Management of Pre-Eruptive Intra-Coronal Resorption: A Case Report

Omar Al Mohsen¹ and Lama Al Athel²
1. King Abdulaziz Medical City, Riyadh, Saudi Arabia
2. Pediatric Dentistry Division, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
Correspondence to: Omar Al Mohsen, omarali1417@gmail.com

DOI: https://doi.org/10.70389/PJD.100007

Additional information

• Ethical approval: This case report was reviewed and approved by the Institutional Review Board at King Abdulaziz Medical City, Riyadh, Saudi Arabia
• Consent: Written informed consent was obtained from the legal guardian for the publication of any images or data in this case report.
• Funding: Self-funded
• Conflicts of interest: N/a
• Author contribution: Omar Al Mohsen and Lama Al Athel — designed the research study. Omar Almohsen performed the Procedure. Lama Al Athel provided help and advice and supervised the procedure. Omar Omar Al Mohsen and Lama Al Athel wrote the manuscript. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript
• Guarantor: Omar Al Mohsen
• Provenance and peer-review: Unsolicited and externally peer-reviewed
• Data availability statement: N/a

Keywords: Pre-eruptive intracoronal resorption, Vital pulp therapy, Unerupted permanent molar lesions, Radiographic incidental diagnosis, Pediatric mixed-dentition management.

Peer Review
Received: 19 December 2025
Last revised: 11 January 2026
Accepted: 18 January 2026
Version accepted: 3
Published: 7 January 2026

Plain Language Summary Infographic

Introduction

Pre-eruptive intra-coronal resorption (PEIR) stands as a unique dental condition where the resorption occurs within the dentinal tissues before the tooth erupts into the oral cavity.¹ This condition is also known as pre-eruptive caries or intrafollicular caries.² Since the affected teeth are not exposed to the oral cavity, they do not undergo the histopathological processes that often occur in dental caries. Therefore, the term PEIR is preferred.³ The reported prevalence of PEIR ranges from 2%–8% per subject and from 0.6%–2% per tooth, with the mandibular first premolars and the second and third molars being the most commonly affected teeth.⁴ PEIR is asymptomatic and may be only detected incidentally in radiographs because of its rarity.⁵

The main causes of PEIR remain unclear.⁶ The correlation between PEIR and race, sex, medical conditions, systemic disorders, or fluoride intake is not well established.⁷ However, some predisposing factors, such as genetic factors, trauma, infection, and developmental anomalies, may contribute to the development of such conditions.⁸ Accurate assessment of radiographic findings in unerupted teeth enables early identification and management of PEIR defects. Early diagnosis is crucial to preventing progression and further resorption. The lesions are commonly confined to dentin, although enamel involvement may be observed in more advanced stages. Bitewing, periapical, and panoramic radiographs remain useful for confirming the diagnosis and monitoring lesion progression.⁹ Therefore, this case report presents a rare case of PEIR and the management protocol employed to reduce the risk of future complications.

Case Report

Patient Information and Clinical Findings

A 5-year-old Saudi girl presented to King Abdulaziz Dental Center Clinics for her first dental visit. The chief complaint was pain originating from the posterior region of the left side. Upon taking the medical history, the findings revealed that the patient was diagnosed with bronchial asthma. During the intraoral examination, multiple carious teeth were identified, and the soft tissues appeared normal.

Diagnostic Assessment

According to previous studies, panoramic, periapical, and bitewing radiographs are commonly used and preferred for the assessment of PEIR prevalence.^10,11 These radiographs are also proven to be effective in confirming diagnosis and monitoring the disease progression, offering several advantages over CBCT, such as less cooperation needed in children, low costs, and reduced exposure doses.^9,12,13 Furthermore, according to the American Academy of Pediatric Dentistry (AAPD), radiographic assessment for children in the transitional dentition stage (after eruption of the first permanent molar) should be individualized based on the patient’s clinical findings. For new patients, an individualized radiographic examination consisting of posterior bitewing radiographs is recommended, supplemented by selected periapical or panoramic images when indicated. For recall patients with clinical caries or increased caries risk, posterior bitewing radiographs at 6–12-month intervals are advised.¹⁴ That’s why we employed periapical and bitewing radiographs in this case report.

All teeth in this report were named according to the Federation Dentaire Internationale numbering system. During the radiographic examination, a periapical radiograph (PA) showed a large coronal radiolucency in the unerupted lower left first permanent molar (#36). Additionally, a smaller radiolucent area in the upper left first permanent molar (#26) was detected (Figure 1).

The soft tissues covering the affected tooth were normal, with no symptoms. Root development seemed to be normal with a normal periapical area, and no pathologies were detected. Based on clinical and radiographic examinations, it was concluded that teeth #26 and #36 were diagnosed with PEIR. Because the patient was asymptomatic, regular monitoring was performed until eruption of the affected teeth. At her 6-month recall visit, PAs were obtained (Figure 2). Although the lower left first permanent molar was partially erupted with no radiographic changes in the coronal radiolucent lesion, the patient reported symptoms.

Diagnostic tests, including cold, percussion, and palpation, were performed to confirm the diagnosis, and the patient was diagnosed with reversible pulpitis affecting tooth #36. According to the AAPD, indirect pulp treatment (IPT) is indicated for teeth with deep lesions approaching the pulp, in the absence of irreversible pulpitis or radicular pathology, and for reversible pulpitis. The procedure involves leaving the deepest caries-affected dentin adjacent to the pulp undisturbed and covering it with a biocompatible liner, such as resin-modified glass ionomer cement, calcium hydroxide, or mineral trioxide aggregate, followed by a definitive restoration that provides an effective seal against microleakage to preserve pulp vitality.¹⁵ Since there was no communication between the lesion and the pulp, with the patient not showing any signs of pulpal involvement, IPT was selected to manage PEIR and preserve the vitality of the tooth.¹¹

Therapeutic Intervention

After explaining the case and the treatment plan to the patient’s legal guardian, informed consent was obtained. Prior to the restorative procedure of tooth #36, local anaesthesia was administered, and rubber dam isolation was applied. Access to the defect was obtained using a high-speed handpiece with copious irrigation to preserve pulp vitality, and all resorbed tissues in the affected tooth were removed while preserving as much sound tooth structure as possible. After cavity preparation, all soft dentine surrounding the defect was removed using a spoon excavator to avoid pulp exposure. The pulpal floor was then covered with 3M™ Vitrebond™ Plus Light Cure Glass Ionomer Liner (3M ESPE Ltd., USA) as a liner, and a layer of resin-modified glass ionomer cement (Photac™ Fil Quick Aplicap™) (3M ESPE Ltd., USA) was then placed as a base.

We used resin-modified glass ionomer cement over calcium silicate due to its proven sealing ability, reducing microleakage of bacteria and other endotoxins.¹⁶ Another study also showed that RMGIC exhibited a higher shear bond strength value compared to the three calcium silicate liners, including MTA, Biodentine and TheraCal LC.¹⁷ It was also shown that RMGIC provides sufficient bond strength to withstand polymerization contraction stresses from overlying composite resin, due to its resin matrix, which enhances bonding chemically and mechanically.¹⁸ Finally, a resin-based composite was selected for the final restoration to enhance chemical and mechanical bonding with RMGIC.¹⁸ Tooth #26 was less affected; therefore, the same procedure was performed, but no liner or base was necessary before restoration; only composite restoration was used.

Follow-Up and Outcomes

After 6 months, the patient presented for follow-up, reporting no evident signs or complaints of the treated teeth. Periapical and bitewing radiographs show normal root development, with no signs of a pathological lesion or resorption (Figure 3). The researchers acknowledge the short follow-up period.

Discussion

The PEIR etiology and pathogenesis remain not clearly understood since there is no direct communication between the teeth and cariogenic microorganisms.³ However, apoptosis or loss of continuity of the reduced enamel epithelium is the most accepted theory.^19,20 Additionally, research indicates a significant correlation between tooth ectopic position and PEIR.^21,22 Histological findings indicate that, during the pre-eruptive stage, these lesions contain soft tissue, with multinucleated giant cells, osteoclasts, and chronic inflammatory cells contributing to dentin breakdown through micro-perforations.^4,23 PEIR often occurs in the mandible, with molars being more commonly affected than other teeth.^7,21 Most cases are usually diagnosed in mixed dentition stage during routine radiographic examinations.⁶ This dental anomaly occurs infrequently, making it less likely for clinicians to encounter such cases routinely.⁸ Consequently, limited exposure and familiarity with the condition contribute to oversight or misdiagnosis. Furthermore, PEIR typically lacks specific visible clinical symptoms that alert to its presence.^3,24 Sometimes, patients may not experience pain or discomfort unless secondary complications arise due to infection or pulp involvement.^4,8

Once a tooth erupts, it becomes susceptible to microorganisms, and these defects can become indistinguishable from dental caries. It is important to emphasize the importance of early dental visits for caregivers to prevent further disease progression.⁸ It is challenging to distinguish PEIR from dental caries, as both present as radiolucent areas on radiographs. Unlike caries, PEIR lesions are noncavitated prior to eruption. Additionally, PEIR lesions may have an intact enamel surface clinically. If left untreated, these lesions can compromise the structural integrity of the tooth, increasing the risk of fracture or post-eruptive infection.⁷

Although molar incisor hypomineralization (MIH) and PEIR are both developmental dental defects that can compromise tooth structure, they show major differences in terms of etiology, presentation, and management. MIH results from systemic disturbances during enamel formation, leading to demarcated opacities, post-eruptive enamel breakdown, and hypersensitivity. In contrast, PEIR occurs in the occlusal portion of the crown of unerupted teeth and arises from localized resorption of dentin by osteoclast-like cells after crown formation is complete; it is typically noncavitated before eruption and detected incidentally on radiographs. Mineral content is reduced in both conditions, with MIH showing decreased calcium and phosphate in hypomineralized enamel, while PEIR demonstrates resorption of dentin and reduced mineralization of the overlying enamel.²⁵

Currently, there is no established protocol for managing PEIR. Evidence suggests that the treatment of PEIR primarily depends on several factors, such as the defect size when detected, the nature of disease progression, and the expected eruption timing.^7,9,21 For lesions classified as static (nonprogressive), most authors advocate a conservative approach, monitoring the defect until tooth eruption, with restoration performed after eruption. In progressive (developing) cases, immediate intervention is recommended to prevent. Treatment options include application of sealants, restoration of the defect, IPT, root canal therapy, or extraction.^4,9,26 If the defect is confined to the dentin with no pulpal involvement and symptoms of reversible pulpitis, IPT is recommended to preserve the vitality of the tooth. In cases of pulp exposure, appropriate management involves pulp capping or root canal treatment. When the lesion is extensive or symptomatic, extraction is considered the treatment of choice.^9,15,27

Notably, several studies have explained the effectiveness of various treatment options for PEIR. Manmontri et al.²⁸ described a non-progressive PEIR lesion on the left mandibular second permanent molar of a 17-year-old boy. The lesion was first detected at 8 years and 8 months of age and was monitored clinically and radiographically annually. Given the lesion’s stability over 9 years, the patient’s low caries risk, and the high level of patient and parental compliance, a resin-based sealant was applied to the affected tooth, and the lesion was managed conservatively without operative intervention.

The resin sealant was selected to prevent caries development in the affected area, thereby avoiding significant structural damage. Another case report by Yamana et al.²⁹ reported a severe PEIR lesion on the unerupted mandibular left first permanent molar of a 5-year-old girl. Radiographs revealed a large radiolucent area in the coronal portion of the tooth, extending close to the pulp. After a 12-month follow-up, the tooth had erupted into the oral cavity. Surgical removal of the overlying gingival tissue showed the tooth to be intact; however, removal of the enamel revealed a hollow space approximately 2 mm deep without pulp exposure. Calcium hydroxide was applied, and the defect was restored with cement. Three months post-treatment, the patient exhibited no signs or symptoms of abnormality.

Additionally, Mistry et al.²⁴ reported a case of a 10-year-old female patient with PEIR, diagnosed during evaluation for pain and decayed teeth in the lower right posterior region. Radiographic examination revealed PEIR affecting multiple permanent teeth, along with caries and pre-shedding resorption in primary teeth. The PEIR lesions were managed surgically with caries excavation, placement of Biodentine™, and restoration using light-cured glass ionomer cement under complete isolation. Follow-up over several months, including periodic radiographs, demonstrated pain relief, normal eruption of affected teeth, and no progression of the lesions. Furthermore, in the case reported by Omar et al.,³⁰ a PEIR lesion was diagnosed on the permanent second molar of an 11-year-old patient. Prior to eruption, the tooth was surgically exposed, and a partial pulpotomy using MTA was performed at the site of pulp exposure. Eight weeks later, the tooth was restored with Para Core^® and composite resin. The treatment approach was selected based on the severity of the lesion (to prevent further structural damage).

Conclusions

PEIR is a rare developmental radiolucent lesion that occurs within dentin before tooth eruption. This anomaly has a nonspecific etiology and can be detected only on radiographs in early cases. In asymptomatic cases, regular monitoring is mandatory to ensure the condition is stable. If the patient presents with symptoms such as pain or discomfort, prompt intervention should be considered to prevent pulp involvement, further resorption, or tooth loss. Therefore, early diagnosis and radiographic screening are crucial during the mixed dentition stage. Restorative treatment of progressive resorptive lesions is necessary, and long-term follow-up is essential to monitor clinical and radiographic outcomes after the treatment.

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Cite this article as:
Mohsen OA and Athel LA. Management of Pre-Eruptive Intra-Coronal Resorption: A Case Report. Premier Journal of Dentistry 2026;5:100007

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