Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2016; 61:(1 Suppl): 82–94

doi: 10.1111/adj.12400

Prevention and management of external inflammatory

resorption following trauma to teeth
PV Abbott*
*School of Dentistry, The University of Western Australia, Western Australia, Australia.

ABSTRACT
External inflammatory resorption is one of the potential consequences of trauma to the teeth. It occurs when there has
been loss of cementum due to damage to the external surface of the tooth root during trauma, plus the root canal system
has become infected with bacteria. It is characterized by the radiographic appearance of loss of tooth substance with a
radiolucency in the adjacent periodontal ligament and bone. The loss of cementum allows the intracanal bacteria and/or
their endotoxins to reach the periodontal ligament more readily and this can lead to the development of the inflamma-
tory resorptive process. External inflammatory resorption can ultimately lead to loss of the tooth if it is not managed in
a timely manner. There are some injuries that are very likely to develop this type of resorption and a preventive
approach can be adopted by commencing root canal treatment immediately as part of the emergency management of
such cases. In cases where the resorptive process is already established, root canal treatment can arrest the resorption
and encourage hard tissue repair. The use of a corticosteroid-antibiotic intracanal medicament has been shown to be par-
ticularly useful in the prevention and management of external inflammatory resorption. Calcium hydroxide should not
be used as an immediate medicament because of its inherent toxicity and irritant properties but it is valuable as a subse-
quent medicament to encourage hard tissue repair where required. This review outlines the external inflammatory resorp-
tive process and the management strategies that can be employed to prevent it from occurring, and to treat it if already
present.
Keywords: Calcium hydroxide, inflammatory resorption, Ledermix paste, pulp necrosis, trauma.
Abbreviations and acronyms: PDL = periodontal ligament.

resorption. External inflammatory resorption requires

INTRODUCTION
Trauma to the teeth is a reasonably common
occurrence 1 and any delays in providing the
appropriate treatment may have negative conse-
quences on the prognosis of the injured teeth.
The long-term prognosis of traumatized teeth is
largely dependent on the emergency management
and how quickly this is provided. Both the dental
pulp and the periradicular tissues may be dam-
aged when a tooth is traumatized. The responses
of these tissues to injury may be favourable or
unfavourable, as summarized by Abbott and Cas-
tro Salgado.2 Favourable responses do not gener-
ally require any treatment whereas unfavourable
responses require some form of treatment,
depending on the particular tissue response.
One of the more complex unfavourable responses
to trauma is the development of external inflamma-
tory resorption, also known as infection related
the following two things to occur:
(1) The root canal system is infected or has been con-
taminated with bacteria, plus
(2) There has been mechanical damage to the cemen-
tum during the trauma or cementum has been lost
as a result of external surface resorption such that
the dentinal tubules are exposed to the surround-
ing periodontal ligament (PDL) and bone.3
External inflammatory resorption may occur soon
after a traumatic incident or it may occur at some
later time. It is characterized by the radiographic
appearance of loss of tooth substance together with a
radiolucency involving the adjacent PDL and bone
(Fig. 1). The tooth will not respond to pulp sensibility
testing and there may or may not be other symptoms
or clinical signs, depending on the overall state of the
tooth and surrounding tissues. Most cases do not have
any symptoms or signs. These are generally only pre-
sent if the infected root canal system is also causing

82 © 2016 Australian Dental Association

 Prevention and management of external inflammatory resorption
(a)
(b)
(c)
Fig. 1 (a) Schematic diagram of external inflammatory resorption show-
ing loss of tooth structure and loss of adjacent bone in the form of radi-
olucencies. External inflammatory resorption can occur on the lateral root
surface or at the apex of the root. (b) Radiograph showing external
lateral inflammatory resorption on the mesial surface (indicated by the
arrow) of the root of the upper right central incisor – this was evident 6
months following avulsion and replantation of the tooth. (c) Radiograph
showing external apical inflammatory resorption associated with a long-
standing infected root canal system. (Fig. 1a and 1b reproduced with the
kind permission of the Journal of Oral Health and Dental
Management2).
acute apical periodontitis or if an abscess is present
(see below for further details). External inflammatory
resorption may occur anywhere along the length of
the tooth root – typically it occurs laterally and api-
cally following trauma (Fig. 1a, 1b) but when the
resorption occurs as a result of a long-standing
infected root canal system, it usually occurs apically
(Fig. 1c)
Another form of resorption that may develop fol-
lowing trauma to teeth is external replacement resorp-
tion1 (Fig. 2a–2c) – also known as trauma-induced
resorption – and this resorption may occur in teeth
that also have external inflammatory resorption
(Fig. 2d). This review will not discuss external
replacement resorption in detail but it will be men-
© 2016 Australian Dental Association
tioned where relevant as both types of resorption may
occur in some cases. This is because replacement
resorption is a consequence of the same injuries that
typically cause external inflammatory resorption –
such as intrusion and avulsion where there is signifi-
cant damage to the external root surface during the
injury, as well as sometimes during the repositioning/
replantation of the tooth.1 External replacement
resorption has a different radiographic appearance
with loss of tooth structure and its replacement by
bone being evident (Fig. 2). Clinically, teeth undergo-
ing replacement resorption have reduced mobility and
a different, dull sound on percussion. Dentists should
be familiar with the different types of resorption so
the correct diagnosis established and the appropriate
management provided.
FACTORS AFFECTING TISSUE RESPONSES TO
INJURY
There are several mechanical and biological factors
that affect the tissue responses following trauma to
the teeth. The mechanical factors indirectly affect the
responses because they determine the type of injury
and its severity whilst the biological factors tend to
have a more direct effect on the tissue responses.1 The
most important biological factors are the stage of root
development, whether the pulp is involved, the degree
of displacement of the tooth (if any), and the presence
of concurrent injuries. These factors may all affect the
development of external inflammatory resorption. The
presence or absence of these factors should be deter-
mined during the initial examination following
trauma, which must include adequate (and usually
multiple) radiographs.4–6
The ability of the pulp to recover following treat-
ment is largely influenced by the biological factors. If
the root is not fully developed, then revascularization
of the pulp is more likely7 and therefore further root
development can proceed and inflammatory resorption
is unlikely to occur. This also improves the long-term
prognosis of the tooth by creating more dentine
resulting in a ‘stronger’ tooth which implies that it is
less likely to fracture.8 Hence, an incompletely devel-
oped tooth should be managed with the aim of pre-
serving the pulp. The pulp should only be removed as
part of the emergency management of incompletely
developed teeth in specific circumstances when consid-
ering inflammatory resorption, as outlined below and
in Table 1. There may be other circumstances where
pulp removal is indicated (e.g. a complicated crown
fracture) but these will not be discussed in this paper.
The degree of displacement (luxation) of the tooth
is a major factor affecting both the pulp7,9 and PDL
healing.9,10 Teeth with little or no displacement have
a far better prognosis as there is little or no reduction
83
PV Abbott

(a) (b) (c) (d)

Fig. 2 (a) Schematic diagram of external replacement resorption showing loss of tooth structure and its replacement by bone. (b) Radiograph of an upper
right central incisor that had been avulsed, replanted and splinted. The tooth had been out of the mouth and stored dry for three hours. The dentist per-
formed extraoral root canal treatment and placed a rigid splint. (c) The tooth developed external replacement resorption which slowly progressed. This
radiograph was taken 4 years after the injury and shows extensive resorption and ankylosis. (d) The upper right lateral incisor has both external inflamma-
tory resorption (on the distal surface) and external replacement resorption (apically) following avulsion, 2 hours extraoral saline storage and replantation.
Root canal treatment had been done but no specific measures had been taken to prevent the inflammatory resorption.
(Fig. 2a, 2b and 2c reproduced with the kind permission of the Journal of Oral Health and Dental Management2).

Table 1. The injuries that are likely to result in pulp

a higher chance of pulp necrosis and infection of the
necrosis and infection of the root canal system,
root canal system. This in turn can lead to the tooth
according to the stage of root development at the
being more likely to develop external inflammatory
time of injury. Immediate root canal treatment fol-
resorption as there has also been damage to the root
lowing repositioning/replantation and splinting should
surface as a result of the luxation injury and the repo-
be considered for teeth with these injuries in order to
sitioning/replantation of the tooth. Thus, both of the
prevent the development of external inflammatory
critical requirements needed for external inflammatory
root resorption (see Tables 3 and 4 from Abbott and
resorption to occur are present with concurrent inju-
Castro Salgado2)
ries such as luxation and crown fracture.
Incompletely developed teeth Fully developed teeth

• Avulsion WITH crown fracture • Avulsion EXTERNAL INFLAMMATORY RESORPTION

• Intrusion WITH crown fracture • Intrusion
• Lateral luxation
WITH crown fracture
• Extrusion WITH
crown fracture
of the pulp’s blood supply, and little or no damage to
the cementum and the PDL. Hence, concussion or
subluxation injuries have the most favourable progno-
sis, followed in descending order by extrusion, lateral
luxation, intrusion and avulsion.7,8,10
Concurrent injuries to the same tooth imply that
more tissues will be involved than if there is only one
injury. It is relatively common for teeth to have con-
current injuries – such as a crown fracture and a luxa-
tion injury at the same time.11,12 In these cases, the
pulp may be compromised because of the crown frac-
ture and possible bacterial contamination at the criti-
cal time when the pulp’s blood supply is either
reduced or severed by the luxation injury, resulting in
84
As outlined above, external inflammatory resorption
of tooth roots requires the root canal system to be
infected or contaminated with bacteria, plus there
must be mechanical damage to the cementum or some
cementum has been lost as a result of external surface
resorption.3 The root surface damage results in loss of
the protective mechanisms within the cementum and
PDL. If the damage is sufficient enough to expose the
dentinal tubules, then the bacteria in the root canal
system and/or their endotoxins can readily move
through the dentinal tubules to reach the PDL.
Whenever trauma occurs to the PDL – such as
when a tooth is displaced (luxated) – an inflammatory
response develops immediately within the PDL and
bone as a result of the injury itself. The bacteria
and/or endotoxins from the infected root canal system
can exacerbate this existing inflammation and induce
inflammatory resorption within the root and adjacent
bone by activating clastic cells. Once activated, the
resorptive process will progress for as long as the root
© 2016 Australian Dental Association
 Prevention and management of external inflammatory resorption
canal system remains infected and it can eventually
resorb the entire tooth root. However, it can be
arrested by appropriate treatment, as discussed below.
It is possible to prevent external inflammatory
resorption from occurring following trauma as shown
by several studies.13–18 It is also possible to arrest this
type of resorption if it is already present.3,13,14 In
both situations, the main aims in managing external
inflammatory resorption are to prevent the root canal
system from becoming infected or, if already infected,
to destroy the bacteria that are present. These aims
can be achieved by performing root canal treatment
using the general principles that are used for such
treatment with particular emphasis on the use of
specific intracanal medicaments that can affect the
bacteria and the tissue response in the PDL.13–18
As with any disease process, prevention is preferred
rather than having to intervene when the disease is
already present. Hence, it is important for dentists to
understand and predict when external inflammatory
resorption may occur and then to intervene in a
timely manner. In order to determine whether exter-
nal inflammatory resorption is likely to occur in a
particular tooth following trauma, there are two
important considerations:
(1) How likely is it that there will be pulp necrosis
and infection of the root canal system?
(2) Has the external root surface been damaged
and/or is external surface resorption likely to occur?
The injuries that are likely to have both of the
above occur are summarized in Table 1, according to
the stage of root development at the time of injury.
The literature indicates that pulp necrosis and infec-
tion are more likely to occur with luxation injuries
that have severe displacement of the tooth. These inju-
ries are also the most likely injuries to damage the
external root surface11,12 and root surface damage
generally increases as the degree of displacement
increases. Hence, concussion and subluxation are
rarely associated with subsequent inflammatory
resorption but teeth that have been intruded or
avulsed are very likely to develop this resorption.19
Extrusion and lateral luxation injuries generally have
less damage to the root surface and hence there is less
chance of inflammatory resorption (unless there is also
a crown fracture, as discussed below). Root surface
damage may also cause external replacement resorp-
tion which, unfortunately, cannot be arrested and
therefore it is important to minimize its occurrence
wherever possible. However, this is not usually possi-
ble since most of the damage has already occurred
during the injury.
The presence of a concurrent injury (e.g. a crown
fracture) to a luxated tooth makes pulp necrosis and
infection more likely.12 Crown fractures are the main
concern although cracks and enamel infractions can
© 2016 Australian Dental Association
also lead to pulp necrosis and infection. Fractures pro-
vide pathways for bacteria to enter the tooth and
reach the dental pulp – the pathways could be via a
pulp exposure (e.g. a complicated crown fracture), or
through exposed dentine tubules (e.g. an uncompli-
cated crown fracture). Cracks involving enamel and
dentine provide pathways for bacteria via the tubules
as may enamel infractions that reach the dentine.
LITERATURE REVIEW
The immediate commencement of root canal treat-
ment following repositioning/replantation and splint-
ing of luxated or avulsed teeth should be considered
for teeth with the injuries listed in Table 1. The pur-
pose of the immediate treatment is to prevent the
development of external inflammatory root resorption.
This recommendation is based on several studies that
have investigated inflammatory resorption and the
effects of various intracanal medicaments used during
root canal treatment. Some studies have also investi-
gated the effects of systemic antibiotics on inflamma-
tory resorption. The relevant studies are summarized
below.
Antibiotics
In 1986, Hammarstr€ om et al.14 reported that the
immediate use of systemic antibiotics (penicillin and
streptomycin) prevented external inflammatory resorp-
tion. They extracted teeth from monkeys to simulate
avulsion. The teeth were then infected and replanted.
One group of animals was given systemic antibiotics
and another group was provided with the antibiotics
3 weeks after the extraction/replantation procedure.
The immediate systemic antibiotics group had no
inflammatory resorption whereas the delayed adminis-
tration of the antibiotics did not reduce or stop
inflammatory resorption which was already estab-
lished by that time. The same antibiotics were also
tested as intracanal medicaments. When they were
placed in the root canals immediately after replanta-
tion, they prevented the development of inflammatory
resorption. In another group, they were placed in the
canals 3 weeks after replantation – in this group, the
resorption was almost completely eliminated.14
Hence, this study demonstrated the value of immedi-
ate systemic and intracanal use of antibiotics in pre-
venting inflammatory resorption. This study also
clearly showed that once inflammatory resorption has
started, systemic antibiotics are of no value although
intracanal antibiotics will arrest the resorption.
An ‘inflammatory resorption’ model was developed
and used in dogs by Sae-Lim et al.16 to compare two
systemically-administered antibiotics (tetracycline and
amoxicillin) with a control group that had no antibi-
85
PV Abbott
otics. The tetracycline group had significantly less
inflammatory resorption (33% of the root surface)
than the control group (72%), and it was slightly bet-
ter than the amoxicillin group (43%), although the
difference was not statistically significant. The results
of the amoxicillin group were not significantly differ-
ent to the control group. In light of these results, Sae-
Lim et al.16 recommended the use of systemic tetracy-
cline following avulsion injuries to help prevent
inflammatory resorption since tetracyclines inhibit
clastic cells20 to provide antiresorptive properties in
addition to their antibacterial properties. Tetracyclines
also have other properties which make them useful
following trauma, especially when used within the
tooth as intracanal medicaments. These properties
include substantivity21 and their bacteriostatic nat-
ure.22 Although often considered a disadvantage, the
latter can be an advantage because antigenic by-
products such as endotoxins are not released in the
absence of bacterial cell lysis.22 Tetracyclines also
inhibit mammalian collagenases, which implies that
they can help prevent the breakdown of tissues.20
Sae-Lim et al.23 also developed a ‘replacement
resorption’ model in dogs and tested the same sys-
temic antibiotics as above. Significantly more teeth in
the systemic tetracycline group had over 50% of the
root surface with completely healed sites than in the
systemic amoxicillin and control groups. Overall,
there was more healing in the tetracycline group
(35%) than in the amoxicillin (10.9%) and control
groups (11.2%). Hence, it appears that systemic use
of tetracycline may also help to prevent external
replacement resorption to a limited extent.23
Corticosteroids
Corticosteroids have been tested for their effects on
inflammatory resorption. They can be used topically
on the root surface, systemically, or intradentally as a
root canal medicament. These drugs are potent inhibi-
tors of inflammation and they also inhibit clastic cells
to have direct antiresorptive action. Sae-Lim et al.24
reported that 85% of the root surface had complete
healing in their dog ‘replacement resorption’ model
when dexamethasone was applied topically before
replanting extracted teeth. This result was significantly
better than the group treated with systemic dexam-
ethasone which had 67% of the root surfaces healing.
The latter was similar to the control group (topical
tissue culture medium) where 69% of the root surface
was healing.
When corticosteroids are used as an intracanal
medicament during root canal treatment, they are typ-
ically combined with an antibiotic. This combination
of drugs was first reported in 196125,26 and the antibi-
otic was incorporated into the mixture because of
86
concerns at the time that the corticosteroid may sup-
press the immune system and predispose the patient
to infection.27 However, this concern has never been
proven and is no longer a consideration. Corticos-
teroid/antibiotic mixtures are commercially available
and still commonly used because root canal treatment
is usually performed to reduce infection (of the root
canal system) and inflammation (of the periapical tis-
sues or any remaining pulp tissue in the canal), or in
cases of just inflammation (i.e. pulpitis), the antibiotic
is useful to help prevent infection from occurring dur-
ing treatment.28,29
The effects of a commercially available corticos-
teroid/tetracycline intracanal medicament known as
Ledermix paste (Haupt Pharma GmbH, Wolfrat-
shausen, Germany) on inflammatory resorption was
investigated by Pierce and Lindskog.15 Extracted mon-
key incisors were left on the bench to dry for an hour
and then they were replanted. The root canals were
infected to induce inflammatory resorption. One
group of teeth had Ledermix paste placed in the root
canals after 3 weeks and the canals of the other group
were left empty. Histological examination after 8
weeks demonstrated that the Ledermix group had no
inflammatory resorption and no resorption in the
PDL. In marked contrast, the other group (without a
medicament) had 89.3% of the root surface undergo-
ing inflammatory resorption and a further 8% of the
root surface had inflammation in the PDL. The Leder-
mix group had 25.1% of the root surfaces with exter-
nal surface resorption but this had not progressed to
inflammatory resorption. In addition, that group had
68% of the root surfaces with replacement resorption
and/or ankylosis but this was attributed to the teeth
being left dry on the bench for 1 hour prior to replan-
tation. The drying of the tooth resulted in necrosis of
most of the PDL cells on the root which predisposes
to replacement resorption and ankylosis. Hence, the
delayed placement of Ledermix paste 3 weeks after
injury prevented inflammatory resorption but it had
only minimal effect on replacement resorption.15 In
another study, Pierce et al.30 exposed rat dentinoclasts
to Ledermix paste and to demeclocycline alone in
order to determine whether the antiresorptive activity
was an effect of the whole paste mixture (corticos-
teroid plus tetracycline) or the tetracycline component
(demeclocycline) alone. The demeclocycline was less
effective in inhibiting the clastic cells than the entire
paste, which suggests that the corticosteroid compo-
nent was the most active antiresorptive component
within Ledermix paste. This result is similar to the
work of Suda et al.31 who reported significant inhibi-
tion of osteoclasts when they were exposed to hydro-
cortisone.
The positive effects of corticosteroids on inflamma-
tory resorption have been confirmed by Chen et al.18
© 2016 Australian Dental Association
 Prevention and management of external inflammatory resorption
in a dog study. In this study, Ledermix paste, triamci-
nolone alone, or demeclocycline alone were placed
immediately into the root canals of replanted teeth
and their effects were compared histologically. The
root surfaces of the teeth medicated with Ledermix
paste, triamcinolone alone, and demeclocycline alone
all had statistically significantly more favourable heal-
ing (75.8% of the root surface, 69.8%, 52.4%,
respectively) and more remaining root structure (5.59,
5.48, 5.09 respectively on a scale of 1–6) than the
control group (0, 1.15, respectively) which had root
canal fillings but no treatment to prevent resorption.
The difference between the Ledermix group and the
triamcinolone group was not statistically significant
but these two groups were significantly better than
the demeclocycline group. These results reinforce that
the major antiresorptive agent in Ledermix paste is
the corticosteroid component.18 However, unfortu-
nately, the canals in this study were not infected prior
to application of the medicaments. Hence, the real
value of the tetracycline component is difficult to
assess and likely underestimated. The results of this
study can only really be applied to teeth that have no
possibility of becoming infected, which is uncommon
for most avulsed or luxated teeth. If the canals of a
traumatized tooth become infected, then the role of
the antibiotic component is expected to be more
important since the antibiotic would inhibit any bac-
teria that have entered the root canal system prior to
the medicament being placed. In addition, the antibi-
otic would help to inhibit any bacteria that do enter
the root canal system from subsequently establishing
an infection.
Inflammation within the PDL begins as soon as the
trauma occurs to the tooth. Hence, the timing of
placement of the Ledermix paste becomes a critical
consideration.17 The above studies have demonstrated
that the sooner the anti-inflammatory agent is applied,
the more effective it will be – since the inflammatory
reaction can be reduced before it becomes well estab-
lished with clastic cell activity. In addition, if bacteria
are prevented from entering the root canal system,
then external inflammatory resorption cannot occur.
Hence, if pulp necrosis is expected following an
injury, immediate pulp removal and the placement of
an appropriate intracanal medicament would be
advantageous as shown by Bryson et al.17 who com-
pared the immediate placement of Ledermix paste
with the immediate placement of calcium hydroxide.
The Ledermix group had significantly less resorption,
significantly more healing and significantly more resid-
ual root mass than the calcium hydroxide group.
When Ledermix paste is placed in the root canal
system of teeth, it releases its active components (tri-
amcinolone and demeclocycline),32 which then diffuse
through the dentine as well as through any lateral
© 2016 Australian Dental Association
canals and the apical foramen to reach the periradicu-
lar tissues.32 The major diffusion pathway is via the
dentine tubules32 and this diffusion increases if the
cementum has been removed by trauma or by surface
resorption.33 Hence, the active components of Leder-
mix paste are readily available to the tissues where
they are needed to act to prevent inflammatory
resorption. The tetracycline (antibiotic) component
works mainly within the root canal system itself –
particularly in the dentine tubules by inhibiting bacte-
rial growth. The triamcinolone (corticosteroid) com-
ponent works within the periradicular tissues by
reducing inflammation and inhibiting clastic cells.
Ledermix paste maintains the release and diffusion
process at therapeutic levels for about 6 weeks in fully
developed teeth and for about 4 weeks in incom-
pletely developed teeth.32 After these times, the
amount of each active component that is being
released is less than their therapeutic levels. Hence,
Ledermix paste intracanal dressings should be
removed and replaced after these time intervals so the
treatment can continue to be effective.
Although several corticosteroid/antibiotic pastes are
commercially available, Ledermix paste is the only
one that has been investigated in research projects
and has results reported in the literature. Hence, it is
unclear whether any of the other similar pastes would
have the same effect although this is possible. As a
result of this, Ledermix paste is the material recom-
mended for the treatment protocols outlined below in
this review.
Calcium hydroxide
Calcium hydroxide has been investigated to determine
the pH changes in root dentine, especially when used
for the management of external inflammatory resorp-
tion.34 However, whilst calcium hydroxide does lead
to pH changes across the root dentine34,35 and it has
some useful properties in that it is a powerful antibac-
terial agent,36 it has no direct anti-inflammatory
action. Calcium hydroxide is a relatively toxic mate-
rial which induces cell necrosis when the cells come
into contact with it.37–39 As a result, it can induce
necrosis of both resorbing cells and reparative cells.
Such action on reparative cells in the PDL will favour
ankylosis and replacement resorption rather than heal-
ing.37–39 When calcium hydroxide is used as a root
canal medicament, it releases hydroxyl ion which dif-
fuse through the dentinal tubules and cementum to
reach the PDL.34,35 If cementum has been removed by
the trauma or by surface resorption, then diffusion of
the hydroxyl ions will be faster and more hydroxyl
ions will reach the PDL and bone. The pH in the
outer dentine can reach levels of approximately 8.0–
9.5,35 which is higher than the level at which attach-
87
PV Abbott

ment and growth of human PDL fibroblasts decreases Table 2. Summary of the indications and aims of the
(i.e. 7.8).39 Calcium hydroxide can also affect PDL preventive and interceptive approaches to managing
healing in this way and the response favours ankylosis external inflammatory root resorption
and replacement resorption.39 Hence, whilst it can
Preventive management
arrest inflammatory resorption by inhibiting the clastic
cells, the loss of the protective cementum layer in the Indications:
region of the resorption may predispose the tooth to • Immediately following the
injuries listed in Table 1 - to
ankylosis and replacement resorption if calcium reduce the chances of external
hydroxide is used in the early stages of treatment, as inflammatory resorption
developing
shown by Bryson et al.17 This effect is greatly reduced Aims - to:
if calcium hydroxide is applied later, once the inflam- • Reduce PDL inflammation
mation has resolved through the earlier use of the • Inhibit clastic cells
corticosteroid-antibiotic compound, as discussed above. • Stop bacteria entering the
root canal system
• Kill any bacteria that have
entered the root canal system
MANAGEMENT STRATEGIES during the injury/repositioning
Interceptive management
Indications:
• Teeth where external
inflammatory resorption
is already occurring
Aims - to:
• Reduce PDL inflammation
• Inhibit clastic cells
• Kill all bacteria in the
root canal system
• Encourage healing of PDL
and hard tissue repair of the
periradicular tissues

There are two distinct situations when external

inflammatory resorption needs to be managed. The
first situation is following injuries that are likely to
predispose a tooth to inflammatory resorption – i.e.
the injuries listed in Table 1 where pulp necrosis is
very likely to occur and where there is very likely to
be damage to the root surface.2 In this situation, the
management strategies should be considered as a pre-
ventive approach to reduce the possibility of inflam-
matory resorption developing.2 The second situation
is where external inflammatory resorption has already
commenced and interceptive treatment is required to
arrest the resorption and encourage repair of the PDL
and adjacent bone.3,13 The resorption may occur fol-
lowing trauma (typically on the lateral surfaces of the
root, Fig. 1b) or it may occur as a result of a long-
standing infection within any root canal system, in
which case the resorption usually occurs apically
(Fig. 1c).40
The aims of the preventive and interceptive
approaches are listed in Table 2. The aims of each
approach are similar in that they focus on inhibiting
bacteria and clastic cells. However, there are differ-
ences in how these aims are applied. The main differ-
ence is that cases with established external
inflammatory resorption already have bacteria present
and have already lost hard tissue (tooth and bone).
Hence, they require different management to destroy
the bacteria that are in the root canal system and to
encourage repair of the PDL and surrounding bone/
periradicular tissues. In the preventive approach, pro-
vided it is initiated immediately after the injury, there
is not an established infection in the root canal system
and there has been no loss of hard tissue.
Preventive management for inflammatory resorption
Based on the studies discussed above, immediate com-
mencement of root canal treatment is recommended
following injuries where external inflammatory
88
resorption is likely to occur (Table 1) in order to pre-
vent the development of external inflammatory resorp-
tion.2 The recommended management protocols are
summarized in Table 3 (for incompletely developed
teeth) and Table 4 (for fully developed teeth) since
slightly different approaches are required according to
the stage of root development at the time of injury.
This preventive treatment should form part of the
emergency management of the tooth as soon as possi-
ble after the injury – i.e. once the injuries have been
assessed, the tooth has been repositioned and stabi-
lized (e.g. with a splint) and the soft tissues have been
stabilized (e.g. with sutures).2 As these procedures are
usually performed with the aid of local or general
anaesthesia, it is then a simple matter to place rubber
dam (with a cuff technique) – if it has not already
been applied for the repositioning and splinting pro-
cess – and to cut an endodontic access cavity. The
pulp can be readily removed (e.g. with a barbed
broach) and the root canal can be irrigated with any
suitable irrigant (e.g. ethylene diamine tetraacetic acid
with cetrimide, sodium hypochlorite or even saline) to
remove any pulp remnants. Once the root canal has
been dried with paper points, a corticosteroid/antibi-
otic paste (e.g. Ledermix paste) can be placed as out-
lined below. It is not essential to fully negotiate and
prepare the root canal at this stage, although this can
be done if time permits. Determination of the working
length and the canal preparation can be done at a
subsequent appointment. The most important consid-
eration is to place the corticosteroid/antibiotic medica-
ment as soon as possible in order to reduce the
inflammation and to inhibit bacteria and clastic cells.
Complete healing of the PDL in experimental stud-
ies generally takes 8 weeks following simulated avul-
sion injuries but it is dependent on several factors and
may be delayed and take longer.41 The factors that
© 2016 Australian Dental Association
 Prevention and management of external inflammatory resorption
Table 3. Recommended preventive treatment proto-
col for incompletely developed teeth to prevent exter-
nal inflammatory root resorption after suffering the
injuries listed in Table 1 (adapted from Abbott and
Castro Salgado2)
Incompletely developed teeth – preventive management
• Systemic antibiotics – start IMMEDIATELY
- Check the patient’s age, weight, allergies etc. to determine
appropriate systemic antibiotic and doses
- Tetracycline preferred – e.g. doxycycline 100 mg – 2 tablets
on the 1st day, and then 1 tablet daily for 1 week
- Alternatively use phenoxymethyl penicillin 1000 mg
immediately and then 500 mg every 6 hours (1 hour before
meals) for 1 week
- Or use amoxicillin 1000 mg immediately, then 500 mg every 8
hours for 1 week
• IMMEDIATELY after replantation/repositioning and
stabilization with a splint
- Remove the pulp, clean the root canal – if time: measure, file,
irrigate, dry
- Place a CS-AB paste intracanal dressing – e.g. Ledermix paste
• After 4 weeks – complete canal preparation, place a new CS-AB
paste intracanal dressing
• After another 4 weeks – place a new CS-AB paste intracanal
dressing
• After another 4 weeks – take a periapical radiograph
- If no inflammatory resorption evident – place a new intracanal
dressing using a 50:50 mixture of CS-AB & Ca(OH)2
• After 2–3 months – take a periapical radiograph
- If no inflammatory resorption evident – place a Ca(OH)2
intracanal dressing to induce formation of an apical hard
tissue barrier
• Change the Ca(OH)2 intracanal dressing every 3 months until
hard tissue repair (e.g. apexification) is evident. Periapical
radiograph every 6–9 months to ensure healing
• Place the root canal filling using gutta percha and cement
• Perform internal bleaching if required and then restore the access
cavity
• Arrange to review after 6 months and then annually for at least 5
years.
Notes: (1) The root canal treatment must be commenced as soon as
the tooth has been replanted/repositioned and stabilized with a
splint.
(2) CS-AB = corticosteroid/antibiotic.
(3) Working length and canal preparation can be deferred until the
second appointment if insufficient time available at the emergency
appointment.
(4) Rubber dam must be used for all endodontic procedures.
delay PDL healing include the presence of infection,41
physical damage to the root and bone, contusion, rup-
ture of blood vessels, necrosis of the damaged tissue,
the presence of foreign bodies42 and the effects of
concurrent distant wound healing associated with
other injuries.42,43 Many or all of these factors are
likely to be present following trauma to teeth. Hence,
a cautious approach of allowing at least 3 months –
but preferably longer – for PDL healing should be
considered following most luxation and avulsion inju-
ries. Ideally, the root canal system should be medi-
cated for this time and preferably for longer periods
since the healing response is difficult to assess radio-
graphically during the first 3–6 months.3 A corticos-
teroid/antibiotic paste (i.e. Ledermix paste) is
© 2016 Australian Dental Association
Table 4. Recommended preventive treatment proto-
col for fully developed teeth to prevent external
inflammatory root resorption after suffering the inju-
ries listed in Table 1 (adapted from Abbott and Castro
Salgado2)
Fully developed teeth – preventive management
• Systemic antibiotics – start IMMEDIATELY
- Check the patient’s age, weight, allergies etc. to determine
appropriate systemic antibiotic and doses
- Tetracycline preferred – e.g. doxycycline 100 mg – 2 tablets
on the 1st day, and then 1 tablet daily for 1 week
- If allergy to tetracycline, use phenoxymethyl penicillin 1000
mg immediately and then 500 mg every 6 hours (1 hour
before meals) for 1 week
- Another alternative if allergy to tetracycline: use amoxicillin
1000 mg immediately, then 500 mg every 8 hours for 1 week
• IMMEDIATELY after replantation/repositioning and
stabilization with a splint
- Remove the pulp, clean the root canal – if time: measure, file,
irrigate, dry
- Place a CS-AB paste intracanal dressing – e.g. Ledermix paste
• After 6 weeks – complete canal preparation, place a new CS-AB
paste intracanal dressing
• After another 6 weeks – take a periapical radiograph
- If no inflammatory resorption evident – place an intracanal
dressing using a 50:50 mixture of CS-AB & Ca(OH)2
• After 2–3 months – take a periapical radiograph
- If no inflammatory resorption evident – place the root canal
filling using gutta percha and cement
• Perform internal bleaching if required and then restore the access
cavity
• Arrange to review after 6 months and then annually for at least 5
years.
Notes: (1) The root canal treatment must be commenced as soon as
the tooth has been replanted/repositioned and stabilized with a
splint.
(2) CS-AB = corticosteroid/antibiotic.
(3) Working length and canal preparation can be deferred until the
second appointment if insufficient time available at the emergency
appointment.
(4) Rubber dam must be used for all endodontic procedures.
recommended for the first 3 months and, based on the
diffusion studies discussed above,32 this implies that
two dressings for 6 weeks each should be used in fully
developed teeth, and three dressings for 4 weeks each
in incompletely developed teeth.
Following the 3-month period for initial healing, a
periapical radiograph should be taken to assess
whether external inflammatory resorption is occur-
ring.3 If there is inflammatory resorption evident, then
Ledermix paste should be used for a further 3 months
(and changed regularly as above) in an attempt to
stop the resorption. However, in almost all cases,
there will be no inflammatory resorption evident at
the 3-month review period if the treatment had been
commenced immediately after repositioning and
splinting. Hence, at this stage, calcium hydroxide can
be introduced as part of the medicament by using it
in a 50:50 (approximately) mixture with Ledermix
paste. This combination reduces the toxicity of the
calcium hydroxide44 and thereby reduces the chance
89
PV Abbott
of ankylosis and replacement resorption occurring.
This combination of materials also increases the
antibacterial spectrum compared to when Ledermix
paste is used alone,45,46 plus the hard tissue healing
effects of calcium hydroxide can begin to work. A fur-
ther advantage of the mixture is that the calcium
hydroxide slows down the release and diffusion of the
active components of Ledermix paste, which results in
them remaining in the root canal system for a longer
period of time – up to 3 months maximum.44 A slight
reduction in pH levels of approximately 0.3 pH units
occurs when the medicaments are combined47 but
each active component of the mixture (triamcinolone,
demeclocycline, calcium hydroxide) remains active.47
Hence, a period of 2–3 months with the 50:50 mix-
ture of Ledermix paste and calcium hydroxide can be
used to encourage further PDL healing prior to com-
pleting the root canal filling.
After the mixture of Ledermix paste and calcium
hydroxide has been in the root canal for 2–3 months,
a further periapical radiograph should be taken to
assess PDL healing and to determine whether any
resorption is evident. If there is no resorption (inflam-
matory or replacement), then the root canal filling can
be placed in fully developed teeth using gutta percha
and cement. If any discolouration has occurred as a
result of the trauma or the medicaments, internal
bleaching can be performed before the access cavity
and any fractures of the tooth are definitively
restored.
Some cases will require the formation of an apical
hard tissue barrier (e.g. incompletely developed teeth
requiring apexification) before the root canal filling
can be completed (Table 4). In such cases, calcium
hydroxide paste can be used alone after the 50:50
dressing period. The calcium hydroxide paste should
be replaced every 3 months until the tooth is ready
for the root canal filling once an apical hard tissue
barrier has formed.48
Typically, the average treatment time is only 6–8
months for fully developed teeth when treated as out-
lined above (Fig. 3) whilst the average time for incom-
pletely developed teeth when extra calcium hydroxide
dressings are needed is about 12 months.13 These time
periods are an advantage as they allow time to deter-
mine whether external replacement resorption and
ankylosis are occurring – if so, the overall prognosis
of the tooth will need to be reconsidered and an alter-
native treatment plan (such as extraction at an appro-
priate time) may be necessary. In some cases, the
tooth can be left in place for extended periods until
the patient is ready for extraction and replacement of
the tooth with a prosthesis. In these cases, the root
canal system can be medicated with calcium hydrox-
ide to prevent infection of the canal. There is little
point in completing the root canal filling if the tooth
90
is undergoing replacement resorption as this will only
result in the root canal filling material eventually
being embedded in the alveolar bone, necessitating
surgical removal prior to implant placement if that is
the prosthesis of choice.
The above treatment may also help to reduce, or
delay, replacement resorption to a small extent17,23
but this type of resorption is dependent on the
amount and type of damage to the tooth root and
PDL during the actual injury, as well as during the
repositioning or replantation procedures. Hence,
replacement resorption is likely to occur anyway after
avulsion and intrusion injuries since the majority of
the damage has already occurred prior to the patient
presenting for treatment.
This preventive approach to avoid inflammatory
resorption has been used for many years by the
author. Sixty teeth in 52 patients managed by this
approach have been reviewed and none of the teeth
developed external inflammatory root resorption – a
100% successful outcome.13 It is highly likely that
these teeth may have developed external inflammatory
resorption if the preventive treatment had not been
provided due to the type of injuries sustained by the
patients.
Interceptive management of established inflammatory
resorption
When external inflammatory resorption is already pre-
sent, the root canal system will be pulpless and
infected (Fig. 4) or it may have a previous root canal
filling and an infected root canal system (Fig. 5), plus
the tooth will have some form of apical periodontitis.
In the majority of cases, there are no symptoms which
suggest that there will be chronic apical periodontitis.
These cases are likely to be discovered either as part
of a regular review of a traumatized tooth, or coinci-
dentally when a radiograph has been taken to assess
the tooth or another tooth in the region. However,
some patients may present with symptoms or signs as
a result of the infected root canal system causing a
chronic apical abscess, secondary acute apical peri-
odontitis, a secondary acute apical abscess, or facial
cellulitis. In all cases, the clinical examination (includ-
ing a thorough history, pulp sensibility tests and
radiographs) should lead to the diagnosis including
external inflammatory resorption. As mentioned
above, this resorption is characterized by loss of tooth
structure with an associated radiolucency involving
the PDL and adjacent bone.
When external inflammatory resorption is present,
root canal treatment is the treatment of choice in
order to salvage the tooth. However, the tooth will
need to be assessed to determine if the root canal
treatment is feasible and particularly to determine if
© 2016 Australian Dental Association
 Prevention and management of external inflammatory resorption

(a) (b) (c) (d) (e) (f)

Fig. 3 Preventive management of an avulsed tooth to avoid external inflammatory resorption. The upper right central incisor was avulsed and replanted
within 15 minutes by the patient. The patient was seen by a dentist soon after – the dentist splinted the teeth and commenced root canal treatment immedi-
ately. Ledermix was placed in the root canal system. (a) Periapical radiograph 1 week after the accident. (b) Radiograph taken 3 months after the accident
and after two dressings of Ledermix paste for 6 weeks each – no resorption is evident. Note: the adjacent teeth have had root canal treatment commenced
because of pulp necrosis and infection and acute apical periodontitis. (c) Radiograph taken 6 months after the accident. (d) The root canal filling was com-
pleted 8 months after the accident. (e) Two and a half years after the accident, no resorption is evident. (f) Five years following the accident, there is no
evidence of external inflammatory resorption. Some ankylosis is evident on the distal surface of the coronal third of the root.

(a) (b) (c)

Fig. 4 The tooth shown in Fig. 1b with external lateral inflammatory resorption on the mesial surface was treated according to the interceptive manage-
ment protocol. (a) Periapical radiograph taken after Ledermix paste had been used as a root canal medicament for two periods of 6 weeks each (i.e. 3
months total). The resorption has ceased and repair of the PDL and adjacent bone is evident. A 50:50 mixture of Ledermix paste and Ca(OH)2 was used
for 2 months, followed by three dressings with Ca(OH)2 alone. (b) Periapical radiograph taken following completion of the root canal filling after 14
months of intracanal dressings. There is no sign of any further resorption and there has been good PDL and bone repair. (c) A 4-year follow-up radio-
graph shows no ongoing resorption.

the tooth is suitable for restoration following the root
canal treatment. This can only be assessed by remov-
ing any existing restorations, caries and cracks to
determine how much tooth structure remains.49 If
there is insufficient tooth structure, then the tooth
should be extracted. Alternatively, if the tooth is suit-
able for restoration, then root canal treatment can be
commenced.
Table 5 summarizes the treatment protocol for
teeth that already have external inflammatory resorp-
tion. The general principles are similar to the preven-
tive approach outlined above but with two major
differences. Firstly, systemic antibiotics are not indi-
cated unless the patient has an acute condition with
systemic signs of infection – such as malaise, increased
body temperature, lymph node involvement, or a
rapidly spreading infection (i.e. cellulitis). In these
© 2016 Australian Dental Association
cases, systemic antibiotics are used to control the sys-
temic manifestations of the infection only and they
will not stop the inflammatory resorption. It is impor-
tant to understand that systemic antibiotics are not
indicated for the management of established external
inflammatory resorption as shown by Hammarstr€ om
et al.14 who reported that antibiotics did not reduce
or stop inflammatory resorption once the resorption
was established – even in the early stages of the
resorptive process as they administered the antibiotics
only 3 weeks after the simulated injury.
Secondly, all cases with established external inflam-
matory resorption will have already lost hard tissue –
both tooth and bone. Hence, one of the aims of inter-
ceptive treatment is to encourage repair of the lost
hard tissues and the PDL. The most effective material
for this is calcium hydroxide as long as it is not used
91
PV Abbott

(a) (b) (c) (d) (e)

Fig. 5 Interceptive management of established external inflammatory resorption of the upper left central incisor. This tooth had been traumatized when
the patient was about 12 years old. Root canal treatment and a composite restoration were done soon after that accident. Ten years later the restoration
had broken down leading to an infected root canal system with chronic apical periodontitis and external apical inflammatory resorption. (a) Preoperative
periapical radiograph. (b) ‘Working length’ radiograph showing the extent of the resorption. (c) Radiograph taken after filling the apical third of the root
canal with a customised gutta percha point and cement – after 15 months of intracanal medication according to the protocol outlined in Table 5. The api-
cal hard tissue barrier is clearly evident. (d) Postoperative radiograph on completion of the root canal filling. (e) Review radiograph taken 4 years after
completing the root canal filling. Note: the left lateral incisor now has a pulpless, infected root canal system with chronic apical periodontitis and apical
inflammatory resorption as a result of breakdown of the composite restoration – this tooth now requires the same treatment as the central incisor has had.

in the early stages of the treatment, as outlined above.
Calcium hydroxide has a long and proven track
record in encouraging hard tissue repair and is there-
fore indicated for use as part of the management of
inflammatory resorption. It is likely to be needed for
periods of 6–12 months, with the medicament being
changed every 3 months,48 following the initial use of
Ledermix paste alone and then the 50:50 mixture of
Ledermix with calcium hydroxide.13 Once there are
radiographic signs of hard tissue repair, the root canal
filling can be completed, followed by internal bleach-
ing, if necessary, and appropriate restoration of the
tooth.
This interceptive approach has been used for many
Table 5. Recommended interceptive treatment proto-
col for teeth where external inflammatory root
resorption is occurring. This protocol applies to both
incompletely developed and fully developed teeth
Interceptive management
• Remove all restorations, caries and cracks from the tooth; ensure
the tooth is suitable for root canal treatment and restoration.
- If unsuitable for restoration, extract the tooth
• If suitable for treatment, gain access to the root canal system
• Negotiate the root canal, measure working length and
chemomechanically prepare the root canal; irrigate thoroughly
and dry the canal
• Place a CS-AB paste intracanal dressing – e.g. Ledermix paste
• After 6 weeks – place a new CS-AB paste intracanal dressing
• After another 6 weeks – take a periapical radiograph

years by the author. A review of 118 teeth with exter-

nal inflammatory resorption managed by this
approach in 103 patients has been reported.13 There
were 43 teeth with lateral areas of external inflamma-
tory resorption following earlier trauma to the teeth.
Three teeth were lost but they were all from the same
patient following avulsion and replantation – the pre-
ventive approach had not been followed by the refer-
ring dentist and by the time the author saw the
patient, the resorption was very advanced with signifi-
cant periodontal pocketing and increased horizontal
and vertical mobility. Interceptive root canal treat-
ment stopped the inflammatory resorption from pro-
gressing but the periodontal problems progressed and
the teeth had to be extracted. The other 75 teeth had
apical inflammatory resorption which was controlled
in all cases although two teeth required periapical
curettage in addition to the root canal treatment. The
surgery was required in these cases because chronic
apical abscesses persisted even though the resorption
had been arrested, based on radiographic assessment.
92
- If the inflammatory resorption has not progressed – place a new
intracanal dressing using a 50:50 mixture of CS-AB & Ca(OH)2
• After 2–3 months – take a periapical radiograph
- If the inflammatory resorption has not progressed – place a Ca
(OH)2 intracanal dressing – to induce hard tissue repair
• Change the Ca(OH)2 intracanal dressing every 3 months until
hard tissue repair of the resorptive lesion is evident. Take a
periapical radiograph every 6–9 months to monitor healing and
to determine when the root canal filling can be completed
• Once hard tissue repair is evident, place the root canal filling
using gutta percha and cement
• Perform internal bleaching if required and then restore the access
cavity
• Arrange to review after 6 months and then annually for at least 5
years.
Notes: (1) CS-AB = corticosteroid/antibiotic.
(2) Rubber dam must be used for all endodontic procedures.
(3) Systemic antibiotics are NOT indicated, unless the patient has
systemic signs (i.e. malaise, increased body temperature, lymph node
involvement, rapid spreading infection, etc.) of a systemic infection
associated with the tooth (e.g. secondary acute apical abscess or
facial cellulitis).
It is likely that these teeth had developed extraradicu-
lar infections. Hence, overall, 97.5% of the teeth were
retained in 99% of the patients using the interceptive
© 2016 Australian Dental Association
 Prevention and management of external inflammatory resorption
treatment approach outlined above and in Table 4.
Typically, the average treatment time for the intercep-
tive management of established external inflammatory
resorption is about 12–15 months.13
SUMMARY AND CONCLUSIONS
External inflammatory resorption is a potential conse-
quence of trauma to teeth that may occur when the
external root surface has been damaged and the root
canal system has become infected. External inflamma-
tory resorption can lead to loss of the tooth if it is not
managed in a timely manner. Some injuries are very
likely to develop this resorption and a preventive
approach can be adopted by commencing root canal
treatment immediately as part of the emergency man-
agement of the injury. In cases where the resorptive
process is already established, root canal treatment
can arrest the resorption and encourage hard tissue
repair. A corticosteroid-antibiotic intracanal medica-
ment is particularly useful in the prevention and man-
agement of external inflammatory resorption. Calcium
hydroxide should not be used as an immediate
medicament because of its irritant properties but it is
valuable as a subsequent medicament to encourage
hard tissue repair where required.
DISCLOSURE
The author has no conflicts of interest to declare.
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43. Zederfeld TB. Factors influencing wound healing. In: Viidik A,
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44. Abbott PV, Hume WR, Heithersay GS. The effect of combining
Ledermix and calcium hydroxide pastes on the diffusion of cor-
ticosteroid and tetracycline through human tooth roots in vitro.
Endod Dent Traumatol 1989;5:188–192.
45. Athanassiadis B, Abbott PV, George N, Walsh LJ. An in vitro
study of the antimicrobial activity of some endodontic medica-
ments and their bases using an agar well diffusion assay. Aust
Dent J 2009;54:141–156.
46. Athanassiadis B, Abbott PV, Walsh LJ, George N. An in vitro study
of the antimicrobial activity of some endodontic medicaments against
Enterococcus faecalis biofilms. Aust Dent J 2010;55:150–155.
47. Taylor MA, Hume WR, Heithersay GS. Some effects of Leder-
mix paste and Pulpdent paste on mouse fibroblasts and on bac-
teria in vitro. Endod Dent Traumatol 1989;5:266–273.
48. Abbott PV. Apexification with calcium hydroxide – when
should the dressing be changed? The case for regular dressing
changes Aust Endod J 1998;24:27–32.
49. Abbott PV. Assessing restored teeth with pulp and periapical
diseases for the presence of cracks, caries and marginal break-
down. Aust Dent J 2004;49:33–39.
Address for correspondence:
Winthrop Professor Paul V Abbott AO
School of Dentistry
Oral Health Centre of Western Australia
The University of Western Australia (M512)
35 Stirling Highway
Crawley WA 6009
Australia
Email: paul.v.abbott@uwa.edu.au
© 2016 Australian Dental Association