Clinical Challenges in Regenerative Endodontic Therapy: A Review
Keywords:
Disinfection, Immature teeth, Regenerative endodontic therapy, Scaffolds, Stem cellsAbstract
Regenerative endodontic therapy (RET) has drawn a great deal of interest and is widely recognized because it preserves the function and endurance of teeth. Although it is routinely performed on immature teeth with periapical disease, the treatment outcomes remain unpredictable. Instead of producing fibrous connective tissue and amorphous mineral deposits, pulp-dentin regeneration should be the real benchmark of RET. Still, we have not yet achieved the benchmark of full innervation and vascularization of the generated tissue in the root canal. The main challenges faced with the current clinical protocol of RET are the complete disinfection of root canal space and enhancing pulplike tissue regeneration. This article will address the key challenges and strategies that focus on realizing the goal of regenerative endodontic therapy
Downloads
References
1. Iwaya SI, Ikawa M, Kubota M. Revascularization of an immature permanent tooth with apical periodontitis and sinus tract. Dent Traumatol 2001;17:185-7.
2. Li L, Pan Y, Mei L, Li J. Clinical and radiographic outcomes in immature permanent necrotic evaginated teeth treated with regenerative endodontic procedures. J Endod 2017;43:246-51.
3. Saoud TMA, Sigurdsson A, Rosenberg PA, et al. Treatment of a large cystlike inflammatory periapical lesion associated with mature necrotic teeth using 76 regenerative endodontic therapy. J Endod 2014;40:2081-6.
4. Diogenes A, Hargreaves KM. Microbial modulation of stem cells and future directions in regenerative endodontics. J Endod 2017;43:S95-101.
5. Diogenes A, Ruparel NB, Shiloah Y, et al. Regenerative endodontics: a way forward. J Am Dent Assoc 2016;147:372-80.
6. Trevino EG, Patwardhan AN, Henry MA, et al. Effect of irrigants on the survival of human stem cells of the apical papilla in a platelet-rich plasma scaffold in human root tips. J Endod 2011 37(8):1109-15.
7. Verma P, Nosrat A, Kim JR, et al. Effect of residual bacteria on the outcome of pulp regeneration in vivo. J Dent Res 2017;96:100-6.
8. Fang Y, Wang X, Zhu J, et al. Influence of apical diameter on the outcome of regenerative endodontic treatment in teeth with pulp necrosis: a review. J Endod 2018;44:414-31.
9. Carvalho TS, Lussi A. Age-related morphological, histological and functional changes in teeth. J Oral Rehabil 2017;44:291-8.
10. Pinchi V, Forestieri AL, Calvitti M. Thickness of the dental (radicular) cementum: a parameter for estimating age. J Forensic Odontostomatol 2007;25:1-6.
11. Ostby BN. The role of the blood clot in endodontic therapy. An experimental histologic study. Acta Odontol Scand 1961;19:324-53.
12. Nygaard-Ostby B, Hjortdal O. Tissue formation in the root canal following pulp removal. Scand J Dent Res1971;79:333-49.
13. Banchs F, Trope M. Revascularization of immature permanent teeth with apical periodontitis: New treatment protocol? J Endod 2004;30:196-200.
14. Almutairi W, Yassen GH, Aminoshariae A, et al. Regenerative endodontics: a systematic analysis of the failed cases. J Endod 2019;45:567-77.
15. Fouad AF. Microbial factors and antimicrobial strategies in dental pulp regeneration. J Endod 2017;43:S46-50.
16. Mohammadi Z. Sodium hypochlorite in endodontics: an update review. Int Dent J 2008;58(6):329-41.
17. Galler KM, Buchalla W, Hiller KA, et al. Influence of root canal disinfectants on growth factor release from dentin. J Endod 2015;41:363-8.
18. Galler KM, Widbiller M, Buchalla W, et al. EDTA conditioning of dentine promotes adhesion, migration and differentiation of dental pulp stem cells. Int Endod J 2016;49:581-90.
19. Kim SG, Malek M, Sigurdsson A, et al. Regenerative endodontics: a comprehensive review. Int Endod J 2018;51:1367-88.
20. Portenier I, Haapasalo H, Rye A, et al. Inactivation of root canal medicaments by dentine, hydro-xylapatite, and bovine serum albumin. Int Endod J 2001;34:184-8.
21. Diogenes AR, Ruparel NB, Teixeira FB, et al. Translational science in disinfection for regenerative endodontics. J Endod 2014;40:S52-7.
22. Ruparel NB, Teixeira FB, Ferraz CC, et al. Direct effect of intracanal medicaments on survival of stem cells of the apical papilla. J Endod 2012;38(10):1372-5.
23. Karczewski A, Feitosa SA, Hamer EI, et al. Clindamycin-modified triple antibiotic nanofibers: a stain-free antimicrobial intracanal drug delivery system. J Endod 2018;44:155-62.
24. Arruda MEF, Neves MAS, Diogenes A, et al. Infection control in teeth with apical periodontitis using a triple antibiotic solution or calcium hydroxide with chlorhexidine: a randomized clinical trial. J Endod 2018;44:1474-9.
25. Phumpatrakom P, Srisuwan T. Regenerative capacity of human dental pulp and apical papilla cells after treatment with a 3-antibiotic mixture. J Endod 2014;40:399-405.
26. Vishwanat L, Duong R, Takimoto K, et al. Effect of bacterial biofilm on the osteogenic differentiation of stem cells of apical papilla. J Endod 2017;43:916-2.
27. Ikeda E, Tsuji T. Growing bioengineered teeth from single cells: Potential for dental regenerative medicine. Expert Opin Biol Ther 2008;8:735-44.
28. Huang GT-J, Gronthos S, Shi S. Mesenchymal stem cells derived from dental tissues vs. those from other sources. Their biology and role in regenerative medicine. J Dent Res 2009; 88(9):792-806.
29. Lovelace TW, Henry MA, Hargreaves KM, et al. Evaluation of the delivery of mesenchymal stem cells into the root canal space of necrotic immature teeth after clinical regenerative endodontic procedure. J Endod 2011;37(2):133-8.
30. Gay IC, Chen S, MacDougall M. Isolation and characterization of multipotent human periodontal ligament stem cells. Orthod Craniofac Res 2007; 10(3):149-60.
31. Scadden DT. The stem-cell niche as an entity of action. Nature 2006;441(7097):1075-9.
32. Chmilewsky F, Jeanneau C, Dejou J, et al. Sources of dentin-pulp regeneration signals and their modulation by the local microenvironment. J Endod 2014;40(4):S19-25.
33. Conboy IM, Conboy MJ, Wagers AJ, et al. Rejuvenation of aged progenitor cells by exposure to a young systemic environment. Nature 2005;433(7027):760-4.
34. Galler KM, D’Souza RN, Hartgerink JD, et al. Scaffolds for dental pulp tissue engineering. Adv Dent Res 2011;23(3):333-339.
35. Ulusoy AT, Turedi I, Cimen M, et al. Evaluation of Blood Clot, Platelet-rich Plasma, Platelet-rich Fibrin, and Platelet Pellet as Scaffolds in Regenerative Endodontic Treatment: A Prospective Randomized Trial. J Endod 2019;45(5):560-566.
36. Mehta S, Watson JT. Platelet rich concentrate: basic science and current clinical applications. J Orthop Trauma 2008;22(6):432-8.
37. Petrino JA, Boda KK, Shambarger S, et al. Challenges in regenerative endodontics: a case series. J Endod 2010;36(3):536-41.
38. Lenzi R, Trope M. Revitalization procedures in two traumatized incisors with different biological outcomes. J Endod 2012;38:411-4.
39. Hargreaves KM, Giesler T, Henry M, et al. Regeneration potential of the young permanent tooth: what does the future hold? J Endod 2008;34(7 Suppl):S51-6.
40. Keswani D, Pandey RK. Revascularization of an immature tooth with a necrotic pulp using platelet-rich fibrin. Int Endod J 2013;46:1096-104.
41. Torabinejad M and Turman M. Revitalization of tooth with necrotic pulp and open apex by using platelet-rich plasma: a case report. J Endod 2011;37(2):265-268.
42. Dohan Ehrenfest DM, Del Corso M, Diss A et al. Three-dimensional architecture and cell composition of a Choukroun’s platelet-rich fibrin clot and membrane. J Periodontol 2010;81(4):546-55.
43. Shivashankar VY, Johns DA, Maroli RK, et al. Comparison of the effect of PRP, PRF and induced bleeding in the revascularization of teeth with necrotic pulp and open apex: a triple blind randomized clinical trial. J Clin Diagn Res 2017;11(6):ZC34-ZC39.
44. Murray PE. Platelet-rich plasma and platelet-rich fibrin can induce apical closure more frequently than blood-clot revascularization for the regeneration of immature permanent teeth: a metaanalysis of clinical efficacy. Front Bioeng Biotechnol 2018;6:139.
45. Chai J, Jin R, Yuan G, et al. Effect of liquid platelet-rich fibrin and platelet-rich plasma on the regenerative potential of dental pulp cells cultured under inflammatory conditions: a comparative analysis. J Endod 2019;45(8):1000-8.