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Root Canal Treatment www.symbiosisonline.org Symbiosis www.symbiosisonlinepublishing.com Review Article Journal of Dentistry, Oral Disorders & Therapy Open Access Root Canal Treatment (RCT): From Traditional Endodontic Therapies to Innovating Pulp Regeneration Michel Goldberg* Professor Emeritus, Faculty of Fundamental and Biomedical Sciences, INSERM UMR Received: June 10, 2016; Accepted: July 05, 2016; Published: July 13, 2016 *Corresponding author: Michel Goldberg, Professor Emeritus, Faculty of Fundamental and Biomedical Sciences , INSERM UMR -S 1124 and University Sorbonne City Paris , 45 rue des Saints Pères, 75270, Cedex 06, Paris, France; Tel- +33 6 62 67 67 09 ; Fax- +33 1 49 58 33 29, E-mail :michel.goldberg@ parisdescartes.fr, [email protected] Abstract Traditional protocols involve the cleaning of the pulp chamber accessoryaxial and lateralcanals [4].condensation the root chamber was gradually and root canals, the removal of bacteria and of the smear layer, filled. These steps include the sealing of lateral, secondary and In addition to conventional protocols, more recently pulp, and root lumen. Disinfection combined with mechanical attempts were made to regenerate the dental pulp. A few pulp enlargementand ultimately allows to the occluding sealing theof endodonticlumen of the materials dental pulp filling with the a cells proliferate, and renewed the pulp tissue. We envision the central master cone, and lateral condensation using a series of small formation of a dental pulp and furthermore its mineralization accessory cones. Innovative approaches propose bioengineered occluding the root lumen. Part of the endodontic cavity was still scaffolds, growth and transcription factors. Removal of the smear alive, or proliferation of pulp cells was requested to restore the layer reveals different types of globular and non-globular dentins other growth or transcription factors contributed to regenerate before chemical or mechanical enlargement of the lumen. Three thebiology pulp. of In the contrast dental withpulp. mechanical Extracellular methods, matrix moleculesbiological optionsand/or distinct(osteodentin, options osteodentin, open gates fibrodentin),for classical endodonticcleaning the therapies dentinal before walls were considerate. The innovative approaches proposed were envisaging the implication of structural cells and signaling factors. pulp,conventional involving filling. totipotent, New pulp multipotent therapies derivedand unipotent from apexogenesis stem cell. Proliferationand apexification of structuralcontributes cells, to the signaling formation factors, of a renewed transcription dental growth factors, transcription factors, and cytokines. Altogether, factors, metalloproteinases, and cytokines are involved in pulp theIn thismolecules context, were we implicatedused stem in cells, the differentbioengineered procedures scaffolds, that renewal. Coronal and root microvascularization participate to pulp pave the way as biological substitutes for root canal treatments [5]. MTA and Portland cement may also contribute to the requirements forregeneration pulp bioengineering, and ultimately leading to pulp to the mineralization. future of innovating BMP-2, biological TGF-β1, pulp therapies. concepts and related methods devoted to the traditional Root In the first part of this review, we summarize the basic concepts aiming to regenerate the dental pulp, leading to pulp Introduction renewalCanal Treatment that further (RCT). underwent In the secondmineralization. part, we Along focus these on recent lines of evidences, biological concepts provide the basis of innovating protocols imposing the careful cleaning of the canals, the removal pulp therapies. For many years, Root Canal Treatments (RCT) used traditional Why, how and when traditional root canal treatments theof the manual, smear instrumental layer, and the or sealing chemical of theshaping filling of materials the root lumeninside (RCT) are needed [3].the pulp chamber [1,2]. These procedures were combined with Dental caries are mostly due to bacteria and subsequently to pulp infection [3]. Associated to the dental plaque; microorganisms enlargements. We also took into account the coordination of the Thesuccessive preparation steps, of leadingthe canal(s) ultimately includes to chemical the preparation mechanical of cariousalter enamel lesions surface, is formed either at thisbeneath precocious the proximal stage. contacts areas, or in the face-to-face enamelling occlusal fissures. The initial pulp remnants were removed. A clean root canal was obtained The carious lesion crosses the whole enamel thickness and the root canal before filling the empty space. After disinfection, spread laterally along the enlarged dentino-enamel junction. aafter central root master widening. cone, Endodontic and a series cements of small filled accessory the pulp cones, chamber, after the subjacent circumpulpal dentin through dentinal tubules namely when a zinc oxide eugenol mixture was used. Employing The lesion degrades firstly the mantle dentin. Caries penetrate Symbiosis Group *Corresponding author email: [email protected], [email protected] Root Canal Treatment (RCT): From Traditional Endodontic Therapies to Innovating Copyright: Pulp Regeneration © 2016 Goldberg displaying enlarged diameters. After the destruction of peritubular Endodontic treatments implicate consecutive critical steps. dentin, measurements of the tubule diameter increase from 2 to Following a cascade of preventive actions, endodontic therapies 6 m. Bacterial contamination is initially limited to the coronal are associated with acute pulpitis, and with the terminal degradation of the pulp tissue. Periapical lesions are rapidly the pulp, spread along the tubules, and penetrate into the main diffusing, reaching chronicity at some later stage. These rootpulp. canal. During Afterward, the next step they of reach the disease, the apical microorganisms pulp [6]. invade canal system. Such lesions limit the spread of the lesion to the The progresses of carious lesion leave pulp remnants, and procedures restrain infections. They invade the complex root All the methods used during these procedures involve irrigation surrounding tissues (granuloma, cysts, and osteolytic lesions). processesaltered pulp are cells. associated Fragments with of thevascular disorganized thrombus, extracellular neuronal which constitute selected antimicrobial agents. They contribute painmatrix and and gradual pulp degradationdebris persist of the in dentalthe pulp pulp. chamber. This cascade These of tosolutions clean the (sodium pulp walls hypochlorite, of the pulp and/orchamber, calcium both in hydroxide),the coronal events leads to the therapy of the dentin lesion, associated with and in the root parts of the teeth [6]. Gradually, this underlines the potential for direct or indirect pulp Using traditional root treatment, the various techniques capping,the biocompatibility coronal pulpotomy or cytotoxicity and ultimately of restorative the requirement biomaterials. of endodontic treatments [3]. and H2O2 alternativelyso far used include irrigation, hand and files they (mechanical aim at removing methods), the or NaOClsmear layer [7]. They(chemical precede disinfection). chemical and These mechanical methods enlargement. are using are mostly due to the development of carious lesion. Gradually bacteriaTo summarize, invade the dentaltraditional pulp. PartialRoot Canalor total Treatments destruction (RCT)of the condensation. Sealing the master cone following the Root Canal pulp pave the way for the total degradation of the pulp. Small These step-by-step methods are followed by axial and lateral Hoehl’s cells layers that are present at the outer surface of the Treatment (RCT) allows the apical closure of the main root canal. abscesses are formed some distance away of the odontoblast/ pulp. The destruction of the odontoblast and sub-odontoblastic Compared to a group using contemporary methods (hand/rotary and H2O2 and NiTi files, NaOCl, bacteria-neutralizing chlorhexidin, EDTA part of the root. Micro-abscesses are increasing in size. They irrigation), endodontic therapies favor warm and/or layers is firstly limited, expands and moves toward the apical contaminate and degrade the coronal part of the pulp. Later, lateral condensation. A second group of experimental endodontic they diffuse in the root. Bacterial penetration is initiated by the therapies has the benefit of a surgical microscope, and/or carious decay, and diffusion occurs through the dentinal tubules. ultrasonic instrumentation, electronic apex location and digital Finally, the lesion spreads into the root, and contributes to the betweenradiography. the twoDespite different technological groups [4,8]. specificities, the two groups total destruction of the dental pulp. At that stage, disintegration of treatments did not evidence statistically significant differences of the dental pulp implicates steps that dictate future therapeutic Removal of the smear layer orientations. It is mandatory to suppress the smear layer during the initial cleaning associated to endodontics treatment. The smear layer contains bacteria and by-products, preventing the penetration of Three commitments apply to the different pulp pathologies: or indirectly pulp capping [4]. They contribute to the formation of reactionary1) Deep orcarious reparative lesion dentinal influence bridge. directly The (partially dentin produced or totally) is layerfilling contains materials organic into dentinal remnants tubules,
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