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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 13  |  Issue : 5  |  Page : 886-889  

Foreign body removal and revascularization of teeth with periapical radiolucency: 18 Months' follow-up


1 Department of Conservative Dentistry and Endodontics, Vinayaka Mission's Sankarachariyar Dental College, Vinayaka Mission's Research Foundation (Deemed to be University), Salem, Tamil Nadu, India
2 Department of Oral Medicine, Vinayaka Mission's Sankarachariyar Dental College, Vinayaka Mission's Research Foundation (Deemed to be University), Salem, Tamil Nadu, India
3 Department of Orthodontics and Dentofacial Orthopedics, Vinayaka Mission's Sankarachariyar Dental College, Vinayaka Mission's Research Foundation (Deemed to be University), Salem, Tamil Nadu, India

Date of Submission19-Sep-2020
Date of Decision10-Oct-2020
Date of Acceptance18-Nov-2020
Date of Web Publication05-Jun-2021

Correspondence Address:
Kaarunya Ravikumar
Department of Conservative Dentistry and Endodontics, Vinayaka Mission's Sankarachariyar Dental College, Vinayaka Mission's Research Foundation (Deemed to be University), Salem, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpbs.JPBS_536_20

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   Abstract 


Revascularization of the dental pulp is an emerging regenerative endodontic approach in which a new tissue is formed inside the root canal by induction of blood clot, allowing the continuation in the development of root. In this case report, the effective management of previously fractured immature tooth with the presence of foreign body (wire) inside the canal and radiographic periapical radiolucency had been described. A 17-year-old patient with immature fractured upper left lateral incisor with radiographic evidence of foreign body (wire) inside the canal was treated with removal of wire by H file followed by revascularization protocol that used working length determination, 5.25% sodium hypochlorite irrigation, intracanal medication with calcium hydroxide, final irrigation with 17% ethylenediaminetetraacetic acid and saline, induction of apical bleeding and blood clot formation, and coronal seal with mineral trioxide aggregate. Patient was recalled at every 3 months and response checked as the tooth remained asymptomatic. At 18 months' follow-up, intraoral periapical radiography radiograph was taken to evaluate the revascularization procedure. The periapical radiolucency was healed and root closure began to appear. Increased thickness of root width was also found. Although revascularization shows clinically acceptable results, care should be taken to achieve proper disinfection of canals and regular follow-up to improve long-term efficacy and new approaches.

Keywords: Foreign body removal, open apex, periapical lesion, revascularization


How to cite this article:
Ravikumar K, Chakravarthy Y, Kumar A, Samynathan M, Varshini R J. Foreign body removal and revascularization of teeth with periapical radiolucency: 18 Months' follow-up. J Pharm Bioall Sci 2021;13, Suppl S1:886-9

How to cite this URL:
Ravikumar K, Chakravarthy Y, Kumar A, Samynathan M, Varshini R J. Foreign body removal and revascularization of teeth with periapical radiolucency: 18 Months' follow-up. J Pharm Bioall Sci [serial online] 2021 [cited 2021 Oct 22];13, Suppl S1:886-9. Available from: https://www.jpbsonline.org/text.asp?2021/13/5/886/317515




   Introduction Top


Endodontic treatment of young permanent teeth with pulpal necrosis and open apex is often challenging. Proper preparation and obturation of the immature tooth mainly the apical region is often difficult to attain due to its slender, delicate dentinal walls, and complex anatomy. Calcium hydroxide was earlier used for multi-step apexification.[1] After the introduction of mineral trioxide aggregate (MTA), one-step apexification was followed which greatly decreased the frequency of sessions and duration of treatment.[2] However, both these techniques suffer several disadvantages as they do not allow for the progression of root development which produces fragile root with more prone to fracture.

Pulp revascularization is the currently emerging advance in regenerative endodontic therapy.[3],[4] It is a biological approach which involves the creation of an environment that produces root maturation by induced bleeding. Apexification allows the artificial formation of the apical barrier, whereas revascularization enables root maturation. This technique involves disinfection of root canal with irrigants and intracanal medicaments followed by the creation of inflammatory tissue reaction which result in root development. Revascularization has emerged successful in achieving apical seal, completion of root development, and thickened dentinal walls.

The first step in the pulp revascularization begins with minimal instrumentation and root canal irrigation with disinfectants. Various concentrations of sodium hypochlorite (NaOCl) and chlorhexidine (CHX) have been used as irrigants for intracanal disinfection. The procedure continues by application of intracanal medicament, which may include calcium hydroxide or triple antibiotic paste. The tooth is checked for any signs and symptoms of periradicular diseases. Once the tooth becomes asymptomatic, the intracanal paste is removed with final irrigant, and bleeding is induced into the canals by irritating the periapical tissues. About 17% ethylenediaminetetraacetic acid (EDTA) can be used as a final irrigant which induces the release of growth factors responsible for root maturation. Once the blood clot gets formed, the canal orifice is sealed with MTA by placing over the clot as a biocompatible sealing material. Then, the tooth can be permanently restored. In this article, the management of previously fractured immature tooth with effective revascularization has been described.


   Case Report Top


A 17-year-old male patient reported to the Department of conservative dentistry and endodontics, PGIDS Rohtak with pain in the upper left lateral incisor for about 1 week. The patient recalled a history of trauma of the tooth 8 years before due to the accidental fall and he went to nearby clinic for treatment. The patient was explained to come for three visits to complete the treatment, but he missed two visits as the patient was relieved from pain in the first appointment. On clinical examination, there is Ellis Class III fracture in 22. Tooth mobility was within the normal limits and tenderness on percussion was present. Intraoral periapical radiography (IOPA) showed that there is a radioopaque foreign body present inside the root canal which resembles like broken file or wire. The apex was open and the foreign body was extending beyond the apex. Periapical radiolucency was seen at the apex [Figure 1]. Informed consent was obtained. After local infiltration anesthesia with 1.8 mL of 2% lidocaine with 1:80,000 epinephrine, wire was immediately removed from the root canal using H files [Figure 1].
Figure 1: Preoperative radiograph teeth with foreign body inside. (b) Foreign body after removal. (c) Files depicting the foreign body. (d) After wire removal. (e) Working length determination. (f) Postoperative radiograph-indicating periapical radiolucency. (g) 18 months follow-up showing healed lesion

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The patient was explained about treatment options and alternatives and was given time to decide. The patient was willing for revascularization procedure. In the first visit, after local infiltration anesthesia with 1.8 mL of 2% lidocaine with 1:80,000 epinephrine, the working length determination was done and periapical radiograph was taken with master file to ensure not to violate the open apex [Figure 1]. The root canal irrigation was done with 20 mL of 5.25% NaOCl followed by saline. The canal was dried with sterile paper point and calcium hydroxide medicament was filled. The cavity opening was closed with cotton pellet and temporary restoration was done.

After 3 weeks in the second visit, when the patient was asymptomatic, revascularization procedure was performed under local infiltration with 1.8 mL of 2% lidocaine without vasoconstrictor to facilitate bleeding.[5] The access cavity was opened and the temporary filling was removed using burs and files. The cotton pellet was removed from the canal and irrigated with 17% EDTA and saline. The canal was dried and the blood clot was produced inside the canal by instrumenting sterile H file 1 mm beyond the tooth apex. Then, the Collaplug is placed as a scaffold exactly to the working length. Clot is allowed to form for 15 min. Above the clot layer, ProRoot MTA of about 3 mm thickness was placed slightly below the cementoenamel junction [Figure 1]. Moist cotton is placed over it and glass ionomer filling was done.

Two days later, moist cotton was removed. The surface MTA was checked for setting with an explorer and directly additional layer of glass ionomer cement was applied over MTA. Above the GIC layer, composite restoration was made. Three months later, at the first follow-up, no signs or symptoms were noted. The patient was recalled at every 3 months and response checked as the tooth remained asymptomatic. At 18 months' follow-up, IOPA radiograph was taken to evaluate the revascularization procedure. The periapical radiolucency was healed and root closure began to appear. Increased thickness of root width was also found [Figure 1].


   Discussion Top


In this case report, the patient had trauma of the maxillary lateral incisor before the tooth root has been fully formed. Hence, the patient was having open apex and lesser root width. In order to achieve proper root closure, regenerative endodontic therapy is considered as a better option.[6],[7]

As per the revised AAE guidelines (July 2013), the primary objective of regenerative endodontic therapy is healing of apical periodontitis. According to it, the secondary objective is to increase root wall thickness and/or root length. The tertiary objective is to achieve a positive response to pulp testing. Both the secondary and tertiary objectives are advantageous but not the main criteria to establish the clinical success.[8] Both the primary and secondary goal has been achieved in this case.

Pulp revascularization is a biological procedure that permits the progression of root development with strengthening of root walls and achievement of proper apical seal. This procedure allows the migration of stem cells from the apical region to the pulpal area in young permanent teeth with immature apex. When compared with apexification, the treatment duration is lesser in pulp revascularization for apical closure.[9],[10]

The main success of pulp revascularization depends on eliminating intracanal bacteria with efficient root canal disinfectants. Incomplete elimination of infection in the root canal may hinder the regenerative and repair process of the pulpal tissues, even though numerous stem cells are produced inside the root canal. Root canal disinfection is done with the proper use of irrigants and intracanal medicaments. The dentist should choose the most effective antimicrobial agent for canal irrigation. Since the apex is open, care should be taken not to use a relatively toxic agent as it may destroy the stem cells and vasculature which are responsible for regeneration.

According to literature, the various concentrations of NaOCl (6%,[11] 5.25%,[12] 2.5%,[13] 1.25%[14]) and various concentrations of CHX (0.12% to 2%)[15] have been successfully used as irrigants. About 17% EDTA[16] is more promising as it is beneficial for providing dentin derived growth factors and favors introduction and stimulation of stem cells to reestablish the integrity of canal walls. Commonly used intracanal medicaments include triple antibiotic paste (i.e., metronidazole, minocycline, and ciprofloxacin)[17],[18] or calcium hydroxide.[19] Antibiotic paste is effective against the major intracanal pathogens but it has several disadvantages such as resistance to antibiotic susceptibility, hypersensitivity reaction, and crown discoloration due to minocycline. Calcium hydroxide is considered as effective replacement as an intracanal medicament due to its antibacterial properties.[19] It does not cause crown discoloration, promotes the production of growth factors from dentin, and its ease of access and availability. In this study, 5.25% NaOCl had been used for effective disinfection of root canal followed by intracanal medicament. About 17% EDTA along with saline was used for final irrigation once the medicament inside the canal was removed. Another factor for the success of pulp revascularization is minimal instrumentation to make sure that the infected and residual pulpal tissue was removed without affecting the integrity of the canal walls.[20]

After successful disinfection, the intracanal medicament was eliminated and a file prick was done in the apical region to induce bleeding inside the canal which turns into a blood clot. Local infiltration without vasoconstrictor should be given to promote bleeding in the canal. The blood clot is enriched with numerous growth factors which is an important source for regeneration. Various growth factors such as platelet-derived growth factor, vascular endothelial growth factor, platelet-derived epithelial growth factor, and tissue growth factor produce growth and differentiation of root forming cells such as fibroblasts, odontoblasts, and cementoblasts. These cells contribute to regeneration and revascularization in the root canal.[21] At last, the orifice of the canal was closed with MTA (Dentsply Tulsa Dental, Tulsa, OK). The permanent restoration can be placed over MTA. MTA helps in the maintenance of vitality of pulp tissues and provides the appropriate medium for revascularization and regeneration. The steps in revascularization can be summarized as follows:

  1. Intracanal bacterial elimination with proper root canal disinfectants of root canal – use of irrigants and intracanal medicaments
  2. Induction of bleeding in the apical region with a file to produce blood clots enriched with various growth factors
  3. Bacteria free tight sealing of the canal orifice with hermetic coronary filling.



   Conclusion Top


Re-establishing blood flow and completion of root development are the primary objectives of pulp revascularization. Revascularization of viable tissues of the pulp canal can increase the thickness of root structure which restores the normal anatomy of the tooth. As per the recent studies, the apexification procedure has several disadvantages in treating young permanent teeth, revascularization emerges as a newly encouraging treatment modality that preserves the biological environment and reduces treatment time. Although revascularization shows clinically acceptable results, care should be taken to achieve proper disinfection of canals and regular follow-up to improve long-term efficacy and new approaches.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Rafter M. Apexification: A review. Dent Traumatol 2005;21:1-8.  Back to cited text no. 1
    
2.
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3.
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Huang GT. A paradigm shift in endodontic management of immature teeth: Conservation of stem cells for regeneration. J Dent 2008;36:379-86.  Back to cited text no. 4
    
5.
Trevino EG, Patwardhan AN, Henry MA, Perry G, Dybdal-Hargreaves N, Hargreaves KM, et al. Effect of irrigants on the survival of human stem cells of the apical papilla in a platelet-rich plasma scaffold in human root tips. J Endod 2011;37:1109-15.  Back to cited text no. 5
    
6.
Cvek M, Jones CP, Austin J, Lownie J, Kling M, Fatti P. Pulp revascularization in reimplanted immature monkey incisors–predictability and the effect of antibiotic systemic prophylaxis. Dental Traumatol 1990;6:157-65.  Back to cited text no. 6
    
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8.
Considerations for Regeneration procedures. J Endod 2013;39 (3 Suppl):44-56.  Back to cited text no. 8
    
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Zhang W, Yelick PC. Vital pulp therapy-current progress of dental pulp regeneration and revascularization. Int J Dent 2010:1-9.  Back to cited text no. 9
    
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Lovelace TW, Henry MA, Hargreaves KM, Diogenes A. Evaluation of the delivery of mesenchymal stem cells into the root canal space of necrotic immature teeth after clinical regenerative endodontic procedure. J Endod 2011;37:133-8.  Back to cited text no. 10
    
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Shin SY, Albert JS, Mortman RE. One step pulp revascularization treatment of an immature permanent tooth with chronic apical abscess: A case report. Int Endod J 2009;42:1118-26.  Back to cited text no. 11
    
12.
Petrino JA, Boda KK, Shambarger S, Bowles WR, McClanahan SB. Challenges in regenerative endodontics: A case series. J Endod 2010;36:536-41.  Back to cited text no. 12
    
13.
Chueh LH, Huang GT. Immature teeth with periradicular periodontitis or abscess undergoing apexogenesis: A paradigm shift. J Endod 2006;32:1205-13.  Back to cited text no. 13
    
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Thibodeau B, Trope M. Pulp revascularization of a necrotic infected immature permanent tooth: Case report and review of the literature. Pediatr Dent 2007;29:47-50.  Back to cited text no. 14
    
15.
Hoshino E, Kurihara-Ando N, Sato I, Uematsu H, Sato M, Kota K, et al. In-vitro antibacterial susceptibility of bacteria taken from infected root dentine to a mixture of ciprofloxacin, metronidazole and minocycline. Int Endod J 1996;29:125-30.  Back to cited text no. 15
    
16.
Yamauchi N, Yamauchi S, Nagaoka H, Duggan D, Zhong S, Lee SM, et al. Tissue engineering strategies for immature teeth with apical periodontitis. J Endod 2011;37:390-7.  Back to cited text no. 16
    
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Shah N, Logani A, Bhaskar U, Aggarwal V. Efficacy of revascularization to induce apexification/apexogensis in infected, nonvital, immature teeth: A pilot clinical study. J Endod 2008;34:919-25.  Back to cited text no. 17
    
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Nosrat A, Seifi A, Asgary S. Regenerative endodontic treatment (revascularization) for necrotic immature permanent molars: A review and report of two cases with a new biomaterial. J Endod 2011;37:562-7.  Back to cited text no. 18
    
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Behnen MJ, West LA, Liewehr FR, Buxton TB, McPherson JC 3rd. Antimicrobial activity of several calcium hydroxide preparations in root canal dentin. J Endod 2001;27:765-7.  Back to cited text no. 19
    
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Jadhav G, Shah N, Logani A. Revascularization with and without platelet-rich plasma in nonvital, immature, anterior teeth: A pilot clinical study. J Endod 2012;38:1581-7.  Back to cited text no. 20
    
21.
Wang Q, Lin XJ, Lin ZY, Liu GX, Shan XL. Expression of vascular endothelial growth factor in dental pulp of immature and mature permanent teeth in human. Shanghai Kou Qiang Yi Xue 2007;16:285-9.  Back to cited text no. 21
    


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