Calcium hydroxide and apexogenesis

Evaluation of the Efficacy of Erbium, Chromium-doped Yttrium, Scandium, Gallium, and Garnet Laser in Partial Pulpotomy in Permanent Immature Molars: A Randomized Controlled Trial

INTRODUCTION

The use of the erbium, chromium-doped yttrium, scandium, gallium, and garnet (Er,Cr:YSGG) laser in vital pulp therapy contributes to the formation of dentin bridges and a sterile zone as well as the maintenance of the vitality of the pulp. However, no prior studies have used the Er,Cr:YSGG laser in partial pulpotomy of immature permanent teeth. The aim of this study was to compare the efficacy of partial pulpotomy treatment using mineral trioxide aggregate (MTA) alone and MTA with the Er,Cr:YSGG laser in permanent immature molars.

METHODS

A total of 90 caries-exposed permanent immature molar teeth were included and randomly divided into 2 groups: the MTA group (n = 45) and the laser + MTA group (n = 45). In the MTA group, MTA was applied to the exposed area on the pulp after bleeding control. In the same session, the tooth was restored with a composite resin. In the laser + MTA group, before MTA condensation, the Er,Cr:YSGG laser was applied to the exposure area. Patients were recalled at 1, 3, 6, and 12 months after treatment. The Mann-Whitney U and chi-Square tests were used for statistical analysis.

RESULTS

The success rate (95.5%) of the laser + MTA group was similar to that of the MTA group (88.8%). There was no significant difference between groups in terms of the frequency of at least 1 pathologic clinical or radiographic failure at 12 months (P > .05).

CONCLUSIONS

Partial pulpotomy treatment showed a high success rate in immature permanent molars; however, the use of the laser did not contribute to the success rate compared with MTA alone.

Combined effects of calcium hydroxide and photobiomodulation therapy on apexogenesis of immature permanent teeth in dogs

Treatment of high-risk traumatic immature teeth due to incomplete root development is challenging. Apexogenesis is currently the ideal treatment option that allows normal root development. The purpose of this study was to evaluate the apexogenesis process of immature permanent teeth of dogs when co-administered with calcium hydroxide and photobiomodulation therapy (PBMT). A total of 36 immature permanent anterior and premolar teeth were selected from three 4-6-month-old dogs of Iranian mixed generation. The teeth were categorized into two groups, calcium hydroxide with laser irradiation (CHL) and calcium hydroxide without laser irradiation (CH). All the selected teeth received calcium hydroxide pulpotomy. After restoring teeth with amalgam, the CHL group received gallium‑aluminum-arsenide (GaAlAs) diode laser (810 nm, 4.2 J/cm², 0.3 W, 9 s,CW) on apical one-third of both buccal and lingual roots. The irradiation was repeated every 48 h for fourteen days. Intravenous tetracycline was used to observe newly formed dentin in the first, third, seventh, and fourteenth days. The distance between tetracycline lines (DTL) was examined by Fluorescence microscopy. Generalized estimating equations (GEE) were used for data analysis. In all assessments, the mean DTL were greater in the CHL group. However, the two groups had no significant differences in the amount of deposited dentin between the first and third, third and seventh, and first and seventh lines. Meanwhile, there was a significant difference between the two groups in terms of the distances between lines 7 and 14, 1 and 14 and also 3 to 14 (P < .001). In other words, from the 7th day onwards, there was a significant difference between the two groups. Within the limitation of this study, the combination therapy of PBMT and pulpotomy with calcium hydroxide accelerated apexogenesis in immature permanent dogs' teeth.

Regenerative Endodontic Procedures Using Contemporary Endodontic Materials

Calcium hydroxide apexification and Mineral Trioxide Aggregate (MTA) apexification are classical treatments for necrotic immature permanent teeth. The first tend to fail for lack of compliance given the high number of sessions needed; the second has technical difficulties such as material manipulation and overfilling. With both techniques, the root development is interrupted leaving the tooth with a fragile root structure, a poor crown-to-root ratio, periodontal breakdown, and high risk of fracture, compromising long-term prognosis of the tooth. New scientific literature has described a procedure that allows complete root development of these specific teeth. This regenerative endodontic procedure (REP) proposes the use of a combination of antimicrobials and irrigants, no canal walls instrumentation, induced apical bleeding to form a blood clot and a tight seal into the root canal to promote healing. MTA is the most used material to perform this seal, but updated guidelines advise the use of other bioactive endodontic cements that incorporate calcium and silicate in their compositions. They share most of their characteristics with MTA but claim to have fewer drawbacks with regards to manipulation and aesthetics. The purpose of the present article is to review pertinent literature and to describe the clinical procedures protocol with its variations, and their clinical application.

Pulp Revascularization: A Literature Review

Reestablishing blood flow and allowing the continuation of root development are some of the objectives of pulp revascularization. This procedure is currently indicated for teeth with incomplete root formation as an alternative to the traditional treatment of apecification, which consists of inserting calcium hydroxide paste into the root canal for a determined time period in order to induce the formation of a calcified barrier. Although it is considered as the most classically employed therapy, the permanence of the paste for long time periods may lead to the weakening of the root due to hygroscopic properties, as well as proteolytic activities of calcium hydroxide. Therefore, there has been a permanent search for alternatives which allow the full development of immature teeth. Revascularization has emerged as such an alternative, and a range of treatment protocols can be found in the scientific literature. The aim of this paper is to accomplish a literature review concerning this issue.

Conservative management of dens evaginatus and attached supernumerary tooth/odontome in mandibular premolar with dual radiolucencies

Recently, an innovative, nonsurgical regenerative endodontic treatment protocol “SealBio” was introduced to manage mature nonvital permanent teeth with periapical lesions. This paper explains the management of an unusual case of dens evaginatus and an attached supernumerary tooth/an odontome associated with two distinct radiolucencies in a mandibular premolar with “SealBio” technique and discusses the various hypotheses on the pathogenesis of unusual malformation and associated pericervical cyst-like radiolucency in the involved tooth.

Pulp Revascularization- It's your Future Whether you Know it or Not?

Pulpal regeneration after tooth injury is not easy to accomplish. In teeth with immature apices and exposed vital pulp tissue, partial or complete pulpotomy is indicated to preserve pulpal function and allow continued root development. In many cases, injury causes loss of pulp vitality and arrested root development leading to a tooth with poor crown root ratio, a root with very thin walls, an open blunderbuss apex and development of apical pathosis. The ideal treatment in such cases would be to obtain further root development and thickening of dentinal walls by stimulating the regeneration of a functional pulp dentin complex. This outcome has been observed after reimplantation in avulsed immature permanent teeth but has been thought impossible in a necrotic infected tooth. This case series evaluates the efficacy of revascularization procedure in immature, non vital permanent teeth. Pulp regeneration was attempted in four patients at Department of Conservative Dentistry, ESIC Dental College, New Delhi using blood clotting approach. The cases were treated and followed up regularly at regular intervals ranging from 6 months to 3 years to assess the treatment response clinically and radiographically. The patients remained clinically asymptomatic with three out of four patients even responding positively to pulp responsiveness tests. Radiographic examination also revealed increased root formation and thickening of dentinal walls. It was concluded that the triad of a disinfected canal, a matrix (blood clot) in to which new tissue could grow and an effective coronal seal produced the desirable environment for successful revascularization.

Platelet-rich plasma supplemented revascularization of an immature tooth associated with a periapical lesion in a 40-year-old man

The present case report is the first of its kind that documents the successful outcome of “revascularization,” a regeneration-based treatment protocol in a mature adult patient. It belies the myth that “revascularization” should only be done in children and young, adolescent patients. The misconception that stem cells number as well as viability in older age group patients will not allow revascularization to be successful is also contradicted by this case. The paper highlights all the mechanisms that come into play and the enhancing of regenerative response by supplementation with platelet-rich plasma (PRP).

Triple antibiotic paste in root canal therapy

The success of the endodontic treatment depends on the microbial suppression in the root canal and periapical region. Endodontic instrumentation alone cannot achieve a sterile condition. With the advent of non-instrumentation endodontic treatment and lesion sterilization and tissue repair, local application of antibiotics has been investigated. Triple antibiotic paste (TAP) containing metronidazole, ciprofloxacin, and minocycline has been reported to be a successful regimen in controlling the root canal pathogen and in managing non-vital young permanent tooth. This paper reviews the existing literature on biocompatibility, efficiency, drawbacks of TAP in endodontic therapy and pulp revascularization.

An in vitro Study of Diffusibility and Degradation of Three Calcium Hydroxide Pastes

Aims and objectives : The aim of this in vitro study is to assess the diffusibility and degradation of three calcium hydroxide pastes. Materials and methods : Three pastes were prepared by mixing calcium hydroxide powder with three different vehicles namely water, propylene glycol and CMCP for the investigation. The three pastes were sealed in porcelain caps and immersed in distilled water for the diffusion study. The change in the pH of the surrounding water indicated the rate and degree of diffusion in the degradation study (1 to 7 days, 14th day, 21st day and 30th day). The pastes were exposed to an atmosphere of carbon dioxide in the degradation study to assess the degree to which they can undergo degradation by carbonation. Mordant Black or Solochrome Black indicator was used for the estimation. Results and conclusion : Calcium hydroxide readily diffuses from all the three pastes. Calcium hydroxide diffuses marginally less from a paste made with propylene glycol as compared to CMCP paste. The comparative stability of Ca(OH)2 was studied and the results showed that consistently significant protection is imparted to Ca(OH)2 by CMCP over widely ranging periods.

Dental stem cells for tooth regeneration and repair

Mesenchymal stem cells (MSCs) resident in bone marrow are one of the most studied and clinically important populations of adult stem cells. Cells with, similar properties to these MSCs have been described in several different tooth tissues and the potential ease with which these dental MSCs could be obtained from patients has prompted great interest in these cells as a source of MSCs for cell-based therapeutics. In this review we address the current state of knowledge regarding these cells, their properties, origins, locations, functions and potential uses in tooth tissue engineering and repair. We discuss some of the key controversies and outstanding issues, not least of which whether dental stem cells actually exist.

The hidden treasure in apical papilla: the potential role in pulp/dentin regeneration and bioroot engineering

Some clinical case reports have shown that immature permanent teeth with periradicular periodontitis or abscess can undergo apexogenesis after conservative endodontic treatment. A call for a paradigm shift and new protocol for the clinical management of these cases has been brought to attention. Concomitantly, a new population of mesenchymal stem cells residing in the apical papilla of permanent immature teeth recently has been discovered and was termed stem cells from the apical papilla (SCAP). These stem cells appear to be the source of odontoblasts that are responsible for the formation of root dentin. Conservation of these stem cells when treating immature teeth may allow continuous formation of the root to completion. This article reviews current findings on the isolation and characterization of these stem cells. The potential role of these stem cells in the following respects will be discussed: (1) their contribution in continued root maturation in endodontically treated immature teeth with periradicular periodontitis or abscess and (2) their potential utilization for pulp/dentin regeneration and bioroot engineering.

A paradigm shift in endodontic management of immature teeth: conservation of stem cells for regeneration

OBJECTIVE

This article will review the new concept of regenerative endodontics in the management of immature permanent teeth. The potential role of stem cells to regenerate immature permanent teeth after conservative treatment will be discussed.

DATA AND SOURCES

Two sets of data source are focused in this review: (i) the characterization of various dental stem cells discovered since 2000 and (ii) recent clinical case reports showing that after conservative treatment, severely infected immature teeth with periradicular periodontitis and abscess can undergo healing and apexogenesis or maturogenesis.

RESULTS

A new protocol of treating endodontically involved immature permanent teeth based on published articles to date is summarized in the review. The key procedures of the protocol are (1) minimal or no instrumentation of the canal while relying on a gentle but thorough irrigation of the canal system, (2) the disinfection is augmented with intra-canal medication of a triple-antibiotic paste between appointments, and (3) the treated tooth is sealed with mineral trioxide aggregate (MTA) and glass ionomer/resin cement at the completion of the treatment. Periodical follow-ups will take place to observe any continued maturation of the root.

CONCLUSION

While more clinical research is needed, regenerative endodontics promotes a paradigm shift in treating endodontically involved immature permanent teeth from performing apexification procedures to conserving any dental stem cells that might remain in the disinfected viable tissues to allow tissue regeneration and repair to achieve apexogenesis/maturogenesis.

Calcium hydroxide pastes: classification and clinical indications

REVIEW ARTICLE: Calcium hydroxide has been used in endodontology for many years. The aim of this paper is to review the various formulations of calcium hydroxide that have been described, with specific reference to the vehicle used to carry the compound. The requirements for a vehicle are described, and ex vivo and in vivo studies reviewed. Vehicles can be classified into aqueous, viscous and oily, the clinical properties of calcium hydroxide changing depending on the vehicle. The review also describes the use of various active components that have been added to calcium hydroxide, including antimicrobial and anti-inflammatory agents. This review will help clinicians to make informed judgements about which formulations of calcium hydroxide should be used for specific endodontic procedures.

Esthetic, biologic and restorative considerations in coronal segment reattachment for a fractured tooth: a clinical report

Reattachment of a fractured clinical crown involving minimal invasion of the biologic width can be accomplished without conventional ostectomy and crown lengthening so that satisfactory esthetics can be achieved. Adhesive techniques sometimes in conjunction with traditional mechanical retention, such as a post, can be used to reattach the fractured segment. An esthetic result can be obtained with a minimal number of procedures and cost to the patient.

Delayed endodontic and prosthetic treatment of two traumatized incisors

This case report describes the delayed endodontic and prosthetic treatment of two maxillary central incisors in a 16-year-old patient. Both teeth had been traumatized eight years previously. The examination revealed arrested root formation with wide open apices, periapical inflammation and inflammatory resorption. Endodontic treatment with calcium hydroxide led to formation of hard tissue barriers in both teeth so that definite obturation could be performed. One tooth was lost due to a deep crown-root-fracture and replaced by an intraosseous implant, whereas the other incisor was retained for nearly four years.