Managing necrotic pulp of immature permanent teeth can be very challenging, mainly because the root system was challenging to debride, and the dentinal walls are easily fractured. Because young patients who are still growing are not candidates for dental implants, replacing an immature permanent tooth loss due to complexity is nearly impossible. Missing teeth can cause further complications such as bite problems, difficulty chewing, difficulty speaking, and self-esteem issues.
This is where the scientifically advanced regenerative endodontic therapy comes into play. Regenerative therapy is biologically based and aimed to replace damaged root structures, dentin, and cells using tissue engineering and regenerative medicine. This therapy can result in complete restoration of the pulp and root structure in immature teeth.
Tissue Engineering for Root Canal Treatment
Tissue regeneration is a relatively new field that brings together engineering and biology to regenerate or replace human organs, tissues, or cells that eventually restore function. In dentistry, it is specifically beneficial in pulp regeneration.
Tissue engineering relies on three elements:
- Stem cells: which are undifferentiated cells that fall into one of two categories: embryonic or adult/postnatal. Embryonic stem cells have significant potential as they are capable of dividing and creating over two hundred different types of cells, while adult stem cells can produce only a limited number of cell types.
- Scaffolds: which support vascularization, differentiation, proliferation, and organization of cells. Dentin, blood clots, and platelet-rich plasma have been used in the root canal to support pulp regeneration. Also, other natural and synthetic materials can be used to support these functions as well. They include hyaluronic acid, chitin, collagen, chitosan, polyglycolic acid, polylactic acid, hydroxyapatite, and tricalcium phosphate.
- Growth factors: which bind to receptors and signal proliferation or differentiation. In regenerative endodontic procedures, the growth factors found in dentin and platelets are typically used due to the bioactive molecules contained.
Each of these elements is highly dependent on variables during the procedure, which increases the risk and complexity involved. Endodontists follow best practice recommendations by the American Association of Endodontists (AAE) to limit risk and improve patient outcomes.
What Are The Requirements for Regenerative Endodontics?
Not all patients are good candidates for regenerative endodontics. While a single, simple protocol has not been established, cases with the most favorable outcome have several factors in common:
- the patient is young
- the pulp is necrotic, and the apex is immature
- there is no or minimal instrumentation of dentinal walls
- an intracanal medicament has been placed
- a protein scaffold or blood clot has been created in the canal
- and the coronal seal is effective
As more endodontists perform regenerative endodontic procedures, more evidence will become available to evaluate patient eligibility and outcomes effectively. Endodontists are strongly encouraged to keep up with the most current evidence and recommendations to best serve their young patients.
How Is The Pulp Regeneration Procedure?
In most cases, regenerative endodontic treatment requires two or more appointments. Before the first appointment, the patient is examined and diagnosed by a general dentist, who refers the patient to an endodontist to determine candidacy for regenerative endodontic treatment. Most endodontists begin with a consultation before the first procedural appointment is scheduled. During the first appointment, the endodontist establishes access and removes necrotic pulp and microorganisms from the canal space. During the second appointment, the absence of symptoms should first be confirmed. Then, the endodontist proceeds to:
- remove the antimicrobial medicament
- irritate the dentin with EDTA to release growth factors
- deliver stem cells into the canal by stimulating bleeding
- create a blood clot or platelet-rich plasma to serve as a scaffold
- place a barrier such as MTA and then a restoration to seal the tooth
Choosing an anesthetic that does not contain a vasoconstrictor can make it easier to stimulate bleeding during the second appointment.
Follow-up appointments are required to measure the efficacy of the procedure. On follow-up, the tooth should be fully functional and without symptoms. On the radiograph, there should be no periapical radiolucency by six to twelve months after the procedure, and increased thickness of the dentinal wall and root length should be noted one to two years after the procedure.
Regarding the success rate, the majority of cases that met the above guidelines have shown positive clinical outcomes.
What are the Challenges in Regenerative Treatment?
Because of the variables involved in regenerative treatment, the clinician doesn’t have full control of the outcome of the procedure. The clinician has to rely on the release of growth factors from dentin, a periapical bleed, and the formation of a blood clot for the process to have the highest chance of success.
In the future, lab-generated pulp-like materials possible due to tissue engineering may limit variables during the procedure and improve patient outcomes.
The exciting new field of regenerative endodontics provides a higher quality of life for young patients at risk of losing an immature permanent tooth. Before regenerative treatment options, the outcome was often the extraction of the affected tooth. As research continues, the future of regenerative endodontics is even more promising yet, and Root canal Houston is excited to be qualified and experienced in these scientifically-advanced procedures.