Case Report

Single‑visit regenerative endodontic procedure of necrotic

immature lower permanent molar with acute apical abscess
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Nujud Saleh Alsharqawi1,2, Obadah N. Austah1

1
Department of Endodontics, Faculty of Dentistry, King Abdulaziz University, Jeddah, 2Department of Dental, King Salman Armed Forces
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Hospital, Tabuk, Saudi Arabia

Abstract Regenerative endodontic procedures (REPs) of immature teeth with necrotic pulp and apical pathosis focus
on passive chemomechanical debridement and usually require multiple visits to enhance the antibacterial
effect by placing intracanal medications. However, different case reports showed a favorable clinical and
radiographic outcome in single‑visit REPs of necrotic immature teeth with symptomatic apical periodontitis
or chronic apical abscess. To the best of our knowledge, there are no published reports of single‑visit REPs
on cases with acute apical abscess. Therefore, this case report aimed to present a successful REP performed
in a single visit for immature lower molar with necrotic pulp and acute apical abscess. A 9‑year‑old female
patient referred for the management of the lower right molar (#46), with the chief complaint of localized
moderate pain with cold drinks in the lower right molar for 1 week. The extraoral clinical examination
revealed no significant findings. Intraorally, tooth #46 revealed a deep occlusal caries, with normal
response to palpation, mild pain on percussion, and moderate pain to the cold test. The radiographic
examination showed deep occlusal caries approaching the pulp, and periapical radiolucency related to the
distal root. It was diagnosed as symptomatic irreversible pulpitis with symptomatic apical periodontitis.
After accessing the pulp chamber, the radicular pulp on the mesial root was vital, while necrotic in the
distal root. Therefore, vital pulp therapy was done for the mesial root, and REPs initiated for the distal root
with intracanal medicament placement. However, the patient failed to show up in the scheduled visit to
complete the treatment. The father refused to bring her as she was asymptomatic, and he was afraid of the
COVID‑19 pandemic situation. One month later, she presented to the clinic with pain and facial swelling in
the lower right area of her face. Clinical examination revealed extra‑ and intraoral swelling related to tooth
#46 (i.e., acute apical abscess) with severe pain on palpation and percussion. The patient’s parents insist
to finish the treatment or extract the tooth on the same visit. Hence, a single‑visit REP was done. After
20 months, clinical and radiographic examinations showed that the tooth became asymptomatic, responded
to sensibility tests, and the periapical pathosis healed. It was concluded that regenerative endodontic
treatment can be done in single visit in cases with acute apical abscess. It should be considered in cases
of poor complaint, difficulty in accessing dental care, or pandemic curfew.

Keywords: Apexogenesis, periapical abscess, pulp necrosis, regenerative endodontic, revascularization

Address for correspondence: Dr. Nujud Saleh Alsharqawi, Department of Endodontics, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia.
E‑mail: njood.saleh@hotmail.com
Submission: 26‑10‑22 Revision: 13‑12‑22 Acceptance: 14‑12‑22 Web Publication: 14-04-23

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DOI: How to cite this article: Alsharqawi NS, Austah ON. Single-visit regenerative
10.4103/sej.sej_181_22 endodontic procedure of necrotic immature lower permanent molar with acute
apical abscess. Saudi Endod J 2023;13:204-10.

204 © 2023 Saudi Endodontic Journal | Published by Wolters Kluwer ‑ Medknow

 Alsharqawi and Austah: Single‑visit regenerative endodontic procedure
INTRODUCTION
In immature teeth with necrotic pulp, regenerative
endodontic procedures (REPs) are a treatment option
with a biological basis which allows the continuation of
root development and regaining pulp vitality.[1‑3] REPs
focus on sufficient disinfection of the infected root canal
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space with materials possessing high antimicrobial activity
and low cytotoxicity.[4,5] Using an intracanal medicament
such as triple antibiotic paste (TAP) or calcium hydroxide
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(Ca[OH]2) to enhance the antibacterial effect usually requires
multiple visits.[5,6] This can create a challenge, especially for
incompliant patients or patient who travels for treatment.
Consequently, bleeding is induced in the canal space by
overinstrumentation to create the blood clot (i.e., scaffold)
and place calcium silicate‑based material over it.
The conventional treatment option in such cases used to
be apexification.[7,8] Its main disadvantage is the inability to
allow for a continuation of root development, therefore
increasing the risk of root fracture.[9] Since 2001, REPs
were introduced as an alternative option to apexification
in cases of immature teeth with necrotic pulp. It was
reported that REPs resulted in the healing of apical
periodontitis, thickening of dentin wall, and closing
of the apical foramen.[6] After that, many case reports
showed favorable clinical and radiographic outcomes.[10‑13]
Furthermore, single‑visit REPs showed successful clinical
and radiographic outcomes in some case reports of necrotic
immature teeth with symptomatic apical periodontitis[14,15]
or chronic apical abscess[16] with follow‑up ranging from
18 to 24 months. To the best of our knowledge, there are
no published reports of single‑visit REPs on cases with
acute apical abscess. Therefore, this case report aimed to
present a regenerative endodontic case performed in a
single visit for immature lower molar with necrotic pulp
and acute apical abscess.
CASE REPORTS
A 9‑year‑old Afghani female patient was referred by her
pediatric dentist to the postgraduate endodontic clinic
at Faculty of Dentistry, King Abdulaziz University,
for consultation and management of the lower right
first molar  (#46). The chief complaint of the patient
was localized moderate pain with cold drinks over the
lower right molar for 1  week. Her medical history was
noncontributory. The dental history represented with
multiple dental fillings without any complication. The
extraoral clinical examination revealed no significant
findings. Intraorally, tooth #46 revealed a deep occlusal
caries with normal response to palpation, mild pain on
Saudi Endodontic Journal | Volume 13 | Issue 2 | May-August 2023 205
percussion, and moderate pain response to the thermal
test (Endo Frost‑Coltene Group, Germany). In addition,
multiple carious teeth were noticed. The radiographic
examination showed deep occlusal caries approaching
the pulp, and periapical radiolucency related to the distal
root of tooth #46 [Figure 1a, b and Table 1]. The tooth
was diagnosed as symptomatic irreversible pulpitis with
symptomatic apical periodontitis, and recommended caries
removal with possible vital pulp therapy (VPT).
The consent form was reviewed and signed by the patient’s
mother and agreed to the proposed treatment plan.
Local anesthesia was administered using 2% lidocaine
hydrochloride with 1:100,000 epinephrine (Carestream
Health INC, by Novocol Pharmaceutical of Canada INC,
25 Wolseley Court, Cambridge) for the inferior alveolar
nerve block and one carpule 3% plain mepivacaine
hydrochloride (Scandonest ®  (30  mg/mL) Novocol
Pharmaceutical of Canada INC) as buccal infiltration.
Rubber dam was applied, and the treatment was carried out
using dental operating microscope (ZEISS OPMI® pico,
Carl‑Zeiss‑Straße, Oberkochen, Germany). Caries removal
was completed, and pulp exposure was encountered.
After accessing the pulp chamber, the pulp in the distal
root was necrotic, while the radicular pulp on the mesial
root was vital  [Figure  1c and d]. Therefore, VPT was
decided for the mesial root and REPs of the distal root.
Exposed pulp in the mesial canals was cleaned with 3%
sodium hypochlorite (NaOCl), and the distal canal was
a b
c d
e
Figure 1:  (a) Preoperative BW radiograph.  (b) Preoperative PA
radiograph. (c) Clinical picture showing necrotic radicular pulp on
the distal root. (d) Clinical picture showing vital radicular pulp on the
mesial root. (e) Immediate postoperative PA radiograph; Ca(OH)2
paste in the distal canal and bioceramic reparative cement over mesial
radicular pulp. BW: Bitewing, PA: Periapical
 Alsharqawi and Austah: Single‑visit regenerative endodontic procedure
Table 1: Results of the diagnostic tests
Tooth number Cold Electrical pulp test Percussion
First visit #46 Moderate Response Mild pain
pain
After one No No response Severe pain
month #46 response
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18 months Response Response Normal
follow up #46
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secured with a cotton pellet. After achieving hemostasis,
3 mm thickness of bioceramic reparative cement (BIO‑C®
REPAIR‑Angelus Indústria, Londrina, Brazil) was placed
over the orifices of the mesial canals, then sealed with
glass‑ionomer restoration  (Fuji IX Auto‑cure GIC,
Tokyo, Japan). Subsequently, access cavity for the distal
canal was done; working length was determined (12 mm).
Then, minimal instrumentation was done with hand files
and 3% NaOCl irrigation, followed by the placement of
Ca(OH)2 (Pulpdent Corporation, USA) as an intracanal
medicament [Figure 1e]. The patient was scheduled for the
next visit after 14 days. However, the treatment took place
in 2020 during the COVID‑19 pandemic, and the patient’s
father refused to bring her to the appointment as she was
asymptomatic, and he was afraid of the pandemic situation.
One month later, the patient presented to the clinic
as an emergency with facial swelling in the lower right
area of her face. Her parents requested to either finish
the treatment on the same visit or extract the tooth
due to the pandemic restrictions. Clinical examination
revealed extra‑  and intraoral swelling related to tooth
#46 (i.e., acute apical abscess) with severe pain on palpation
and percussion [Table 1]. Hence, the tooth diagnosis was
necrotic pulp with acute apical abscess. We recommended
a single‑visit regenerative endodontic treatment, and they
agreed to it. Local anesthesia was administered as 1 carpule
2% lidocaine hydrochloride with 1:100,000 epinephrine
for the inferior alveolar nerve block and one carpule 3%
plain mepivacaine hydrochloride as buccal infiltration. After
accessing the pulp chamber and root canal system, pus came
through all the canal orifices. Minimum instrumentation of
root canal system through brushing the walls with hand files
was done, followed by ultrasonic activation (X‑Ultrasonic
Activator. Eighteeth Medical‑Changzhou City, China)
of the 3% NaOCl irrigation with size 25 file tip 2  mm
shorter than the working length  (Distal canal: 12 mm–
mesiobuccal and mesiolingual canals: 13 mm), then irrigation
with 17% Ethylenediaminetetraacetic acid (EDTA)
(MD‑Cleanser– Meta Biomed, Chungcheongbuk, Korea).
Bleeding was induced for all three canals using a size
30K‑file. Blood clot formation was established after 15 min
206 Saudi Endodontic Journal | Volume 13 | Issue 2 | May-August 2023
Palpation Mobility Radiographic assessment
Normal Within Deep occlusal caries
normal limit Open apex
Periapical radiolucency related to the distal root
Severe Within Open apex
pain normal limit Periapical radiolucency
Normal Within Complete resolution of the lesion
normal limit Closure of the apical foramen without any
further increase of root length
at the pulp chamber level [Figure 2a]. Then, bioceramic
reparative cement was placed over the blood clot. The
coronal seal was done with a glass‑ionomer base, followed
by composite resin restoration  (3M Filtek Composite,
Deutschland GmbH)  [Figure  2b and c]. A  prescription
of Augmentin suspension 457 mg/5 mL twice a day for
7 days and ibuprofen 100 mg/5 ml oral suspension three
times a day was given to the patient.
The patient failed to attend all scheduled follow‑up
visits; her parents stated on the phone that the signs
and symptoms subsided gradually after the treatment to
become completely asymptomatic after about 1 week. Nine
months later, the patient presented to the clinic; the tooth
was asymptomatic and was not sensitive to palpation and
percussion. Furthermore, it gave a positive response to both
sensibility tests. The periapical radiograph showed a decrease
in the size of the periapical radiolucency and an increase
in root width [Figure 2d]. The next follow‑up was after
18 months, and the tooth was functioning and responded
normally to sensibility tests, palpation, and percussion.
The periapical radiograph showed a complete resolution
of the lesion and closure of the apical foramen without
any further increase of root length [Table 1 and Figure 2e].
The cuspal coverage with stainless‑steel crown was placed
after 20 months [Figure 2f].
DISCUSSION
In this case report, we attempted to utilize a more conservative
combination treatment protocol by saving radicular pulp
vitality in the mesial root and performed regenerative
endodontic treatment on the distal root. Lee et al. presented
a successful case of combined VPT and REPs treatment in
the molar diagnosed with necrotic pulp and chronic apical
abscess.[17] Many factors could contribute to the success of
VPT: state of pulp inflammation, cause and the size of the
exposure, the ability to obtain hemostasis, capping material
used, and sealing of the coronal restoration.[18] However, in
our case, VPT failed when the patient presented 1 month
later with an acute apical abscess. This failure could be
explained by microbial overwhelming of the mesial pulp
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a b c
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d e f
Figure 2: (a) Clinical picture showing both canal orifices after induction of bleeding. (b) Immediate postoperative PA radiograph. (c) Immediate
postoperative BW radiograph.  (d) Periapical radiograph  (9‑month follow‑up) showing decrease in the size of periapical lesion on D
root. (e) Periapical radiograph (18‑month follow‑up) showing a complete resolution of the periapical lesion and apical closure. (f) Periapical
radiograph, after SSC placement (20‑month follow up). BW: Bitewing, PA: Periapical

tissue and the leakage of the temporary restoration when
the patient was unable to follow the scheduled treatment
visits. Furthermore, it is a sensitive challenging technique
requires extra caution and care to successfully perform both
procedures in a very confined space.
REP for necrotic immature teeth has been adopted as an
alternative treatment option by implementing a modified
approach first described by Iwaya et al. in 2001.[4] In the
present case, due to the COVID‑19 pandemic curfew
restrictions, single‑visit REP was decided when the patient
presented with acute abscess and her parents insisted on
finishing the treatment on the same visit. A  study was
conducted by Patel et al. to evaluate the success of palliative
care on endodontic emergencies during COVID‑19
pandemic.[19] Thirteen percent of the treatment failure were
occurred due to patient unwilling to take COVID test or
refusing to continue the treatment due to the perceived
risk of COVID infection. Our case is a successful example
of managing an emergency case in the pandemic curfew,
through implementing a single‑visit REP on immature
molar with necrotic pulp and acute apical abscess.
Intracanal medication TAP[4,6,7,20,21] or Ca(OH)2 paste[22]
was used as a part of the disinfection protocol in most of
the studies with multiple visit REPs. The use of intracanal
medicaments might adversely affect the treatment through
possible tooth discoloration and decrease dentin fracture
resistance.[23,24] Moreover, the use of intracanal medicaments
increases the number of visits, which necessitates the
patient compliance.[21] Therefore, a significant advantage
might be obtained when REPs can be done in a single visit,
and adequate disinfection can be attained.
Saudi Endodontic Journal | Volume 13 | Issue 2 | May-August 2023 207
According to the  American Association of Endodontists
(AAE), they recommend using 1.5% NaOCl for controlling
the infection in REPs with intracanal medication to overcome
the bacterial challenge in multiple‑visit REPs.[25] However, in
single‑visit REPs, previous studies used a full concentration
of 5.25%–6% NaOCl in irrigation protocol to increase the
antibacterial effect.[14‑16] Therefore, in our case, we used 3%
NaOCl with ultrasonic activation. Cause a full concentration
of NaOCl can denature growth factors in dentin, resulting
in adverse effects on stem cell attachment, survival, and
differentiation. These deleterious effects can be minimized
with a lower concentration of NaOCl.[26] Irrigation activation
with ultrasonic has been shown to enhance solution
penetration, antibacterial activity, and disruption of bacterial
biofilm.[27‑30] Furthermore, immature teeth with open apices
had a potential higher risk for irrigation extrusion. Thus, a
lower concentration of NaOCl was used to lower the chance
of adverse effects on periapical tissue in case a minute amount
of irrigant extruded.[31] Furthermore, using 17% EDTA
enhances the release of growth factors from dentin, which
positively participate in the regenerative process through
angiogenesis, stem cell proliferation, and differentiation.[26,32]
For the management of acute apical abscess in permanent
teeth, the abscess should be drained either through the
canal as in our case or through incision and drainage.
Prescribing systemic antibiotic can be beneficial when
systemic involvement is evident  (e.g.,  lymphadenopathy,
fever, or cellulitis) in addition to drainage of the tooth.[33]
This case report was prepared according to the PRICE
2020 Guidelines [Figure 3].[34]
The scarcity of single‑visit REPs cases in the literature
with different diagnoses gave this case report a strength
 Alsharqawi and Austah: Single‑visit regenerative endodontic procedure

Patient demographic: a 9-year-old Afghani female patient

Patient symptoms
“Localized moderate pain with cold drinks over the lower right molar for 1 week”
The lower right first molar (#46)
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Medical history: noncontributory

Past dental history: multiple dental filings

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Clinical findings
First visit
Deep occlusal caries
Second visit "1 month later"
Occlusal restoration
Extra/& intraoral swilling

Diagnostic tests performed and their results: presented in Table-1

Diagnosis
First visit: symptomatic irreversible pulpitis with symptomatic apical periodontitis
Second visit "1 month later": necrotic pulp with acute apical abccess

Informrd consent was taken by patient's parent

Treatment performed
First visit: combined treatment (VPT in the mesial root, and initiate REPs in the distal root)
Second visit "1 month later": single-visit REPs

Follow-up periods: 9 and 20 months

Follow-up assessment methods: clinical examination (percussion, palpation, cold test, and EPT)
and radiographic assessment (periapical radiograph)

Treatment outcome
Normal response to percussion & palpation. Responded to cold test & EPT.
The periapical radiograph showed a complete resolution of the lesion and closure of the apical foramen

Patient perspective
Patient is asymptomatic and the tooth is functioning

Conclusion
Single-visit REPs showed a sucessful outcome in case of necrotic pulp with acute apical abscess

Funding details: None

Conflict of interest: None

Figure 3: PRICE 2020 flowchart

as it will help in adding to the cumulative work, therefore short follow‑up period. It is a case report which represents
build a better understanding for the future development the least rank in the evidence‑based hierarchy. However, it
in the treatment techniques; while the limitation was the considers the first line of evidence in recording new therapy
208 Saudi Endodontic Journal | Volume 13 | Issue 2 | May-August 2023
 Alsharqawi and Austah: Single‑visit regenerative endodontic procedure
or techniques, and helpful for developing a hypothesis that
can be tested with an analytical study design. Furthermore,
the inability to investigate the type of tissue formed, as it
requires a histological assessment which was unapplicable
unless the tooth was extracted.
CONCLUSION
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The presented case report showed a successful single‑visit
REPs in necrotic immature molar with acute apical
abscess. The noticeable advantages in single‑visit REPs
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are the lower risk of reinfection to the canal space from
subsequent access in multiple visits and the convenience in
poor‑compliant patients, especially during unprecedented
global events such as the COVID‑19 pandemic, or in cases
where it is difficult to access dental care.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form, the patient has given
her consent for her images and other clinical information
to be reported in the journal. The patient understands that
her name and initials will not be published, and due efforts
will be made to conceal her identity, but anonymity cannot
be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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210 Saudi Endodontic Journal | Volume 13 | Issue 2 | May-August 2023