Endo Journal Review

7/27/2019 Endo Journal Review

1/47

Endodontic Journal Review

Presenter: PGY1

Date: 2013.07.30


2/47

RevascularizationOdontoblastic

layersInnervation

Pulp Regeneration


3/47

Stem/ProgenitorCells

ScaffoldGrowthFactors

Principles of

Tissue

Engineering


4/47


5/47

Regenerative Endodontic Treatment of

Permanent Teeth

after Completion of Root Development:A Report of Two Cases

Paryani et al, J Endod 2013


6/47

CASE PRESENTATION


7/47

Case 1 Case 2

General

Data

14 y/o girl presented on

August 5, 2010

11 y/o girl presented on

September 2, 2010

Chief

Complain

Pain on her upper front

tooth for 3 or 4 days.

The pain was constant

but not severe

Pain on her upper front

tooth

Present

Illness

Emergency treatment

was done

Emergency patient

Medical

History

Noncontributory Noncontributory


8/47

Case 1 Case 2

ExtraoralExamination

Non significant Non significant

Intraoral

Examination

Tooth 11

Uncomplicated crown

fracture with a largetemporary restoration

on palatal surface

Cold test: (-)

Percussion (+)

Palpation (-) PD: 5 mm in palatal

gingiva

Mobility: normal

Tooth 21

Uncomplicated crown

fracture with anexisting composite

restoration

Cold test: (-)

Percussion (-)

Palpation (-) PD: WNL

Mobility: normal


9/47

Case 1 Case 2X-ray Periradicular

rarefaction along mesial

aspect of the root with

closed apex

Periradicular

rarefaction

approximately 5x5 mm

in size around the

mature apex

Diagnosis Previously initiated Symptomatic apical

periodontitis

Pulp necrosis

Asymptomatic apical

periodontitis


10/47

Treatment Course

First appointment

Second appointment

First appointment

Second appointment

1 week

22 days

Case 1

Case 2


11/47

First Appointment

Case 1 Case 2

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

Informed consent



isolation

Access cavity preparation

performed under a microscope

Take working length radiograph


12/47


13/47

Case 1 Case 2

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 0.6mm with #60 K-file

Canal dried and medicated with

a paste form calcium hydroxide

to the root apex

Temporized with Cavit

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 theapex with a hand plugger

Canal coated with the powder

by using hand files

Temporized with Cavit


14/47

Second Appointment

Case 1 Case 2

Asymptomatic: percussion (-),palpation (-)



isolation

Calcium hydroxide completely

removed with 5.25% sodium

hypochlorite

Canal irrigated with 17% EDTA

for 1 minute and dried withpaper points

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


15/47

Case 1 Case 2

Bleeding induced in the canal by

passing #40 sterile K-file 3 mmbeyond 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

Bleeding induced in the canal by

passing #30 sterile H-file 3 mmbeyond the apex

Collacote placed in the canal

MTA placed 4 mm below

cementoenamel junction

against Collacote

Tooth restored with GI


16/47


17/47

Follow-up

Case 1 Case 2

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 (-)

1-month Asymptomatic: percussion (-

), palpation (-)

Reduction in size of

periradicular radiolucency

5-month

Periapical radiolucency had

almost disappeared


18/47

Case 1 Case 2

1 year and 3 months

Tooth restored by general

dentist Further decrease in size of

radiolucency

Endo-Ice: normal response

PD: WNL

EPT: 79/80

22-month

Percussion (-), palpation (-)

Endo-Ice: normal response

EPT: 34/80

PD: WNL

Complete resolution of

periapical radiolucency with

thinning of the root canal at

the apical one-third

18-month

Asymptomatic: percussion (-

), palpation (-) EPT (-)

Cold test (-)

Complete resolution of the

periapical radioluceny with

intact lamina dura and

normal PDL space.

Thinning of the root canal at

the apical one-third (-)


19/47

Case 1

Post-OP 1 month 15 months 22 months


20/47

Case 2

Post-OP 1 month 5 months 18 months


21/47

DISCUSSION AND CONCLUSION


22/47

22

Immature Teeth Mature Teeth

Challenge 1:

Stem/Progenitorcells

More

Greater regenerationpotential

Less

Less regeneration potentialdue to aging

Challenge 2:Apical pathways

Open apex allow morestem/progenitor cells to

migrate into root canals

Narrower apical pathways

Challenge 3:Canal disinfection

Less difficult Greater difficulty


23/47

SCAP: Stem cells of the

apical papilla

Presence in mature teethhas not been reported

May participate in pulp

regeneration

Need to be stimulated to

migrate into root canal

space Haynesworth et 1992Seo et al, 2004


24/47

24

Immature Teeth Mature Teeth

Challenge 1:

Stem/Progenitorcells

More

Greater regenerationpotential

Less

Less regeneration potentialdue to aging

Challenge 2:Apical pathways

Open apex allow more

stem/progenitor cells to

migrate into root canals

Narrower apical pathways

Challenge 3:Canal disinfection

Less difficult Greater difficulty


25/47

Clinical Protocols for Mature Teeth

Challenge 1

Necessity toinduce

bleeding

Challenge 2

Proper apicalenlargement

Challenge 3

Sufficientdisinfection


26/47

Induced Bleeding

Successful revascularization cases by using

calcium hydroxide without induced bleedingChueh et al, 2009

The presence of SCAP in immature teeth

Failed regenerative procedures attributed to

inability to evoke bleeding into the canalDing et al, 2009


27/47

600-fold increase in stem cell markers in canal

blood compared with the level in systemic

blood when bleeding was induced inimmature teeth

Lovelace et al, 2011

Bleeding induced by passing files beyond theapex thought to stimulate the migration of

adult stem/progenitor cells into the root canal

Evoked bleeding may be critical in pulprevascularization of mature necrotic teeth


28/47


Challenge 1

Necessity toinduce

bleeding

Challenge 2


Challenge 3



29/47

Critical Apical Size

Revascularization can be accomplished inimmature teeth with the apical foramen

greater than about 1 mm in diameter

Pulp necrosis was observed in 87% ofautotransplanted 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


30/47

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


31/47


Challenge 1

Necessity toinduce

bleeding

Challenge 2


Challenge 3



32/47

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


33/47

Effect of Chemical Agents

Ca(OH)2

Antibiotics

Combination

Cirpofloxacin

EDTA


34/47

Calcium Hydroxide

Did not kill human mesenchymal stem cells

when concentration range between 0.01

mg/ml~100 mg/mLRuparel et al, 2012

Calcium hydroxide dressing in Case 1 but not in

Case 2


35/47

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 regenerationsignificantly higher


36/47

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


37/47

Combination antibiotics could be more

effective in immature teeth where no or

minimal mechanical instrumentation is

performed

A combination of antibiotics may not beneeded in mature teeth ifthorough

chemomechanical instrumentation is

performed


38/47

Ciprofloxacin

Broad-spectrum antibiotic against both gram-

positive 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 migratedstem/progenitor cells


39/47

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 beingcontaminated by remaining bacteria


40/47

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


41/47

5.25% sodium hypochlorite and 17% EDTA

used at the second appointment in both cases

More thorough chemomechanicalinstrumentation 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 migratedcells and angiogenesis


42/47

Cell Viability Suggested Use

Ca(OH)2 0.01 mg/ml~100 mg/mL

Combination

ABX

< 1 mg/mL, not necessary in mature teeth

if thorough chemomechanical

instrumentation is performed

Cirpofloxacin < 1 mg/mL, promote almost 100% survivalof SCAP

EDTA Final irrigation with EDTA

NaOCl Necessary for more thoroughchemomechanical instrumentation

required in mature necrotic teeth


43/47

Outcome Assessment

Radiographic healing of apical periodontitisand 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


44/47

Case 1 Case 2

Revacularization+ +

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


45/47

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


46/47

Thanks for your attention!

Presenter: PGY1

Date: 2013.07.30


47/47

Date post:	14-Apr-2018
Category:	Documents
Upload:	jennifer-chen
View:	218 times
Download:	0 times

Endo Journal Review

Documents