Regenerative Endodontics
Revascularization-associated Intracanal
Calcification: A Case Report with an 8-year
Review
Bill Kahler, DClinDent, PhD,* Sam L. Kahler, BBioMedSc,† and Louis M. Lin, BDS, DMD, PhD‡
Abstract
Revascularization-associated intracanal calcification
(RAIC) is a common finding in immature teeth managed
with regenerative endodontic treatment (RET). The aim
of this report was to illustrate a case in which 2 mandib-
ular premolar teeth developed complete canal oblitera-
tion and have been reviewed for 8 years. The 3 primary
outcome goals as defined by the American Association
of Endodontists after RET are resolution of signs and
symptoms of pulp necrosis, further root maturation,
and achievement of responses to pulp vitality testing.
The teeth had been included in an earlier quantitative
study in which an increase in root canal width of
72.1% and 39.6% and an increase in root length of
1.7% and 0% were reported for teeth #20 and #29,
respectively. Qualitative assessments over the 8-year re-
view period showed no pathosis and a response to elec-
tric pulp testing at the final review. A quantitative
assessment at the 8-year review showed an increase
of 100% for canal width because complete calcification
had occurred and no substantive change in root length
( 0.17% and 0.68% for teeth #20 and #29, respec-
tively). In this report, complete RAIC occurred in both
teeth over time. RAIC has the potential to complicate
future endodontic or prosthodontic treatment if neces-
sary. Therefore, it is recommended that the American
Association of Endodontists clinical considerations for
a regenerative endodontic procedure be updated to
include the incidence of RAIC after RET. (J Endod
2018;44:1792–1795)
Key Words
American Association of Endodontists clinical consider-
ations for a regenerative endodontic procedure, regener-
ative endodontic treatment, revascularization-associated
intracanal calcification
From the *School of Dentistry, The University of Queensland Oral Health Centre, Herston; †The University of Queensland, School of Biomedical Sciences, St Lucia,
Queensland, Australia; and ‡Department of Endodontics, New York University College of Dentistry, New York, New York.
Address requests for reprints to Dr Bill Kahler, School of Dentistry, The University of Queensland Oral Health Centre, 288 Herston Road, Corner Bramston Terrace and
Herston Road, Herston, QLD 4006, Australia. E-mail address: w.kahler@uq.edu.au
0099-2399/$ - see front matter
Copyright ª 2018 American Association of Endodontists.
https://doi.org/10.1016/j.joen.2018.08.009
1792 Kahler et al.
R egenerative endodon-
tic treatment (RET) of
immature teeth with
Significance
Because revascularization-associated intracanal
calcification is a common finding in immature teeth
pulp necrosis has compa-
treated with regenerative endodontic treatment,
rable outcomes for the
the AAE considerations for a regenerative proced-
resolution of signs and
ure should outline the potential for this variation of
symptoms of apical peri-
healing outcome.
odontitis with other treat-
ment approaches of
calcium hydroxide apexification and mineral trioxide aggregate (MTA) apical barrier
techniques (1–4). The advantage of RET is the potential for future root maturation
with increased canal wall thickness, root length, and apical closure (1, 2, 5–8).
Several studies have shown the extent of further root maturation is variable (1–3,
7–9). Intracanal calcification has been described as a calcific response after RET
(10). However, a recent review identified a high prevalence of revascularization-
associated intracanal calcification (RAIC) at 62.1% of revascularization cases and
the progressive nature of this condition with time (11). Teeth were reviewed for an
average of 24.9 months with a range of 12–71 months. There is a paucity of cases
with long-term follow-ups, which are needed to adequately assess the efficacy of RET
(1, 9, 12) and posttreatment sequelae.
The American Association of Endodontists (AAE) clinical considerations for a
regenerative endodontic procedure define 3 outcome measures (13). The primary
goal is the elimination of symptoms and the evidence of bony healing. The secondary
goal is increased root wall thickness and/or increased root length (desirable but
perhaps not essential). The tertiary goal is a positive response to vitality testing (which,
if achieved, could indicate more organized vital pulp tissue). The possible adverse ef-
fects stated are staining of crown/root, lack of response to treatment, and pain/infection
(13). Other posttreatment sequelae like intracanal calcification and/or ingrowth of
bone are not outlined despite the significance of these phenomena on potential adverse
future clinical outcomes. Long-term reports are more likely to show variations on the
healing responses such as progressive intracanal calcification. The purpose of this
report was to illustrate extensive RAIC of 2 mandibular premolars treated with RET
at an 8-year review.
Case Report
An 11-year-old female patient was referred because of the presence of a draining
sinus associated with the left mandibular second premolar (tooth #20) (Fig. 1A). Both
mandibular premolar teeth on the left had small occlusal composite resin restorations.
JOE — Volume 44, Number 12, December 2018

The second premolar was tender to percussion and nonresponsive to
cold pulp sensibility testing. Radiographically, a wide open apex and
large periapical radiolucency were evident. A gutta-percha point in-
serted into the sinus tracked to the apex of the tooth (Fig. 1B). The diag-
nosis was consistent with that of an infected root canal system, pulp
necrosis, and a chronic periapical abscess. Interestingly, within a
month of regenerative endodontic procedures being instigated for
this tooth, the contralateral tooth, the right mandibular second premo-
lar developed symptoms (Fig. 2A). The tooth was painful and tender to
percussion and exhibited grade II mobility. The tooth was nonrespon-
sive to cold pulp sensibility testing. Radiographically, there was an
extensive periapical radiolucency (Fig. 2B). The diagnosis was consis-
tent with an infected root canal system, pulp necrosis, and symptomatic
apical periodontitis.
RET involved the administration of local anesthesia, and the tooth
was isolated with a rubber dam. Access preparation was made, and the
working length was estimated with an apex locater (SybronEndo, Or-
ange, CA) and/or a periapical radiograph taken with a file inserted
into the canal for length confirmation. The canal was then irrigated
with 1% sodium hypochlorite 2 mm from the working length before dry-
ing the canal with large-size paper points. A triantibiotic paste (TAP)
was carefully introduced into the canal with a Lentulo spiral root canal
filler. The TAP consisted of an equal mixture of 50 mg each of metro-
nidazole, ciprofloxacin, and amoxicillin mixed with 1 mL sterile water to
obtain a thin creamy paste. The root canal was filled to just below the
cementoenamel junction. Care was taken to minimize placement in
the coronal portion of the tooth. A double seal of approximately
4 mm Cavit (ESPE, Seefeld, Germany) and Fuji IX (GC, Alsip, IL) was
used to close the access cavity.
Figure 1. (A) A photograph showing a chronic periapical abscess associated with tooth #20 in which the dens evaginatus had been restored. (B) A preoperative
radiograph with a gutta-percha marker. (C) A photograph showing an induced blood clot in the canal after RET. (D) A postoperative radiograph after treatment with
RET. (E–K) Annual review radiographs at 1 to 8 years.
JOE — Volume 44, Number 12, December 2018
Regenerative Endodontics
Teeth were usually reviewed 4 weeks later. Local anesthesia
without a vasoconsrictor (Scandonest 3% Plain; Septodont, Saint-
Maur-des-Fosses, France) was administered for this visit. The tooth
was isolated with a rubber dam. The canal was irrigated with 1% sodium
hypochlorite. After the canal was dried with paper points, a D11T NiTi
hand spreader (Dentsply Tulsa Dental, Johnson City, TN) or a size 35
file (SybronEndo) with a small bend at the tip to enable laceration of
the periapical tissues was used to initiate bleeding into the root canal
space. The blood was allowed to clot to a level 3 mm below the cemen-
toenamel junction. Then, 3 mm ProRoot White MTA (Dentsply Tulsa
Dental) was placed onto the clot with Buchannan pluggers (Sybro-
nEndo). The access cavity was sealed with 3 mm glass ionomer cement
(Figs. 1C and 2C).
The teeth were reviewed every 6 months after access closure for
18 months. Assessments at the review included an evaluation of clin-
ical signs and symptoms, periapical status, the presence of further
root maturation, and pulp sensibility testing. At the 18-month review,
a quantitative analysis was undertaken as part of an earlier study. An
increase in root canal width of 72.1% and 39.6% and an increase in
root length of 1.7% and 0% were reported for teeth #20 and 29,
respectively (7). Further qualitative reviews were continued to date
until this 8-year review (Figs. 1D–K and 2D–K). Progressive calcifica-
tion was noted, and there was no evidence of pathosis. The teeth were
nonresponsive to electric pulp sensibility testing until the 8-year re-
view when both teeth were responsive. A quantitative assessment at
the 8-year review showed an increase of 100% for canal width
because complete calcification had occurred and no substantive
change in root length ( 0.17% and 0.68% for teeth #20 and #29,
respectively). Because the teeth were discolored, both teeth were
Revascularization-associated Intracanal Calcification 1793
Regenerative Endodontics
Figure 2. (A) A photograph of tooth #29 showing the fractured occlusal tubercle. (B) A preoperative radiograph. (C) A postoperative radiograph after treatment
with RET. (D–K) Annual review radiographs at 1 to 8 years.
bleached internally using Opalescence Endo (Ultradent Products, Inc,
Sydney, Australia) and restored with composite resin.
Discussion
In the presented case, all 3 treatment goals (ie, elimination of clin-
ical symptoms/signs of infection, further root maturation, and a positive
response to pulp sensibility testing) were achieved. Partial to complete
canal obliteration is common after trauma to teeth (14), and RAIC is
also a common finding in teeth treated with RET (11). In the current
report, extensive (complete to near complete) RAIC was noted at the
2-year and 5-year review for teeth #20 and #29, respectively. The exten-
sive canal calcification that occurred would complicate endodontic re-
treatment if further infection were to occur. However, endodontic
retreatment would likely be a viable treatment option to retain the tooth
if necessary.
After trauma to teeth not treated with RET, the incidence of pulp
necrosis secondary to total pulp canal obliteration was 21% after 10
to 23 years (15). Therefore, intracanal calcification is a common post-
trauma sequela after acute dental trauma and has a higher incidence in
teeth with an open apex when compared with mature teeth with a closed
apex (16). This is a phenomenon of vital teeth and has been described
because of a compromise of the neurovascular supply leading to altered
function. In RET, teeth have developed necrosis and lost the neurovas-
cular supply because of ingress of bacteria. RET has been described as
the reestablishment of the “pulp/dentin complex” (17). In the pre-
sented case, both teeth were responsive to pulp sensibility testing at
the 8-year review only. The possibility of a false-positive result cannot
be excluded although the test was repeated to confirm the reading,
which was consistent. Song et al (11) did not undertake pulp sensibility
teeth in the study of 29 teeth but stated that complete obliteration of the
1794 Kahler et al.
root canal would impede normal function of dental pulp tissues. How-
ever, this was not observed in the presented case. Song et al also
described RAIC as more prevalent when bleeding was induced in the
canal (69.6%) compared with cases without bleeding (33.4%). Also,
RAIC was higher in cases medicated with calcium hydroxide (76.9%)
compared with teeth medicated with antibiotic pastes (46.2%) (11).
In the present case report, bleeding was induced, and the teeth were
medicated with TAP.
Several studies have undertaken quantitative analysis of further
root maturation using a geometric imaging program to account for dif-
ferences in angulation between preoperative and postoperative images
and ImageJ software (National Institutes of Health, Bethesda, MD) for
measurement of changes in root length and width (1, 3, 5–7, 18,
19). These are usually undertaken at a defined time point such as an
18-month review so quantitative analysis and statistical assessment of
changes in root length and width can be determined. However, as
shown by Song et al (11) and the current report, further calcific mate-
rial and intracanal calcification can continue to occur. In the current
case, when quantitative analysis was undertaken as a part of an earlier
study (7), there were substantial increases in canal width and minimal
to no change in root length. It is likely that when the periapical tissues
are lacerated per the RET protocol (13) damage to the Hertwig epithe-
lial root sheath precludes further significant increases in root length
(20). Quantitative analysis at the 8-year review showed no substantive
change in root length over the review period. The small changes in
length are within the standard deviation of error as described earlier
(7). Recently, Lin et al (4) reported that etiology had an impact on
RET outcome; dens evaginatus cases had greater increases in root
length and width than teeth in which trauma was the etiology for necro-
sis. However, RET has been shown to be a reparative process rather than
true regeneration histologically. In animal and human studies, the
JOE — Volume 44, Number 12, December 2018

damaged pulp tissue in the canal space of immature teeth after RET is
replaced by bone-, cementum-, and periodontal ligament–like tissue
(21, 22).
There are few long-term follow-up cases of RET in the literature
(9, 12, 23). A recent report described long-term follow-up as 36 months
(24). Song et al (11) reported an incidence of RAIC of 62.1% after
following 29 teeth treated with RET with follow-up ranging from 12–
71 months (average = 24.9 months) (11). The American Association
of Endodontists clinical considerations should be updated to include
RAIC as a potential posttreatment outcome.
Discoloration of teeth treated with RET has been recently reviewed
(25) and can be attributed to when minocycline is used in TAP (26, 27)
and also from the MTA used as an intracanal barrier in the coronal third
of the root (27, 28). In the current study, minocycline in the TAP was
replaced with amoxicillin, and both teeth discolored. In the earlier
study, 10 of the 16 (62.5%) teeth discolored despite the minocycline
being replaced with amoxycillin (7). In another study, 10 of 12
(83.3%) teeth medicated with TAP discolored compared with 3 of 11
(27.3%) medicated with calcium hydroxide (29). However, in the cur-
rent case, teeth discolored after treatment with RET were successfully
bleached, as has been shown in other studies (30).
Conclusion
Because RAIC is a common finding after RET, it is recommended
that the AAE clinical considerations for a regenerative endodontic pro-
cedure be updated to include the potential of RAIC after RET.
Acknowledgments
The authors deny any conflicts of interest related to this study.
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