Regenerative Endodontic Therapy in the Management of Nonvital Immature Permanent teeth: A Systematic Review and Meta-analysis

Periapical Healing Outcome of Endodontic Re-Treatment Using Calcium Silicates Versus Resin-Based Sealers: A Systematic Review

Aim

This systematic review was conducted with the purpose of analyzing the effects of root-end sealers in endodontic re-treatment cases and comparing calcium-based sealers with sealers, which were resin-based.

Methodology

We conducted this review based on the principles of Cochrane systematic type of studies and also based on guidelines of Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). An exhaustive search was conducted across PubMed, Medline, and Embase databases for the studies, which were based on root end sealers in cases of endodontic re-treatments. The data were then analyzed statistically with the help of SPSS 25.0.

Results

It was seen that when comparing pain levels in post-obturation cases with these sealers after 24 hours and 48 hours, not much of statistically noteworthy differences were evident. Mean difference (MD) values at 24 hours were -0.20 with confidence intervals between -0.44 and 0.07 and P value of 0.15, whereas in case of 48 hours, MD was -0.36, CI- 0.65, and P value was 0.03. However, the results were slightly better with calcium-based sealers.

Conclusion

Calcium silicate-based root end obturation sealers had similar performance when compared to resin-based sealers when we compared variables like pain intensity, etc.

Clinical Evaluation of the Retention of Four Different Pit and Fissure Sealants on the First Permanent Molars - An Original Research

Objective

In this study, the retention rates of four different pit and fissure sealant materials on the first permanent molars were clinically assessed and compared.

Materials and Methods

A total of 120 kids aged 7 to 10 participated in a randomized controlled experiment. On their first permanent teeth, the subjects each got one of the four sealant materials (A, B, C, or D). Over the course of 24 months, the retention rates were evaluated every 6 months. The Chi-square test and Kaplan-Meier survival analysis were used for statistical analysis.

Results

At 6, 12, 18, and 24 months, the following retention rates were observed overall: A (85%, 78%, 65%, 52%), B (90%, 82%, 70%, 60%), C (78%, 70%, 55%, 42%), and D (95%, 88%, 75%, 62%). At each time point, the sealant materials showed significant variations in retention rates (P 0.05). While sealants A and C showed lower retention rates, sealant D showed the best retention rates, followed by sealant B.

Conclusion

This study shows that different materials have different retention rates for pit and fissure sealants on first permanent molars. Higher retention rates for sealants D and B suggest that they may be superior than sealants A and C. These results highlight how crucial it is to choose the right sealant materials to guarantee long-term retention and effectiveness in avoiding dental cavities.

Outcomes of Regenerative Endodontic Treatment Performed Using Different Magnification Devices: A Systematic Review

Aim

In this systematic review, we assessed whether the effects of the usage of various devices help with magnification in endodontics and whether they resulted in any significant changes in the clinical result of treatment.

Materials and Methods

An exhaustive search was performed across MEDLINE and Cochrane Registers for various clinical studies, which were focused on comparing regenerative endodontic treatment based on the usage of magnification devices. Various terms were used to search these clinical trials such as microscope, regenerative endodontic surgery, apicoectomy, endoscope, and loupes.

Results

After scrutinizing the studies, around three clinical trials based on magnification in endodontic surgeries were included in the present review. It was observed that no statistically noteworthy betterment of treatment outcome was seen in patients treated with either of the magnification devices such as loupes and microscope.

Conclusion

It was evident that these magnification devices can alter the effectiveness of regenerative endodontic treatment in a very minimal way. However, we believe that more randomized clinical studies should be conducted in this area.

Management Strategies for Immature Teeth with Pulp Necrosis: An Umbrella Review of Systematic Reviews

Introduction

This review evaluates the effectiveness of treatment modalities for immature teeth with pulp necrosis, focusing on calcium hydroxide (CH) and mineral trioxide aggregate (MTA) apexification, as well as regenerative endodontic treatments (RETs). Recent advancements and clinical outcomes are highlighted.

Materials and Methods

A comprehensive search of MEDLINE (PubMed), Embase, Cochrane Library, Scopus, and grey literature was conducted from inception to July 2024. Systematic reviews and meta-analyses (SR/MAs) assessing apexification and RET outcomes in immature teeth with pulp necrosis were included. Studies were selected based on predefined criteria, and data on study design, interventions, and outcomes were extracted. Methodological quality was evaluated using the AMSTAR-2 tool.

Results

31 SR/MAs were included. The quality ranged from critically low to low, except one rated as high. MTA apexification was more effective than CH for faster apical barrier formation, though overall success rates were similar. MTA is preferred for its efficiency, but standardized protocols are needed, and tooth discoloration was noted as a potential complication. RET generally outperforms apexification in root maturation, with platelet concentrates like platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) showing promising results; PRP was associated with greater root length, while PRF showed superior apical healing. Variability in RET outcomes was noted due to the lack of standardized protocols. Comparative studies of RET versus apexification showed no significant differences in survival or overall success rates. RET often provides better apical closure and root development, though results vary. Both approaches are viable, but more research with standardized protocols and larger samples is needed to establish definitive clinical advantages.

Conclusions

MTA apexification and RET are viable alternatives to CH apexification, with RET showing greater potential for root development and apical healing. Future research should focus on developing standardized protocols and uniform RET guidelines, and evaluating long-term outcomes to establish efficacy and safety.

A Potential Intracanal Medicament, 2-Hydroxyisocaproic Acid (HICA): Cytotoxicity, Genotoxicity, and Its Effect on SCAP Differentiation

Intracanal medicaments with maximal antimicrobial efficacy and minimal damage to resident stem cells are essential for successful regenerative endodontic procedures. 2-Hydroxyisocaproic acid (HICA) could have the attributes of a potential intracanal medicament. This study evaluates its cytotoxicity, genotoxicity, and effects on the odontogenic and osteogenic differentiation of the stem cells of the apical papilla (SCAP). Cytotoxicity and cell viability assays were performed on cells treated for 24, 48, and 72 h with varying concentrations of HICA and compared to the standard intracanal medicament, calcium hydroxide. The genotoxicity was assessed via immunofluorescence for two markers of DNA double-strand breaks: phosphorylated γH2AX and 53BP1. The SCAP differentiation was evaluated based on the alkaline phosphatase activity, Alizarin Red staining, and expression of odontogenic and osteogenic genes (DSPP1, BSP1, OCN, RUNX2) in the presence of selected HICA concentrations. HICA was not cytotoxic at concentrations up to 10 mg/mL, regardless of the exposure time, although it was cytostatic at all tested concentrations. HICA was not genotoxic at concentrations below 5 mg/mL. No difference in cytotoxicity or genotoxicity was found between HICA and calcium hydroxide at 1 mg/mL. HICA retained about 70% of the osteogenic differentiation potential at 1 mg/mL. Within the limitations of this in vitro study, we show that HICA at 1 mg/mL could be a potential intracanal medicament for REPs.

Regeneration of immature incisor using platelet rich fibrin: report of a novel clinical application

BACKGROUND

Endodontic treatment of young permanent teeth with necrotic pulp presents a clinical challenge for the dentist, and conventional endodontic treatment will result in tooth fracture along with a poor prognosis. Regenerative endodontics is a new protocol that has been advanced in the last decades for managing immature permanent teeth. Rare successful management of immature permanent incisors using platelet-rich fibrin is a technique-sensitive procedure.

CASE PRESENTATION

A 08 years 04 months old female reported the chief complaint of pain in the upper front tooth region for one week. A blunderbuss canal was identified on radiographic examination, and revascularization using platelet-rich fibrin was planned and adopted. After the treatment, apical closure and root lengthening were noted without complications during subsequent follow-ups. Complete periapical healing with greater than 1.5 cm of dentinal thickness was noted.

CONCLUSION

Revascularization can be considered a viable treatment option for immature nonvital permanent teeth; with advancements in regenerative medicine and clinical practices, revascularization therapies could be developed as a novel mode of treatment in non-vital and dental traumatic cases.

Outcomes reporting in systematic reviews on revitalization: A scoping review for the development of a core outcome set

BACKGROUND

Revitalization is a type of regenerative endodontic treatment (RET) that offers the exciting prospect of revitalizing damaged tissue, therefore improving outcomes for non-vital immature teeth. To evaluate its potential, there needs to be consistency in outcome reporting of clinical studies investigating revitalization to allow for evidence synthesis and inform clinical decision making.

OBJECTIVES

The aim of this scoping review was to identify outcomes that are reported in systematic reviews on revitalization including how and when these outcomes are measured. Additionally, evidence of selective reporting bias in the reviews was assessed.

METHODS

A comprehensive electronic search of healthcare databases and grey literature was conducted to identify systematic reviews published in the English language reporting outcomes of revitalization in permanent immature teeth. There was no restriction on the date of publication. Outcome data was extracted by four reviewers independently and mapped with a healthcare taxonomy into five core areas: survival, clinical/physiological changes, life impact, resource use and adverse events. Selective reporting bias and how it was measured was assessed independently by two reviewers.

RESULTS

Twenty-six systematic reviews were included in this scoping review. There was lack of standardization in reporting and significant heterogeneity across reviews in outcome endpoints. The outcomes reported could be aligned within the five core areas of the taxonomy including tooth survival which was reported in nine reviews. Patient-reported outcomes were generally limited and no review reported on Oral Health Related Quality of Life. Many of the reviews reporting on randomized control trials were at low risk of selective reporting bias whilst other study designs were at higher risk.

DISCUSSION

Consistency in outcome reporting is necessary to realize the benefits of old but particularly novel therapies. Data from this review confirmed heterogeneity in reporting outcomes of revitalization and the need for development of a core outcome set (COS).

CONCLUSIONS

Several important outcomes including survival, root development, tooth discolouration and periapical healing have been identified in this review which could inform the development of a COS in this area.

REGISTRATION

Core Outcome Measures in Effectiveness Trials (COMET) database (registration no. 1879).

Expert consensus on regenerative endodontic procedures

Regenerative endodontic procedures (REPs) is a biologic-based treatment modality for immature permanent teeth diagnosed with pulp necrosis. The ultimate objective of REPs is to regenerate the pulp-dentin complex, extend the tooth longevity and restore the normal function. Scientific evidence has demonstrated the efficacy of REPs in promotion of root development through case reports, case series, cohort studies, and randomized controlled studies. However, variations in clinical protocols for REPs exist due to the empirical nature of the original protocols and rapid advancements in the research field of regenerative endodontics. The heterogeneity in protocols may cause confusion among dental practitioners, thus guidelines and considerations of REPs should be explicated. This expert consensus mainly discusses the biological foundation, the available clinical protocols and current status of REPs in treating immature teeth with pulp necrosis, as well as the main complications of this treatment, aiming at refining the clinical management of REPs in accordance with the progress of basic researches and clinical studies, suggesting REPs may become a more consistently evidence-based option in dental treatment.

Tooth Bleaching of Discolorations Caused by Hydraulic Cements in Regenerative Endodontic Treatment: A 3-Year In Vitro Study

This study aimed to evaluate the color change caused by hydraulic cements after 3 years in vitro by simulating their use in regenerative endodontic treatment (RET) and to quantify the color change after external bleaching with 40% hydrogen peroxide at 1, 6, and 12 months of follow-up. Fifty teeth were treated simulating RET. Samples were distributed according to the hydraulic cement to be used (n = 10 per group): negative control (no cement), ProRoot-MTA, MM-MTA, TotalFill BC-RRM, or Biodentine. Three years after RET, two sessions of external bleaching with Opalescence Boost were performed. The color was measured in the cervical and incisal halves of the teeth at different time points: baseline, 3 years after performing RET, and after 1, 6, and 12 months after bleaching. The ΔL, Δa, and Δb were determined. A generalized linear model was used to compare color considering group and time. The ΔEab and the ΔE00 were calculated and the acceptability in color change was determined. Three years after RET, a reduction in lightness (negative ΔL values) was found in all groups. These values significantly increased 1 month after bleaching in all groups (p < 0.05) and reversed at 6 months. One month after bleaching, ΔE00 values (color difference tolerance (CIEDE2000)) ranged from very good (>3.6 ≤ 5.4) to excellent (>5.4). One year after bleaching, the color reverted to values similar to those found 3 years after RET. All groups became darker after RET. The color recovered and even improved compared with the baseline measurement after one month of bleaching but did not remain stable over time.

Use of scaffolds and regenerative materials for the treatment of immature necrotic permanent teeth with periapical lesion: Umbrella review

BACKGROUND

Current treatment of immature necrotic permanent teeth with a periapical lesion is regenerative endodontics, which is based on tissue engineering under the triade of stem cells, scaffolds and bioactive molecules.

OBJECTIVES

This Umbrella Review was aimed to evaluate the success of scaffold and regenerative materials used for the treatment of these teeth, in terms of apical closure, tooth length increase, widening of root canal walls, tissue vitality and periapical lesion repair.

METHODS

An extensive literature research was carried out in the Medline, ISI Web of Science, and Scopus databases for relevant systematic reviews matching the keyword search strategy. Based on inclusion and exclusion criteria, reviewers independently rated the quality of each study to determine their level of evidence. Methodological quality assessment of each article was obtained using A Measurement Tool to Assess Systematic Reviews (AMSTAR)-2 tool, and risk of bias was assessed with the Risk of Bias in Systematic Reviews (ROBIS) tool.

RESULTS

After removing duplicates, 155 articles were found; from which 133 were excluded for being non-relevant and 15 other due to exclusion criteria. One more was discarded after methodological quality evaluation, for a total of six articles remaining. The most common scaffold used was the blood clot, others used were poly lactic-co-glycolic acid and platelet-rich fibrin matrix. The most common regeneration material used was Mineral Trioxide Aggregate (MTA), followed by Biodentine. An increase in tooth length and widening of root canal walls were reported in all selected studies with different proportions, as well as periapical lesion repair. ROBIS analysis showed that only one article had low bias, two were classified as unclear bias, while the remaining three had high risk of bias.

DISCUSSION

An exhaustive literature search was carried out applying language filters, high-quality indexed journals, year of publication, which ensures the best quality articles were included. Blood clot was the most used scaffold as is the most easy to place inside the canal and does not require to extract blood from the patient. The use of MTA and Biodentine as sealing materials has been associated with thickening of canal walls, apical closure and reduced signs and symptoms of apical periodontitis. However, most of the included reviews assessed were case reports and only in a few of them were clinical trials included. There is also a lack of risk of bias analysis in most reviews.

CONCLUSION

The blood clot is the most common scaffold used for inducing regeneration during the treatment of immature necrotic teeth. Tooth length increase and widening of root canal walls are the most common criteria used in the studies as success indicators. MTA and Biodentine did not show differences in the results analysed. Quality assessment and bias risk evaluation showed that it is necessary to design better studies with rigorous methodology to recommend a trustable and predictable protocol for the treatment of immature necrotic permanent teeth with periapical lesions.

REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO) CRD42021248404.