What is the best long-term treatment modality for immature permanent teeth with pulp necrosis and apical periodontitis?

Intraradicular reinforcement of traumatized immature anterior teeth after MTA apexification

This review article describes the methods and clinical recommendations for reinforcing traumatized anterior immature teeth with pulp necrosis treated with mineral trioxide aggregate (MTA) apexification. Traumatic injury can cause pulp necrosis and incomplete root formation in immature teeth. MTA apexification is the treatment of choice for necrotic immature teeth, particularly during the middle or late stages of root development. MTA apexification has a high success rate; however, failures due to cervical or root fractures occasionally occur. The risk of fracture is higher in immature teeth with thin root dentin, particularly those with external root resorption. Furthermore, the loading force from any parafunctional habit also increases fracture risk. Therefore, intra-radicular reinforcement may be necessary after MTA apexification. In vitro, intraradicular restoration with a resin composite/core build-up material or a prefabricated fiber post demonstrated better root reinforcement than root canal obturation materials (i.e., gutta-percha and sealer). However, the root-reinforcement effect of MTA orthograde filling in the entire root canal remains unclear. In vivo, the survival of fractured teeth with intraradicular restorations (resin composite/core build-up material or prefabricated fiber posts) is extremely high. Moreover, the survival of teeth with gutta-percha/sealer obturation or MTA orthograde filling and restoration with resin composite extending into the cervical third of the root canal approximately 1-2 mm below the cemento-enamel junction is acceptably high. Based on this evidence, the remaining tooth/root structure and loading force should be carefully examined when considering intra-radicular reinforcement of immature anterior teeth treated with MTA apexification.

Regenerative endodontic treatment and traumatic dental injuries

Pulp necrosis is the most common complication following dental trauma and is often associated with apical periodontitis. The management of these teeth is challenging in terms of large root canals, open apices, thin dentinal walls, and short roots. Over decades the conventional treatment for these teeth was calcium hydroxide apexification, a time-consuming procedure despite high success rates. Subsequently after the introduction of mineral trioxide aggregate and hydraulic calcium silicate materials single visit apical plug procedures became increasingly practiced with comparable success rates to the conventional apexification. The search continued afterward for a clinical procedure that may stimulate further root development and apical closure to avoid the long-term complication of root fracture after apexification. Regenerative procedures using stem cells derived from the apical papilla and blood clots as scaffolds were then introduced for the management of immature teeth, with variable protocols and success rates. This review will cover the evidence available and current position of regenerative endodontic procedures in traumatized immature teeth with apical periodontitis, in terms of clinical protocols, outcome, and potential prognostic factors.

Role of mesenchymal stem cell-derived exosomes in the regeneration of different tissues

Exosomes are nanovesicles with multiple components used in several applications. Mesenchymal stem cells (MSCs) are well known for their great potential in clinical applications. MSC-derived exosomes (MSC-Exos) have been shown to mediate tissue regeneration in various diseases, including neurological, autoimmune, and inflammatory diseases, cancer, ischemic heart disease, lung injury, and liver fibrosis. They can modulate the immune response by interacting with immune effector cells in the presence of anti-inflammatory compounds and are involved in intercellular communication through various types of cargo. This review summarizes the MSC-Exos-mediated tissue regeneration in various diseases, including neurological, cardiovascular, liver, kidney, articular cartilage, and oral tissue applications. In addition, we discuss the challenges and prospects of MSC-Exos in tissue regeneration.

Outcomes of apexification in immature traumatised necrotic teeth and risk factors for premature tooth loss: A 20-year longitudinal study

BACKGROUND/AIM

To evaluate the long-term survival of immature traumatized incisors with pulp necrosis and apical periodontitis after endodontic treatment with two apexification techniques (calcium hydroxide apexification and MTA-apical plug) and to identify major factors affecting the survival of these teeth.

MATERIALS AND METHODS

Records of 2400 children and adolescents were screened for presence of traumatic dental injuries to immature incisors where endodontic treatment with the two apexification techniques was performed during January 2003 and December 2022, compared to a control group of mature teeth treated with conventional endodontic techniques. The studied variables were age; sex; apexification technique, presence of luxation and hard tissue injuries; preoperative root development stage (RDS), preoperative and postoperative periapical index (PAI), the time-point for tooth loss, and overall survival time in years. Kaplan-Meier estimates were used to graphically present the survival functions and Cox proportional hazard model to calculate hazard ratios (HR, 95% CI).

RESULTS

The median survival time was 10 years for calcium hydroxide apexification, 16.1 for MTA-apexification, for luxation injuries other than intrusions and avulsions 15.5 years, for intrusions 12.5 years and for avulsions 6.8 years. The variables with significant negative impact on tooth survival were calcium hydroxide apexification, avulsion and postoperative PAI 3-5. No significant relationships were found for the variables MTA apexification, concussion; subluxation; lateral luxation; extrusion, intrusion, hard tissue injuries, preoperative RDS and PAI scores and postoperative PAI 1-2. After adjustment, the risk for premature tooth loss was 13.5 times higher in calcium hydroxide apexification, approximately 2 to 4 times higher in PAI 3-5, and 5.6 times higher in avulsions.

CONCLUSIONS

Calcium hydroxide apexification, avulsion, and postoperative PAI 3-5 were identified as prognostic variables with significant negative impact on the risk for premature tooth loss.

Differential expression of circRNAs during osteogenic/odontogenic differentiation of stem cells from apical papilla promoted by blue light-emitting diode

BACKGROUND

Circular RNA (circRNA) is a key player in regulating the multidirectional differentiation of stem cells. Previous research by our group found that the blue light-emitting diode (LED) had a promoting effect on the osteogenic/odontogenic differentiation of human stem cells from apical papilla (SCAPs). This research aimed to investigate the differential expression of circRNAs during the osteogenic/odontogenic differentiation of SCAPs regulated by blue LED.

MATERIALS AND METHODS

SCAPs were divided into the irradiation group (4 J/cm2) and the control group (0 J/cm2), and cultivated in an osteogenic/odontogenic environment. The differentially expressed circRNAs during osteogenic/odontogenic differentiation of SCAPs promoted by blue LED were detected by high-throughput sequencing, and preliminarily verified by qRT-PCR. Functional prediction of these circRNAs was performed using Gene Ontology (GO) and the Kyoto Encyclopedia of Genes and Genomes (KEGG) and the circRNA-miRNA-mRNA networks were also constructed.

RESULTS

It showed 301 circRNAs were differentially expressed. GO and KEGG analyses suggested that these circRNAs were associated with some signaling pathways related to osteogenic/odontogenic differentiation. And the circRNA-miRNA-mRNA networks were also successfully constructed.

CONCLUSION

CircRNAs were involved in the osteogenic/odontogenic differentiation of SCAPs promoted by blue LED. In this biological process, circRNA-miRNA-mRNA networks served an important purpose, and circRNAs regulated this process through certain signaling pathways.

Impact of using XP-endo finisher and nanobubble water during EDTA dentin conditioning on TGF-β1 release in regenerative endodontic procedures

INTRODUCTION

Transforming Growth Factor-Beta 1 (TGF-β1) plays a crucial role in the success of Regenerative Endodontic Procedures (REPs) as they directly impact the proliferation and differentiation of stem cells. TGF-β1 is released by conditioning of the dentin matrix using 17% EDTA. EDTA was found to have deleterious effects on dentin especially in immature teeth with fragile dentin walls. Decreasing the irrigation time was reported to decrease these effects. Accordingly, enhancement and activation of the EDTA solution to maintain its efficiency in TGF-β1 release from dentin and thus compensating the reduction in irrigation time was employed. EDTA solution was enhanced by adding Nanobubble (NB) water which contains oxygen filled cavities less than 200 nm in diameter. Additionally, EDTA was activated with XP-endo Finisher rotary file. The aim of this study was to assess the impact of NB enhancement and/or XP-endo Finisher activation of the EDTA solution on the TGF-β1 release from dentin.

METHODS

Fifty standardized root segments with open apex were allocated to two main groups according to whether EDTA was enhanced with NB water or not, and within each group whether XP-endo Finisher activation was used or not in addition to a Negative Control group. The concentration of the released TGF-β1 in the root canal was measured using enzyme-linked immunosorbent assay (ELISA). The statistical analysis was done using the Shapiro- Wilk, Kolmogorov Smirnov, ANOVA and Post-hoc Tukey tests.

RESULTS

All groups released a considerable amount of TGF-β1 with the highest values in the EDTA/NB/XP group, followed by EDTA/NB, EDTA/DW/XP, EDTA/DW and Negative Control groups respectively.

CONCLUSIONS

The results of this study suggest that NBs can promote the success of REPs since it revealed a significant increase in the TGF-β1 release following its use in the enhancement of the EDTA solution. A comparable effect was obtained by XP-endo finisher activation of the EDTA solution. The combined use of NBs and XP-endo Finisher can be a promising addition in REPs. Accordingly, Enhancement and activation of the EDTA solution may compensate decreasing the EDTA irrigation time attempted to avoid the deleterious effect of EDTA on dentin.

Can a dentin bonding agent prevent color change in regenerative endodontic procedures? An in vitro evaluation

This in vitro study aimed to determine the efficacy of dentin bonding agents in preventing color changes following Regenerative Endodontic Procedures. One hundred twenty bovine incisors were endodontically prepared and randomly assigned to a two main factors design: application of a dentin bonding agent (Scotchbond Adper, 3M ESPE, St Paul, MN, USA) in the pulp chamber (Group 1, n=60) versus no bonding intervention (Group 2, n=60), and five levels of intracanal medication (n=12/subgroup): Triple antibiotic paste (TAP), double antibiotic paste (DAB), calcium hydroxide (CH), modified triple antibiotic paste (TAPM), and Control (CTL). Color changes were measured over 28 days at multiple time points (1, 3, 7, 14, 21, and 28 days) using the CIEDE2000 formula to calculate the color difference (ΔE00) from baseline (T0). The ΔE00 quantifies the perceptible color difference between the initial and final tooth color, with lower values indicating less discoloration. The results were analyzed using repeated measures ANOVA-2 and post-hoc Holm-Sidak tests. The TAP subgroups, both with and without the bonding agent, exhibited the highest color variation. However, a pulp chamber seal with a bonding agent showed a protective effect against discoloration compared to no seal, even though complete prevention was not achieved. All groups demonstrated ΔE00 values beyond acceptable interpretation thresholds for clinical application, primarily driven by a reduction in lightness (L*) and a decrease in redness (a* value, shifting towards green). In conclusion, while the pulp chamber seal with a bonding agent mitigated TAP-induced discoloration, it did not eliminate it.

Evaluation of Outcomes in Immature Teeth After Revitalization or Apexification Procedures: A Systematic Review and Meta-Analysis

There are two main treatment options for immature teeth with necrotic pulp and apical periodontitis. Apexification creates a mineralized tissue barrier, while revitalization aims to regenerate vital tissue in the canal space. There is no conclusive evidence to determine the most effective procedure regarding root length and dentin wall thickness. The objective of this systematic review was to compare the outcomes of revitalization and apexification procedures in immature non-vital teeth in terms of root length and dentin wall thickness. A literature search was conducted using the PubMed, ScienceDirect, Google Scholar, and Embase databases. Articles relevant to the study topic were gathered according to the selection criteria, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The included studies had to be published in English, conducted over a six-year period, and compared the outcomes of revitalization and apexification procedures in immature non-vital teeth. Data were collected using appropriate keywords from the eligible studies. Six articles were included for qualitative and quantitative analysis. The eligible studies showed a low risk of bias. In all revitalization cases, the root length increased significantly (mean difference (MD) (%) = 5.91; 95% confidence interval (CI) = 2.39-9.43; p = 0.0010; MD (mm) = 2.43; 95% CI = 2.05-2.80; p < 0.00001). The dentin wall thickness was statistically significant in most cases (MD (%) = 10.94; 95% CI = 7.01-14.88; p < 0.00001), MD (mm) = 0.16; 95% CI = 0.07-0.25; p = 0.0007). The systematic review and meta-analysis showed both procedures to be credible treatment options for necrotic immature teeth. Apexification had a positive impact, to some extent, on the development of root length. Revitalization yielded a significantly greater increase in root length and root dentin wall thickness and appeared to be superior in promoting root development.

Applications of selected polysaccharides and proteins in dentistry: A review

In the last ten years, remarkable characteristics and a variety of functionalities have been created in biopolymeric materials for clinical dental applications. This review gives an overview of current knowledge of natural biopolymers (biological macromolecules) in terms of structural, functional, and property interactions. Natural biopolymers such as polysaccharides (chitosan, bacterial cellulose, hyaluronic acid, and alginate) and polypeptides (collagen and silk fibroin) have been discussed for dental uses. These biopolymers exhibit excellent properties alone and when employed with other composite molecules making them ideal for treatment of periodontitis, endodontics, dental pulp regeneration and oral wound healing. These biopolymers together with the composite materials exhibit better biocompatibility, inertness, elasticity and flexibility which makes them a leading candidate to be used for other dental applications like caries management, oral appliances, dentures, dental implants and oral surgeries.

Long-Term Success of Regenerative Endodontic Treatment in Managing Traumatized Teeth: A Case Report With Seven-Year Follow-Up

Traumatic injuries to maxillary incisors often result in complex dental complications, such as pulp necrosis and periapical pathology, particularly in young patients. Traditional root canal treatments may prove insufficient, especially for immature teeth requiring apexification. Regenerative endodontic treatment (RET) presents a promising alternative, aiming to eliminate infection while fostering root development and tooth vitality. This case report illustrates the successful management of a necrotic-infected traumatized maxillary incisor in a seven-year-old girl using RET. The treatment involved a meticulously planned protocol comprising disinfection, induction of bleeding, and placement of a calcium-enriched mixture (CEM) cement plug, followed by composite restoration. Remarkably, despite the initial detection of an endodontic lesion in the postoperative radiograph, the clinical outcomes remained aesthetically pleasing, with subsequent radiographs revealing regression of the apical lesion and complete tooth maturation over the seven-year follow-up period. This case highlights the efficacy and feasibility of RET using CEM in managing infected, traumatized teeth, emphasizing its potential for long-term healing and functional restoration. The absence of tooth discoloration further underscores the benefits of utilizing specific materials and protocols.

Advances in Regenerative Dentistry Approaches: An Update

Regenerative dentistry is a rapidly evolving field in dentistry, which has been driven by advancements in biomedical engineering research and the rising treatment expectations and demands that exceed the scope of conventional approaches. Tissue engineering, the foundation of regenerative dentistry, mainly focuses on 3 key components: stem cells, bioactive molecules, and scaffolds. Dental tissue-derived stem cells are especially significant in this regard due to their remarkable properties. Regenerative techniques have provided novel approaches to many conventional treatment strategies in various disciplines of dentistry. For instance, regenerative endodontic procedures such as pulp revascularisation have provided an alternative approach to conventional root canal treatment. In addition, conventional surgical and nonsurgical periodontal treatment is being taken over by modified approaches of guided tissue regeneration with the aid of 3-dimensional bioprinting and computer-aided design, which has revolutionised oral and maxillofacial tissue engineering. This review presents a concise overview of the latest treatment strategies that have emerged into clinical practice, potential future technologies, and the role of dental tissue-derived stem cells in regenerative dentistry.

Injectable Methacrylated Gelatin Hydrogel for Safe Sodium Hypochlorite Delivery in Endodontics

Keeping sodium hypochlorite (NaOCl) within the root canal is challenging in regenerative endodontics. In this study, we developed a drug delivery system using a gelatin methacryloyl (GelMA) hydrogel incorporated with aluminosilicate clay nanotubes (HNTs) loaded with NaOCl. Pure GelMA, pure HNTs, and NaOCl-loaded HNTs carrying varying concentrations were assessed for chemo-mechanical properties, degradability, swelling capacity, cytocompatibility, antimicrobial and antibiofilm activities, and in vivo for inflammatory response and degradation. SEM images revealed consistent pore sizes of 70-80 µm for all samples, irrespective of the HNT and NaOCl concentration, while HNT-loaded hydrogels exhibited rougher surfaces. The hydrogel's compressive modulus remained between 100 and 200 kPa, with no significant variations. All hydrogels demonstrated a 6-7-fold mass increase and complete degradation by the seventh day. Despite an initial decrease in cell viability, all groups recovered to 65-80% compared to the control. Regarding antibacterial and antibiofilm properties, 12.5 HNT(Double) showed the highest inhibition zone on agar plates and the most significant reduction in biofilm compared to other groups. In vivo, the 12.5 HNT(Double) group displayed partial degradation after 21 days, with mild localized inflammatory responses but no tissue necrosis. In conclusion, the HNT-NaOCl-loaded GelMA hydrogel retains the disinfectant properties, providing a safer option for endodontic procedures without harmful potential.

Treatment outcomes of immature permanent necrotic evaginated teeth: A retrospective study comparing regenerative endodontic procedures with apexification

BACKGROUND

Few studies have compared the outcomes of regenerative endodontic procedures (REPs) and calcium hydroxide apexification focusing on necrotic teeth with dens evaginatus.

AIM

To qualitatively and quantitatively compare the treatment outcomes of REPs and calcium hydroxide apexification in teeth with dens evaginatus.

DESIGN

Immature permanent necrotic evaginated teeth treated with REPs or calcium hydroxide apexification for a follow-up period of at least 12 months were included. Tooth success and survival rates were analyzed. Changes in radiographic root length, apical diameter, and radiographic root area (RRA) were quantified. Prognostic factors that might influence RRA were identified via multivariate linear regression analysis.

RESULTS

A total of 112 teeth (50 REP cases and 62 apexification cases) with a median follow-up period of 26.5 months were included. Regenerative endodontic procedures and calcium hydroxide apexification exhibited similar satisfactory success and survival rates (p > .05). Additionally, 88 teeth were quantitatively analyzed. The REP group presented a significantly greater percentage increase in RRA and less decrease in apical diameter than the calcium hydroxide apexification group (p < .05). Teeth treated with REPs and with Stages 7 and 8 of root development showed a better gain in RRA (p < .05).

CONCLUSION

While REP and calcium hydroxide apexification had similar success and survival rates, teeth with REPs showed an increase in RRA, indicating that REP is the preferred choice.

Effectiveness of endodontic tissue engineering in treatment of apical periodontitis: A systematic review

BACKGROUND

Regenerative endodontics has evolved in recent years with tissue engineering concepts in particular appearing promising. Endodontic tissue engineering (ETE) describes the various approaches based on the orthograde introduction of scaffolds or biomaterials (with or without cells) into the root canal to achieve pulp tissue regeneration. There are currently no systematic reviews investigating whether ETE is a suitable method for the treatment of endodontic disease in both mature and immature permanent teeth.

OBJECTIVES

The purpose of this systematic review was to determine the effectiveness of ETE in permanent teeth with pulp necrosis in comparison with conventional endodontic treatment.

METHODS

We searched MEDLINE, Embase and the Cochrane Library for published reports as well as Google Scholar for grey literature up to November 2021. Included were studies of patients with permanent immature or mature teeth and pulp necrosis with or without signs of apical periodontitis (P) comparing ETE (I) with calcium hydroxide apexification, apical plug and root canal treatment (C) in terms of tooth survival, pain, tenderness, swelling, need for medication (analgesics and antibiotics), radiographic evidence of reduction in apical lesion size, radiographic evidence of normal periodontal ligament space, function (fracture and restoration longevity), the need for further intervention, adverse effects (including exacerbation, restoration integrity, allergy and discolouration), oral health-related quality of life (OHRQoL), presence of sinus tract and response to sensibility testing (O). An observation period of at least 12 months was mandatory (T) and the number of patients in human experimental studies or longitudinal observational studies had to be at least 20 (10 in each arm) at the end (S). Risk of bias was appraised using the Cochrane risk-of-bias (RoB 2) tool. Two authors independently screened the records, assessed full texts for eligibility and evaluated risk of bias. Heterogeneity of outcomes and limited body of evidence did not allow for meta-analysis.

RESULTS

Two randomized clinical trials investigating cell transplantation approaches with a total of 76 participants (40 treated immature teeth and 36 treated mature teeth) were included for qualitative analysis. Both studies had moderate concerns in terms of risk of bias. Due to the lack of homogeneity a meta-analysis was not possible. Tooth survival for ETE, root canal treatment and apexification was 100% after 12 months. Teeth treated with ETE showed a higher number of cases with positive pulpal responses to sensitivity tests and with blood perfusion compared with root canal treatment or apexification.

DISCUSSION

This systematic review highlights that there is limited evidence for ETE approaches. Even though the results of this review suggest a high survival with ETE in mature and immature teeth, there is a moderate risk of bias due to methodological limitations in the included studies, so the overall results should be interpreted with caution. Lack of a robust control group was a common problem during literature screening, and outcomes besides dental survival were reported inconsistently. Future clinical trials need to address methodical as well as assessment concerns and report long-term results.

CONCLUSION

The benefits and high survival rates reported for ETE techniques suggest that this procedure might be an alternative to conventional procedures for permanent teeth with pulpal necrosis. However, more appropriate studies are needed to derive clinical recommendations.

REGISTRATION

PROSPERO (CRD42021266350).

Long-term Outcome of Endodontically Treated Traumatized Immature Upper Incisors

INTRODUCTION

In a growing child, preservation of traumatized immature permanent upper incisors is challenging. This study aimed to evaluate the long-term outcome of endodontically treated traumatized immature upper incisors and associated variables.

METHODS

A total of 183 traumatized immature upper incisors treated with pulpotomy, apexification, or regenerative endodontic procedure (REP), with follow-up between 4 and 15 years, were assessed for presence of pulpal responses or periodontal/bone responses using standardized clinical and radiologic criteria. Logistic regression, including stage of root development, type and complexity of traumatic event, type of endodontic intervention, and history of orthodontic management, were used to estimate impact on tooth survival and occurrence of tissue responses. Study approved by Ethics Committee Research UZ/KU Leuven (S60597).

RESULTS

After a median follow-up of 7.3 years (interquartile range, 6.1-9.2), 159 teeth (86.9%) were still functional. From these teeth, 58 (36.5%) developed tissue responses. This was significantly associated with stage of root development at moment of trauma (root length <¾) and type of endodontic intervention (REP presenting worst outcome). Tooth loss (24 teeth, 13.1%) occurred after a mean time span of 3.2 years (±1.5) and was significantly associated with type and complexity of the traumatic event and type of endodontic intervention, with apexification showing better results than REP (odds ratio, 0.30; 95% confidence interval, 0.11-0.79).

CONCLUSIONS

A large number of endodontically treated traumatized immature teeth could be kept functional. Very immature teeth, teeth with periodontal tissue damage, and teeth treated with REP were at highest risk for an unfavorable outcome.

Stem Cells from the Apical Papilla (SCAPs): Past, Present, Prospects, and Challenges

Dental diseases occurring on young permanent teeth usually lead to the premature arrest of tooth root development. Sustained tooth root elongation is necessary to achieve the goal of long-term preservation of affected teeth. To this end, stem cell-based regenerative endodontic treatment has been regarded as one of the most promising strategies for treating young permanent teeth with pulp and periapical infections. Endogenous stem cells residing in the apical papilla, named stem cells from the apical papilla (SCAPs), have been intensively investigated due to their critical roles in pulp regeneration and root redevelopment. The present review summarizes advances in the field of SCAPs studies and discusses the challenges that need to be further addressed.

Is Revascularization the Treatment of Choice for Traumatized Necrotic Immature Teeth? A Systematic Review and Meta-Analysis

Regenerative endodontic treatment (RET) has been considered a reliable procedure to treat immature necrotic teeth; however, the effect of dental trauma on the prognosis of RET is questionable. This systematic review aimed to evaluate the current level of evidence for revascularization techniques (the RET) in the management of traumatized necrotic immature permanent teeth with or without periapical radiolucent areas. Four electronic databases—PubMed, Web of Science, Scopus, and Embase—were searched until November 2022. Only randomized clinical trials, cohort studies, and case-control studies with a minimum of 10 cases and 12 months of follow-ups were included. The search identified 363 preliminary results. After discarding the duplicates and screening the titles, abstracts, and full texts, 13 articles were considered eligible. The results showed that RET techniques seemed to have high survival and success rates, 93.8% and 88.3%, respectively, in the treatment of traumatized necrotic immature permanent teeth. Root maturation with RET techniques seemed to be lower in traumatized teeth. Future studies are needed to evaluate root maturation in traumatized teeth using 3-dimensional radiographic evaluations. In addition, the lack of literature on the studies comparing RET and apexification (calcium hydroxide or an MTA) in the treatment of traumatized necrotic immature teeth highlights the necessity for high-level clinical studies comparing these treatment modalities.

The Effect of General Anesthesia on the Outcome of Root Canal Treatment in Pediatric Patients—A Retrospective Cohort Study

This study aimed to evaluate the effect of general anesthesia (GA) on the 1-year outcome of Root Canal Treatment (RCT) performed in pediatric patients and to compare it to the outcome of RCT in pediatric patients without GA. Patients admitted for RCT in permanent dentition in a public hospital, dated 2015 to 2020, age 8–15 with a minimum of one year follow-up period, were included in the study. The sample consisted of 326 teeth from 269 patients treated by a single operator, with a recall rate of 81%. Overall, 124 teeth were treated under GA and 142 teeth were without GA. The mean follow-up time was 31.5 months. Data underwent statistical analysis and the significance threshold was set for p < 0.05. Of the total cases, 90% showed favorable outcomes. A significantly higher favorable outcome was seen in the GA group than in the non-GA group (98% and 85%, respectively, p < 0.001). The outcome was significantly affected by the type and quality of the coronal restoration, degree of root development, and lesion size (p < 0.05). According to the current study, in uncooperative pediatric patients, a more favorable outcome of root canal treatment can be obtained under GA than LA if the procedure is carried out with immediate restoration.

EVL Promotes Osteo-/Odontogenic Differentiation of Dental Pulp Stem Cells via Activating JNK Signaling Pathway

Objective

Human dental pulp stem cells (hDPSCs) were recognized as a suitable and promising source of stem cells in dental pulp regeneration. However, the mechanism by which hDPSCs differentiation into osteo-/odontogenic lineage remains unclear. Ena/VASP-like protein (EVL) has been found to be involved in diverse biological processes. In this study, we explored the role and underlying mechanism of EVL in osteo-/odontogenic differentiation of hDPSCs.

Methods

Expression of EVL was detected in hDPSCs by quantitative reverse transcription polymerase chain reaction (qRT-PCR) and western blot (WB) analyses during osteo-/odontogenic differentiation. The function of EVL in osteo-/odontogenic differentiation and involvement of MAPK signaling pathways were evaluated by alkaline phosphatase (ALP) staining and activity, alizarin red staining (ARS), and qRT-PCR and western blot analyses.

Results

The expression of EVL was upregulated during osteo-/odontogenic differentiation of hDPSCs. Overexpression of EVL significantly increased osteo-/odontogenic capacity of hDPSCs, which was reflected in increased alkaline phosphatase (ALP) staining, ALP activity, mineralized nodule formation, and the expressions of genes related to osteo-/odontogenic differentiation, while downregulation of EVL inhibited it. In addition, EVL activated the JNK pathway and phosphorylation of p38 MAPK during differentiation procedure of hDPSCs. The EVL-enhanced differentiation of DPSCs was suppressed by blocking the JNK pathway, rather than the p38 MAPK pathway.

Conclusion

EVL promotes the osteo-/odontogenic differentiation of hDPSCs by activating the JNK pathway, providing a future target for osteo-/odontogenic differentiation and dental pulp regeneration.

Outcomes reporting in systematic reviews on revitalization: A scoping review for the development of a core outcome set

BACKGROUND

Revitalization is a type of regenerative endodontic treatment (RET) that offers the exciting prospect of revitalizing damaged tissue, therefore improving outcomes for non-vital immature teeth. To evaluate its potential, there needs to be consistency in outcome reporting of clinical studies investigating revitalization to allow for evidence synthesis and inform clinical decision making.

OBJECTIVES

The aim of this scoping review was to identify outcomes that are reported in systematic reviews on revitalization including how and when these outcomes are measured. Additionally, evidence of selective reporting bias in the reviews was assessed.

METHODS

A comprehensive electronic search of healthcare databases and grey literature was conducted to identify systematic reviews published in the English language reporting outcomes of revitalization in permanent immature teeth. There was no restriction on the date of publication. Outcome data was extracted by four reviewers independently and mapped with a healthcare taxonomy into five core areas: survival, clinical/physiological changes, life impact, resource use and adverse events. Selective reporting bias and how it was measured was assessed independently by two reviewers.

RESULTS

Twenty-six systematic reviews were included in this scoping review. There was lack of standardization in reporting and significant heterogeneity across reviews in outcome endpoints. The outcomes reported could be aligned within the five core areas of the taxonomy including tooth survival which was reported in nine reviews. Patient-reported outcomes were generally limited and no review reported on Oral Health Related Quality of Life. Many of the reviews reporting on randomized control trials were at low risk of selective reporting bias whilst other study designs were at higher risk.

DISCUSSION

Consistency in outcome reporting is necessary to realize the benefits of old but particularly novel therapies. Data from this review confirmed heterogeneity in reporting outcomes of revitalization and the need for development of a core outcome set (COS).

CONCLUSIONS

Several important outcomes including survival, root development, tooth discolouration and periapical healing have been identified in this review which could inform the development of a COS in this area.

REGISTRATION

Core Outcome Measures in Effectiveness Trials (COMET) database (registration no. 1879).

Expert consensus on regenerative endodontic procedures

Regenerative endodontic procedures (REPs) is a biologic-based treatment modality for immature permanent teeth diagnosed with pulp necrosis. The ultimate objective of REPs is to regenerate the pulp-dentin complex, extend the tooth longevity and restore the normal function. Scientific evidence has demonstrated the efficacy of REPs in promotion of root development through case reports, case series, cohort studies, and randomized controlled studies. However, variations in clinical protocols for REPs exist due to the empirical nature of the original protocols and rapid advancements in the research field of regenerative endodontics. The heterogeneity in protocols may cause confusion among dental practitioners, thus guidelines and considerations of REPs should be explicated. This expert consensus mainly discusses the biological foundation, the available clinical protocols and current status of REPs in treating immature teeth with pulp necrosis, as well as the main complications of this treatment, aiming at refining the clinical management of REPs in accordance with the progress of basic researches and clinical studies, suggesting REPs may become a more consistently evidence-based option in dental treatment.

Dental implants in growing patients: A systematic review and meta-analysis

BACKGROUND: Dental implants provide a suitable and reliable treatment for the replacement of missing teeth. Very few studies have been reported in the literature regarding the application of dental implants in growing and developing patients. OBJECTIVE: This systematic review with meta-analysis aimed to systematically review the available literature regarding the application of dental implants in growing and developing patients. METHODS: A detailed search in the literature was performed with the help of keywords such as dental implants, treatment planning, children, adolescents, growing patients, and developing jaws. PubMed, Scopus, Web of Sciences, and Ovidsp databases were searched for papers published between 1980 and 2021. The papers focused on children, adolescents, developing jaws, and implants. In this systemic review, the dataset concerned with the type of study, aim, number of patients and specimens included, age of patients, total number of implants placed, total number of implants evaluated, medical history of developmental disorders of teeth such as ectodermal dysplasia, congenital absence of teeth, were evaluated. RESULTS: Out of the total literature searched, 33.45% of studies and case reports documented no complications in any implant treatment. In 47.21% of studies and case reports, there was both success and failure of implants while in 13.21% of studies and case reports there was a complete failure of implants. The most common cause for loss of permanent teeth in growing children and adolescent patients was dental trauma (73.13%) followed by congenital developmental disturbance of teeth (18.19%). CONCLUSION: It can be concluded from this systematic review that the use of implants in edentulous growing patients is determined by several parameters, including the patient’s overall health, the stage of jaw growth, the number of teeth to be replaced, and soft and hard tissue anatomic features. Still, the use of a conservative treatment strategy for missing teeth management in patients with developing jaws is common and recommended until the patient’s growth is completed, as there are chances of changes in the position of dental implants placed in the developing and growing jaws due to the continuous changes taking place in their body. However, placement of implants can be done in these patients successfully with proper treatment planning and taking into account the phase of growth with proper follow-up.

Clinical Outcome and Comparison of Regenerative and Apexification Intervention in Young Immature Necrotic Teeth-A Systematic Review and Meta-Analysis

This systematic review aimed to evaluate interventions individually and compare the clinical outcome of young, immature teeth treated with regenerative endodontic therapy (RET) and apexification procedure. The protocol was registered with PROSPERO (International Prospective Register of Systematic Reviews), bearing the registration number CRD42021230284. A bibliographic search in the biomedical databases was conducted in four databases—PubMed, CENTRAL, EMBASE and ProQuest—using searching keywords and was limited to studies published between January 2000 and April 2022 in English. The search was supplemented by manual searching, citation screening and scanning of all reference lists of selected paper. The study selection criteria were randomized clinical trial, prospective clinical studies and observational studies. The search found 32 eligible articles, which were included in the study. The quality assessment of the studies was performed using the Cochrane risk of bias tool for randomized control trials and non-randomized clinical studies. The meta-analysis was performed using Review Manager software (REVMAN, version 5). The results indicated that a clinicians’ MTA apexification procedure was more successful compared to calcium hydroxide. In RET, apical closure and overall success rate is statistically same for both apical platelet concentrates (APCs) and blood clots (BC). Both interventions have similar survival rates; however, RET should be preferred in cases where the root development is severely deficient, there is insufficient dentine and the tooth’s prognosis is hopeless even with an apexification procedure.

Endodontic Regenerative Procedures in Necrotic Adult Teeth

There have been published regenerative endodontic protocols for treating immature teeth in young patients, but there are no clinical considerations for the adult teeth. The goal of the present review is to propose a specific clinical protocol for both mature and immature adult teeth with necrotic pulps. Research was performed from January to April of 2021. From the 539 studies identified through the initial search, 23 studies were qualified for the final analysis (3 randomized controlled trials and 20 case reports). The results in mature adult teeth indicate a success rate of 96.35 and 100% in bone healing through the randomized controlled trials and case reports, respectively; 100% in absence of clinical symptoms, and 58 and 62.5% in positive response to sensibility tests. The success rate in the case reports in teeth with open apex reported a 61.5% of root development, 100% of bone healing, 96.15% of absence of clinical symptoms, and 43.7% of positive response to sensibility tests. The current evidence is scarce but emerging, so REPs may be a promising alternative for treating adult necrotic teeth. The clinical protocol proposed is based on the evidence available and age considerations, and should be updated in the future.

Endodontic pulp revitalization in traumatized necrotic immature permanent incisors: Early failures and long-term outcomes - a longitudinal cohort study

Aim

This prospective cohort study evaluates clinical and radiographical outcomes of endodontic pulp revitalization (PR) of traumatized necrotic incisors.

Methodology

Pulp revitalization was performed in 75 traumatized necrotic immature incisors from 71 patients. The radiographic outcome measures were continued root formation (width and length), root resorption, apex closure, periapical index, and root development stage. The clinical outcome measures were percussion pain, palpation pain, pathological tooth mobility, swelling, sinus tract, ankylosis, crown discolouration, response to pulp sensitivity test, and subjective pain. Treatment outcomes were categorized as a success based on the absence of clinical symptoms and when radiographic evidence was present for apical healing and continued root development. The performed statistical tests were repeated measures anova, pairwise comparisons of interactions (t‐test), McNemar's test, and linear regression model.

Results

In 45 of 75 teeth (60%), PR was successful with the resolution of clinical and radiographic signs and continued root development. PR failed due to the absence of bleeding (n = 19) and persistent infection (n = 11). PR showed statistically significant increases in root length (11%), and dentinal wall thickness (30%), root maturation (pre‐operative 3.38 [CI 1.88; 4.88]; post‐operative 4.04, [CI 2.56; 5.52]) apical closure (71.4%), healing of pre‐operative apical periodontitis (100%), and healing of pre‐operative inflammatory root resorptions (100%). Three predictive variables for continued root maturation were identified – root development stage at entry (p = .0001, β 0.649), [CI 0.431; 0.867], trauma to the soft tissues (p = .026, β −0.012), [CI −0.0225; −0.015], and pre‐operative dentinal wall thickness (p = .009, β −0.001); [CI −0.001; 0.0001].

Conclusions

Our findings indicate that PR provides satisfactory clinical and radiographical outcomes in traumatized necrotic incisors. The failed cases were related to lack of bleeding and persistent infections, indicating that new techniques are needed to improve the predictability of PR.

Deciduous Tooth Pulp Autotransplantation for the Regenerative Endodontic Treatment of Permanent Teeth with Pulp Necrosis: A Case Series

INTRODUCTION

In young individuals, deciduous tooth pulp might be utilized as a natural, biologic scaffold for the regenerative endodontic treatment (RET) of young permanent teeth with necrotic pulps and apical periodontitis. The present case series demonstrates the clinical and radiographic outcomes of a novel RET utilizing deciduous pulp autotransplantation in traumatized, necrotic young permanent incisors.

METHODS

Five previously-traumatized maxillary incisors of four 8-11,5-year-old patients were treated with a RET protocol that used 2.5% NaOCl irrigation and placement of calcium hydroxide dressing in the first visit. After 4 weeks, the intracanal medication was removed, and the whole pulp tissue harvested from the neighboring maxillary deciduous canine was transplanted into the disinfected root canal without induced apical bleeding. Following placement of an MTA coronal barrier, the access cavities were restored with acid-etch resin composite. The root canals of donor primary canines were filled with calcium hydroxide-iodoform paste and were restored as with the permanent incisors.

RESULTS

Three patients were followed-up for 24 months, and one patient for 12 months. All teeth demonstrated radiographic evidence of complete periapical healing, slight increase in dentinal wall thickness, and continued apical closure in the absence of clinical symptoms. A positive response to cold test was obtained in one incisor at 12 months and two at 24 months.

CONCLUSIONS

Based on 12- and 24-month clinical and radiographic findings, the present cases demonstrate a favorable outcome of a regenerative endodontic treatment protocol utilizing deciduous pulp autotransplantation in young permanent incisors with pulp necrosis.

Radiographic differences observed following apexification vs revascularization in necrotic immature molars and incisors: a follow-up study of 18 teeth

PURPOSE

To evaluate the effectiveness of apexification versus revascularization in the treatment of necrotic immature teeth and determine which strategy affords the greatest radiological success rate.

METHODS

An analysis was made of 18 teeth subjected to mineral trioxide aggregate (MTA) apical plugging and regenerative endodontic treatment, assessing healing of the apical lesions and the changes in root dimensions.

RESULTS

Significantly greater root growth was observed with revascularization in terms of the percentage change in length (12.75% at 6 months) and dentin thickness (34.57% at 6 months) (p < 0.05). There were no significant differences between the two treatments in terms of the apical healing scores after 6 months of follow-up (p > 0.05).

CONCLUSION

Apexification with an MTA apical plug and pulp regeneration are reliable treatments for non-vital immature teeth. The radiographic outcomes are comparable between the immature teeth subjected to MTA apexification versus those subjected to revascularization. The results of the present study indicate a greater increase in root length and width with regenerative endodontic treatment.

Cell-Based Transplantation versus Cell Homing Approaches for Pulp-Dentin Complex Regeneration

Regenerative dentistry has paved the way for a new era for the replacement of damaged dental tissues. Whether the causative factor is dental caries, trauma, or chemical insult, the loss of the pulp vitality constitutes one of the major health problems worldwide. Two regenerative therapies were introduced for a fully functional pulp-dentin complex regeneration, namely, cell-based (cell transplantation) and cell homing (through revascularization or homing by injection of stem cells in situ or intravenously) therapies, with each demonstrating advantages as well as drawbacks, especially in clinical application. The present review is aimed at elaborating on these two techniques in the treatment of irreversibly inflamed or necrotic pulp, which is aimed at regenerating a fully functional pulp-dentin complex.

Experimental study the anti-inflammatory and osteo-regenerative qualities of the paste based on symphytum officinale tincture and calcium hydroxide

Replacement of the damaged bone remains actual and is far from being completely solved nowadays, despite its centuries-old history. The purpose of study was to investigate the anti-inflammatory and osteo-regenerative qualities of the paste based on Symphytum officinale tincture and calcium hydroxide in treatment on teeth with chronic granulating apical periodontitis in children and in an experiment on animals. Performed morphological and densitometric studies showed that remodeling of bone injury of the lower jaw in rats occurs almost equally in both experimental and control groups, and a paste based on Symphytum officinale tincture and calcium hydroxide also promotes bone regeneration at the defect site and stimulates osteosynthesis. Analysis of liver tissue, soft and hard tissues of the lower jaw in animals suggest that the proposed paste does not produce any toxic effect and provides significant anti-inflammatory properties. The gained result provide grounds to recommend the developed paste for therapeutic use in children as a temporary root canal sealing material in permanent teeth with granulating apical periodontitis.