Table 1.
American Association of Endodontists clinical considerations for a regenerative procedure
| Case Selection: |
|---|
| • Tooth with necrotic pulp and an immature apex. |
| • Pulp space not needed for post/core, final restoration. |
| • Compliant patient/parent. |
| • Patients not allergic to medicaments and antibiotics necessary to complete procedure (ASA 1 or 2). |
| Informed Consent |
| • Two (or more) appointments. |
| • Use of antimicrobial(s). |
| • Possible adverse effects: staining of crown/root, lack of response to treatment, pain/infection. |
| • Alternatives: MTA apexification, no treatment, extraction (when deemed non salvageable). |
| • Permission to enter information into AAE database (optional). |
| First Appointment |
| • Local anesthesia, dental dam isolation and access. |
| • Copious, gentle irrigation with 1.5% NaOCl (20ml/canal, 5 min) followed by irrigation with saline (20ml/canal, 5 min), with irrigation needle positioned about 1 mm from root end |
| • Dry canals with paper points. |
| • Place calcium hydroxide or low concentration of triple antibiotic paste. If the triple antibiotic paste is used: 1) consider sealing pulp chamber with a dentin bonding agent (to minimize risk of staining) and 2) mix 1:1:1 ciprofloxacin: metronidazole: minocycline to a final concentration of 0.1 mg/ml. |
| • Deliver into canal system via syringe. |
| • If triple antibiotic is used, ensure that it remains below CEJ (minimize crown staining). |
| • Seal with 3-4 mm of a temporary material such as Cavit, IRM, glass-ionomer or another temporary material. Dismiss patient for 1-4 weeks |
| Second Appointment (1-4 weeks after 1st visit) |
| • Assess response to initial treatment. If there are signs/symptoms of persistent infection, consider additional treatment with antimicrobial, or alternative antimicrobial. |
| • Anesthesia with 3% mepivacaine without vasoconstrictor, dental dam isolation. |
| • Copious, gentle irrigation with 20ml of 17% EDTA. |
| • Dry with paper points. |
| • Create bleeding into canal system by over-instrumenting (endo file, endo explore) (induce by rotating a pre-curved K-file at 2 mm past the apical foramen with the goal of having the entire canal filled with blood to the level of cemento-enamel junction). Stop bleeding at a level that allows for 3-4 mm of restorative material. |
| • Place a resorbable matrix such as CollaPlug, Collacote, CollaTape or other material over the blood clot if necessary and white MTA/CaOH as capping material. A 3-4 mm layer of glass ionomer (e.g., Fuji IlLCTM, GC America, Alsip, IL) is flowed gently over the capping material and light-cured for 40s. Alternatives to MTA (such as bioceramics or tricalcium silicate cements [e.g., Biodentine®, Septodont, Lancasted, PA, USA, EndoSequence® BC RRM-Fast Set Putty, Brasseler, USA]) should be considered in teeth where there is an esthetic concern. |
| • Anterior and premolar teeth – Consider use of Collatape/Collaplug and restoring with 3 mm of RMGI followed by bonding a filled composite to the beveled enamel margin. |
| • Molar teeth or teeth with PFM crown – Consider use of Collatape/Collaplug and restoring with 3 mm of MTA, followed by RMGI or alloy. |
| Follow-up (6-, 12-, 24-months) |
| Clinical and Radiographic exam |
| • No pain, soft tissue swelling or sinus tract (often observed between first and second appointments). |
| • Resolution of apical radiolucency (often observed 6-12 months after treatment) |
| • Increased width of root walls (this is generally observed before apparent increase in root length and often occurs 12-24 months after treatment). |
| • Increased root length. |
| • Positive Pulp vitality test response |
| • Recommended yearly follow-up after the first 2 years |
| • CBCT is highly recommended for initial evaluation and follow-up visits |