C.E. Credit. Management of Severe Intrusive Injury in an Immature Permanent Incisor with Revascularization

ABSTRACT

Background

Traumatic intrusion is considered one of the most severe dentoalveolar injuries; however, there is limited research detailing the management and treatment of these injuries, particularly in immature permanent teeth.

Case Description

This case report describes the management of a severe traumatic intrusion presenting with an uncomplicated crown fracture, pulp necrosis and external root resorption in a 7-year-old African American female. The left maxillary central incisor (tooth No. 9) was intruded approximately 10 mm and inaccessible. The tooth was orthodontically extruded over the course of five months. Once exposed, a regenerative endodontic procedure under oral sedation was completed. Clinical and radiographic examinations during the follow-up period showed cessation of the resorption process and discontinuation of signs and symptoms.

Practical Implications

This case demonstrates that severe intrusive injuries in immature permanent teeth can be effectively managed with revascularization even when initiation of revascularization must be delayed due to extended time needed for orthodontic repositioning.

Continuing Education Credit Available: The practice worksheet is available as supplemental material for this article: https://doi.org/10.1080/19424396.2023.2176580.

A CDA Continuing Education quiz is online for this article: https://www.cdapresents360.com/learn/catalog/view/20

KEYWORDS:

• Revascularization
• pediatric dentistry
• intrusion

Traumatic dentoalveolar injuries occur very frequently within the pediatric population and most commonly effect the maxillary incisors.^1,2 Intrusion injuries account for approximately 2% of traumatic dentoalveolar injuries in permanent teeth.² Intrusion injuries occur when a tooth is pushed axially into the tooth socket; thereby crushing the periodontal ligament and damaging the cementum, alveolar bone, and vasculature.^3–5 Intrusive injuries are classified based on the degree of clinical displacement as mild (<3 mm), moderate (3 mm-7 mm) and severe (>7 mm).^6,7 Traumatic intrusion is considered one of the most severe dentoalveolar injuries and the prognosis for healing and tooth retainment decreases with increasing intrusion severity.^5,8 Furthermore, intrusion injuries have the potential to cause permanent orofacial issues that last into adulthood.⁶ Premature loss of an anterior tooth, particularly in young patients, can lead to malocclusion, negative parafunctional tongue habits, impair aesthetics and damage the self-esteem of the patient.⁹ While intrusion injuries are severe and may have negative consequences, there is limited research detailing the management and treatment of these injuries, particularly in immature permanent teeth.

Literature states that intrusion injuries result in pulp necrosis in 45% of teeth with immature apices and 100% in cases of mature apices.^5,10–12 For severely intruded teeth with immature apices, the risk of pulpal necrosis increases.^4,5,8 Currently, the literature suggests two major procedures for managing a non-vital immature permanent tooth with an open apex – apexification and revascularization. The first, and more well-known procedure is apexification. In apexification procedures, the end of a root is closed with an apical barrier such as ga collagen plug and then packed with mineral trioxide aggregate (MTA) or gutta percha to fill the canal space.^8,9,13 While this procedure usually results in successful removal of infected pulp, the tooth is much more susceptible to fracture due to the incomplete formation of the root and thin dentinal walls.¹⁴

Another possible treatment option for non-vital immature permanent teeth is revascularization. In this procedure, the root canal is filled with calcium hydroxide or triple antibiotic paste and then bleeding is induced to promote revascularization of the pulp and continued root development.^9,14–17 While this revascularization technique has been attempted for non-vital immature permanent teeth, minimal literature could be found documenting an attempt to revascularize a severely intruded immature permanent tooth in the five months following orthodontic extrusion. The purpose of this case report is to demonstrate how revascularization can be used to manage traumatized immature permanent teeth with pulp necrosis and external root resorption after five months of orthodontic repositioning.

Case Summary

Appointment 1: Initial Examination

A 7-year-old African American female presented to Howard University Pediatric Dental Clinic for a limited oral exam regarding intrusion of tooth No. 9 (Figure 1). The patient sustained the injury approximately two weeks prior to the first appointment at Howard University Pediatric Dental Clinic (Figure 1). At the initial appointment, a limited oral exam was performed, and an intraoral photo (Figure 2) and occlusal radiograph (Figure 3) were obtained. The radiograph revealed a severely intruded maxillary left central incisor, tooth No. 9, uncomplicated enamel-dentin crown fracture at the incisal edge and widened PDL space surrounding the mesial and distal root aspects (Figure 3). The patient did not present with any dental pain. The tooth was non-mobile and intruded approximately 10 mm with only 2 mm of the clinical crown showing. Any tooth intruded greater than 7 mm may undergo spontaneous extrusion, however re-eruption could take much longer than a few weeks.^6,18 If spontaneous eruption does not occur within two to four weeks, the International Association of Dental Traumatology (IADT) Guidelines state that the tooth should be repositioned orthodontically or surgically.^6,19

Figure 1. Intruded tooth No. 9 on the first day of initial injury. Photo taken by mother at time of incident.

Figure 2. Appointment 1 intraoral photo taken two weeks after initial injury.

Figure 3. Appointment 1 radiograph.

At this appointment, the tooth was not tested for pulp vitality due to the severity of the intrusion and literature stating that in 96% of cases, intrusions result in necrotic diagnosis.^5,20 Additionally, pulp testing was delayed to avoid further exacerbating the anxiety of the child.²¹ The child demonstrated FRANKL 3 behavior, characterized by reluctant acceptance of treatment displaying caution and apprehension.²²

A variety of multidisciplinary treatment options were discussed with the parents including the risks, benefits and alternatives for treatment. Periodontal exposure of the tooth followed by orthodontic repositioning and revascularization were selected as the best option by the provider and parent. The team agreed to proceed with revascularization with the understanding that the prognosis would be guarded for long-term survival. The benefits of revascularization include maintenance of short-term aesthetics, function and alveolar bone preservation for potential future implant placement if tooth failure occurs as the child continues growth and development.

Appointment 2: Consultations and Orthodontic Button Placement

At the second appointment, consults from an orthodontist and periodontist were obtained. The orthodontic team determined that the tooth could be orthodontically extruded with light continuous forces, thereby permitting endodontic access and preventing ankylosis.²³ Extrusion with light continuous forces helps maintain the PDL space, alveolar bone level and minimize replacement resorption, while excessive heavy forces increase the risk for PDL damage, ankylosis and root resorption.²³

A periodontist assessed the supporting structures surrounding the intruded tooth and performed vitality tests of tooth No. 9 and adjacent teeth. Pulp vitality testing was performed at this appointment in adherence to American Academy of Endodontics (AAE) recommendations stating that pulp testing should be completed at the next follow-up visit following a traumatic injury.²⁴ The pulp testing verified the non-vitality of tooth No. 9 with no response and confirmed that there were no concomitant pulpal injuries in the adjacent teeth as they all had normal responses.

A limited view CBCT scan was also obtained. The CBCT showed no signs of alveolar fracture or abnormal pathology. The CBCT scans were unavailable for visualization in this article due to compatibility difficulties when downloading the images.

The periodontal team determined that the main goal of this case was to maintain an adequate amount of bone and tissue long enough to create an esthetic periodontium in case animplant or prosthesis is needed in the future. The periodontist advised against surgically repositioning the tooth as a surgical flap may result in subsequent tooth loss and interfere with periodontal healing.²⁵ To decrease the risk for complications and increase the likelihood of maintaining periodontal stability long-term, the periodontist agreed to perform a gingivectomy on tooth No. 9 to facilitate orthodontic button placement necessary for orthodontic extrusion.

After the consults, the patient was taken to the pediatric clinic for tooth No. 9 gingivectomy (Figure 4). The gingivectomy was completed to expose more tooth surface for orthodontic button placement. The region was anesthetized, approximately 2 mm of attached gingiva was excised with an external bevel incision on the facial surface of tooth No. 9. Only 2 mm of attached gingiva was excised so that an appropriate amount of tissue would be left to create an esthetic periodontium in the future if a definitive prosthesis such as an implant or bridge is warranted (Figure 4). Hemostasis was achieved and an MBT bracket was placed on tooth No. 9 with composite (Figure 5). Nitrous oxide inhalation sedation was used throughout the procedure and 100% oxygen was provided for five minutes after the procedure.

Figure 4. Appointment 2 after gingivectomy.

Figure 5. Appointment 2 orthodontic button placement.

At the end of the appointment, verbal and written postoperative instructions were given to the patient and parent. The patient was encouraged to continue an at home oral hygiene regimen including brushing twice per day using a fluoridated toothpaste, daily flossing and daily chlorhexidine gluconate 0.12% mouth rinse until gingival health improves.⁶ The parent also understood that following the gingivectomy, orthodontic extrusion and endodontic revascularization, the tooth still has a questionable prognosis.^26–28

Appointment 3: Orthodontic Band and Wire Placement

Three days after the second appointment, the patient’s mother called to report that the patient was playing in the grocery store and bumped her mouth on the grocery cart handle. The patient was instructed to come into the clinic for an emergency appointment immediately, but mother reported that tooth No. 8 chipped and did not want to bring patient in for an exam as the next appointment was only three days away. The conversation was documented.

When the patient arrived at the clinic, another periapical radiograph of teeth Nos. 8 and 9 was taken (Figure 6). Upon review of the periapical radiograph, a nutrient canal was observed, presenting as a jagged radiolucent line through the root of tooth No. 9. External root resorption of tooth Nos. 8 and 9 was also observed, as the roots of the teeth showed widened PDL spaces, open apices and ragged moth-eaten mesial and distal aspects of the roots. Vitality tests were performed on teeth Nos. 7–10. The pulpal response was normal in Nos. 7, 8 and 10, and no response was obtained from tooth No. 9.

Figure 6. Appointment 3 periapical radiograph showing uncomplicated fracture on teeth Nos. 8 and 9, external inflammatory root resorption, widened PDL spaces, open apices, ragged moth-eaten mesial and distal aspects of the roots. Tooth No. 9 bracket engaged to main arch wire with ligature tie.

The fracture on tooth No. 8 was fixed with a composite bandage. The surface was rinsed, glass ionomer liner placed (TheraCal, Bisco, San Jose, Calif.) and a thin layer of composite applied to seal the tooth. Orthodontic bands were placed on teeth Nos. 3 and 14, and brackets placed on teeth Nos. 7, 8 and 10. A 0.018 × 0.025 stainless steel main arch wire was engaged to the molar tubes and brackets on teeth Nos. 7, 8 and 10. With a separate ligature tie, the bracket was engaged on tooth No. 9 and tied to the main arch wire (Figure 6) to begin extrusion. The patient was given verbal and written oral hygiene instructions and dismissed with orthowax and chlorhexidine rinse. The patient returned to the orthodontist for biweekly visits for the next three months until the tooth was extruded enough to obtain lingual access to the tooth for revascularization (Figures 7 and 8).

Figure 7. Orthodontic progress photo at three months since initial injury.

Figure 8. Orthodontic progress photo at four months since initial injury.

Appointment 4: First Revascularization Appointment

The revascularization technique was obtained from the AAE guidelines.¹⁷ A preoperative radiograph was obtained and 36 mg of mepivacaine (Carbocaine, Cook-Waite, New York) was administered via local infiltration as any anesthetic with epinephrine may cause vasoconstriction and hinder bleeding.^17,29 Initially, a rubber dam was placed in the usual manner, however the patient’s behavior did not allow continued use throughout the duration of treatment and an Isolite (Zyris, Santa Barbara, Calif.) was placed instead. The access opening was initiated from the lingual aspect of the tooth crown. The canal was identified. A barbed broach was used to remove remnants of necrotic pulp tissue; careful not to graze canal walls and avoid root apex. No bleeding was observed, as expected. The pulp chamber and canal were gently irrigated with 20 mL NaOCl (1% concentration) using apical negative pressure irrigation (EndoVac, Kerr Corp., Brea, Calif.) for five minutes. A working length radiograph was then obtained (Figure 9, left). The canal was then irrigated with 20 mL of 17% ethylenediaminetetraacetic acid (EDTA) for five minutes and dried with paper points. EDTA is an “irrigant known to expose endogenous growth-factor proteins embedded in the dentinal walls.”⁹ Calcium hydroxide (CaOH) was placed into the canal using a syringe (Figure 9, middle). A periapical radiograph was obtained to confirm CaOH placement (Figure 9, right). The canal orifice was then covered with a 3 mm layer of temporary filling material (Cavit, 3 M, St. Paul, Minn.) and temporized with a fluoride releasing alternative glass ionomer (GC Fuji IX GP, GC America, Alsip, Ill.).

Figure 9. Appointment 5 first revascularization visit. (left) working length (middle) CaOH insertion (right) postoperative.

At the start of the appointment, consent for treatment was obtained from the parent; including nitrous consent, procedural consent and oral sedation consent. Hydroxyzine and meperidine were the oral sedation medications used. The patient’s vital signs were confirmed at the end of the appointment, and the patient was then dismissed with no complications and parent given verbal and written postoperative instructions.

Appointment 5: Second Revascularization Appointment

No signs or symptoms of persistent infection were observed. According to AAE guidelines, if swelling, pain or other symptoms persist then consider allowing additional disinfection treatment time by repeating first appointment procedure using another antimicrobial or alternative antimicrobial.¹⁷

A preoperative radiograph was obtained, and the patient was anesthetized with 36 mg of mepivacaine via maxillary local infiltration. An isolite was placed and the temporary restoration was removed. The canal was then gently irrigated with EDTA to remove the CaOH and dried with paper points (Figure 10). Bleeding was induced into the canal up to the cementoenamel junction (CEJ) by passing a No. 40 K-file through the apex. A small piece of gel foam was placed over the blood clot and MTA cap placed to the level of the CEJ (Figure 11). The tooth access was then restored with composite resin. Consent for treatment was obtained from the parent; including nitrous consent, procedural consent and oral sedation consent. After confirming pre-sedation vital signs, hydroxyzine and meperidine were administered based on the patient’s weight. At the end of the appointment, the patient’s vital signs were confirmed, and the patient was then dismissed with no complications. The parent was provided verbal and written postoperative instructions.

Figure 10. Appointment 5 irrigation with EDTA.

Figure 11. Appointment 5 postoperative PA with MTA cap and composite seal.

Over the next nine months following the second revascularization appointment, the patient attended monthly orthodontic visits to continue extruding the tooth and regain proper alignment of the tooth. The patient also returned for regular recall visits and was encouraged to continue an at home oral hygiene regimen including brushing twice per day using a fluoridated toothpaste, flossing and rinsing with chlorhexidine gluconate 0.12%.⁶

Periapical radiographs were obtained over the next 14 months following the second revascularization appointment. At 14 months, clinical and radiographic examination showed cessation of the resorption process, the beginning of apical root closure and discontinuation of signs and symptoms (Figure 12). Gingival inflammation was present due to the orthodontic appliance and poor oral hygiene (Figure 13). The patient was placed on three month recalls for prophy and fluoride varnish application. In the future after orthodontic debonding, the patient will obtain a gingivectomy to adjust the gingival zenith of incisors, a final restoration and continue clinical and radiographic follow-up.

Figure 12. Periapical radiograph at 14 months postoperative showing cessation of the resorption process and apical root closure and root development.

Figure 13. Intraoral photo one year since initial injury. Gingival inflammation and uneven gingival zenith noted.

Discussion

Traumatic intrusion is considered one of the most severe dentoalveolar injuries. Intrusion injuries comprise only 0.5%-2% of all dental trauma injuries.^2,30,31 Severe intrusions make up a fraction of that percentage. Consequently, there is limited research detailing the management and treatment of severe intrusive injuries, particularly in immature permanent teeth.

Intrusion injuries have the poorest pulp vitality prognosis of all dentoalveolar injuries.^5,10–12 Tooth survival is predominantly impacted by degree of intrusion. Tooth survival decreases with increasing severity of intrusion.⁵ In a study analyzing the clinic outcomes of permanent incisor luxation, Humphrey and colleagues found that 90% to 100% of mild and moderate intrusions (<7 mm) survived for five years, while only 45% severe intrusions (>7 mm) survived in that same five years.⁵ The majority of severely intruded incisors in this study experienced pulp necrosis in less than two years.⁵

In addition to pulp necrosis, the poor tooth survival of severe intrusive injuries may also be due to injury related complications such as concomitant crown or root fracture, root resorption, marginal bone loss and/or ankylosis.^{8,20,25,32–35} The complications that were encountered in this case were pulp necrosis, uncomplicated crown fracture and external inflammatory root resorption.

In immature permanent teeth, pulp necrosis is the most common complication following an intrusion injury.³⁴ Pulp necrosis can occur in two ways; first, through severance of the pulp blood supply and secondly, through direct bacterial invasion of the dental pulp.^35,36 In intrusion injuries, the pulp loses its source of nutrients and becomes necrotic when the tooth is pushed axially through the tooth socket crushing the periodontal ligament (PDL), alveolar bone and blood vessels.^35,36

The rate for pulp necrosis increases when the intrusion is accompanied by an uncomplicated or complicated crown fracture.^8,31,36 In a normal functioning tooth, there is a continuous outward flow of dentinal fluid that flushes out sporadically migrating bacteria.^36,37 However, when the pulp vascular supply is damaged as in severe intrusive injuries, there is no intrapulpal pressure to facilitate the outward flow of dentinal fluid that usually prohibits bacterial invasion.³⁶ With this cessation of dentinal fluid flow, microorganisms are able to enter the pulp through the exposed dentinal tubules from an uncomplicated crown fracture. Therefore, when an intrusion is accompanied by an uncomplicated fracture as in this case, bacteria is able to quickly infect the pulp resulting in a diagnosis of infected pulp necrosis.

Both the American Academy of Pediatric Dentistry (AAPD) and AAE recommend that a necrotic pulp in an immature permanent tooth be managed with endodontic revascularization.^17,38 Revascularization procedures have two steps; first, the root canal is filled with a biocompatible disinfecting agent such as calcium hydroxide or triple antibiotic paste. After three to four weeks and no recurrent signs or symptoms of pain or swelling, bleeding is induced and MTA cap placed to create a scaffold to encourage generation of new tissue within the root canal.^9,14–17,39 This is based off the fact that even if a pulp has lost vitality, residual pulp stem cells and apical papilla stem cells can still survive.³⁹ While it is generally recommended that revascularization be initiated immediately to disinfect the root canal system; in this case, revascularization was delayed by five months to allow for slow orthodontic repositioning of the tooth with light continuous forces. Slow orthodontic repositioning with light continuous forces decreases replacement resorption and aids in maintenance of the periodontium.⁴⁰

While orthodontic repositioning may be beneficial in decreasing ankylosis, external inflammatory root resorption still may occur soon after a traumatic incident or at a later time due to the severity of the intrusion.⁴¹ External inflammatory root resorption was observed at the third appointment, approximately one month after the initial intrusive injury. External inflammatory root resorption occurs when the root’s cemental barrier is broken and inflammatory stimulators from the necrotic pulp diffuse through the dentin tubules and stimulate an inflammatory response in the periodontal ligament that resorbs the tooth structure.^9,41 The treatment goal for external root resorption in this case was to remove the inflammatory stimulators and destroy the bacteria that is present by initiating endodontic revascularization.

As previously stated, ideally the team would have preferred to initiate revascularization immediately, however the tooth was inaccessible for endodontic access due to the severity of the intrusion. While surgically repositioning the tooth may have permitted more immediate pulpal access, this technique was not performed due to the high rate of complications that can occur particularly in pediatric patients with immature permanent teeth. Potential complications include pulp necrosis, external root resorption, ankylosis, marginal bone loss, contamination, infection, root fractures and iatrogenic exarticulation.^20,25,42

Orthodontic extrusion of a severely intruded tooth is recommended, since it is believed to facilitate remodeling of the supporting tissues and provide early endodontic access.^20,25,43 Additionally, placement of bands and wires in orthodontics does not require the use of local anesthetic making orthodontic repositioning less frightening for pediatric patients afraid of needles.⁴⁴ Orthodontic treatment may also be a motivating factor for many young patients to continue with extensive dental treatment.^44–46 In congruence with this literature, the team opted to continue with orthodontic extrusion and commence with revascularization once the tooth became accessible for lingual access.

In revascularization as in all endodontic procedures, rubber dam placement is the standard of care. The original treatment plan for this case included moderate oral conscious sedation and dental dam isolation. However, the child did not tolerate the rubber dam as indicated by excessive movement, whining and noncompliance upon placement. After evaluating the patient’s cooperative potential through observation and interaction with the patient, the uncooperative behavior subsided after the removal of the rubber dam and an Isolite was used alternatively. This decision was made in adherence to the AAPD guideline, “Behavioral Guidance for the Pediatric Dental Patient,” stating that maladaptive changes in patient behavior may require alterations to the treatment plan.⁴⁷

The risks and benefits of immediate treatment with an Isolite versus deferred treatment until the patient can tolerate a rubber dam was deliberated. After careful consideration, the decision was made to continue treatment with the Isolite, which provides light, suction, retraction and prevention of aspiration similar to a rubber dam.⁴⁸ Additionally, endodontists have documented that Isolites can be useful in pediatric patients with incompletely erupted teeth.⁴⁸ Lastly, delaying treatment by waiting for the patient to mature enough to tolerate rubber dam placement prior to revascularization may increase the risk of further bacterial invasion and external inflammatory root resorption over time; whereas immediate revascularization treatment with the Isolite may decrease that risk.

In the second revascularization appointment, MTA was placed at the cervical portion of the root canal. The AAE recommends MTA as the best biomaterial for sealing the pulp space in regenerative endodontics.¹⁷ MTA has high biocompatibility, aids in dentin bridge formation and forms a good barrier,⁹ however it causes gray staining. Perhaps a white MTA or a bioactive dental substitute (Biodentine, Safco Dental Supply, Buffalo Grove, Ill.) would have been a better material choice esthetically, but literature states that gray MTA, white MTA and Biodentine all contribute to tooth discoloration in some degree.⁴⁹

The AAE also recommends the use of glass ionomer cement for the cervical seal where aesthetics are a concern, however there is limited evidence demonstrating its success.^17,49 MTA was properly used in this case to seal the tooth by creating a pulp space barrier. In the future upon apical closure and continued root development, the MTA can be removed and root canal treatment performed to regain tooth color.

Since 2018, the AAE has recommended the use of triple and double antibiotic pastes in low concentrations and calcium hydroxide to disinfect the root canal system during revascularization.^17,50 Some antibiotic combination examples include: ciprofloxacin, metronidazole and minocycline or cefaclor, metronidazole and ciprofloxacin.⁵⁰

According to Althumairy and colleagues, high concentrations of triple antibiotic paste may hinder the survival of stem cells of the apical papilla, whereas calcium hydroxide promotes the survival and proliferation of these cells.^50,51 The study also revealed that toxicity to stem cells is a concentration-dependent effect that can be avoided when the concentration of the paste is one mg per mL or less.^50,51 Additionally, previous studies demonstrated that when minocycline, doxycycline, amoxicillin or cefaclor was used in the paste, clinically visible tooth discoloration was observed.⁵⁰

While multiple sources stated that calcium hydroxide and triple antibiotic pastes are equally effective in disinfecting the root canal system, calcium hydroxide was used in this case due to increased accessibility and decreased risk of concentration toxicity as can occur when using triple antibiotic paste. After the first revascularization appointment, the root resorption radiographically subsided, which demonstrates the effectiveness of calcium hydroxide in complete removal of the inflammatory stimulators in the tooth.

This case demonstrates that severe intrusive injuries in immature permanent teeth can be effectively managed with revascularization even when initiation of revascularization must be delayed due to extended time needed for orthodontic repositioning. After one year follow-up, all signs and symptoms have been discontinued and radiographs indicate cessation of the resorptive process. The parents and patient have been informed that the prognosis of long-term tooth retainment is still guarded, however, revascularization achieved the primary goal of retaining alveolar bone, maintaining dental function, preserving aesthetics and maintaining an adequate periodontium in case a future implant or prosthesis is needed in the future. Clinical and radiographic exams will be obtained at yearly intervals to determine if and when subsequent intervention is necessary. The hope is that this tooth continues to grow with the dentoalveolar complex, averts ankylosis and regains pulpal vitality.

Conclusion

This case is significant due to the rare occurrence of this injury particularly within the pediatric population, the severity of the intrusive injury, and the increased time delay between injury and endodontic revascularization therapy. Traumatic intrusion is a severe dentoalveolar injury and the prognosis for healing and tooth retainment decreases with increasing intrusion severity. However, this case shows that severe intrusive injuries in immature permanent teeth can be effectively managed with revascularization even when initiation of revascularization must be delayed due to extended time needed for orthodontic repositioning. Revascularization achieved the primary goal of retaining alveolar bone, maintaining dental function, preserving aesthetics and maintaining an adequate periodontium in case a future implant or prosthesis is needed in the future.

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/19424396.2023.2176580

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

Ariel Snell

Ariel Snell, DMD, MPH is a pediatric dental resident at Howard University College of Dentistry in Washington, D.C.

Jonathan Bacon

Jonathan Bacon, DDS, is an assistant clinical professor in the department of pediatric dentistry at Howard University College of Dentistry in Washington, D.C. He is a diplomate of the American Board of Pediatric Dentistry and the American Dental Board of Anesthesiology.

Crystal McIntosh

Crystal McIntosh, DDS, MS, is the director of the division of periodontics at Howard University College of Dentistry in Washington, D.C. She is a diplomate of the American Board of Periodontology.

Paula Nesbitt

Paula Nesbitt, DDS, MSD, is a director and assistant professor in the department of endodontics at Howard University College of Dentistry in Washington, D.C.