Pulp revascularization of immature permanent teeth: a review of the literature and a proposal of a new clinical protocol

Assessment of apical extrusion in regenerative endodontics: a comparative study of different irrigation methods using three-dimensional immature tooth models

To investigate the apical extrusion of sodium hypochlorite in immature permanent teeth caused by conventional syringe irrigation (CSI), EDDY, XP-endo Finisher file (XP-F), and a new laser irrigation activation system [shock-wave-enhanced-emission-photo-acoustic-streaming (SWEEPS)]. Three-dimensionally printed forty-nine teeth with immature central incisor morphology were randomly assigned to seven experimental groups, based on the irrigation activation methods and insertion depths (1 mm and 2 mm short of the working length) as follows: CSI-1, CSI-2, EDDY-1, EDDY-2, XP-1, XP-2, and SWEEPS. Prior to the irrigation activation process, samples were placed in metacresol mixed agar gel in Eppendorf tubes. To evaluate NaOCI extrusion into the gel, each sample was digitally photographed, and the area of apical extrusion was analyzed using ImageJ software. To examine potential significant differences between the continuous variables, the Mann-Whitney U test and Kruskal-Wallis H test, were applied (P = .05). The SWEEPS resulted in a greater amount of apical extrusion compared to the CSI method, regardless of the insertion depth (P < 0.001). The SWEEPS resulted in greater apical extrusion scores compared to EDDY-2 (P < 0.001). The EDDY-1 resulted in greater amount of apical extrusion scores compared to EDDY-2 (P < 0.001). This study, the first to show the effect of the novel SWEEPS technology on NaOCI extrusion, found that irrigation activation can cause different levels of apical extrusion depending on the method and distance from the working length. It is crucial to consider the potential occurrence of apical extrusion when applying activation methods to immature teeth.

Non-surgical Management of a Large Periapical Lesion: A Case Study of the Successful Application of a Modified Triple Antibacterial Paste

Infection of the dental pulp involves mainly Gram-negative, anaerobic bacterial flora and due to this infection, the periapical area experiences an immunological response, which is termed a periapical lesion. This lesion may appear as a radiolucent (dark) area on X-rays, which indicates periapical inflammation and infection. Its prevalence depends on factors such as age, oral health maintenance, and dental care. Men are more likely to be affected by this infection than women. There are two modalities for the treatment of periapical lesions: surgical or non-surgical endodontic therapy. The modified triple antibiotic paste (TAP) comprising ciprofloxacin, metronidazole, and clindamycin in the ratio of 1:1:1 was first prepared expressly to treat the teeth with necrotic pulp and to support the protocol for revitalization and regrowth. The treatment was very successful in eliminating germs from the root canal system. It provides broad-spectrum antimicrobial activity against a wide range of bacteria commonly associated with endodontic infections. The modified TAP is usually inserted into the canal for a predetermined amount of time and then removed followed by the irrigation of root canal, which helps to eliminate the microorganisms from the root canal. The non-surgical treatment should always be the first choice over the surgical approach so as to avoid a more invasive procedure.

Platelet-rich fibrin as an apical barrier for MTA placement in the treatment of teeth with open apices: a pilot study

OBJECTIVE

The aim of the present pilot study was to assess the effectiveness of the platelet-rich fibrin (PRF) apical barrier for the placement of MTA for the treatment of teeth with periapical lesions and open apices.

METHODS

A total of thirty teeth on twenty-eight patients with open apices and periapical periodontitis were enrolled and divided into two groups in the present pilot study. In the PRF group (fourteen teeth in thirteen patients), nonsurgical endodontic treatment was performed using PRF as an apical matrix, after which the apical plug of the MTA was created. For the non-PRF group (fourteen teeth in fourteen patients), nonsurgical endodontic therapy was performed using only the MTA for an apical plug with no further periapical intervention. Clinical findings and periapical digital radiographs were used for evaluating the healing progress after periodic follow-ups of 1, 3, 6, and 9 months. The horizontal dimension of the periapical lesion was gauged, and the changes in the dimensions were recorded each time. The Friedman test, Dunn-Bonferroni post hoc correction, and Mann-Whitney U test were used for statistical analysis, with P < 0.05 serving as the threshold for determining statistical significance.

RESULTS

All patients in both groups in the present pilot study had no clinical symptoms after 1 month, with a significant reduction in the periapical lesion after periodic appointments. The lesion width of the PRF group was significantly smaller than that of the non-PRF group in the sixth and ninth month after treatment.

CONCLUSIONS

PRF is a promising apical barrier matrix when combined with MTA for the treatment of teeth with open apices and periapical periodontitis. Small number of study subjects and the short time of follow-up period limit the generalizability of these results.

TRIAL REGISTRATION

TCTR, TCTR20221109006. Registered 09 November 2022 - Retrospectively registered, https://www.thaiclinicaltrials.org/show/TCTR20221109006 .

Pulp regeneration treatment using different bioactive materials in permanent teeth of pediatric subjects

Background and Objectives

The present systematic review aims to assess the success rate of the pulp regeneration treatment, according to the American Association of Endodontists (AAE) criteria, using different bioactive materials in permanent teeth of pediatric subjects (6-17 years of age).

Materials and Methods

The study protocol was registered on PROSPERO and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. The question formulation was accomplished using the PICO model, and an electronic search was carried out on Scopus, MEDLINE/PubMed, Web of Science, and Cochrane databases till April 1, 2023. A total of 30 studies were established to fulfill the inclusion criteria of this systematic review.

Results

A total of 273 teeth have been treated with pulp regeneration treatment. By comparing different biomaterials and the success criteria defined by the AAE, the material associated with a higher success rate was found to be the white mineral trioxide aggregate. However, the overall success rate of pulp regeneration treatment was reported for 248 out of 273 teeth (91.20%).

Conclusions

Data obtained support the potential that regenerative endodontics aids in continuing root development in permanent immature teeth. Further studies are needed for a more extensive evaluation of the use of different biomaterials and the success rate in regenerative endodontics.

Revascularization Revisited with Modified Triple Antibiotic Paste and NeoPutty MTA®

Introduction and Aim

Performing endodontic treatment in an immature permanent tooth that has experienced trauma or carious exposure can pose challenges. The root canals in these teeth are typically open and fragile, making instrumentation and obturation difficult. Traditional apexification, which involves placing calcium hydroxide paste in the root canal for a specified period to induce the formation of a calcified barrier, has been a long-standing approach. While it is a widely used method, leaving the paste in the root for extended periods can weaken it due to the paste's hygroscopic properties and the proteolytic activities of calcium hydroxide. As a result, researchers have been exploring alternative treatments that allow for the full development of immature teeth. Revascularization has emerged as one such alternative, with a variety of treatment protocols documented in scientific literature.

Description of the Case

This case report, for the first time, describes the use of NeoPutty MTA® and triple antibiotics paste for revascularization in a young female child on a carious, exposed lateral incisor with opex apex with success.

Conclusion

The revascularization process attempted on the infected tooth met with success and closure of apex was noticed in a short period of time.

Platelet rich fibrin and MTA in the treatment of teeth with open apices

BACKGROUND

The present study aimed to evaluate the effectiveness of using platelet-rich fibrin (PRF) as the apical matrix for the placement of MTA in nonsurgical endodontic therapy for teeth with periapical lesions and open apices.

METHODS

Twelve teeth from eleven patients with periapical periodontitis and open apices were enrolled in the study. Nonsurgical endodontic therapy was performed with the PRF used as an apical barrier and the MTA manipulated as an apical plug for further thermoplasticized gutta percha in the remaining part of the root canal. Clinical signs and periapical digital radiographs were recorded and analyzed to evaluate the curing progress after periodical follow-ups of 1, 3, and 6 months. The horizontal dimension of the periapical lesion was determined, and the changes in the dimensions were recorded each time. The Friedman test was used for statistical analysis, with P < .05 serving as the threshold for determining statistical significance.

RESULTS

All patients had no clinical symptoms after the first month of treatment, with a significant reduction in the periapical lesion after periodical appointments.

CONCLUSIONS

PRF is an effective barrier when combined with MTA for the treatment of teeth with periapical periodontitis and open apices.

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.

Efficacy of disinfection procedures performed prior to regenerative endodontic therapy: An integrative review

The aim of this integrative review was to identify whether the disinfection procedures performed prior to regenerative endodontic treatment were effective on biofilm removal from the root canals. The research was based on PubMed, Latin American and Caribbean Health Sciences Literature (Lilacs) and Scientific Electronic Library Online (SciELO) databases. Four articles were selected; one of the studies was in vivo and the others ex vivo. Different disinfection procedures were studied, characterised mainly by the use of intracanal medication, highlighting the double antibiotic paste, triple antibiotic paste and calcium hydroxide paste. Disinfection ability was evaluated against Enterococcus faecalis and multispecies biofilms by using the fluorescence technique and colony forming unit counting, for 7 to 21 days. Double antibiotic paste and triple antibiotic paste demonstrated excellent antibiofilm activity, unlike CH paste that showed limited disinfection, even when associated with different antimicrobial agents. Triple antibiotic paste was the most effective medication against biofilm.

Review of guidance for the selection of regenerative endodontics, apexogenesis, apexification, pulpotomy, and other endodontic treatments for immature permanent teeth

This review guidance is a work in progress because the limitations of regenerative endodontics are still being discovered. The endodontic treatments for immature permanent teeth with a necrotic pulp can vary considerably among endodontic practitioners. Whereas, regenerative endodontic treatments are growing in popularity and are creating ever more complex treatment protocols, involving revascularization and/or autologous platelet-rich plasma and scaffolds to elicit host stem cell de novo tissue formation to reestablish the vitality of immature teeth for the purpose of continuing root maturation. Despite much evolving controversy about their potential benefits, risks, prognosis, and contraindications, this review is aimed to discuss how to ensure that regenerative endodontic treatments are successful, by strictly adhering to case selection criteria, and following precise steps to accomplish and monitor the success of the treatment. A review of the endodontic literature was performed, together with practical observations of the problems and outcomes of performing regenerative endodontic treatments. Traditionally, apexification has long been the treatment of choice provided to immature teeth with a necrotic pulp. Regenerative endodontics may be provided as an alternative to apexification, if the tooth and patient meet all the case selection criteria, and if there are no contraindications. Regenerative endodontics has the unique potential advantage of being able to continue the root development in immature permanent teeth, thereby potentially saving the teeth for the lifetime of the patient. Whereas, conventional endodontic root canal treatment, Cvek partial pulpotomy, apexogenesis, and apexification, should always be provided when these treatments are more likely to benefit the patient because they can be more successful than regenerative endodontics.

Is pulpotomy a promising modality in treating permanent teeth? An umbrella review

Emerging evidence suggests the use of less invasive therapy such as pulpotomy in treating permanent teeth with pulp exposure and signs of pulpitis. Hence, this umbrella review aims to evaluate the available systematic reviews on pulpotomy treated permanent teeth. Articles published between January 1970 and May 2021 were searched in ten electronic databases and five textbooks. Only systematic reviews published in English that examined the use of pulpotomy on either carious or traumatic pulpal exposed in mature or immature permanent teeth with signs of pulpitis were selected. The Corrected Covered Areas (CCAs) were calculated to identify the overlap in primary studies, whereas the AMSTAR 2 assessment tool was used to analyze the risk of bias in each included review. Nine systematic reviews were chosen of which two systematic reviews focused solely on coronal pulpotomy, one on partial pulpotomy, and the remaining focused on both coronal and partial pulpotomies. Overall, only two reviews were rated as 'High Quality'. Umbrella analyses showed that both coronal and partial pulpotomies revealed overall high success rates ranging from 88.5% to 90.6%. However, the currently available evidence on the effects of different pulpal medicaments and restorative materials on the success rate of pulpotomy were still inconclusive. Pulpotomy can be regarded as a promising modality in treating mature and immature permanent teeth with carious pulpal exposure or signs of pulpitis. Nonetheless, further high-quality clinical trials with long-term follow-up and better control of confounding factors are warranted in the future.

Host defense peptide IDR-1002 associated with ciprofloxacin as a new antimicrobial and immunomodulatory strategy for dental pulp revascularization therapy

Regenerative therapies such as dental pulpal revascularization appear as an option for traumatized immature permanent teeth. However, the triple antibiotic paste - TAP (metronidazole, minocycline, and ciprofloxacin), used for these therapies, can generate cytotoxicity and dentin discoloration. In contrast, host defense peptides (HDPs) are promising antimicrobial and immunomodulatory biomolecules for dentistry. This study aimed to evaluate in vitro the antimicrobial activity (against Staphylococcus aureus and Enterococcus faecalis) and the immunomodulatory potential (by the evaluation of IL-1α, IL-6, IL-12, IL-10, TNF-α and NO, in RAW 264.7 macrophages and IL-6, TGF-β and NO, in L929 fibroblast) of synthetic peptides (DJK-6, IDR-1018, and IDR-1002), compared to TAP in an in vitro infection model containing heat-killed antigens from E. faecalis and S. aureus. Furthermore, the synergistic potential of ciprofloxacin and IDR-1002 was evaluated by checkerboard. Ciprofloxacin was the best antimicrobial of TAP, besides acting in synergism with IDR-1002. TAP was pro-inflammatory (p < 0.05), while the association of ciprofloxacin and IDR-1002 presented an anti-inflammatory profile mainly in the presence of both heat-killed antigens (p < 0.05). Based on these results, ciprofloxacin associated with IDR-1002 may demonstrate an efficient antimicrobial and immunomodulatory action in this in vitro model. Further in vivo studies may determine the real potential of this combination.

Antimicrobial Therapeutics in Regenerative Endodontics: A Scoping Review

INTRODUCTION

This review aimed to provide a critical appraisal of alternative antimicrobial strategies in lieu of traditional triple antibiotic paste (TAP).

METHODS

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The literature search was performed in 8 databases (PubMed/Medline, Embase, LILACS, Web of Science, Scopus, BVS, SciELO, and the Cochrane Library), selecting clinical, in vitro, in vivo, and in situ studies that evaluated antimicrobial alternatives to TAP in regenerative endodontics. Studies lacking an experimental TAP group were excluded.

RESULTS

A total of 1705 potentially relevant records were initially identified. From the 38 studies retrieved for full-text reading, 16 fulfilled all selection criteria and were included in the qualitative analysis. According to the study design, 11 studies were solely in vitro, 1 study was both in vitro and in vivo (animal model), 2 studies were solely animal experiments, and 2 studies were clinical trials. The alternative antimicrobial agents to TAP consisted of modified TAP formulations (eg, a combination of TAP with chitosan); TAP-eluting nanofibers; propolis; chlorhexidine (CHX) gels/solutions; double antibiotic pastes composed of distinct combinations of antibiotics; Ca(OH)₂-based formulations; and sodium hypochlorite. Overall, most of the alternative agents performed similarly to TAP, although some strategies (eg, Ca(OH)₂- and CHX-based formulations) seemed to present dubious importance in the control of infection.

CONCLUSIONS

TAP still remains an excellent option in terms of the complete elimination of microorganisms. This review points to the use of electrospun fibers as a drug delivery system to offer a controlled release of the antimicrobial agent, as well as the use of natural compounds, deserving future investigation.

Endodontic approach in a replanted tooth with an immature root apex and chronic apical periodontitis: a case report

This study describes the clinical steps taken in the treatment of a patient who had an avulsed right upper central incisor that presented with incomplete root development and chronic apical periodontitis. A 7-year-old boy was referred from a private dentist to a dental office specializing in endodontics. The tooth had remained in a dry environment for 20 minutes, and tooth replantation was performed at an emergency appointment. After clinical and radiographic examinations, root canal decontamination was performed, followed by several changes in intracanal calcium hydroxide medication. Blood clot formation was attempted, but bleeding within the root canal was insufficient; therefore, we opted for an intracanal medication change to stimulate mineralized tissue formation in the apical region. Root obturation was performed 45 days after the last change of intracanal medication, and clinical, radiographic, and tomographic follow-up examinations were performed at 3, 6, 18, and 40 months after the endodontic intervention. The increase in thickness and length of the root structure and the absence of root resorption were verified through follow-up examinations. Therefore, it was concluded that the procedures used were successful for tooth replantation.

Apexification with Calcium Hydroxide vs. Revascularization

Treatment of necrotic immature teeth has always been a real challenge for the clinician due to the open apex and weak root structure, which does not allow a conventional endodontic treatment. Several therapeutic options are possible to treat those teeth. Calcium hydroxide apexification is the oldest and most studied therapeutic option, but it has some disadvantages, including the long term of treatment, the possibility of reinfection, and the weakness of the wall. To solve these problems, several authors recommend the revascularization technique. This therapy allows the continuation of root edification with apical closure and thickening of the walls. The aim of our work is to compare the two therapeutic procedures, apexification with calcium hydroxide and revascularization, through a clinical case treated and followed up for 24 months at the pediatric dentistry department in Casablanca, Morocco.

Negative Pressure Irrigation Presents Mineralizing Potential in Dogs' Immature Teeth with Periapical Lesion

The objective of this in vivo study was to assess the effect of the root canal irrigation by negative and positive apical pressure on the expression of molecules that are an indicative of cell differentiation with mineralizing phenotype in teeth of dogs with incomplete rhizogenesis and induced periapical lesion. A total of 30 teeth (60 roots) were distributed into 3 groups (n=20): EndoVac®, Conventional and Control. After 90 days, the routine histotechnical procedures were performed and the sections were submitted to immunohistochemical technique for the staining of osteopontin (OPN), alkaline phosphatase (ALP) and the RUNX2 transcription factor in the apical and periapical regions of the roots. A semi-quantitative analysis of the positive immunostaining was performed and the intensity of the expression was classified in absent (0), mild (1), moderate (2), or intense (3). Scores data were statistically analyzed by the Kruskal-Wallis non-parametric test and Dunn post-test, and the significance level was set at 5%. RUNX2 immunostaining revealed that in the negative pressure group there was a significantly stronger (p<0.05) immunostaining in comparison to the control group. Regarding the OPN expression, it was not possible to detect a statistically significant difference between the groups (p>0.05). After analyzing ALP immunostaining, a statistically significant difference was observed between the groups (p<0.05), and the negative pressure group showed a markedly stronger mark immunostaining than the control group. The results of the present in vivo study allowed concluding that negative apical pressure irrigation presents mineralizing potential in immature teeth with apical periodontitis.

Concentrated Growth Factor Promotes Dental Pulp Cells Proliferation and Mineralization and Facilitates Recovery of Dental Pulp Tissue

Background

Dental pulp cells (DPCs) play vital roles in the recovery of dental pulp tissue. Concentrated growth factor (CGF) can promote proliferation and mineralization of various cells. However, the functions of CGF on DPCs and dental pulp tissue are unclear. The object of our study was to identify the roles of CGF in DPCs proliferation and mineralization in vitro and to assess the effects of CGF on direct pulp capping in vivo.

Material/Methods

We performed CCK-8 and Transwell assay to detect proliferation and migration activity of DPCs. Alizarin Red staining was performed to examine mineralized nodules. Alkaline phosphatase activity test was used to measure the mineralization capacity of DPCs. We assessed the odontogenic differentiation gene expression level by Western blot and qPCR. The effect of CGF on direct pulp capping in vivo were evaluated by radiography and histopathology.

Results

CGF increased the number of proliferative and migratory DPCs. CGF enhanced DPCs mineralized nodules and improved the gene expression levels of DSPP, DMP-1, BSP, and ALP. CGF upregulated the protein levels of ALP, BMP2, SMAD5, Runx2, and p-Smad, and the effect could be partially reversed by Noggin. CGF promoted pulp recovery and kept its vitality in directly pulp capping.

Conclusions

CGF promotes DPCs proliferation and mineralization. It regulates the mineralization of DPCs via the BMP2/SMAD5/Runx2 signaling pathway. CGF can be used as the effective graft for direct pulp capping.

Evaluation of the Apical Complex and the Coronal Pulp as a Stem Cell Source for Dentin-pulp Regeneration

INTRODUCTION

This study compared the stemness and differentiation potential of stem cells derived from the apical complex (apical complex cells [ACCs]) and coronal pulp (dental pulp stem cells [DPSCs]) of human immature permanent teeth with the aim of determining a more suitable source of stem cells for regeneration of the dentin-pulp complex.

METHODS

ACC and DPSC cultures were established from 13 human immature permanent teeth using the outgrowth method. The proliferation capacity and colony-forming ability of ACCs and DPSCs were evaluated. ACCs and DPSCs were analyzed for mesenchymal stem cell markers using flow cytometry. The adipogenic and osteogenic differentiation potential of ACCs and DPSCs were evaluated using the quantitative real-time polymerase chain reaction and histochemical staining. ACCs and DPSCs were transplanted subcutaneously in immunocompromised mice using macroporous biphasic calcium phosphate as a carrier. The histomorphologic characteristics of the newly formed tissues were verified using hematoxylin-eosin staining and immunohistochemical staining. Quantitative alkaline phosphatase analysis and quantitative real-time polymerase chain reaction using BSP, DSPP, POSTN, and ColXII were performed.

RESULTS

ACCs and DPSCs showed similar cell proliferation potential and colony-forming ability. The percentage of mesenchymal stem cell markers was similar between ACCs and DPSCs. In the in vitro study, ACCs and DPSCs showed adipogenic and osteogenic differentiation potential. In the in vivo study, ACCs and DPSCs formed amorphous hard tissue using macroporous biphasic calcium phosphate particles. The quantity and histomorphologic characteristics of the amorphous hard tissue were similar in the ACC and DPSC groups. Formation of periodontal ligament-like tissue, positive to Col XII, was observed in ACC transplants, which was absent in DPSC transplants.

CONCLUSIONS

ACCs and DPSCs showed similar stemness, proliferation rate, and hard tissue-forming capacity. The notable difference was the periodontal ligament-like fiber-forming capacity of ACCs, which indicates the presence of various lineages of stem cells in the apical complex compared with the coronal pulp. Regarding regeneration of the dentin-pulp complex, the coronal pulp can be a suitable source of stem cells considering its homogenous lineages of cells and favorable osteo/odontogenic differentiation potential.

Materials for pulpotomy in immature permanent teeth: a systematic review and meta-analysis

BACKGROUND

Pulpotomy is one of the most widely used methods in preserving vital pulp in teeth, which is of great significance in achieving continue root formation in immature permanent teeth suffering from dental caries or trauma. The aim of this meta-analysis and systemic review is to synthesize the available evidences to compare different pulpotomy dressing agents for pulpotomy treatment in immature permanent teeth.

METHODS

Electronic databases including MEDLINE (via Pubmed), EMBASE, the Cochrane library (CENTRAL) and the clinicaltrials.gov database were searched. The references of all included articles or relevant reviews were cross-checked. Only randomized controlled trials (RCTs) comparing two or more pulp dressing agent in permanent teeth with open apex would be included. Also, the studies should have at least 6 months of follow-up, report clinical and radiographic success in detail and publish in English.

RESULTS

Five RCTs were included for a systematic review, and all of them had a high risk of bias. There is little difference in success rate between mineral trioxide aggregate (MTA) and calcium hydroxide (CH) at 6-month follow-up (risk ratio (RR) 1; 95% confidence interval (CI) 0.94 to 1.06) and 12-month follow-up (RR 1.04; 95% CI 0.96 to 1.13). There is no difference between MTA versus platelet-rich fibrin and MTA versus calcium-enriched mixture (CEM). There is only weak evidence of increased success rate in using MTA and triple antibiotic paste (TAP) rather than abscess remedy.

CONCLUSIONS

Based on the present evidence, similar success rates with MTA were found between the dressing agents CH, CEM, RPF and TAP as pulpotomy-dressing agents in the treatment of immature permanent teeth. More high-quality RCTs are needed in this field in future studies.

Conservative pulp treatment for Oehlers type III dens invaginatus: A case report

BACKGROUND

Diverse presentations of dens invaginatus (DI) and root canal treatment with an immature open apex often pose challenges to dentists. Adequate treatment planning for DI is the main reason for successful approach, i.e., we should consider the shape and depth of the concave folding, the condition of the original pulp, and the growth stage of the root formation.

CASE SUMMARY

A 9-year-old girl complained of severe pain of the right maxillary incisor (tooth 12) when chewing for two weeks. Following clinical and radiographic examinations, Oehlers type III DI of tooth 12, with an immature open apical foramen and a symptomatic periapical pathosis, was diagnosed. Cone-beam computed tomography verified the specific spatial and stereoscopic data regarding the communication between the main root canal and pseudo root canal of the involved tooth. After removing the source of infection, a mineral trioxide aggregate was selected to fill and seal the pseudo root canal; additionally, pulp capping of the main canal was performed through the interconnections between the root canals in the middle segment to preserve pulp vitality and enable continual root formation and eventual root apex closure.

CONCLUSION

We propose to conduct main root canal pulp capping for DI with communication between the main and pseudo root canals.

Clinical and radiographic evaluation of Biodentine and Mineral Trioxide Aggregate in revascularization of non-vital immature permanent anterior teeth (randomized clinical study)

OBJECTIVE

To asses clinically and radiographically the effect of using two types of coronal plug materials in revascularization of non-vital immature teeth.

METHODS

A total of 26 necrotic immature permanent anterior teeth were enrolled for pulp revascularization using a double antibiotic mix for root canal disinfection. They were randomly divided into the following based on coronal plug materials used: Biodentine (Group I) and white Mineral Trioxide Aggregate (Group II; n = 13). Clinical and radiographic assessments were performed after 3, 6, 9, and 12 months.

RESULTS

When comparing the overall clinical successes and percentage of increase in root length between the two groups, there was no statistically significant difference (P > 0.05). There was a significant difference in the distribution of discoloration between the two groups. One case was reported in Group I, and seven cases were reported in Group II (P = 0.01).

CONCLUSIONS

Both Biodentine and Mineral Trioxide Aggregate were successful clinically regarding the resolution of signs and symptoms associated with the necrotic teeth.

Towards a New Era in the Management of Large Periapical Lesion in Permanent Tooth Using Stemcells: A 2-Year Clinical Application Report

Stem cells are considered as the principal source of differentiated cells. In the past few years, the research on the stem cell in various fields had shown success, but the stem cell-based therapies in the dentistry had confined to a particular extent. The present case report was aimed to evaluate the efficacy of stem cells from human exfoliated deciduous teeth (SHED) in the management of a large periapical lesion. A 12-year-old girl reported with a chief complaint of pain in the lower right back tooth region since 5 days. Intraoral examination revealed a deep occlusal cavity in relation to tooth#46 with tenderness on percussion. Radiograph examination revealed periapical radiolucency measuring 1.8×1.0cm in size with perforation at the floor of the pulp chamber in relation to 46. A deciduous tooth from the same child was collected to isolate stem cells. After access opening for tooth #46, pulp was extirpated and a thick mucoperiosteal flap was raised. This was followed by homing of SHED into the periapical area through the window created in the buccal cortical plate and into the root canals of tooth #46 until the orifice. The access cavity was sealed with glass ionomer cement. The patient was subjected to evaluation at regular intervals i.e., two weeks, four months, twelve months, and twenty-four months. The case treated demonstrated complete resolution of periapical radiolucency in the fourth-month review with a positive response to electric pulp testing. This clinical application report concludes that SHED can be effective in treating the periapical lesions in permanent teeth.

Comparative evaluation of coronal discoloration induced by two triple antibiotic revascularization protocols when used at varying depths of temporary sealing material at the end of varying time periods

Aim:

The aim of this study is to evaluate and compare the coronal discoloration induced by two Triple antibiotic paste (TAP 1 and 2), when used with varying depths of 2 and 4 mm of temporary sealing materials at the end of 0, 3, and 6 weeks.

Objectives:

(1) To evaluate coronal discoloration induced by TAP-1 when the depth of the temporary restorative material is 2 mm below cementoenamel junction at the end of 0, 3, and 6 weeks.

Materials and Methods:

Forty extracted permanent maxillary central and lateral incisors or single-rooted tooth were collected and chosen for the study. They were then divided into two groups and each group was then subdivided into two subgroups.

Results:

Both the triple antibiotic paste showed discoloration but it reduced with increase in thickness of temporary cement.

Conclusion:

TAP 1 and TAP 2 both showed an increase in discoloration, greater discoloration was seen with TAP, containing minocycline. There was a steady change in the discoloration from 0 to 6^th week. In both the groups, TAP 1 and TAP 2, there was a reduction in discoloration with increase thickness of the temporary restorative material.

Triple antibiotic paste: momentous roles and applications in endodontics: a review

This study investigated the latest findings and notions regarding ‘triple antibiotic paste’ (TAP) and its applications in dentistry, particularly endodontics. TAP is a combination of 3 antibiotics, ciprofloxacin, metronidazole, and minocycline. Despite the problems and pitfalls research pertaining to this paste has unveiled, it has been vastly used in endodontic treatments. The paste's applications vary, from vital pulp therapy to the recently introduced regeneration and revascularisation protocol. Studies have shown that the paste can eliminate the root canal microorganisms and prepare an appropriate matrix for further treatments. This combination is able to remove diverse groups of obligate and facultative gram-positive and gram-negative bacteria, providing an environment for healing. In regeneration protocol cases, this allows the development, disinfection, and possible sterilization of the root canal system, so that new tissue can infiltrate and grow into the radicular area. Moreover, TAP is capable of creating a discipline in which other wanted and needed treatments can be successfully performed. In conclusion, TAP, as an antibacterial intracanal medication, has diverse uses. Nevertheless, despite its positive effects, the paste has shown drawbacks. Further research concerning the combined paste and other intracanal medications to control microbiota is a must.

Wnt and BMP Signaling Crosstalk in Regulating Dental Stem Cells: Implications in Dental Tissue Engineering

Tooth is a complex hard tissue organ and consists of multiple cell types that are regulated by important signaling pathways such as Wnt and BMP signaling. Serious injuries and/or loss of tooth or periodontal tissues may significantly impact aesthetic appearance, essential oral functions and the quality of life. Regenerative dentistry holds great promise in treating oral/dental disorders. The past decade has witnessed a rapid expansion of our understanding of the biological features of dental stem cells, along with the signaling mechanisms governing stem cell self-renewal and differentiation. In this review, we first summarize the biological characteristics of seven types of dental stem cells, including dental pulp stem cells, stem cells from apical papilla, stem cells from human exfoliated deciduous teeth, dental follicle precursor cells, periodontal ligament stem cells, alveolar bone-derived mesenchymal stem cells (MSCs), and MSCs from gingiva. We then focus on how these stem cells are regulated by bone morphogenetic protein (BMP) and/or Wnt signaling by examining the interplays between these pathways. Lastly, we analyze the current status of dental tissue engineering strategies that utilize oral/dental stem cells by harnessing the interplays between BMP and Wnt pathways. We also highlight the challenges that must be addressed before the dental stem cells may reach any clinical applications. Thus, we can expect to witness significant progresses to be made in regenerative dentistry in the coming decade.

Relevance of the plasminogen system in physiology, pathology, and regeneration of oral tissues - From the perspective of dental specialties

Plasmin is a proteolytic enzyme that is crucial in fibrinolysis. In oral tissues, the plasminogen system plays an essential role in physiological and pathological processes, which in addition to fibrinolysis include degradation of extracellular matrix, inflammation, immune response, angiogenesis, tissue remodeling, cell migration, and wound healing. Oral tissues reveal a change in the plasminogen system during pathological processes such as periodontitis, peri-implantitis, or pulpitis, as well as in response to mechanical load. The plasminogen system is also a key element in tissue regeneration. The number of studies investigating the plasminogen system in dentistry have grown continuously in recent years, highlighting its increasing relevance in dental medicine. In this review, we present the diverse functions of the plasminogen system in physiology and its importance for dental specialists in pathology and regeneration. We thus provide an overview of the current knowledge on the role of the plasminogen system in the different fields of dentistry, including endodontics, orthodontics, periodontics, and oral surgery.

Cytotoxicity and osteogenic potential of silicate calcium cements as potential protective materials for pulpal revascularization

OBJECTIVES

In pulpal revascularization, a protective material is placed coronal to the blood clot to prevent recontamination and to facilitate osteogenic differentiation of mesenchymal stem cells to produce new dental tissues. Although mineral trioxide aggregate (MTA) has been the material of choice for clot protection, it is easily displaced into the clot during condensation. The present study evaluated the effects of recently introduced calcium silicate cements (Biodentine and TheraCal LC) on the viability and osteogenic differentiation of human dental pulp stem cells (hDPSCs) by comparing with MTA Angelus.

METHODS

Cell viability was assessed using XTT assay and flow cytometry. The osteogenic potential of hDPSCs exposed to calcium silicate cements was examined using qRT-PCR for osteogenic gene expressions, alkaline phosphatase enzyme activity, Alizarin red S staining and transmission electron microscopy of extracellular calcium deposits. Parametric statistical methods were employed for analyses of significant difference among groups, with α=0.05.

RESULTS

The cytotoxic effects of Biodentine and TheraCal LC on hDPSCs were time- and concentration-dependent. Osteogenic differentiation of hDPSCs was enhanced after exposure to Biodentine that was depleted of its cytotoxic components. This effect was less readily observed in hDPSCs exposed to TheraCal LC, although both cements supported extracellular mineralization better than the positive control (zinc oxide-eugenol-based cement).

SIGNIFICANCE

A favorable tissue response is anticipated to occur with the use of Biodentine as a blood clot-protecting material for pulpal revascularization. Further investigations with the use of in vivo animal models are required to validate the potential adverse biological effects of TheraCal LC on hDPSCs.