Root Canal Treatment

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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 the of 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 endodontic cleaning 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 derived and 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 implicated used stem in cells, the different bioengineered 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 The successive 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 degradation debris persist of the in dental the 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 dental traditional pulp. Partial Root 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, of odontoblastic hence leaving processes, an unwanted pulp very similar to osteodentin. tissuegap between and bacteria. the filling Inorganic of the in root composition, and dentin this walls. layer The is present smear in dentinal tubules up to a depth of 40m [9]. still alive in the root. This step is associated with chemical Morphological data implicate the opening of dentinal tubules, disinfection.2) Surgical However, pulpotomy the cleaning allows the solution preservation should not of a be pulp too and the presence in the labial and lingual segments of root surfaces of globular and interglobular dentin. Globular structures heavily cytotoxic, and allows the preservation of cell vitality. provide evidence for osteodentin. By contrast, the mesial and This last possibility implicates either a conventional endodontic 3) The third and ultimate step consists in a total pulpectomy. distal surfaces look flat, amorphous, and deprived of tubules. In treatment, or pulp regeneration. An endodontic filling (gutta consequence,Smear layer these removal surfaces is mandatory display afibrodentin in order to clean appearance. the dentin surfaces of the root, and open dentin tubuli. The cleaning process thispercha, ultimate endodontic step. Pulp paste cells containing colonized zinc the oxide, dental associated pulp and with axial and lateral condensation) theoretically supports associated with disinfection includes chemical, ultrasonic and laser techniques. Mechanical enlargement of the main canal regeneration follows pulp renewal, and subsequently root canal diameter contributes to eliminate the smear layer, and provides mineralizationcontribute to the [5]. formation of a dense extracellular matrix. Pulp a homogeneous view on the dentin walls, including in sights on Only a few lesions have a traumatic non-infectious origin, dentinal tubules. whereas most pulp lesions result from carious infections.

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Goldberg M (2016) Root Canal Treatment (RCT): From Traditional Endodontic Therapies to Innovating Pulp Regeneration. J Dent Oral Disord Ther 4(2): 1-6. Root Canal Treatment (RCT): From Traditional Endodontic Therapies to Innovating Copyright: Pulp Regeneration © 2016 Goldberg

Chemical removal is essential to remove pulp debris broken associated with the smear layer created by the instrumentation are the main reasons of endodontic failures, even in apparently process. Sodium hypochlorite used during or after well-treated instruments, teeth. Bacteria perforations, located overfillingin areas such or as under isthmuses, filling, instrumentation produces clean dentin walls. Chelating agents seem to be not affected by endodontic disinfection procedures remnants up to a depth of 20-30 m for treatment lasting about ramifications, deltas, irregularities, niches and dentinal tubules 5based minutes. on EDTA The decalcified addition of dentin a quaternary remove dentinal ammonium plugs bromide and cell [11].Treatments of teeth affected by deep caries preserve in the the lumens of dentinal tubules. They reveal a ring of peritubular apical part of the root remnants that are still alive after indirect dentin(cetrimide) around increases the lumens the elimination of the tubules. of the Organic smear layer, acids opening used at

capping. Direct pulp capping with Calcium Hydroxide (CH), preparation and cleaning of dentin surfaces. Ultrasonic removal therapies. They contribute to the formation of dentinal bridges 10%, 25% and 50% citric acid concentration are efficient for the and/or Mineral Trioxide Aggregates (MTA) constitutes actual ultrasonic delivery system. Laser removal vaporizes tissue in lacunae. Among the different options for the available therapies, of smear layer combined with NaOCl may be activated by an pulpotomycontaining tunnel(partial defects, ablation fissures, of the pulp and in bone-like the coronal osteocyte pulp

laser.the main The canal, main disruptcanal is the easier smear to layer,penetrate and meltwhen the the superficial available to a solution removing totally the dental pulp. Chemo-mechanical structure. Recrystallization process is associated with the Er:Yag chamber) constitute a valid option. However, we give privilege constitutes a useful method. This end-point is very close to non- probesCleaning removed the the root smear canal layer [7,9,10]. and careful cleaning of the cavity (also named pulpectomy) chemo-mechanical preparation combined with ultrasonic infectious conditions, as mentioned below [8]. : The smear layer is removed during irrigation, mainly when sodium hypochlorite is used at 60°C The risk factors associated with endodontic failures increase

vitaltogether and withnecrotic a 3% remnants, sodium mingled hypochlorite with combinedmicroorganisms with 17%and the chance of success of a RCT (Root Canal Treatment). It is based on EDTA for 1 minute. Large amount of dentin debris mixed with the accuracy of the initial diagnosis, the excellence of disinfection, penetrate into dentinal tubules and are associated with the the value of the instrumentation and filling procedures, leading microbial toxins, constitute fractions of the smear layer. They inactivation of microorganisms. It is mandatory to disrupt the bacteria located near the border of the tubules. The removal of finally to rehabilitation management. The treatment requires smear layer is never achieved totally in the apical third with these coronal and apical seal appears to be key-factors for a successful techniques, and it should be remember that the other protocols bacterial biofilm. Antimicrobial strategies, root canal shaping, and so far used remove the smear layer in the coronal and middle treatment. Finally the rehabilitation management appears to be third of the root canal [7]. essential for the success of endodontic therapy. Absence of pain, regression of the bone lesion, tight seal of the canal and coronal Traditional root canal treatment using Thermafil and spaces, recoveries of the tooth function are parameters that cold lateral condensation filling techniques should be re-evaluated over time [5]. The basic aims of endodontic therapy are in distinguishable Root Canal Treatments (RCT) using either ThermaFil (TF) or Lateral Condensation (LC) were compared. No statistically samein adults lines and of evidence. children [6,12].Three techniques Removal of have the been infection, proposed and sealed,significant and difference compressed was laterally detectable with between spreaders. the The two process groups reduction of chronic inflammation are identical and follows the was[10]. repeated After selecting until the the total Master RCT was Cone achieved. (MC), the After apical conventional cone was andVital they areformocresol requiring pulpotomyspecific therapies: filling, most of the treated teeth failed because vertical fracture : The pulp tissue of deciduous occurred. The fissures were detected within the first two teeth is dipped in a 1 :5 dilution of Buckley’s formocresol years following endodontic treatment. Up to 30% and 11% (tricresolDevitalization 35%, formaldehyde pulpotomy: 19%, glycerol The 16%, paste water includes31%). afterfractures condensation were reported of calibrated in teeth gutta restored percha with cones amalgam inside and/ the enlargedor after light-cured main canal. composite Fractures resin. occurred Vertical probably fissures because appeared the paraformaldehyde 1.00g, carbowax 1500: 1.30g, lignocaine overall dentin thickness was reduced by the canal preparation, 0.06g,Non-vital propylene pulpotomy glycol 0.5ml, and carmine 10mg. and consequently the root was more easily broken. : Beechwood creosote solution is sealed Endodontic Failures into the cavity with a zinc oxide-eugenol dressing (0-Methoxy In some cases, RCT leads to a failure after endodontic phenol (guaicol) 47%, P-methoxy phenol 26%, 2-methoxy, 4 treatments. It results from the microorganism colonies methylThese phenol three (Cresol) distinct 13%, options M-methoxy open gatesphenol for 7%, conventional other 7%). persisting in the apical portion. A whole list of traumatic failures endodontic therapies. Pulp regeneration and mineralization is available. In addition to intraluminal endodontic infection, allows new therapeutic approaches.

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Failure and success of conventional Root-Canal Therapy- toward regeneration of the dental pulp adults, regenerative strategies are required for the replacement ofchamber cells during by zinc root oxide, canal after therapies. condensation with gutta percha. In

associated with a poor apical seal. It is obvious that necrotic Stem cells may be isolated and cultured from bone marrow- debrisExamination and microorganisms of 104 cases cannot of failure, be completely shows that eliminated 66 were derived and adipose tissue-derived mesenchymal progenitors. from the prepared root canal. Chemically active, adhesive, root- ECM molecules stimulate the increase of numerous precursor cells, leading the terminal differentiation of pulpoblasts toward dental pulp cells bearing a terminal phenotype. ECM form When immature teeth are affected by caries or trauma, the canal sealers minimize coronal microleakage [13]. scaffolds containing associated structural and functional protein pulp reaction requires management depending on the presence simplicated in pulp regeneration. They present a complete engineered pulp environment containing growth factors, of inflammation and pulp vitality. Necrotic pulp, and root-end cytokines and metalloproteases. The biomimetic ECM scaffold closure are required if the apex is not fully formed. Disinfection may trigger vascularization within the dental pulp. isusing depending sodium hypochlorite on the closure and or calcium opening hydroxide of the apical (CT therapy) ending. ECM dental pulp stem cells may be used for pulp tissue Closurecontribute results to apexogenesis from the root and canal to therapy, apexification whereas [14]. an open This engineering. Using somatic MSCs, root canal may regenerate a functional pulp, displaying sensitivity and vitality. DPSCs Complete root development requires a viable pulp containing cells thatapex potentially is related to differentiate the root-end into closure dentin-producing and/or pulp odontoblasts.regeneration. ahave vascularized been identified pulp-like as sources tissue. Angiogenesisfor pulp renewal. is a crucial There is step, no andneed ECM for growth scaffolds factors enriched and/or with differentiation VEGF contribute factors actively to form to adult stem cells. Stem cells have the capacity of self-renewal and pulp regeneration. Coronal and root vascularization provide the multiple-differentiationStem cell-based regeneration (nerve, muscle, of root apexblood, may lungs, be mediated pancreatic by scaffold that is needed for pulp renewal. Stem cells found in the

including totipotent cells, pluripotent, multipotent and unipotent progenitors.and skin cells). HSCs They isolated can befrom divided bone intomarrow four differentiate stem cell types, into alongapical part the root.of the root In the proliferate, crown part, slide arteriolar,beneath the pre-capillaries odontoblast/ all blood cells of the myeloid and lymphoid cell lineages. andHoehl’s capillaries layers, and contribute participate to theto the formation fisher-like of network terminal located loops,

includeMSCs bone, (e.g. cartilage, lineages of fat, mesenchymal connective tissue, origin), and as muscle they were and 100-150m in diameter irrigating consecutive area. When the marrowdefined bystroma. Friedenstein, MSCs have et a al. high [16] proliferative and later bypotential. Caplan They [17], Raschkow’s sub-odontoblastic plexus of capillaries irrigate the coronal part of the tooth, stem cells contribute in this context to rebuildDental a pulp pulp thatregeneration is still alive [18].and Mineralization express Oct-4, Nanog, STRO-1, CD73, CD90, CD105, and CD146. Regeneration of the dental pulp appears as resulting They are negative for CD14, CD34, CD45 and human leukocyte from pulp degradation. Pulp degeneration by bacteria results cellsantigen-DR. of the periodontalStem Cells of ligament, the Dental and Pulp dental (DPSCs), follicle from precursor human from microorganism’s invasion. Deep carious lesion leads to exfoliated deciduous teeth, from the apical papilla (SCAPs), stem degenerative processes of the coronal pulp. Pulp alteration potential capability during tissue therapies. They may be used in leads to a gradual disorganization of the connective tissue. cells still need to be better explored in order to define their Metalloproteases, such as collagenases and other MMPs are implicated in the degradation of the collagen network. In addition to the traditional root canal treatment, structural the context of pulp regeneration. Proteoglycans are subjected to the action of stromelysin, elastase cells, signaling factors, and a series of stem cells are concerned. They are implicated in pulp regeneration. Bioengineered addition, small peptides are cleaved and released from the ECM scaffolds, growth factors, transcription factors, and cytokines are tri-dimensionaland other ECM architecture. components Dissociation also identified of fragments within the from pulp. the In involved in pulp renewal. They are implicated in the different procedures that play an actual role as biological substitutes for components. In the course of pulp degeneration, precocious conventional root canal treatments. entire molecules contributes to the structural scaffold of matrix Discussion part near the apical ending. Abscesses of limited size increases destruction occurs firstly in the coronal pulp and later in the root Pulp regeneration, Stem cells and Extracellular matrix point of such degradation consists in pulp destruction. proteins in size, merge and finally form large degradation areas. The end The treatment of infected necrotic canal implicates the removal of remnants of the contaminated pulp. This involves bindingThe together dental pulp pulpoblasts includes and colonies forming of a fibroblast/pulpoblast continuous network. careful disinfection, eliminating bacterial colonies. The end Thesecells. Intercellular cells are implicated gap junctional in collagen complexes synthesis link and fibroblasts, secretion. Pulp cells strongly linked move from the central part of the pulp point of endodontic therapies is reached by the filling of the pulp Citation: Page 4 of 6

toward the periphery. Other groups of cells involve macrophages. subodonto and 3 are detected in perivascular cells. blastic zone, beneath lesions treated with CH. Notch 1 Inflammatory cells include immune cells, T-cells, helper/inducer T Cells, cytotoxic/suppressor T cells, macrophages and class T-lymphocytes are also found among pulp cells. Mast cells, Mineral Trioxide Aggregate (MTA) is an alternative pulp II antigen-expressing cells. Dendritic cells, B-lymphocytes and dendritic cells are implicated in phagocytosis. They produce capping material. No necrotic tissue is found after MTA capping differentiationafter 1-3 months. of dental MTA pulp induced cell. It may ERKs be a activityvaluable Thealternative ERK/ MAPK pathway seems to be involved in the proliferation and cytotoxic T-cells. They are natural killer T, usually producing to the use of CH [22]. chemokines and inflammatory cytokines. This group of cells appearsIn addition, to be also microvascularization implicated in pulp isregeneration produced within [19]. the pulp. reparative dentin formation in short-term evaluation. Used for Microvasculature implies arterioles, pre-capillaries, capillaries Portland cement is non-toxic and biocompatible. It induces and venules. Pericytes are located around capillaries. Limited compatibledental root with perforations, normality. damages It is a non-irritant filled with material Portland that cement does anastomoses, contributing to the pulp chamber vascularization. notwere affect clinically the structural silent. A integrity 9-years andof cells. 11-years follow-up appear areas about 100-150m wide, form bypass and arteriovenous of the blood in the apical direction. Lymph vascularization collect TGF-betas are cytokines, members of the TGF superfamily. By contrast, in the root a fisher-net organization allows drainage They induce odontoblast differentiation and dentin bridge

the lymph, drained toward the apex via lymph capillaries [24]. odontoblasts, via c-jun, a nuclear proto-oncogene, and further Laterally, venules and arterioles fan out in the crown and form formation. It up-regulates type I collagen expression in A central innervation penetrates the dental pulp by the apex. dentin through the predentin, crossing intercellular junctions regulates an activation factor protein-1 (AP-1). Collagen the subodontoblastic Raschkow plexus. Axons penetrate in culturemembrane of dental containing pulp cells. TGF-β1 Osteodentin promotes formation dentin/pulp in injured healing. pulp isBMP-2, enhanced BMP-4, when and treated BMP-6 by BMP-7. are identified Osteopontin in human is implicated primary in arebetween horizontally odontoblast oriented cell andbodies. connect Axons a fewpenetrate tubules. into the inner dentin border along 150m from the mineralization front. They Pulp Regeneration: Two distinct groups of progenitor cells reparative dentin formation [18,23]. A significant reduction in the expression levels of growth have been identified. The first group concerns apical cells. In the factors BMP-4, -5, IGF-1, and TGFβ1 was observed, attributed to apical part of the root (molar), cells are immunolabeled by the the down-regulation of RUNX2 and ECM protein biglycan, and Proliferative Cell Nuclear Antigen (PCNA). They multiply and ultimately with a reduction in type I collagen [18]. Fibroblast slide in the root pulp beneath the odontoblast/sub-odontoblast growth factor-2 (FGF-2) is involved in neo-vessel formation. layers. PCNA labeled cells are located mainly in the apical part necessary for the mineralization process. MEPE, amelogenin and become undetectable in the root. By contrast, labeled cells were Bone Sialo-Protein (BSP) activates initial nucleation located[20]. Six in et the al., crown, [21] have around shown the that agarose after beads 2 weeks, used labeled as carriers. cells Beads loaded with labeled cells accumulate around amelogenin- 6enamel months matrix to 3 proteins years was are used, also includinguseful. Pulp a thickening revascularization of the dentinalwas seen walls clinically. as radiographically Examination assessed. at intervals Alternative ranging methods from

Hoehl’sloaded beads.layers. Hence,They contribute progenitor at cells later appear stages tofirstly label in the the crown root. Then they slide along the pulp chamber beneath the odontoblast/ include plasma derived fibrin clots as scaffold and other methods of regeneration. Apexification procedures allow to produce part of the pulp. Sliding of the cells from the apex to the coronal contributes to pulp regeneration factor-Iapical development, is also implicated either in using reparative calcium dentin dihydroxide formation. or MTA, Pulp part, near the exposure area, constitute the pathway that together with a new mixture of antibiotics. Insulin-like growth Pulp capping: Selecting [14,15]. bioactive Materials and Molecules revascularization treatment depends on: Using scaffolds containing growth factors, dentin regeneration 1) Root canal disinfection (even after irrigation with sodium was induced. Dental and non-dental clinical problems were hypochlorite at 2.5%), mineralization, e.g. bone and dentin-pulp regeneration. 2) The presence of a scaffold (blood clot) and 3) hermetic clarified by using these alternative approaches, leading to coronaryThe generation filling. of a functional tissue requires three key

defectsCalcium are due hydroxide to multiple (CH) tissue displays inclusions an alkali in the pH. dentin However, bridge. anelements: acid pH, stem and cells, metronidazole, growth factors the andonly a antibiotic scaffold. Thethat combined display a TheCH produces dentin bridge inflammation becomes within permeable the underlying and allow pulp. bacterial Tunnel neutralmixture pH, of three are implicated antibiotics: in minocycline, the new clinical ciprofloxacin protocol displaying proposed

needed by stem cells [25]. invasion of the pulp. mRNA expression of Bone Morphogenetic for pulp revascularization. The mixture has no cytotoxicity and is Protein -2 (BMP-2) is enhanced. Notch 1 is expressed in the Citation: Page 5 of 6

Conclusion Saunder WP, Saunder EM. Coronal leakage as a cause of failure in root- To conclude, root canal treatment displays a number of 11. Carrotte P. Endodontic treatment for children.British Dental Journal successes and a few failures. Alternatively, the removal of the canal therapy: a review. Endod Dent Traumatol. 1994;10:105-108. 12. condensation allows appropriate sealing of the lumen of the 2005;198(1):9-15. smear layer, enlargement of the main canal, axial and lateral canal. It seems however, that reduction in thickness of the dentin 13. Colombo JS, Moore AN, Hartgerink JD, D’Souza RN. Scaffolds to control inflammation and facilitate dental pulp regeneration. J Enddod. regenerate, pulp cells have the capacity to proliferate, restore 2014;40:S6–S12. alayer pulp leads tissue, to which tunnel will defects further and mineralize. vertical fissures. Pulp regeneration Pulp may 14. Shababang S. Treatment options: apexogenesis and apexification. J Endod. 2013;39:526-529. for of pulp conventional treatments or leading for the future of innovatingfulfills the requirementsbiological pulp for therapies. pulp bioengineering. It opens gates 15. Li Y, Shu LH, Yan M, Dai WY, Li JJ, Zhang GD, et al. Adult stem cell-based apexogenesis. World J Methodol. 2014;4(2):99-108. References 16. Friedenstein AJ, Chailakhjan RK, Lalykina KS. The development of fibroblast colonies in monolayer cultures of guinea-pig bone marrow histology and physiology”. First edition. AR Hand and Marion E Frank. and spleen cells. Cell Tissue Kinet. 1970;3:393–403. 1. Goldberg M (a). Dentin, pulp, and tooth pain. In “Fundamentals of oral 17. Caplan AI. Mesenchymal stem cells. J Orthop Res. 1991;9:641–650. 2. Chapter 5. John Wiley & sons, Blackwell inc. 2014; 85-112. 18. Ravindran S, Huang C-C and George A. Extracellular matrix of dental Goldberg M (b). Pulp anatomy and characterization of pulp cells. in: pulp stem cells : applications in pulp tissue engineering using somatic “Biology, pathology, and regenerative therapies”. Springer Verlag, MSCs. Front Physiol . 2014; 4,article 395 (1-11). 3. Bergenholtz G, Spângberg L. Controversies in endodontics. Crit Rev Berlin, Heidelberg 2014. 13-33. 19. Ravindran S, George A. Biomimetic extracellular matrix mediated somatic stem cell differentiation : applications in dental pulp tissue 20. 4. OralFleming Biol Med. CH, Litaker2004;15(2):99-114. MS, Alley LW, Eleazer PD. Comparison of regeneration. Front Physiol. 2015,6:118;(1- 9). classic endodontic techniques versus contemporary techniques on proliferatingHirata A, Dimitrova-Nakov pulp cells located S, Djole in theS-X, apicalArdila niche.H, Baudry Connective A, Kellermann Tissue O, et al. Plithotaxis, a collective cell migration, regulates the sliding of 5. endodontic treatment success. J of Endo. 2010;36(3):414-418. et al. Treatment of pulp in teeth affected by deep caries- a systematic Research 2014;55(Suppl 1): 68-72. reviewBergenholtz of the G, literature. Axelsson Singapore S, Davidson Dental T, Frisk Journal. F, Hakeberg M, Kvist T, characterization of the cells involved in reparative dentin formation 21. Six N, Tompkins K, Septier D, Veis A, Goldberg M.Recruitment and 6. 2013;34:1-12. splice products A+4 and A-4. Oral Biosciences & Medicine. Characterization of successful root canal treatment. Brazilian Dental 44.in the exposed rat molar pulp after implantation of amelogenin gene Estrela C, Holland R, Estrela CR de A, Alencar HG, Sousa-Neto MD, et al. 2004;1:35- 22. 7. Journal. 2014;25(1):3-11. Simon S, Rilliard F, Berdal A, Machtou P. The use of mineral trioxide Guo X, Miao H, Li L, Zhang S, Zhou D, Lu D, et al. Efficacy of four aggregate in one-visitt apexification treatment: a prospective study. different irrigation techniques combined with 60°C 3% sodium 23. Int Endo J. 2007;40:186-197. hypochlorite and 17% EDTA in smear layer removal. BMC Oral Health. essential for type I collagen secretion in reparative dentin. J Dent Res. 8. 2014;14:114-120. Saito K, Nakatomi M, Ida-Yonemochi H, Ohshima H. Osteopontin is treated teeth can fail. Int Endod J. Siqueira JF Jr. Aetiology of root canal treatment failure: why well- 24. 2016:1-8. 9. 2001;34:1-10. Ravindran S, Zhang Y, Huang C-C, George A. Odontogenic induction of Violich DR, Chandler NP. The smear layer in endodontics- a review. dental stem cells by extracellular matrix-inspired three-dimensional InternatChu CH, LoEndodontic ECM, Cheung J. 2010;43:2-15. GSP. Outcome of root canal treatment using 25. scaffold. Tissue Eng Part A. 2014;20(1-2):92-102. 10. Namour M, Theys S. Pulp revascularization of immature permanent Thermafil and cold lateral condensation filling techniques. Int Endo J. teeth: a review of the literature and a proposal of a new clinical 2005;38:179-185. protocol. Scientific World Journal. 2014; Article ID 737503, 9 pages.

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Goldberg M (2016) Root Canal Treatment (RCT): From Traditional Endodontic Therapies to Innovating Pulp Regeneration. J Dent Oral Disord Ther 4(2): 1-6.