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Title Biomechanical Preparation of the Canal Space is Unnecessary with Pulpal Regeneration Therapy
Clinical Question When treating an immature necrotic tooth with pulpal regeneration, does minimal biomechanical preparation of the canal, compared to no biomechanical preparation of the canal, result in greater clinical success?
Clinical Bottom Line There is no evidence that biomechanical preparation is necessary for adequate disinfection of the canal space when attempting a pulpal regeneration treatment. The level of evidence available to support this is low.
Best Evidence (you may view more info by clicking on the PubMed ID link)
PubMed ID Author / Year Patient Group Study type
(level of evidence)
#1) 25301351Kontakiotis/201460 publications Narrative Review
Key resultsThis article seeks to analyze the different clinical protocols that have been employed in regenerative endodontic therapy. Of the 60 articles included, two are prospective cohort studies, one is a retrospective cohort study, and the rest are case series / case reports. 68% of articles reported no biomechanical instrumentation of the canal walls and an additional 28% reported minimal instrumentation. The lack of studies with a high level of evidence prohibits making any conclusion regarding the use, or not, of biomechanical instrumentation. In addition, the review shows that there is considerable variation of protocols used for regenerative endodontic therapy. A systematic analysis of the different available protocols could potentially provide meaningful clinical considerations for regenerative endodontic procedures.
#2) 22980172Jeeruphan, T, et al/201261 cases (20 revascularization)Retrospective Comparative Study
Key resultsThe treatment protocol for the 20 revascularization cases included no biomechanical instrumentation of the canals. Disinfection was achieved through irrigation with 2.5% NaOCl and placement of triple antibiotic paste for 28.85 +/- 13.08 days. Treatment outcomes were considered for success and survival. For the pulpal revascularization group, there was 100% survival, 80% healed and 20% healing at the recall interval.
#3) 24461403Nagy, M, et al/201436 patients (24 pulpal regeneration)Randomized Clinical Trial
Key resultshe treatment protocol included “minimal” instrumentation and irrigation with 2.6% NaOCl of the canal space before placing triple antibiotic paste for 3 weeks. The two regenerative protocols used, consisted of blood clot induction with or without hydrogel placement in the canal. Recall periods of 3, 6, 12, and 18 months were used and patients were evaluated for increase in root length and width, size of apical diameter and change in periapical bone density. Success rates for the protocols were 90% for the no hydrogel group and 80% for the hydrogel group.
#4) 25301351AAE Regenerative Endodontics CommitteeN/AExpert Opinion
Key resultshttp://www.aae.org/uploadedfiles /publications_and_research/research/ currentregenerativeendo donticconsiderations.pdf The committee regularly updates the treatment guidelines according the most current and best evidence available. The most recent update was on 4-12-15. The committee states, “These considerations should be seen as one possible source of information and, given the rapid evolving nature of this field, clinicians should also actively review new findings elsewhere as they become available. “ Within the recommendations provided, no biomechanical instrumentation of the canal is recommended.
Evidence Search Pulp regeneration protocols and Revascularization immature teeth
Comments on
The Evidence
There does not exist a study or review that directly discusses the necessity of biomechanical preparation of the canal space. The studies done by Jeeruphan, et al(2012) and Nagy, et al (2014) are able to report success rates due to study design but biomechanical preparation of the canals was not an examined variable. These studies have been included here to demonstrate high success rates using either no or minimal biomechanical preparation of the canal. In the review done by Kontakiotis, et al (2014), there were 3 case reports identified where “complete” canal instrumentation prior to the regeneration treatment was performed. The remainder of the cases reported (96%) used either “no” or “minimal” biomechanical preparation. Since the vast majority of the articles included in the review are case reports or case series, no conclusions about success rates of the different protocols can be established. Opponents to instrumentation express concern over further weakening and thinning of already compromised dentinal walls. There is also some speculation that the bioactive molecules that may aid in stem cell differentiation contained in the dentin may be damaged or destroyed by the instrumentation. The argument in favor of instrumentation is complete debridement and disinfection of the canal space. While it is agreed upon that disinfection is necessary for pulpal regeneration to occur, it appears that use of NaOCl irrigation and triple antibiotic paste is adequate to obtain an appropriate level of disinfection. High level evidence in the form of a randomized controlled clinical trial to definitively establish a treatment protocol is currently lacking in the literature. The AAE is offering funding for high level research projects to fill this void in the evidence. Due to the lack of an established clinical protocol, the clinical considerations for regenerative endodontic procedures established by the AAE is usually used as the standard protocol. However, the AAE recommends that clinicians should also actively review new clinical findings as they become available in the literature.
Applicability Regenerative Endodontic Therapy may be considered the best treatment for immature necrotic teeth.  Many treatment protocols appear in the literature, but due to low level of evidence, it is not possible to choose one protocol as best.  It is recommended to follow the AAE’s current best practice.
Specialty/Discipline (Endodontics)
Keywords regenerative endodontic therapy, systematic review, pulp regeneration protocols, Revascularization immature teeth, regenerative endodontic review
ID# 2916
Date of submission: 12/31/2015spacer
E-mail maryhen.arrieta@ucdenver.edu
Author Maryhen Arrieta
Co-author(s) Ana Puente
Co-author(s) e-mail ana.puente@ucdenver.edu
Faculty mentor/Co-author Thomason Ethelyn, DMD
Faculty mentor/Co-author e-mail ethelyn.thomasonlarsen@ucdenver.edu
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