Clinical Research

Treatment of Mature Permanent Teeth with Necrotic Pulps

and Apical Periodontitis Using Regenerative Endodontic
Procedures: A Case Series
Tarek Mohamed Saoud, BDS, MSC, PhD,* Gabriela Martin, DDS, PhD,
Yea-Huey M. Chen, DDS, MS, Kuang-Liang Chen, DDS, Chao-An Chen, DDS,
Kamolthip Songtrakul, DDS, MS, Matthew Malek, DDS, Asgeir Sigurdsson, DDS, MS,
and Louis M. Lin, BDS, DMD, PhD
Abstract
Introduction: Regenerative endodontic procedures
(REPs) are usually used to treat human immature permanent teeth with necrotic pulps and/or apical periodontitis. Successful REPs result in the elimination of clinical
signs/symptoms, the resolution of apical periodontitis,
and, in some cases, thickening of the canal walls and/
or continued root development with or without apical
closure. REPs can restore the vitality of tissue in the
canals of immature permanent teeth previously
destroyed by infection or trauma. Vital tissue is inherited
with immune defense mechanisms to protect itself from
foreign invaders. Recently, REPs have also been used to
successfully treat human mature permanent teeth with
necrotic pulps and apical periodontitis. The purpose of
this case series was to present the potential of using
REPs for mature permanent teeth with necrotic pulps
and apical periodontitis. Methods: This case series consisted of 6 patients, 4 females and 2 males. The patients
ages ranged from 821 years old. Seven permanent
teeth, 4 anterior and 3 molar teeth, with necrotic pulps
and apical periodontitis were treated using REP. Radiographically, the root development of all teeth was
almost completed except the apices of 2 molars, which
showed slightly open. Complete chemomechanical
debridement of the canals of the teeth was performed,
and the canals were dressed with Metapaste (Meta Biomed Co, Ltd, Chungbuk, Korea) during treatment visits.
Periapical bleeding into the canals was induced at the
last treatment visit by placing a hand #20 or #25 K-file
with the tip slightly bent through the apical foramina
into the periapical tissues. A 3-mm thickness of
mineral trioxide aggregate was placed into the coronal
canals over semicoagulated blood. The access cavities
were restored with either composite resin or amalgam.

Results: Follow-ups of the 7 teeth ranged from 8 to 26 months. The periapical lesions
of 2 teeth were considered healed, and 5 teeth revealed healing. Clinical signs/symptoms were absent in all teeth at follow-up visits at different time points. None of the
treated teeth responded to cold and electric pulp tests. Conclusions: This case series
shows the potential of using REPs for mature teeth with necrotic pulp and apical periodontitis. (J Endod 2015;-:19)

Key Words
Apical periodontitis, immune defense mechanisms, mature teeth, necrotic pulps, regenerative endodontic therapy, vital tissue

egenerative endodontics is defined as biologically based procedures designed to

physiologically replace a damaged tooth structure, including dentin and root structures, and the pulp-dentin complex (1). Regenerative endodontic procedures (REPs)
are currently used to treat immature permanent teeth with infected or noninfected
necrotic pulps (2). REPs have been shown to be able to eliminate clinical signs/symptoms and resolve apical periodontitis. In addition, thickening of the canal walls and/or
continued root development have been shown in some cases (35). According to the
American Association of Endodontists Clinical Considerations for a Regenerative
Procedure, the primary goal of REPs is elimination of clinical signs/symptoms and
resolution of apical periodontitis (6). Increased thickening of the canal walls and/or
continued root development are secondary goals in those considerations (6). Therefore, it can be stated that the primary goal of REPs is similar to that of nonsurgical
root canal therapy.
Traditionally, mature permanent teeth with infected or noninfected necrotic pulps
are treated with nonsurgical root canal therapy, which includes chemomechanical
debridement, intracanal mediation, and root filling. The outcome of nonsurgical
root canal therapy is considered predictable (7). Recently, REPs have been used to successfully treat mature teeth with necrotic pulps and apical periodontitis (810). The
treatment also resulted in the elimination of clinical signs/symptoms and resolution
of apical periodontitis. The difference between nonsurgical root canal therapy and
an REP is that the disinfected canals are filled with biocompatible, nonvital foreign
materials in the former therapy and vital tissue in the latter therapy.

From the*Department of Endodontics, Faculty of Dentistry, University of Benghazi, Benghazi, Libya; Department of Endodontics, Faculty of Dentistry, National
University of Cordoba, Cordoba, Argentina; Department of Endodontics, Chi Mei Medical Center, Yong Kang and Liouying, Tainan, Taiwan; and Department of
Endodontics, College of Dentistry, New York University, New York, New York.
Address requests for reprints to Dr Louis M. Lin, Department of Endodontics, NYU College of Dentistry, 345 East 24th Street, New York, NY 1000. E-mail address:
lml7@nyu.edu
0099-2399/$ - see front matter
Copyright 2015 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2015.09.015

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Teeth with Necrotic Pulps and Apical Periodontitis

Clinical Research
and 3 molar teeth, were treated using REPs. Three teeth had caries,
which caused pulp necrosis and apical periodontitis. Five teeth had a
history of trauma and subsequently developed pulp infection and apical
periodontitis. Four teeth were associated with intraoral swelling. Two
traumatized teeth showed discoloration. Radiographically, the roots
of all teeth had a periapical radiolucent lesion of endodontic origin
(Table 2). The root development of all teeth was almost complete,
except the apices of the distal roots of 2 mandibular first molars
(#19), which showed exhibited slightly open (Figs. 1AD and 2AD).

TABLE 1. Demographics of Patients

Patient no.
1
2
3
4
5
6

Sex

Age (y)

Tooth no.

M
F
F
M
F
F

14
18
21
11
9
8

25
8, 9
8
30
19
19

F, female; M, male.

The tissues generated in the canals of human immature permanent

teeth with infected necrotic pulps and apical periodontitis after REPs are
cementumlike, bonelike, periodontal ligamentlike tissues; blood vessels; and nerve fibers (1114). Although these tissues are not true pulp
tissue, they are the hosts own vital tissue, which is inherited with
immune defense mechanisms to protect itself from foreign invaders.
Therefore, REPs are able to restore the vitality of tissue in the canals
of immature permanent teeth that was previously destroyed by
infection or trauma. However, it is not known whether tissues can be
generated in the canals of human mature permanent teeth after REPs
because there are no histologic studies available.
Based on previous case reports (810) and the primary goal of
REPs, it was believed that REPs might have the potential to be used to
treat human mature permanent teeth with infected or noninfected
necrotic pulp. The purpose of this case series was to present the
potential of using REPs for human mature permanent teeth with
infected or noninfected necrotic pulps and apical periodontitis in
terms of elimination of clinical signs/symptoms and resolution of
apical periodontitis. The present case series is part of our multiinstitutional clinical trials of REPs for human mature permanent teeth
with infected or noninfected necrotic pulps. Written informed consents
were obtained from the patients.

Case Series
Six patients were treated in the endodontic clinic at the faculty of
dentistry, University of Benghazi. The patients chief complaint and the
dental and medical histories were obtained. Preoperative radiographs
of all teeth were taken. Pulp tests using cold, heat, and an electric pulp
tester were performed. Intraoral and extraoral examinations were
conducted. Swelling, the presence of draining sinus tracts, and tooth
discoloration were recorded. A diagnosis of pulpal-periapical disease
was based on the chief complaint, clinical signs/symptoms, pulp tests,
and radiographic findings.
The demographics of the patients are summarized in Table 1. The
present case series consisted of 6 patients, 4 females and 2 males. The
patients ages ranged from 821 years. Seven mature teeth, 4 anterior

Summary of Treatment Procedures

To avoid repetition of some treatment procedures among 7 cases,
the treatment procedures are summarized as follows.
First Treatment Visit. Local anesthetic with 2% lidocaine containing 1:100,000 epinephrine was given as local infiltration for anterior
teeth and an inferior alveolar block for molar teeth. The endodontically
involved tooth was isolated with a rubber dam. All caries were removed.
The access cavity was made through the lingual surface of the crown of
anterior teeth and the occlusal surface of the crown of molar teeth. The
canal/canals were located. The pulp chamber was irrigated with 2.5%
sodium hypochlorite solution (Household Cleaning Products Company
of Egypt, Cairo, Egypt). A working length 0.5 mm short of the radiographic apex was determined with the electronic apex locator and periapical radiographs. The canals were initially instrumented to the
working length with hand K-files to #20 and then prepared with ProTaper Universal rotary files (Dentsply International, Ballaigues,
Switzerland) to F1 (tip size #20) with copious amounts of sodium hypochlorite irrigation during instrumentation. The canals were dried
with paper points and dressed with Metapaste (calcium hydroxide;
Meta Biomed Co, Ltd, Chungbuk, Korea). The access cavity was closed
with a sterile cotton pellet and intermediate restorative material (IRM)
(Dentsply International) for 2 weeks.
Second Treatment Visit. Under local anesthesia with 2% lidocaine containing 1:100,000 epinephrine, the tooth was isolated with
a rubber dam and reopened. The cotton pellet and IRM were removed
from the access cavity. Metapaste was flushed out of the canal with sodium hypochlorite irrigation. The canal was again prepared with ProTaper Universal Rotary files to F5 (tip size #40) for teeth #8 and #9
and F3 (tip size #30) for tooth #25. The mesiobuccal and mesiolingual
canals were prepared to F2 (tip size #25) and the distal canals to F4 (tip
size #35) of teeth #19 and #30 with copious amounts of sodium hypochlorite irrigation. After complete chemomechanical debridement, a
#15 K-file was used to penetrate into the periapical tissues through
all canals to ensure the patency of the apical foramina. The canals
were dried and dressed with Metapaste. The access cavity was closed
with a cotton pellet and IRM for 2 weeks.

TABLE 2. Clinical Signs/Symptoms, Diagnosis, and Treatment Outcomes of 7 Teeth Treated Using RET
Patient Tooth
no.
no.
1
2
3

25
8
9
8

4
5
6

30
19
19

Dental history

Clinical examination

Clinical tests

Trauma
Trauma pain
Trauma pain
Trauma intraoral
swelling,
sinus tract
Caries
Caries
Caries

Tooth discoloration
Crown fracture
Crown fracture
Tooth discoloration

e(
e(
e(
e(

Intraoral swelling
Intraoral swelling
Intraoral swelling

e( ), pc(+), pp(+)
e( ), pc(+), pp(+)
e( ), pc(+), pp(+)

), pc( ), pp( )
), pc(+), pp(+)
), pc(+), pp(+)
), pc(+), pp(+)

Radiologic
examination

Clinical
diagnosis

Periapical Last control

status
(month)

PAP
PAP
PAP
PAP

PN and AAP
PN and SAP
PN and SAP
PN and CAA

Healed
Healing
Healing
Healed

13
12
12
26

PAP
PAP
PAP

PN and AAA
PN and AAA
PN and AAA

Healing
Healing
Healing

12
12
8

AAA, acute apical abscess; AAP, asymptomatic apical periodontitis; CAA, chronic apical abscess; e, electric pulp test; PAP, periapical pathology; pc, percussion; PN, pulp necrosis; pp, palpation; SAP, symptomatic
apical periodontitis.

Saoud et al.

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Clinical Research

Figure 1. (A) A preoperative radiograph of tooth #19. Small periapical radiolucent lesions at the apices of the mesial and distal roots. The roots are fully developed. The apex of the distal root is slightly open. (B) A postoperative radiograph after REPs. (C) Seven-month follow-up, evidence of healing of periapical radiolucent lesions of both roots. (D) Twelve-month follow-up, periapical radiolucent lesions of both roots show healing. The tooth was asymptomatic.

Third Treatment Visit. Local anesthetic with 3% Carbocaine

(Septodont, Paris, France) without vasoconstrictor was administered.
The tooth was reopened, and the cotton pellet and IRM were removed
from the access cavity under rubber dam isolation. Metapaste was
flushed out of the canals with sodium hypochlorite irrigation. The canals were dried and rinsed with sterile saline solution and dried. Finally,
the canals were irrigated with 17% EDTA and dried with paper points. A
hand #25 K-file with the tip slightly bent was introduced 3 mm into the
periapical tissues through the distal canals of teeth #19 and #30 and the
canals of other teeth (#8, #9, and #25), whereas a #20 K-file was used
for the mesiobuccal and mesiolingual canals of teeth #19 and #30 to
provoke bleeding into the canals up to the canal orifices under the
observation of a magnifying surgical loupe. Bleeding could not be
achieved to the canal orifices of the mesiobuccal and mesiolingual
canals of teeth #19 and #30. An attempt was made to provide bleeding
from the distal canals to the mesial canals. After approximately 15 minutes, when the blood became semicoagulated, a 3-mm thickness of
mineral trioxide aggregate (MTA; Dentsply Tulsa Dental, Tulsa, OK)
mixed with saline solution to a putty consistence was placed into the
coronal canals using an amalgam carrier. Collagen matrix was not
used because the canal space of mature teeth was not as large as that
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of immature teeth. A moist cotton pellet was placed over MTA, and
the access cavity was closed with IRM for 3 days. Postoperative radiographs were taken.
Fourth Treatment Visit. Without local anesthesia, the IRM and
cotton pellet were removed under rubber dam isolation. Setting of
MTA was confirmed with an endodontic explorer. The access cavities
were restored with either composite resin or amalgam.

Follow-up Examination
Follow-ups of 7 cases ranged from 8 to 26 months (Table 1).
Radiographic assessment of the change in periapical lesions of 7 teeth
after treatment was evaluated based on the criteria of healed, healing,
and disease used by Orstavik et al (15, 16). Healed is defined as no
clinical signs/symptoms and normal periapical radiographic
presentation. Healing is reduced periapical radiolucency and no
clinical signs/symptoms. Disease is new development or persistence
of periapical radiolucency or the presence of clinical signs/symptoms
(16). Two teeth were considered healed, and 5 teeth revealed healing
at their last control (Table 1). All teeth were asymptomatic at their
follow-up visits with no response to cold or electric pulp tester tests.
Teeth with Necrotic Pulps and Apical Periodontitis

Clinical Research

Figure 2. (A) A preoperative radiograph of tooth #19. A large periapical radiolucent lesion at the apex of the distal root and thickening of periodontal ligament
space at the apex of the mesial root. Both mesial and distal roots are well developed. (B) A postoperative radiograph after REPs. (C) Five-month follow-up, evidence
of healing of periapical radiolucent lesions at both roots. (D) Eight-month follow-up, periapical radiolucent lesions of both roots show healing. The tooth was
asymptomatic. The patient lost contact after the 8-month follow-up.

We lost contact with patient #6 after the 8-month follow-up. Radiographs of the treatment outcomes of 7 cases using REPs are shown in
Figures 16.

Discussion
Mature permanent teeth with necrotic pulps and/or apical periodontitis are traditionally treated with nonsurgical root canal therapy
because the treatment outcome is considered predictable (7). Recently,
REPs have been used to successfully treat mature permanent teeth with
infected necrotic pulps and apical periodontitis. The treatment resulted
in elimination of clinical signs/symptoms and resolution of apical periodontitis (810). In the present case series, we have presented 7 cases
of mature permanent teeth with necrotic pulps and apical periodontitis
successfully treated using REPs.
The root development of mandibular first molars normally completes at 9 or 10 years of age. Although the apices of the distal roots
of 2 mandibular first molars (#19) were slightly open, which could
4

Saoud et al.

be because of apical periodontitis, we considered that these 2 molars

could be treated as mature teeth because the development of the canal
walls and the root length of the distal roots were nearly completed.
The size of the apical foramen appears to be a major concern in
REPs. It was suggested that an apical foramen of at least 1.1 mm in diameter was necessary for successful revascularization of the pulp tissue in
reimplanted human permanent incisors (17). Therefore, human
mature permanent teeth with completely formed root apices having
necrotic pulps were considered not suitable for REPs. However, a study
using an animal model showed that an apical foramen 0.32 mm in diameter did not prevent revascularization and ingrowth of new tissue into
canals after transplantation (18).
In studying regeneration of dental pulplike tissue by
chemotaxis-induced cell homing, the apical foramina of the human
mature permanent incisors and canines were not enlarged. Dental
pulplike tissue was formed in the entire root canal from the root
apex to the pulp chamber upon delivery of growth factors into the chemomechanically debrided canals of the teeth implanted in mouse
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Figure 3. (A) A preoperative radiograph of tooth #25. A well-defined periapical radiolucent lesion at the apex. The root is completely formed. (B) A postoperative
radiograph after REPs. (C) Ten-month follow-up, healing of periapical radiolucent lesion. (D) Thirteen-month follow-up, the periapical radiolucent lesion is
healed. The tooth was asymptomatic.

dorsum (19). Complete pulp regeneration in the canals of mature

teeth with closed apices was also observed after pulpectomy by transplantation of autologous pulp CD105+ stem cells with stromal cell
derived factor-1 implanted in dogs (20). Furthermore, it was shown
histologically that new tissues could be generated in the canals of
mature teeth with necrotic pulps and apical periodontitis after an
REP when the canals were instrumented to a #60 K-file in an animal
model (21).
In human REP studies of mature permanent teeth with necrotic
pulps and apical periodontitis, Shah and Logani (8) enlarged the apical
foramen to a #30 K-file, Paryani and Kim (9) to a #60 K-file, and Saoud
et al (10) to a #35 K-file. Based on these animal and human studies, it
can be concluded that the size of the apical foramen does not have to be
1 mm in diameter for new tissue to grow into the canals after REP. However, enlargement of the apical foramen to a large size may facilitate the
ingrowth of new tissue into the canal from the periapical area after REPs
of mature teeth.
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Proper control of root canal infection is the key to success of endodontic treatment in terms of elimination of clinical signs and/or symptoms and resolution of apical periodontitis (22, 23). Contemporary
root canal infection control protocols, including mechanical
instrumentation, sodium hypochlorite irrigation, and intracanal
medication with calcium hydroxide are not able to eliminate all
bacteria in the root canal system because of its anatomic complexity
(24, 25). Calcium hydroxide, the popular intracanal medication in
root canal therapy, has its shortcomings in eliminating intracanal
bacteria because dentin and hydroxylapatite have an inhibitory effect
on the antimicrobial activity of calcium hydroxide (26). The triple antibiotic paste (ciprofloxacin, metronidazole, and minocycline) may also
have limitations in killing intracanal bacteria. It has been shown that triple antibiotic paste was capable of disinfecting the infected root dentin
and eliminating bacteria in vitro (27, 28). However, these in vitro
experiments did not exactly simulate the clinical situation in which
the teeth indicated for regenerative endodontic therapy usually have

Teeth with Necrotic Pulps and Apical Periodontitis

Clinical Research

Figure 4. (A) A preoperative radiograph of teeth #8 and #9. Well-defined periapical radiolucent lesions at the apices of teeth #8 and #9, respectively. The roots of
teeth #8 and #9 are completely developed. (B) A postoperative radiograph of both teeth after REPs. (C) Seven-month follow-up, there is evidence of healing of
periapical radiolucent lesions of both teeth. (D) Twelve-month follow-up, the periapical lesions of #8 and #9 show healing. Both teeth were asymptomatic.

had a long-standing history of infection with well-established biofilm in

the canal and bacteria in the dentinal tubules. An in vivo study also
showed that triple antibiotic paste was able to eliminate most but not
all bacteria in artificially infected root canals in dogs (29). Ciprofloxacin inhibits DNA gyrase synthesis, metronidazole inhibits DNA synthesis,
and minocycline inhibits protein synthesis of microbes (30). These antibiotics are effective when microbes are in an active state of replication
and synthesis of cell walls, proteins, or DNA but not in a stationary state.
Therefore, residual bacteria are likely to remain in the canals of infected
mature or immature permanent teeth after root canal disinfection using
sodium hypochlorite irrigation and intracanal medication with calcium
hydroxide and/or triple antibiotic paste.
Another concern of REPs for mature or immature permanent teeth
with infected necrotic pulp and/or apical periodontitis is the residual
bacteria in the root canal system because they may grow in unfilled canals. Therefore, root filling is recommended and expected to prevent
coronal leakage, retard residual bacteria in the canal from penetrating
into the periapical tissues, and, hopefully, entomb bacteria in the canal
in nonsurgical root canal therapy. However, a systematic review of the
outcome of primary root canal treatment does not support that these
expectations always occur because it is well recognized that the
outcome of root canal therapy in cases of teeth with necrotic pulps
and apical periodontitis is not always successful (7).
The fate of bacteria remaining in the canals and root dentinal tubules after REPs of mature or immature permanent teeth with infected
necrotic pulps is not known. In nonsurgical root canal therapy, residual
bacteria in the root dentinal tubules after properly chemomechanical
debridement do not appear to be the primary cause of post-treatment
apical periodontitis (31). In fact, inflammatory periapical lesions
6

Saoud et al.

were able to heal even without root fillings if root canal infection was
properly controlled and coronal leakage was prevented in human
and animal studies (32, 33). There are no convincing studies to
support that bacteria in the root dentinal tubules are capable of
sustaining or inducing apical periodontitis of endodontically involved
teeth after proper root canal therapy.
The induction of periapical bleeding into the disinfected canal of
immature or mature permanent teeth during REPs brings mesenchymal
stem cells (34) and likely growth factors (platelet-derived growth factor, platelet-derived endothelial growth factor, transforming growth factor, and insulinlike growth factor) mainly derived from platelets as well
as fibrin scaffold (35, 36) from the periapical tissues into the canal
space. Also included are components of innate and adaptive immune
system, such as antibacterial molecules (complement components
and immunoglobulins), phagocytes (polymorphonuclear leukocytes
and macrophages), antimicrobial peptides, and cytokines. All these
bioactive proteins and immune cells are contained in the blood (37).
Complement component C3b can opsonize bacteria, and immunoglobulins can coat and localize bacteria to facilitate phagocytosis by activated
polymophonuclear leukocytes and macrophages through C3b and Fc
receptors on these phagocytes. In addition, mesenchymal stem cells
can secrete antimicrobial peptide LL-37 (38); up-regulate genes
involved in promoting phagocytosis and bacterial killing (39); and
augment the antibacterial activity of immune cells and secret large
amounts of interleukin (IL)-6, IL-6, IL-8, and tumor necrosis factor
cytokines to recruit and activate polymorphonuclear leukocytes (40).
It was also suggested that LL-37 might contribute to regeneration of
the dentin-pulp complex in regenerative endodontics (41). The induction of periapical bleeding into the canals during REPs may enhance
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Figure 5. (A) A preoperative radiograph of tooth #8. A small periapical radiolucent lesion at the apex. The root is completely formed. (B) A postoperative radiograph after REPs. (C) Twelve-month follow-up, healing of periapical radiolucent lesion of tooth #8. (D) Twenty-six month follow-up, periapical radiolucent lesion
of tooth #8 is healed. Note that tooth #9 was treated with nonsurgical root canal therapy. Tooth #8 was asymptomatic.

antimicrobial clearance in the canals. In addition, the possibility that

residual bacteria in the canals may also be killed by immune defense
mechanisms of generated vital tissue after REPs cannot be ruled out.
This rationale is supported by the high success rate of immature permanent teeth with infected pulps and apical periodontitis after REPs (2).
However, there are case reports showing periapical wound healing,
thickening of the canal walls, and/or continued root development
without inducing periapical bleeding into the canals after revascularization (4244). The interaction between the numbers and virulence of
microbes and the host resistance plays an important role in
microbial infection (30).
It is not known whether tissue can be generated in the canals of
human mature permanent teeth with necrotic pulps after REPs
because there are no histologic studies available. In an animal model,
cementumlike, bonelike, and periodontal ligamentlike tissues were
observed generated in the canals of mature teeth with necrotic pulps
and apical periodontitis after REPs (21). These tissues are similar to
those tissues generated in the canals of immature teeth with necrotic
pulps and apical periodontitis after REPs in humans and animals (11
14, 45, 46). Although the tissues generated in the canals of mature
teeth in an animal model after REPs are not pulp tissue, they are
the hosts vital tissue. In our previous case reports (10, 47), 2
mature permanent teeth, one with necrotic pulp and apical
periodontitis and another one with persistent apical periodontitis
after root canal therapy, showed thickening of the canal walls and
apical closure after REPs. These observations indicate that cells
capable of producing mineralized tissue have migrated into the
canals and formed hard tissue on the canal walls and at the root
apex. Therefore, similar to an animal study (21), it is likely that
new vital tissue might also be able to generate in the canals of human
mature permanent teeth with necrotic pulps after REPs.
Vital tissue is endowed with an immune defense mechanism to
detect and protect itself from foreign invaders, such as bacteria.
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Recently, it was shown that the induction of periapical bleeding into

the disinfected root canals of human mature teeth with necrotic pulps
and apical periodontitis during REPs was able to bring apical mesenchymal stem cells into the canal space (48). These multipotent mesenchymal stem cells are capable of differentiating into different cell
lineages depending on the differentiation signals that they receive and
produce tissue/tissues to replace the pulp tissue in the canals of mature
teeth destroyed by infection or trauma (21).
The goal of treating disease is to assist the hosts natural wound
healing processes by enhancing innate and adaptive immune defense
mechanisms to eliminate irritants and create a favorable microenvironment conducive for tissue regeneration and/or repair to occur. The induction of bleeding is the first phase of wound healing processes. REPs
appear to be able to promote the hosts wound healing processes and
restore the vitality of tissue in the canals previously destroyed by infection or trauma. In contrast, a traditional nonsurgical root canal therapy
prevents the hosts natural wound healing processes and the restoration
of vitality of damaged tissue in the canal to take place. Biologically, it may
be preferable to have disinfected root canals filled with the hosts own
vital tissues rather than with nonvital foreign materials. Pulpal biology
and endodontic therapy are finally coming together (49).
In general, periapical lesions of teeth in the healing group had a
short follow-up. It is possible that, given more time, the healing group
could become the healed group (42).
Similar to revascularization of immature permanent teeth with infected necrotic pulps and apical periodontitis reported by Iwaya et al in
2001 (50), REPs for mature permanent teeth with infected or noninfected necrotic pulps are still in the early stage of clinical trials. If
more case reports and case series of REPs for mature permanent teeth
with infected or non-infected necrotic pulps show favorable treatment
outcomes, REPs may become a feasible treatment for mature permanent
teeth with infected or noninfected necrotic pulps. Hopefully, our multiinstitutional clinical trials of REPs for mature teeth with infected or

Teeth with Necrotic Pulps and Apical Periodontitis

Clinical Research

Figure 6. (A) A preoperative radiograph of tooth #30, small periapical radiolucent lesions at the apices of the mesial and distal roots. The roots are fully formed.
(B) A postoperative radiograph after REPs. (C) Eight-month follow-up, evidence of healing of periapical radiolucent lesions at both roots. (D) Twelve-month
follow-up, periapical radiolucent lesions of both roots show healing. The tooth was asymptomatic.

noninfected necrotic pulps will provide more information about treatment outcomes in the near future.

Conclusion
Based on the present case series, REPs, a biologically based therapy, have the potential to be used to treat mature permanent teeth with
infected necrotic pulp and apical periodontitis in terms of elimination of
clinical signs/symptoms and resolution of apical periodontitis. However, randomized, prospective clinical trials are needed to compare the
outcome of nonsurgical root canal therapy and REPs for mature permanent teeth with infected necrotic pulps and apical periodontitis. In addition to randomized, prospective clinical trials, long-term follow-ups of
cases are required to show complete healing and no recurrence of apical pathosis.

Acknowledgments
The authors deny any conflicts of interest related to this study.

References
1. American Association of Endodontists. Glossary of Endodontic Terms, 8th ed.
Chicago: AAE; 2012.
2. Diogenes A, Henry M, Teixeira B, et al. An update on clinical regenerative endodontics. Endod Topics 2013;15:32832.
3. Chen MY, Chen KL, Chen CA, et al. Responses of immature permanent teeth with
infected necrotic pulp tissue and apical periodontitis/abscess to revascularization
procedures. Int Endod J 2012;45:294305.
4. Saoud TM, Zaazou A, Nabil A, et al. Clinical and radiographic outcomes of traumatized immature permanent necrotic teeth after revascularization/revitalization therapy. J Endod 2014;40:194652.
5. Alobaid AS, Cortes LM, Lo J, et al. Radiographic and clinical outcomes of the treatment of immature permanent teeth by revascularization or apexification: a pilot
retrospective cohort study. J Endod 2014;40:106370.

Saoud et al.

6. AAE Clinical Considerations for a Regenerative Procedure. Revised 4-12-15. Available at: www.aae.org. Accessed October 23, 2015.
7. Ng YL, Mann V, Gulabivala K. Outcome of primary root canal treatment: systematic
review of the literaturepart 1. Effects of study characteristics on probability of
success. Int Endod J 2007;40:91239.
8. Shah N, Logani A. SealBio: a novel, non-obturation endodontic treatment based on
concept of regeneration. J Conserv Dent 2012;15:32832.
9. Paryani K, Kim SG. Regenerative endodontic treatment of permanent teeth after
completion of root development: a report of 2 cases. J Endod 2013;39:92934.
10. Saoud TM, Sigurdsson A, Rosenberg PA, et al. Treatment of a large cystlike inflammatory periapical lesion associated with mature necrotic teeth using regenerative
endodontic therapy. J Endod 2014;40:20816.
11. Shimizu E, Ricucci D, Albert J, et al. Clinical, radiographic, and histological observation of a human immature permanent tooth with chronic apical abscess after revitalization therapy. J Endod 2013;39:107883.
12. Martin G, Ricucci D, Gibbs JL, Lin LM. Histological findings of revascularized/revitalized immature permanent molar with apical periodontitis using platelet-rich
plasma. J Endod 2013;39:13844.
13. Becerra P, Ricucci D, Loghin S, et al. Histological study of a human immature permanent premolar with chronic apical abscess after revascularization/revitalization.
J Endod 2014;40:1339.
14. Lei L, Chen Y, Zhou R, et al. Histologic and immunohistochemical findings of a human immature permanent tooth with apical periodontitis after regenerative endodontic therapy. J Endod 2015;41:11729.
15. Orstavik D, Kerekes K, Eriksen HM. The periapical index: a scoring system for radiographic assessment of apical periodontitis. Endod Dent Traumatol 1986;2:234.
16. Orstavik D. Time-course and risk analysis of the development and healing of chronic
apical periodontitis in man. Int Endod J 1996;29:1505.
17. Kling M, Cvek M, Mejare I. Rate and predictability of pulp revascularization in therapeutically reimplanted permanent incisors. Endod Dent Traumatol 1986;2:839.
18. Laureys WG, Guvelier GA, Dermaut IR, et al. The critical apical diameter to obtain
regeneration of the pulp tissue after tooth transplantation, replantation, or regenerative endodontic therapy. J Endod 2013;39:75963.
19. Kim JY, Xin X, Moioli EK, et al. Regeneration of dental-pulp-like tissue by
chemotaxis-induced cell homing. Tissue Eng Part A 2010;16:302331.
20. Iohara K, Imabayashi K, Ishizaka R, et al. Complete pulp regeneration after pulpectomy by transplantation of CD105+ stem cells with stromal cell-derived factor-1. Tissue Eng Part A 2011;17:191133.

JOE Volume -, Number -, - 2015

Clinical Research
21. Gomes-Filho JE, Tobias Duarte PC, Ervolino E, et al. Histological characterization of
engineered tissues in the canal space of closed-apex teeth with apical periodontitis.
J Endod 2013;39:154956.
22. Sjogren U, Figdor D, Persson S, Sundqvist G. Influence of infection at the time of root
filling on the outcome of endodontic treatment of teeth with apical periodontitis. Int
Enod J 1997;30:297306.
23. Fabricius L, Dahlen G, Sundqvist G, et al. Influence of residual bacterial on periapical tissue healing after chemomechanical treatment and root filling of experimentally infected monkey teeth. Eur J Oral Sci 2006;114:27885.
24. Siqueira JF, Rocas IN. Clinical implications and microbiology of bacterial persistence after treatment procedures. J Endod 2008;34:1291301.
25. Wu MK, Dummer PM, Wesselink PR. Consequences of and strategies to deal with
residual post-treatment root canal infection. Int Endod J 2006;39:34356.
26. Portenier I, Haapasalo H, Rye A, et al. Inactivation of root canal medicaments
by dentine, hydroxylapatite, and bovine serum albumin. Int Endod J 2001;34:
1848.
27. Sato I, Ando-Kurihara N, Kota K, et al. Sterilization of infected root-canal dentine by
topical application of mixture of ciprofloxacin, metronidazole and minocycline in
situ. Int Endod J 1996;29:11824.
28. Hoshino E, Kurihara-Ando N, Sato I, et al. In-vitro antibacterial susceptibility of bacteria taken from infected root dentine to a mixture of ciprofloxacin, metronidazol
and minocycline. Int Endod J 1996;29:12530.
29. Windley W, Teixeira F, Levine L, et al. Disinfection of immature teeth with a triple
antibiotic paste. J Endod 2005;31:43943.
30. Mims C, Dockrell H, Goering R, et al. Medical Microbiology. St Louis, MO: Mosby;
2004.
31. Peters LB, Wesselink PR, Moorer WR. The fate and role of bacteria in root dentinal
tubules. Int Endod J 1995;28:959.
32. Klevant FJ, Eggink CO. The effect of canal preparation on periapical disease. Int Endod J 1983;16:6875.
33. Sabeti MA, Nekofar M, Motahhary P, et al. Healing of apical periodontitis after endodontic treatment with and without obturation in dogs. J Endod 2006;32:612833.
34. 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;37:1338.
35. Civinini R, Macera A, Redi B, Innocenti M. Blood-derived growth factors. Clin Cases
Miner Bone Metab 2010;7:194.

JOE Volume -, Number -, - 2015

36. Lubkowska A, Dolegowska B, Banfi G. Growth factor content in PRP and their applicability in medicine. J Biol Regul Homeost Agents 2012;26:3S22.
37. Abbas AK, Lichtman AH, Pillai S. Cellular and Molecular Immunology, 6th ed. Philadelphia: Saunders; 2010.
38. Krasnodembskaya A, Song Y, Fang X, et al. Antibacterial effect of human mesnechymal stem cells is mediated in part from secretion of the antimicrobial peptide LL-37.
Stem Cells 2010;28:222938.
39. Mei SH, Haitsma JJ, Dos Santos CC, et al. Mesenchymal stem cells reduce inflammation while enhancing bacterial clearance and improving survival in sepsis. Am J Respir Crit Care Med 2010;182:104757.
40. Brandau S, Jakob M, Bruderek K, et al. Mesenchymal stem cells augment the antibacterial activity of neutrophil granulocytes. PLoS One 2014;9:e114201.
41. Kajiya M, Shiba H, Komatsuzawa H, et al. The antimicrobial peptide LL37 induces the
migration of human pulp cells: a possible adjunct for regenerative endodontics.
J Endod 2010;36:100913.
42. Chueh LH, Ho YC, Kuo TC, et al. Regenerative endodontic treatment for necrotic
immature permanent teeth. J Endod 2009;35:1604.
43. Shin S, Albert J, Mortman R. One step pulp revascularization treatment of an immature permanent tooth with chronic apical abscess: a case report. Int Endod J 2009;
42:111826.
44. Jung IY, Lee SJ, Hargreaves KH. Biologically based treatment of immature permanent
teeth with pulpal necrosis: a case series. J Endod 2008;34:87687.
45. Wang X, Thibodeau B, Trope M, et al. Histological characterization of regenerated
tissues in canal space after revascularization/revitalization procedure of immature
dog teeth with apical periodontitis. J Endod 2010;36:5663.
46. Yamauchi N, Yamauchi S, Nagaoka H, et al. Tissue engineering strategies for immature teeth with apical periodontitis. J Endod 2011;37:3907.
47. Saoud TM, Huang GT, Gibbs JL, et al. Management of teeth with persistent apical
periodontitis after root canal treatment using regenerative endodontic therapy.
J Endod 2015;41:17438.
48. Chrepa V, Henry MA, Daniel BJ, Diogenes A. Delivery of apical mesenchymal stem
cells into root canals of mature teeth. J Dent Res 2015; http://dx.doi.org/10.1177/
0022034515596527. [Epub ahead of print].
49. Hargreaves KM, Diogenes AR, Teixeira FB. Treatment options: biological basis of
regenerative endodontic procedures. J Endod 2013;39:3043.
50. Iwaya S, Ikawa M, Kubota M. Revascularization of an immature permanent tooth
with apical periodontitis and sinus tract. Dent Traumatol 2001;17:1857.

Teeth with Necrotic Pulps and Apical Periodontitis