Professional Documents
Culture Documents
Key Words
Dens in dente, dens invaginatus, mineral trioxide aggregate, revascularization, revitalization, supraventricular
tachycardia, tissue regeneration
From the Melbourne Dental School, University of Melbourne, Melbourne, Victoria, Australia.
Address requests for reprints to Dr Peter Parashos, Melbourne Dental School, University of Melbourne, 720 Swanston
Street, Melbourne, Victoria, Australia 3010. E-mail address:
parashos@unimelb.edu.au
0099-2399/$ - see front matter
Copyright 2014 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2013.10.030
725
Kumar et al.
Case Report
A 10-year-old boy was referred by a private general dental practitioner to the endodontic unit of the Royal Dental Hospital of Melbourne,
Australia for evaluation and management of persistent infection arising
from the permanent maxillary left lateral incisor with a history of recurrent pain and parulis formation. Three courses of amoxicillin (Amoxil;
GlaxoSmithKline, Victoria, Australia) were prescribed during a 2-month
period by the local general medical practitioner, with no resolution of
the parulis. At the dental examination, a systems review revealed the
patient had SVT, was not taking any medications, and was otherwise
healthy. The patient was able to control his frequent cardiac palpitations
with the Valsalva maneuver (51).
JOE Volume 40, Number 5, May 2014
Figure 2. (A) Preoperative radiograph of the permanent maxillary left lateral incisor demonstrating type II Oehlers dens invaginatus with an associated periapical
radiolucency. (B) Preoperative radiograph of the permanent maxillary right lateral incisor demonstrating type II Oehlers dens invaginatus. (C) Preoperative radiograph of the permanent maxillary right lateral incisor 7 weeks later with associated periapical radiolucency.
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Figure 4. Five months after initial canal debridement, periapical healing of both (A) permanent maxillary right and (B) left lateral incisors is evident radiographically. (C) Twenty-six months postoperative radiograph of the permanent maxillary left lateral incisor. Radiographs of the permanent maxillary right lateral incisor
displaying apexogenesis and progressive canal sclerosis taken (D) 8 months, (E) 18 months, and (F) 28 months postoperatively.
the right lateral incisor. The left lateral incisor was not to be treated at
this time because of after-hours emergency time constraints.
A radiograph taken under GA of the right lateral incisor revealed a
periapical radiolucency (which was not present in the radiograph taken
7 weeks earlier), consistent with the clinical presentation. The diagnosis
of an infected necrotic pulp with an acute apical abscess and facial
cellulitis associated with a type II Oehlers DI was made (Fig. 2C). Under
rubber dam isolation, an access cavity was prepared where a highspeed diamond fissure bur was used to remove the DI and create
straight-line access to the canal. Purulent discharge from the canal
along with bleeding was noted. The canal was irrigated copiously
with 1% sodium hypochlorite (Endosure hypochlor 1%; Dentalife,
Croydon, Victoria, Australia). Bleeding tissue was encountered in the
apical 4 mm of the canal, and thus the canal walls were lightly hand
instrumented with an ISO 25 K file to the level of the bleeding tissue.
Once bleeding was deemed to have been sufficiently controlled,
Odontopaste (5% clindamycin hydrochloride and 1% triamcinolone
acetonide; ADM, Brisbane, Queensland, Australia) was placed with an
ISO 25 K-file as the canal dressing. This was followed by a 3-mm-thick
zinc oxide-eugenolfree temporary primary access seal (Coltosol F;
Coltene/Whaledent Inc, Cuyahoga Falls, OH) placed in the pulp
chamber and a light-cured resin reinforced glass ionomer cement
secondary filling (Fuji II LC; GC Corp, Sydney, Australia). This
double-seal temporary filling was limited to the pulp chamber of the
tooth and did not extend into the canal (Fig. 4).
A postoperative review at 8 days revealed complete resolution of
the swelling. Both lateral incisors were asymptomatic, but the parulis
of the left lateral incisor was still present. Behavioral desensitization
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Kumar et al.
Discussion
The described case demonstrated possible pulpal regeneration of
an infected maxillary right lateral incisor with DI and an immature apex
after minimal canal debridement and dressing with an antibiotic/corticosteroid paste (Odontopaste). To the authors knowledge, there are no
similar reports. The possibility of Hertwigs root sheath and pulpal and
apical papilla stem cells surviving the destructive effect of the acute
infection has been proposed (19). Their survival would have allowed
for regeneration of the pulp and continued root maturation endowed
by a favorable environment after controlling the infection in the root
canal system (14). The response of this lateral incisor could imply
some remaining vital tissue in the apical portion of the canal, which
may then represent partial pulp regeneration as opposed to de novo
regeneration as defined by Huang (52). Geisler (10) proposed that
the degree of success of regenerative endodontic procedures can be
measured by the attainment of primary (control of symptoms and
healing of apical periodontitis), secondary (increased root wall
thickness and/or increased root length), and tertiary (positive response
to pulp testing) goals. Accordingly, the upper right incisor in this report
demonstrates a high degree of success despite minimal disinfection.
Dentin matrix contains growth factors that have been found to
induce odontoblast-like cell differentiation as well as angiogenesis
(15, 26, 5355). These growth factors (eg, transforming growth
factor-b1, dentin matrix protein-1) are released in varying concentrations by endodontic irrigants such as sodium hypochlorite, citric acid,
and EDTA, with the latter releasing the highest concentrations of
transforming growth factor-b1 (53). In addition to the well-known
cytotoxicity, high concentration of sodium hypochlorite (5.25%)
conditioning of dentin may cause clastic activity on the dentin surface
(15, 56). This clastic activity is assumed to be due to masking of the
dentin surface with a heavy smear layer (15). On the other hand,
conditioning of the dentin surface with EDTA and removal of the smear
layer may facilitate binding sites for stem cells and encourage differentiation of odontoblast-like cells (15). In this report, EDTA was not used
in the upper right lateral incisor because the treatment provided was
only intended to be emergency GA management under tight time constraints rather than definitive treatment. In this case, light instrumentation of the canal of the maxillary right lateral incisor may have served to
release growth factors and avoid large areas of smear layer formation,
whereas the low concentration of sodium hypochlorite (1%) allowed
for microbial control and avoided destruction of potential stem cells.
JOE Volume 40, Number 5, May 2014
729
Conclusion
Pulpal regeneration techniques are an emerging approach to management of infected necrotic immature teeth. This article has reported 2
different treatment outcomes of permanent lateral incisors with type II
Oehlers DI and apical abscesses. This report introduces the possibility
of the use of Odontopaste in endodontic regeneration procedures and
highlights the need for regular reviews of teeth with open apices and
caution when treating a patient with SVT under local anesthesia or GA.
Acknowledgments
The authors acknowledge Emeritus Professors Louise BrearleyMesser and Harold Messer, both at Melbourne Dental School,
University of Melbourne, Australia; Clinical Associate Professor
Kerrod Hallett, director of dentistry at The Royal Childrens
Hospital, Melbourne, Australia; and Dr Justin Wong, pediatric
dentist, for their contributions to this case report.
The authors deny any conflicts of interest related to this study.
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