Review Article
Pulpal Reactions to Orthodontic Force Application
in Humans: A Systematic Review
ohl, DDS, PhD,* Yijin Ren, DDS, PhD,† Piotr S. Fudalej, DDS, PhD,*
Martina von B€
and Anne M. Kuijpers-Jagtman, DDS, PhD*
Abstract
Introduction: Force application to a tooth during ortho-
dontic treatment evokes a biological response of the
dental pulp. The aim of this systematic literature review
was to investigate the relationship between orthodontic
force level and pulp reaction in humans. Methods: Elec-
tronic search was made of publications in PubMed/old
MEDLINE, Web of Science, EMBASE, CINAHL, Scopus,
and the Cochrane Library (DARE, CENTRAL) until July
21, 2012. Hand search was made of publications before
1954 and the most recent ones in main dental and ortho-
dontic journals. Additional studies were identified by
hand search of reference lists of relevant articles from
both the electronic and hand searches. Search terms
included biomechanics, force, orthodontic*, tooth move-
ment, dental pulp, and pulpal reaction. Two independent
observers assessed eligibility for inclusion, extracted the
data, applied quality indicators, and graded level of
evidence. Results: Twenty-four studies matched the
inclusion criteria. The outcomes concerned histologic
and cell biological parameters after orthodontic tooth
movement in 19 studies and pulpal blood flow in
5 studies. The methodologic quality of most studies
was graded moderate to low. Conclusions: Because of
a lack of high-quality studies there is no conclusive scien-
tific evidence for a relation between force level and dental
pulp tissue reaction in humans. There is contradictory
scientific support for a force-dependent reduction of
blood flow. (J Endod 2012;38:1463–1469)
Key Words
Dental pulp, force level, humans, inflammatory
response, orthodontics, systematic review, tooth
movement
From the *Department of Orthodontics and Craniofacial
Biology, Radboud University Nijmegen Medical Centre,
Nijmegen; and †Department of Orthodontics, University
Medical Centre Groningen, Groningen, The Netherlands.
Address requests for reprints to Prof Anne M. Kuijpers-
Jagtman, Radboud University Nijmegen Medical Centre,
Department of Orthodontics and Craniofacial Biology, PO Box
9101, 6500 HB Nijmegen, The Netherlands. E-mail address:
orthodontics@dent.umcn.nl
0099-2399/$ - see front matter
Copyright ª 2012 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2012.07.001
JOE — Volume 38, Number 11, November 2012
O rthodontic tooth movement is based on the principle of force application to a tooth
for a certain period of time, varying from months up to several years. This inevitably
evokes a pronounced biological reaction in the periodontal ligament (PDL) and the
dental pulp. In the early phase of orthodontic tooth movement, force application evokes
an acute inflammatory response in the PDL, which is characterized by vasodilatation and
migration of leukocytes out of the capillaries (1). These migratory cells produce various
local biochemical signal molecules and cytokines, which interact with the population of
native periodontal cells. A day or 2 later, the acute phase is replaced by a chronic
process involving fibroblasts, endothelial cells, osteoblasts, and alveolar bone
marrow cells. During this phase, leukocytes continue to migrate into strained peri-
odontal tissues and modulate the remodeling process (2, 3).
Although numerous studies have described the reaction of the PDL to force
application, fewer have dealt with pulpal changes. The pulpal response to orthodontic
force involves cell damage, inflammation, and wound healing, which are processes
that could adversely affect the dental pulp. Published histologic data demonstrated
that pulp, in response to orthodontic forces, shows reactions ranging from circula-
tory vascular stasis to necrosis (4). Depression of the tissue respiration rate, reduced
alkaline phosphatase activity, apoptosis, aspiration and vacuolization of odontoblasts,
and tissue damage have been reported after orthodontic force application (5, 6). In
humans angiogenic changes were found in the dental pulp, and an increase in the
number of microvessels was demonstrated, suggesting an increase in angiogenic
growth factors in the dental pulp (7). The authors concluded that epithelial growth
factor (EGF) released after orthodontic force application plays a role in the angio-
genic response of the pulp (7–10). The same research group (9) identified the
expression of angiogenic growth factors by pulp fibroblasts such as vascular endo-
thelial growth factor (VEGF), fibroblast growth factor-2 (FGF-2), platelet-derived
growth factor (PDGF), and transforming growth factor-beta (TGF-b) in pulp tissues
after application of orthodontic forces. The progression of the inflammatory process
apparently depends on stimulation by neuropeptides and production of inflammatory
cytokines such as interleukin-1 and interleukin-3 (IL-1, IL-3) and tumor necrosis
factor-alpha (TNF-a).
The clinical impact of pulpal changes after force application is whether they could
jeopardize the long-term vitality of teeth. Not many data are available about prevalence
of long-term dental pulp damage due to orthodontic treatment, and figures vary widely,
ranging from 2%–17% for root canal obliteration and from 1%–14% for pulpal
necrosis in orthodontically treated adolescents (11). There are occasional reports of
loss of tooth vitality associated with poorly controlled orthodontic forces such as jiggling
forces (6). Other studies demonstrated pulp necrosis after various tooth movements
such as retraction (12, 13), intrusion, and extrusion (4). Although these reports
described the pathologic changes in the dental pulp tissue in response to orthodontic
force application in general, no clear answer could be found for a possible correlation
between the magnitude of an orthodontic force and pulp tissue reaction. It is generally
assumed that pulpal changes and their consequences appear to be more severe with
larger orthodontic forces (14), but sound scientific data to support this assumption
are lacking. This is an important question to be answered because the optimal force
level is still a matter of debate in clinical orthodontics. Therefore, a systematic review
was performed to investigate the relationship between orthodontic force level and pulp
reaction in humans.
Pulpal Reaction to Orthodontic Tooth Movement 1463
Review Article
Materials and Methods
Information Sources and Search Strategy
Studies were identified by an electronic database search. No
language limitation was imposed. A list of terms and the search strategy
were developed, and databases were selected with the help of a senior
librarian who specialized in health sciences. The electronic search was
applied to PubMed/old MEDLINE (1947–present) and adapted for
Web of Science (1966–present), EMBASE (1974–present), Scopus
(1966–present), and CINAHL (1982–present). The Cochrane Library
(DARE and CENTRAL) was reviewed until July 2012. The last search
for all databases was run on July 21, 2012.
We conducted the literature search following the concatenated
search strategy: #1: search (‘‘biomechanics’’[MeSH] OR force*[tiab]
OR mechanism*[tiab]); #2: search (orthodontic[tiab] OR orthodon-
tics[tiab]); #3: search (‘‘tooth movement’’[MeSH] OR ‘‘tooth move-
ment’’[tiab]); #4: #2 OR #3; #5: #1 AND #4; #6: search (‘‘dental
pulp’’[MeSH Terms] OR (‘‘dental’’[tiab] AND ‘‘pulp’’[tiab]) OR ‘‘dental
pulp’’[tiab]) OR (pulpal[ti] AND reactions[tiab]) OR ‘‘pulpal reac-
tion’’[tiab]; and #7: #5 AND #6.
Publications before 1954 and the most recent ones were hand
searched in main dental and orthodontic journals. Finally, reference
lists of relevant articles from both the electronic and hand searches
were screened.
Study Selection
Abstracts retrieved by query #7 and by hand search were reviewed by
2 observers (M.v.B, A.M.K.-J.), independently of each other, according to
the following inclusion criteria: study in humans, quantification of ortho-
dontic force magnitude, type of tooth movement mentioned, quantifica-
tion of duration of force application, and description of pulpal reaction.
The following exclusion criteria were used: animal studies,
reviews, and case reports and letters to the editor.
Eligibility assessment of the retrieved records was based on title
and abstract. The abstracts were scored as included, excluded, or
unclear after review of title and abstract only. Disagreements between
observers were resolved by consensus. Then, the articles that apparently
fulfilled the inclusion criteria and articles of which title or abstract did
not present enough relevant information were retrieved full text and re-
viewed according to all the inclusion criteria. In the event of a discrep-
ancy between observers, a consensus decision was taken.
Data Extraction
A data extraction sheet was developed, piloted on 8 studies, and
refined accordingly. One observer (M.v.B.) extracted the following
data from included studies, and the second observer (A.M.K.-J.)
checked the extracted data. Disagreements were resolved by consensus.
Information was extracted from each included study as follows:
author(s), year of publication, research design, number of patients,
number and type of teeth that were moved, initial force magnitude in
centinewtons (cN), type of tooth movement (intrusion, extrusion,
tipping, bodily movement), duration of force application, control or
experimental tooth for comparison, and outcome variables.
Quality Assessment and Level of Evidence
Two observers (M.v.B., A.M.K.-J.) evaluated independently the
methodologic quality of the included studies according to a grading
system developed by the Swedish Council on Technology Assessment
in Health Care (15), which was based on the criteria for assessing study
quality from the Centre for Reviews and Disseminations in York, United
Kingdom (16). The methodologic quality criteria are listed as follows.
1464 von B€ohl et al.
Grade A (High). Randomized controlled trial or prospective study
is composed of a well-defined control group; defined diagnosis and
end points; diagnostic reliability tests and reproducibility tests
described; and blinded outcome measurements (all criteria should
be met).
Grade B (Moderate). Cohort study or retrospective case series is
composed of a defined control or reference group; defined diag-
nosis and end points; and diagnostic reliability tests and reproduc-
ibility tests described (all criteria should be met; if not, grade C).
Grade C (Low). One or more of the following conditions are found:
large attrition of the sample, unclear diagnosis and end points, and
poorly defined patient material.
The final level of evidence for each conclusion was judged accord-
ing to the following scale (17).
Strong Scientific Support (Evidence Grade 1). Conclusion is
based on at least 2 studies with level A evidence. Studies with oppo-
site conclusions may lower the evidence grade.
Moderately Strong Support (Evidence Grade 2). Conclusion is
based on 1 study with strong evidence (A) and at least 2 with
moderately strong evidence (B). Studies with opposite conclusions
may lower the evidence grade.
Limited Scientific Support (Evidence Grade 3). Conclusion is
based on at least 2 studies with moderately strong evidence (B).
If studies contradicting the conclusion exist, the scientific basis is
judged as insufficient or contradictory.
Inconclusive Scientific Support (Evidence Grade 4). If studies
fulfilling the evidence criteria are lacking, the scientific basis for
conclusion is considered insufficient.
Results
Study Selection
The electronic search revealed a total of 419 citations: 82 from
PUBMED/(old) MEDLINE, 93 from Web of Science, 53 from EM-
BASE, 167 from Scopus, 7 from CINAHL, and 17 from the Cochrane
Library (DARE, CENTRAL). In addition, 13 publications were identi-
fied by hand search. After exclusion of duplicate records, 144 re-
mained for further screening. Those that did not present enough
relevant information in the abstract were retrieved in full. Of those
144 articles, 109 studies were discarded because after reading the
abstracts, these articles clearly did not meet the inclusion criteria.
The full text of the remaining 35 articles was reviewed in detail,
and it appeared that 11 articles did not meet the inclusion criteria.
Thus, finally 24 publications remained that were included in the
systematic review. The PRISMA flow diagram (18) provides an over-
view of the selection process (Fig. 1).
Study Characteristics
The outcomes reported in the included studies concerned
pulpal blood flow (PBF) and histologic and cell biological parame-
ters. Five studies reported changes in the PBF (Table 1), and 19 of
the 24 publications dealt with histologic and cell biological reactions
(Table 2).
The forces used in human studies ranged from 25–4400 cN
(Tables 1 and 2). The duration of force application ranged from 20
seconds to 152 days. In 19 of the 24 studies the tooth, which had
been moved, was the bicuspid (upper or lower), and in 4 studies it
was a maxillary incisor (19–22). In 1 study the maxillary cuspid had
been moved (12). Most studies dealt with intrusive and extrusive move-
ments of the experimental teeth.
JOE — Volume 38, Number 11, November 2012

Figure 1. PRISMA flow diagram of the study.
Quality Assessment
Most of the publications were graded moderate to low for meth-
odologic quality (Tables 1 and 2). The main reasons for lower grading
were no random assignment to experimental and control treatment and
no description of reliability tests.
Changes of PBF
To measure PBF, laser Doppler flowmetry was used in all studies
(Table 1). Force application had a significant effect on basal blood flow
in 4 of the 5 studies that investigated PBF (12, 19–21). In these studies
basal blood flow was reduced irrespective of the type of tooth
movement and the tooth that was moved. Only 1 investigation
reported no alteration of the PBF after the first 4 minutes of
intrusive force application (22). In 3 studies force levels were
increased in several steps (19, 20, 22). They reported opposite
results; 1 study reported a force-dependent reduction of blood flow
(19), and the other 2 did not (20, 22).
Histologic and Cell Biological Changes
In 4 of the 19 included studies Derringer et al (7–10) found an
increase of the number of microvessels (quality score B) (Table 2).
The number of microvessels was related to the presence of EGF released
after force application (10). The same authors found a combination of
VEGF, FGF-2, PDGF, and TGF-b (9) involved in the angiogenic response
(quality score B).
JOE — Volume 38, Number 11, November 2012
Review Article
Vacuolization of the pulp, disruption of the odontoblastic layer,
and vascular degeneration were common findings (4, 23–27),
although 1 study did not report pulpal changes with an extrusive
force of 75 cN (28). However, the methodologic quality of these studies
was low (quality grade C).
Several high-quality studies into enzyme activity of the dental pulp
after force application showed an increased aspartate aminotransferase
(AST) activity after 7 days (29–31), with a return to normal values after
14 days (29), and a reduction of alkaline phosphatase (ALP) activity
(32). Different force levels were not investigated in these studies.
In 1 of the 19 studies Hamersky et al (33) observed a significant
correlation between age of the patient and the amount of depression in
the pulp tissue respiration rate. Their study also showed that age was
more relevant for the pulp tissue respiration than force level. However,
the quality of that publication was low (grade C).
In only 3 studies a direct comparison was made between different
force levels (34–36) and the subsequent pulpal reaction, but in 2 of
them no correlation was found between force level and any of the
studied variables (34, 35). In the third study (36) after 24 hours
a greater calcitonin gene-related peptide (CGRP) expression was found
in the dental pulp of premolars that were subjected to a force of 224 cN
than in the group with a 56-cN force.
In summary, the histologic and cell biological studies included in
this review showed that orthodontic force application in humans caused
a reduction of ALP activity, an increase of AST activity, an increase of
number and diameter of microvessels, and a release of angiogenic
and vascular endothelial growth factors. Vacuolization of the pulp tissue,
Pulpal Reaction to Orthodontic Tooth Movement 1465
Review Article
disruption of the odontoblastic layer, and reduction of pulp tissue respi-

Quality
grade
ration seemed to occur as a reaction on orthodontic force application,

A
B
B

B
but there was inconclusive scientific support for these findings.

displacement
LDF, PBF, tooth
Discussion
variables
Outcome This systematic review aimed to investigate the relationship between

LDF, PBF

LDF, PBF

LDF, PBF
LDF, PBF
force levels during orthodontic force application and dental pulp reaction
in humans. We used the Centre for Reviews and Disseminations’ quality
assessment tool to judge the quality of the individual studies (16). It is
not enough to simply report the quality criteria that were met by studies
Same tooth without

Contralateral I2sup

Contralateral Csup
different forces
included in a systematic review (37). The quality assessment should be re-
Same tooth with
Comparison
5 of 13 no force

flected in the interpretation of the results. This was achieved by using the
grading system of Mohlin et al (17) to synthesize the final level of evidence
of the results. Grading of evidence is a complicated issue, and numerous
force

scales have been proposed to do so. We avoided using a scale that allocates
points to individual quality items because this approach has proved to be
inadequate (38, 39). Although attempts continue to arise, currently there is
1, 2, 3, 4 d

still no agreed gold standard quality assessment system (40–42).

Duration
of force

The results of this systematic review show that there is limited

152 d
4 mo
14 d

scientific support (evidence grade 3) that intrusive forces have an effect

20 s

on blood supply of the pulp regardless of force level used. The range of
applied forces in these studies was high, from 50–4400 cN, and the
Intrusion, extrusion

canines; tipping

duration of force application also varied considerably.

Type of tooth
movement

With respect to histologic and cell biological reactions, in only 3

Retraction of

studies a direct comparison between different force levels to achieve

Intrusion
Intrusion

Intrusion

tipping or extrusion of premolars was made (34–36). CGRP

expression in the dental pulp was demonstrated to be greater (36)
with the highest force level used in this study (224 cN). However,
CGRP expression was only measured 24 hours after force application,
75, 125, 500, 4400

which therefore reflects a model of acute infection. To get more insight

Csup, maxillary canine; I1sup, maxillary central incisor; I2sup, maxillary lateral incisor; LDF, laser doppler flowmetry; N, number of patients.

into the significance of this finding, a longer time period of orthodontic

Force (cN)
50, 100, 200
50, 100, 500

force application is needed. Therefore, because of the quality of these

studies there is inconclusive scientific support (evidence grade 4) for
any relation between force level and studied variables.
200

50

Although several studies described histologic changes (23–28,

34), the quality of these studies is generally low, and therefore the
Tooth

I1sup

I1sup
I1sup

I2sup

scientific support for their findings is inconclusive. The effect of age

Csup

on pulpal reaction is also not clear (33). There is limited scientific

support (evidence grade 3) for the role of VEGF, FGF-2, PDGF, TGF-ß,
17
13

10
6
8
N

and EGF in the angiogenic response of the pulp. Release of these growth
TABLE 1. Studies on PBF after Orthodontic Force Application in Humans

factors leads to an increase of the number of microvessels (7–10).

Split-mouth

Split-mouth

Strong scientific support was found for changes in pulpal enzyme

Crossover

Crossover
Design

activity, expressed as a reduction of ALP activity (32) and increase of

AST activity (29–31), because of force application. Because dental
CCT

pulp fibroblasts and odontoblasts synthesize and release ALP (43,

44), it can be assumed that reduction in ALP activity under stress is
1994
2002

1996
2001

1996
Year

mainly due to an alteration in these cells (32), but the influence of

the force level is unknown because this was not investigated. The release
Reference

of angiogenic growth factors as shown in the studies of Derringer et al

(8–10) is of interest because other studies have shown that a decrease
12
19
20

21
22

in ALP activity was associated with the release of these factors. Among
others, EGF, FGF-2, PDGF, TGF-b, and TNF-a have been related to
a reduction in dental pulp cell ALP activity (45–48). Therefore, pulp
McDonald and Pitt Ford

cell injury in the earliest phases of orthodontic treatment in

Barwick and Ramsay

combination with an increase in levels of angiogenic growth factors

Authors

appears to be the basis for the decrease in ALP activity (32). AST is
another enzyme involved in tissue damage, and increased AST activity
Brodin et al
Ikawa et al
Sano et al

has been found in the gingival crevicular fluid in periodontitis (49),

during orthodontic treatment (31, 50), and in inflammation of the
dental pulp tissue (51). The increased AST activity in dental pulp under
stress probably points to tissue damage, but the significance of this

1466 von B€ohl et al. JOE — Volume 38, Number 11, November 2012
 TABLE 2. Studies on Histologic and Cell Biological Reactions in Dental Pulp after Orthodontic Force Application in Humans
JOE — Volume 38, Number 11, November 2012

No. of Type of
No. of teeth tooth Duration Quality
Author Reference Year Design patients exp + C Tooth Force (cN) movement of force Comparison Outcome variables grade
Caviedes-Bucheli 36 2011 RCT? ? 20 + 10 PM 56, 224 Extrusion 24 h No force CGRP expression C
et al
Veberiene et al 29 2010 Split-mouth 13 13 + 13 PM inf/sup 61  4.5 Intrusion 14 d 7 d + 7 d rest AST activity and electrical A
RCT pulp testing
Ramazanzadeh 27 2009 Split-mouth 3 3+3 PM1sup 25 Intrusion 3d No force Histology of odontoblast C
et al RCT 3 3+3 PM1sup 75 Extrusion 3d No force layer and pulpal
7 7+7 PM1sup 25 (intrusion), Intrusion 3d Extrusion changes
75 (extrusion
3 3+3 PM1sup 25 Intrusion 21 d No force
3 3+3 PM1sup 75 Extrusion 21 d No force
7 7+7 PM1sup 25 (intrusion), Intrusion 21 d Extrusion
75 (extrusion)
Veberiene et al 30 2009 Split-mouth 21 42 PM inf/sup 61 Intrusion 7d No force AST activity and electrical A
RCT pulp testing
Derringer and 10 2007 Case series 10 10 PM2sup 50–100 Extrusion 14 d Cultures of vertical EGF release and no. of B
Linden halves of same microvessels
pulp
Perinetti et al 32 2005 Split-mouth 16 16 + 16 PM1sup 30–90 Tipping 7d Contralateral ALP activity A
RCT PM1sup
Perinetti et al 31 2004 Split-mouth 17 17 PM1sup 30–90 Tipping 7d No force AST activity A
RCT
Derringer and 9 2004 Case series 20 80 PM2sup 50–100 Extrusion 14 d Cultures of vertical VEGF, FGF2, PDGF, TGF-b B
Linden PM2inf halves of same release, and no. of
pulp microvessels
Derringer and 8 2003 Split-mouth 18 10 + 8 PM2sup 50–100 Extrusion 14 d 14 d force VEGF, FGF2, PDGF, TGF-b, B
Linden CCT (4 teeth) 35–42 d EGF release, and no. of
force (4 teeth); microvessels
cultures of
vertical halves
of same pulp
€ bay et al
Su 28 2001 Case series 15 40 PM1sup 75 Extrusion 10, 40 d Extrusion by sect Histologic changes C
PM1inf wire (10 patients,
Pulpal Reaction to Orthodontic Tooth Movement

20 teeth) or
elastics (5 patients,
20 teeth)
Raiden et al 26 1998 Split-mouth 20 40 PM1sup 150 Intrusion 15–20 d No force Histologic changes C
CCT
Derringer et al 7 1996 Split-mouth ? 30 PMsup inf 50–100 Tipping 14 d No force Light- and electron C
CCT microscopy of
endothelial cell
morphology
€ çu
€ kkeleş

Review Article
Ku 25 1994 Split-mouth 2 4 PM1sup 150 Intrusion 90 d Force, level? Electron microscopy C
and Okar CCT of pulp and root
Mostafa et al 4 1991 Split-mouth 18 36 PM1sup 50 Extrusion 7, 14, No force Histology of pulp C
RCT 28 d
Parris et al 35 1989 CCT 11 + 9 44 + 36 PM1+2 sup 120, 140, 150, Tipping 21–78 min No force Immunohistochemistry B
ligated 180, 200, of pulp neuropeptides
together 210, 215,
230, 245, 600
1467

(Continued )
Review Article
finding is difficult to judge because our knowledge of AST activity in the
Quality
grade
dental pulp is limited. For both enzymes, AST and ALP, their involvement

C
on the pulp tissue after force application is still not understood and
should be investigated further.
Four main problems were encountered in performing this review.

Histology after 4–104 d

Histology directly after

Outcome variables

These concern the experimental setup, the accuracy and variability of the

Histology after 2, 6,
Radiorespirometry

force level, the type of tooth movement, and duration of the experiment.
of pulpal tissue

First, although several studies used a split-mouth design, in only

respiration

a few the experimental sites were assigned at random (27, 29–31).

Histology
Derringer and Linden (10) used a ‘‘split tooth’’ design by preparing

28 wk
exp
2 halves of a human pulp for culturing to determine 2 different anti-
human EGF antibodies. The advantage of the split-mouth design is the
removal of much of the intersubject variability, which increases the
reference 33 1970

power of the study compared with the whole-mouth design (52). For
Both groups from

Both groups from

Both groups from

orthodontic force application experiments a split-mouth design or

Comparison

reference 23

reference 23

a crossover design is to be preferred because it is known that the bio-

logical response to orthodontic force application is mostly individually
No force

No force

determined (53). Unfortunately, most split-mouth studies in this review

lack randomization of the sites of the experimental intervention.
The second consideration about the experimental setup of the
included studies is the reported force level, which ranged from 25–
Duration
movement of force

?, information not clear in the original article; CCT, controlled clinical trial; inf/sup, inferior/superior; exp + C, experimental + controls; PM, premolar; RCT, randomized clinical trial.
5–28 d

7–14 d

7–14 d

4–35 d

4400 cN. However, in most studies the force level was not measured
3d

accurately, and only a range for the force level was given. This makes
it difficult to draw conclusions about force levels in relation to the bio-
logical reaction of the dental pulp.
Extrusion

Extrusion

Extrusion
Type of

Intrusion

Intrusion

The third problem was the large variety of types of tooth movement,
tooth

such as extrusion, intrusion, or tipping forces, and the impossibility of

comparing them with each other. Extrusive forces have been shown to
cause odontoblastic layer degeneration (4, 27) because of circulatory
disturbances, whereas the latter study (27) observed the same effect after
Force (cN)

100, 200
60–180?

50–250

35–250

intrusion. The outcomes of studies in which tipping movements were

200

performed (Table 2) are even more difficult to interpret. Tipping forces

evoke an uneven distribution of stresses and strains within the PDL. The
clinical result is that crown and root move at different rates or even into
different directions. The center of rotation, which determines the rate of
PM1 sup/inf

35 + 35 PM1 sup/inf

crown and root movement, is difficult to determine and very likely to

Tooth

change during tipping movement. Therefore, a well-defined and repro-

PM?

PM?

PM?

ducible tipping tooth movement is almost impossible to achieve, which

means that the interpretation of the results is hampered (54).
patients exp + C
No. of
No. of teeth

The fourth difficulty has been the wide variety in length of exper-
68

25

15

11

imental period. Most experiments on PBF were short-term experiments,

with the shortest experimental period being 20 seconds (20). The
longest experimental period of all included studies was 152 days
17

(21). This wide variety made reliable comparisons between the results
of different studies difficult.
1980 Split-mouth

Although many studies have demonstrated that orthodontic force

historical
controls
Design

historical

application may lead to pathologic changes in the dental pulp tissue,

controls
1971 Cohort;

1971 Cohort;

1970 Cohort
CCT

this systematic review showed that our knowledge concerning dental

pulp reactions and orthodontic force application is still limited. A
number of questions remain to be answered. The data indicate that
Reference Year

during orthodontic tooth movement there is a certain balance between

maintaining a healthy pulp or ending up with pulp necrosis. However,
the exact nature of the balance between force level and dental pulp reac-
24

34

23
33

tion is still unclear. Clinically, both continuous and intermittent forces

are evoked by orthodontic appliances. It might be possible that their
TABLE 2. (Continued )

effect on dental pulp vascularization is different, but this was not inves-
€r

€r
Stenvik and Mjo

Stenvik and Mjo

tigated in any of the studies included in this review. Remarkably enough,

Hamersky et al

the relationship between force level and vitality or long-term changes of

Author

human pulpal tissue has also not been elucidated, and this is of utmost
Stenvik

clinical importance. Therefore, future studies should focus on pulp reac-

tions after applying different force levels and types of force, preferably in
a split-mouth design, with proper randomization for side. The study of

1468 von B€ohl et al. JOE — Volume 38, Number 11, November 2012

translational tooth movement is still an underexposed area as compared
with studies on effects of intrusive and extrusive movements. Much atten-
tion should be given to the biomechanical model of force application
because translational movement is often accompanied by tipping move-
ment, which, as explained above, makes it difficult to judge the results.
Finally, because orthodontic treatment does not take place overnight, it is
of vital importance to evaluate dental pulpal reaction during a longer
time span (at least 3 months) than has been reported before.
Conclusions
Force application to a tooth during orthodontic treatment evokes
a biological response of the dental pulp. Because of a lack of high-
quality studies there is no conclusive scientific evidence for a relation
between force level and dental pulp tissue reaction in humans. There
is contradictory scientific support for a force-dependent reduction of
blood flow.
Acknowledgments
The authors deny any conflicts of interest related to this study.
References
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view. In: Krishnan V, Davidovitch Z, eds. Biological mechanisms of tooth movement.
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