endo journal review
TRANSCRIPT
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Endodontic Journal Review
Presenter: PGY1
Date: 2013.07.30
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RevascularizationOdontoblastic
layersInnervation
Pulp Regeneration
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Stem/ProgenitorCells
ScaffoldGrowthFactors
Principles of
Tissue
Engineering
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Regenerative Endodontic Treatment of
Permanent Teeth
after Completion of Root Development:A Report of Two Cases
Paryani et al, J Endod 2013
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CASE PRESENTATION
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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
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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
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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
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Treatment Course
First appointment
Second appointment
First appointment
Second appointment
1 week
22 days
Case 1
Case 2
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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
Anesthetized with 2% lidocaine
(1:100,000 epinephrine) and RD
isolation
Access cavity preparation
performed under a microscope
Take working length radiograph
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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
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Second Appointment
Case 1 Case 2
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 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
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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
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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
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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 (-)
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Case 1
Post-OP 1 month 15 months 22 months
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Case 2
Post-OP 1 month 5 months 18 months
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DISCUSSION AND CONCLUSION
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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
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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
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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
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Clinical Protocols for Mature Teeth
Challenge 1
Necessity toinduce
bleeding
Challenge 2
Proper apicalenlargement
Challenge 3
Sufficientdisinfection
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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
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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
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Clinical Protocols for Mature Teeth
Challenge 1
Necessity toinduce
bleeding
Challenge 2
Proper apicalenlargement
Challenge 3
Sufficientdisinfection
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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
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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
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Clinical Protocols for Mature Teeth
Challenge 1
Necessity toinduce
bleeding
Challenge 2
Proper apicalenlargement
Challenge 3
Sufficientdisinfection
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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
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Effect of Chemical Agents
Ca(OH)2
Antibiotics
Combination
Cirpofloxacin
EDTA
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Thanks for your attention!
Presenter: PGY1
Date: 2013.07.30
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