Review Article
Orthodontic-induced External Root Resorption of
Endodontically Treated Teeth: A Meta-analysis
Hatem A. Alhadainy, BDS, MSD, MSc (Epidem), PhD,*†
Carlos Flores-Mir, DDS, MSc, PhD, FRCD(C),* Amany H. Abdel-Karim, PhD,†‡
Jacqueline Crossman, MSc,* and Tarek El-Bialy, PhD, FRCD(C), EMBA, ABO*
Abstract
Introduction: The difference in the amount of
orthodontic-induced external root resorption (OIERR)
of endodontically treated teeth (ETT) compared with vi-
tal pulp teeth (VPT) treatment is controversial. This sys-
tematic review and meta-analysis assessed the available
evidence regarding OIERR of ETT compared with VPT.
Methods: PubMed, Scopus, MEDLINE, Web of Science,
and Cochrane databases were searched up to May 2018
to retrieve relevant studies. The studies were evaluated
for eligibility criteria, and the risk of bias was assessed
using the Risk of Bias In Non-randomised Studies of In-
terventions tool (Cochrane Bias Methods Group,
Odense, Denmark). Weighted means of OIERR in ETT
and VPT were calculated using a fixed effects model,
and a random effects model was used to assess the sig-
nificance of treatment effects. Results: Eight studies
were identified, from which 7 were included in the
meta-analyses. The funnel plot of the random effects
model exhibited a symmetrical distribution, which indi-
cates no publication bias of the included studies.
Because of the significant heterogeneity between
studies, a random effects model was used. Significantly
less OIERR for ETT was identified compared with their
contralateral VPT. Conclusions: Endodontic treatment
does not seem to increase OIERR. (J Endod 2019;-
:1–7)
Key Words
Orthodontic treatment, root canal treatment, root
resorption, systematic review, vital teeth
From the *Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; †Tanta University, Tanta, Egypt; and ‡Department of Statistics and
Operation Research, University of North Carolina, Chapel Hill, North Carolina.
Address requests for reprints to Dr Hatem A. Alhadainy, Department of Endodontics, Faculty of Dentistry, Tanta University, Tanta, Egypt. E-mail address: alhadain@
ualberta.ca
0099-2399/$ - see front matter
Copyright ª 2019 American Association of Endodontists.
https://doi.org/10.1016/j.joen.2019.02.001
JOE — Volume -, Number -, - 2019
T he durability
endodontically treated
teeth (ETT) depends
of Significance
Root canal treatment does not increase the possi-
bility of OIERR, and it is recommended to be per-
mainly on the remaining
formed for teeth with pulp inflammation and
tooth structures. Loss of
required orthodontic treatment.
tooth structures because
of any cause jeopardizes
the function of the tooth, especially for those with nonvital pulp (1). One form of tooth
structure loss is external root resorption, which is an irreversible pathological process
affecting the cementum, root dentin, or apex (2).
Successful endodontic treatment should allow the treated tooth to be fully func-
tioning and can serve as abutment for a bridge, support for a partial denture, or be
involved in orthodontic treatment. The clinician should be aware of the fact that ETT
may be subjected to different kinds of forces in addition to the normal masticatory force
(3). Functional or parafunctional overload can cause external root resorption because
of a sterile inflammatory process initiated by force application (4).
Generally, teeth involved in orthodontic treatment are subjected to external root
resorption (4). A significant number of studies have suggested an association between
orthodontic treatment and external root resorption (2, 4, 5) because it occurs in 90%
of teeth involved in orthodontic movement (6). Orthodontic-induced external root
resorption (OIERR) may lead to loss of up to one third of the original root length in
1%–5% of the involved teeth (7). Among the orthodontic-related factors that affect
OIERR are duration, magnitude, and types of orthodontic force applied (8). If some
degree of OIERR shows during the first 6 months of active treatment, it is considered
that these teeth are more likely to undergo further resorption in the following 6-month
period (9).
Published studies reported controversial findings about the ETT involved in ortho-
dontic treatment. Some researchers reported that ETT show more OIERR compared
with vital pulp teeth (VPT) when involved in orthodontic treatment (10–14), other
researchers reported less OIERR with ETT (15–17), and a third group reported no
significant differences in OIERR between ETT and VPT (18–21). Because of these
contrasting reports, OIERR on ETT remains uncertain and needs to be properly
assessed in an evidence-based manner through a systematic reviews and meta-
analyses. Therefore, this study was designed to qualitatively evaluate the currently exist-
ing evidence using a systematic review and to perform a quantitative analysis of the avail-
able data by meta-analysis to assess a possible difference in OIERR between ETT and
VPT.
Orthodontic-induced External Root Resorption 1
Review Article
Materials and Methods
Protocol Registration
The protocol for this systematic review was registered in the Inter-
national Prospective Register of Systematic Reviews database (registra-
tion number: CRD42018094492). The protocol was reported following
the Preferred Reporting Items for Systematic Reviews and Meta-Analyses
statement as closely as possible (22), and the systematic review was
focused on the following research question: “Among orthodontic pa-
tients, is there any difference in OIERR of ETT compared with VPT?”
Eligibility Criteria
We reviewed OIERR in patients undergoing orthodontic treatment
to compare the amount of OIERR between ETT and their VPT collaterals.
Because it was not expected to identify randomized clinical trials (RCTs)
during the searching process because of ethical concerns, prospective
and retrospective controlled clinical trial (CCT) articles were included
in this study. No nonelectronic supplemental databases or sources were
used, and the included studies were published in full not just abstracts
from conference proceedings. Study selection excluded the following:
case report, animal, in vitro, and cross-sectional studies.
Information Sources
PubMed, Scopus, MEDLINE (Ovid), Web of Science, and Cochrane
Library databases were used as the electronic databases (last search up-
dated in May 2018). The search was conducted using the following key
words: (TITLE-ABS-KEY ((“root resorption*”)) AND TITLE-ABS-KEY
((endodontic* OR (“root canal*”))) AND TITLE-ABS-KEY (orthodon-
tic*)). This search key was initially created for MEDLINE, and appro-
priate modifications were made according to the database.
Study Selection
Screening of titles and abstracts was conducted based on inclusion
and exclusion criteria (phase 1). For those studies that appeared poten-
tially useful, a full-text screening with the same criteria was conducted
(phase 2). Two reviewers were independently involved in the study se-
lection, and any disagreement was discussed between the 2 reviewers; a
third reviewer was involved if necessary.
Data Collection
Two independent reviewers were involved in extracting relevant
data, and interagreement was assessed by the Cohen kappa statistic.
In case of disagreements, a third reviewer made the final decision.
Data Items
The following data were extracted for each included study: study
characteristics (author, year of publication, study design, and method
of evaluation), population characteristics (sample size and patient
age in years), exposition characteristics (treatment type, treatment
duration in months, and teeth type), and outcome characteristics
(OIERR in millimeters).
Summary Measures
OIERR was assessed as the difference of the linear root length in
millimeters between preoperative and postoperative radiographs.
OIERR was expressed by means in millimeters and its 95% confidence
intervals.
Assessment of Risk of Bias
Because all included studies did not use randomized allocation for
subjects in the intervention comparison groups, the Risk of Bias In
2 Alhadainy et al.
Non-randomised Studies of Interventions tool (Cochrane Bias Methods
Group, Odense, Denmark) (23) was used to assess risk of bias in es-
timates of the comparative effectiveness of interventions. The consid-
ered preintervention risks of bias were bias of confounding and bias
in selection of participants into the study. At-intervention risk of bias
was the bias in classification of interventions, and, finally, postinterven-
tion risks included bias caused by deviations from intended interven-
tions, missing data, bias in measurement of outcomes, and bias in
selection of the reported results.
Assessment of Certainty in the Evidence. Grading of Recom-
mendations, Assessment, Development, and Evaluations assessment
(24) was performed to rate the quality of evidence for the included
studies and to make a final decision for the level of quality of the relevant
evidence. CCTs, as observational studies, start with low-quality evidence
supporting estimates of intervention. The overall quality of evidence was
modified downward to very low or upward to moderate depending on
the risk of bias, consistency, precision, publication bias, and consider-
ation of all possible confounders.
Synthesis of Results
The generic inverse variance method was performed using REV-
MAN software version 5.3 (Cochrane Collaboration, Copenhagen,
Denmark) to integrate outcome measures from similar studies and pro-
vides a common numeric estimate for OIERR. Means and standard de-
viations were used to summarize the data for each group (ETT vs VPT)
with 95% confidence intervals, and the effect estimate of an intervention
was expressed as mean differences. Weighted means of OIERR across
the studies were calculated using a fixed effects model. A test of signif-
icance was performed with the Cochran test for heterogeneity between
the studies using the I2 statistic, which describes the variation percent-
age caused by heterogeneity rather than chance. I2 over 50% was
considered as moderate to high heterogeneity, and P < .1 was consid-
ered significant. A random effects model was used to assess the signif-
icance of treatment effects where statistically significant heterogeneity
was detected.
Additional Analyses
The funnel plot of the random effects model was used to explore
publication bias such as the selective reporting bias, citation bias,
dissemination bias, and literature bias.
Results
Study Selection
The initial search yielded 55 studies that met the initial search
criteria. Twenty studies were excluded in phase 1 because they were
out of the scope of the current review, and the remaining 35 studies
were reviewed in phase 2 by 2 reviewers independently. During this
phase, 27 studies were discarded because of differences in methodol-
ogy (OIERR was not assessed as the difference of the linear root length
in millimeters). The kappa score before reconciliation for the study se-
lection was 0.802, indicating substantial interreviewer agreement. The
remaining 8 studies (11, 15–21) met the inclusion criteria for the
quantitative meta-analyses. One study (19) was not further processed
into the meta-analyses because the authors reported resorption propor-
tions and not linear measurement changes. The kappa score for data
extraction was 1.000, which indicated a perfect interreviewer agree-
ment. Figure 1 summarizes the selection process according to Preferred
Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
JOE — Volume -, Number -, - 2019
 Review Article

Idenficaon
Records identified through database searching
(n = 55)

Records screened Records excluded

Screening

(n = 55) (n = 20)

Full-text articles assessed for Full-text articles

eligibility excluded, with
(n =35) reasons
(n =27)
Eligibility

Studies included in qualitative synthesis

(n =8)
Included

Studies included in quantitative meta-

analysis
(n= 7)

Figure 1. A flowchart of the methodology according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Characteristics of the Included Studies
The included CCTs are either prospective (17, 19–21) or
retrospective (11, 15, 16, 18). Only 1 study (11) reported significantly
more OIERR in ETT compared with VPT. Castro et al (21) was the only
study that used cone-beam computed tomographic imaging for resorp-
tion assessment. Llamas-Carreras et al (19, 20) and Lee and Lee (17)
used digital panoramic radiographs, Esteves et al (18) and Spurrier et al
(11) used periapical radiographs, and Mirabella and Artun (15, 16)
used cephalograms and periapical radiographs to assess the amount
of resorption. Characteristics of the included studies are presented in
Table 1.
Results of Individual Studies
Lee and Lee (17) studied the clinical contributing factors for apical
OIERR in ETT and their contralateral VPT . In this prospective cohort
study, they measured OIERR from 35 patients with a mean age of
25.23  4.92 years. The studied confounders were patients’ age and
sex, types and durations of orthodontic treatment, periapical lesions,
and types of teeth. The authors reported significantly less OIERR for
ETT compared with their contralateral VPT. OIERR was influenced by
patients’ age, treatment duration, treatment type, and periapical lesions
but not by tooth type or sex of the patient. They also suggested that root
canal treatment can be considered for stopping or decreasing apical
OIERR when severe resorption occurs during orthodontic treatment.
Castro et al (21) detected apical OIERR in 20 posterior ETT and
their contralateral VPT from 6 adolescents (age 12.8  1.8 years).
The authors reported no increase in apical OIERR in ETT after ortho-
dontic treatment compared with VPT. The periapical radiographs
analyzed by Estevez et al (18) also revealed no statistically significant
difference in apical OIERR between ETT and VPT. They investigated
the possible similarity in OIERR in the maxillary root-filled central
incisor and its VPT homologous in 16 patients subjected to orthodontic
movement.
Llamas-Carreras et al (19, 20) published 2 articles that
investigated the difference in apical OIERR between ETT and
contralateral VPT. In the first study (19), the sample size was 77 patients
with a mean age of 32.7  10.7 years, and the patients had completed
orthodontic therapy for at least 1 year. They determined the proportion
of apical OIERR and reported no significant difference in the amount or
severity of OIERR between ETT and their contralateral VPT. The propor-
tion of OIERR was significantly greater in incisors compared with other
teeth and in women compared with men. In their second study (20),
they determined OIERR in 38 patients (14 males and 24 females).
The authors reported no significant difference in the amount or severity
of OIERR after orthodontic movement between root-filled incisors and
their contralateral VPT. Multivariate logistic regression suggested that
OIERR did not correlate with any of the studied variables (patients’
sex, type of teeth, and type of treatment).
Mirabella and Artun (15, 16) published 2 articles focused on the
difference in apical OIERR between ETT and VPT when involved in
orthodontic treatment. In the first study (15), they evaluated the prev-
alence and severity of apical OIERR of maxillary anterior teeth in a sam-
ple of adult orthodontic patients by calculating the differences in tooth

JOE — Volume -, Number -, - 2019 Orthodontic-induced External Root Resorption 3

Review Article
length measurements of standardized periapical radiographs made

Maxillary anterior
Maxillary anterior
Maxillary Incisors
Maxillary incisors

Maxillary incisors
before and after treatment. Evaluation of the 39 contralateral pairs of

Posterior teeth
Nonspecific
Teeth type
teeth with and without endodontic treatment in 36 of the patients re-

Multiple
vealed less resorption of the ETT (P < .05). In their second study
(16), they investigated the risk factors for apical OIERR using cephalo-
grams and periapical radiographs. Multiple linear regression analyses
revealed that endodontic treatment was a preventive factor that can pro-
tect ETT from OIERR. The amount of root movement, long roots, narrow
Treatment duration

24.0  12.0 months

roots, abnormal root shape, and use of class II elastics were significant

2.0  0.7 year

2.0  0.7 year
risk factors. No association was found between OIERR and treatment
<12 months
<20 months

<12 months
22 months
Multiple

time, use of rectangular arch wires, proximity of the root to the palate,
or type of initial malocclusion treatment.
Spurrier et al (11) aimed to determine whether ETT and VPT of
incisors exhibit a similar severity of apical OIERR. Periapical radio-
graphs of 43 patients who had 1 or more incisors with ETT before or-
thodontic treatment and who exhibited signs of apical OIERR after
0.022  0.028-inch bracket slots
0.022  0.028-inch bracket slots

treatment were studied. In each patient, the VPT contralateral incisor

Straight-wire technique

served as a control. VPT incisors resorbed to a significantly greater de-

Multiband/bracket

Multiband/bracket

gree than ETT incisors (P < .05). VPT in males exhibited a significant
Treatment type

increase in OIERR compared with females, whereas ETT incisors

Multiple

Multiple
Brackets

showed no significant differences between males and females.

Assessment of Risk of Bias

Using the Risk of Bias In Non-randomised Studies of Interventions
tool to assess risks of bias indicated no bias in classification of interven-
tions appeared in the included studies because only patients who
required orthodontic treatment and have ETT were included in the
Not mention
25.23  4.92

30.7  10.2
32.7  10.7
Age in year

12.8  1.8

34.5  9.0
34.5  9.0

intervention comparison groups. ETT were evaluated in comparison

with their VPT collaterals, and there was no chance for subject alloca-
14

tion. Blinding of outcome assessment was not clear in the included

studies.
None of the included studies considered all possible confounders
343 patients
343 patients
Sample size
35 patients

38 patients
77 patients
16 patients

43 patients

such as types and conditions of the treated teeth, initial malocclusion,

20 teeth

patient age and sex, type and duration of orthodontic treatment, and
longevity of root canal treatment. Mirabella and Artun (15, 16)
investigated several confounders in their studies including treatment
*Orthodontic-induced external root resorption (OIERR) is significantly less in endodontically treated teeth (ETT).

type and duration, root shape, and type of initial malocclusion, but
TABLE 1. The Characteristics of the Studies Included in the Meta-analysis Evaluation

Digital panorama

Digital panorama
Digital panorama

they did not identify the sex of their sample. Lee and Lee (17) studied
cephalograms

the OIERR in response to patient age and sex, treatment duration and
Evaluation

periapical
Periapical

Periapical
Periapical
CBCT

type, type of tooth, and the presence of periapical lesions. Llamas-

Carreras et al (19, 20) investigated OIERR in ETT in different types of
teeth for both sexes and different types of treatment, and Spurrier
et al (11) studied OIERR in both sexes. Castro et al (21) and Esteves
et al (18) did not mention the age of the treated sample of their study,
Retrospective
Retrospective

Retrospective
Retrospective

which may affect the reporting of their results. The study by Llamas-
Prospective
Prospective
Prospective
Prospective

Carreras et al (19) reported resorption proportions and not the means

Study

No significant difference in OIERR between ETT and vital pulp teeth.

of measurements, which may be considered as incomplete outcome

data.
There was bias in measurement of outcomes caused by using
different types of radiographic images in the assessment of OIERR. Spur-
Mirabella and Artun, 1995 (16)*
Mirabella and Artun, 1995 (17)*
Llamas-Carreras et al, 2012 (21)†
Llamas-Carreras et al, 2010 (20)†

rier et al (11) used periapical radiographs, Lee and Lee (17) and
Llamas-Carreras et al (19, 20) used digital panoramic radiographs,
CBCT, cone-beam computed tomography.

Mirabella and Artun (15, 16) and Esteves et al (18) used cephalograms
Spurrier et al, 1990 (12)‡
Lee and Lee, 2016 (18)*

Esteves et al, 2007 (19)†

Castro et al, 2015 (22)†

OIERR is significantly more in ETT.

and periapical radiographs, and Castro et al (21) used cone-beam

Authors

computed tomographic imaging.

Assessment of Certainty in the Evidence. Grading of Recom-
mendations, Assessment, Development, and Evaluations assessment
indicated a very low level of certainty of the included studies because
of heterogenous methodology of the CCTs and clinical factors that might
affect study intervention. Examples of such factors are the type of CCT,
methods of resorption assessment, type of the treated tooth, age and sex
†

4 Alhadainy et al. JOE — Volume -, Number -, - 2019

 Review Article
of patients, and type and duration of the orthodontic treatment. In addi-

Very low
Certainty
tion, none of the included studies investigated all possible confounders,
which affected the overall quality of evidence. Other evaluated charac-
teristics were inconsistency, imprecision, indirection, and publication
bias. Although no publication bias was evidenced in the included
studies, precision and consistency were not clear. A summary of find-

Publication bias
ings table (Table 2) was constructed using the GRADEpro GDT (Evi-

Undetected
dence Prime Inc., Ontario, Canada) app to summarize the
assessment of certainty.

Synthesis of Results
Figure 2 shows the fixed effects for the meta-analysis for the
included studies with similar comparisons and outcome measuring.
Imprecision
Assessment of certainty

Serious‡

The pooled data showed statistically significant less OIERR in favor of

ETT (mean difference = 0.31 mm; 95% confidence interval, 0.5
to 0.11 mm; P < .05; I2 = 69%). Because I2 was 69%, a random ef-
fects model was performed that showed a funnel graph with symmetric
distribution of the included studies.
Indirectness
Not serious

Additional Analyses
The funnel plot of the random effects model (Fig. 3) exhibited a
symmetrical distribution, which does not suggest publication bias
among the included studies, such as selective reporting bias, citation
Inconsistence

bias, dissemination bias, and literature bias. There was no deviation

Serious†

from the intended intervention and the overall risk of bias in the
included studies regarding intervention of moderate risk.

Discussion
Summary of Evidence
Very serious*
Risk of bias

This systematic review screened published data in an attempt to

determine the certainty of the effect of orthodontic treatment on ETT.
Searching the studies on OIERR of ETT yielded 8 studies (12, 15–18,
20, 21) that met the inclusion criteria. Although OIERR was found to
be less in ETT compared with their contralateral VPT, this difference
is unlikely to be clinically significant. This result should encourage
0.5 to
Pooled data

dental clinicians to perform root canal treatment if the tooth is

0.11

indicated for that treatment and will be involved in orthodontic

95% CI,

movement.
The included studies were performed in patients of both sexes and
different ages. Lee and Lee (17) studied OIERR in patients with a mean
age of 25.23  4.92 years and reported that apical OIERR was influ-
*Studies were considerably heterogeneous and did not consider all possible confounders.
Sample

enced by patients’ age but not by sex. Castro et al (21) used 6 adoles-
416

cents (12.8  1.8 years) but did not record the sex of the patients.
Different methodology, heterogeneous sample, and different types of treatment.

Llamas-Carreras et al (19, 20) investigated OIERR in 38 patients (14

CI, confidence interval; OIERR, orthodontic-induced external root resorption.

men and 24 women) with a mean age of 32.7  10.7 years. In their
Observational
Study design

first study (19), they reported that OIERR was significantly greater in
description

The studies involved various age groups and different types of teeth.
Studies

women compared with men; however, in their second study (20),

they reported that the proportion of OIERR was not correlated with pa-
tients’ sex. Estevez et al (18) did not identify the age or sex of their sam-
ple. Mirabella and Artun (15, 16) evaluated OIERR in patients with a
mean age of 34.5  9.0 years but did not identify the sex of their
TABLE 2. Summary of Findings Table

No. of studies

sample. Spurrier et al (11) investigated OIERR in both sexes, and the

age range was 11.3–28.5 years. They reported that VPT showed signif-
icantly more OIERR in males than females, whereas ETT incisors ex-
7

hibited no significant differences between males and females.

Tooth type may affect the amount of root resorption when ETT are
involved in orthodontic treatment. Castro et al (21) used posterior teeth
in their study of OIERR in ETT. Llamas-Carreras et al (20) and Esteves
Outcome

et al (18) used maxillary incisors, whereas Mirabella and Artun (15,

OIERR

16) and Spurrier et al (11) used maxillary anterior teeth. Lee and
Lee (17) and Llamas-Carreras et al (19) investigated different types
†

JOE — Volume -, Number -, - 2019 Orthodontic-induced External Root Resorption 5

Review Article
Figure 2. The funnel plot showing symmetrical distribution, which indicates no publication bias of the included studies.
of teeth and reported that OIERR was not affected by the type of teeth.
However, in another study, Llamas-Carreras et al (20) reported that the
proportion of OIERR was significantly greater in incisors compared with
other teeth. Comparisons of teeth types were not included in the meta-
analysis for the included studies because of the absence of sufficient
data. This limitation in the source studies did not allow an analysis
for this subgroup or other confounders.
Several studies have confirmed the association between external
root resorption and the type and duration of orthodontic treatment
(2, 4, 5). The included studies reported the duration and type of
their treatment, but not all of them investigated the effect of these
variables on OIERR. Lee and Lee (17) reported that OIERR was influ-
enced by the treatment duration and treatment type. However,
Llamas-Carreras et al (20) and Mirabella and Artun (16) suggested
that the proportion of root resorption did not correlate with treatment
type (with or without extraction) or duration.
The meta-analysis indicated that OIERR was less in ETT than their
contralateral VPT. This agreed with the results of several studies that
found significantly less OIERR in ETT compared with VPT when involved
in orthodontic movement (11, 15–17). Other studies reported no
significant difference in OIERR between ETT and VPT (18–21). The
current meta-analysis showed that root canal treatment seems to protect
teeth from OIERR. Lee and Lee (17) suggested that root canal treatment
can be considered for stopping or decreasing apical OIERR when severe
resorption occurs during orthodontic treatment. The findings of this
Figure 3. Fixed effects of the included studies with a similar intervention and
outcome measuring.
6 Alhadainy et al.
review are in accordance with such suggestions but without direct
evidence. Remington et al (25) mentioned that VPT with an active in-
flammatory process are more susceptible to root resorption because
orthodontic movement may create an inflammatory response with the
increase of OIERR.
Our findings disagreed with other studies that reported more
OIERR in ETT. Iglesias-Linares et al, in 3 articles (12–14), explained
their results for the increased risk of OIERR in ETT. In the first
article (12), they reported a direct relationship for the interleukin-
1b gene in the comparative analysis of homozygous subjects (2/2
[TT]) and (1/1[CC]), which led to an increased risk of OIERR in
ETT. In a second article (13), they reported that genetic variations in
the interleukin-1b gene (rs1143634) increased the risk of OIERR in
ETT for matched pairs secondary to orthodontic treatment in a different
way from their VPT control. In the third article (14), they reported that
variants in allele 1 of the interleukin-1 receptor antagonist gene
(rs419598) are associated with an increased risk of OIERR in ETT.
Iglesias-Linares et al evaluated OIERR in teeth of all types, which could
be considered as a confounding factor such that maxillary incisors al-
lowed more OIERR during orthodontic treatment compared with other
types of teeth.
Gulabivala and Naini (26) stated that tooth movement during or-
thodontic treatment of VPT can cause neurovascular disturbances with
inflammatory changes and eventual degenerative changes in the pulp.
This process is mediated through variations in the expression of con-
trolling molecular signaling systems that are displayed as vascular, neu-
ral, metabolic, cellular, and tissue changes. The severity of orthodontic
force on the pulp tissues is affected by the magnitude, direction, nature,
and duration of orthodontic forces and the previous history of pulpal
stimulation, such as trauma, caries, restorations, or periodontal disease
(26). These alterations of pulp tissue may explain the increased OIERR
in VPT and the protective role of endodontic treatment for teeth involved
in orthodontic movement.
Limitations
The small number of studies (7 studies) processed for the quan-
titative meta-analysis is 1 of the limitations of this systematic review.
Because the included studies were prospective and retrospective
CCTs, sample selection and allocation in all studies were nonprobability
sampling. More CCTs on OIERR of ETT are recommended with designs
that have less risk of bias, a large sample size, and controlled variables
as well as better imaging techniques. Therefore, the findings of the cur-
rent study should be considered with caution because of the lack of
JOE — Volume -, Number -, - 2019

original high-quality RCTs. However, it is unethical to measure OIERR in
ETT from RCTs, and the only available studies would be designed as CCT
studies. In addition, variation in the methods of resorption evaluation
may cause discrepancies in the reported outcomes. The meta-
analysis was performed for the included studies, regardless of the
method of evaluation, which is considered another limitation of the cur-
rent study.
Conclusion
The conclusion that can be drawn from this study is endodontic
treatment does not seem to increase OIERR. The strength of this conclu-
sion is moderate and should be considered with caution because of the
limitations mentioned earlier. Future related studies are expected to
have an important impact on the confidence of OIERR estimate and
may change the certainty of the effect of ETT on OIERR.
Acknowledgments
The authors deny any conflicts of interest related to this study.
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