Journal Club

Regenerative Endodontic
A New Treatment Modality


DR.MALIHAH MAHMUD
FIRST YEAR DENTAL OFFICER
BDS (UIAM)
MDC NO.:6330
Introduction
The management of immature permanent teeth with pulpal
necrosis is challenging as;
the root canal system is often difficult to debride and
the thin dentinal walls are at an increased risk of a subsequent
cervical fracture.
This results in a restorative problem since implants are
generally contraindicated in young patients with a growing
craniofacial skeleton.
Regenerative endodontic therapy (RET) provides an
alternative treatment approach that builds on the principles
of regenerative medicine and tissue engineering.
There are three key elements for tissue engineering: stem cells, scaffolds
and growth factors.
1. Stem Cells
undifferentiated cells that continuously divide.
2. Scaffolds
provide support for cell organization, proliferation, differentiation and
vascularization.
In RET the dentin and the blood clot or platelet-rich plasma act as
scaffolds in the root canal.
3. Growth Factors
proteins that bind to receptors on the cell and act as signals to induce
cellular proliferation and/or differentiation.
Current REPs aim to utilize growth factors found in platelets and dentin .



What is Regenerative Endodontics?
biologically based procedures designed to replace
damaged structures, including dentin and root
structures, as well as cells of the pulp-dentin
complex
In the immature tooth with pulpal necrosis, this
optimally translates to complete restoration of pulpal
function and subsequent completion of root
development

- American association of endodontists
Rationale

Apical area surrounding teeth with incomplete root
development is rich in stem cells, and this region has been
termed stem cell of the apical papilla (SCAP).
SCAP similar to dental pulp progenitor cells.
with intense disinfection and provision of a biological scaffold
and signaling,
the stem cells from SCAP can migrate into the scaffold in the
root canal and repopulate the root canal with vital tissue
Rationale
The advantage is that the vital tissue will produce
further hard tissue, thereby reinforcing the root
canal system roots less prone to fracture in the
future.

LA + rubber dam
Pulp extirpation + copius irrigation for 30 mins
Dressing with mixture of antibiotics *
*minocycline, ciproflaxacin, metronidazole
Temporary restoration + review in 2 weeks
General technique
Welbury et al.(2012)
Review visit
Re-accessed & antibiotics flushed out with saline
Induce bleeding into the root canal using:
23 gauge needle/endo file/ endo explorer
* 2mm beyond the working length
Allow bleeding to fill the root canal +
wait for formation of blood clot (apical 2/3)
Sealed with MTA/GIC + IOPA radiograph
Welbury et al.(2012)
Notes
Minocycline can cause discoloration
If there are concerns about this, perhaps only the two
antibiotics should be used.
To avoid discoloration ensure that there is no antibiotic in
the pulp chamber or the coronal part of the tooth.
Periapical radiograph is essential for comparison with
future 6-monthly radiographs to determine
continued root development,
hard tissue deposition in root canal as well as
success of the treatment.





- American association of endodontists

What are the Considerations for Clinical Regenerative
Endodontic Procedures?

1. Young patient
2. Necrotic pulp and immature apex
3. Minimal or no instrumentation of the dentinal walls
4. Placement of an intracanal medicament
5. Creation of a blood clot or protein scaffold in canal
6. Effective coronal seal
Invited review :
Dental Traumalogy 2011 Recommendations for using
regenerative endodontic procedure in permanent immature
traumatized teeth
A review conducted by Garcia-Godoy and Muray in 2011
come out with the following recommendations:
1. The traumatized tooth must be non-vital and not be suitable
for apexogenesis, apexification, partial pulpotomy or root
canal obturation treatments.
2. The tooth must be permanent and very immature with wide
open apex and exposed pulp. The tooth must have thin
walls that will benefit from continued development of the
root .

3. The patient must be aged 7-16 years, in good
health, and have parents/guardians willing to take
them to attend multiple appointments.
4. The patients/parents/guardians must be told that
the endodontic regeneration treatment is
experimental and that no standardized guidelines
have yet been created.
5. Antibiotic paste can be used as an additional
disinfectant to sodium hypochloride, and the
patient needs to be warned about the potential
discoloration.
6. An anesthetic without a vasoconstrictor should be
used when attempting to induce revascularization
(bleeding) into the root canal.


7. A thin liner of white MTA or calcium hydroxide
should be placed above the blood clot.
8. An endodontic sealer is not biocompatible for
regeneration and cannot be used.
9. The tooth should be restored with resin modified
glass ionomer to help prevent microleakage, or full
crown replacement depending on the severity of
crown damage.
Non-surgical root canal
MTA apexification
Non-vital teeth with necrotic pulp
Non-surgical root canal apexification
Non-vital teeth with necrotic pulp
Root canal revascularization
Root canal
revascularization
Non-vital teeth with necrotic pulp
Endodontic
regeneration
Endodontic regeneration
Vital teeth with some healthy pulp
Root canal apexogenesis
Root canal
apexogenesis
Summary

Regenerative endodontics is one of the most exciting developments
in dentistry today .
Knowledge in the fields of pulp biology, dental trauma and tissue
engineering can be applied to deliver biologically based
regenerative endodontic treatment of necrotic immature
permanent teeth resulting in continued root development,
increased thickness in the dentinal walls, and apical closure.
These developments in regeneration of a functional pulp-dentin
complex have a promising impact on efforts to retain the natural
dentition, the ultimate goal of endodontic treatment.
References
Welbury R., Duggal M.S., and Hosey M.T. (2012),
Paediatric Dentistry 4
th
Edition: Oxford University Press
Endodontics Colleagues of Excellence (2013),
Regenerative Endodontics: American Association of
Endodontists
DiAngelis, A. J., Andreasen, J. O., Ebeleseder, K. A., Kenny,
D. J., Trope, M., Sigurdsson, A., Andersson, L.,
Bourguignon, C., Flores, M. T., Hicks, M. L., Lenzi, A. R.,
Malmgren, B., Moule, A. J., Pohl, Y. and Tsukiboshi, M.
(2011), International Association of Dental Traumatology
guidelines for the management of traumatic dental
injuries: 1. Fractures and luxations of permanent teeth.
Dental Traumatology