Endodontic Journal Review

Presenter: PGY1 Date: 2013.07.30

Pulp Regeneration

Revascularization

Odontoblastic layers

Innervation

Principles of Tissue Engineering

Stem/Progenitor Cells

Growth Factors

Scaffold

What about mature permanent teeth?

Regenerative Endodontic Treatment of Permanent Teeth after Completion of Root Development: A Report of Two Cases
Paryani et al, J Endod 2013

CASE PRESENTATION

Case 1
General Data Chief Complain

Case 2

14 y/o girl presented on 11 y/o girl presented on August 5, 2010 September 2, 2010 Pain on her upper front tooth for 3 or 4 days. The pain was constant but not severe Emergency treatment was done Noncontributory Pain on her upper front tooth

Present Illness Medical History

Emergency patient Noncontributory

Case 1
Extraoral Non significant Examination

Case 2
Non significant

Intraoral Tooth 11 Examination Uncomplicated crown

fracture with a large temporary restoration on palatal surface Cold test: (-) Percussion (+) Palpation (-) PD: 5 mm in palatal gingiva Mobility: normal

Tooth 21
Uncomplicated crown fracture with an existing composite restoration Cold test: (-) Percussion (-) Palpation (-) PD: WNL Mobility: normal

Case 1
X-ray

Case 2

Periradicular Periradicular rarefaction along mesial rarefaction aspect of the root with approximately 5x5 mm closed apex in size around the mature apex

Diagnosis

Previously initiated Symptomatic apical periodontitis

Pulp necrosis Asymptomatic apical periodontitis

Treatment Course
Case 1
First appointment
1 week

Second appointment

Case 2
First appointment
22 days

Second appointment

First Appointment
Case 1
Informed consent Anesthetized with 2% lidocaine (1:100,000 epinephrine) and RD isolation No bleeding observed in the root canal on removal of the temporary restoration Irrigation with 5.25% sodium hypochlorite and drying with paper points Methyline blue dye application to check for fractures but none detected under microscope Take working length radiograph

Case 2
Informed consent Anesthetized with 2% lidocaine (1:100,000 epinephrine) and RD isolation Access cavity preparation performed under a microscope Take working length radiograph

Case 1
Mechanical instrumentation by step-back technique and copious 5.25% sodium hypochlorite irrigation Canal cleaned and shaped to the radiographic apex Apical foramen enlarged to 0.6 mm with #60 K-file Canal dried and medicated with a paste form calcium hydroxide to the root apex Temporized with Cavit

Case 2
Mechanical instrumentation by step-back technique and copious irrigation with 5.25% sodium hypochlorite and 17% EDTA Apical foramen enlarged to 0.6 mm with #60 K-file Canal partially dried with paper points and dusted with ciprofloxacin powder with a mini amalgam carrier The powder carried down to the apex with a hand plugger Canal coated with the powder by using hand files Temporized with Cavit

Second Appointment
Case 1
Asymptomatic: percussion (-), palpation (-) Anesthetized with 2% lidocaine (1:100,000 epinephrine) and RD isolation Calcium hydroxide completely removed with 5.25% sodium hypochlorite Canal irrigated with 17% EDTA for 1 minute and dried with paper points

Case 2
Asymptomatic: percussion (-), palpation (-) Anesthetized with 3% mepivacaine and RD isolation Canal irrigated with 5.25% sodium hypochlorite Canal irrigated with 17% EDTA for 1 minute and dried with paper points

Case 1
Bleeding induced in the canal by passing #40 sterile K-file 3 mm beyond the apex Collacote placed in the canal after dusted with ciprofloxacin powder MTA placed 2 mm below cementoenamel junction against Collacote Tooth restored with GI

Case 2
Bleeding induced in the canal by passing #30 sterile H-file 3 mm beyond the apex Collacote placed in the canal MTA placed 4 mm below cementoenamel junction against Collacote Tooth restored with GI

Follow-up
Case 1
2-week Asymptomatic Percussion (-), palpation (-), Cold test (-) 1-month Asymptomatic Percussion (-), palpation (-) Decrease in size of radiolucency along the mesial side of the root 2-month Sensitive to cold drink Cold test (-)

Case 2
1-month Asymptomatic: percussion (), palpation (-) Reduction in size of periradicular radiolucency 5-month Periapical radiolucency had almost disappeared

Case 1

Case 2

1 year and 3 months 18-month Tooth restored by general Asymptomatic: percussion (dentist ), palpation (-) Further decrease in size of EPT (-) radiolucency Cold test (-) Endo-Ice: normal response Complete resolution of the PD: WNL periapical radioluceny with EPT: 79/80 intact lamina dura and 22-month normal PDL space. Percussion (-), palpation (-) Thinning of the root canal at Endo-Ice: normal response the apical one-third (-) EPT: 34/80 PD: WNL Complete resolution of periapical radiolucency with thinning of the root canal at the apical one-third

Case 1

Post-OP

1 month

15 months

22 months

Case 2

Post-OP

1 month

5 months

18 months

DISCUSSION AND CONCLUSION

Immature Teeth
More Challenge 1: Stem/Progenitor Greater regeneration potential cells

Mature Teeth
Less Less regeneration potential due to aging

Challenge 2: Apical pathways

Open apex allow more stem/progenitor cells to migrate into root canals

Narrower apical pathways

Less difficult Challenge 3: Canal disinfection

Greater difficulty

22

 SCAP: Stem cells of the apical papilla Presence in mature teeth has not been reported

May participate in pulp regeneration Need to be stimulated to migrate into root canal space
Haynesworth et 1992 Seo et al, 2004

Immature Teeth
More Challenge 1: Stem/Progenitor Greater regeneration potential cells

Mature Teeth
Less Less regeneration potential due to aging

Challenge 2: Apical pathways

Open apex allow more stem/progenitor cells to migrate into root canals

Narrower apical pathways

Less difficult Challenge 3: Canal disinfection

Greater difficulty

24

Clinical Protocols for Mature Teeth

Challenge 1 Challenge 2 Challenge 3

Necessity to induce bleeding

Proper apical enlargement

Sufficient disinfection

Induced Bleeding
Successful revascularization cases by using calcium hydroxide without induced bleeding
Chueh et al, 2009

The presence of SCAP in immature teeth

Failed regenerative procedures attributed to inability to evoke bleeding into the canal
Ding et al, 2009

 600-fold increase in stem cell markers in canal blood compared with the level in systemic blood when bleeding was induced in immature teeth Lovelace et al, 2011 Bleeding induced by passing files beyond the apex thought to stimulate the migration of adult stem/progenitor cells into the root canal Evoked bleeding may be critical in pulp revascularization of mature necrotic teeth

Clinical Protocols for Mature Teeth

Challenge 1 Challenge 2 Challenge 3

Necessity to induce bleeding

Proper apical enlargement

Sufficient disinfection

Critical Apical Size

Revascularization can be accomplished in immature teeth with the apical foramen greater than about 1 mm in diameter Pulp necrosis was observed in 87% of autotransplanted premolars when the diameter of the apical foramen was smaller than 1.0 mm
Andreasen et al 1990, Kling et al 1990, Cvek et al 1990

 The apical foramen enlarged only up to 0.6 mm in the present report

Bleeding was not induced in tooth replantation studies Bleeding evoked to enhance the migration of stem/progenitor cells

No clinical evidence yet with regard to the critical apical size in clinical regenerative endodontic treatment

Clinical Protocols for Mature Teeth

Challenge 1 Challenge 2 Challenge 3

Necessity to induce bleeding

Proper apical enlargement

Sufficient disinfection

Canal Disinfection
Mature teeth have more complex root canal anatomy than immature teeth Disinfection in immature necrotic teeth
Chemical means: antimicrobial irrigation and intracanal medication Mechanical (-)

Disinfection in mature necrotic teeth

Chemical + Mechanical instrumentation

Effect of Chemical Agents

Ca(OH)2 Antibiotics
Combination Cirpofloxacin

EDTA

Calcium Hydroxide
Did not kill human mesenchymal stem cells when concentration range between 0.01 mg/ml~100 mg/mL
Ruparel et al, 2012

Calcium hydroxide dressing in Case 1 but not in Case 2

Antibiotics
4 different combination antibiotics including triple, double, and modified triple antibiotics and Augmentin showed detrimental effects on survival of the stem cells in all concentrations 1 mg/mL
Ruparel et al, 2012

Concentration of pastes used in regeneration significantly higher

Combination
Triple antibiotics (metronidazole, ciprofloxacin and minocycline) Double antibiotics (metronidazole and ciprofloxacin) Eradicate bacteria isolated from infected dentin and pulp in vitro, although complete eradication not shown in vivo

 Combination antibiotics could be more effective in immature teeth where no or minimal mechanical instrumentation is performed A combination of antibiotics may not be needed in mature teeth if thorough chemomechanical instrumentation is performed

Ciprofloxacin
Broad-spectrum antibiotic against both grampositive and gram negative bacteria
Case 1: 7-day Ca(OH)2 dressing and Ciprofloxacin dusting after bleeding was evoked Case 2: Medicated with ciprofloxacin for 22 days

Ciprofloxacin dusting procedure might be harmful for survival of migrated stem/progenitor cells

 Concentration of ciprofloxacin used in the present report

Dusted in the wet canal Did not show a thick paste-like or slurry-like consistency in the canal

Not strong enough to kill the migrated cells Prevent the migrated cells from being contaminated by remaining bacteria

EDTA
Suggested to be a single irrigant for pulp regeneration in immature necrotic teeth at the second appointment
Promote SCAP survival (89% viability)

Lower cell viability (74%) was observed when both sodium hypochlorite and EDTA were used

 5.25% sodium hypochlorite and 17% EDTA used at the second appointment in both cases
More thorough chemomechanical instrumentation required in mature necrotic teeth A significant decrease in viability of migrated cells was expected Final irrigation with EDTA may
Stimulate the release of growth factors embedded in dentin matrix Enhance the odontogenic differentiation of migrated cells and angiogenesis

Cell Viability
Ca(OH)2
Combination ABX Cirpofloxacin EDTA NaOCl

Suggested Use
0.01 mg/ml~100 mg/mL

< 1 mg/mL, not necessary in mature teeth if thorough chemomechanical instrumentation is performed < 1 mg/mL, promote almost 100% survival of SCAP Final irrigation with EDTA

Necessary for more thorough chemomechanical instrumentation required in mature necrotic teeth

Outcome Assessment
Radiographic healing of apical periodontitis and clinical symptoms
Case 1 and Case 2: complete resolution

Positive response to pulp vitality test

Case 1: EPT (+), cold test (+) Case 2: negative

Thickening of root dentin

Case 1: apical third, < immature teeth Case 2: not observe, longer f/u required

Case 1
Revacularization
+

Case 2
+

Odontoblastic Layer Innervation

+ (?)
+

Other diagnostic tools to detect the presence of apical vital tissues in root canals may need to be developed for more accurate initial outcome assessment

Clinical Situations
Immature teeth with irreversible pulpitis
Filled with pulp-like loose connective tissues 3.5 weeks after regenerative endodontic treatment on the basis of histologic observation Shimizu et al 2012

Immature teeth pulp necrosis

No histologic findings reported yet

Mature teeth with pulp necrosis and apical periodontitis

Cell transportation and cell homing might be needed

Thanks for your attention!

Presenter: PGY1 Date: 2013.07.30