Limited Evidence Suggests Benefits of Single Visit Revascularization Endodontic Procedures - A Systematic Review.

Revascularization endodontic procedures commonly require multiple treatment sessions. However, single visit procedures may be advantageous from the clinical and patient management standpoints. The purpose of this review was to evaluate the outcomes of single-visit revascularization endodontic procedures for the management of immature permanent teeth with non-vital pulp. Two electronic databases (Scopus and PubMed) were searched, from their inception to July 2018, for studies that assessed clinical and/or radiographic and/or histologic outcomes of single-visit revascularization endodontic procedures performed in immature permanent teeth with non-vital pulp. Case reports, animal studies and clinical trials were included. The quality of case reports was appraised by Joanna Briggs Institute Critical Appraisal Checklist for Case Reports. The quality of randomized clinical trials was assessed by the revised Cochrane risk of bias tool for randomized trials. The risk of bias for animal studies was assessed using SYRCLE's risk of bias tool. Tabulation followed by narrative synthesis was used to draw conclusions. Seven studies satisfied the selection criteria. Five were classified as case reports, one as a randomized clinical trial and one as animal study. The latter presented with a high risk of bias, whilst the remaining showed a low risk. The evidence supporting the potential use of single-visit revascularization endodontic procedures is scarce. Successful single-visit revascularization endodontic procedures commonly include the use of high concentrations of sodium hypochlorite and EDTA combined with the use of agitation systems. Further clinical trials with long term follow up are needed to confirm the results of the current review.

Limited evidence suggests benefits of single visit revascularization endodontic procedures - a systematic review

Abstract Revascularization endodontic procedures commonly require multiple treatment sessions. However, single visit procedures may be advantageous from the clinical and patient management standpoints. The purpose of this review was to evaluate the outcomes of single-visit revascularization endodontic procedures for the management of immature permanent teeth with non-vital pulp. Two electronic databases (Scopus and PubMed) were searched, from their inception to July 2018, for studies that assessed clinical and/or radiographic and/or histologic outcomes of single-visit revascularization endodontic procedures performed in immature permanent teeth with non-vital pulp. Case reports, animal studies and clinical trials were included. The quality of case reports was appraised by Joanna Briggs Institute Critical Appraisal Checklist for Case Reports. The quality of randomized clinical trials was assessed by the revised Cochrane risk of bias tool for randomized trials. The risk of bias for animal studies was assessed using SYRCLE's risk of bias tool. Tabulation followed by narrative synthesis was used to draw conclusions. Seven studies satisfied the selection criteria. Five were classified as case reports, one as a randomized clinical trial and one as animal study. The latter presented with a high risk of bias, whilst the remaining showed a low risk. The evidence supporting the potential use of single-visit revascularization endodontic procedures is scarce. Successful single-visit revascularization endodontic procedures commonly include the use of high concentrations of sodium hypochlorite and EDTA combined with the use of agitation systems. Further clinical trials with long term follow up are needed to confirm the results of the current review.

Resumo Os protocolos clínicos de procedimentos endodônticos de revascularização comumente requerem múltiplas sessões. Entretanto, procedimentos em única sessão podem apresentar vantagens clínicas relacionadas ao paciente. O objetivo desta revisão sistemática foi avaliar os resultados clínicos dos procedimentos endodônticos de revascularização para o manejo de dentes permanentes imaturos realizados em única visita. Duas bases de dados eletrônicas (Scopus e PubMed) foram utilizadas, do seu início à julho de 2018, buscando estudos que avaliaram resultados de procedimentos endodônticos clínicos e/ou radiográficos, e/ou histológicos da revascularização em sessão única realizados em dentes permanentes imaturos com necrose pulpar. Relatos de casos, estudos em animais e estudos clínicos foram incluídos e avaliados quanto à qualidade e risco de viés. A qualidade dos relatos de casos foi avaliada utilizando-se a ferramenta própria de análise crítica do Instituto Joanna Briggs. A qualidade dos estudos clínicos randomizados controlados foi analisada pela ferramenta de risco de viés da Cochrane. O risco de viés para os estudos em animais foi mensurado utilizando-se a ferramenta SYRCLE. Os dados foram tabulados e a síntese narrativa foi utilizada para análise dos mesmos. Sete estudos satisfizeram os critérios de inclusão. Cinco foram classificados como relatos de casos, um como ensaio clínico randomizado e um outro como estudo em modelo animal. Este último apresentou alto risco de viés, enquanto o restante dos estudos mostrou baixo risco. A evidência que apoia a utilização potencial de procedimentos endodônticos de revascularização em sessão única é escassa. Os procedimentos endodônticos de revascularização em sessão única geralmente incluem o uso de altas concentrações de hipoclorito de sódio e EDTA, combinadas com o uso de sistemas de agitação. Assim, estudos clínicos com longos períodos de acompanhamento são necessários para confirmação dos resultados do presente estudo.

Nonuniformity in ligaments is a structural strategy for optimizing functionality.

Ligaments serve as compliant connectors between hard tissues. In that role, they function under various load regimes and directions. The 3D structure of ligaments is considered to form as a uniform entity that changes due to function. The periodontal ligament (PDL) connects the tooth to the bone and sustains different types of loads in various directions. Using the PDL as a model, employing a fabricated motorized setup in a microCT, we demonstrate that the fibrous network structure within the PDL is not uniform, even before the tooth becomes functional. Utilizing morphological automated segmentation methods, directionality analysis, as well as second harmonic generation imaging, we find high correlation between blood vessel distribution and fiber density. We also show a structural feature in a form of a dense collar around the neck of the tooth as well as a preferred direction of the fibrous network. Finally, we show that the PDL develops as a nonuniform structure, with an architecture designed to sustain specific types of load in designated areas. Based on these findings, we propose that ligaments in general should be regarded as nonuniform entities, structured already at developmental stages for optimal functioning under variable load regimes.

Current challenges in human tooth revitalization.

Tooth vitality and health are related to the presence of a living connective tissue, the dental pulp (DP), in the center of the dental organ. The DP contains the tooth immune defence system that is activated against invading oral cariogenic bacteria during the caries process and the tissue repair/regeneration machinery involved following microorganisms' eradication. However, penetration of oral bacteria into the DP often leads to complete tissue destruction and colonization of the endodontic space by microorganisms. Classical endodontic therapies consist of disinfecting then sealing the endodontic space with a gutta percha-based material. However, re-infections of the endodontic space by oral bacteria can occur, owing to the lack of tightness of the material. Recent findings suggest that regenerating a fully functional pulp tissue may be an ideal therapeutic solution to maintain a tooth defence system that will detect and help manage future injuries. The objective of this paper was to explain the different revascularization and regeneration strategies that have been proposed to reconstitute a living DP tissue and to discuss the main challenges that have to be resolved to improve these therapeutic strategies.

Pulp Vascularization during Tooth Development, Regeneration, and Therapy.

The pulp is a highly vascularized tissue situated in an inextensible environment surrounded by rigid dentin walls, with the apical foramina being the only access. The pulp vascular system is not only responsible for nutrient supply and waste removal but also contributes actively to the pulp inflammatory response and subsequent regeneration. This review discusses the underlying mechanisms of pulp vascularization during tooth development, regeneration, and therapeutic procedures, such as tissue engineering and tooth transplantation. Whereas the pulp vascular system is established by vasculogenesis during embryonic development, sprouting angiogenesis is the predominant process during regeneration and therapeutic processes. Hypoxia can be considered a common driving force. Dental pulp cells under hypoxic stress release proangiogenic factors, with vascular endothelial growth factor being one of the most potent. The benefit of exogenous vascular endothelial growth factor application in tissue engineering has been well demonstrated. Interestingly, dental pulp stem cells have an important role in pulp revascularization. Indeed, recent studies show that dental pulp stem cell secretome possesses angiogenic potential that actively contributes to the angiogenic process by guiding endothelial cells and even by differentiating themselves into the endothelial lineage. Although considerable insight has been obtained in the processes underlying pulp vascularization, many questions remain relating to the signaling pathways, timing, and influence of various stress conditions.

Tissue characterization following revascularization of immature dog teeth using different disinfection pastes.

Revascularization of immature teeth with necrotic pulps traditionally involves the use of triple antibiotic paste, which may sometimes lead to undesirable complications. The objective of this study was to assess tissue repair in immature dog teeth with apical periodontitis subjected to revascularization, comparing two different pastes used for root canal disinfection. Apical periodontitis was induced in 30 dog premolars. Teeth were randomly divided into three experimental groups: root canals filled with triple antibiotic paste (n = 10); root canals filled with 1% propolis paste (n = 10); and no medication (n = 10). An additional group (n = 10, no intervention) was used as control. After 7 months, the jaws were histologically evaluated for the following variables: newly formed mineralized tissue (present/absent); vital tissue in the canal space (absent/periodontal ligament-like/pulp-like); apical extension of root (present/absent); and severity of inflammatory process (absent/mild/moderate/severe). There were no statistically significant differences among the experimental groups in new mineralized tissue formation and apical root development. The formation of vital tissue in the canal space, in turn, was statistically different between the triple paste and propolis groups: vital tissues were present in all revascularized teeth disinfected with propolis paste (100%), compared to 71% of those disinfected with the triple paste. Severity of inflammatory process was different between the triple paste and no medication groups. The new tissues formed onto canal walls and in the root canal space showed characteristics of cementum and periodontal ligament, respectively. Propolis may have some advantages over the triple paste for the revascularization of immature teeth.

Effects of age, sex, and blood pressure on the blood flow velocity in dental pulp measured by Doppler ultrasound technique.

OBJECTIVE: To examine the effects of age, sex, and BP on the PBFV in human maxillary anterior teeth. METHODS: A total of 332 maxillary anterior teeth from 95 participants were included. The age and sex of each subject were recorded. The systolic and diastolic BPs were measured by a digital sphygmomanometer. The PBFV of each tooth was measured by a Doppler ultrasound system with a 20 MHz transducer. RESULTS: Among the variables, only systolic BP demonstrated a significant association with the PBFV. There were significant decreases in the PBFV with the groups of lower BP (P<.05). Age, sex, and tooth type were not significantly associated with the PBFV. CONCLUSIONS: Within the limitations of this study, it is considered that the PBFV increases with an increase in systolic BP. Age, sex, and tooth type had no significant effect on the PBFV of maxillary anterior teeth.

Tissue characterization following revascularization of immature dog teeth using different disinfection pastes

Abstract Revascularization of immature teeth with necrotic pulps traditionally involves the use of triple antibiotic paste, which may sometimes lead to undesirable complications. The objective of this study was to assess tissue repair in immature dog teeth with apical periodontitis subjected to revascularization, comparing two different pastes used for root canal disinfection. Apical periodontitis was induced in 30 dog premolars. Teeth were randomly divided into three experimental groups: root canals filled with triple antibiotic paste (n = 10); root canals filled with 1% propolis paste (n = 10); and no medication (n = 10). An additional group (n = 10, no intervention) was used as control. After 7 months, the jaws were histologically evaluated for the following variables: newly formed mineralized tissue (present/absent); vital tissue in the canal space (absent/periodontal ligament-like/pulp-like); apical extension of root (present/absent); and severity of inflammatory process (absent/mild/moderate/severe). There were no statistically significant differences among the experimental groups in new mineralized tissue formation and apical root development. The formation of vital tissue in the canal space, in turn, was statistically different between the triple paste and propolis groups: vital tissues were present in all revascularized teeth disinfected with propolis paste (100%), compared to 71% of those disinfected with the triple paste. Severity of inflammatory process was different between the triple paste and no medication groups. The new tissues formed onto canal walls and in the root canal space showed characteristics of cementum and periodontal ligament, respectively. Propolis may have some advantages over the triple paste for the revascularization of immature teeth.

Blocking VEGF signaling delays development of replacement teeth in zebrafish.

The dentition in zebrafish is extremely and richly vascularized, but the function of the vasculature, in view of the continuous replacement of the teeth, remains elusive. Through application of SU5416, a vascular endothelial growth factor receptor inhibitor, we studied the role of the blood vessels in the dentition of the zebrafish. We were unable to show an effect on the development of first-generation teeth as well as first tooth replacement. However, in juvenile fish, a delay was observed in the developmental state of the replacement tooth compared with what was expected based on the maturation state of the functional tooth. Furthermore, we observed a difference between treated and nontreated fish in the distance between blood vessels and developing replacement teeth. In conclusion, our results provide support for a nutritive, rather than an inductive, function of the vasculature in the process of tooth development and replacement.

Pulp revascularization of immature permanent teeth: a review of the literature and a proposal of a new clinical protocol.

Tissue engineering is a growing field. In the near future, it will probably be possible to generate a complete vital tooth from a single stem cell. Pulp revascularization is dependent on the ability of residual pulp and apical and periodontal stem cells to differentiate. These cells have the ability to generate a highly vascularized and a conjunctive rich living tissue. This one is able to colonize the available pulp space. Revascularization is a new treatment method for immature necrotic permanent teeth. Up to now, apexification procedures were applied for these teeth, using calcium dihydroxide or MTA to produce an artificial apical barrier. However, the pulp revascularization allows the stimulation of the apical development and the root maturation of immature teeth. Two pulp revascularization techniques are used in the literature, one using calcium dihydroxide and the second using a triple antibiotic paste. Based on these two different pulp revascularization protocols, which obtain the desired therapeutic success, the literature will be reviewed and analyzed according to the relevance of their choice of materials. Based on the literature, we propose a new relevant protocol and a new mixture of antibiotics.

Characterization of blood flow rate in dental pulp by speckle patterns of backscattered light from an in vivo tooth.

Experimental data on the hemodynamics of dental pulp at different stages of caries treatment are given. Observations of speckle patterns in backscattered laser light are used as a measurement method to qualitatively characterize changes in blood flow rate through the dental pulp. The measurements were made by the author-designed experimental setup. Theoretical estimations showed that stationary reflected light from an in vivo tooth contains a negligibly small information body on changes in the pulpal blood flow due to the shadowing of the pulp by optically thick enamel and dentin. Therefore, the temporal variations in the speckle patterns are the only possible way that can provide monitoring of blood conditions in the pulp by using backscattered light. Various statistical characteristics of the random reflected light fields are studied as indicators of blood flow rate changes. There were selected five statistical parameters of backscattered speckle images that give self-consistent data on these changes. The parameters include four combinations of integrals of the Fourier transforms of the observed temporal variations as well as the speckle image contrast. The selected parameters are shown to qualitatively agree with general considerations on the effects of reduced or increased blood flow rates on the selected integral quantities.

Maturogenesis by revascularization in an infected immature permanent tooth.

Root canal treatment in teeth with incomplete root formation is a challenge. A case of maturogenesis in an immature infected tooth along with probable factors needed for success is discussed. Although clinical and radiographic evidence points to healing and root development, the long-term prognosis and the behavior of tissue occupying the canal space needs further investigation before the procedure can be adopted into routine clinical practice.

Outcomes of revascularization treatment in immature dog's teeth.

AIM: The purpose of the current study was to examine the success rate of a revascularization treatment protocol involving canal space disinfection using copious irrigation, a triantibiotic dressing, and induction of a blood clot matrix in immature dog's teeth. MATERIALS AND METHODS: Thirty-six immature mongrel dog's teeth were divided into two experimental and two control groups. The experimental groups included a necrotic-infected group (n = 20) and a vital group (n = 10). In the group with the necrotic-infected teeth, periapical lesions were induced, and disinfection of the canals was carried out using copious irrigation and a triple antibiotic medication (metronidazole, ciprofloxacin, and tetracycline). Subsequently, the periapical tissues were irritated to initiate bleeding, producing a blood clot. A double seal of the coronal access was then placed. In the vital group, the pulp was aseptically removed before the canal was irrigated and periapical tissues irritated to induce bleeding. The same protocol as that used for the necrotic-infected group was used to seal the coronal access. In the positive control group (n = 3), after pulp removal, sterile sponges soaked in plaque suspension were placed in the pulp chambers of the teeth, after which the chambers were sealed. In the negative control group (n = 3), one untouched 1st premolar tooth in each dog was assigned and left to develop naturally. Radiographic and histological findings were evaluated at 3 and 6 months. Data analysis was performed using Fisher's exact test. RESULTS: The necrotic-infected group radiographically demonstrated apical healing and apical closure in 70% of the cases and thickening of the walls in 40% after 6 months. The vital group showed apical closure in 77% and thickened walls in 44% of the cases after 3 months. Histological findings confirmed the radiographic findings. No significant difference was observed between the two groups (P > 0.05). CONCLUSIONS: If necrotic-infected canals are effectively disinfected and treated according to the protocol, the ensuing revascularization response is similar to that of vital immature teeth.

Unravelling the blood supply to the zebrafish pharyngeal jaws and teeth.

We describe the vascular supply to the pharyngeal jaws and teeth in zebrafish, from larval stages to juveniles, using serial high quality semithin sections and 3D reconstructions. We have identified that the arterial blood supply to the last pair of branchial arches, which carries the teeth, issues from the hypobranchial artery. Surprisingly, the arteries supplying the pharyngeal jaws show an asymmetric branching pattern that is modified over ontogeny. Moreover, the blood vessel pattern that serves each jaw can best be described as a sinusoidal cavity encircling the bases of both the functional and replacement teeth. Capillaries branching from this sinusoidal cavity enter the pulp and constitute the intrinsic blood supply to the attached teeth. The role of these blood vessels during tooth development (whether instructive or nutritive) remains to be determined and requires further study. However, we have provided a firm morphological basis that will aid in the interpretation of experiments addressing this question.

Morphology of the dentin structure of sloths Bradypus tridactylus: a light and scanning electron microscopy investigation.

The aim of this study was to describe the dentine morphology of sloths (Bradypus tridactylus). The sloth teeth were removed and prepared for light microscopy (LM) and scanning electron microscopy analyses (SEM). LM revealed two patterns of tubular dentins: an outer with dentinary tubules over the all tooth length and one in the inner part with larger diameter and more spaced tubules, when compared to those present in the outer dentine. These findings were confirmed by SEM, which revealed a tubular pattern in the outer dentine like in humans. The inner dentine displayed pared grouped tubules that were characterized as vascular channels. It can be concluded that this sloth species present two types of dentins: an inner dentin (ortodentin) and an outer dentin characterized as a vascular dentin. This suggests a partial evolutive/adaptive process of this dental tissue, as compared to other mammalian species.

Expression patterns of Sema3F, PlexinA4, -A3, Neuropilin1 and -2 in the postnatal mouse molar suggest roles in tooth innervation and organogenesis.

OBJECTIVE: Semaphorins form a family of axon wiring molecules but still little is known about their role in tooth formation. A class 3 semaphorin, Semaphorin3F (Sema3F), besides acting as a chemorepellant for different types of axons, controls a variety of non-neuronal developmental processes. MATERIALS AND METHODS: Cellular mRNA expression patterns of Sema3F as well as neuropilin 1 (Npn1), neuropilin 2 (Npn2), plexinA3 and plexinA4 receptors were analyzed by sectional in situ hybridization in the mouse molar tooth during postnatal days 0-7. The expression of the receptors was studied in PN5 trigeminal ganglia. RESULTS: Sema3F, Npn1, -2 and plexinA4 exhibited distinct, spatiotemporally changing expression patterns, whereas plexinA3 was not observed in the tooth germs. Besides being expressed in the base of the dental mesenchyme Sema3F, like plexinA4, Npn1 and -2, was present in the ameloblast cell lineage. Npn1 and Npn2 were additionally seen in the pulp horns and endothelial cells and like PlexinA4 in the developing alveolar bone. Npn1, plexinA3 and -A4 were observed in trigeminal ganglion neurons. CONCLUSIONS: Sema3F may act as a tooth target-derived axonal chemorepellant controlling establishment of the tooth nerve supply. Furthermore, Sema3F, like Npn1, -2 and plexinA4 may serve non-neuronal functions by controlling the development of the ameloblast cell lineage. Moreover, Npn1 and Npn2 may regulate dental vasculogenesis and, together with PlexinA4, alveolar bone formation. Further analyses such as investigation of transgenic mouse models will be required to elucidate in vivo signaling functions of Sema3F and the receptors in odontogenesis.

Immunohistochemical localization of four and a half LIM domains 2 in the odontoblasts of mature human teeth.

Four and a half LIM domains 2 (FHL2) participates in cell differentiation and cancer development of various tissues, possessing dual functions either as an activator or as a repressor depending on the protein partners involved. Recent studies show that FHL2 plays an important role in osteoblast differentiation and bone formation. The present study was to investigate the expression and localization of FHL2 in human pulp-dentin complex by immunohistochemistry. Our results showed that in sound mature human teeth, FHL2 was expressed in odontoblasts and some endothelial cells of blood vessels. Moreover, in carious teeth FHL2 immunoreactivity was detected in odontoblasts, odontoblast-like cells and endothelial cells of blood vessels. FHL2 was mainly distributed in cytosol of the odontoblast cell bodies and partly located in nuclei of odontoblasts, but not in the odontoblast processes. Our data suggest a role of FHL2 in odontoblast differentiation and dentin formation both in normal and in carious teeth.

Vascularization of engineered teeth.

The implantation of cultured dental cell-cell re-associations allows for the reproduction of fully formed teeth, crown morphogenesis, epithelial histogenesis, mineralized dentin and enamel deposition, and root-periodontium development. Since vascularization is critical for organogenesis and tissue engineering, this work aimed to study: (a) blood vessel formation during tooth development, (b) the fate of blood vessels in cultured teeth and re-associations, and (c) vascularization after in vivo implantation. Ex vivo, blood vessels developed in the dental mesenchyme from the cap to bell stages and in the enamel organ, shortly before ameloblast differentiation. In cultured teeth and re-associations, blood-vessel-like structures remained in the peridental mesenchyme, but never developed into dental tissues. After implantation, both teeth and re-associations became revascularized, although later in the case of the re-associations. In implanted re-associations, newly formed blood vessels originated from the host, allowing for their survival, and affording conditions organ growth, mineralization, and enamel secretion.

Identification of a Ca2+-sensing receptor in rat trigeminal ganglia, sensory axons, and tooth dental pulp.

Extracellular Ca2+ regulates dentin formation, but little information is available on this regulatory mechanism. We have previously reported that sensory denervation reduces dentin formation, suggesting a role for sensory nerves in tooth mineralization. The G protein-coupled Ca2+-sensing receptor (CaR) is expressed in dorsal root ganglia and perivascular sensory nerves in mesenteric arterioles, and activation of these receptors by Ca2+ has been shown to induce vascular relaxation. The present study determined CaR expression in tooth dental pulp (DP), sensory axons, and trigeminal ganglion (TG) as well as the effect of increased [Ca2+]e or a calcimimetic on tooth blood flow. The distribution of CaR, studied by immunochemistry, RT-PCR, and Western blot, indicates abundant expression of CaR in sensory axons in the jaws, TG, and DP. Restriction analysis of PCR products with specific endonucleases showed the presence of CaR message in TG and DP, and Western blotting indicates the expression of mature and immature forms of the receptor in these tissues. Pulpal blood flow, measured by laser-Doppler flowmetry, increased by 67% +/- 6% (n = 12) following receptor stimulation with 5 mM Ca2+, which was completely inhibited by 5 microM IBTx, a high-conductance KCa channel blocker indicating a mechanism involving hyperpolarization. NPS R-467 (10 microM) increased blood flow by 85% +/- 18% (n = 6), suggesting regulation through the CaR. Our results suggest that the CaR is present in sensory nerves, DP, and TG and that an increase in Ca2+ in the DP causes vasodilatation, which may contribute to accumulation of Ca2+ during dentin mineralization.

Odontology or philologic: medical disputation about the teeth.

The dissertation, here rendered, was published at the gymnasium of Hof in 1669. It is remarkable that the respondent, who was probably also its author, declared in the title page that he intends to do his task "following the custom of the blessed Hebrews and any other conventions of true Israelites" and cites in the following text repeated proverbs of Rabbis. Therefore, we suppose him to have been a Jew converted to the Christian faith. His Odontology is a large collection of knowledge about the teeth, the etymology of this term, the question of them belonging to the bones, their anatomy and fixation in the jaws, and their tasks in the crushing of foods and helping in pronunciation, and in animals for self-protection. With respect to their removal, he emphasizes that one read Sennert's Institutiones Medicae. The points of view discussed by the author depended more heavily on philological than on medical authors. Nevertheless, there are mentioned also "paramedical" opinions of the general population. The monograph seems to us important for the history of dentistry.