These recommendations are based on best available data at this time and should be one possible source of information used by clinicians to make treatment decisions. Moreover, given the rapid evolving nature of thus field, clinicians should actively review new findings as they become available. Update March 7, 2012.
Case Selection
- Tooth with necrotic pulp and an immature apex
- Pulp space not needed for post/core, final restoration
- Compliant patient
Informed Consent
- Two (or more) appointments
- Use of antimicrobial(s)
- Possible adverse effects: staining of crown/root, lack of response to treatment, pain/infection
- Alternatives: MTA apexification, no treatment, extraction (when deemed nonsalvageable)
- Permission to enter information into AAE database (optional)
First Appointment
- Local anesthesia, rubber dam isolation, access
- Copious, gentle irrigation with 20ml NaOCl using an irrigation system that minimizes the possibility of extrusion of irrigants into the periapical space (e.g., needle with closed end and side-vents, or EndoVac). To minimize potential precipitate in the canal, use sterile water or saline between NaOCl. Lower concentrations of NaOCl are advised, to minimize cytotoxicity to stem cells in the apical tissues
- Dry canals
- Place antibiotic paste or calcium hydroxide. If the triple antibiotic paste is used: 1) consider sealing pulp chamber with a dentin bonding agent [to minimize risk of staining] and 2) mix 1:1:1 ciprofloxacin:metronidazole:minocycline
- Deliver into canal system via Lentulo spiral, MAP system or Centrix syringe
- If triple antibiotic paste is used, ensure that it remains below CEJ (minimize crown staining)
- Seal with 3-4mm Cavit, followed by IRM, glass ionomer cement or another temporary material
- Dismiss patient for 3-4 weeks
Second Appointment
- Assess response to initial treatment. If there are signs/symptoms of persistent infection, consider additional treatment time with antimicrobial or alternative antimicrobial.
- Anesthesia with 3% mepivacaine without vasoconstrictor, rubber dam, isolation
- Copious, gentle irrigation with 20ml EDTA, followed by normal saline, using a similar closed-end needle.
- Dry with paper points
- Create bleeding into canal system by over-instrumenting (endo file, endo explorer)
- Stop bleeding 3mm from CEJ
- Place CollaPlug/Collacote at the orifice, if necessary
- Place 3-4mm white MTA and reinforced glass ionomer and place permanent restoration
Follow-up
- Clinical and Radiographic exam:
- No pain or soft tissue swelling (often observed between first and second appointments)
- Resolution of apical radiolucency (often observed 6-12 months after treatment)
- Increased width of root walls (this is generally observed before apparent increase in root length and often occurs 12-24 months after treatment)
- Increased root length
References
Chapters
Hargreaves KM, Law AS. Regenerative Endodontics. Chapter 16. Pathways of the Pulp 10th ed. Eds, Hargreaves KM, Cohen S. Mosby Elsevier, St Louis, MO, 2011: 602-19.
Murray PE, Garcia-Godoy F. Stem cells and regeneration of the pulpodentin complex. Chapter 5. Seltzer and Bender’s Dental Pulp – 2nd ed. Eds, Hargreaves KM, Goodis HE, Tay FR.
Quintessence Publishing Co Inc, Hanover Park, IL, 2012:91-108.
Articles
Banchs F, Trope M. Revascularization of immature permanent teeth with apical periodontitis: new treatment protocol? J Endod 2004;30:196-200.
Bose R, Nummikoski P, Hargreaves K. A retrospective evaluation of radiographic outcomes in immature teeth with necrotic root canal systems treated with regenerative endodontic procedures. J Endod 2009;35:1343-9.
da Silva LAB, Nelson-Filho P, da Silva RAB, Flores DSH, Heilborn C, Johnson JD, Cohenca N. Revascularization and periapical repair after endodontic treatment using apical negative pressure irrigation versus conventional irrigation plus triantibiotic intracanal dressing in dogs' teeth with apical periodontitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:779-87.
Galler KM, D'Souza RN, Federlin M, Cavender AC, Hartgerink JD, Hecker S, Schmalz G. Dentin conditioning codetermines cell fate in regenerative endodontics. J Endod. 2011 Nov;37(11):1536-41.
Hargreaves KM, Geisler T, Henry M, Wang Y. Regeneration Potential of the Young Permanent Tooth: What Does the Future Hold? J Endod 2008;34:S51-S6.
Huang GTJ. Apexification: the beginning of its end. Int Endod J 2009;42:855-66.
Huang GTJ. A paradigm shift in endodontic management of immature teeth: Conservation of stem cells for regeneration. J Dent 2008;36:379-86.
Lovelace TW, Henry MA, Hargreaves KM, Diogenes A. Evaluation of the delivery of mesenchymal stem cells into the root canal space of necrotic immature teeth after clinical regenerative endodontic procedure. J Endod. 2011 Feb;37(2):133-8.
Nosrat A, Seifi A, Asgary S. Regenerative endodontic treatment (revascularization) for necrotic immature permanent molars: a review and report of two cases with a new biomaterial. J Endod. 2011 Apr;37(4):562-7. Review.
Petrino JA, Boda KK, Shambarger S, Bowles WR, McClanahan SB. Challenges in regenerative endodontics: a case series. J Endod. 2010 Mar;36(3):536-41.
Reynolds K, Johnson JD, Cohenca N. Pulp revascularization of necrotic bilateral bicuspids using a modified novel technique to eliminate potential coronal discolouration: a case report. Int Endod J. 2009 Jan;42(1):84-92.
Rodríguez-Lozano FJ, Bueno C, Insausti CL, Meseguer L, Ramírez MC, Blanquer M, Marín N, Martínez S, Moraleda JM. Mesenchymal stem cells derived from dental tissues. Int Endod J. 2011 Sep;44(9):800-6.
Thibodeau B, Teixeira F, Yamauchi M, Caplan DJ, Trope M. Pulp revascularization of immature dog teeth with apical periodontitis. J Endod 2007;33:680-9.
Thibodeau B, Trope M. Pulp revascularization of a necrotic infected immature permanent tooth: case report and review of the literature. Pediatr Dent 2007;29:47-50.
Torabinejad M, Turman M. Revitalization of tooth with necrotic pulp and open apex by using platelet-rich plasma: a case report. J Endod. 2011 Feb;37(2):265-8.
Trevino EG, Patwardhan AN, Henry MA, Perry G, Dybdal-Hargreaves N, Hargreaves KM, Diogenes A. Effect of irrigants on the survival of human stem cells of the apical papilla in a platelet-rich plasma scaffold in human root tips. J Endod. 2011 Aug;37(8):1109-15.
Wang XJ, Thibodeau B, Trope M, Lin LM, Huang G. Histologic characterization of regenerated tissues in canal space after the revitalization/revascularization procedure of immature dog teeth with apical periodontitis. J Endod 2010;34:56-63.
Yamauchi N, Nagaoka H, Yamauchi S, Teixeira FB, Miguez P, Yamauchi M. Immunohistological characterization of newly formed tissues after regenerative procedure in immature dog teeth. J Endod. 2011 Dec;37(12):1636-41.