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During this 21st century endodontics is being reinvented and redefined as a result of advances in cellular biology, microscopy and digital technology along with reconceptualization of how to clean and shape root canals. Due to space limitations it would not be possible to explore all the changes in endodontics that are taking place; rather we will touch on just a few which are already in practice.
Keywords: Regenerative endodontics, Endoscopic endodontics, CBCT, SAF. Regenerative Endodontics
Stephen Cohen MA, DDS, FICD, FACD Diplomate, American Board of Endodontics Author: “Pathways of the Pulp” Private practice, California, USA firstname.lastname@example.org
The primary purpose of endodontic therapy is the prevention or treatment of apical periodontitis. Although traditional endodontic procedures treat apical periodontitis by disinfection of the root canal system followed by placing an intracanal restoration (obturation), a biologically based procedure would instead focus on regenerating a functional pulp-dentin complex.1,2 This approach offers the advantage of maintaining normal pulpal function with appropriate formation of secondary or tertiary dentin, and continued immunological and neuronal surveillance of tissue status.3 Thus, biologicallybased regenerative endodontic procedures offer the potential for saving natural teeth that otherwise might be doomed to extraction. The concept of regenerating the pulp-dentin complex is not new. Indeed, more than 50 years ago, Nygaard-Ostby reported several case series of tissue evascularization that were based on the concept of the initial healing event (revascularization) of surgical wounds.4,5 Although a fibrous connective tissue was found in many of his preclinical and clinical endodontic cases, the tissue did not renew the pulp-dentin complex. This is not a surprising outcome given the level of knowledge, materials and instruments available to investigators many years ago. In the intervening decades, several critical advances have occurred that greatly improve the potential for developing regenerative endodontic procedures. For example, the entire field of tissue engineering was only established in the 1990s.6 In contrast to the mechanical philosophy of “revascularization”, where tissue bleeding is thought to be sufficient for healing, the concept of tissue engineering focuses on the three dimensional assembly of the appropriate combination of cells, growth factors and scaffolds to achieve the desired regeneration of a functional pulp-dentin complex. These concepts have been systematically evaluated in the endodontic literature, with studies focused on stem cells,7-10 growth factors11,12 and scaffolds13-15 capable of promoting the differentiation of odontoblastlike cells. This has led to the regeneration of dentin-like structures in some,16 but not all preclinical studies.17 The great challenge going forward is the development and validation of tissue engineering concepts into effective and predictable endodontic therapeutic procedures. Although the full application of tissue engineering principles for clinical regenerative endodontic procedures remains an active area of research, several clinical case studies have already reported success in treating the immature permanent tooth with a necrotic pulp. These teeth often have a very poor prognosis due to the thin dentinal walls and incomplete stage of root development (Figure 1). In these regenerative cases, “success” is defined as restoration of continued root development, lack of signs or symptoms and closure of sinus tracts, if previously present.1 In general, these procedures are conducted
Kenneth Hargreaves DDS, PhD Editor-in-Chief: “Journal of Endodontics” Private practice, Texas, USA email@example.com
Louis Berman DDS, FACD Diplomate, American Board of Endodontics Private practice, USA Berman@annapolisendodontics.com
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in children who present with a diagnosis of pulpal necrosis of a permanent tooth that shows radiographic evidence of partial development. Following informed consent, anesthesia and rubber dam isolation, the tooth is accessed, and generally irrigated with NaOCl and medicated with an antimicrobial agent consisting of either a combination of a triple antibiotic (ciprofloxacin, metronidazole, minocycline)18-22 or Ca(OH)2.23,24 Little to no instrumentation is performed due to the risk of fracturing the very thin dentinal walls. Instead, the disinfection protocol relies on the chemical actions of the irrigants and medicaments. The tooth is then sealed with a temporary restoration and the patient is discharged. The patient is recalled about 3-4 weeks later and the tooth is re-anesthetized, isolated and accessed. At this appointment, a file is inserted a small distance beyond the root length and rotated to stimulate bleeding into the root canal system up to the CEJ; a local anesthetic that does not contain a vasoconstrictor is often used since this facilitates the bleeding step. The tooth is then sealed with mineral trioxide aggregate (MTA) followed by a permanent restoration. The bleeding step reported in these clinical procedures partially addresses the three precepts of tissue engineering since the apical papilla of the developing tooth has a high concentrations of post-natal mesenchymal stem cells10, 25 permitting delivery of the stem cells into the root canal system. In addition, the blood clot (fibin polymer) serves as a scaffold and both dentin and platelets provide sources of certain growth factors. Although this clinical procedure at least partially addresses the concepts of tissue engineering, the explicit application of cells, growth factors and scaffolds will likely be required to predictably regenerate a pulp-dentin complex in somewhat more mature teeth. A recent retrospective study compared the radiographic outcomes (dentinal wall thickness at the apical third and root length) of 48 regenerative endodontic cases to 40 control cases consisting of either MTA apexification or conventional non-surgical root canal treatment.21 The data were analyzed as the percent increase in dentinal wall thickness (or root length) by comparing preoperative values to the post-operative recall values. The results (Figure 2) indicate that antimicrobial treatment consisting of either the triple antibiotic paste and the Ca(OH)2 treatment lead to continued radiographic development of the immature tooth. In contrast, the results do not support the use of formocresol for this treatment. Secondary analyses of these data indicated that the follow-up time should be at least 12-18 months before an interpretation of clinical success can be made (and 36 months provides even stronger evidence for clinical interpretation) and that the level of placement of Ca(OH)2 is critical; this material should be retained within the coronal half of the root canal system since placement into the apical half greatly reduces clinical success.
In general, these regenerative endodontic procedures are well tolerated. However, some adverse events and technical challenges have been discussed.19, 20, 26 First, the triple antibiotic paste may cause staining of the crown, possibly due to the minocycline component. Although this can be managed clinically using a walking bleach procedure, it is important to minimize this potential problem by careful placement below the CEJ. Second, the MTA barrier is placed over the immature blood clot and this can lead to diffusion of the material into the root canal system, particularly given the long setting time of MTA. This can be prevented by placing a collagen plug over the blood clot prior to placement of the MTA. Third, as discussed above, the use of a local anesthetic that does not contain a vasoconstrictor greatly facilitates the ability to stimulate bleeding into the root canal system. Fourth, even with this anesthetic, it is occasionally quite difficult to stimulate bleeding into the root canal system. Interestingly, radiographic
(Fig. 1-a) Radiographic image showing an incompletely developed apex and a periradicular radiolucency of tooth #29. Note the gutta percha cone in the sinus tract that traces to the apex of tooth #29.
(Fig. 1-b) Photograph of a purulent hemorrhagic exudate discharged from tooth #29.
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success has been reported in cases that were disinfected but without generation of clinical bleeding into the root canal system26 and even in a case where the root canal system was obturated by conventional endodontic procedures.10 This suggests that the disinfection of the root canal system is critically important and that a stem
(Fig. 1-c) Radiograph showing the placement of MTA over a collagen plug.
(Fig. 2-a) Percentage change in root length from preoperative image to postoperative image, measured from the CEJ to the root apex. ***P < .001 versus MTA apexification control group (n = 20) and NSRCT control group (n = 20). (1) P < .05 versus MTA control group only. Median values for each group are depicted by horizontal line, and individual cases are indicated by the corresponding symbol.
(Fig. 1-d) 3-month recall. A slight increase of the thickness of the root canal wall and continued development of the apex are observed.
(Fig. 1-e) Two years later showing continued root development. Reproduced with permission from Jung, Lee and Hargreaves, J Endod 34:876, 2008.
(Fig. 2-b) Percentage change in dentinal wall thickness from preoperative image to postoperative image, measured at the apical third of the root (position of apical third defined in the preoperative image). ***P < .001 versus MTA apexification control group and NSRCT control group. (2) P < .05 versus NSRCT control group only. (3) P < .05 versus Ca(OH)2 and formocresol groups. (4) P < .05 versus NSRCT control group only. Reproduced with permission from Bose, Nummikoski and Hargreaves, J Endod 35:1343, 2009.
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cell source in the periradicular tissues are critical for root development. Clearly, regenerative endodontics is a field of active research that is dynamically growing in both basic research and clinical applications. Future developments have potential to revolutionize the practice of endodontics, possibly saving many teeth that would otherwise have a poor to hopeless prognosis. Although current case reports focus on applying these methods to the immature teeth with a necrotic pulp, it will be particularly interesting to apply the best lessons learned to the future application of regenerative endodontic procedures on the fully formed permanent tooth.
Successful surgical and non-surgical endodontics have one important concept in common: visualization is essential. For non-surgical endodontics, canals orifices, many of which are often less than .1mm in diameter, need to be visualized and negotiated through an access opening that may be less than 3mm in width or length. For surgical endodontics, visual differentiation between bone and root is imperative with apical root preparation and restoration often being a visualization challenge. Historically, loupes on eyeglasses allowed for magnification of 3-4 power. In the early 1990s, surgical operating microscopes (SOM) were introduced to endodontics, and presently all specialty programs certified by the American Dental Association require advanced training in the use of surgical operating microscopes. Magnification, with a directed light source, typically can be as low as 4X and as high as 25X. This outstanding visualization allows for better canal negotiation with less tooth structure removal as well as the visualization of cracks, fractures, restorative and resorption defects. For surgical endodontics, more precision is offered allowing for better location of key anatomic structures. When evaluating the success of surgical endodontic procedures using more contemporary techniques, including the use of surgical microscopy, a recent investigation yielded almost 50% greater success over using more traditional techniques.27 There are several problems that the clinician has to overcome when using a dental operating microscope. Specifically, the DOM is large and often cumbersome over the patient. It must be mounted on the ceiling or on an adjacent wall; there are also portable DOMs, which can occupy an excessive amount of floor space. For the dental assistant viewing during procedures, a separate ocular is required; when the clinician needs to reposition the microscope for better visualization, the position of the assistant’s ocular will also be changed. The DOM often has difficulty visualizing areas lateral to the long axis of the tooth, especially during surgical procedures, often requiring the patient to reposition their head or to have the DOM positioned in a direction that might be
(Fig. 3-a) Endoscopic probe with light-transmitting and image-transmitting elements incorporated into a flexible protective sleeve attached to a handle.
(Fig. 3-b) Endoscopic probe with light-transmitting and image-transmitting elements incorporated into a flexible protective sleeve attached to a handle.
(Fig. 4) The light source emanates from a central source and the images are directed from the probe to the central source for viewing and storing.
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uncomfortable for the surgeon. In addition, the depth of field is fixed; requiring repeated re-focusing when attempting to visualize objects inside or outside the field of view. The advent of endoscopy as an adjunct for endodontic diagnosis began in the early 1970s.28-31 Endoscopy facilitates the use of a fiber optic probe to explore internal and external components of the root canal and adjacent structures. Images taken via the handheld probe are projected onto a video monitor for imaging purposes. Besides superb visualization with no issue of depth of field focusing, the images can be archived and reviewed as single images or videos. The endoscopic probe can be maneuvered into areas that would otherwise not be practical with a surgical microscope, which would be especially useful during endodontic surgery or for finding canals during nonsurgical endodontic treatment. Besides aiding the clinician in diagnosis and procedures, there is enhanced communication between the doctor and patient because the patient can see what the doctor can image. The configuration of the endoscope involves an endoscopic probe with light-transmitting and imagetransmitting elements incorporated into a flexible protective sleeve attached to a handle (Figure 3). The light source emanates from a central source and the images are directed from the probe to the central source for viewing and storing (Figure 4). For certain applications, an empty micro-lumen channel is present in the handle and probe for the integration of forceps and other devices for operating use. Therefore, the endodontic endoscope permits to visualize, irrigate, and clean and shape the root canal at the same time. Presently, the dental operating microscope is considered by most endodontists to be the standard for visualization for surgical and non-surgical endodontics. However, newer technology involving endoscopic visualization might change how endodontic procedures are performed and ultimately increase overall clinical success.32
an inability to visualize pathoses three dimensionally. In addition, bony lesions are often not visible if they are only confined to cancellous bone. They might not be radiographically detected until the bone loss extends into the internal junction of the cancellous and cortical bone.33,34 Therefore, three dimensional imaging can often provide an earlier detection of lesions in the bone. Three dimensional radiography has been used in medicine for about 30 years using a large field of vision imaging with computerized axial tomography scans known as CAT scans.35 More recently, as computer and radiographic technology have become more advanced and affordable, this technology has entered the dental market as CBCT (cone beam computerized tomography).36 These devices are similar to conventional panoramic radiography whereby a cone shape radiographic beam is directed to a target area and the image is captured on a reciprocating sensor on the opposite side of the target. The captured digital information is digitally interpreted and displayed as either slices of the targeted area or reconstructed to provide a three dimensional image. In an investigation37 which examined “endodontic problems” in 48 teeth, radiographic evidence of pathosis was detected in 32 of these teeth using convention radiography; but when evaluated with CBCT, the radiologists were able to find demonstrable lesions in 42 of the teeth. In a series of case reports, Cotton et al.38 presented situations whereby CBCT was essential is making diagnoses when anatomic structures mimicked endodontic pathosis, like an enlarged incisive canal. Using CBCT, they were also able to better visualize the extent of root fractures, internal resorption, invasive cervical resorption, a failed implant, and an assessment of critical anatomy associated with the apex of a tooth that had paresthesia following endodontic treatment. Although Simon et al.39 attempted to correlate the radiographic findings of CBCT when comparing cysts and granulomas to histologic findings, a more recent investigation found CBCT imaging not reliable in differentiating radicular cysts from granulomas. Surgical biopsy with histopathological evaluation still remains the only way to differentiate a radicular cyst from granuloma.40 CBCT should not be seen as a substitute for traditional dental radiographs. Periapical radiographs have the advantage for allowing the visualization of a given area in one image. Although CBCT can give outstanding visualization without the superimposition of any anatomic structures, it also gives us this information only as a “slice” of the area which may not give all of the pertinent details if the “slice” is not where the pathosis presents. The future for CBCT is very promising in dentistry and especially for endodontic diagnosis and appropriate treatment.
Cone Beam Computerized Tomography
Dental radiography provides extensive information necessary for endodontic diagnosis and treatment planning. The useful information obtained typically relates to irregularities in hard tissues such as root and bone resorption, root configurations, canal morphology, presence of caries and restorations, and the assessment of associated alveolar bone and root fractures. Traditionally, two-dimensional dental radiography, using either film based or digital imaging, has been utilized for these examinations. Although the diagnostic value is indisputable, unfortunately there are many limitations with traditional dental radiography such as the obstruction from associated anatomic structures and
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Traditionally, root canals are cleaned and shaped by alternating between irrigating (usually with sodium hypochlorite) and then hand and/or rotary filing with a stainless steel hand file or a NiTi (nickel-titanium) rotary instrument. Until now this has been the Standard of Care. Hand files and rotary instruments have two things in common: 1- they have a central core of metal; 2- they occasionally break inside the canal! Additionally the clinician has to alternate between putting down the irrigating syringe to place the shaping instruments, and then back to the irrigating syringe, etc. Imagine if these functions could be combined into a single instrument that could irrigate the canal, shape the canal………… and not break! Is this possible? Yes!
The SAF Instrument™, a New Concept in Cleaning and Shaping Root Canals
The introduction of newer technologies and concepts briefly described here will dramatically improve how we provide endodontic therapy. Indeed, the application of regenerative treatment will ultimately require that we even redefine the specialty of Endodontics requiring clinicians to acquire new skills through continuing education.
1. 2. 3. 4. 5. 6. 7.
(Fig. 5) SAF instrument™
The SAF instrument™ officially debuted at the 2010 annual session of the American Association of Endodontists. This unique instrument has no central core, rather it consists of a hollow thin cylindrical nickeltitanium lattice that adapts to the cross-section of the root canal (Figure 5) regardless of its cross-sectional shape. After the canal has been opened initially to a #20 file, the SAF is inserted into the canal and, with an upand-down reciprocal motion, the coarse-filing threads expand to fill the entire canal while simultaneously irrigating the entire length of the canal with the irrigating solution (Figure 6).
12. 13. 14.
(Fig. 6) Reservoir with the irrigating solution attached to the SAF system.
Hargreaves KM, Giesler T, Henry M, Wang Y. Regeneration potential of the young permanent tooth: what does the future hold? Journal of endodontics. 2008;34(7 Suppl):S51-6. Murray PE, Garcia-Godoy F, Hargreaves KM. Regenerative endodontics: a review of current status and a call for action. Journal of endodontics. 2007;33(4):377-90. Hargreaves KM, Law A. Regenerative Endodontics. In: Hargreaves KM, Cohen S, Berman L, editors. Cohen’s Pathways of the Pulp. 10 ed. St Louis, MO: Mosby; 2010. Nygaard-Østby B. The role of the blood clot in endodontic therapy. An experimental histologic study. Acta Odont Scand. 1961;19:323-53. Nygaard-Østby B, Hjortdal O. Tissue formation in the root canal following pulp removal. Scandinavian journal of dental research. 1971;79(5):333-49. Langer R, Vacanti JP Tissue engineering. Science. . 1993;260(5110):920-6. Zhang C, Chang J, Sonoyama W, Shi S, Wang CY. Inhibition of human dental pulp stem cell differentiation by Notch signaling. Journal of dental research. 2008;87(3):250-5. Huang GT, Gronthos S, Shi S. Mesenchymal stem cells derived from dental tissues vs. those from other sources: their biology and role in regenerative medicine. Journal of dental research. 2009;88(9):792-806. Huang GT. Pulp and dentin tissue engineering and regeneration: current progress. Regen Med. 2009;4(5):697-707. Huang GT, Sonoyama W, Liu Y, Liu H, Wang S, Shi S. The hidden treasure in apical papilla: the potential role in pulp/dentin regeneration and bioroot engineering. Journal of endodontics. 2008;34(6):645-51. Okamoto Y, Sonoyama W, Ono M, Akiyama K, Fujisawa T, Oshima M, et al. Simvastatin induces the odontogenic differentiation of human dental pulp stem cells in vitro and in vivo. Journal of endodontics. 2009;35(3):367-72. Huang GT, Shagramanova K, Chan SW. Formation of odontoblast-like cells from cultured human dental pulp cells on dentin in vitro. Journal of endodontics. 2006;32(11):1066-73. Gebhardt M, Murray PE, Namerow KN, Kuttler S, Garcia-Godoy F. Cell survival within pulp and periodontal constructs. Journal of endodontics. 2009;35(1):63-6. Goldberg M, Six N, Chaussain C, DenBesten P Veis A, Poliard , A. Dentin extracellular matrix molecules implanted into exposed pulps generate reparative dentin: a novel strategy in regenerative dentistry. Journal of dental research. 2009;88(5):396-9. Wei X, Ling J, Wu L, Liu L, Xiao Y. Expression of mineralization markers in dental pulp cells. Journal of endodontics. 2007;33(6):703-8. Huang GT, Yamaza T, Shea LD, Djouad F, Kuhn NZ, Tuan RS, et al. Stem/Progenitor cell-mediated de novo regeneration of dental pulp with newly deposited continuous layer of dentin in an in vivo model. Tissue engineering. 2010;16(2):605-15. Wang X, Thibodeau B, Trope M, Lin LM, Huang GT. Histologic characterization of regenerated tissues in canal space after the revitalization/revascularization procedure of immature dog teeth with apical periodontitis. Journal of endodontics. 2010;36(1):56-63. Thibodeau B, Trope M. Pulp revascularization of a necrotic infected immature permanent tooth: case report and review of the literature. Pediatric dentistry. 2007;29(1):47-50.
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19. Petrino JA, Boda KK, Shambarger S, Bowles WR, McClanahan SB. Challenges in Regenerative Endodontics: A Case Series. Journal of endodontics. 2010;36(3):536-41. 20. Ding RY, Cheung GS, Chen J, Yin XZ, Wang QQ, Zhang CF. Pulp revascularization of immature teeth with apical periodontitis: a clinical study. Journal of endodontics. 2009;35(5):745-9. 21. Bose R, Nummikoski P Hargreaves K. A retrospective , evaluation of radiographic outcomes in immature teeth with necrotic root canal systems treated with regenerative endodontic procedures. Journal of endodontics. 2009;35(10):1343-9. 22. Banchs F, Trope M. Revascularization of immature permanent teeth with apical periodontitis: new treatment protocol? Journal of endodontics. 2004;30(4):196-200. 23. Chueh LH, Huang GT. Immature teeth with periradicular periodontitis or abscess undergoing apexogenesis: a paradigm shift. Journal of endodontics. 2006;32(12):1205-13. 24. Chueh LH, Ho YC, Kuo TC, Lai WH, Chen YH, Chiang CP . Regenerative endodontic treatment for necrotic immature permanent teeth. Journal of endodontics. 2009;35(2):160-4. 25. Sonoyama W, Liu Y, Yamaza T, Tuan RS, Wang S, Shi S, et al. Characterization of the Apical Papilla and Its Residing Stem Cells from Human Immature Permanent Teeth: A Pilot Study. Journal of endodontics. 2008;34(2):166-71. 26. Jung IY, Lee SJ, Hargreaves KM. Biologically based treatment of immature permanent teeth with pulpal necrosis: a case series. Journal of endodontics. 2008;34(7):876-87. 27. Tsesis I, Rosen E, Schwartz-Arad D, Fuss Z. Retrospective evaluation of surgical endodontic treatment: traditional versus modern technique. J Endod. 2006;32(5):412-6. 28. Del Fabbro M, Taschieri S, Lodi G, Ban G, Weinstein RL. Magni cation devices for endodontic therapy. Cochrane Database Syst Rev. 2009;8(3):CD005969. 29. D etsch SG, Cunningham WT, Langloss JM. Endoscopy as an aid to endodontic diagnosis. J Endod. 1979;5(2):60-2. 30. Bahcall JK, Barss JT. Orascopy: a vision for the new millennium, Part 2. Dent Today. 1999;18(9):82-5. 31. Mines P Loushine RJ, West LA, Liewehr FR, Zadinsky JR. , Use of the microscope in endodontics: a report based on a questionnaire. J Endod. 1999;25:755-8. 32. Taschieri S, Del Fabbro M. Endoscopic endodontic microsurgery: 2-year evaluation of healing and functionality. Braz Oral Res. 2009;23(1):23-30. 33. Bender IB, Seltzer S: Roentgenographic and direct observation of experimental lesions in bone I, J Am Dent Assoc. 1961;62:152. 34. Bender IB, Seltzer S: Roentgenographic and direct observation of experimental lesions in bone II, J Am Dent Assoc. 1961;62:708. 35. Robb RA, Sinak LJ, Ho man EA, Kinsey JH, Harris LD, Ritman EL: Dynamic volume imaging of moving organs. J Med Syst. 1982;6:539-54. 36. Mozzo P Proccacci A et al. : A new volumetric CT machine , for dental imaging based on the cone-beam technique: preliminary results. Eur Radiol. 1998;8:1558-64. 37. Lofthag-Hansen S, Huumonen S, Grondahl K, Grondeh HG: Limited cone-beam CT and intraoral radiography for the diagnosis of periapical pathology. Oral Surg, Oral Med Oral Pathol Oral Radio Endod. 2007;103(1):114-9. 38. Cotton TP Geisler TM, Holden DT, Schwartz SA, Schindler , W: Endodontic Applications of Cone-Beam Volumetric Tomography. J Endod. 2007;33(9):1121-32. 39. Simon JH, Enciso R, Malfaz JM, et al. : Di erential diagnosis of large periapical lesions using cone-beam computed tomography measurements and biopsy. J Endod. 2006;32:833-7. 40. Rosenberg PA, Frisbie J, Lee J, Lee K, et al. : Evaluation of Pathologists (Histopathology) and Radiologists (Cone Beam Computed Tomography) Di erentiating Radicular Cysts from Granulomas. J Endod. 2010;36:423-8.
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