Regenerative endodontics: a true paradigm shift or a bandwagon about to be derailed?

Aims: Regenerative endodontic techniques (RETs) have been hailed as a paradigm shift for the management of traumatised non-vital immature permanent anterior teeth. In this article the aim was to critically appraise the literature with regards to the outcome of regenerative endodontics on root development. Methods: Critical review of the literature where regenerative endodontic techniques have been used in the management of immature non-vital teeth with continuation of root development as the main outcome reported. Results: Most studies published were in the form of case reports and series with very few randomised controlled trials with a high risk of bias. Continuation of root development following the use of RET has been shown to be unpredictable at best with lower success in those teeth losing vitality as a result of dental trauma. Conclusions: Despite the high success of regenerative endodontics in terms of periodontal healing including resolution of clinical and radiographic signs and symptoms of infection, continuation of root development remains an unpredictable outcome. The use of a blood clot as a scaffold in regenerative endodontics should be reviewed carefully as that might offer an environment for repair rather than regeneration. In addition, preservation of structures, such as Hertwig’s epithelial root sheath, may have an important bearing on the success of this approach and should be further investigated

Erratum to: Interventions for the endodontic management of non-vital traumatised immature permanent anterior teeth in children and adolescents: a systematic review of the evidence and guidelines of the European Academy of Paediatric Dentistry

Aim: This systematic review was undertaken in order to develop guidelines for the European Academy of Paediatric Dentistry for the management of non-vital permanent anterior teeth with incomplete root development. Methods: Three techniques were considered; apexification by single or multiple applications of calcium hydroxide, use of Mineral Trioxide Aggregate (MTA) for the creation of an apical plug followed by obturation of the root canal, and finally a Regenerative Endodontic Technique (RET). Scottish Intercollegiate Guideline Network (SIGN) Guidelines (2008) were used for the synthesis of evidence and grade of recommendation. Results: Variable levels of evidence were found and generally evidence related to these areas was found to be weak and of low quality. It was not possible to produce evidence-based guidelines based on the strength of evidence that is currently available for the management of non-vital immature permanent incisors. Conclusions: Based on the available evidence the European Academy of Paediatric Dentistry proposes Good Clinical Practice Points as a guideline for the management of such teeth. It is proposed that the long term use of calcium hydroxide in the root canals of immature teeth should be avoided and apexification with calcium hydroxide is no longer advocated. The evidence related to the use of a Regenerative Endodontic Technique is currently extremely weak and therefore this technique should only be used in very limited situations where the prognosis with other techniques is deemed to be extremely poor. The current review supports the use of MTA followed by root canal obturation as the treatment of choice

Regenerative approaches in endodontic therapies of immature teeth

Regenerative therapies in endodontics have recently gained momentum in clinical dentistry primarily due to the availability of effective root canal disinfection protocols, biocompatible materials with enhanced marginal seal, and discovery of mesenchymal stem cells (MSCs) in the dental pulp. These constitute the “triad” of tissue engineering required for pulp regeneration, assembled to meet the unique needs of the pulp-dentin microenvironment. Endodontic regeneration may be offered to patients at varying levels, including direct and indirect pulp capping, partial and complete pulpotomy, apexogenesis, apexification, and revascularization procedures, all of which require the triad of pulp tissue preservation or engineering. Successful outcomes in revascularization, for example, depend on root canal disinfection employing irrigation and medicaments using biocompatible calcium silicate-based cements (CSCs) paired with adhesion-based restorations that ultimately promote recruitment of MSCs from the apical papillae. These regenerative procedures yield high success rates in treatment outcome, although they are not routinely performed in the day-to-day practice of dentistry. In this chapter, we discuss the rationale for endodontic regeneration procedures in the era of markedly successful conventional therapies, and we outline the procedural aspects of available regenerative endodontic therapies