{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,27]],"date-time":"2026-03-27T02:32:35Z","timestamp":1774578755812,"version":"3.50.1"},"reference-count":62,"publisher":"MDPI AG","issue":"11","license":[{"start":{"date-parts":[[2021,11,12]],"date-time":"2021-11-12T00:00:00Z","timestamp":1636675200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Background and Objectives: This systematic review aimed to assess the literature focusing on the clinical management of traumatized teeth with Pulp Canal Obliteration (PCO) and propose an updated clinical decision-making algorithm. The present review follows the PRISMA guidelines and was registered on PROSPERO database (CRD42020200656). Materials and Methods: An electronic search strategy was performed in Pubmed, EBSCOhost and LILACS from inception to March 2021. Only anterior permanent teeth with PCO due to dental trauma were included. Regarding clinical approaches, only teeth managed with a \u201cwatchful waiting\u201d approach, tooth bleaching or root canal treatment (RCT) were included. Quality assessment was performed using the JBI Critical Appraisal Tool for Case Reports. Results: Twenty case reports were selected, resulting in a total of 27 patients. The number of traumatized teeth diagnosed with PCO was 33. The \u201cwatchful waiting\u201d approach was the most implemented clinical strategy. Discolored non-symptomatic PCO teeth were mostly managed with external bleaching. The prevalence of pulp necrosis (PN) was 36.4%. For teeth diagnosed with PN, non-surgical RCT was performed in 10 teeth and surgical RCT in one tooth. Guided endodontic technique was performed in six of those teeth. Conclusions: For discolored non-symptomatic PCO teeth, external bleaching is advocated and the RCT approach should not be implemented as a preventive intervention strategy. Symptomatic PCO teeth should follow regular endodontic treatment pathways. Clinical approach of teeth with PCO should follow a decision-making algorithm incorporating clinical and radiographic signs and patient-reported symptoms.<\/jats:p>","DOI":"10.3390\/medicina57111237","type":"journal-article","created":{"date-parts":[[2021,11,14]],"date-time":"2021-11-14T20:51:53Z","timestamp":1636923113000},"page":"1237","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":34,"title":["Management of Pulp Canal Obliteration\u2014Systematic Review of Case Reports"],"prefix":"10.3390","volume":"57","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6929-3807","authenticated-orcid":false,"given":"Alexandra","family":"Vinagre","sequence":"first","affiliation":[{"name":"Institute of Operative Dentistry, Faculty of Medicine, University of Coimbra, 3000-075 Coimbra, Portugal"},{"name":"Center for Innovation and Research in Oral Sciences (CIROS), Faculty of Medicine, University of Coimbra, 3000-075 Coimbra, Portugal"}]},{"given":"Catarina","family":"Castanheira","sequence":"additional","affiliation":[{"name":"Institute of Operative Dentistry, Faculty of Medicine, University of Coimbra, 3000-075 Coimbra, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4019-9379","authenticated-orcid":false,"given":"Ana","family":"Messias","sequence":"additional","affiliation":[{"name":"Institute of Oral Implantology and Prosthodontics, Faculty of Medicine, University of Coimbra, 3000-075 Coimbra, Portugal"},{"name":"CEMMPRE\u2014Center for Mechanical Engineering, Materials and Processes, University of Coimbra, 3030-788 Coimbra, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4730-8072","authenticated-orcid":false,"given":"Paulo J.","family":"Palma","sequence":"additional","affiliation":[{"name":"Center for Innovation and Research in Oral Sciences (CIROS), Faculty of Medicine, University of Coimbra, 3000-075 Coimbra, Portugal"},{"name":"Institute of Endodontics, Faculty of Medicine, University of Coimbra, 3000-075 Coimbra, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1965-1092","authenticated-orcid":false,"given":"Jo\u00e3o C.","family":"Ramos","sequence":"additional","affiliation":[{"name":"Institute of Operative Dentistry, Faculty of Medicine, University of Coimbra, 3000-075 Coimbra, Portugal"},{"name":"Center for Innovation and Research in Oral Sciences (CIROS), Faculty of Medicine, University of Coimbra, 3000-075 Coimbra, Portugal"}]}],"member":"1968","published-online":{"date-parts":[[2021,11,12]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"2","DOI":"10.1111\/j.1600-9657.2011.01103.x","article-title":"International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth","volume":"28","author":"Diangelis","year":"2012","journal-title":"Dent. Traumatol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"603","DOI":"10.1111\/j.1600-9657.2008.00696.x","article-title":"Epidemiology of traumatic dental injuries\u2014A 12 year review of the literature","volume":"24","author":"Glendor","year":"2008","journal-title":"Dent. Traumatol."},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Oginni, A.O., and Adekoya-Sofowora, C.A. (2007). Pulpal sequelae after trauma to anterior teeth among adult Nigerian dental patients. BMC Oral Health, 7.","DOI":"10.1186\/1472-6831-7-11"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1111\/j.1600-9657.1996.tb00087.x","article-title":"Dental pulp response to traumatic injuries\u2014A retrospective analysis with case reports","volume":"12","author":"Feiglin","year":"1996","journal-title":"Endod. Dent. Traumatol."},{"key":"ref_5","first-page":"447","article-title":"Calcific metamorphosis: A challenge in endodontic diagnosis and treatment","volume":"32","author":"Amir","year":"2001","journal-title":"Quintessence Int."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"294","DOI":"10.1111\/edt.12635","article-title":"Traumatic dental injuries and pulp sequelae in an adolescent population","volume":"37","author":"Bratteberg","year":"2021","journal-title":"Dent. Traumatol."},{"key":"ref_7","unstructured":"American Association of Endodontists (2020). AAE Glossary of Endodontic Terms, American Association of Endodontists. [10th ed.]."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"177","DOI":"10.1111\/j.1365-2591.2011.01963.x","article-title":"Pulp canal obliteration: An endodontic diagnosis and treatment challenge","volume":"45","author":"McCabe","year":"2012","journal-title":"Int. Endod. J."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"620","DOI":"10.1111\/j.1600-9657.2009.00819.x","article-title":"Evaluation of radiographs, clinical signs and symptoms associated with pulp canal obliteration: An aid to treatment decision","volume":"25","author":"Oginni","year":"2009","journal-title":"Dent. Traumatol."},{"key":"ref_10","first-page":"527","article-title":"Clinical approach to pulp canal obliteration: A case series","volume":"12","author":"Machado","year":"2017","journal-title":"Iran Endod. J."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"103","DOI":"10.1111\/j.1600-9657.1987.tb00611.x","article-title":"Occurrence of pulp canal obliteration after luxation injuries in the permanent dentition","volume":"3","author":"Andreasen","year":"1987","journal-title":"Endod. Dent. Traumatol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"224","DOI":"10.1016\/0300-5712(81)90058-0","article-title":"The effect of luxation and subluxation upon the prognosis of traumatized incisor teeth","volume":"9","author":"Rock","year":"1981","journal-title":"J. Dent."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"557","DOI":"10.1016\/S0099-2399(96)80018-5","article-title":"Incidence of pulp necrosis subsequent to pulp canal obliteration from trauma of permanent incisors","volume":"22","author":"Robertson","year":"1996","journal-title":"J. Endod."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"825","DOI":"10.1016\/0030-4220(67)90521-X","article-title":"Calcific metamorphosis of the pulp: Its incidence and treatment","volume":"24","author":"Holcomb","year":"1967","journal-title":"Oral Surg. Oral Med. Oral Pathol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"94","DOI":"10.1016\/0030-4220(65)90272-0","article-title":"Calcific metamorphosis of the dental pulp","volume":"20","author":"Patterson","year":"1965","journal-title":"Oral Surg. Oral Med. Oral Pathol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"89","DOI":"10.3109\/00016358009003483","article-title":"A light microscopy study of pulps from traumatized permanent incisors with reduced pulpal lumen","volume":"38","author":"Lundberg","year":"1980","journal-title":"Acta Odontol. Scand."},{"key":"ref_17","first-page":"55","article-title":"Pulp canal obliteration after extrusive and lateral luxation in young permanent teeth: A scoping review","volume":"22","author":"Spinas","year":"2021","journal-title":"Eur. J. Paediatr. Dent."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"223","DOI":"10.3109\/00016358209019816","article-title":"Failures and healing in endodontically treated non-vital anterior teeth with posttraumatically reduced pulpal lumen","volume":"40","author":"Cvek","year":"1982","journal-title":"Acta Odontol. Scand."},{"key":"ref_19","first-page":"4","article-title":"Calcific metamorphosis","volume":"27","author":"Munley","year":"2005","journal-title":"Clin. Update"},{"key":"ref_20","unstructured":"Aromataris, E., and Munn, Z. (2017). Systematic reviews of etiology and risk. Joanna Briggs Institute Reviewer\u2019s Manual, The Joanna Briggs Institute. Available online: https:\/\/reviewersmanual.joannabriggs.org\/."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"60","DOI":"10.1136\/bmjebm-2017-110853","article-title":"Methodological quality and synthesis of case series and case reports","volume":"23","author":"Murad","year":"2018","journal-title":"BMJ Evid. Based Med."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"3782","DOI":"10.18203\/2320-6012.ijrms20184264","article-title":"Aesthetic management of complete calcific metamorphosis: A case report","volume":"6","author":"AlDaiji","year":"2018","journal-title":"Int. J. Res. Med. Sci."},{"key":"ref_23","first-page":"195","article-title":"Pulp and periodontal healing after replantation of a maxillary immature incisor: A 13-year follow-up","volume":"15","author":"Biagi","year":"2014","journal-title":"Eur. J. Paediatr. Dent."},{"key":"ref_24","first-page":"661","article-title":"Obliteration of pulp canal space after concussion and subluxation: Endodontic considerations","volume":"33","year":"2002","journal-title":"Quintessence Int."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"247","DOI":"10.1111\/iej.12809","article-title":"Microguided Endodontics: A method to achieve minimally invasive access cavity preparation and root canal location in mandibular incisors using a novel computer-guided technique","volume":"51","author":"Connert","year":"2018","journal-title":"Int. Endod. J."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"165","DOI":"10.1111\/j.1600-9657.2011.01105.x","article-title":"Traumatic intrusion of permanent teeth: 10 years follow-up of 2 cases","volume":"29","author":"Gomes","year":"2013","journal-title":"Dent. Traumatol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"420","DOI":"10.1016\/0030-4220(85)90266-X","article-title":"Replantation of avulsed teeth with immature root development","volume":"60","author":"Johnson","year":"1985","journal-title":"Oral Surg. Oral Med. Oral. Pathol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"240","DOI":"10.1111\/edt.12235","article-title":"Guided Endodontics: A novel treatment approach for teeth with pulp canal calcification and apical pathology","volume":"32","author":"Krastl","year":"2016","journal-title":"Dent. Traumatol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"229","DOI":"10.1016\/j.cden.2011.01.001","article-title":"Whitening the single discolored tooth","volume":"55","author":"Kwon","year":"2011","journal-title":"Dent. Clin. N. Am."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"bcr-2018-227318","DOI":"10.1136\/bcr-2018-227318","article-title":"Endodontic management of maxillary central incisor with pulp canal obliteration","volume":"2018","author":"Lakinepally","year":"2018","journal-title":"BMJ Case Rep."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1578","DOI":"10.1016\/j.joen.2018.07.006","article-title":"A New Approach for Minimally Invasive Access to Severely Calcified Anterior Teeth Using the Guided Endodontics Technique","volume":"44","author":"Barbosa","year":"2018","journal-title":"J. Endod."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"572","DOI":"10.2341\/13-349-T","article-title":"Bleaching options for pulp-calcified teeth: Case history reports","volume":"39","author":"Lise","year":"2014","journal-title":"Oper. Dent."},{"key":"ref_33","first-page":"287","article-title":"Obliteration after recurrent dental trauma in a 7-year-old patient: 4-year follow-up","volume":"49","author":"Mourad","year":"2018","journal-title":"Quintessence Int."},{"key":"ref_34","first-page":"557","article-title":"Clareamento externo: Uma solu\u00e7\u00e3o conservadora para dentes com calcifica\u00e7\u00e3o distr\u00f3fica: Relato de caso cl\u00ednico com trinta meses de acompanhamento\/External bleaching: A conservative solution for teeth with dystrophic calcification: Clinical case report with 30 months follow up","volume":"2","author":"Muniz","year":"2005","journal-title":"Rev. Dental Press Est\u00e9t."},{"key":"ref_35","first-page":"76","article-title":"Endodontic management of traumatized permanent anterior teeth with radiographically calcified root canal\u2014Report of two cases","volume":"3","author":"Raghuvanshi","year":"2015","journal-title":"IJOCR"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"105","DOI":"10.14295\/bds.2013.v16i4.922","article-title":"Conservative esthetic treatment of a discoloured calcified permanent tooth: Five-year clinical evaluation","volume":"16","author":"Ramos","year":"2013","journal-title":"Braz. Dental Sci."},{"key":"ref_37","first-page":"210","article-title":"Oblitera\u00e7\u00e3o do canal pulpar do incisivo central superior esquerdo de uma paciente jovem ap\u00f3s trauma\u2014Acompanhamento cl\u00ednico-radiogr\u00e1fico\/Pulp canal obliteration of upper left central incisor of a young patient after trauma\u2014Monitoring clinical-radiographic","volume":"19","author":"Sacchetto","year":"2011","journal-title":"Rev. ABO Nac."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"408","DOI":"10.1016\/S0099-2399(88)80126-2","article-title":"Rationale for the management of calcific metamorphosis secondary to traumatic injuries","volume":"14","author":"Schindler","year":"1988","journal-title":"J. Endod."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"460","DOI":"10.1016\/S0099-2399(06)80039-7","article-title":"Unusual pattern of pulp canal obliteration following luxation injury","volume":"20","author":"Shuler","year":"1994","journal-title":"J. Endod."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"247","DOI":"10.9771\/cmbio.v6i2.4216","article-title":"Clareamento externo para dentes com calcifica\u00e7\u00e3o distr\u00f3fica da polpa: Relato de caso cl\u00ednico","volume":"6","author":"Silva","year":"2007","journal-title":"Revista de Ci\u00eancias M\u00e9dicas e Biol\u00f3gicas"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"1195","DOI":"10.1016\/j.joen.2018.04.014","article-title":"Guided Endodontic Access of Calcified Anterior Teeth","volume":"44","year":"2018","journal-title":"J. Endod."},{"key":"ref_42","first-page":"233","article-title":"Single discolored tooth: An alternative treatment approach","volume":"24","author":"Chong","year":"1993","journal-title":"Quintessence Int."},{"key":"ref_43","doi-asserted-by":"crossref","unstructured":"European Society of Endodontology (2006). Quality guidelines for endodontic treatment: Consensus report of the European Society of Endodontology. Int. Endod. J., 39, 921\u2013930.","DOI":"10.1111\/j.1365-2591.2006.01180.x"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"367","DOI":"10.1046\/j.1365-2591.1998.00176.x","article-title":"Gaining access through a calcified pulp chamber: A clinical challenge","volume":"31","author":"Ngeow","year":"1998","journal-title":"Int. Endod. J."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"559","DOI":"10.1111\/iej.13038","article-title":"Guided root canal preparation using cone beam computed tomography and optical surface scans\u2014An observational study of pulp space obliteration and drill path depth in 50 patients","volume":"52","author":"Buchgreitz","year":"2019","journal-title":"Int. Endod. J."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"S122","DOI":"10.1111\/j.1834-7819.2007.tb00520.x","article-title":"The endodontic management of traumatized permanent anterior teeth: A review","volume":"52","author":"Moule","year":"2007","journal-title":"Aust. Dent. J."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"441","DOI":"10.1016\/0030-4220(82)90393-0","article-title":"Calcific metamorphosis: A treatment dilemma","volume":"54","author":"Smith","year":"1982","journal-title":"Oral Surg. Oral Med. Oral Pathol."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"327","DOI":"10.1016\/j.joen.2018.11.006","article-title":"Guided Endodontics versus Conventional Access Cavity Preparation: A Comparative Study on Substance Loss Using 3-dimensional-printed Teeth","volume":"45","author":"Connert","year":"2019","journal-title":"J. Endod."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"286","DOI":"10.1016\/j.joen.2020.10.025","article-title":"Minimization of Tooth Substance Removal in Normally Calcified Teeth Using Guided Endodontics: An In Vitro Pilot Study","volume":"47","author":"Kostunov","year":"2021","journal-title":"J. Endod."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"46","DOI":"10.1016\/j.jclinepi.2013.08.003","article-title":"The CARE guidelines: Consensus-based clinical case report guideline development","volume":"67","author":"Gagnier","year":"2014","journal-title":"J. Clin. Epidemiol."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"966","DOI":"10.1111\/iej.12544","article-title":"Guided endodontics: Accuracy of a novel method for guided access cavity preparation and root canal location","volume":"49","author":"Zehnder","year":"2016","journal-title":"Int. Endod. J."},{"key":"ref_52","doi-asserted-by":"crossref","unstructured":"Zubizarreta-Macho, A., Valle Castano, S., Montiel-Company, J.M., and Mena-Alvarez, J. (2021). Effect of Computer-Aided Navigation Techniques on the Accuracy of Endodontic Access Cavities: A Systematic Review and Meta-Analysis. Biology, 10.","DOI":"10.3390\/biology10030212"},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"101","DOI":"10.1111\/aej.12360","article-title":"Access to original canal trajectory after deviation and perforation with guided endodontic assistance","volume":"46","author":"Casadei","year":"2020","journal-title":"Aust. Endod. J."},{"key":"ref_54","first-page":"196","article-title":"Computer-aided dynamic navigation: A novel method for guided endodontics","volume":"50","author":"Chong","year":"2019","journal-title":"Quintessence Int."},{"key":"ref_55","first-page":"119","article-title":"Guided endodontics: A comparative in vitro study on the accuracy and effort of two different planning workflows","volume":"23","author":"Krug","year":"2020","journal-title":"Int. J. Comput. Dent."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"839","DOI":"10.1016\/j.joen.2020.03.014","article-title":"3-Dimensional Accuracy of Dynamic Navigation Technology in Locating Calcified Canals","volume":"46","author":"Jain","year":"2020","journal-title":"J. Endod."},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"315","DOI":"10.1016\/j.joen.2020.11.026","article-title":"Guided Endodontics for Managing Severely Calcified Canals","volume":"47","author":"Vidal","year":"2021","journal-title":"J. Endod."},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"1221","DOI":"10.1111\/iej.13508","article-title":"Endodontic management of traumatized permanent teeth: A comprehensive review","volume":"54","author":"Krastl","year":"2021","journal-title":"Int. Endod. J."},{"key":"ref_59","doi-asserted-by":"crossref","unstructured":"Pinto, D., Marques, A., Pereira, J.F., Palma, P.J., and Santos, J.M. (2020). Long-Term Prognosis of Endodontic Microsurgery-A Systematic Review and Meta-Analysis. Medicina, 56.","DOI":"10.3390\/medicina56090447"},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"1963","DOI":"10.1016\/j.joen.2017.08.019","article-title":"A Systematic Review of the Survival of Teeth Intentionally Replanted with a Modern Technique and Cost-effectiveness Compared with Single-tooth Implants","volume":"43","author":"Mainkar","year":"2017","journal-title":"J. Endod."},{"key":"ref_61","doi-asserted-by":"crossref","first-page":"992","DOI":"10.1016\/j.joen.2015.01.004","article-title":"Survival of Intentionally Replanted Teeth and Implant-supported Single Crowns: A Systematic Review","volume":"41","author":"Torabinejad","year":"2015","journal-title":"J. Endod."},{"key":"ref_62","doi-asserted-by":"crossref","first-page":"127","DOI":"10.1034\/j.1600-9657.2001.017003127.x","article-title":"Periodontal healing after replantation of intentionally rotated teeth with healthy and denuded root surfaces","volume":"17","author":"Kawanami","year":"2001","journal-title":"Dent. Traumatol."}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/57\/11\/1237\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T07:29:36Z","timestamp":1760167776000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/57\/11\/1237"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,11,12]]},"references-count":62,"journal-issue":{"issue":"11","published-online":{"date-parts":[[2021,11]]}},"alternative-id":["medicina57111237"],"URL":"https:\/\/doi.org\/10.3390\/medicina57111237","relation":{},"ISSN":["1648-9144"],"issn-type":[{"value":"1648-9144","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,11,12]]}}}