The present case report is the first of its kind that documents the successful outcome of “revascularization,” a regeneration-based treatment protocol in a mature adult patient. It belies the myth that “revascularization” should only be done in children and young, adolescent patients. The misconception that stem cells number as well as viability in older age group patients will not allow revascularization to be successful is also contradicted by this case. The paper highlights all the mechanisms that come into play and the enhancing of regenerative response by supplementation with platelet-rich plasma (PRP). 1. Introduction Revascularization as a treatment option for the management of nonvital, immature teeth is an established ADA procedure code [1]. Numerous case reports/case series have documented its efficacy and success. Till date, its application has been limited to the patients between the age group of 8 and 16 years [2] and in teeth with minimal periapical pathology. However the scope of this procedure stands to change with the growing evidence of persistence of self-maintained mesenchymal stem cells (MSCs) in adults [3] and advent of superior scaffolds like platelet-rich plasma and platelet-rich fibrin that delivers enhanced concoction of growth factors. In addition, the presence of inflamed periapical progenitor cells (iPAPCs) [4], infection survived stem cells from apical papilla (SCAP) [5] in teeth with large periapical pathology, may further widen its horizon. The present case reports the use of platelet-rich plasma as a supplementary scaffold for successful revascularization of a maxillary lateral incisor associated with large periapical lesion in a forty-year-old Asian male. 2. Case Report A 40-year-old healthy Asian male presented with the chief complaint of intermittent pus discharge from the right upper gums. Patient gave a history of trauma sustained thirty years ago while playing. Clinical examination revealed a discolored right maxillary lateral incisor and an associated intraoral draining sinus in the labial vestibular region. On palpation a localized bony hard swelling was discernible. The tooth was nontender to percussion and had a grade I mobility. Vitality tests (cold and electric pulp tests) were negative. Intraoral tracer periapical radiograph with a 30 gutta-percha point was exposed (Figure 1(a)). It revealed a blunderbuss root apex with thin lateral dentinal walls associated with a large periapical pathology measuring (Figure 1(a)). Based on clinical, pulp sensibility and radiographic findings, a diagnosis of pulp necrosis
References
[1]
American Dental Association, CDT, 2011-2012: The ADA Practical Guide to Dental Procedure Codes, American Dental Association, Chicago, Ill, USA, 2010.
[2]
F. Garcia-Godoy and P. E. Murray, “Recommendations for using regenerative endodontic procedures in permanent immature traumatized teeth,” Dental Traumatology, vol. 28, no. 1, pp. 33–41, 2012.
[3]
E. Fuchs and J. A. Segre, “Stem cells: a new lease on life,” Cell, vol. 100, no. 1, pp. 143–155, 2000.
[4]
K. M. Hargreaves, A. Diogenes, and F. B. Teixeira, “Treatment options: biological basis of regenerative endodontic procedures,” Journal of Endodontics, vol. 39, pp. S30–S43, 2013.
[5]
R. Y. Ding, G. S. P. Cheung, and J. Chen, “Pulp revascularization of immature teeth with apical periodontitis: a Clinical Study,” Journal of Endodontics, vol. 35, pp. 745–749, 2009.
[6]
E. Hoshino, N. Kurihara-Ando, I. Sato et al., “In-vitro antibacterial susceptibility of bacteria taken from infected root dentine to a mixture of ciprofloxacin, metronidazole and minocycline,” International Endodontic Journal, vol. 29, no. 2, pp. 125–130, 1996.
[7]
E. G. Trevino, A. N. Patwardhan, M. A. Henry 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,” Journal of Endodontics, vol. 37, no. 8, pp. 1109–1115, 2011.
[8]
G. T.-J. Huang, “A paradigm shift in endodontic management of immature teeth: conservation of stem cells for regeneration,” Journal of Dentistry, vol. 36, no. 6, pp. 379–386, 2008.
[9]
L. Sp？ngberg, “Biological effects of root canal filling materials. 4. Effect in vitro of solubilised root canal filling materials on HeLa cells,” Odontologisk Revy, vol. 20, no. 3, pp. 289–299, 1969.
[10]
A. Y. Saad, “Calcium hydroxide and apexogenesis,” Oral Surgery, Oral Medicine, Oral Pathology, vol. 66, no. 4, pp. 499–501, 1988.
[11]
T. Sato, E. Hoshino, H. Uematsu, and T. Noda, “In vitro antimicrobial susceptibility to combinations of drugs on bacteria from carious and endodontic lesions of human deciduous teeth,” Oral Microbiology and Immunology, vol. 8, no. 3, pp. 172–176, 1993.
[12]
J.-H. Kim, Y. Kim, S.-J. Shin, J.-W. Park, and I.-Y. Jung, “Tooth discoloration of immature permanent incisor associated with triple antibiotic therapy: a case report,” Journal of Endodontics, vol. 36, no. 6, pp. 1086–1091, 2010.
[13]
N. Cohenca, C. Heilborn, J. D. Johnson, D. S. H. Flores, I. Y. Ito, and L. A. B. da Silva, “Apical negative pressure irrigation versus conventional irrigation plus triantibiotic intracanal dressing on root canal disinfection in dog teeth,” Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology, vol. 109, no. 1, pp. e42–e46, 2010.
[14]
N. Shah, A. Logani, U. Bhaskar, and V. Aggarwal, “Efficacy of revascularization to induce apexification/apexogensis in infected, nonvital, immature teeth: a Pilot Clinical Study,” Journal of Endodontics, vol. 34, no. 8, pp. 919–925, 2008.
[15]
K. M. Hargreaves, T. Giesler, M. Henry, and Y. Wang, “Regeneration potential of the young permanent tooth: what does the future hold?” Journal of Endodontics, vol. 34, no. 7, pp. S51–S56, 2008.
[16]
B. Thibodeau, F. Teixeira, M. Yamauchi, D. J. Caplan, and M. Trope, “Pulp revascularization of immature dog teeth with apical periodontitis,” Journal of Endodontics, vol. 33, no. 6, pp. 680–689, 2007.
[17]
G. Jadhav, N. Shah, and N. Logani, “Revascularization with and without Platelet-rich Plasma in non-vital, immature, anterior teeth: a Pilot Clinical Study,” Journal of Endodontics, vol. 38, pp. 1581–1157, 2012.
[18]
V. Y. Shivashankar, D. A. Johns, S. Vidyanath, and M. R. Kumar, “Platelet rich fibrin in revitalization of tooth with necrotic pulp and open apex,” Journal of Conservative Dentistry, vol. 15, pp. 395–398, 2012.
[19]
J. A. Petrino, K. K. Boda, S. Shambarger, W. R. Bowles, and S. B. McClanahan, “Challenges in regenerative endodontics: a case series,” Journal of Endodontics, vol. 36, no. 3, pp. 536–541, 2010.
[20]
A. Nosrat, A. Seifi, and S. Asgary, “Regenerative endodontic treatment (revascularization) for necrotic immature permanent molars: a review and report of two cases with a new biomaterial,” Journal of Endodontics, vol. 37, no. 4, pp. 562–567, 2011.
[21]
I. Blazsek, J. Chagraoui, and B. Péault, “Ontogenic emergence of the hematon, a morphogenetic stromal unit that supports multipotential hematopoietic progenitors in mouse bone marrow,” Blood, vol. 96, no. 12, pp. 3763–3771, 2000.
[22]
L. Song, N. E. Webb, Y. Song, and R. S. Tuan, “Identification and functional analysis of candidate genes regulating mesenchymal stem cell self-renewal and multipotency,” Stem Cells, vol. 24, no. 7, pp. 1707–1718, 2006.
[23]
T. W. Lovelace, M. A. Henry, K. M. Hargreaves, and A. Diogenes, “Evaluation of the delivery of mesenchymal stem cells into the root canal space of necrotic immature teeth after clinical regenerative endodontic procedure,” Journal of Endodontics, vol. 37, no. 2, pp. 133–138, 2011.
