Open Apex Management in Traumatized Teeth: Latest Evidence-Based Recommendations

Dental trauma frequently affects immature permanent teeth, particularly in children and adolescents. When trauma occurs before complete root development, it often results in teeth with open apices, posing significant clinical challenges.

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Open apex management in traumatized teeth aims to control infection, preserve tooth structure, and promote continued root development or apical closure using evidence-based techniques.

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✅ Understanding Open Apex in Traumatized Teeth
An open apex is characterized by:

▪️ Incomplete root formation
▪️ Thin dentinal walls
▪️ Wide apical foramen

Traumatic injuries such as luxation, avulsion, or complicated crown fractures may compromise pulpal vitality, interrupting root development and increasing the risk of infection and fracture.
Early and accurate diagnosis is critical to determine prognosis and select the most appropriate therapeutic approach.

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✅ Diagnostic Considerations
Key diagnostic factors include:

▪️ Type and severity of trauma
▪️ Pulp vitality status
▪️ Stage of root development
▪️ Presence of infection or apical pathology

Radiographic evaluation (periapical radiographs or CBCT when indicated) is essential to assess root length, apical diameter, and periapical status.

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✅ Evidence-Based Treatment Options

➤ Apexification
Apexification is indicated for non-vital immature teeth and aims to create an apical barrier to allow obturation.
Calcium hydroxide (traditional method)
Mineral trioxide aggregate (MTA) or bioceramic materials (modern approach)
Bioceramic apexification has largely replaced long-term calcium hydroxide due to improved outcomes and reduced treatment time.

➤ Regenerative Endodontic Procedures (REPs)
Regenerative endodontics is currently the preferred approach for many immature teeth with necrotic pulps. Benefits include:
▪️ Continued root maturation
▪️ Increased dentinal wall thickness
▪️ Improved fracture resistance
This approach is supported by AAPD and IADT guidelines, particularly in young patients.

➤ Vital Pulp Therapy in Traumatized Teeth
In cases of reversible pulp damage, procedures such as:
▪️ Partial pulpotomy (Cvek pulpotomy)
▪️ Direct pulp capping
may allow continued root development (apexogenesis) when performed promptly.

📊 Comparative Table: Evidence-Based Management Options for Open Apex Teeth

Aspect	Advantages	Limitations
Calcium Hydroxide Apexification	Long history of use, induces apical hard tissue barrier	Long treatment time, increased fracture risk, multiple visits
MTA / Bioceramic Apexification	Shorter treatment time, predictable apical seal, biocompatible	No continued root development, higher material cost
Regenerative Endodontic Procedures	Promotes root maturation and dentinal thickening	Technique-sensitive, variable outcomes
Vital Pulp Therapy	Preserves pulp vitality and allows apexogenesis	Limited to cases with minimal pulpal inflammation

💬 Discussion
Recent evidence supports a paradigm shift toward biologically based therapies, particularly regenerative endodontics, for immature teeth with necrotic pulps. While apexification remains a valid option, it does not promote continued root development, which is critical for long-term tooth survival.
Case selection, patient compliance, and clinician expertise remain decisive factors in treatment success.

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🎯 Clinical Recommendations
▪️ Prioritize pulp vitality preservation whenever possible
▪️ Consider regenerative endodontic procedures as first-line therapy for necrotic immature teeth
▪️ Use bioceramic materials for apexification when regeneration is not feasible
▪️ Ensure long-term follow-up to monitor root development and periapical healing
▪️ Follow IADT and AAPD trauma guidelines strictly

✍️ Conclusion
Management of traumatized teeth with open apices requires an evidence-based, individualized approach. Advances in regenerative endodontics and bioceramic materials have significantly improved clinical outcomes. Early intervention, accurate diagnosis, and adherence to current guidelines are essential to ensure functional and long-lasting results.

📚 References

✔ American Academy of Pediatric Dentistry. (2023). Pulp therapy for primary and immature permanent teeth. The Reference Manual of Pediatric Dentistry.
✔ Diogenes, A., Henry, M. A., Teixeira, F. B., & Hargreaves, K. M. (2013). An update on clinical regenerative endodontics. Endodontic Topics, 28(1), 2–23.
✔ Fouad, A. F., Abbott, P. V., Tsilingaridis, G., et al. (2020). International Association of Dental Traumatology guidelines for the management of traumatic dental injuries. Dental Traumatology, 36(4), 314–330.
✔ Torabinejad, M., & Parirokh, M. (2010). Mineral trioxide aggregate: A comprehensive literature review. Journal of Endodontics, 36(1), 16–27.
✔ American Association of Endodontists. (2021). Clinical considerations for regenerative procedures.

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Pediatric Dental Trauma Management: Key IADT 2024–2025 Guideline Updates

Pediatric dental trauma remains one of the most common emergencies in childhood, requiring fast, evidence-based intervention.

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The IADT 2024–2025 guidelines provide updated recommendations on the diagnosis, management, and follow-up of injuries to both primary and permanent teeth in children. Understanding these updates is essential for preventing long-term complications such as pulp necrosis, enamel defects, and growth disturbances.

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1. Classification of Pediatric Dental Trauma
The IADT organizes trauma injuries into:

▪️ Enamel and enamel-dentin fractures
▪️ Crown-root fractures
▪️ Root fractures
▪️ Concussion, subluxation, luxation injuries
▪️ Intrusion, extrusion, avulsion
▪️ Alveolar fractures
Each injury requires a customized approach, especially in young patients whose teeth and bone structures are still developing.

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2. Updates in Diagnosis (IADT 2024–2025)

2.1 Clinical Assessment
The latest guidelines emphasize:

▪️ Careful evaluation of pulp vitality
▪️ Monitoring for color changes in primary teeth
▪️ Assessment of occlusion, mobility, and periapical tissues
▪️ Screening for associated injuries (lip, soft tissue, head trauma)

2.2 Radiographic Protocols
The IADT now recommends:

▪️ Periapical radiographs with different angulations
▪️ Soft-tissue radiographs for embedded fragments
▪️ CBCT only for complex cases, minimizing radiation in children

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3. Management of Trauma in Primary Teeth
Primary teeth require a conservative, non-aggressive approach to protect developing permanent successors.

➤ Key updates include:
▪️ Intrusion injuries: Spontaneous re-eruption is preferred.
▪️ Luxation injuries: Extraction only if the tooth poses a risk to permanent bud.
▪️ Avulsion: Primary teeth must not be replanted.
These recommendations aim to reduce complications such as enamel hypoplasia or eruption disturbances in permanent teeth.

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4. Management of Trauma in Permanent Teeth
The IADT 2024–2025 updates include:

▪️ Immediate replantation for avulsed permanent teeth whenever possible.
▪️ Use of flexible splints for 1–4 weeks depending on injury type.
▪️ Pulp therapy (partial pulpotomy, full pulpotomy, or pulpectomy) depending on apex development.
▪️ Emphasis on calcium silicate materials for pulpal healing.
▪️ Close monitoring for external inflammatory root resorption.

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5. Follow-Up Protocols
The guidelines stress structured follow-ups:

▪️ At 1 week, 4 weeks, 12 weeks, 6 months, and 1 year
▪️ Annually for up to 5 years in permanent teeth trauma
Vitality tests, radiographs when indicated, and clinical exams ensure early detection of complications.

📊 Comparative Table: Key Updates in IADT 2024–2025 Pediatric Trauma Guidelines

Aspect	Advantages	Limitations
Conservative Primary Tooth Management	Protects permanent tooth germ; minimizes unnecessary extraction	Limited treatment options for severe trauma
Bioactive Pulp Therapies in Permanent Teeth	Promotes healing; reduces risk of root resorption	Requires clinician expertise and proper materials
Flexible Splinting Protocols	Improves healing outcomes; reduces ankylosis risk	Poor patient compliance may affect stability
Structured Long-Term Follow-Up	Enables early diagnosis of complications; ensures better prognosis	Requires consistent parental commitment

💬 Discussion
The IADT 2024–2025 updates reflect a shift toward minimally invasive, biologically respectful care, especially in primary dentition. The emphasis on conservative management, use of bioactive materials, and systematic follow-up significantly improves long-term outcomes. Clinicians must remain vigilant, as delayed diagnosis or inadequate management can lead to pulp necrosis, ankylosis, root resorption, or esthetic issues that affect a child’s development and quality of life.

✍️ Conclusion
Pediatric dental trauma requires precise, evidence-based management. The IADT 2024–2025 guidelines offer updated, structured recommendations that help clinicians protect both primary and permanent teeth. Adhering to these protocols ensures optimal healing, preserves pulp vitality when possible, and reduces long-term complications.

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🔎 Recommendations
▪️ Follow IADT step-by-step protocols for each injury type.
▪️ Avoid over-treating primary teeth to protect permanent successors.
▪️ Prioritize bioactive materials for pulp protection in permanent teeth.
▪️ Educate parents about emergency care for avulsion and luxation.
▪️ Ensure long-term follow-up to detect complications early.

📚 References

✔ American Academy of Pediatric Dentistry. (2024). Guideline on Management of Acute Dental Trauma. AAPD Reference Manual. https://www.aapd.org
✔ International Association of Dental Traumatology. (2020). IADT guidelines for the evaluation and management of traumatic dental injuries. Dental Traumatology, 36(4), 314–330. https://doi.org/10.1111/edt.12589
✔ Levin, L., Day, P. F., Hicks, L., Cohenca, N., Kenny, D. J., & Trope, M. (2020). International Association of Dental Traumatology guidelines for management of traumatic dental injuries: General introduction. Dental Traumatology, 36(4), 309–313. https://doi.org/10.1111/edt.12578

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Protocols for the Management of Dentoalveolar Trauma in Children: Updated Clinical Guidelines

Dentoalveolar trauma in children requires rapid diagnosis, structured decision-making, and age-appropriate treatment protocols.

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This article reviews evidence-based guidelines, focusing on emergency response, tooth-specific approaches, and follow-up recommendations.

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✅ Introduction
Dentoalveolar trauma represents one of the most frequent pediatric dental emergencies, with an incidence peak in children aged 8 to 12 years. Injuries may affect the teeth, periodontal ligament, alveolar bone, and soft tissues. Proper management relies on accurate classification, immediate stabilization, and long-term monitoring to prevent complications such as pulp necrosis, ankylosis, or tooth loss.

1. Diagnosis and Initial Assessment
A systematic evaluation includes:

▪️ Trauma history: mechanism, timing, contamination.
▪️ Clinical examination: tooth mobility, displacement, soft-tissue injuries.
▪️ Radiographic assessment: periapical radiographs or occlusal views to detect fractures or displacement.
▪️ Assessment for non-accidental injury in very young children.

Key diagnostic criteria involve identifying the type of injury according to the International Association of Dental Traumatology (IADT) classification.

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2. Common Types of Dentoalveolar Trauma in Children

2.1. Concussion and Subluxation
➤ Features: Tenderness, mobility without displacement.
➤ Management: Occlusal relief if needed; soft diet for 7–10 days; periodic monitoring for pulp vitality.

2.2. Luxation Injuries
➤ Lateral luxation: Displacement with alveolar fracture; reposition and splint for 4 weeks.
➤ Extrusion: Gentle repositioning and flexible splinting for 2 weeks.
➤ Intrusion:
▪️ Primary teeth: allow spontaneous re-eruption.
▪️ Permanent teeth: spontaneous repositioning or orthodontic repositioning depending on root development.

2.3. Dental Avulsion
➤ Primary teeth: Replantation not recommended.
➤ Permanent teeth: Immediate replantation is the gold standard when feasible.
▪️ Transport medium: HBSS, milk, saline.
▪️ Splint: Flexible, 2 weeks.
▪️ Systemic antibiotics may be indicated (amoxicillin or doxycycline depending on age).

2.4. Crown and Root Fractures
➤ Uncomplicated fractures: Composite restoration.
➤ Complicated fractures: Pulp therapy based on stage of root development.
➤ Root fractures: Repositioning and 4-week splint.

2.5. Alveolar Process Fractures
➤ Repositioning of the segment and 4–6 week rigid splinting.

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3. Follow-Up Protocols
Follow-up intervals recommended by the IADT:

▪️ 1 week, 1 month, 3 months, 6 months, and 1 year, then annually for 5 years.
▪️ Pulp vitality monitoring: thermal, electric tests, and radiographs.
Early detection of pulp necrosis, pulp canal obliteration, or inflammatory root resorption is essential.

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4. Prevention Strategies

▪️ Use of mouthguards during sports.
▪️ Parental education on safe home environments.
▪️ Management of behavioral conditions (e.g., ADHD) associated with higher trauma incidence.

📊 Comparative Table: Splint Options in Pediatric Dental Trauma

Aspect	Advantages	Limitations
Flexible Splints	Promote periodontal healing; recommended by IADT	Not suitable for alveolar fractures requiring rigid fixation
Rigid Splints	Provide stability for alveolar process fractures	Higher risk of ankylosis and root resorption in teeth

💬 Discussion
Management of dentoalveolar trauma requires prompt intervention, but treatment decisions must consider the child’s age, tooth type, root development, and prognosis. Evidence indicates that improper or delayed management increases risks of pulp necrosis, ankylosis, and tooth loss. The IADT 2020 guidelines emphasize minimally invasive approaches, flexible splints, and reduced use of antibiotics.
Interdisciplinary collaboration between pediatric dentists, endodontists, and radiologists improves long-term outcomes.

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✍️ Conclusion
Effective management of pediatric dentoalveolar trauma relies on accurate diagnosis, timely stabilization, and evidence-based treatment protocols. Long-term follow-up is essential to prevent complications such as root resorption or pulp necrosis. Prevention strategies significantly reduce incidence and severity. Updated IADT guidelines remain the gold standard in clinical practice.

🔎 Recommendations
▪️ Use IADT-based classification for all trauma cases.
▪️ Prioritize minimally invasive repositioning techniques and flexible splints.
▪️ Avoid unnecessary replantation of primary teeth.
▪️ Provide written post-operative instructions to parents.
▪️ Schedule structured follow-ups for at least 12 months after injury.

📚 References

✔ American Academy of Pediatric Dentistry. (2024). Guideline on Management of Acute Dental Trauma. AAPD Reference Manual.
✔ Andersson, L., Andreasen, J. O., Day, P., Heithersay, G., Trope, M., DiAngelis, A., Kenny, D. J., Sigurdsson, A., Bourguignon, C., & Flores, M. T. (2020). International Association of Dental Traumatology guidelines for the management of traumatic dental injuries. Dental Traumatology, 36(4), 314–330. https://doi.org/10.1111/edt.12589
✔ Malikaew, P., Watt, R. G., & Sheiham, A. (2003). Dental injuries in primary teeth. Dental Traumatology, 19(5), 252–256. https://doi.org/10.1034/j.1600-9657.2003.00204.x
✔ Flores, M. T. (2002). Traumatic injuries in the primary dentition. Dental Traumatology, 18(6), 287–298. https://doi.org/10.1034/j.1600-9657.2002.00122.x

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Dental Splinting (Ferulization) in Primary and Young Permanent Teeth: Indications and Materials

✅ Abstract
Dental splinting (ferulization) stabilizes mobile or traumatised teeth to promote healing of periodontal and pulpal tissues.

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This review summarizes indications in primary and immature permanent dentitions, compares available splinting materials, and provides practical recommendations for clinicians based on current guidelines and evidence.

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✅ Introduction
Ferulization (tooth splinting) is the clinical procedure of joining mobile or displaced teeth to adjacent teeth to provide temporary stability during healing. The goals are to reduce pain, protect healing periodontal ligament (PDL), enable reattachment or root development, and facilitate endodontic or restorative therapy when needed. Recommendations for splint type and duration differ for primary teeth and young permanent teeth, and should follow contemporary trauma guidelines.

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✅ Indications: importance and clinical situations

➤ Primary teeth (deciduous dentition)
° Splinting is considered for selected luxation injuries or root fractures when repositioning is attempted and where stabilization will improve function or comfort. However, the decision is conservative because of risks to the developing successor tooth; therefore, non-invasive management is often preferred. Evidence supports flexible, short-term splinting in some primary tooth root fractures to improve outcomes.

➤ Young permanent teeth (immature permanent dentition)
° Splinting is important in extrusive, lateral luxation, root fractures, and avulsions to allow PDL healing and continued root development (apexogenesis). The IADT recommends passive, flexible splints (eg. 0.016" stainless steel or comparable flexible wire/fiber) for most traumatized permanent teeth, typically for 2 weeks (longer—4 weeks—if alveolar fracture or root fracture is present). Early stabilization preserves vascular and PDL healing and can improve pulpal survival in immature teeth.

➤ Why splinting matters
° Proper splinting reduces micromovement, lessens further tissue damage, and facilitates clot stabilization in replanted avulsed teeth and luxation injuries—thereby improving prognosis for both periodontal and pulpal healing.

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✅ Types of splints and choice rationale
Clinicians should prefer flexible and passive splints that allow physiologic tooth movement while providing stabilization. Rigid splints are generally avoided because they may cause ankylosis or inhibit PDL healing. Modern options include:

▪️ Wire-composite splints (stainless steel wire + composite) — traditional, widely available.
▪️ Fiber-reinforced composite (FRC) splints — superior aesthetics, less plaque retention, good strength.
▪️ Direct composite splints (wire-free) — quick application but technique-sensitive; some materials demonstrated good short-term retention in training studies.
▪️ Glass ionomer-based connectors — easier removal in some settings, but lower flexural strength.
▪️ Emerging options: 3D-printed or CAD/CAM fabricated removable splints for specific cases, an expanding field with promising early data.

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✅ Clinical protocol (practical points)

▪️ Reposition tooth carefully, then place a passive, flexible splint. Follow IADT timing recommendations (commonly 2 weeks; 4 weeks for root/alveolar fractures). Document occlusion and ensure splint does not cause premature contacts.
▪️ Combine splinting with appropriate endodontic management when indicated (eg. immature teeth with necrotic pulp require apexification/regenerative approaches).
▪️ Provide oral hygiene instructions, soft diet, and follow-up radiographs to monitor healing and detect complications (resorption, ankylosis).

💬 Discussion
Current evidence and guidelines emphasize flexibility, passivity, and short duration of splints to maximize periodontal healing and minimize adverse sequelae such as ankylosis or root resorption. Comparative studies show that fiber-reinforced composite splints may offer improved aesthetics and comparable mechanical performance to wire-composite splints, while new technologies (CAD/CAM, 3D printing) can produce customized appliances for special cases. However, heterogeneity in study designs and limited high-quality randomized trials mean clinical judgment and guideline adherence remain essential.

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✍️ Conclusion
Ferulization is a key tool in the management of dental trauma and mobility in both primary and young permanent teeth when appropriately indicated. Choosing a passive, flexible splint and limiting duration according to injury type optimizes healing while minimizing complications. Ongoing advances in materials (FRC, CAD/CAM splints) broaden clinicians’ options but should be adopted guided by evidence and practicality.

🔎 Recommendations

1. Prefer passive, flexible splints (eg. 0.016" stainless wire or FRC) and avoid rigid fixation.
2. Duration: generally 2 weeks for most luxations and avulsions; extend to 4 weeks for root or alveolar fractures as per IADT.
3. Primary teeth: be conservative—splint selectively and weigh risks to successors.
4. Combine splinting with appropriate endodontic, restorative, and follow-up care; monitor radiographically for resorption and ankylosis.
5. When available and indicated, consider fiber-reinforced or CAD/CAM solutions for improved patient comfort and aesthetics, while recognizing cost and accessibility limitations.

📊 Symptoms: Mild - Severe: Splinting Materials — Pros and Cons

Aspect	Advantages	Limitations
Wire-composite (stainless steel wire + composite)	Widely available; reliable stabilization; cost-effective; good clinical familiarity	Aesthetic concerns; plaque retention if excess resin; technique sensitivity for passive placement
Fiber-reinforced composite (FRC)	Better aesthetics; low profile; good flexural strength; reduced metal visibility	Higher material cost; requires precise technique; may need special fiber handling
Direct composite splint (wire-free)	Fast application; no metal components; comfortable for patients	May have lower long-term retention; increases polymerization shrinkage risk if bulky
Glass ionomer connectors	Easy to remove; fluoride release may benefit caries-prone patients	Lower mechanical strength; higher wear; less suitable for high-load stabilization
CAD/CAM or 3D-printed removable splints	Custom-designed fit; predictable passive support; minimal chair time for placement	Requires lab workflow or in-clinic 3D printing; higher cost; limited data in pediatric trauma

📚 References

✔ Bourguignon, C., et al. (2020). International Association of Dental Traumatology (IADT) guidelines for the management of traumatic dental injuries. Dental Traumatology. (IADT guidelines).
✔ Deery, C., et al. (2023). Should we splint traumatised primary teeth? British Dental Journal Open / Systematic Review. Retrieved from PubMed Central.
✔ Goswami, M., et al. (2020). Management of traumatic dental injuries using different splinting methods. Journal of Clinical and Experimental Dentistry.
✔ Sobczak-Zagalska, H., et al. (2020). Best splinting methods in case of dental injury. Journal of the American Academy of Pediatric Dentistry / JOCPD (article discussing splint types and techniques).
✔ Šimunović, L., et al. (2025). Three-dimensionally printed splints in dentistry: review and applications. Journal of Clinical Dentistry / MDPI Reviews.
✔ Moon, W., et al. (2022). Mechanical evaluation of dental trauma splints fabricated with various materials. Dental Materials Journal.

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Traumatic Dental Injuries in Children: Diagnosis and Management

Traumatic dental injuries (TDIs) are highly prevalent in children, particularly in the primary and mixed dentition stages. They represent one of the most common dental emergencies in pediatric patients, often resulting from falls, sports activities, and accidents.

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TDIs not only affect the teeth but may also compromise the supporting periodontal tissues, alveolar bone, and surrounding soft tissues (Andersson, 2018). Early and accurate diagnosis followed by appropriate management is critical to ensure favorable long-term outcomes.

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✅ Types of Traumatic Dental Injuries
TDIs in children are classified according to the World Health Organization (WHO) and the International Association of Dental Traumatology (IADT) guidelines. The main categories include:

° Crown fractures (enamel or enamel-dentin)
° Crown-root fractures
° Root fractures
° Luxation injuries (concussion, subluxation, extrusion, lateral luxation, intrusion)
° Avulsion

Each type of injury presents unique diagnostic features and management protocols.

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✅ Diagnosis
Diagnosis involves clinical examination, radiographic assessment, and patient history. Key diagnostic steps include:

° Assessing tooth mobility, sensitivity, and displacement.
° Evaluating pulp vitality through sensibility testing (in older children).
° Identifying associated soft tissue injuries and possible alveolar fractures.
° Radiographic imaging using periapical, occlusal, or panoramic radiographs depending on injury type.

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✅ Management of Traumatic Dental Injuries

° Crown fractures: Management ranges from smoothing minor enamel fractures to composite restoration or pulp therapy if the pulp is exposed.
° Luxation injuries: Treatment may involve observation, repositioning, splinting, or extraction depending on severity.
° Avulsion: Immediate replantation is the best prognosis for permanent teeth. Primary teeth should not be replanted due to risk of damage to developing permanent successors (Fouad & Abbott, 2020).
° Root fractures: Stabilization with flexible splints and long-term monitoring are essential.

📊 Differences Among Traumatic Dental Injuries in Children

Type of Injury	Key Characteristics	Management Approach
Crown Fractures	Loss of enamel/dentin; pulp may be exposed	Restoration, pulp therapy if exposure occurs
Luxation Injuries	Mobility, displacement, or intrusion of the tooth	Observation, repositioning, splinting, or extraction
Root Fractures	Fracture line affecting root structure	Stabilization with splints, follow-up monitoring
Avulsion	Complete displacement of tooth from socket	Immediate replantation (permanent teeth); no replantation for primary teeth

💬 Discussion
Traumatic dental injuries in children demand immediate and careful intervention to minimize long-term complications, such as pulp necrosis, ankylosis, or developmental disturbances in permanent teeth. The management strategy depends largely on the child’s age, dentition stage, and type of injury. While modern guidelines from the IADT provide structured protocols, challenges include compliance, prognosis prediction, and follow-up in pediatric patients (Bourguignon et al., 2020).

🔎 Recommendations

° Educate parents and caregivers on emergency management of avulsed teeth, emphasizing immediate replantation or storage in suitable media.
° Ensure routine follow-ups to monitor pulp vitality and root development.
° Use protective measures, such as mouthguards, during sports to prevent injuries.
° Apply minimally invasive techniques whenever possible to preserve pulp vitality in young patients.

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✍️ Conclusion
Traumatic dental injuries in children represent complex clinical challenges requiring prompt diagnosis and evidence-based management. A multidisciplinary approach involving pediatric dentists, endodontists, and parents ensures optimal outcomes. Preventive strategies and long-term monitoring are essential to reduce complications and improve the prognosis of traumatized teeth.

📚 References

✔ Andersson, L. (2018). Epidemiology of traumatic dental injuries. Journal of Endodontics, 44(3), S19–S27. https://doi.org/10.1016/j.joen.2017.11.013
✔ Bourguignon, C., Cohenca, N., Lauridsen, E., Flores, M. T., O’Connell, A. C., Day, P. F., ... & Tsilingaridis, G. (2020). International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations. Dental Traumatology, 36(4), 314–330. https://doi.org/10.1111/edt.12578
✔ Fouad, A. F., & Abbott, P. V. (2020). Endodontic-related traumatic dental injuries: Epidemiology, diagnosis, and treatment considerations. Endodontic Topics, 39(1), 1–11. https://doi.org/10.1111/etp.12295

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Pink Tooth in Dentistry: Etiology, Diagnosis, Treatment, and Forensic Relevance

The “pink tooth” phenomenon describes a pink discoloration of dentin visible through the enamel. It can occur both in living patients and postmortem.

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In clinical dentistry, it is associated with trauma, internal resorption, pulp necrosis, or iatrogenic staining, while in forensic contexts it has been linked to deaths caused by drowning, asphyxiation, or cranial trauma. This article reviews the causes, differential diagnosis, clinical and forensic implications, as well as available treatment options.

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✅ Introduction
Dental discolorations are a frequent reason for consultation. Among them, a pink hue in a tooth crown is of particular interest due to its varied etiology. For years, the pink tooth was thought to be exclusive to drowning or asphyxia victims. However, the literature shows that it may also occur in clinical ante mortem cases, associated with pathological or iatrogenic factors. This article aims to provide an updated and precise overview of this phenomenon.

✅ Etiology

➤ Ante mortem / Clinical

° Internal resorption: the most classic cause in living patients; inflamed and vascularized tissue behind the enamel gives rise to a pink shade.
° Dental trauma: intrapulpal hemorrhages diffuse blood pigments into dentin, creating a transient pink discoloration.
° Early pulp necrosis: tissue breakdown releases byproducts that stain dentin.
° Endodontic materials: some sealers and cements may cause pink or reddish staining in the crown.

➤ Post mortem / Forensic

° Caused by hemolysis and hemoglobin diffusion into dentinal tubules.
° Commonly observed in drowning, asphyxia, and cranial trauma, although not exclusive to these causes.
° Environmental factors such as temperature, humidity, and postmortem interval influence the intensity of discoloration.

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✅ Differential Diagnosis

° Medical and dental history: trauma, pulp vitality, prior treatments.
° Vitality tests (cold, heat, electric pulp test).
° Periapical radiography or CBCT to assess resorption extent.
° Differentiate from discolorations caused by systemic conditions, medications, or restorative materials.

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✅ Treatment and Clinical Management

° Initial internal resorption: root canal treatment with disinfection and obturation.
° Intracanal medications: calcium hydroxide between appointments.
° Prosthetic restorations or crowns in cases of structural loss.
° Extraction: last resort when the tooth is unrestorable or has extensive perforations.

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✅ Forensic Relevance

° The pink tooth may suggest drowning or asphyxia but is neither exclusive nor pathognomonic.
° Its probative value is limited and must be interpreted alongside other evidence.
° Intensity and localization of discoloration vary depending on anatomical and environmental factors.

📊 Comparative Table: Pink Tooth — Clinical vs. Forensic Causes

Aspect	Clinical Causes	Forensic Causes
Etiology	Internal resorption, pulp necrosis, dental trauma, endodontic sealers with pigments.	Drowning, mechanical asphyxia, severe cranial trauma, postmortem hematic diffusion.
Characteristics	Pink coloration visible in the pulp chamber or crown; may progress to reddish hues.	Intense pink coloration in the crown, usually homogeneous and associated with postmortem findings.
Relevance	Important for differential diagnosis in clinical dentistry to avoid confusion with forensic cases.	Auxiliary indicator in forensic investigations of criminal or accidental death.
Limitations	May be confused with staining caused by endodontic materials or chronic pulp lesions.	Not exclusive to asphyxia; must be correlated with other forensic findings.

💬 Discussion
The belief that the pink tooth is exclusive to drowning or asphyxia victims has been disproven. In living patients, it may result from internal resorption, trauma, pulp necrosis, or endodontic materials. Postmortem, it is more frequent in asphyxia or drowning, but may also occur under other conditions. Clinically, early diagnosis is essential for tooth preservation, while in forensic dentistry it should be interpreted as a nonspecific finding requiring correlation with other data.

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✍️ Conclusions
° The “pink tooth” is not exclusive to drowning or asphyxia.
° It may occur in both living patients (trauma, necrosis, resorption, materials) and postmortem (hemolysis).
° Early diagnosis improves clinical prognosis and prevents tooth loss.
° In forensic dentistry, it has indicative but not conclusive value for determining cause of death.

📚 References

✔ Carney, K. A., Colloc, T. N. E., & Kilgariff, J. K. (2024). Management of rarely seen internal tunnelling root resorption associated with a maxillary permanent incisor. British Dental Journal, 236(7504), 955–961. https://doi.org/10.1038/s41415-024-7504-7

✔ Nilsson, E., et al. (2013). Management of Internal Root Resorption on Permanent Teeth. Journal of Endodontics, 39(12), 1521–1527. https://doi.org/10.1016/j.joen.2013.08.020

✔ Minegishi, S., et al. (2022). Association of Cadaveric Factors with the Degree and Region of Discoloration in the Phenomenon of Pink Teeth. Applied Sciences, 12(9), 4242. https://doi.org/10.3390/app12094242

✔ Sumi, N., et al. (2023). Study on the Mechanism of the Pink Tooth Phenomenon. Diagnostics, 13(16), 2699. https://doi.org/10.3390/diagnostics13162699

✔ Regalado-Barrera, J. D., Hernández-Salas, C., Murillo-López, E., Reyes-Moreno, D. C., Cano-Sánchez, D., & Rosales-González, H. (2023). Etiology of the pink tooth: a curious postmortem phenomenon. Contexto Odontológico, 13(25), 23-28. https://revistas.uaz.edu.mx/index.php/contextoodontologico/article/view/2568

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Webinar: Pediatric Dental Trauma and Odontogenic Infections - Dr. Kelly A. Kirtland DDS

Pediatric dental trauma and odontogenic infections remain among the most frequent and challenging conditions faced in children’s oral health. These events can compromise not only the integrity of the teeth but also the function, aesthetics, and overall well-being of young patients.

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Understanding how to recognize, diagnose, and manage trauma early is crucial for preserving tooth vitality and preventing long-term complications in both primary and permanent dentition.

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Likewise, odontogenic infections demand prompt and accurate intervention, as they may progress rapidly and affect adjacent tissues or even systemic health. Modern pediatric dentistry emphasizes evidence-based protocols, the use of minimally invasive techniques when possible, and a patient-centered approach that reduces anxiety and improves cooperation.

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By combining preventive strategies, clinical expertise, and multidisciplinary collaboration, dental professionals can ensure safer, more predictable outcomes. This video explores the current knowledge and best practices that empower clinicians to provide effective and compassionate care when facing dental trauma and infections in children.

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Guidelines for the management of traumatic dental injuries in the primary dentition

Dental traumas in pediatric patients represent 18% of all injuries and that is due to the activities of children, and they occur more frequently when they learn to crawl, walk or run.

The lesions can compromise dental tissue (enamel, dentin, root), dental pulp, alveolar bone, and periodontal ligaments. Soft tissues such as lips and cheeks are also included.

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We share an article that does not offer different recommendations for the diagnosis and treatment of traumatic injuries in the primary dentition.

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How to handle dental trauma?

👉 READ AND DOWNLOAD "Guidelines for the management of traumatic dental injuries in the primary dentition" IN FULL IN PDF👈

Day PF, Flores MT, O’Connell AC, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 3. Injuries in the primary dentition. Dent Traumatol 2020;36(4):343-359. https://doi.org/10.1111/edt.12576

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Reimplantation of avulsed dry permanent teeth after three days: A report of two cases

Dental avulsion is one of the most severe traumatic injuries affecting permanent teeth, particularly in children and adolescents. The prognosis of an avulsed tooth is highly dependent on extraoral time, storage conditions, and prompt reimplantation.

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When the tooth remains dry for an extended period, periodontal ligament cell necrosis is inevitable, significantly compromising long-term outcomes and increasing the risk of ankylosis and root resorption.

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Despite the generally unfavorable prognosis associated with delayed reimplantation of dry avulsed teeth, current guidelines recognize reimplantation as a viable option in selected cases to preserve alveolar bone, maintain esthetics, and support psychological well-being, especially in young patients.

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PDF 🔽 Guidelines for the management of traumatic dental injuries in the primary dentition ... The lesions can compromise dental tissue (enamel, dentin, root), dental pulp, alveolar bone, and periodontal ligaments. Soft tissues such as lips and cheeks are also included.

📌 Read and download the article in PDF:



Ize-Iyamu IN, Saheeb B. Reimplantation of avulsed dry permanent teeth after three days: A report of two cases. Niger J Clin Pract 2013;16:119-22.

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Dental trauma in children: What can we do?

Dental trauma occurs in a higher percentage in children and adolescents. The causes are falls and injuries related to games and sports.

Although oral accidents are not fatal, they do compromise the child's health


Dental trauma should be attended to immediately by a professional, since not only the teeth would be compromised, but also the bone and soft parts such as the lip and tongue.

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How to handle dental trauma?

Dental accidents and trauma occur with some frequency, the highest incidence is in children and adolescents, but adults are not oblivious to these events. Trauma can involve not only the tooth, but also the lips, gums, and bone.


It is important to act immediately and take the injured person to a dental hospital or clinic. Getting to a dentist within 30 minutes after the accident can make a difference.

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