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Regenerative Endodontics
The primary purpose of endodontic therapy is the prevention or treatment of apical
Stephen Cohen
periodontitis. Although traditional endodontic procedures treat apical periodontitis
MA, DDS, FICD, FACD
by disinfection of the root canal system followed by placing an intracanal restoration
Diplomate, American Board of
Endodontics
(obturation), a biologically based procedure would instead focus on regenerating a
Author: “Pathways of the Pulp” functional pulp-dentin complex.1,2 This approach offers the advantage of maintaining
Private practice, California, USA normal pulpal function with appropriate formation of secondary or tertiary dentin, and
scohen@cohenendodontics.com continued immunological and neuronal surveillance of tissue status.3 Thus, biologically-
based regenerative endodontic procedures offer the potential for saving natural teeth that
otherwise might be doomed to extraction.
Kenneth Hargreaves The concept of regenerating the pulp-dentin complex is not new. Indeed, more than 50
DDS, PhD
years ago, Nygaard-Ostby reported several case series of tissue evascularization that were
Editor-in-Chief: “Journal of based on the concept of the initial healing event (revascularization) of surgical wounds.4,5
Endodontics”
Private practice, Texas, USA Although a fibrous connective tissue was found in many of his preclinical and clinical
endodontic cases, the tissue did not renew the pulp-dentin complex. This is not a surprising
hargreaves@uthscsa.edu
outcome given the level of knowledge, materials and instruments available to investigators
many years ago.
Louis Berman In the intervening decades, several critical advances have occurred that greatly improve
DDS, FACD
the potential for developing regenerative endodontic procedures. For example, the entire
Diplomate, American Board of field of tissue engineering was only established in the 1990s.6 In contrast to the mechanical
Endodontics
Private practice, USA philosophy of “revascularization”, where tissue bleeding is thought to be sufficient for
healing, the concept of tissue engineering focuses on the three dimensional assembly of
Berman@annapolisendodontics.com
the appropriate combination of cells, growth factors and scaffolds to achieve the desired
regeneration of a functional pulp-dentin complex. These concepts have been systematically
evaluated in the endodontic literature, with studies focused on stem cells,7-10 growth
factors11,12 and scaffolds13-15 capable of promoting the differentiation of odontoblast-
like cells. This has led to the regeneration of dentin-like structures in some,16 but not all
preclinical studies.17 The great challenge going forward is the development and validation
of tissue engineering concepts into effective and predictable endodontic therapeutic
procedures.
Although the full application of tissue engineering principles for clinical regenerative
endodontic procedures remains an active area of research, several clinical case studies
have already reported success in treating the immature permanent tooth with a necrotic
pulp. These teeth often have a very poor prognosis due to the thin dentinal walls and
incomplete stage of root development (Figure 1). In these regenerative cases, “success”
is defined as restoration of continued root development, lack of signs or symptoms and
closure of sinus tracts, if previously present.1 In general, these procedures are conducted