Regenerative Endodontics
Microbial Factors and Antimicrobial Strategies in
Dental Pulp Regeneration
Ashraf F. Fouad, DDS, MS
Abstract
Dental pulp regeneration after pulp necrosis in immature
teeth represents a major departure from traditional end-
odontic therapy of these conditions. Preliminary clinical
attempts have shown the feasibility of developing
mineralized repair tissue, which may provide a clinically
acceptable outcome. However, this outcome may not
provide sufficient host response and root strength to
ensure the longevity of the involved teeth. It is not clear
if these preliminary suboptimal results are caused by the
inability to fully disinfect the pulp space or the absence
of a suitable progenitor cell/scaffold template together
with adequate vascularity. Moreover, it is not known
to what degree the root canal system needs to be
disinfected in order for clinical success to be evident.
This article describes the current clinical strategies and
protocols for the optimal disinfection and preparation
of the pulp space environment to promote periapical
healing as well as soft and hard tissue development
after an infectious process. Current and future strategies
for disinfecting the pulp space with minimal disruption
of the necessary biological factors from dentin, the
progenitor cells in periapical vital tissues, and the vascu-
larity are discussed. The potential for success of pulp
regeneration after necrosis and infection would trans-
form the practice of endodontics, even for mature teeth.
This is a goal worth pursuing because it would achieve
the restoration of normal host responses in the pulp
space and the regeneration of destroyed dental tissues.
(J Endod 2017;-:1–5)
Key Words
Antibiotics, bacteria, endodontic infections, pulp regen-
eration
From the Department of Endodontics, School of Dentistry, University of North Carolina, Chapel Hill, North Carolina.
Address requests for reprints to Dr Ashraf F. Fouad, Department of Endodontics, School of Dentistry, University of North Carolina, 1098 First Dental Building, CB#
7450, Chapel Hill, NC 27599-7450. E-mail address: afouad@email.unc.edu
0099-2399/$ - see front matter
Copyright ª 2017 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2017.06.010
JOE — Volume -, Number -, - 2017
D ental pulp revasculari-
zation after irrevers-
ible pulpitis or pulp
Significance
Considerable amount of information is now avail-
able on the methods of root canal disinfection, in
necrosis is not a new
preparation for regenerative endodontic proced-
concept or practice. For
ures. This paper discusses the importance of
decades, it has been
optimal root canal disinfection, as well as recent
known that, in the absence
evidence for the efficacy of the different protocols,
of infection, in immature
materials, and concentrations that have been
teeth or a widened apical
investigated.
foramen, the dental pulp
can be promoted to grow
back into the root canal. This may occur after devitalization caused by pulp extirpation
(1), trauma and replantation (2, 3), or autotransplantation (4). There is also older
experimental evidence in animal models that show in extracted apicoectomized and
replanted or autotransplanted teeth vascular networks reach the pulp horns within
30 days (5–7). The pulp in similarly treated teeth with mature apex became necrotic.
Other animal model work showed success of revascularization with collagen/calcium
phosphate gel scaffolds (8). One animal study showed success of revascularization after
complete removal of the original pulp tissue after 1 week of cryopreservation (9). In this
study, revascularization was similar in immature or mature apicoectomized teeth.
In addition to the immature or wide apical foramen, which allows adequate
vascular supply to the tissue, the key element for success of these procedures has always
been attributed to the absence of infection (10). Infection within the pulp space is
thought to disrupt the ability of host tissues to develop within the pulp space, in the
way that wound healing occurs in many other tissues. In addition, the potent antimicro-
bial agents that are needed to disinfect the pulp space are insufficient to sterilize the root
canal space and may interfere with the growth of host connective tissues.
The change in thinking on this issue came about in the first decade of the 21st
century. Several published case reports and case series showed that strong antimicrobial
therapy with minimal mechanical root canal preparation may control the infection and
promote clinically successful mineralization and maturation of the root (11–13). The
publication of clinical evidence for the success of revascularization or revitalization in
cases with previous infection has been accompanied by a large amount of preclinical
research into the feasibility of pulp regeneration with a multitude of materials,
protocols, and approaches, the objective of which has been to maximize clinical
success and regenerate a tissue as close phenotypically as possible to the original
pulp and dentin. At this time, pulp regeneration procedure codes are available, and
many dentists, primarily endodontists and pediatric dentists, perform these
procedures routinely. Both the American Association of Endodontics (14) and the
European Society of Endodontology (15) have published guidelines to help practitioners
stay current with the advancing scientific literature. In addition, case reports have
Dental Pulp Regeneration 1
Regenerative Endodontics
recently been published on expanding the use of these protocols to
mature teeth (16), retreatments (17), cases with root resorption (18,
19), and cases with complex congenital anomalies such as dens
invaginatus (20–22). These publications demonstrate an acceptance
of pulp regenerative techniques into the mainstream procedures in
dentistry and recognition of this modality as an option for the
management of a variety of endodontic situations.
However, important fundamental questions remain unanswered in
this field. For example, it is not known which procedures, materials, and
protocols provide the most effective disinfection of root canals of imma-
ture teeth while maintaining biocompatibility with periapical tissues and
the least biological alteration of dentin. The qualitative and quantitative
extent of bacterial disinfection necessary to allow revitalization is not
clear. The exact disinfection and/or tissue engineering protocols that
are required to promote the regeneration of actual pulp and dentin
are not known. The following discussion will discuss recent advances
in addressing these areas and describe areas of ongoing research.
Microbial Pathogenesis of Pulp Space Infection
in Immature Teeth
It is generally accepted that teeth erupt into the oral cavity about
2 to 3 years before complete radiographic maturation of the root
apex. Teeth with an immature apex appear to have a higher healing
capacity and resistance to disease than teeth with a mature apex. For
example, the pulp in immature teeth that are subjected to luxation
injuries such as extrusion or lateral luxation has a much higher chance
for survival than that in mature teeth (23). The pulp in intruded or
avulsed mature teeth has no chance of survival, but for immature teeth
the current guidelines call for observation and monitoring for sponta-
neous revascularization (23–25).
During the time between tooth eruption and apical maturation, 3
main etiologic factors may result in pulp necrosis and subsequent root
canal infection: caries, trauma, or congenital anomalies. Microbial
proliferation and invasion of the dental tissues are different in these
conditions. In cases of caries and congenital anomalies of the crown,
such as dens evaginatus and dens invaginatus, the progression of
disease occurs from a coronal source of infection in an apical direction.
The progression of the infection in cases with an immature apex is likely
slower than that in mature teeth, given the higher collateral circulation
in immature teeth. In these teeth, this progression of the infectious pro-
cess may occur to a higher degree in one region of the pulp more than
another or in some canals but not others in multirooted teeth. For
example, in cases with dens evaginatus, a common etiology for pulp
necrosis in mandibular premolars of adolescent patients of Asian
heritage, the tooth may have no response to pulp testing, periapical
radiolucency, and a draining sinus tract but have bleeding upon access
preparation (26, 27). This bleeding may be related to purulence and
infection but occasionally occurs before any canal manipulation and
may simply be related to severe inflammation together with the
localized areas of infection in these cases.
The pathogenesis of pulp necrosis in immature teeth that receive
traumatic injuries may be different. In cases of avulsion or luxation
injuries, the bacterial invasion of the pulp space likely occurs from
multiple directions, including lateral canals, the apical foramen, and
coronal fractures if present. In these cases, the pulp is likely devitalized
at the time of injury and thus loses much of its capacity to resist
microbial advances. The monitoring period, during which clinicians
determine whether the pulp will spontaneously revascularize, repre-
sents a race between the growth of a vital tissue with a functional
host response against bacterial infection and the growth of the bacterial
biofilm. It would be beneficial to intervene therapeutically before a
2 Fouad
formidable biofilm is formed. However, clinical diagnosis in these cases
is hampered by the unreliability of pulp testing after traumatic injuries
and the difficulty of establishing whether a periapical radiolucency is
part of the tooth follicle that is a source of stem cells (28, 29), a
transient apical breakdown (24, 30), or a developing periapical
lesion. The most definitive sign of an infection at this early stage, and
the risk of delaying intervention, is the development of infection-
related (previously inflammatory) root resorption, which can destroy
the root at a fairly fast rate (31, 32).
The microbiology of immature teeth with necrotic pulp and apical
periodontitis has not been adequately studied. One study revealed the
endodontic pathogens commonly found in teeth with an immature
apex (Table) (33). Interestingly, of the specific species targeted in
this study, the most prevalent species in this group of 15 teeth was
Actinomyces naeslundii. This organism is capable of forming periap-
ical colonies that resist host responses and is identified in biopsies after
surgical treatment. This is important because the apex is wide open in
these cases, and the canal microflora can easily be translocated to the
apical lesion spontaneously or during canal preparation. However, it is
recognized that this study was limited in its examination of the micro-
flora present, and the presence of Actinomyces spp in the root canal
is not predictive of apical actinomycosis.
In general, given the limited data available on the microbiology of
endodontic infections in immature teeth thus far, it can only be
surmised that endodontic pathogens present in these cases are similar
to those found in cases with mature apex. However, this microflora may
be influenced or modulated, at least in part, by the more robust host
responses found in the periapex of immature teeth.
Concerns with Traditional Antimicrobial
Strategies for Immature Teeth Undergoing
Regenerative Procedures
In traditional root canal treatment, strong antimicrobials are used
to disinfect the infected root canal and eliminate necrotic tissues. The
prevention of further infection or growth of residual bacteria is primar-
ily achieved through interappointment antimicrobial medicaments and
final obturation and sealing of the root canal environment.
Sodium hypochlorite is perhaps the most potent endodontic
antimicrobial agent (34), and its use at a concentration of 1.25%–6%
usually results in about a 40%–60% reduction in the number of teeth
with residual cultivable bacteria (35–37). However, sodium
hypochlorite has a number of deleterious effects on dentin, which
could interfere with the regenerative process. For example, it
interferes with stem cell attachment to dentin (38) and abrogates the
ability of dentin-based growth factors to be effective in mediating pulp
regeneration (39). Fortunately, these effects of sodium hypochlorite
could be moderated and/or ameliorated by the application of 17%
TABLE 1. Prevalence of Specific Bacterial Species Detected in Necrotic Pulps
of 15 Immature Teeth
Microorganism Percentage
Actinomyces naeslundii 67
Porphyromonas endodontalis 33
Parvimonas micra 33
Fusobacterium nucleatum 33
Porphyromonas gingivalis 26
Prevotella intermedia 26
Tannerella forsythia 20
Filifactor alocis 13
Treponema denticola 13
Data from Nagata et al (33).
JOE — Volume -, Number -, - 2017

EDTA as a final irrigation (40, 41), particularly if the original
concentration of hypochlorite is 1.5% (42).
Chlorhexidine has been successfully used as an irrigant (43, 44)
or combined with calcium hydroxide as a medicament (45) in pulp
revascularization cases. However, the use of chlorhexidine has not
been shown to contribute significantly to disinfection after hypochlorite
use (33) although the medicament variant was equivalent to the triple
antibiotic paste in that study. Chlorhexidine may have other problems
when used in regenerative techniques, including toxicity to stem cells
of the apical papilla (40) and the formation of toxic chemicals with
the interaction with sodium hypochlorite, that are difficult to prevent
(46).
Although irrigation with 1.5% sodium hypochlorite is generally
advocated as a good strategy for revascularization cases, an earlier
animal study showed that it is insufficient to disinfect the root canals
(47). In this animal study, 1.5% hypochlorite irrigation resulted in
the elimination of cultivable bacteria in 10% of the root canals, whereas
triple antibiotic paste application increased the efficacy to 70%. More
recently, this was further confirmed by another animal study in which
the use of modified triple antibiotic paste (TAP) (in which minocycline
was replaced with cefixime) produced significant improvements in
tissue growth and apical closure (48). Therefore, although there is at
least 1 case report of successful revascularization after a single
appointment (44), most practitioners and guidelines now agree that
2 appointments with an interappointment medicament is an appropriate
protocol for these procedures (14, 15).
The type of medicament used has received a considerable amount of
interest. TAP made up of a mixture of ciprofloxacin, minocycline, and
metronidazole, which was first introduced in the 1990s (49), has been
one of the most popular medicaments to use. This followed its use in
the compelling case report that popularized the revascularization proced-
ure currently being advocated (12). The most significant side effect of this
paste is crown discoloration caused by minocycline (50, 51). An earlier
case report in which only ciprofloxacin and metronidazole were used is
frequently cited for the use of double antibiotic paste (DAP) to avoid
discoloration (11). Other antibiotics or antibiotic combinations have
been proposed to avoid discoloration, such as the use of amoxicillin
and clavulanic acid (Augmentin; GlaxoSmithKline, Philadelphia, PA)
(52) or replacing minocycline in the TAP with clarithromycin or fosfomy-
cin (53). However, minocycline is a very effective antibiotic for endodon-
tic microorganisms (54, 55), and, as is the case with all tetracyclines, has
a strong anti-inflammatory effect. Both minocycline and doxycycline have
also been shown to improve revascularization of replanted immature
teeth in patients and animal models (56–59). Using a dentin bonding
agent internally in the crown portion of the canal before applying TAP
has been shown to reduce the risk of discoloration (60). As noted before,
when minocycline was replaced with cefixime in a recent animal study
(48), the results were also acceptable. However, no direct comparisons
of these antibiotics on the effectiveness of the procedure have been re-
ported.
The higher concentration of topically applied antibiotics is pur-
ported to dramatically improve their antimicrobial effect, particularly
against biofilm bacteria. However, one report has suggested that antibi-
otics at a concentration higher than 1 mg/mL can be toxic to stem cells
(61). Reducing the antibiotic concentration down to this level would
reduce their antimicrobial efficacy. It would also necessitate that the
biofilm be disrupted during the treatment procedure because plank-
tonic bacteria are more sensitive to antibiotics. Finally, it would raise
the importance of antibiotic sensitivity and resistance in selecting the
right antibiotic.
Available data show that lower concentrations of antibiotics are
indeed less efficacious against Enterococcus faecalis (62, 63), an
JOE — Volume -, Number -, - 2017
Regenerative Endodontics
organism that has not been shown to be present in endodontic
infections of immature teeth but is used as a representative of other
resistant microflora. In one study, 10 mg/mL TAP was effective in
eliminating cultivable bacteria; lower concentrations of TAP and all
concentrations of DAP were not capable of achieving this (63). More-
over, calcium hydroxide was not capable of reducing cultivable bacteria
in this study. More recently, it was shown that DAP at 5 mg/mL provided
a significantly higher residual antimicrobial effect on dentin against
biofilms obtained from mature and immature teeth with root canal
infections than 1 mg/mL DAP (64). In this study, calcium hydroxide
provided no residual antimicrobial effect.
The difficulty in balancing the benefit of the antimicrobial action of
antibiotics and the risk of cytotoxicity to stem cells raises the question of
whether applying a medicament that is then removed is the optimal
protocol for regenerative procedures. Perhaps lower concentrations
of antibiotics can be applied within a scaffold to support the developing
tissue on a permanent basis. This approach would reduce the cytotox-
icity and maintain the antimicrobial action while the host tissue is devel-
oping. In this regard, it was recently demonstrated in vitro that TAP-
containing polymer nanofibers had a significant antimicrobial effect
and promoted the proliferation of stem cells 9-fold compared with
pure TAP (65).
One study that examined the removal of antibiotics showed that
needle irrigation is less effective in removing TAP or DAP compared
with photon-induced photoacoustic streaming or sonic activation using
the Endoactivator (Dentsply Sirona, York, PA) (66). Another study
showed that sonic and ultrasonic activation together with hypochlorite
and EDTA improved the removal of antibiotics (67). However, it is not
clear to what extent the complete removal of antibiotics is necessary for
successful regenerative procedures because numerous cases have been
published showing success after just needle irrigation. The success of
these cases may, in fact, indicate that small concentrations of residual
antibiotics may have a beneficial effect.
To What Degree Does Optimal Disinfection Affect
Success of Treatment?
It is well-known that endodontic treatment procedures,
including those used for regenerative procedures, do not sterilize
the root canal system. However, a large number of published individ-
ual cases, case series, and cohorts have shown clinical success.
Therefore, there must be a threshold of residual bacterial presence
that is still conducive to clinical success. A recently published regen-
erative endodontics case illustrates this concept (68). In this case,
root canal infection was well-documented in an immature mandibular
premolar and was successfully treated and followed for 2 years. The
tooth was then extracted for orthodontic reasons and examined his-
tologically. Despite evidence of apical mineralization and connective
tissue growth in the canal, there was a small portion of the repair tis-
sue that contained inflammation, surrounding a small amount of bac-
teria. Therefore, the procedure was successful despite the presence of
a small amount of residual bacteria.
In a recent animal study, this very question was further explored
(69). In this study, a tissue-engineered construct that used dental
pulp stem cells in a hydrogel was compared with traditional revascular-
ization using a blood clot after root canal disinfection and medication
with TAP. In addition to histologic analysis of the results, bacterial stains
were used to determine whether residual bacteria affected the outcomes
3 months after treatment. The results showed no significant differences
between the tissue-engineered construct and the traditional revascular-
ization protocols. However, root development was significantly depen-
dent on the elimination of demonstrable root canal bacteria and
Dental Pulp Regeneration 3
Regenerative Endodontics
Figure 1. The effect of bacteria and inflammation on radiographic growth. All
differences were statistically significant: bacteria present, P = .0016; intracanal
inflammation, P = .0095; and periapical inflammation, P = .036. [Data from
Verma et al (69)].
periapical inflammation (Fig. 1). These results demonstrated clearly
that root canal disinfection was the single most important variable in
the success of root development, which is the seminal objective of
regenerative endodontic procedures.
Concluding Remarks and Future Directions
It is clear from the available evidence at this time that the absence of
intracanal infection is conducive to the regeneration of tissues within the
root canals of immature teeth. As noted before, this concept is not novel
and has been published for decades. However, new evidence suggests
that reducing the infection in cases that have clinically demonstrable
preoperative infection to a low level allows the regenerative
procedures to be successful. It appears that the current revasculariza-
tion protocols do not promote actual pulp and tubular dentin to develop
in cases with prior infection, whether in humans or in animal models
even when no infection is present (68–70). However, the
mineralization that results in root development and healing of
periapical inflammation may be sufficient for clinical success and
warrants promoting these procedures.
Newer technologies used in effective disinfection of the root canals
before regenerative therapy with a reduced effect on periapical vital
tissues should be explored. For example, the use of negative pressure
irrigation (EndoVac; SybronEndo, Orange, CA) has been shown to be
efficacious in disinfecting immature teeth in animal models (71, 72).
A newer generation of these systems is now available that promises to
simplify and expand the use of this technology. Other technologies
that have had only preliminary testing in traditional root canal
treatment may also be beneficial. These include photodynamic
therapy with laser activation of reactive oxygen species/oxygen
radical-producing dyes, innovative expandable file systems (such as
Self-Adjusting files; ReDentNova, Ra’anana, Israel), disinfection with
multisonic activation (GentleWave; Sonendo, Laguna Hills, CA), or pas-
sive ultrasonic irrigation. The critical decision on the use of these tech-
nologies will be the balance between the efficacy of disinfection,
particularly when the root canal anatomy is more complex, and the
preservation of the root canal environment and periapical tissues in a
state that promotes vital tissue development. It is essential when using
any of these technologies in evaluating clinical outcomes that the out-
comes are very narrowly defined, represent health-related parameters
rather than surrogate measures, and adequate controls and randomiza-
tion protocols are advocated.
4 Fouad
References
1. Nygaard-Ostby B, Hjortdal O. Tissue formation in the root canal following pulp
removal. Scand J Dent Res 1971;79:333–49.
2. Nevins A, Wrobel W, Valachovic R, Finkelstein F. Hard tissue induction into pulpless
open-apex teeth using collagen-calcium phosphate gel. J Endod 1977;3:431–3.
3. Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Replantation of 400 avulsed
permanent incisors. 2. Factors related to pulpal healing. Endod Dent Traumatol
1995;11:59–68.
4. Paulsen HU, Andreasen JO, Schwartz O. Pulp and periodontal healing, root
development and root resorption subsequent to transplantation and orthodontic
rotation: a long-term study of autotransplanted premolars. Am J Orthod Dentofacial
Orthop 1995;108:630–40.
5. Skoglund A, Tronstad L, Wallenius K. A microangiographic study of vascular
changes in replanted and autotransplanted teeth of young dogs. Oral Surg Oral
Med Oral Pathol 1978;45:17–28.
6. Skoglund A. Pulpal changes in replanted and autotransplanted apicoectomized
mature teeth of dogs. Int J Oral Surg 1981;10:111–21.
7. Skoglund A. Vascular changes in replanted and autotransplanted apicoectomized
mature teeth of dogs. Int J Oral Surg 1981;10:100–10.
8. Nevins AJ, Finkelstein F, Borden BG, Laporta R. Revitalization of pulpless open apex
teeth in rhesus monkeys, using collagen-calcium phosphate gel. J Endod 1976;2:
159–65.
9. Laureys W, Beele H, Cornelissen R, Dermaut L. Revascularization after cryopreser-
vation and autotransplantation of immature and mature apicoectomized teeth. Am J
Orthod Dentofacial Orthop 2001;119:346–52.
10. Fouad AF. The microbial challenge to pulp regeneration. Adv Dent Res 2011;23:
285–9.
11. Iwaya SI, Ikawa M, Kubota M. Revascularization of an immature permanent tooth
with apical periodontitis and sinus tract. Dent Traumatol 2001;17:185–7.
12. Banchs F, Trope M. Revascularization of immature permanent teeth with apical
periodontitis: new treatment protocol? J Endod 2004;30:196–200.
13. Chueh LH, Huang GT. Immature teeth with periradicular periodontitis or abscess
undergoing apexogenesis: a paradigm shift. J Endod 2006;32:1205–13.
14. American Association of Endodontists. AAE clinical considerations for a re-
generative procedure. 2016. Available at: https://www.aae.org/uploadedfiles/
publications_and_research/research/currentregenerativeendodonticconsiderations.
pdf. Accessed June 8, 2016.
15. Galler KM, Krastl G, Simon S, et al. European Society of Endodontology position
statement: Revitalization procedures. Int Endod J 2016;49:717–23.
16. Paryani K, Kim SG. Regenerative endodontic treatment of permanent teeth after
completion of root development: a report of 2 cases. J Endod 2013;39:929–34.
17. Saoud TM, Huang GT, Gibbs JL, et al. Management of teeth with persistent apical
periodontitis after root canal treatment using regenerative endodontic therapy.
J Endod 2015;41:1743–8.
18. Saoud TM, Mistry S, Kahler B, et al. Regenerative endodontic procedures for
traumatized teeth after horizontal root fracture, avulsion, and perforating root
resorption. J Endod 2016;42:1476–82.
19. Santiago CN, Pinto SS, Sassone LM, et al. Revascularization technique for the
treatment of external inflammatory root resorption: a report of 3 cases. J Endod
2015;41:1560–4.
20. Narayana P, Hartwell GR, Wallace R, Nair UP. Endodontic clinical management of a
dens invaginatus case by using a unique treatment approach: a case report. J Endod
2012;38:1145–8.
21. Yang J, Zhao Y, Qin M, Ge L. Pulp revascularization of immature dens invaginatus
with periapical periodontitis. J Endod 2013;39:288–92.
22. Cho WC, Kim MS, Lee HS, et al. Pulp revascularization of a severely malformed
immature maxillary canine. J Oral Sci 2016;58:295–8.
23. Andreasen FM. Pulpal healing after luxation injuries and root fracture in the
permanent dentition. Endod Dent Traumatol 1989;5:111–31.
24. Andreasen FM, Kahler B. Pulpal response after acute dental injury in the permanent
dentition: clinical implications-a review. J Endod 2015;41:299–308.
25. Andreasen FM, Pedersen BV. Prognosis of luxated permanent teeth–the development
of pulp necrosis. Endod Dent Traumatol 1985;1:207–20.
26. Chen X, Bao ZF, Liu Y, et al. Regenerative endodontic treatment of an immature
permanent tooth at an early stage of root development: a case report. J Endod
2013;39:719–22.
27. Petrino JA, Boda KK, Shambarger S, et al. Challenges in regenerative endodontics: a
case series. J Endod 2010;36:536–41.
28. Wu J, Jia Q, He W, et al. Conditioned medium from periapical follicle cells induces
the odontogenic differentiation of stem cells from the apical papilla in vitro.
J Endod 2013;39:1015–22.
29. Chen G, Sun Q, Xie L, et al. Comparison of the odontogenic differentiation potential
of dental follicle, dental papilla, and cranial neural crest cells. J Endod 2015;41:
1091–9.
JOE — Volume -, Number -, - 2017

30. Andreasen FM. Transient apical breakdown and its relation to color and sensibility
changes after luxation injuries to teeth. Endod Dent Traumatol 1986;2:9–19.
31. Hermann NV, Lauridsen E, Ahrensburg SS, et al. Periodontal healing complications
following extrusive and lateral luxation in the permanent dentition: a longitudinal
cohort study. Dent Traumatol 2012;28:394–402.
32. Bastos JV, Ilma de Souza Cortes M, Andrade Goulart EM, et al. Age and timing of pulp
extirpation as major factors associated with inflammatory root resorption in
replanted permanent teeth. J Endod 2014;40:366–71.
33. Nagata JY, Soares AJ, Souza-Filho FJ, et al. Microbial evaluation of traumatized teeth
treated with triple antibiotic paste or calcium hydroxide with 2% chlorhexidine gel
in pulp revascularization. J Endod 2014;40:778–83.
34. Fouad AF, Barry J. The effect of antibiotics and endodontic antimicrobials on the
polymerase chain reaction. J Endod 2005;31:510–3.
35. Bystrom A, Sundqvist G. The antibacterial action of sodium hypochlorite and EDTA
in 60 cases of endodontic therapy. Int Endod J 1985;18:35–40.
36. Card SJ, Sigurdsson A, Orstavik D, Trope M. The effectiveness of increased apical
enlargement in reducing intracanal bacteria. J Endod 2002;28:779–83.
37. Shuping GB, Orstavik D, Sigurdsson A, Trope M. Reduction of intracanal bacteria
using nickel-titanium rotary instrumentation and various medications. J Endod
2000;26:751–5.
38. Ring KC, Murray PE, Namerow KN, et al. The comparison of the effect of endodontic
irrigation on cell adherence to root canal dentin. J Endod 2008;34:1474–9.
39. Casagrande L, Demarco FF, Zhang Z, et al. Dentin-derived BMP-2 and odontoblast
differentiation. J Dent Res 2010;89:603–8.
40. 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;37:1109–15.
41. 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.
42. Martin DE, De Almeida JF, Henry MA, et al. Concentration-dependent effect of
sodium hypochlorite on stem cells of apical papilla survival and differentiation.
J Endod 2014;40:51–5.
43. Shivashankar VY, Johns DA, Vidyanath S, Kumar MR. Platelet Rich Fibrin in the
revitalization of tooth with necrotic pulp and open apex. J Conserv Dent 2012;
15:395–8.
44. Shin SY, Albert JS, Mortman RE. One step pulp revascularization treatment of an
immature permanent tooth with chronic apical abscess: a case report. Int Endod
J 2009;42:1118–26.
45. Soares Ade J, Lins FF, Nagata JY, et al. Pulp revascularization after root canal
decontamination with calcium hydroxide and 2% chlorhexidine gel. J Endod
2013;39:417–20.
46. Mortenson D, Sadilek M, Flake NM, et al. The effect of using an alternative irrigant
between sodium hypochlorite and chlorhexidine to prevent the formation of
para-chloroaniline within the root canal system. Int Endod J 2012;45:878–82.
47. Windley W 3rd, Teixeira F, Levin L, et al. Disinfection of immature teeth with a triple
antibiotic paste. J Endod 2005;31:439–43.
48. Stambolsky C, Rodriguez-Benitez S, Gutierrez-Perez JL, et al. Histologic character-
ization of regenerated tissues after pulp revascularization of immature dog teeth
with apical periodontitis using tri-antibiotic paste and platelet-rich plasma. Arch
Oral Biol 2016;71:122–8.
49. Hoshino E, Kurihara-Ando N, Sato I, et al. In-vitro antibacterial susceptibility of
bacteria taken from infected root dentine to a mixture of ciprofloxacin, metronidazole
and minocycline. Int Endod J 1996;29:125–30.
50. Kahler B, Rossi-Fedele G. A review of tooth discoloration after regenerative
endodontic therapy. J Endod 2016;42:563–9.
51. Lenherr P, Allgayer N, Weiger R, et al. Tooth discoloration induced by endodontic
materials: a laboratory study. Int Endod J 2012;45:942–9.
52. Nosrat A, Li KL, Vir K, et al. Is pulp regeneration necessary for root maturation?
J Endod 2013;39:1291–5.
JOE — Volume -, Number -, - 2017
Regenerative Endodontics
53. Mandras N, Roana J, Allizond V, et al. Antibacterial efficacy and drug-induced tooth
discolouration of antibiotic combinations for endodontic regenerative procedures.
Int J Immunopathol Pharmacol 2013;26:557–63.
54. Jaouni M, Tolba M, Romberg E, et al. Penetration of systemic antibiotics into
necrotic pulp space. J Endod 2010;36:558.
55. Kuriyama T, Karasawa T, Nakagawa K, et al. Bacteriologic features and antimicrobial
susceptibility in isolates from orofacial odontogenic infections. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 2000;90:600–8.
56. Ritter AL, Ritter AV, Murrah V, et al. Pulp revascularization of replanted immature
dog teeth after treatment with minocycline and doxycycline assessed by laser
Doppler flowmetry, radiography, and histology. Dent Traumatol 2004;20:75–84.
57. Cvek M, Cleaton-Jones P, Austin J, et al. Effect of topical application of doxycycline
on pulp revascularization and periodontal healing in reimplanted monkey incisors.
Endod Dent Traumatol 1990;6:170–6.
58. Cvek M, Cleaton-Jones P, Austin J, et al. Pulp revascularization in reimplanted
immature monkey incisors–predictability and the effect of antibiotic systemic
prophylaxis. Endod Dent Traumatol 1990;6:157–69.
59. Yanpiset K, Trope M. Pulp revascularization of replanted immature dog teeth after
different treatment methods. Endod Dent Traumatol 2000;16:211–7.
60. Reynolds K, Johnson JD, Cohenca N. Pulp revascularization of necrotic bilateral
bicuspids using a modified novel technique to eliminate potential coronal discolouration:
a case report. Int Endod J 2009;42:84–92.
61. Ruparel NB, Teixeira FB, Ferraz CC, Diogenes A. Direct effect of intracanal medicaments
on survival of stem cells of the apical papilla. J Endod 2012;38:1372–5.
62. Sabrah AH, Yassen GH, Liu WC, et al. The effect of diluted triple and double antibiotic
pastes on dental pulp stem cells and established Enterococcus faecalis biofilm. Clin
Oral Investig 2015;19:2059–66.
63. Latham J, Fong H, Jewett A, et al. Disinfection efficacy of current regenerative
endodontic protocols in simulated necrotic immature permanent teeth. J Endod
2016;42:1218–25.
64. Jacobs JC, Troxel A, Ehrlich Y, et al. Antibacterial effects of antimicrobials used in
regenerative endodontics against biofilm bacteria obtained from mature and
immature teeth with necrotic pulps. J Endod 2017;43:575–9.
65. Pankajakshan D, Albuquerque MT, Evans JD, et al. Triple antibiotic polymer
nanofibers for intracanal drug delivery: effects on dual species biofilm and cell
function. J Endod 2016;42:1490–5.
66. Arslan H, Akcay M, Capar ID, et al. Efficacy of needle irrigation, EndoActivator, and
photon-initiated photoacoustic streaming technique on removal of double and triple
antibiotic pastes. J Endod 2014;40:1439–42.
67. Topcuoglu HS, Akti A, Topcuoglu G, et al. Effectiveness of conventional syringe
irrigation, vibringe, and passive ultrasonic irrigation performed with different
irrigation regimes in removing triple antibiotic paste from simulated root canal
irregularities. J Conserv Dent 2016;19:323–7.
68. Becerra P, Ricucci D, Loghin S, et al. Histologic study of a human immature permanent
premolar with chronic apical abscess after revascularization/revitalization. J Endod
2014;40:133–9.
69. 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.
70. Nosrat A, Kolahdouzan A, Hosseini F, et al. Histologic outcomes of uninfected human
immature teeth treated with regenerative endodontics: 2 case reports. J Endod 2015;
41:1725–9.
71. Cohenca N, Heilborn C, Johnson JD, et al. Apical negative pressure irrigation
versus conventional irrigation plus triantibiotic intracanal dressing on root canal
disinfection in dog teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2010;109:e42–6.
72. da Silva LA, Nelson-Filho P, da Silva RA, et al. Revascularization and periapical repair
after endodontic treatment using apical negative pressure irrigation versus conventional
irrigation plus triantibiotic intracanal dressing in dogs’ teeth with apical periodontitis.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:779–87.
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