Documente Academic
Documente Profesional
Documente Cultură
Pulp Regeneration
Revascularization
Odontoblastic layers
Innervation
Stem/Progenitor Cells
Growth Factors
Scaffold
Regenerative Endodontic Treatment of Permanent Teeth after Completion of Root Development: A Report of Two Cases
Paryani et al, J Endod 2013
CASE PRESENTATION
Case 1
General Data Chief Complain
Case 2
14 y/o girl presented on 11 y/o girl presented on August 5, 2010 September 2, 2010 Pain on her upper front tooth for 3 or 4 days. The pain was constant but not severe Emergency treatment was done Noncontributory Pain on her upper front tooth
Case 1
Extraoral Non significant Examination
Case 2
Non significant
Tooth 21
Uncomplicated crown fracture with an existing composite restoration Cold test: (-) Percussion (-) Palpation (-) PD: WNL Mobility: normal
Case 1
X-ray
Case 2
Periradicular Periradicular rarefaction along mesial rarefaction aspect of the root with approximately 5x5 mm closed apex in size around the mature apex
Diagnosis
Treatment Course
Case 1
First appointment
1 week
Second appointment
Case 2
First appointment
22 days
Second appointment
First Appointment
Case 1
Informed consent Anesthetized with 2% lidocaine (1:100,000 epinephrine) and RD isolation No bleeding observed in the root canal on removal of the temporary restoration Irrigation with 5.25% sodium hypochlorite and drying with paper points Methyline blue dye application to check for fractures but none detected under microscope Take working length radiograph
Case 2
Informed consent Anesthetized with 2% lidocaine (1:100,000 epinephrine) and RD isolation Access cavity preparation performed under a microscope Take working length radiograph
Case 1
Mechanical instrumentation by step-back technique and copious 5.25% sodium hypochlorite irrigation Canal cleaned and shaped to the radiographic apex Apical foramen enlarged to 0.6 mm with #60 K-file Canal dried and medicated with a paste form calcium hydroxide to the root apex Temporized with Cavit
Case 2
Mechanical instrumentation by step-back technique and copious irrigation with 5.25% sodium hypochlorite and 17% EDTA Apical foramen enlarged to 0.6 mm with #60 K-file Canal partially dried with paper points and dusted with ciprofloxacin powder with a mini amalgam carrier The powder carried down to the apex with a hand plugger Canal coated with the powder by using hand files Temporized with Cavit
Second Appointment
Case 1
Asymptomatic: percussion (-), palpation (-) Anesthetized with 2% lidocaine (1:100,000 epinephrine) and RD isolation Calcium hydroxide completely removed with 5.25% sodium hypochlorite Canal irrigated with 17% EDTA for 1 minute and dried with paper points
Case 2
Asymptomatic: percussion (-), palpation (-) Anesthetized with 3% mepivacaine and RD isolation Canal irrigated with 5.25% sodium hypochlorite Canal irrigated with 17% EDTA for 1 minute and dried with paper points
Case 1
Bleeding induced in the canal by passing #40 sterile K-file 3 mm beyond the apex Collacote placed in the canal after dusted with ciprofloxacin powder MTA placed 2 mm below cementoenamel junction against Collacote Tooth restored with GI
Case 2
Bleeding induced in the canal by passing #30 sterile H-file 3 mm beyond the apex Collacote placed in the canal MTA placed 4 mm below cementoenamel junction against Collacote Tooth restored with GI
Follow-up
Case 1
2-week Asymptomatic Percussion (-), palpation (-), Cold test (-) 1-month Asymptomatic Percussion (-), palpation (-) Decrease in size of radiolucency along the mesial side of the root 2-month Sensitive to cold drink Cold test (-)
Case 2
1-month Asymptomatic: percussion (), palpation (-) Reduction in size of periradicular radiolucency 5-month Periapical radiolucency had almost disappeared
Case 1
Case 2
1 year and 3 months 18-month Tooth restored by general Asymptomatic: percussion (dentist ), palpation (-) Further decrease in size of EPT (-) radiolucency Cold test (-) Endo-Ice: normal response Complete resolution of the PD: WNL periapical radioluceny with EPT: 79/80 intact lamina dura and 22-month normal PDL space. Percussion (-), palpation (-) Thinning of the root canal at Endo-Ice: normal response the apical one-third (-) EPT: 34/80 PD: WNL Complete resolution of periapical radiolucency with thinning of the root canal at the apical one-third
Case 1
Post-OP
1 month
15 months
22 months
Case 2
Post-OP
1 month
5 months
18 months
Immature Teeth
More Challenge 1: Stem/Progenitor Greater regeneration potential cells
Mature Teeth
Less Less regeneration potential due to aging
Open apex allow more stem/progenitor cells to migrate into root canals
Greater difficulty
22
SCAP: Stem cells of the apical papilla Presence in mature teeth has not been reported
May participate in pulp regeneration Need to be stimulated to migrate into root canal space
Haynesworth et 1992 Seo et al, 2004
Immature Teeth
More Challenge 1: Stem/Progenitor Greater regeneration potential cells
Mature Teeth
Less Less regeneration potential due to aging
Open apex allow more stem/progenitor cells to migrate into root canals
Greater difficulty
24
Sufficient disinfection
Induced Bleeding
Successful revascularization cases by using calcium hydroxide without induced bleeding
Chueh et al, 2009
Failed regenerative procedures attributed to inability to evoke bleeding into the canal
Ding et al, 2009
600-fold increase in stem cell markers in canal blood compared with the level in systemic blood when bleeding was induced in immature teeth Lovelace et al, 2011 Bleeding induced by passing files beyond the apex thought to stimulate the migration of adult stem/progenitor cells into the root canal Evoked bleeding may be critical in pulp revascularization of mature necrotic teeth
Sufficient disinfection
No clinical evidence yet with regard to the critical apical size in clinical regenerative endodontic treatment
Sufficient disinfection
Canal Disinfection
Mature teeth have more complex root canal anatomy than immature teeth Disinfection in immature necrotic teeth
Chemical means: antimicrobial irrigation and intracanal medication Mechanical (-)
EDTA
Calcium Hydroxide
Did not kill human mesenchymal stem cells when concentration range between 0.01 mg/ml~100 mg/mL
Ruparel et al, 2012
Antibiotics
4 different combination antibiotics including triple, double, and modified triple antibiotics and Augmentin showed detrimental effects on survival of the stem cells in all concentrations 1 mg/mL
Ruparel et al, 2012
Combination
Triple antibiotics (metronidazole, ciprofloxacin and minocycline) Double antibiotics (metronidazole and ciprofloxacin) Eradicate bacteria isolated from infected dentin and pulp in vitro, although complete eradication not shown in vivo
Combination antibiotics could be more effective in immature teeth where no or minimal mechanical instrumentation is performed A combination of antibiotics may not be needed in mature teeth if thorough chemomechanical instrumentation is performed
Ciprofloxacin
Broad-spectrum antibiotic against both grampositive and gram negative bacteria
Case 1: 7-day Ca(OH)2 dressing and Ciprofloxacin dusting after bleeding was evoked Case 2: Medicated with ciprofloxacin for 22 days
Ciprofloxacin dusting procedure might be harmful for survival of migrated stem/progenitor cells
Not strong enough to kill the migrated cells Prevent the migrated cells from being contaminated by remaining bacteria
EDTA
Suggested to be a single irrigant for pulp regeneration in immature necrotic teeth at the second appointment
Promote SCAP survival (89% viability)
Lower cell viability (74%) was observed when both sodium hypochlorite and EDTA were used
5.25% sodium hypochlorite and 17% EDTA used at the second appointment in both cases
More thorough chemomechanical instrumentation required in mature necrotic teeth A significant decrease in viability of migrated cells was expected Final irrigation with EDTA may
Stimulate the release of growth factors embedded in dentin matrix Enhance the odontogenic differentiation of migrated cells and angiogenesis
Cell Viability
Ca(OH)2
Combination ABX Cirpofloxacin EDTA NaOCl
Suggested Use
0.01 mg/ml~100 mg/mL
< 1 mg/mL, not necessary in mature teeth if thorough chemomechanical instrumentation is performed < 1 mg/mL, promote almost 100% survival of SCAP Final irrigation with EDTA
Necessary for more thorough chemomechanical instrumentation required in mature necrotic teeth
Outcome Assessment
Radiographic healing of apical periodontitis and clinical symptoms
Case 1 and Case 2: complete resolution
Case 1
Revacularization
+
Case 2
+
+ (?)
+
Other diagnostic tools to detect the presence of apical vital tissues in root canals may need to be developed for more accurate initial outcome assessment
Clinical Situations
Immature teeth with irreversible pulpitis
Filled with pulp-like loose connective tissues 3.5 weeks after regenerative endodontic treatment on the basis of histologic observation Shimizu et al 2012