Revascularisation solution for infected, non-vital

immature teeth

A new treatment option of revascularization, which involves disinfecting the root canal system, providing a
matrix of blood clot into which cells grow, and sealing of the coronal access, has proven an effective way to
treat immature non-vital, infected permanent teeth. A recent pilot study conducted at the Department of
Conservative Dentistry and Endodontics at the All India Institute of Medical Sciences in New Delhi, India,
evaluated the efficacy of revascularization in 14 cases of infected, immature teeth. None of the cases
presented with pain, re-infection, or radiographic enlargement of pre-existing apical pathology. Lead
researcher, Dr Naseem Shah, explained the significance of the study. 

Question: Give some brief background on this new method of revascularization.

Naseem Shah: The concept of revascularization, per se, is not new. It was introduced by Ostby in 1961 1 and
later, Rule and Winter in 19662 documented root development and apical barrier formation in cases of pulpal
necrosis in children. Treatment of the immature non-vital anterior tooth with apical pathosis presents
several treatment challenges. Endodontic management of such teeth includes surgery and retrograde
sealing, calcium hydroxide-induced apical closure (apexification) and more recently, placement of an apical
plug of mineral trioxide aggregate and gutta percha obturation.
 
Occasional cases of regeneration of apical tissues after traumatic avulsion and replantation led to the search
for the possibility of regeneration of the whole pulp tissue in a necrotic, infected tooth (Ham et al 19723,
Skoglund A19784, Cvek 19905). The development of normal, sterile granulation tissue within the root canal is
thought to aid in revascularization and stimulation of cementoblasts or the undifferentiated mesenchymal
cells at the periapex, leading to the deposition of a calcific material at the apex as well as on the lateral
dentinal walls.
 
In 2001, Iwaya, Ikawa, Kubota6 and in 2004 Banchs and Trope7 demonstrated the advantages of this
treatment modality, which resulted in a radiographically apparent normal maturation of the entire root
versus an outcome of only a calcific barrier formation at the apex following conventional calcium hydroxide-
induced apexification. So far, only isolated case reports and small case series have been reported in the
literature.
 
Question: What are the most significant outcomes of this pilot study?
Naseem Shah: This pilot study documents a favorable outcome of revascularization procedures conducted in
immature non-vital, infected permanent teeth. Radiographic resolution of periradicular radiolucencies was
judged to be good-to-excellent in 93% (13 of 14) of the cases. In the majority of cases, a narrowing of the
wide apical opening was evident. In three cases, thickening of apical dentinal walls and increased root length
was observed. The striking finding was complete resolution of clinical signs and symptoms and appreciable
healing of periapical lesions in 78% (ll of 14) of cases.
 
Question: How do you see this study contributing to the evidence base of treatment options for
non-vital immature teeth? 
Naseem Shah: The present pilot clinical study offers several advantages over other established treatment
protocols for the management of immature, infected non-vital teeth. A surgical approach with retrograde
seal, has been used in the past. It is an invasive procedure with its accompanying shortcomings, including
possibility of surgical complications as well as increased cost of treatment, and possible psychological
distress, especially in children. Recently, Mineral Trioxide Aggregate (MTA) has been used to create an apical
plug followed by gutta-percha backfilling of the remaining root canal space. 

MTA treatment is expensive and also it does not reinforce the root canal (Tittle  et al  19968). It only forms an
artificial barrier at the peri-apex without maturation or root lengthening. Some authors have suggested the
use of growth factors and bone morphogenic factors with an artificial scaffold (Krebsbach 1997 9, Gronthos S
200210). The method involves precise placement of the scaffold with BMPs and growth factors at the peri-
apex. This concept besides being expensive is still under research. 

Regeneration of tissues rather than replacement with artificial substitutes is an emerging and exciting field
in the health sciences. Revascularization of infected, non-vital, immature teeth has been documented to
stimulate regeneration of apical tissues as well as to induce apexogenesis and is emerging as a new
treatment modality for such teeth. 

It is a relatively inexpensive procedure which involves formation of a blood clot at the apex which acts as a
scaffold for formation of new soft and hard tissues. A larger case series with longer follow up period would
establish it as the standard protocol for management of such teeth.
 
Question: Will you conduct further research on this new method? 
Naseem Shah: Further research on revascularization procedures is being carried out with new cases being
started and maintaining follow up of the previous cases. Narrowing of apical opening, increase in root length
and resolution of periapical radiolucencies is measured. Use of Laser Doppler Flowmetry to document
revascularization of pulp is highly desirable and would be used in future to strengthen the case for this
procedure.