Search

The European Society of Endodontology and the American Association for Endodontists have released position statements and clinical considerations for regenerative endodontics. There is increasing literature on this field since the initial reports of Iwaya et al. (Dental Traumatology, 17, 2001, 185) and Banchs & Trope (Journal of Endodontics, 30, 2004, 196). Endogenous stem cells from an induced periapical bleeding and scaffolds using blood clot, platelet rich plasma or platelet-rich fibrin have been utilized in regenerative endodontics. This approach has been described as a 'paradigm shift' and considered the first treatment option for immature teeth with pulp necrosis. There are three treatment outcomes of regenerative endodontics; (i) resolution of clinical signs and symptoms; (ii) further root maturation; and (iii) return of neurogenesis. It is known that results are variable for these objectives, and true regeneration of the pulp/dentine complex is not achieved. Repair derived primarily from the periodontal and osseous tissues has been shown histologically. It is hoped that with the concept of tissue engineering, namely stem cells, scaffolds and signalling molecules, that true pulp regeneration is an achievable goal. This review discusses current knowledge as well as future directions for regenerative endodontics. Patient-centred outcomes such as tooth discolouration and possibly more appointments with the potential for adverse effects needs to be discussed with patients and parents. Based on the classification of Cvek (Endodontics and Dental Traumatology, 8, 1992, 45), it is proposed that regenerative endodontics should be considered for teeth with incomplete root formation although teeth with near or complete root formation may be more suited for conventional endodontic therapy or MTA barrier techniques. However, much is still not known about clinical and biological aspects of regenerative endodontics., (© 2018 International Endodontic Journal. Published by John Wiley & Sons Ltd.)

Introduction: Immature necrotic teeth are at a high risk of fracture, especially at the cervical region, after treatment. This study aimed to compare the impact and fracture strength of immature permanent teeth treated with revascularization versus a mineral trioxide aggregate (MTA) plug and fiber post., Methods: This in vitro, experimental study was conducted on 160 maxillary central incisors, which were randomly divided into 10 groups. The groups included a fracture (F) and impact (I) negative control group, F and I positive control groups, F and I MTA groups, F and I revascularizing group, and F and I revascularized groups. Fracture strength was measured using a universal testing machine with a crosshead speed of 1 mm/min. Other tooth samples were then subjected to the Charpy impact test for impact strength measurements, and the amount of energy absorbed by the teeth was determined. Data were analyzed using the Kolmogorov-Smirnov test, analysis of variance, and the Tukey test., Results: The mean load to fracture of the negative, positive, MTA, revacularizing, and revascularized groups was 1931.8, 1350.1, 1003.8, 1262.5, and 1100.2 N, respectively, and the mean impact strength was 5.04, 3.6, 3.68, 3.16, and 3.65 J, respectively. The fracture and impact strength of the negative control group was significantly higher than that of the other groups (P < .05), but the other groups were not significantly different in this respect (P > .05)., Conclusions: Despite the limitations of this study, the results showed that none of the tested modalities could significantly increase the impact and fracture strength of simulated immature teeth., (Copyright © 2018 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.)

Aim: To detect the unknown components of the oral microbiome and the effects of root canal treatment in a Turkish population and to evaluate the changes in microbial diversity in the root canals before and after treatment., Methodology: Single-rooted central and lateral maxillary incisors with one canal were chosen from 20 patients. Baseline samples of intact intracanal microbiota were collected from 20 root canals of permanent teeth with necrotic pulps using sterile paper points. After root canal preparation, the root canals were filled with a calcium hydroxide paste for 7 days. Calcium hydroxide was removed from root canal with 2.5% sodium hypochlorite and 17% EDTA using passive ultrasonic irrigation (PUI). A second bacteriologic samples were taken with sterile paper points prior to root filling. The samples were processes with DNase-I treatment using next-generation sequencing (NGS). Reduction in bacterial numbers during root canal treatment was evaluated using real-time quantitative PCR (qPCR). All statistical analyses were conducted using the MINITAB 17 software (Minitab Ltd. Co., Coventry, UK). A one-sample t-test was used to analyse the data. Statistical significance was accepted at P < 0.05., Results: Relative abundances of Mycoplasma sp., Paludibacter sp., Tannerella sp., Prevotella spp. and an uncultured species from the order Bacteroidales decreased with root canal preparation and medication (98.7%, 99.8%, 98.8%, 97.7% and 99.3%, respectively), whilst the relative abundances of Methylobacterium sp., Corynebacterium sp. and Streptococcus infantis increased (93.1%, 94.8% and 99.4%, respectively). Considerable numbers of Streptophyta species were detected before and after treatment. The ratio of Agrobacterium sp. in the treated teeth community and the ratio of order Streptophyta in the infected canals had negative correlations with the success of bacterial elimination., Conclusions: The combination of NGS and qPCR techniques resulted in detection of previously unknown components of the oral microbiome and the effects of root canal treatment on their relative abundance in a Turkish population., (© 2018 International Endodontic Journal. Published by John Wiley & Sons Ltd.)

Background: Many challenges encounter the endodontist, especially when dealing with necrotic teeth with chronic periapical lesions. Postoperative pain may be induced following conventional endodontic therapy and total eradication of the bacteria is almost unachievable even with recently available techniques. In recent years, diode laser usage in the endodontic field has gained acceptance. Thus, this study aimed to investigate the ability of the diode laser (DL) to decrease postoperative pain and achieve root canal sterility. Methods: 56 patients with anterior teeth with chronic periapical lesions in upper anterior teeth were randomly divided into two groups (n = 28). All patients were treated with two visits of conventional root canal treatment with ProTaper Universal. The DL group: root canals were irradiated with 200 µm fiber optic at both visits; the control group (Endo): the DL fiber was placed in root canal with no activation. Bacterial samples were collected from all the cases at each step of the treatment. Pain levels were evaluated using a numerical rating scale preoperatively, and after 6, 12, 24, 48 hours and 7 days. Bacterial count was used to detect both aerobic and anaerobic bacterial load.  Results: The qualitative pain scores revealed statistically significant lower pain levels in the DL group compared with the Endo group at all time intervals (P<0.001), except preoperatively where there was no significant difference. There was a statistically significant lower bacterial count for both aerobic and anaerobic bacteria in the DL group compared with the Endo group in both S3 samples (after laser application) and S4 samples (bacterial colonization) (P<0.001). Conclusion : The 980 nm diode laser may be a successful adjunct to conventional endodontic treatment of necrotic cases with chronic periapical lesions in terms of postoperative pain and root canal disinfection.   Trail registration: PACTR201511001275414 (date: 23 rd September 2015)., Competing Interests: No competing interests were disclosed.

Introduction: The outcomes of an immature tooth with necrotic pulp treated with regenerative endodontic procedures (REPs) were assessed clinically and radiographically. Root maturation is an important outcome of REPs, and several radiographic measurement methods have been used to measure this. The aim of this study was to compare radiographic measurement methods, measuring root maturation in immature teeth with necrotic pulp treated with REPs., Methods: Seventy-one radiographic images of REP cases were measured and compared using 3 radiographic measurement methods described by Bose et al (2009), Alobaid et al (2014), and Flake et al (2014). The intraclass correlation coefficient values were evaluated using the intra- and interobserver reliability test and the effect of the stage of root development., Results: The intra- and interobserver reliability for Alobaid et al's method and Flake et al's method were slightly higher than Bose et al's method as quantified by the intraclass correlation coefficient without a significant difference (P > .05). The stage of root development did not affect the reliability of the measurement methods. A high level of agreement was found among the 3 stages of root development for all 3 quantitative radiographic measurement methods., Conclusions: All 3 quantitative radiographic measurement methods exhibited high agreement regarding reliability. The stage of root development did not have an impact on the reliability of the measurement methods., (Copyright © 2018 American Association of Endodontists. All rights reserved.)

Aim: The aim of this in vivo study was to evaluate the revascularization procedure both in immature and mature teeth with necrotic pulp and open apices, disinfected with triple antibiotic paste followed by inducing blood clot in the root canal., Materials and Methods: Fifteen patients were selected who presented with immature and mature permanent teeth with pulpal necrosis and open apices. In the first visit, the root canal was accessed with LA and rubber dam isolation; then the canal was disinfected using triple antibiotic paste containing ciprofloxacin, metronidazole, and clindamycin in the ratio of 1:1:1 and closed with IRM. In the second visit, after administering local anesthesia and isolating with a rubber dam, the triple antibiotic paste was washed out by saline irrigation, and apical papilla beyond the confines of the root canal was stimulated with sterile H file to produce a blood clot. Finally, the access was closed using a double seal with mineral trioxide aggregate (MTA) placed apical to cementoenamel junction and resin bonded cement over the MTA. Radiographic examination and pulp sensibility test was done during the follow-up period of 2,4,6,8 and 10 months., Result: After 10 months follow-up, 10 out of 13 patients showed root development and apical closure. The eight patients out of 13 showed root development, apical closure and lateral thickening of radicular dentin and 2 out of 13 patients showed a positive response to electric sensibility test., Conclusion: Within the limitation of this study, it can be concluded that there is evidence of root development, increase in lateral wall thickness, apical closure and positive response to pulp sensibility test in both mature and immature teeth with necrotic pulp., Clinical Significance: The conventional approach for management of teeth with necrotic pulp and the open apex is altered with the possibility of tissue regeneration within the pulp space and continued root development through revascularization procedures. It also re-establishes the vitality in a previously nonvital and necrosed tooth.

Competing Interests: Competing interests: None declared.

Background: Deep carious lesions in immature permanent molars with pulp necrosis pose a serious challenge to contemporary paedodontic practice. A further complex clinical scenario is an immature permanent molar with varying root formation in both roots. This case report demonstrates the successful management of an immature permanent mandibular first molar., Case Report: An 8-year-old boy was referred for endodontic management of 36 by a general practitioner. After clinical and radiographic evaluation, a diagnosis of recurrent chronic periapical abscess with abrupt root closure in the mesial root and cessation of root closure in the distal root was made. Apexification was undertaken in three appointments. In the first appointment, under local analgesia and isolation, the mesial canals were prepared to size #F3 with rotary Protaper Universal and the distal canal was left unprepared. Both canals were irrigated with 5% sodium hypochlorite and calcium hydroxide intracanal medicament was placed. One week later, the mesial canals were obturated and a 4 mm white MTA apical plug was placed in the distal canal. Partial extrusion of the MTA was seen periapically. After 24 h, the hard-setting of the MTA plug was verified, remainder of the distal canal was obturated and core filling was placed followed by a preformed metal crown as an intermediate restoration., Follow-Up: The patient was asymptomatic and showed resolution of the lesion, normal thickness of the PDL space with continuity of the lamina dura after 12 months. Extruded MTA was partially resorbed. Three years follow-up showed complete resorption of the extruded MTA and an intact lamina dura.

This article describes 2 unusual cases of mucosal fenestration associated with necrotic infected teeth, resulting in exposure of the root apex to the oral cavity. Both cases consisted of maxillary incisors with pulp necrosis and radiographic/tomographic evidence of apical periodontitis. Clinically, the root apex was exposed to the oral cavity through a fenestration in both bone and mucosa and covered with bacterial plaque and calculus. These teeth were treated by a combination of nonsurgical and surgical endodontic treatment. During surgery, the root apices were resected to within the alveolus and the fenestrated area covered by the flap. Specimens consisting of the root apex and surrounding soft tissues were subjected to histopathological and histobacteriological analyses. Histobacteriological analysis revealed extensive resorptive defects on the root apices filled with thick bacterial biofilm, irregular detachment of the cementum layers with consequent infection of the underlying spaces, and heavy infection in the apical foramina. The soft tissue specimens exhibited no or minimal inflammation. The 2 cases showed satisfactory postsurgical healing of the hard and soft tissues. Both cases of mucosal fenestration showed root apices covered with dense bacterial biofilms and associated with a bone crypt with no significant inflammatory tissue therein. The 2 cases were successfully treated by conservative approaches involving a combination of nonsurgical and surgical endodontic treatment with root-end resection., (Copyright © 2018 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.)

Introduction: The aim of the present study was to evaluate the possibility of regaining pulp sensibility in mature necrotic teeth using modified regenerative endodontic procedures by inducing bleeding in root canals and using platelet-rich fibrin (PRF)., Methods: Fifteen patients with necrotic pulp with symptomatic or asymptomatic apical periodontitis were included. At the first visit, the tooth was anesthetized, and an access cavity was performed. Mechanical preparation of root canals was performed using the standardized technique reaching apical canal preparation to K-file size #60-80. Double antibiotic paste was injected into the canal, and the cavity was temporarily sealed using glass ionomer cement. Three weeks from the first visit, regenerative endodontic procedures were performed by inducing bleeding, and a freshly prepared PRF membrane was placed in the canal. White mineral trioxide aggregate was placed directly over the PRF matrix, and the tooth was restored with a glass ionomer cement base and resin composite restoration. The electric pulp test was used to record if the teeth included in the study regained sensibility or not every 3 to 12 months follow-up. Readings at different times were compared as categoric qualitative data using the chi-square test and compared as means and standard deviations using the analysis of variance test., Results: Readings of tooth sensibility revealed a highly significant difference (P < .0001) between baseline and the 12-month follow-up period., Conclusions: The presence of sensibility is indicative of the formation of vital pulplike tissue. Reestablishing real pulp tissue after regenerative endodontic treatment is debatable and still needs high level of evidence with large-scale investigations., (Copyright © 2018 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.)

Background: This study aimed at investigating dental clinicians' preferences on management of necrotic pulp with acute apical abscess (NPAAA) cases., Methods: Following an ethical approval and two pilot studies, an electronic survey was emailed to 400 general dental practitioners (GDPs) and 56 endodontists. The email explained the study's methods and assured that participants' identities and information given would remain anonymous and confidential. A reminder email was sent after eight weeks. Responses were collected and data were analyzed using the Chi-square test at p = 0.05., Results: The majority of respondents (86.3%) would deal with NPAAA cases "differently" from vital-pulp ones (p < 0.001). More endodontists (40%) used two or three irrgants than GDPs (29.5%). Whilst the highest proportion of endodontists (29.7%) rarely prescribed antibiotics, the highest proportion of GDPs (26%) generally did so (p < 0.001). Whilst the highest proportion of GDPs (26.9%) over-instrumented the largest canal in the first visit, most endodontists (56.8%) performed complete cleaning & shaping (C&S) (p < 0.001). In cases of non-stopped exudates, whilst the highest proportions of endodontists would either let the patient wait till the exudates significantly reduce then continue their intended approach (40.5%) or insert ICMs and temporize the tooth (40.5%), the highest proportion of GDPs (30.8%) would insert only dry cotton pellet without temporizing the tooth (p = 0.002). Of those who would leave the tooth open if non-stopped exudates presents in the first visit, the majority (81.9%) would temporize the tooth if little exudates present after C&S (p < 0.001)., Conclusions: Clinicians, especially GDPs, opted to treat teeth involved in NPAAA differently from those with vital-pulp, such as: were using different ICMs and irrigants, C&S to different apical size preparation. GDPs should improve their practice by implementing multi-irrigants protocol while C&S, limit prescribing antibiotics, perform complete debridement of the root canal system and not to leave the tooth open between visits. Clinicians, especially GDPs, relied on their own experiences in managing NPAA cases which necessitates scientific-based guidelines.

Aim: To develop an inexpensive simulation model for training of revitalization procedures., Methodology: A replica of an immature maxillary central incisor was equipped with a mock blood reservoir at the root apex and embedded in a plaster model. Mock blood consisted of water supplemented with red pigments and fibrinogen, whilst thrombin was inserted into the root canal to allow for clot formation., Results: A true-to-life training model for revitalization procedures was established, where the induction of bleeding and formation of a blood clot can be mimicked. The model can be fastened to a patient mannequin and thus closely simulate the clinical setting., Conclusions: The newly developed model can be used for training purposes, both for dental students and for practitioners, to perform the treatment steps of a revitalization procedure., (© 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd.)

Aim: To evaluate the treatment outcomes of a revitalization endodontic technique (RET) for the management of traumatized immature teeth with necrotic pulps in children., Methodology: Fifteen healthy children (age range = 7-10 years) with traumatized immature maxillary incisors with necrotic pulps treated with bi-antibiotic revitalization endodontic technique were prospectively assessed over approximately two years (mean = 22 months). One operator undertook all treatments, clinical reviews and standardized radiographic exposures with radiographic analysis being carried out by two calibrated experienced clinicians. Crown colour change was assessed using an objective published methodology. Wilcoxon signed-rank test was used to compare root lengths, root dentinal widths and apical foramen widths over time., Results: Interoperator measurement reliability was consistently strong for all measurements. There was no significant difference in root lengths or root dentinal wall widths following RET. A significant difference in apical foramen widths was observed after 2 years (P = 0.013) with resolution of clinical signs of infection in all cases. Despite omitting minocycline and using Portland cement (nonbismuth containing cement), a noticeable crown colour change (yellower, redder and lighter), as measured by an objective colour measurement system with ΔE = 7.39, was recorded. Most patients, however, were satisfied with the aesthetic outcome., Conclusion: Traumatized immature teeth with necrotic pulps treated with revitalization endodontic technique did not demonstrate continuation of root development or dentine formation when assessed by periapical radiographs. However, apical closure and periodontal healing were observed. A measurable change in crown colour (yellower, redder and lighter), with mostly no aesthetic concern to the patients/parents, was also observed., (© 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd.)

Apexification is an endodontic technique used in immature necrotic teeth, the primary goal of which is to induce a calcified barrier in roots with open apices and to promote the continuation of apical root development. A 7-year-old patient with a coronal fracture in a maxillary central incisor was treated with an apexification technique using calcium hydroxide. The apical closure was obtained after one year, then a permanent root canal filling was performed. The tooth was monitored for a period of 20 years, up to when a trauma caused its extraction. The newly formed root was analyzed macroscopically, histologically and through scanning electron microscopy. A morphologically normal root was observed, with a large apex and accessory foramina, showing a combination of tissue structures similar to secondary and tertiary dentine, close to amorphous mineralized areas. Despite the final evolution of the case, calcium hydroxide apexification is a good therapy in order to treat pulp necrosis in an immature tooth, leading to complete development of the root and allowing the tooth to be kept in the mouth., (Copyright © 2017 Elsevier GmbH. All rights reserved.)

Introduction: Although regenerative treatment approaches in teeth with incomplete root formation and pulp necrosis have become part of the suggested therapeutic endodontic spectrum, little is known about the effect of orthodontic movement in the tissue that has been regenerated. Furthermore, as the number of adults undergoing orthodontic treatment increases, there is an increasing need to investigate the changes that these tissues may undergo during orthodontic movement. Here we describe the alterations observed after the application of orthodontic forces in a case of an apically root-fractured necrotic immature root that had been managed with regenerative endodontic procedures in the past., Methods: A 9-year-old male patient was referred after suffering the third incidence of trauma in the anterior maxilla. Radiographic evaluation revealed a periapical rarefaction associated with an apically root-fractured immature central incisor. Clinical evaluation revealed a buccal abscess and grade 3 tooth mobility. Periodontal probing was within normal limits. The tooth was accessed and disinfected by using apical negative pressure irrigation of 6% NaOCl. Intracanal dentin conditioning was achieved by using 17% EDTA for 5 minutes. A blood clot was induced from the periapical area, and calcium silicate-based cement was placed in direct contact with the blood clot at the same visit. The composite resin restoration was accomplished in the same appointment., Results and Conclusions: Recall radiographic examination after 24 months revealed healing of the periapical lesion and signs of continuous root development despite the apical root fracture. Clinical evaluation revealed normal tooth development, normal mobility, and a resolving buccal infection. The tooth was subjected to orthodontic treatment because of Class II division 1 malocclusion with an overjet of 11 mm. After completion of the orthodontic treatment, 5.5 years after the initial intervention, the radiographic image revealed marked remodeling of the periapical tissues and repair of the apical fractures, and the buccal infection had resolved completely., (Copyright © 2017 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.)

Aims: To determine the efficacy of a single session protocol (SSP) in the reduction of septic content of primary teeth root canals and identify the persistence of bacterial species associated with unsuccessful treatment., Methods: Primary teeth root canals (16) with pulp necrosis and peri-radicular lesions were treated. Samples were collected at baseline (T1), and after chemo-mechanical preparation, before filling (T2). Identification of the microorganisms was determined using checkerboard DNA-DNA hybridisation., Statistical Analysis: Wilcoxon test was applied for comparison of mean number of species, proportion and mean count of each species between the evaluation times., Results: Significant reductions were found in the mean number of bacteria species between T1 and T2 (p < 0.05), but not for the reduction in proportion (p > 0.05). There was a reduction (6.0-4.6) of the mean number of species associated with failure, without statistical significance., Conclusion: The SSP was capable of significantly reducing the septic content, even though, many of the bacteria associated with failure persisted at the time of root canal filling.

Introduction: Intrusive luxation is one of the most severe traumatic injuries of permanent teeth that may adversely affect the pulp and the periodontium. Pulp necrosis and root resorption are the main pathologic entities associated with this injury. The present report describes the endodontic management of an intruded immature maxillary central incisor presented with pulp necrosis and severe inflammatory root resorption by using the regenerative approach., Methods: A 7-year-old boy with dental trauma to the anterior maxillary region was referred for the management of a traumatized maxillary central incisor. Clinical examination revealed an uncomplicated crown fracture, whereas radiographic examination showed that the tooth was immature, confirming the intrusion that was calculated between 3 and 4 mm. The tooth was left to re-erupt, but after 2 months the boy presented with intraoral swelling. Radiographic examination showed initial signs of root resorption. The tooth was treated by using a regenerative endodontic approach., Results: Clinical and radiographic examinations during the initial follow-up period showed resolution of the signs and symptoms as well as inhibition of the resorption process. At the follow-up examinations, the tooth remained free of signs and symptoms and completely functional. The radiographic recall examinations showed a gradual thickening of the root canal walls but incomplete apical closure., Conclusions: The present case shows that severely injured teeth with uncertain prognosis may have a considerable percentage of chance to remain functional and free of signs and symptoms by using a regenerative endodontic procedure, confirming the efficacy of this procedure as a viable treatment option., (Copyright © 2017 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.)

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.

Introduction: A prospective, multicentered, randomized clinical trial was designed to assess if controlled irrigation with cold saline could result in less incidence and intensity of postoperative pain in patients presenting with pulp necrosis and symptomatic apical periodontitis., Methods: A total of 210 patients (presenting with necrotic uniradicular teeth with a diagnosis of symptomatic apical periodontitis and a preoperative visual analog scale (VAS) score higher than 7) were randomly allocated in the control or experimental group after the completion of shaping and cleaning procedures. The experimental group received a final irrigation with 20 mL sterile cold (2.5°C) saline solution delivered to the working length with a sterile, cold (2.5°C) Endovac microcannula (Kerr Endo, Orange Country, CA) for 5 minutes. The same protocol was used in the control group with room temperature saline solution. Patients were instructed to record the presence, duration and level of postoperative pain, and analgesic medication intake. A logistic regression was used to compare the incidence of postoperative pain and the need for painkillers between groups. Differences in general pain intensity between groups were analyzed using the ordinal (linear) chi-square test. Postoperative pain after 6, 24, and 72 hours (recorded in a VAS scale) and the need for analgesic medication intake between the 2 groups were assessed using the Mann-Whitney U test., Results: Patients in the control group presented a significantly higher incidence of postoperative pain, intensity, and need for medication intake (P < .05)., Conclusions: Cryotherapy reduced the incidence of postoperative pain and the need for medication intake in patients presenting with a diagnosis of necrotic pulp and symptomatic apical periodontitis., (Copyright © 2017 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.)

Objective: This clinical study compared the effectiveness of 7- and 14-day intracanal medications in the reduction of bacteria/endotoxins from primarily infected root canals and determined their antigenicity against macrophages through the levels of cytokines., Methods: Seventy-two primarily infected teeth were randomly divided into six groups according to medication and time of application: 7-day groups = G1, Ca(OH) 2 + saline solution (SSL); G2, Ca(OH) 2 + 2% chlorhexidine (CHX) gel; and G3, 2% CHX gel and 14-day groups = G4, Ca(OH) 2 + SSL; G5, Ca(OH) 2 + 2% CHX gel; and G6, 2% CHX gel (all groups, n = 12). Bacterial and endotoxin samples were collected from root canals and inflammatory cytokines of macrophages supernatants. Culture techniques were used to determine bacterial counts and limulus amebocyte lysate (LAL) assay to quantify endotoxins. IL-1β, TNF-α, and PGE 2 were measured by ELISA-assay., Results: With regard to the bacterial reduction, no differences were found between all protocols tested (p > 0.05). The CHX protocols (G3 and G6) exhibited the lowest effectiveness against endotoxins (p < 0.05). All protocols were effective in lowering the levels of IL-1β, TNF-α, and PGE 2 (p < 0.05), with no difference between the medications tested on days 7 or 14 (p > 0.05). Particularly, the 7-day CHX-protocol (G3) exhibited the lowest effectiveness in lowering the levels of most cytokines compared to the 14-day protocols (G6) (p < 0.05)., Conclusions: All the 7- and 14-day intracanal medications were effective in reducing bacteria and endotoxins as well as in lowering the levels of inflammatory cytokines, with CHX showing limited effectiveness against endotoxins. Moreover, 7-day CHX-protocol exhibited the lowest effectiveness in lowering the levels of most cytokines compared to the 14-day protocols., Clinical Significance: Seven-day CHX protocol is the less effective protocol and should be carefully applied by the clinician.

Aim: To evaluate tissue engineering technology to regenerate pulp-dentin like tissues in pulp canals of immature necrotic permanent teeth with apical periodontitis in dogs., Study Design: The study was performed on 36 teeth in 12 dogs. The experiment was carried out using split mouth design. In each dog 3 teeth were selected for implementing the study procedure. Apical periodontitis was induced in Group A and B teeth. Group (A): immature upper left 2 nd permanent incisors that were transplanted with a construct of autologous dental pulp stem cells with growth factors seeded in a chitosn hydrogel scaffold. Group (B): immature upper right 2 nd permanent incisor that received only growth factors with scaffold. A third tooth in each dog was selected randomly for isolation of dental pulp stem cells (DPSCs). Both groups were closed with a double coronal seal of white MTA (Mineral trioxide aggregate) and glass ionomer cement. Both groups were monitored radiographically for 4 months and histologically after sacrificing the animals., Results: There was no statistically significant difference in radiographic findings between group (A) and group (B) for healing of radiolucencies, while there was statistically significant difference between group (A) and group (B) regarding radicular thickening, root lengthening and apical closure. Histologically, group (A) teeth showed regeneration of pulp- dentin like tissue while group (B) teeth did not show any tissue regeneration., Conclusion: Dental pulp stem cells and growth factors incorporated in chitosan hydrogel are able to regenerate pulp- dentine like tissue and help in complete root maturation of non-vital immature permanent teeth with apical periodontitis in dogs.

Aim: To compare the clinical and radiographic success rates of an antibiotic mix consisting of metronidazole, minocycline and ciprofloxacin (3Mix-MP) and another mix where minocycline was replaced with clindamycin (3Mix-MP-R) in non-instrumentation endodontic treatment (NIET) of necrotic primary molars and to determine the effect of root resorption on the success of the treatment., Materials and Methods: Forty-two necrotic mandibular primary molars from 22 healthy children were randomly assigned to either mixture. Blinded clinical evaluation was conducted after 1, 3, 6 and 12 months by the operator, and blinded radiographic evaluation was conducted at 6 and 12 months follow-ups by other two investigators with inter-examiner reproducibility of 0.95., Results: Overall success rates of 3Mix-MP and 3Mix-MP-R were 80.96% and 76.20% respectively, with no statistically significant difference. Radiographically, resorption of more than one third of the root length had a lower failure rate with no statistically significant difference (p<0.5)., Conclusion: Primary teeth with necrotic pulp can be treated with 3Mix-MP or 3Mix-MP-R irrespective of the degree of root resorption.

Purpose: To compare the effect of Nd:YAP laser and Hoshino's triple antibiotic paste on root canal disinfection in the treatment of pulp revascularization, and to provide reference for root canal disinfection in dental pulp revascularization., Methods: Forty immature permanent teeth diagnosed as acute or chronic periapical periodontitis were included. The periapical lesions and root development were recorded. The cases were divided into 2 groups: the control group and the Nd:YAP laser disinfection experimental group. Clinical examination and X-ray evaluation of each case were performed after treatment. Statistical analysis was performed using SPSS 19.0 software package., Results: Two cases showed symptoms in control group 1 week after treatment, while 4 cases had symptoms in the experimental group. The clinical symptoms disappeared in the control group 2 weeks after treatment, while 1 case still had symptoms in the experimental group. There was no significant difference between the two groups (P>0.05). Clinical evaluation at 18 months of follow-up showed that 2 and 3 cases had recurrent symptoms in the control group and the experimental group, respectively; continuous development of the root was noted in 12 and 10 cases on X-ray film in the control and experimental group, respectively, while 3 and 4 teeth had no obvious root development in the control and experimental group, respectively. There was no significant difference between the control group and the experimental group (P>0.05)., Conclusions: Nd:YAP laser can be used for effective root canal disinfection without obvious effect on the prognosis of dental pulp revascularization.

Background: Pulp revascularisation with MTA sealing has been accepted as an alternative treatment for non-vital immature permanent teeth. Successful revascularisation cases with GIC sealing were also reported, but lack of long-term researches., Aim: To evaluate long-term outcomes of revascularisation using MTA and GIC as canal-sealing materials in non-vital immature permanent teeth., Design: Clinical and radiographic data of 60 non-vital immature permanent teeth treated with revascularisation (36.8 ± 12.4 months of follow-up) were reviewed. Of these, 28 teeth were sealed with MTA, and 32 with GIC. Tooth survival, success rate, and increases in root length and dentine wall thickness were evaluated., Results: Teeth in MTA group showed a similar survival rate (96%) to GIC group (100%). The success rate in MTA group (93%) was greater than that in GIC group (59%). Eight of fourteen failed teeth due to recurrent apical disease (seven teeth in GIC group and one in MTA group) achieved complete root development. There was no statistically significant difference in root length or dentine wall thickness increase between the groups., Conclusions: Long-term outcome of revascularisation in non-vital immature permanent teeth sealed with GIC was not as good as that with MTA. Although more recurrent apical disease developed, results on root development were acceptable in GIC sealed cases., (© 2017 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Introduction: The purpose of this prospective study was to compare the success of primary root canal treatment between type 2 diabetic and nondiabetic patients and to investigate the effect of periapical healing on glycated hemoglobin (HbA1c) in type 2 diabetic patients with apical periodontitis., Methods: Sixty mandibular molars with necrotic pulps and apical radiolucency (size ≥ 2 mm × 2 mm) were included in the study. Based on the HbA1c levels, patients were divided into 2 groups: type 2 diabetic (HbA1c ≥6.5%) and nondiabetic (HbA1c <6.5%). Forty-six teeth were evaluated at the 12-month follow-up time period. The primary outcome measure was the change in apical bone density as determined by the periapical index., Results: Both the diabetic and nondiabetic group depicted a significant reduction in the periapical score after endodontic treatment at the 12-month follow-up (P < .05). Significantly less periapical healing was observed in the diabetic group (43%) compared with the nondiabetic group (80%) at the 12-month follow-up (P < .05). HbA1c levels in the diabetic group increased at each follow-up after endodontic treatment., Conclusions: Diabetes mellitus may have a negative impact on the outcome of endodontic treatment in terms of periapical healing. Nonsurgical endodontic treatment did not improve HbA1c levels in patients with type 2 diabetes., (Copyright © 2017 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the matrix metalloproteinase-2 (MMP-2) levels in root-canal exudates from teeth undergoing root-canal treatment., Material and Methods: The root-canal exudates from six teeth with normal pulp and periradicular tissues that required intentional root canal treatment for prosthodontic reasons and from twelve teeth with pulp necrosis and asymptomatic apical periodontitis (AAP) were sampled with paper points for bacterial culture and aspirated for the detection of proMMP-2 and active MMP-2 by gelatin zymography and the quantification of MMP-2 levels by ELISA., Results: By gelatin zymography, both proMMP-2 and active MMP-2 were detected in the first collection of root-canal exudates from teeth with pulp necrosis and AAP, but not from teeth with normal pulp, and their levels gradually decreased and disappeared at the last collection. Consistently, ELISA demonstrated a significant decrease in MMP-2 levels in the root-canal exudates of teeth with pulp necrosis and AAP following root canal procedures (p<0.05). Furthermore, the MMP-2 levels were significantly lower in the negative bacterial culture than those in the positive bacterial culture (p<0.001)., Conclusions: The levels of MMP-2 in root-canal exudates from teeth with pulp necrosis and AAP were gradually reduced during root canal procedures. Future studies are required to determine if MMP-2 levels may be used as a biomolecule for the healing of apical lesions, similar to the clinical application of MMP-8 as a biomarker., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Aim: This clinical study was conducted to investigate the influence of 17% ethylenediaminetetraacetic acid (EDTA) ultrasonic activation after chemomechanical preparation (CMP) on eliminating/reducing oral bacterial lipopolysaccharides (known as endotoxins) and cultivable bacteria in teeth with pulp necrosis and apical periodontitis., Methodology: Samples were taken from 24 root canals at several clinical periods: S1 - before CMP; S2 - after CMP; S3 - after EDTA: G1 - with ultrasonic activation (n = 12) and G2 - without ultrasonic activation (n = 12). Root canals were instrumented using Mtwo rotary files. Culture techniques were used to determine the number of colony-forming units (CFU). Limulus amebocyte lysate (LAL) was used to measure endotoxin levels. Friedman's and Wilcoxon signed-rank tests were used to compare the amount of bacteria and endotoxin levels in each period (P < 0.05)., Results: Endotoxins and cultivable bacteria were recovered in 100% of the initial samples (S1). CMP was effective in reducing endotoxins and bacterial load (all with P < 0.05). Higher values of endotoxin reduction were achieved with EDTA ultrasonic activation [G1, 0.02 EU mL -1 (range 0.01-0.75)] compared with the no activation group [G2, 1.13 EU mL -1 (range 0.01-8.34)] (P < 0.05). Regarding bacterial reduction, no statistically significant difference was found in S3, regardless of the group (G1, G2, P > 0.05)., Conclusions: Chemomechanical preparation was effective in reducing bacteria and endotoxins, but could not completely eliminate them. The ultrasonic activation of EDTA was effective in further reducing endotoxin levels in the root canals of teeth with pulp necrosis and apical periodontitis., (© 2016 International Endodontic Journal. Published by John Wiley & Sons Ltd.)

This is a case report on the management of a vital lateral incisor with a radiolucent cervical area associated with the presence of necrotic pulp due to a dens invaginatus (DI) type III. A nine-year-old boy presented to a university pediatric dental clinic with dental trauma. The examination showed poor oral hygiene, an uncomplicated fracture in the permanent maxillary left central incisor, and a fistula near the permanent maxillary right lateral incisor. A radiograph showed that the right lateral incisor had incomplete root development and a type III DI. Although sensitive to thermal pulp testing, tracing of the fistula indicated that the radiolucent area was associated with the DI, extending laterally to the periodontal ligament. Endodontic treatment was performed only in the invagination, keeping the root canal of the lateral incisor vital. After two years of follow-up, complete root formation and injury repair associated with invagination were observed.

The aim of this scoping study was to evaluate the survival rate and nature of tissue formed inside root canals of human immature permanent teeth with necrotic pulps (NIPT) under root canal revascularization (RCR). The search was performed in SciVerse Scopus®, PubMed/MEDLINE, Web of Science®, BIREME and in the grey literature up to November 2015. The keywords were selected using MeSH terms and DECs. Two independent reviewers scrutinized the records obtained considering specific inclusion criteria. The included studies were evaluated in accordance with a modified Arksey and O' Malley's framework. From 375 studies that were evaluated, 75 were included. A total of 367 NIPT were submitted to RCR, from which only 21 needed further endodontic treatment. The weighted mean follow-up time was 17.6 months. The data were derived mainly from case reports (69%) or small case series (15%). NaOCl [0.5-6%] was applied as the disinfecting solution in almost all studies. Triple antibiotic paste was as effective as Ca(OH) 2 as on intracanal medicament. De novo tissue was cementum and poorly mineralized bone positive to bone sialoprotein (BSP) but negative to dentine sialoprotein (DSP). Failures were associated mainly with reinfection of the root canal. The majority of included studies reported a significant increase in both root length and width. However, as most of these data came from case reports, they must be interpreted with care, as most were focused on treatment successes (not failures). Therefore, well-designed randomized controlled trials comparing RCR with available apexification treatments are needed to address this gap in the literature., (© 2016 International Endodontic Journal. Published by John Wiley & Sons Ltd.)

Aim: The aim of this study is to describe the protocol used in the treatment of pulpally necrosed primary molars and to evaluate the effectiveness of ultrasonic instrumentation technique in primary dentition., Materials and Methods: A total of 50 primary molars in 40 children, ranging from 8 to 10 years of age, were endodonti-cally treated using standard protocols and ultrasonic instrumentation. The follow-up was done for each case ranging from 1 to 2/4 years., Results: Clinical and radiographic controls showed a success rate of 97.5%, considering an evaluation time of 19 ± 9.02 months., Conclusion: The use of ultrasonic instrumentation in primary molars with pulpal necrosis succeeded in reducing appointment time and showed a high success rate., Clinical Significance: Ultrasonic instrumentation should be used as a standard protocol in instrumentation of endodontic treatment of primary molars so as to increase the success rate of primary teeth pulpectomies.

The goal of endodontics is to save teeth. Since inception, endodontic treatments are performed to obturate disinfected root canals with inert materials such as gutta-percha. Although teeth can be saved after successful endodontic treatments, they are devitalized and therefore susceptible to reinfections and fractures. The American Association of Endodontists (AAE) has made a tremendous effort to revitalize disinfected immature permanent teeth in children and adolescents with diagnoses including pulp necrosis or apical periodontitis. The American Dental Association (ADA) in 2011 issued several clinical codes for regenerative endodontic procedures or apical revascularization in necrotic immature permanent teeth in children and adolescents. These AAE and ADA initiatives have stimulated robust interest in devising a multitude of tissue engineering approaches for dental pulp and dentin regeneration. Can the concept of regenerative endodontics be extended to revitalize mature permanent teeth with diagnoses including irreversible pulpitis and/or pulp necrosis in adults? The present article was written not only to summarize emerging findings to revitalize mature permanent teeth in adult patients but also to identify challenges and strategies that focus on realizing the goal of regenerative endodontics in adults. We further present clinical cases and describe the biological basis of potential regenerative endodontic procedures in adults. This article explores the frequently asked question if regenerative endodontic therapies should be developed for dental pulp and/or dentin regeneration in adults, who consist of the great majority of endodontic patients., (Copyright © 2017 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.)

Introduction: Regenerative treatments in necrotic immature teeth are suggested as alternatives to conventional multiple or single-step apexification procedures. Although case reports and case series provide promising results, the treatment protocol is not yet fully established and regenerative procedure might fail. Once failure is encountered, the apexification treatment options still remain., Methods: Repetition of the regenerative procedure after initial revitalization failure has not been suggested yet. Here, 3 cases of failing regenerative endodontic procedures are reported. All 3 cases had been initially treated by single-step disinfection/revascularization procedures. In different time intervals, all cases showed signs of recurrent disease. The first case was managed with renegotiation and apical mineral trioxide aggregate plug placement; the second case was managed with renegotiation and conventional root canal treatment; and the third case was managed with renegotiation, long-term calcium hydroxide disinfection, and repetition of the regenerative endodontic procedure., Results: Two years after the second intervention, all cases were considered successful., Conclusions: Repetition of failed regenerative treatment procedures might be a viable alternative to conventional apexification procedures., (Copyright © 2017 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.)

This case report discusses the successful endodontic treatment of an open apex maxillary right permanent central incisor that had been avulsed and incorrectly replanted in a 7-year-old patient. The tooth was carefully re-extracted followed by cleaning of the alveolar socket and immediate replantation. However, pulp necrosis was diagnosed, and regenerative endodontic treatment was performed. The root canal system was disinfected by passive ultrasonic irrigation with 2.5% sodium hypochlorite. At the first visit, the tooth was repositioned and immobilized with an appropriate semirigid splint. After 14 days, the splint was removed, and the diagnosis of pulp necrosis was confirmed by thermal testing. The root canal was emptied, disinfected, and filled with calcium hydroxide paste, which was left in place for 7 days. At the third visit, calcium hydroxide was removed with hand files and passive ultrasonic irrigation, and the canal was filled with a mixture of double antibiotic paste (metronidazole/ciprofloxacin) and zinc oxide. The antibiotic paste was left in place for 30 days. At the final visit, the paste was removed and the periapical area stimulated with a #80 K-file to encourage clot formation within the pulp cavity. A mineral trioxide aggregate paste cervical plug was placed, and the tooth was restored with glass ionomer cement. Clinical and imaging (radiographic and tomographic) follow-up at 3, 6, 12, and 36 months showed endodontic success with continued root formation., (Copyright © 2017 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.)

This case series evaluated the long-term clinical outcome of nonvital immature teeth treated with mineral trioxide aggregate (MTA) as an apical barrier and an adhesive restoration with or without a fiber post. Eighty-three teeth in 72 patients were treated by the first author with an apical MTA plug and an adhesive restoration of composite resin and in 45 of the 83 teeth 1 or more fiber posts. All of the patients had been referred to the first author's private endodontic practice with at least 1 immature tooth with signs of pulpal necrosis and subsequent apical periodontitis that had been caused by a variety of traumatic dental injuries. Three teeth presented had dens invaginatus. Of 83 teeth, 69 teeth in 60 patients were available for follow-up after 5 to 15 years (recall rate = 83%). The mean follow-up time was 8.29 years. No teeth were lost because of a root fracture. Ninety-six percent (66/69) of the recalled teeth were characterized as healed. Based on periapical radiographs and clinical examination, 96% of teeth treated with the MTA barrier technique and adhesive restorations were characterized as "healed" and were in function after 5 to 15 years (mean = 8.29 years). These results indicate that this is a viable and predictable treatment approach for the long-term success of nonvital immature teeth., (Copyright © 2017 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.)

Background/aim: The concept of regenerative endodontic procedures remains controversial. The aim of this study was to evaluate the histology of the tissues formed in immature animal teeth with necrotic and infected pulps after attempted endodontic regeneration procedures using different scaffolds., Design: A systematic electronic literature search was performed in PubMed, Web of Science, Scopus, EMBASE, DOSS, and Cochrane Library databases. The terms used were a combination of the following: "immature permanent necrotic tooth or teeth" or "open apex or apices" and "regeneration or revitalization or revascularization" and "histology." The inclusion criteria comprised animal studies with histological examination following regenerative endodontics in immature necrotic-infected permanent teeth., Results: From 123 screened studies, 13 met the inclusion criteria. Formation of dentin-like tissue on the dentinal walls was reported in only 4% of teeth treated with blood clot scaffold and 2% treated with blood clot with additional materials. Cementum-like hard tissue was found in 64% of teeth with blood clot, 80% treated with blood clot with additional materials, 50% treated with alternative scaffolds, and 5% that were left empty. Bone-like tissue was reported in 10% of teeth treated with blood clot, 2% treated with blood clot with additional materials, and 4% treated with alternative scaffolds. The tissues in the canal space were found to be connective tissue with infiltration of fibroblast-like cells and blood vessels. Forty-six percent of the studies reported formation of periodontal ligament-like tissues., Conclusions: None of the regeneration protocols resulted in the predictable formation of a true pulp-dentin complex., (© 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background/aim: Complicated crown fractures are relatively common in children where the maintenance of the pulp is especially important in young permanent teeth. The aim of this study was to analyze the pulp prognosis of permanent teeth with complicated crown fractures treated with conservative pulp treatment in adolescents., Material and Methods: Complete dental records of teeth with complicated crown fractures treated with conservative pulp treatment were obtained. The risk of pulp necrosis and infection was evaluated by the Kaplan-Meier method and Cox regression (P<.05). Risk factors included gender, age, time interval between dental injury and treatment, stage of root development, type of pulp treatment, and coronal restoration., Results: The study involved 375 teeth treated with direct pulp capping, partial or coronal pulpotomy, and direct pulp capping retreated by pulpotomy (partial or coronal). The frequency of pulp necrosis and infection was 10.1% (11/109) for partial pulpotomy and 9.8% (22/205) for coronal pulpotomy. There was no difference between partial and coronal pulpotomy (P=.673). The risk of pulp necrosis and infection was not significantly different between pulpotomy (partial and coronal; 33/314, 10.5%) and retreatment by pulpotomy (partial or coronal) after direct pulp capping (2/33, 6.1%; P=.436). However, the frequency of pulp necrosis and infection after direct pulp capping (16/28, 57.1%) was significantly higher than that with pulpotomy (partial or coronal; odds ratio=8.216, P<.001). The time interval between dental injury and treatment did not significantly influence pulp survival after pulpotomy (partial or coronal; P=.312), but the stage of root development had a significant impact (P<.001)., Conclusions: Partial or coronal pulpotomy, employed either as a primary pulp treatment or secondary to emergency pulp capping, had similarly satisfactory pulp survival rates., (© 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Introduction: The aim of this study was to evaluate histologically the newly formed tissues after regenerative endodontic procedures (REPs) in dogs using either a blood clot (BC) or 2 different formulations of a chitosan hydrogel as scaffolds., Methods: Apical periodontitis was induced by inoculating immature teeth with oral plaque in 4 beagle dogs. Teeth (n = 96) were divided into 2 control (n = 20) and 4 test groups (n = 76) according to the treatment: apexification and REPs with BC, sodium hyaluronate:chitosan (HA:CS) scaffolds, or pectin:chitosan (P:CS) scaffolds. All root canals were disinfected with 2.5% sodium hypochlorite and a triple antibiotic paste intracanal medicament before evoked bleeding, clot formation, or scaffold placement. Thirteen weeks after treatment, the animals were sacrificed and the jaw blocks harvested for histologic processing, histomorphometric analysis, and statistical analysis., Results: The lumens of the root canals were completely filled with mineral trioxide aggregate with evidence of a mineralized apical bridge between the root canal walls in 83% of the samples in the apexification group. Vital vascularized tissue was found in the REP groups; apical closure happened in 66.7% of these treatments, and root growth was detected more often as an increase in thickness (85.6%) than in length (45.6%). The greatest amount of mineralized tissue inside the canal was observed in the BC group, with statistical significance compared with the HA:CS and P:CS groups (P < .05). Further histologic evaluation revealed the presence of apical papilla., Conclusions: The addition of chitosan scaffolds to blood in regenerative procedures in dogs did not improve the formation of new mineralized tissues along the root canal walls or the histologic evidence of the regeneration of a pulp-dentin complex., (Copyright © 2017 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.)

Introduction: Two fundamental assumptions for teeth treated with regenerative endodontic procedures (REPs) are (1) that the clinical outcome is comparable with the traditional techniques of calcium hydroxide apexification and mineral trioxide aggregate apical barrier techniques and (2) that REPs will result in further root maturation., Methods: A systematic review of the electronic databases (Scopus, PubMed, and Web of Science) involved a search for studies that used quantitative assessments of root maturation. The search terms were "dental pulp," "regenerative endodontic therapy," "revascularization," and "revitalization." The identified studies were further screened for cohort studies that compared clinical outcomes between teeth treated with REPs and apexification/apical barrier approaches. The primary question under review was framed according to the population, exposure, and outcome format., Results: Of the 368 studies identified by the search, 6 cohort studies used quantitative assessments of any further root maturation after REPs, and a subset of 4 of these cohort studies assessed and compared clinical outcomes between the different treatment approaches., Conclusions: Immature teeth with pulp necrosis treated with REPs generally show further root maturation although the results are variable. Clinical outcomes were similar for both groups. Patient-based criteria such as tooth discoloration, indications for changing the treatment option, and number of treatment appointments are all important for discussion before electing the appropriate treatment plan for the management of immature teeth with pulp necrosis., (Copyright © 2017 American Association of Endodontists. All rights reserved.)

Introduction: Current treatment options for immature permanent teeth with pulpal necrosis include both apexification and regenerative endodontics. The purpose of this study was to survey endodontists on the use of these 2 treatment options., Methods: Surveys were created by using Qualtrics and Teleform software and distributed by using the Salant and Dillman method. Endodontists (n = 1615) in 4 geographically and demographically diverse states, North Carolina, New York, Texas, and California, were surveyed. Data were analyzed by using descriptive statistics and χ 2 analysis. Level of significance was set at 0.05., Results: A 32.9% response rate was obtained. The majority of responders reported that apexification was the treatment of choice when considering the evidence base supporting the treatment (60%) and the predictability of treatment outcome (77.8%). Apexification was also the preferred treatment by 57.3% of respondents when asked to consider patient compliance, by 51.2% when considering the number of required patient appointments, and by 53.3% when considering the likelihood of tooth discoloration. Regenerative endodontics was reported as the preferred treatment by 89% of respondents when considering continued root development and by 66.7% when considering apical closure. The respondents' age and continuing education courses taken were significantly associated with their preferred treatment option., Conclusions: The results of our study indicate that endodontists consider both clinical and patient factors when treating immature teeth with pulpal necrosis. Increase in continuing education options may increase adoption of regenerative endodontic therapy., (Copyright © 2017 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.)

Background/aim: There is a lack of studies of fractures of the alveolar process (FAP). Only five were published in the last 50 years. The aim of this study was to analyze the risk of pulp necrosis and infection (PN), pulp canal obliteration (PCO), infection-related root resorption (IRR), ankylosis-related resorption (ARR), marginal bone loss (MBL), and tooth loss (TL) as well as to identify the possible risk factors for teeth involved in an isolated alveolar process fracture. In the second part, any late complications of the involved teeth were reported in patients who responded to a follow-up examination., Material and Method: This study was a retrospective analysis of 126 patients with 329 traumatized permanent teeth treated in a regional dental trauma clinic. Follow-up examination was performed on 31 (24.6%) patients with 75 (22.8%) teeth. The risks of PN, PCO, RR, MBL, and TL were analyzed using the Kaplan-Meier method. Possible risk factors for PN (stage of root development, fracture position in relation to the root apex, concomitant injury, treatment delay, and antibiotics) were analyzed using univariate and multivariate Cox regression and generalized estimating equation. The level of significance was 5%., Results: Pulp necrosis was observed in 43% of the teeth, and it was significantly associated with the presence of a concomitant injury and complete root formation. PCO was recorded in 2.8%, root resorption (RR, IRR, and ARR) in 4%, MBL in 8%, and TL in 0.6% of the teeth. Thirty-four percent of the teeth were assumed to have normal pulps, but they did not respond to pulp sensibility testing. At the follow-up examination, PN was found in 49%, PCO in 28%, RR (IRR and ARR) in 4%, MBL in 17%, and TL in 5%. Estimated risk after a 5-years follow up was as follows: PN: 48.2% (95% confidence interval (CI): 42.0-54.5), IRR: 7.2 (95% CI: 3.5-10.9), ARR: 33.0% (95% CI: 22.4-43.6), BL: 16.7% (95% CI: 9.6-23.8), TL: 4.0% (95% CI: 0.0-8.5). The following factors significantly increased the risk of PN: mature root development (hazard ratio [HR]: 7.50 [95% CI: 1.84-30.64], P=.005) and concomitant injury (HR: 2.68 [95% CI: 1.76-4.09], P<.001). In a logistic regression model, teeth with mature roots had a threefold risk of becoming non-responsive to pulp testing., Conclusion: Teeth involved in an isolated alveolar process fracture and managed with a conservative treatment approach appear to have a good prognosis. The most common complication was PN which did not negatively affect the survival of the teeth after root canal treatment., (© 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

The endodontic treatment of necrotic primary teeth with missing successors presents a unique clinical challenge. The purpose of this report was to describe the clinical and radiological outcomes of regenerative endodontic treatment (revascularization) of necrotic primary molars. Four infected necrotic primary second molars with missing premolars were treated with a two-visit revascularization protocol. The crowns were restored with amalgam or acid-etch composite resin. The teeth were followed-up clinically and radiographically for 18 months. At six months, all teeth demonstrated radiographic evidence of complete periradicular healing and positive response to cold test, and remained symptomless thereafter.

Background: Dental trauma and deep caries are frequent findings in children and adolescents that may lead to pulp necrosis in young permanent teeth. As a consequence, the root stops its development, and managing these immature teeth becomes challenging due to the presence of open apexes and fragile dentinal walls., Aim: We aimed to carry out a systematic review including a meta-analysis to compare the endodontic treatments available in the management of immature necrotic permanent teeth and determine which one provides the best clinical and radiographic outcomes., Design: The literature was screened via PubMed/MEDLINE, the Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials databases until August 2015 to select randomized clinical trials that compared at least two different treatments regarding immature necrotic permanent teeth comprising clinical and radiographic success as outcome. Two reviewers independently performed the screening and evaluation of the articles. A total of 648 studies were retrieved from the databases, in which only 14 were selected to full-text analysis by the appliance of inclusion criteria. After the exclusion criteria, the remaining seven studies had their data extracted and assessed for bias risk. Pooled-effect estimates were obtained comparing clinical and radiographic success rates among MTA Versus other treatments., Results: Evaluation of clinical (Z = 2.32, P = 0.02, OR = 5.37, 95% CI: 1.29-22.23, I = 0%) and radiographic (Z = 2.45, P = 0.01, OR = 4.31, 95% CI: 1.34-13.82, I = 0%) outcomes favored the MTA (control group) when compared to other endodontic treatments (P < 0.05). No evidence of heterogeneity was detected among the studies (I < 50%), whereas a moderate risk of bias was identified in five of them., Conclusions: Although almost all of the identified studies presented moderate risk of bias, MTA apexification seems to produce overall better clinical and radiographic success rates among the endodontic treatment available in immature necrotic permanent teeth., (© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Introduction: The purpose of this case series was to report the clinical and radiographic results of a pulp regenerative procedure using platelet-rich fibrin (PRF), a second-generation platelet concentrate, in immature teeth with necrotic pulps., Methods: Root canal revascularization using PRF was performed on 4 immature teeth with necrotic pulps. After access cavity preparation, the root canals were irrigated with low concentration sodium hypochlorite solution (1.5% sodium hypochlorite [20 mL/canal, 5 minutes]) and then irrigated with saline (20 mL/canal, 5 minutes). Equal proportions (167 mg) of ciprofloxacin, metronidazole, and cefaclor were mixed and diluted to a final concentration of 1 g/mL. Finally, the canal was sealed with 3-4 mm of a temporary restorative material, and patients were dismissed for 2 to 3 weeks. At the second appointment, 9 mL of the patient's whole blood was obtained and centrifuged to prepare a PRF clot. Canals were irrigated with 17% EDTA, and a sharp spreader was inserted beyond the apex. Then, the PRF clot was placed inside the root canals, and Biodentine (Septodont, Saint-Maur, France) was placed directly over the PRF. The teeth were restored permanently with glass ionomer cement and composite resin., Results: Clinical examinations revealed that all cases were asymptomatic at the recall appointments at 1, 3, 6, 12, and 18 months. Radiographs revealed resolution of the periapical lesions, further root development, and apical closure in all cases., Conclusions: On the basis of the short-term results up to 12 months, PRF clots acted as successful scaffolds for the regeneration of pulpal contents in immature teeth with necrotic pulps., (Copyright © 2016 American Association of Endodontists. All rights reserved.)

Introduction: The treatment of immature necrotic permanent teeth presents several clinical challenges in endodontics. Regenerative endodontic procedures (REPs) permit root development, increased canal wall thickness, and apical closure. This longitudinal cohort study aimed to evaluate the long-term clinical and radiographic outcomes of REPs of immature necrotic permanent teeth over a 30-month period., Methods: This study was performed at the Division of Dentistry of the Montreal Children's Hospital, Montreal, Quebec, Canada. Twenty-eight immature necrotic permanent teeth from 22 patients were included in this study. All teeth were treated with a standardized REP protocol. Patients had follow-up appointments at 1, 2, 3, 6, 12, 18, 24, and 30 months. At each appointment, signs and symptoms were evaluated. Radiographic evaluation was also performed by a calibrated endodontist in order to analyze different parameters., Results: Our results show a high survival rate (96.4%), clinical success (92.8%), and resolution of apical pathology (100%). Significant increases in the average root length (8.1%, P < .0001) and root thickness area (11.6%, P = .03) were observed after 30 months. In the study period, a significant decrease in the apical diameter was also noted, with 30.8% of the cases showing complete apical closure. Teeth with more immature stages of root development had a higher percentage of change in root thickness, length, and apical diameter; however, these results were not statistically significant., Conclusions: Teeth treated with REPs presented resolution of symptoms. Although clinical meaningful change was not achieved in all cases, increased root thickness, root length, and apical closure were observed at 30 months., (Copyright © 2016 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.)

Introduction: This article reports 3 representative cases of interdisciplinary management of a palatogingival groove in maxillary lateral incisors. The development, pathology, and effectiveness of management approaches in cases involving a combined periodontal-endodontic lesion with a palatogingival groove are discussed., Methods: We describe 3 patients with a noncontributory medical history presenting with a chief complaint related to a maxillary incisor and diagnosed with a combined periodontal-endodontic lesion with a palatogingival groove at Seoul National University Dental Hospital, Seoul, Korea., Results: Palatogingival grooves were mostly associated with deep periodontal pockets connected to a periapical lesion. Optional collaborative treatments were performed according to the condition as follows: case 1, root canal treatment (RCT), open flap debridement, odontoplasty, and guided tissue regeneration; case 2, RCT, apicoectomy, open flap debridement, and odontoplasty; and case 3, RCT, crown restoration, root planning, and odontoplasty. After clinical examination and radiographic assessments, the periapical lesion and periodontal deep pocket were successfully resolved with periodontal-endodontic collaborative treatment involving both periodontal surgical procedures (cases 1 and 2) and a nonsurgical procedure (case 3)., Conclusions: Within the limitations of this study, these case reports show that accurate diagnosis of developmental anomalies and elimination of inflammatory irritants are key factors for favorable long-term outcomes., (Copyright © 2016 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.)

Root canal treatment of immature teeth is considered a great challenge for both the dentist and the patient. The thinness of the root canals walls and the lack of an apical barrier leads to unpredictable treatment results. Revascularization is a novel promising treatment option in the field of regenerative endodontics for management of immature necrotic permanent teeth. This case presents a successful treatment of an 8-year-old patient with a partially necrotic, immature permanent mandibular right first molar pulp by revascularization. The revascularization procedure was performed in two appointments using nitrous oxide sedation to reduce the child's anxiety during treatment. Following root canal disinfection with NaOCl, a triple antibiotic paste (ciprofloxacin, metronidazole, and minocycline) was applied into the canal. One week later, induction of bleeding, application of MTA, and tooth restoration using a stainless steel crown were performed. At the subsequent follow-up appointments (3, 9, and 16 months) the tooth was asymptomatic. After 2 years a radiographic assessment revealed complete periapical healing and apical closure, as well as increase in root length and dentin thickness., Conclusion: This case supports the evidence of revascularization as a biological treatment option for the management of necrotic young permanent teeth.

Apical revascularization (AR) and platelet-rich plasma have been used to restore dental pulp vitality in infected immature permanent teeth. Two regenerative therapies are cell transplantation and cell homing. This article updates and benchmarks these therapies with cell homing. A case report concluded that AR increased root length; however, quantitative and statistical assessments disproved this. Regenerative endodontic therapies require prospective clinical trials demonstrating safety and efficacy. These therapies are intrinsically susceptible to procedural and patient variations. Cell homing uses novel molecules that drive therapeutic efficacy, and may be less sensitive to procedural and patient variations., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction: The purpose of this retrospective case series was to investigate the outcome of the revascularization procedure in necrotic immature teeth., Methods: The residents and faculty members at the University of Pennsylvania endodontic department were invited to submit consecutive revascularization cases treated by them, irrespective of the outcome, during the time period of 2009 to 2012. Twenty-eight of 35 submitted necrotic immature teeth met the inclusion criteria. The treatment protocol included minimal instrumentation and irrigation with 3% sodium hypochlorite and 17% EDTA. Triple antibiotic paste was placed for a minimum of 21 days. After blood clot induction, either EndoSequence Bioceramic Putty (Brasseler, Savannah, GA) or mineral trioxide aggregate was placed below the cementoenamel junction, and composite was used as a final restoration. The follow-up period ranged from 7 to 72 months. The outcome was assessed as complete healing (the absence of clinical signs and symptoms, complete resolution of periradicular radiolucency, increase in the root dentin thickness/length, and apical closure), incomplete healing (the absence of clinical signs and symptoms, the periapical lesion completely healed without any signs of root maturation or thickening, the periapical lesion either reduced in size or unchanged with/without radiographic signs of increasing root dentin thickness/length, or apical closure), and failure (persistent clinical signs and symptoms and/or increased size of the periradicular lesion)., Results: Twenty-one of 28 cases (75%) healed completely, 3 cases (10.7%) failed during the observation period and needed further treatment, and 4 cases (14%) presented with incomplete healing., Conclusions: Within the limitation of this study, the outcome of revascularization, wherein healing of periapical periodontitis and maturation of roots occurs, is fairly high, making it a viable treatment option in comparison with apexification., (Copyright © 2016 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.)

The aim of this report is to describe a novel method of revascularization therapy done in a non-vital, immature permanent tooth using Platelet-rich fibrin (PRF),in a recently developed scaffold material to overcome limitations associated with the traditional method of revascularization using natural blood clot. PRF prepared from autologous blood was placed in the root canal and patient was followed up regularly at one, three, six, nine and 12 months for detailed clinical and radiographic evaluation. At 12 months, radiographic examination revealed root elongation, root end closure, continued thickening of the root dentinal walls, obliteration of root canal space, and normal periradicular anatomy. However, more long term prospective trials and histological studies are highly needed before to testify PRF a panacea for the regenerative endodontic therapy in children.