Treatment outcomes of regenerative endodontic therapy in immature permanent teeth with pulpal necrosis: A systematic review and network meta-analysis.

AIM: The aim of this study was to assess which treatment modality regarding scaffold selection for immature permanent teeth with pulpal necrosis will be the most successful for regenerative endodontic treatment (RET). METHODOLOGY: PubMed, Cochrane, Web of Science and Embase, and additional records until August 2022 were searched providing a total of 3021 articles, and nine of these articles were included for quantitative synthesis. The reviewers selected eligible randomized controlled trials and extracted pertinent data. Network meta-analysis was conducted to estimate treatment effects for primary outcomes (clinical and radiographic healing) and secondary outcomes (apical closure, root length and root wall thickness increase) following RET [mean difference (MD); 95% credible interval (CrI) and surface under the cumulative ranking curve (SUCRA)]. The quality of the included studies was appraised by the revised Cochrane risk of bias tool, and the quality of evidence was assessed using the GRADE approach. RESULTS: Six interventions from nine included studies were identified: blood clot scaffold (BC), blood clot scaffold with basic fibroblast growth factor, blood clot scaffold with collagen, platelet pellet, platelet-rich plasma (PRP) and platelet-rich fibrin (PRF). The PRP scaffold showed the greatest increase in root lengthening at 6-12 months (MD = 4.2; 95% CrI, 1.2 to 6.8; SUCRA = 89.0%, very low confidence). PRP or PRF achieved the highest level of success for primary and secondary outcomes at 1-6 and 6-12 months. Blood clot scaffold (with collagen or combined with basic fibroblast growth factor (bFGF)) achieved the highest level of success for secondary outcomes beyond 12 months follow-up. A very low to low quality of evidence suggests that both PRP and PRF exhibit the greatest success evaluating primary and secondary outcomes within 12 months postoperatively compared to the traditional blood clot scaffold protocol. CONCLUSION: Limited evidence suggests both PRP and PRF exhibit success in the short-term, not long-term. The value of this information stems in its recommendation for future randomized trials prioritizing both of these materials in their protocol.

[Pulp revascularization procedure for external inflammatory dental root resorption treatment]. / Primenenie metodiki regeneratsii pul'popodobnoi tkani dlya ostanovki naruzhnoi vospalitel'noi rezorbtsii kornya zuba.

THE AIM OF THE STUDY: To assess the effectiveness of pulp revascularization procedure in children with external inflammatory root resorption (EIRR) after constant teeth injury. MATERIALS AND METHOS: The study comprised 17 children aged 6-10 years diagnosed with EIRR as a long-term complication of dental trauma in 19 teeth. EIRR was diagnosed with periapical radiographs and CBCT was performed to further assess the pathology extension. Pulp revascularization was carried out in all 19 teeth. RESULTS: There was no resorption progression in all cases. EIRR areas were substituted by bone. In 10 from 19 teeth with early stages of root development bone or cement-like tissue ingrowth into the root canal was observed radiologically. In cases of severe EIRR this ingrowth may partially compensate for lost tissues which is confirmed by a high percentage (94.7%) of functional teeth during mean follow up time of 38±10 months. CONCLUSION: Pulp revascularization is an effective method for retaining teeth with EIRR for a relatively long period of time and allows maintaining alveolar bone volume both due to functional tooth preservation and healing of bone lesions in periapical and resorption areas.

Evaluation of removal efficiency of capping materials used in pulp revascularization in vitro.

BACKGROUND: This study aimed to evaluate the removal efficiency of different capping materials used in pulp revascularization (PR) in a failure scenario. METHODS: The apices of freshly extracted 30 maxillary incisors were cut to mimic the immature teeth; then, root canals were shaped up to #6 Peeso reamers. The regeneration steps of the American Association of Endodontists (AAE) were followed to simulate PR treatment in vitro. The canals were dressed with the Ciprofloxacin and Metronidazole medicament mixture for 2 weeks. Then capping material groups were created: BioDentine (BD), ProRootMTA (PMTA), and RetroMTA (RMTA) (n = 10). The sealed specimens were stored for 2 weeks at 37 ºC in phosphate-buffered saline then the samples were examined by micro-computed tomography (µ-CT) analysis. Set capping materials were retrieved using a specific cement removal kit by a single blind operator. The residue materials were examined again by µCT. Kruskal-Wallis and Mann-Whitney U tests sought the significance for residue volumes. One-way ANOVA and Tukey post hoc tests with the Bonferroni corrections sought significance for the duration (p = 0.05). RESULTS: In the first examined µCT data, the mean (SD) capping material volumes of the PMTA, BD, and RMTA were 6.447 µm3 (1.086), 8.771 µm3 (0.491), and 8.114 µm3 (2.447), respectively. In the last examined µCT data, the median (IQR) residual volumes of the PMTA, BD, and RMTA were 0.051 µm3 (0.1), 0.313 µm3 (0.5), and 0.124 µm3 (0.1), respectively. A significant difference was found between BD and PMTA in the residual volumes (p < 0.05). The mean (SD) durations of the retrieving procedures of PMTA, BD, and RMTA were 19.83 min (2.34), 19.24 (3.60), and 22.04 (1.68), respectively (p = 0.063). CONCLUSIONS: Within the limitations of the presented study, it was concluded that the capping materials were largely removed from the root canals using a non-invasive approach. Nevertheless, this duration of the retrieving could be described as long.

Management of internal inflammatory root resorption using injectable platelet-rich fibrin revascularization technique: a clinical study with cone-beam computed tomography evaluation.

OBJECTIVES: The current study evaluated clinically and radiographically the management of internal inflammatory root resorption (IIRR) in permanent anterior teeth with or without periapical lesions using injectable platelet-rich fibrin (i-PRF) regenerative approach. METHODS: Ten systemically healthy patients, with thirteen anterior mature teeth diagnosed with IIRR were selected for the study. At the first visit, the tooth was anesthetized, access cavity opened, root canals were mechanically prepared then medicated with calcium hydroxide and temporarily sealed. After 2-4 weeks, regenerative endodontic procedures were performed by preparing and applying i-PRF inside the canal, then a freshly prepared PRF membrane was placed over it. White mineral trioxide aggregate was placed over the PRF matrix, and the tooth was restored with a glass ionomer cement base and resin composite restoration. The patients were recalled for clinical and radiographic evaluation and follow-up every 3 months for 12 months. Cone-beam computed tomography (CBCT) imaging was performed preoperatively and after 12 months. RESULTS: Clinical evaluation results showed resolution of signs and symptoms through the follow-up period in all of the cases. Both CBCT imaging readings of IIRR lesions and periapical lesions revealed a volumetric significant difference (p = 0.00) between the preoperative and the 12-month follow-up period. CONCLUSIONS: Usage of i-PRF could arrest and allow for healing of IIRR in permanent mature teeth and allow for periapical healing with successful clinical results. CLINICAL RELEVANCE: i-PRF revascularization technique proved to be a successful REP in the treatment of the IIRR, reducing the number of appointments and increasing patient compliance.

Host defense peptide IDR-1002 associated with ciprofloxacin as a new antimicrobial and immunomodulatory strategy for dental pulp revascularization therapy.

Regenerative therapies such as dental pulpal revascularization appear as an option for traumatized immature permanent teeth. However, the triple antibiotic paste - TAP (metronidazole, minocycline, and ciprofloxacin), used for these therapies, can generate cytotoxicity and dentin discoloration. In contrast, host defense peptides (HDPs) are promising antimicrobial and immunomodulatory biomolecules for dentistry. This study aimed to evaluate in vitro the antimicrobial activity (against Staphylococcus aureus and Enterococcus faecalis) and the immunomodulatory potential (by the evaluation of IL-1α, IL-6, IL-12, IL-10, TNF-α and NO, in RAW 264.7 macrophages and IL-6, TGF-ß and NO, in L929 fibroblast) of synthetic peptides (DJK-6, IDR-1018, and IDR-1002), compared to TAP in an in vitro infection model containing heat-killed antigens from E. faecalis and S. aureus. Furthermore, the synergistic potential of ciprofloxacin and IDR-1002 was evaluated by checkerboard. Ciprofloxacin was the best antimicrobial of TAP, besides acting in synergism with IDR-1002. TAP was pro-inflammatory (p < 0.05), while the association of ciprofloxacin and IDR-1002 presented an anti-inflammatory profile mainly in the presence of both heat-killed antigens (p < 0.05). Based on these results, ciprofloxacin associated with IDR-1002 may demonstrate an efficient antimicrobial and immunomodulatory action in this in vitro model. Further in vivo studies may determine the real potential of this combination.

Antimicrobial and immunomodulatory in vitro profile of double antibiotic paste.

AIM: To evaluate the antimicrobial and immunomodulatory activity of double antibiotic paste (DAP) in an in vitro infection model. METHODOLOGY: The minimum inhibitory and bactericidal concentrations (MIC and MBC) and the antibiofilm activities (TTC assay) of DAP and its components (ciprofloxacin and metronidazole) were evaluated against Staphylococcus aureus and Enterococcus faecalis compared with triple antibiotic paste (TAP). The cellular viability of RAW 264.7 macrophages (24 and 72 h) and L929 fibroblasts (48 and 72 h) was evaluated by MTT. Furthermore, the production of TNF-α, IL-12, IL-6, IL-1α, IL-10 and NO (on RAW 264.7), besides IL-6, TGF-ß and NO (on L929), stimulated with DAP in baseline and associated with heat-killed microbial-antigen conditions was measured by ELISA and Griess reaction. Data were analysed using the one-way ANOVA test with Bonferroni's corrections. RESULTS: The MBC of pharmacopoeia DAP was similar to TAP for E. faecalis (0.25 µg.  mL-1 ) and lower for S. aureus (DAP 1 µg. mL-1 and TAP 2 µg. mL-1 ; p < .001). Ciprofloxacin was the most effective antibiofilm drug from the pastes (35% of reduction for E. faecalis and S. aureus; p < .0001), and both pastes had a similar antibiofilm eradication against both biofilm species (29% and 35% for S. aureus and 76% and 85% for E. faecalis; p < .0001). DAP was cytotoxic against the tested cells. DAP significantly upregulated IL-1α (p < .001), IL-6 (p < .0001), TNF-α (p < .01) and IL-12 (p < .05; in the absence of antigens) and significantly reduced IL-6 (p < .0001; in the presence of HK-S. aureus) and IL-10 (p < .05; in the presence of both antigens) on macrophages. Furthermore, DAP upregulated IL-6 (p < .001) and NO (p < .05; in the absence of antigens), IL-6 (p < .001; in the presence of HK-S. aureus) and reduced NO (p < .001; in the presence of HK-S. aureus). CONCLUSIONS: Double antibiotic paste and TAP had similar antimicrobial activity against S. aureus and E. faecalis. DAP upregulated pro-inflammatory cytokines mainly in the absence of antigens and had pro- and anti-inflammatory activity in RAW 264.7 macrophages and L929 fibroblasts in the presence of antigens involved in pulp infections.

Successful pulp revascularization of an autotransplantated mature premolar with fragile fracture apicoectomy and plasma rich in growth factors: a 3-year follow-up.

AIM: This case report demonstrates a positive outcome of the adjuvant use of fragile fracture (FF), which is a technique used to harvest dental pulp stem cells (DPSCs), and platelet-rich plasma (PRP) in a mandibular premolar (tooth 44) with a completely formed root that was transplanted into a surgically created socket and which maintained pulp vitality and function. SUMMARY: After virtual surgical planning, a 3D tooth replica of tooth 44 was fabricated. A surgical socket was created in the position of tooth 14; then, tooth 44 was extracted and the root dentine was abraded using a turbine diamond bur 3 mm from the apex until a circular groove was prepared around the outer circumference of the root; and then, an FF was performed without damaging the pulp tissue. PRP was placed in the socket, after which the donor tooth was inserted in the recipient area. At 2 weeks post-treatment, orthodontic traction was applied. At 3-year follow-up, the tooth had adequate alignment and was asymptomatic. Response to pulp testing was positive, and the presence of pulp canal obliteration was observed as a sign of pulpal healing. KEY LEARNING POINTS: Autotransplantation is a good alternative for replacing missing teeth, with repair of tissues and pulp revascularization. Revascularization of an autotransplanted mature tooth using the fragile fracture technique and PRP scaffold is a feasible option and might have positive effects on the long-term outcome of the procedure. Including completely formed teeth as donors in autotransplantation, maintaining vitality and their functions is an option that warrants further study.

Long-term outcomes of autotransplantation of teeth: A case series.

The aim of autotransplantation of teeth (ATT) is to replace a lost tooth with a functional tooth within the same patient. Although it has recently become more of a recognized and viable treatment approach in dentistry, the long-term outcomes are still not well-documented. The principal author (MT) has performed more than 1000 ATTs for reasons such as treating missing teeth, deep caries, poor endodontic results, and periodontitis over the past 30 years in private practice. During the course of private practice, 2 separate analyses were performed on a total of 319 cases with follow-up ranging from 2 to 26 years. The results showed a tendency toward higher success rates in younger patients; the success rate was highest in ATTs performed on immature teeth (about 95%), about 90% in patients younger than 30 years of age and approximately 80% in patients older than 30. The failures were most often caused by replacement resorption (ie, ankylosis-related resorption). The purpose of this case series was to show successful long-term outcomes of ATT as well as to provide clinical insights and describe tendencies noted over the course of 30 years of performing ATTs.

Pulp Revascularization or Apexification for the Treatment of Immature Necrotic Permanent Teeth: Systematic Review and Meta-Analysis.

This systematic review and meta-analysis assessed clinical, radiographic and functional retention outcomes in immature necrotic permanent teeth treated either with pulp revascularization or apexification after a minimum of three months to determine which one provides the best results. The literature was screened via PubMed/MEDLINE and Embase databases up to June 2017 to select observational studies that compared pulp revascularization and apexification treatments assessing clinical, radiographic and functional retention outcomes. Two reviewers independently performed screening and evaluation of articles. A total of 231 articles were retrieved from databases, wherein only four articles were selected for full-text analyses. After exclusion criteria, three studies remained in quantitative and qualitative analyses. Pooled-effect estimates were obtained comparing clinical and radiographic outcomes ('overall outcome') and functional retention rates between apexification and pulp revascularization treatment. The meta-analysis comparing apexification vs. revascularization for 'overall outcome' (Z=0.113, p=0.910, RR=1.009, 95%CI:0.869-1.171) and functional retention rates (Z=1.438, p=0.150, RR=1.069, 95%CI:0.976-1.172) showed no statistically significant differences between the treatments. All studies were classified as high quality. The current literature regarding the clinical, radiographic and functional retention outcomes in immature necrotic permanent teeth treated either with pulp revascularization or apexification is limited. Based on our meta-analysis, the results do not favor one treatment modality over the other.

Effectiveness and clinical implications of the use of topical antibiotics in regenerative endodontic procedures: a review.

Regenerative endodontic procedures (REPs) are biologically based procedures planned to replace damaged tissues, including dentinee and root structures, as well as cells of the pulp-dentine complex. Effective sterilization of the root canal is essential in REPs, and antibiotics have been widely used to disinfect root canals. The aim of this paper was to review the scientific literature on (i) Effectiveness of antibiotics used in REPs against bacteria implicated in endodontic disease; (ii) Scientific evidence supporting the use of topical antibiotics in REPs; (iii) Clinical implications of the use of antibiotics in REPs and the possible side effects; (iv) Effect of antibiotics on dental pulp stem cells; and (v) Ongoing research on the use of antibiotics in REPs. Antibiotics used in REPs are effective against bacteria implicated in endodontic infections. Triple antibiotic pastes with minocycline attain complete disinfection of immature teeth with necrotic pulps, without affecting SCAP. Experimental studies carried out in dogs support the use of antibiotics in REPs. Clinical studies report high success rates of RET using antibiotics as intracanal dressings. However, tooth discolouration is an important side effect of the use of TAP. An antibiotic paste containing only metronidazole and ciprofloxacin could be a good alternative to the use of TAP. The use of antibiotic-containing scaffolds or clindamycin-modified triple antibiotic (metronidazole, ciprofloxacin and clindamycin) polymer could be a biologically safe antimicrobial drug delivery system in REPs.

[Pulp revascularization for the management of avulsed incisors with immature roots and pulp necrosis]. / Regeneratsiia pul'popodobnoi tkani pri lechenii patsientov s periodontitom vsledstvie vyvikha reztsov s nesformirovannymi korniami.

The aim of the study was to assess the efficacy of pulp revascularization (PR) in children with pulp necrosis in immature roots incisors with the history of avulsion. The study group comprised 11 children (4 girls and 7 boys aged 86-133 months) with 13 traumatized incisors with pulp necrosis. Mean age at the time of injury was 98.0 months. In 5 children pulp necrosis was associated with extensive periapical lesion (PL, 5-26 mm diameter), 4 children with the history of inadequate or ineffective endodontic treatment had radiological signs of external root resorption. PR was performed according to standard protocol and the results were assessed 3, 6, 12, 18 and 24 months after the procedure. All 13 teeth were clinically asymptomatic 24 months after PR, but continuous root growth and/or apexification was seen in 9 teeth only. PL resolved in all cases, root apexification correlated positively with the absence of PL and external root resorption, continuous root growth and dentinal walls thickening were less evident in patients with pulp necrosis at earlier stages of root development. No progression of external root resorption was observed. PR is a useful tool for the treatment of immature root incisors with pulp necrosis after teeth avulsion but extensive PL and external root resorption prevent adequate apexification probably because of the apical papilla necrosis.

The effectiveness of pulp revascularization in root formation of necrotic immature permanent teeth: A systematic review.

OBJECTIVE: The objective of the present study was to carry out a systematic review to analyse the effectiveness of pulp revascularization in the root formation of necrotic immature permanent teeth, as well as the level of scientific evidence regarding this theme. MATERIALS AND METHODS: The methodology was based on searching electronic databases such as Web of Science, Pubmed, BVS (Medline, Scielo, Lilacs and BBO), Scopus and Cochrane, including manual searches for the references listed in the studies found. The terms used for the literature search were pulp revascularization and endodontics. RESULTS: Initially, 277 articles were identified from the electronic databases; 17 studies remained after analysis and exclusion of duplicates; exclusion criteria also eliminated six articles; 11 remained for evaluation. CONCLUSIONS: Although the results found in the present systematic review are relevant, the scientific evidence should be interpreted with caution as the articles report different methods and evaluation parameters. Despite the capacity of the pulp revascularization technique to stimulate the development of the apical closure and thickening of radicular dentin, several aspects still remain unknown, like the key factors of this repair, the type of tissue formed and the long-term prognosis.

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.

Revascularization of a Permanent Tooth with Necrotic Pulp and Apical Periodontitis.

This case report details a pulp revascularization treatment administered to a mature permanent tooth exhibiting pulp necrosis. A 22-years old female patient complained of the recurrence of a sinus tract labial of the maxillary right central incisor; which was tender on biting. Diagnosis of pulp necrosis and symptomatic apical periodontitis. Preoperative periapical and CBCT radiographs showed root with wide apical foramen and large apical radiolucency. Pulp revascularization procedure was performed using 1.3% sodium hypochlorite irrigation, 17% Ethylenediaminetetraacetic acid irrigation, and calcium hydroxide intracanal dressing for 2 weeks. During the last visit, intentional bleeding was induced, collagen matrix was set over the blood clot, 2 mm of mineral trioxide aggregate and glass-ionomer filling was placed. A year of follow-up, the tooth showed no signs or symptoms and responded normally to the sensibility tests. Intra-oral periapical radiograph and the CBCT showed significant reduction in the periapical lesion's size, slight reduction in the apical foramen's size, and hard radiopaque material deposition at the root's middle third.

Discoloration after revascularization using calcium phosphosilicate-based bioceramic versus mineral trioxide aggregate in necrotic immature permanent anterior teeth: A Randomized clinical trial.

Aim: The aim of the current study is to evaluate the effect of calcium phophosilicate-based bioceramic "Totalfill bioceramic putty" and white mineral trioxide aggregate (WMTA) as the coronal plug on discoloration after revascularization of necrotic immature permanent anterior teeth. Materials and Methods: This study was conducted on (48) necrotic young permanent central incisors in children ranging from 8 to 14 years old, that were randomly allocated to either Totalfill bioceramic (Group I = 24) or WMTA (Group II = 24) as the coronal plug. Two visits revascularization protocol was adopted in this study using 1.5% sodium hypochlorite, followed by 17% ethylenediaminetetraacetic acid, and ending with a saline flush as irrigation solution. The double antibiotic paste was used as intracanal medication. The blood clot was used as scaffold followed by the application of collagen membrane followed by coronal plud malterial. Finally, the access was sealed using resin composite restoration and composite restoration. Clinical assessment was conducted at 1, 3, 6, 9, and 12 months, while radiographic assessment was conducted at 6 and 12 months. Data were statistically analyzed using the Chi-squared test for intergroup comparisons and Cochran's Q test for intragroup comparison. Results: Clinically, Group I exhibited a success rate of 100%, whereas Group II exhibited a success rate of 85.7%. Radiographically, both materials showed a 90.5% success rate. There was no statistically significant difference between both materials for all assessed clinical and radiographic parameters at different follow-up periods. Conclusions: Both Totalfill bioceramic putty and WMTA can be used successfully as coronal plug in esthetic areas.

Pulp Revascularization After Autotransplantation of the Mandibular Canines With Partially Resected Roots: Report of 5 Cases With Follow-ups Between 26 and 80 Months.

INTRODUCTION: Transmigrated (migrated through the midline) mandibular canines constitute a treatment challenge. Advanced transmigration can be successfully treated by autotransplantation. In developing canines, pulp revascularization is typical after transplantation. On the contrary, the pulp of teeth with completed apex formation does not undergo revascularization. In this case, root canal treatment becomes compulsory and decreases the success of autotransplantation. The aim of this observational retrospective study was to evaluate whether partial resection of the root (performed during the autotransplantation of mature canines) would enable revascularization of the pulp after the surgery. METHODS: Five transmigrated mandibular canines with complete apex formation before the surgery were evaluated. During the autotransplantation surgery, the resection of 2 to 4 mm of the root apex was performed to open the path for revascularization of the pulp after surgery. The transplanted teeth were observed during healing after the surgery for the presence of pulp obliteration. Clinical and radiographic examinations were performed. RESULTS: All treated canines survived the minimum observation period of 2 years (ranging from 26 to 80 months, mean: 55 months) without pulp healing complications. The survival was 100%, and the success was 80%. In one canine, the external cervical root resorption was diagnosed and treated 1 year after the surgery. At the final examination, transplanted canines presented radiographic features of pulp obliteration, normal mobility, and healthy periodontal tissues. CONCLUSIONS: The surgical protocol proved to be successful in promoting revascularization to maintain pulp vitality, in all cases. The outcomes confirm that autotransplantation, combined with the resection of the root, constitutes a valid treatment for mature ectopic canines.

Different endodontic treatments induced root development of two nonvital immature teeth in the same patient: A case report.

BACKGROUND: Pulp revascularization is a novel way to treat immature teeth with periapical disease, and the technique has become increasingly well established in recent years. By puncturing the periapical tissue, bleeding is induced, and a blood clot is formed in the root canal. The blood clot acts as a natural bioscaffold onto which mesenchymal stem cells from periapical tissue can be seeded and restore pulp vascularity, thus promoting root development as well as apical closure. Although the effect of pulp revascularization is ideal, there are certain requirements for the apical condition of the teeth. The apical barrier technique and apexification are still indispensable for teeth that cannot achieve ideal blood clot formation. In addition, a meta-analysis of several clinical studies concluded that pulp revascularization has no significant advantages over other treatments. CASE SUMMARY: A 10-year-old girl complained of pain in the right upper and lower posterior teeth for 2 d. Clinical and radiological examinations revealed that both the right maxillary and mandibular second premolars were immature with periapical radiolucency. The right maxillary second premolar was treated by pulp revascularization, while the right mandibular second premolar was treated by conventional apical barrier surgery after revascularization failed. The purpose of this report is to compare the different root maturation processes induced by the pulp revascularization and apical barrier techniques in the same patient in homonymous teeth from different jaws. Twelve months of follow-up showed that the apical foramen of both teeth presented a clear tendency to close; however, the tooth treated with pulp revascularization showed a significant increase in root length as well as root canal wall thickness. CONCLUSION: For the treatment of nonvital immature teeth, pulp revascularization showed a superior therapeutic effect in comparison with the apical barrier technique.

Efficacy of Ciprofloxacin, Metronidazole and Minocycline in Ordered Mesoporous Silica against Enterococcus faecalis for Dental Pulp Revascularization: An In-Vitro Study.

Pulp revascularization of teeth with necrotic pulp has become an alternative treatment in cases with immature apex. Microbial control is essential to achieve a successful outcome and continued root development. Enterococcus faecalis (E. faecalis) is the most frequently isolated bacterial species in root canals of endodontically failed teeth. Our main goal was to compare the in-vitro antimicrobial efficacy of different antibiotic formulations delivered by ordered mesoporous silica (OMS) against E. faecalis. To determine antibiotic susceptibility, we tested OMS and triple antibiotic paste (TAP; ciprofloxacin:metronidazole:minocycline) with different reagents in different concentrations, using the Kirby−Bauer disk diffusion method. OMS and metronidazole showed no antibacterial activity against E. faecalis. Mixtures of OMS and antibiotics in proportions of 2:2:14 and 4:1:7 (mg/L of ciprofloxacin:metronidazole:minocycline, respectively) showed the lowest antibacterial activity. The antibacterial activity of the combined solutions of ciprofloxacin and metronidazole was significantly higher (p < 0.005). Combinations in different concentrations of minocycline, ciprofloxacin, and metronidazole in OMS have shown activity against E. faecalis, although the combined use of ciprofloxacin and metronidazole has shown the most effective results. This study demonstrates the efficacy of intracanal antibiotic combination paste activity against E. faecalis, avoiding the use of minocycline, whose undesirable effect of teeth staining is a common problem for patients and professionals in dental clinic.

Pulp revascularization on an adult mandibular right second premolar: A case report.

BACKGROUND: Pulp revascularization has become a new method for the treatment of periapical diseases in young permanent teeth in recent years. Through root canal flushing and disinfection, avoiding mechanical preparation, guiding apical stem cells into the root canal and promoting the continuous development of tooth roots, it has achieved good clinical curative effects. But in adult patients with chronic periapical periodontitis with immature roots and open apices, apical barrier technology is often used to treat these teeth. CASE SUMMARY: Pulp revascularization of a 26-year-old patient's tooth was performed using cefaclor instead of minocycline and iRoot BP instead of mineral trioxide aggregate as intracanal medication. The case was followed up for 36 mo. Observations showed evidence of regression of clinical signs and symptoms, resolution of apical periodontitis and no discolouration of affected teeth. CONCLUSION: For adult patients with chronic periapical periodontitis with immature roots and open apices, pulp revascularisation showed favourable results in treating these teeth.

Angiogenic hydrogels for dental pulp revascularization.

Angiogenesis is critical for tissue healing and regeneration. Promoting angiogenesis in materials implanted within dental pulp after pulpectomy is a major clinical challenge in endodontics. We demonstrate the ability of acellular self-assembling peptide hydrogels to create extracellular matrix mimetic architectures that guide in vivo development of neovasculature and tissue deposition. The hydrogels possess facile injectability, as well as sequence-level functionalizability. We explore the therapeutic utility of an angiogenic hydrogel to regenerate vascularized pulp-like soft tissue in a large animal (canine) orthotopic model. The regenerated soft tissue recapitulates key features of native pulp, such as blood vessels, neural filaments, and an odontoblast-like layer next to dentinal tubules. Our study establishes angiogenic peptide hydrogels as potent scaffolds for promoting soft tissue regeneration in vivo. STATEMENT OF SIGNIFICANCE: A major challenge to endodontic tissue engineering is the lack of in situ angiogenesis within intracanal implants, especially after complete removal of the dental pulp. The lack of a robust vasculature in implants limit integration of matrices with the host tissue and regeneration of soft tissue. We demonstrate the development of an acellular material that promotes tissue revascularization in vivo without added growth factors, in a preclinical canine model of pulp-like soft-tissue regeneration. Such acellular biomaterials would facilitate pulp revascularization approaches in large animal models, and translation into human clinical trials.