by cone-beam computed
tomography. Clin Oral Investig 2017;21:2327–33.

53. Ioannidis JP, Patsopoulos NA, Rothstein HR. Reasons or excuses for avoiding meta-analysis in
forest plots. BMJ 2008;336:1413–5.

JOE
Volume 48, Number 3, March 2022 Orthodontic Force and Dental Pulp Changes 311