Revitalization of Open Apex Teeth with Apical Periodontitis Using a Collagen-Hydroxyapatite Scaffold

Successful retreatment of a maxillary central incisor with a wide-open apex using MTA to fill the entire canal: 24-year follow-up

Managing teeth with open apices can be a challenging scenario for clinicians. This case report describes the 24-year follow-up of a maxillary central incisor that failed to develop after a traumatic injury resulting in a wide-open apex. A 10-year-old girl presented complaining of discomfort in her upper teeth. Tooth #9 had received a traumatic blow several years before and was discoloured with a resin composite restoration on the mesio-incisal edge. The tooth was painful to percussion and palpation. An inadequate root canal filling and incomplete root formation were observed on the initial periapical radiograph. Root canal retreatment was initiated, and the canal filled entirely with mineral trioxide aggregate (MTA) because of the extremely wide canal and open apex. The patient was asymptomatic at the 24-year follow-up with the cone beam computed tomography and periapical radiographs demonstrating the stability of the MTA.

Biomaterial scaffolds for clinical procedures in endodontic regeneration

Regenerative endodontic procedures have been rapidly evolving over the past two decades and are employed extensively in clinical endodontics. These procedures have been perceived as valuable adjuvants to conventional strategies in the treatment of necrotic immature permanent teeth that were deemed to have poor prognosis. As a component biological triad of tissue engineering (i.e., stem cells, growth factors and scaffolds), biomaterial scaffolds have demonstrated clinical potential as an armamentarium in regenerative endodontic procedures and achieved remarkable advancements. The aim of the present review is to provide a broad overview of biomaterials employed for scaffolding in regenerative endodontics. The favorable properties and limitations of biomaterials organized in naturally derived, host-derived and synthetic material categories were discussed. Preclinical and clinical studies published over the past five years on the performance of biomaterial scaffolds, as well as current challenges and future perspectives for the application of biomaterials for scaffolding and clinical evaluation of biomaterial scaffolds in regenerative endodontic procedures were addressed in depth.

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Overview of biomaterials for scaffolding in regenerative endodontics are presented.

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Findings of preclinical and clinical studies on the performance of biomaterial scaffolds are summarized.

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Challenges and future prospects in biomaterial scaffolds are discussed.

Patient centered outcomes among a cohort receiving regenerative endodontic procedures or apexification treatments

INTRODUCTION

This multi-centered cohort study evaluated factors associated with patient-centered outcomes of immature permanent teeth that received regenerative endodontic procedures (REPs) or apexification treatment (APEX).

METHODS

A record review identified teeth treated with REPs or APEX between September 2005-December 2014. Data regarding treatment and patient-centered outcomes were extracted from records with a 3-month minimum recall. When possible, participants presented for an in-person prospective research visit. Patient-centered success was defined as an asymptomatic, functional tooth, not requiring further endodontic or surgical intervention following completion of the original treatment during the study observation. Risk ratios and adjusted and unadjusted Cox proportional hazard ratios were calculated.

RESULTS

The analytic cohort of 187 individuals included 211 teeth (93 REPs; 118 APEX) with an average follow-up of 32 months. Most cases were successful (81% REPs; 92% APEX) and survived the observation period (96% REPs; 97% APEX). The success rate of REPs was lower than APEX and decreased more rapidly over time. Cox regression analysis demonstrated that when controlling for other variables, the association between treatment type and outcome is not significant. Preoperative infection, teeth with more immature roots, and REPs treatment are potentially important predictors. Among teeth receiving REPs, a lower failure rate was observed for teeth that received multi-antibiotic paste (3/43) compared to calcium hydroxide (11/45).

CONCLUSIONS

Teeth receiving REPs required clinical intervention earlier than teeth that received APEX treatment, although preoperative abscess and more immature root also affected this outcome. Using multi-antibiotic paste versus calcium hydroxide in REPs may improve success.

Effect of 1,25-Dihydroxyvitamin D3 on Stem Cells from Human Apical Papilla: Adhesion, Spreading, Proliferation, and Osteogenic Differentiation

Currently, it still remains a difficult problem to treat apical insufficiency of young permanent teeth resulted from pulp necrosis or periapical periodontitis. Previous studies have demonstrated that the treatment of revascularization using stem cells from apical papilla (SCAPs) results in increased root length and thickness of traumatized immature teeth and necrotic pulp. In this study, we investigated the role of 1,25-dihydroxyvitamin D3 in regulating the adhesion, spreading, proliferation, and osteogenic differentiation of SCAP, laying the foundation for subsequent clinical drug development. The immature tooth samples were collected in clinical treatment. SCAPs with stable passage ability were isolated and cultured. The multidifferentiation potential was determined by directed induction culture, while the stem cell characteristics were identified by flow cytometry. There were three groups: group A—SCAPs general culture group; group B—SCAPs osteogenesis induction culture group; and group C—SCAPs osteogenesis induction culture+1,25-dihydroxyvitamin D₃ group, and the groups were compared statistically. The proliferation of SCAPs in each groups was detected through CCK-8 assay. RT-qPCR was used to detect the transcription levels of Runx2, ALP, Col I, and OCN of SCAPs in each groups. Results exhibited that the isolated SCAPs had multidifferentiation potential and stem cell characteristics. After 24 h culturing, cells in group C spread better than those in groups A and B. The proliferation activity of SCAPs factored by CCK-8 ranked as group C > group B > group A, while the transcription levels of Runx2, ALP, Col I, and OCN leveled as group C > group B > group A. These results suggested that 1,25-dihydroxyvitamin D₃ can significantly promote the adhesion, spreading, and proliferation of SACPs and improve the osteogenic differentiation of SCAPs by means of regulating upward the transcription level of osteogenic differentiation marker.

Revitalizing previously treated teeth with open apices: A case report and a literature review

Revitalizing the root canals of previously treated teeth with open apices is appealing to clinicians and patients. However, there are fundamental differences in the microbiome and the microenvironment between a canal with a primary endodontic infection and a canal with a persistent endodontic infection. The aims of this report are to report a case where a previously treated tooth with an open apex and a large apical radiolucency was treated successfully using regenerative endodontic treatment (RET) and to review and critically appraise the literature on procedures and outcomes of RET that result in revitalization of canal(s) in previously treated teeth with open apices. A maxillary central incisor with poor-quality root filling, a large apical radiolucency and an open apex was retreated using RET using platelet-rich fibrin as the scaffold. After 24 months, there was complete healing of the periapical lesion and obvious radiographic signs of apical root closure. Electronic searches were performed in MEDLINE, Scopus and Embase, and the baseline, procedural and outcome data of qualified articles were collected. An assessment tool was developed to rate the quality of evidence reported in these case report/series. Nine articles, three case series and six case reports, with a total of 17 teeth of all types, were included in the reports identified. The age of patients ranged from 7 to 48 years (mean: 19.4 years). The recall period ranged from 12 to 72 months (mean: 29 months). All 17 teeth survived and were functional with healing/healed outcomes. "Apical closure" was the most common radiographic finding regarding root development. The quality of evidence using the new assessment tool was rated "Excellent" in three case reports but only "Fair" in the other six articles. The present case report, as well as the review of the literature, suggests that revitalizing the root canal system of teeth with open apices and post-treatment disease using RET is a potentially valid treatment option. However, more clinical studies with higher levels of evidence and higher quality of evidence are required to confirm the viability of this treatment approach.

Clinical and Radiographic Outcomes of Immature Teeth Treated with Different Treatment Protocols of Regenerative Endodontic Procedures: A Retrospective Cohort Study

Regenerative endodontic procedure (REP) is a progressive treatment modality for immature permanent teeth with necrotic pulp. The ambiguousness about the predictability of REP outcome in relation to complete disinfection of the root canal system and the occurrence of discoloration still exists. The aim of this retrospective study was to analyze two treatment protocols on clinical success rate, radiographic root development and the occurrence of discoloration. Eighteen patients were treated by a single operator by either treatment protocol according to the American Association of Endodontists (AAEP, n = 9) or a modified protocol (MP, n = 9) with the use of 5% sodium hypochlorite and sandblasting. Patients were followed up after 3, 6, 9, 12, 18 and 24 months and clinical success, radiographic root development and the occurrence of discoloration were assessed. The clinical success of MP was significantly higher in two years follow-up (p = 0.015), but the change in radiographic root area was higher for AAEP (p = 0.017) and the occurrence of discoloration was higher in AAEP (p = 0.029). The use of 5% sodium hypochlorite for a longer period of time leads to a higher success rate. The sandblasting of the access cavity reduces the occurrence of discoloration.

Clinical Outcomes of Immature Teeth Treated with Regenerative Endodontic Procedures-A San Antonio Study

INTRODUCTION

Factors that influence clinical outcomes for regenerative endodontic procedures (REPs) are unknown. This retrospective study aimed to assess tooth healing, root development, pulp vitality, and esthetics post-REPs and categorize them into clinician- and patient-centered outcomes. Furthermore, this study identified significant predictors affecting such outcomes.

METHODS

Immature permanent teeth diagnosed with pulp necrosis treated with REPs between 2008 and 2018 with a minimum of 1-year follow-up were included. Outcomes included success and survival rates, changes in root development using 2-dimensional radiographic root area (RRA) and 3-dimensional measurements, pulp vitality, and tooth discoloration. Predictor variables of success included age, sex, etiology of pulp necrosis (PN), type of medicament, sodium hypochlorite (NaOCl) concentration, type of biomaterial used over the blood clot, and preoperative apical diagnosis. Statistical analyses included Cox proportional hazard analyses and generalized regression models.

RESULTS

Fifty-one teeth with an average of 2.1 years of follow-up satisfied the criteria. The survival rate was 92%. The success rate was 84.3% with age, etiology of PN, type of medicament, and NaOCl concentration being significant predictors of failure. Root development occurred in 91.4% of cases with age, sex, etiology of PN, type of medicament, NaOCl concentration, and apical diagnosis being significant predictors for RRA change. Positive pulp sensibility responses were associated with greater RRA change, and, finally, the type of biomaterial was a significant predictor for tooth discoloration after treatment.

CONCLUSIONS

REPs provide a high survival rate. Patient and clinical factors may affect outcomes, and this knowledge may help to define the criteria for optimal treatment planning of REPs.

Controllable Synthesis of Biomimetic Hydroxyapatite Nanorods with High Osteogenic Bioactivity

The development of biodegradable materials with high osteogenic bioactivity is important for achieving rapid bone regeneration. Although hydroxyapatite (HAp) has been applied as a biomaterial for bone engineering due to its good osteoconductivity, conventional synthetic HAp nanomaterials still lack sufficient osteogenesis, likely due to their high crystallinity and uncontrollable architecture. A design of HAp nanoparticles mimicking bone features may create good microenvironments that promote osteogenesis for rapid bone regeneration. In this study, HAp nanoparticles with a comparatively less crystalline structure and nanorod shapes mimicking biological HAp nanocrystals of natural bone were fabricated using a simple chemical precipitation approach with mild temperature control in the absence of any organic solvents. Transmission electron microscopy (TEM) indicated that HAp nanorods with aspect ratios from 2.0 to 4.4 were synthesized by adjusting the reaction time as well as the reaction temperature. Fourier transform infrared spectroscopy and X-ray diffraction experiments displayed that HAp nanorods prepared at 30 °C (HAp-30 with an aspect ratio of 2.9) had a low crystalline structure and B-type CO₃^2- substitution similar to those of natural HAp originating from bone tissue. The energy-dispersive spectroscopy (EDS) results showed that the Ca/P ratio of HAp-30 was 1.66 ± 0.13. An in vitro biological evaluation against rat bone marrow-derived mesenchymal stem cells indicated that the resulting HAp nanorods had excellent biocompatibility (with an ∼80-fold increase in IC50 compared to that of conventional HAp nanoparticles). Interestingly, the alkaline phosphatase (ALP), alizarin red S, and immunofluorescence staining results all showed that stem cells display an obvious osteogenesis dependence on the HAp nanostructure. Specifically, HAp nanorods with a moderate aspect ratio had the optimal osteogenic capacity (e.g., HAp-30 offered a 2.8-fold increase in ALP expression and a 4-fold increase in OCN expression relative to that provided by irregular HAp at day 14). It is expected that HAp nanorods with controllable architectures and size have potential as a kind of new bioactive bone filler for bone defect repair.

Clinical, Radiographic, and Histologic Outcome of Regenerative Endodontic Treatment in Human Teeth Using a Novel Collagen-hydroxyapatite Scaffold

INTRODUCTION

Histologic examination of teeth after regenerative endodontic treatment (RET) shows that the type, quality, and quantity of tissues formed in the root canal space are not predictable. The aim of this study was to examine clinically, radiographically, and histologically the outcome of RET in immature noninfected human teeth using SynOss Putty (Collagen Matrix Inc, Oakland, NJ) as a scaffold.

METHODS

Three pairs of maxillary/mandibular first premolars in 3 patients scheduled for extraction were included. Sensibility tests confirmed the presence of vital pulps. After informed consent, anesthesia, and rubber dam isolation, the pulps were removed. RET was performed using the following scaffolds: SynOss Putty + blood in both teeth in patient #1, SynOss Putty with or without blood in patient #2, and SynOss Putty + blood or blood only in patient #3. After a follow-up period of 2.5-7.5 months, the teeth were clinically and radiographically evaluated, extracted, and examined histologically.

RESULTS

Patients remained asymptomatic after treatment. Radiographic examination of the teeth showed signs of root development after treatment. In teeth treated with SynOss Putty + blood, histologic examination showed formation of intracanal mineralized tissue around the scaffold particles solidifying with newly formed cementumlike tissue on the dentinal walls. The tooth treated with SynOss Putty without blood showed the formation of a periapical lesion. The tooth treated with a blood clot only showed tissues of periodontal origin growing into the root canal space.

CONCLUSIONS

SynOss Putty + blood showed a predictable pattern of tissue formation and mineralization when used as a scaffold for RET in human immature noninfected teeth. The newly formed mineralized tissue solidifies with newly formed cementum on the dentinal walls.

Bone, Periodontal and Dental Pulp Regeneration in Dentistry: A Systematic Scoping Review

The aim of presented systematic scoping review was to investigate the actual and future clinical possibilities of regenerative therapies and their ability to regenerate bone, periodontal and pulp with histological confirmation of the nature of formed tissue. Electronic search was conducted using a combination between Keywords and MeSH terms in PubMed, Scopus, ISI-Web of Science and Cochrane library databases up to January 2016. Two reviewers conducted independently the papers judgment. Screened studies were read following the predetermined inclusion criteria. The included studies were evaluated in accordance with Arksey and O'Malley's modified framework. From 1349 papers, 168 completed inclusion criteria. Several characterized and uncharacterized cells used in Cell Therapy have provided bone regeneration, demonstrating bone gain in quantity and quality, even as accelerators for bone and periodontal regeneration. Synthetic and natural scaffolds presented good cell maintenance, however polyglycolid-polylactid presented faster resorption and consequently poor bone gain. The Growth Factor-Mediated Therapy was able to regenerate bone and all features of a periodontal tissue in bone defects. Teeth submitted to Revascularization presented an increase of length and width of root canal. However, formed tissues not seem able to deposit dentin, characterizing a repaired tissue. Both PRP and PRF presented benefits when applied in regenerative therapies as natural scaffolds. Therefore, most studies that applied regenerative therapies have provided promising results being possible to regenerate bone and periodontal tissue with histological confirmation. However, pulp regeneration was not reported. These results should be interpreted with caution due to the short follow-up periods.

Trends in polymeric electrospun fibers and their use as oral biomaterials

Electrospinning is one of the techniques to produce structured polymeric fibers in the micro or nano scale and to generate novel materials for biomedical proposes. Electrospinning versatility provides fibers that could support different surgical and rehabilitation treatments. However, its diversity in equipment assembly, polymeric materials, and functional molecules to be incorporated in fibers result in profusion of recent biomaterials that are not fully explored, even though the recognized relevance of the technique. The present article describes the main electrospun polymeric materials used in oral applications, and the main aspects and parameters of the technique. Natural and synthetic polymers, blends, and composites were identified from the available literature and recent developments. Main applications of electrospun fibers were focused on drug delivery systems, tissue regeneration, and material reinforcement or modification, although studies require further investigation in order to enable direct use in human. Current and potential usages as biomaterials for oral applications must motivate the development in the use of electrospinning as an efficient method to produce highly innovative biomaterials, over the next few years. Impact statement Nanotechnology is a challenge for many researchers that look for obtaining different materials behaviors by modifying characteristics at a very low scale. Thus, the production of nanostructured materials represents a very important field in bioengineering, in which the electrospinning technique appears as a suitable alternative. This review discusses and provides further explanation on this versatile technique to produce novel polymeric biomaterials for oral applications. The use of electrospun fibers is incipient in oral areas, mainly because of the unfamiliarity with the technique. Provided disclosure, possibilities and state of the art are aimed at supporting interested researchers to better choose proper materials, understand, and design new experiments. This work seeks to encourage many other researchers-Dentists, Biologists, Engineers, Pharmacists-to develop innovative materials from different polymers. We highlight synthetic and natural polymers as trends in treatments to motivate an advance in the worldwide discussion and exploration of this interdisciplinary field.

A scoping review of root canal revascularization: relevant aspects for clinical success and tissue formation

The aim of this scoping study was to evaluate the survival rate and nature of tissue formed inside root canals of human immature permanent teeth with necrotic pulps (NIPT) under root canal revascularization (RCR). The search was performed in SciVerse Scopus®, PubMed/MEDLINE, Web of Science®, BIREME and in the grey literature up to November 2015. The keywords were selected using MeSH terms and DECs. Two independent reviewers scrutinized the records obtained considering specific inclusion criteria. The included studies were evaluated in accordance with a modified Arksey and O' Malley's framework. From 375 studies that were evaluated, 75 were included. A total of 367 NIPT were submitted to RCR, from which only 21 needed further endodontic treatment. The weighted mean follow-up time was 17.6 months. The data were derived mainly from case reports (69%) or small case series (15%). NaOCl [0.5-6%] was applied as the disinfecting solution in almost all studies. Triple antibiotic paste was as effective as Ca(OH)2 as on intracanal medicament. De novo tissue was cementum and poorly mineralized bone positive to bone sialoprotein (BSP) but negative to dentine sialoprotein (DSP). Failures were associated mainly with reinfection of the root canal. The majority of included studies reported a significant increase in both root length and width. However, as most of these data came from case reports, they must be interpreted with care, as most were focused on treatment successes (not failures). Therefore, well-designed randomized controlled trials comparing RCR with available apexification treatments are needed to address this gap in the literature.

Hydroxyapatite-polymer biocomposites for bone regeneration: A review of current trends

Bone tissue engineering has emerged as one of the most indispensable approaches to address bone trauma in the past few decades. This approach offers an efficient and a risk-free alternative to autografts and allografts by employing a combination of biomaterials and cells to promote bone regeneration. Hydroxyapatite (HA) is a ceramic biomaterial that mimics the mineral composition of bones and teeth in vertebrates. HA, commonly produced via several synthetic routes over the years has been found to exhibit good bioactivity, biocompatibility, and osteoconductivity under both in vitro and in vivo conditions. However, the brittle nature of HA restricts its usage for load bearing applications. To address this problem, HA has been used in combination with several polymers in the form of biocomposite implants to primarily improve its mechanical properties and also enhance the implants' overall performance by simultaneously exploiting the positive effects of both HA and the polymer involved in making the biocomposite. This review article summarizes the past and recent developments in the evolution of HA-polymer biocomposite implants as an "ideal" biomaterial scaffold for bone regeneration. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 2046-2057, 2018.

Quantitative stereological analysis of the highly porous hydroxyapatite scaffolds using X-ray CM and SEM

BACKGROUND

Material properties of the scaffolds as well as their microstructure are vital in determining in vivo cellular response. Three-dimensional (3D), highly porous scaffolds are used in tissue engineering to provide a suitable microenvironment and to support regeneration of bone. Both pore sizes and their architecture, in particular interconnection density, impact functionality of scaffold during its biomedical applications.

OBJECTIVE

In this paper a comparative study of the microstructure of highly porous hydroxyapatite scaffolds produced via gelcasting of foamed slurries and replication of polyurethane sponge were carried out.

METHODS

Quantitative stereological analysis of the microstructure was conducted using transmission X-ray computed microtomography (μCT) and scanning electron microscopy (SEM). Application of the X-ray microtomography allowed obtaining the 2D cross-sectional images of examined samples, and then the 3D reflection of individual samples.

RESULTS

In our studies we proved that the distribution of pores in HAp bioceramics can be controlled by selection of the manufacturing method. In the case of material produced by the gelcasting method, the porosity of the samples was about ∼78 vol.%, while for the method of replication of the porous organic matrix it was higher ∼84 vol.%. Application of gelcasting method resulted in bioceramics with the macropores ranging from 95 μm to 158 μm (the modal value of 120 μm). Furthermore, micropores of size 34 μm-60 μm - so called "windows", were observed on spherical macropores surfaces. In the case of replication of polyurethane sponge only macropores from 295 μm to 337 μm (the modal value of 300 μm) were obtained. Application of μCT and SEM give more information than classical mercury intrusion porosimetry in studies of porous bioceramics. Developed materials met the criteria for porous bone substitutes.

CONCLUSIONS

The results of quantitative description of microstructure allowed determining the differences between porous hydroxyapatite bioceramics obtained via replication of porous organic matrix and gelcasting of foamed slurry. The stereological analysis demonstrated, that bioceramics prepared via gelling of foamed slurry has a lower pore size and grains (1.1-1.9 μm) than the material obtained by the method of replication of polyurethane sponge (2.1-2.3 μm). Based on morphological analysis the porosity of tested materials was determined. In the case of material produce by the gelcasting, porosity of the samples was about ∼78 vol.%, while for method of replication of the porous organic matrix the porosity was higher and constituted ∼84 vol.%. Furthermore, evaluated materials varied in porosity and the pore size distribution. It was stated that the method of gelcasting resulted in hydroxyapatite bioceramics with the macropores diameter (95-158 μm), micropores so called "windows" (34-60 μm) - observed on spherical macropores walls and micropores of size 0.6 μm-1.3 μm, which were visible in sintered areas. When the method of replication of polyurethane sponge was applied only macropores from 295 μm to 337 μm were obtained. The comparable values of shape factors such as elongation, curvature of pours boundary and convexity, confirmed that macropores in both studied series had similar shape.

Regeneration and Repair in Endodontics-A Special Issue of the Regenerative Endodontics-A New Era in Clinical Endodontics

Caries is the most common cause of pulp-periapical disease. When the pulp tissue involved in caries becomes irreversibly inflamed and progresses to necrosis, the treatment option is root canal therapy because the infected or non-infected necrotic pulp tissue in the root canal system is not accessible to the host's innate and adaptive immune defense mechanisms and antimicrobial agents. Therefore, the infected or non-infected necrotic pulp tissue must be removed from the canal space by pulpectomy. As our knowledge in pulp biology advances, the concept of treatment of pulpal and periapical disease also changes. Endodontists have been looking for biologically based treatment procedures, which could promote regeneration or repair of the dentin-pulp complex destroyed by infection or trauma for several decades. After a long, extensive search in in vitro laboratory and in vivo preclinical animal experiments, the dental stem cells capable of regenerating the dentin-pulp complex were discovered. Consequently, the biological concept of ‘regenerative endodontics’ emerged and has highlighted the paradigm shift in the treatment of immature permanent teeth with necrotic pulps in clinical endodontics. Regenerative endodontics is defined as biologically based procedures designed to physiologically replace damaged tooth structures, including dentin and root structures, as well as the pulp-dentin complex. According to the American Association of Endodontists’ Clinical Considerations for a Regenerative Procedure, the primary goal of the regenerative procedure is the elimination of clinical symptoms and the resolution of apical periodontitis. Thickening of canal walls and continued root maturation is the secondary goal. Therefore, the primary goal of regenerative endodontics and traditional non-surgical root canal therapy is the same. The difference between non-surgical root canal therapy and regenerative endodontic therapy is that the disinfected root canals in the former therapy are filled with biocompatible foreign materials and the root canals in the latter therapy are filled with the host's own vital tissue. The purpose of this article is to review the potential of using regenerative endodontic therapy for human immature and mature permanent teeth with necrotic pulps and/or apical periodontitis, teeth with persistent apical periodontitis after root canal therapy, traumatized teeth with external inflammatory root resorption, and avulsed teeth in terms of elimination of clinical symptoms and resolution of apical periodontitis.

Management of Teeth with Persistent Apical Periodontitis after Root Canal Treatment Using Regenerative Endodontic Therapy

Regenerative endodontic therapy (RET) is currently used to treat immature teeth with necrotic pulp and/or apical periodontitis. However, recently RET has been used to treat mature teeth with necrotic pulp and/or apical periodontitis and resulted in regression of clinical signs and/or symptoms and resolution of apical periodontitis. The purpose of this case report was to describe the potential of using RET to treat 2 mature teeth with persistent apical periodontitis after root canal therapy using RET. Two male patients, one 26-year old and another 12-year old, presented for retreatment of persistent apical periodontitis after root canal treatment of 2 mature teeth (#9 and #19). The gutta-percha fillings in the canals of teeth #9 and #19 were removed with Carvene gutta-percha solvent (Prevest DenPro, Jammu, India) and ProTaper Universal rotary retreatment files (Dentsply Maillefer, Ballaigues, Switzerland). The canals of both teeth were further chemomechanically debrided with rotary retreatment files and copious amounts of sodium hypochlorite irrigation and dressed with Metapaste (Meta Biomed, Chungbuk, Korea). RET was performed on teeth #9 and #19. Periapical bleeding was provoked into the disinfected root canals. The blood clots were covered with mineral trioxide aggregate plugs, and the access cavities were restored with intermediate restorative material. Teeth #9 and #19 showed regression of clinical signs and/or symptoms and healing of apical periodontitis after 13-month and 14-month follow-ups, respectively. Tooth #9 revealed narrowing of the canal space and apical closure by deposition of hard tissue. RET has the potential to be used to retreat teeth with persistent apical periodontitis after root canal therapy.