Monday, June 5, 2017

Efficacy of revascularization to induce apexification/apexogenesis in infected, non-vital immature teeth: a pilot clinical study

Department of Pediatric Dentistry
Lutheran Medical Center
           
Resident’s Name: Brian Darling                                                                                             Date: 6/7/2017
Article Title: Efficacy of revascularization to induce apexification/apexogenesis in infected, non-vital immature teeth: a pilot clinical study
Author(s): Shah, N et al
Journal: Journal of Endodontics
Date: 2008 34 (8): 919-925
Major Topic: Revascularization of Immature Teeth
Type of Article: Case series
Main Purpose: This article aimed to describe the results of a series of cases in which revascularization is performed on traumatized, nonvital, immature teeth.

·      Root development takes place about 2 years after tooth has erupted into the oral cavity
·      Methods
o   14 traumatized, nonvital, immature teeth
o   Irrigation with 3% hydrogen peroxide and 2.5% sodium hypochlorite
o   Light cotton pellet with formocresol as interappointment dressing was placed in chamber and IRM seal
o   Tooth left open 24-48 hours if frank purulent discharge
o   Revascularization done once tooth was asymptomatic
o   Sterile 23 gauge was placed 2mm beyond working length to induce bleeding
o   Dry cotton pellet used to stop bleeding once at cervical area by dabbing 3-4mm into canal and pulp chamber and held there for 7-10 minutes to allow clot formation in apical 2/3 of canal
o   Sealed access with glass ionomer cement extending 4mm into coronal portion of root canal system
o   Follow-up at 6 month intervals
·      Results
o   Complete resolution of clinical signs and symptoms and appreciable healing of periapical lesions was evident in 11/14 cases
o   Thickening of lateral walls evident in 8/14 cases
o   Increased root lengthin in 10/14 cases
o   Zero cases presented with pain, reinfection, or enlargement of periapical radioulucency at recall appointments
·      Apexogenesis is a natural physiologic process of root development. This term is often used to describe the procedure of preserving pulp vitality in traumatized tooth with pulp involvement so that the affected tooth could develop its full growth potential
·      Maturogenesis has been suggested as a better term than apexification because the entire root is allowed to mature rather than just the apex
·      Revascularization of infected, nonvital infected, immature tooth could stimulate regeneration of apical tissues and induce apexogenesis
·      Limitations of calcium hydroxide apexification
o   Length of time required – may take 6-24 months to form apical barrier
o   Apical barrier formed is often porous and not continuos or compact, and so requires obturation after barrier formation
o   Obturation difficult to form tight seal without splitting tooth
o   No further development of root
o   Hygroscopic and proteolytic properties of calcium hydroxide may make tooth more brittle
o   Calcium hydroxide may damage cells at the apex that have regenerative capacity
o   Not uncommon for these teeth to fracture (after four years, one report said 77% of most immature teeth and 28% of most fully developed teeth)
·      MTA apexification
o   MTA apexification can be done in 1 visit
o   MTA is biocompatible with osteoinductive properties and sets in presence of moisture  
·      Rationale for revascularization is that if a sterile tissue matrix is provided in which new cells can grow, pulp vitality can be reestablished
·      Infection control is largely via chemical debridement – sodium hypochlorite or chlorhexidine, or povidone-iodine or antibiotic paste
·      There are several suggested mechanisms of how revascularization occurs
·      Advantages of revascularization
o   Shorter treatment time
o   Cost-effective (decreased number of visits and no additional material required)
§  Continued root development and strengthening of root
·      Disadvantags of revascularization
o   Calcification of entire canals may make esthetics compromised and future endodontic treatment more difficult
o   Post and core needed for restoration (because you can’t violate the apical 2/3 of the canal with revascularization)

Remarks:
1- I wonder what they did to treat the 3 cases where signs/symptoms did not resolve
2- Did they use anesthetic with vasoconstrictor?
3- Only placed GIC over blood clot?
Assessment of Article:  Level of Evidence/Comments: III


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