Eur Arch Paediatr Dent DOI 10.1007/s40368-017-0289-5 SYSTEMATIC REVIEW Interventions for the endodontic management of non-vital traumatised immature permanent anterior teeth in children and adolescents: a systematic review of the evidence and guidelines of the European Academy of Paediatric Dentistry 1,2 2 1 1 1 M. Duggal • H. Jinn Tong • M. Al-Ansary • W. Twati • P. F. Day • H. Nazzal1 Received: 27 March 2017 / Accepted: 10 April 2017 Ó The Author(s) 2017. This article is an open access publication Abstract Regenerative Endodontic Technique is currently extremely Aim This systematic review was undertaken in order to weak and therefore this technique should only be used in develop guidelines for the European Academy of Paedi- very limited situations where the prognosis with other atric Dentistry for the management of non-vital permanent techniques is deemed to be extremely poor. The current anterior teeth with incomplete root development. review supports the use of MTA followed by root canal Methods Three techniques were considered; apexification obturation as the treatment of choice. by single or multiple applications of calcium hydroxide, use of Mineral Trioxide Aggregate (MTA) for the creation Keywords Calcium Hydroxide apexification Á of an apical plug followed by obturation of the root canal, Endodontics Á Immature non vital incisors Á Mineral and finally a Regenerative Endodontic Technique (RET). Trioxide aggregate Á Regeneration/revitalisation Á Scottish Intercollegiate Guideline Network (SIGN) Trauamtized teeth Guidelines (2008) were used for the synthesis of evidence and grade of recommendation. Results Variable levels of evidence were found and gen- Introduction erally evidence related to these areas was found to be weak and of low quality. It was not possible to produce evidence- Dental trauma is common in young children and is the most based guidelines based on the strength of evidence that is frequent cause of pulpal non-vitality in immature perma- currently available for the management of non-vital nent incisors. The 2003 Children’s Dental Health Survey in immature permanent incisors. England and Wales (Harker and Morris 2003) found that Conclusions Based on the available evidence the European 11% of 12 year olds and 13% of 15 year olds had sustained Academy of Paediatric Dentistry proposes Good Clinical accidental damage to their permanent teeth with the Practice Points as a guideline for the management of such majority of injuries being left untreated. The highest levels teeth. It is proposed that the long term use of calcium of treatment were at age 15 years, of which only 27% had hydroxide in the root canals of immature teeth should be their damaged incisors treated. avoided and apexification with calcium hydroxide is no Managing non-vital immature teeth is extremely chal- longer advocated. The evidence related to the use of a lenging due to compromised crown root ratio, thin root den- tine walls and wide-open apex lacking an apical stop against & M. Duggal which root filling materials can be condensed. Treating these [email protected]; [email protected] teeth is therefore time consuming and technically difficult. 1 Traditionally the treatment has been aimed at producing a Department of Paediatric Dentistry, Leeds Dental Institute, barrier against which a root canal filling material can be University of Leeds, The Worsley Building, Clarendon Way, Leeds LS2 9LU, UK placed, thereby preventing the extrusion of material into the surrounding tissues. This has usually and most commonly 2 Discipline of Orthodontics and Paediatric Dentistry, Faculty of Dentistry, National University of Singapore, 11 Lower been achieved through calcium hydroxide (Ca(OH)2)apexi- Kent Ridge Road, Singapore 119083, Singapore fication technique that involves repeated and prolonged 123 Eur Arch Paediatr Dent dressing of the root canal. Although this technique has been Methodology reliable and with consistent clinical outcomes, there have been recent concerns about the long-term use of Ca(OH)2 in root Search strategy for identification of studies canals. The technique also carries a higher risk of cervical root fractures, with frequencies being related to the stage of root A comprehensive search was developed for ensuring that development (Cvek 1992). This is possibly attributed to its as many studies as possible were identified through a hygroscopic and proteolytic properties, which induces desic- structured electronic search, hand search, and personal cation of dentinal proteins and reduces root dentinal wall contacts. modulus of elasticity, thus predisposing the tooth to root fracture (Andreason et al. 2002). Electronic search strategy In the last decade the introduction of Mineral Trioxide Aggregate (MTA) has meant that an apical plug can be created A search for relevant studies began with OVID electronic by dentists, which allows immediate obturation of the root canal bibliographic databases using a structured search strategy (Pradhan et al. 2006). However, this material remains expen- that was developed by the Trials Search Co-ordinator of the sive and also does not confer any qualitative or quantitative UK Cochrane Oral Health Group to determine an article’s increase in root dimensions. In addition, MTA has been shown relevance to this review based on the title and abstract. in an in vitro study to have similar weakening effect on the dentine to that of calcium hydroxide (Twati et al. 2009a). Subject search strategy for MEDLINE via OVID Recently there has been a paradigm shift in the proposed treatment for such teeth. Uncontrolled longitudinal studies The subject search used a combination of controlled and randomised controlled trials (RCTs) have shown suc- vocabulary and free text terms. There was no restriction on cessful continuation of root canal growth following the use the language of publication. of Regenerative Endodontic Therapy (RET). These tech- niques have been suggested to harness the stem cells pre- Databases searched sent at an apical area of immature incisors, thereby allowing repopulation of the root canal with vital tissues, The following databases were searched via OVID gateway: and allowing continued deposition of hard tissue and fur- • ACP Journal Club (ACP). ther root development (Banchs and Trope 2004). • Cochrane Central Register of Controlled Trials In order to develop guidelines for the European Academy of (CENTRAL). Paediatric Dentistry, this systematic review attempts to com- • Cochrane Database of Systematic Reviews (CDSR). pare various types of interventions for treating traumatised • Cochrane Oral Health Group Trials Register. immature permanent anterior teeth, and their respective effects. • Database of Abstracts of Reviews of Effects (DARE). This was performed by evaluating the research evidence in • EMBASE databases; the Excerpta Medica Database these fields using explicit, systematic methods to limit bias (EMBASE), EMBASE Drugs and Pharmacology (systematic errors) and reduce chance effects, hoping to provide (EMDP), and EMBASE Psychiatry (EMPS). more reliable results upon which conclusions could be drawn • Index to Scientific and Technical Proceedings. and decisions can be made. In drawing conclusions and making • National Library of Medicine-Toxnet (http://toxnet. recommendations the authors are very mindful of the fact that nlm.nih.gov). there are a few randomised controlled trials (RCTs) with low • Ovid MEDLINE(R) (1966 to date). level of bias in these areas which stand up to rigorous scrutiny • Ovid MEDLINE(R) (daily update). that is normally applied to such studies. • Ovid MEDLINE(R) in-process, other non-indexed citations. • Science Citation Index Expanded. Objectives of the review • Social Science Citation Index. • System for Information on Grey Literature in Europe. • To evaluate the relative effectiveness of the following interventions for treating traumatised non-vital imma- ture permanent anterior teeth: Personal contacts (a) Apexification techniques; (b) Apical plug technique using MTA; Personal communication via e-mail correspondence was (c) Regenerative Endodontic Therapy (RET). initiated with the author(s) of the identified relevant studies • To evaluate any immediate and/or long-term side-effects in an attempt to identify on-going, unpublished or unlisted and limitations of the materials and techniques used. studies that may be eligible for inclusion in this review. A 123 Eur Arch Paediatr Dent list of these relevant articles along with the inclusion cri- any signs or symptoms related to these teeth. The diagnosis teria for the review was sent to the first author of those of pulp status in traumatised teeth can be difficult. This has reports concerning the studies included asking if they knew been demonstrated in laser doppler studies, where the pulp of any additional studies (published or unpublished) that has been shown to be healthy but the tooth has not might be relevant. The same correspondence was sent to responded to traditional sensibility tests (Gazelles et al. other experts and others with an interest in the area. 1988). The diagnosis of non-vital immature teeth should The manufacturers of dental materials were contacted to depend on trauma history (including previous episodes of obtain information on relevant published or unpublished trauma) as well as one or more clinical signs and symptoms studies that may have involved the materials that they (abscess formation, sinus tracts), negative sensibility test- manufacture. Companies were also asked for reference lists ing or radiographic