DECIDUOUS TOOTH PULP

AUTOTRANSPLANTATION FOR THE

REGENERATIVE ENDODONTIC
TREATMENT OF PERMANENT TEETH
WITH PULP NECROSIS: A CASE SERIES

SHAMEENA K
JR2
DEPT OF PEDODONTICS
 INTRODUCTION
 The purpose of pulp treatment is to maintain the tooth structure intact in order to
preserve optimal function.
 Maintaining the vitality of teeth damaged due to dental caries or trauma is also one
of the purposes of pulp treatment.
 If the pulp of immature permanent teeth is infected, apexification that includes
removal of the infected pulp and application of calcium hydroxide has been
performed traditionally.
 However, while apexification can induce apical closure, it cannot maintain pulp
vitality. Recently, regenerative endodontic treatment procedure has been suggested
in order to replace the damaged pulp tissue with the viable tissue.
 Regenerative endodontic procedures are defined as “biologically-
based procedures aimed to replace damaged structures, including
dentin and root structures, as well as cells of the pulp-dentin
complex”.
 Two decades ago, revascularization was introduced as a biologically based treatment
for regenerating the pulp-dentin complex in immature teeth with pulp necrosis.

 Since then, there has been an exponential growth in the number of clinical and
preclinical publications in the field of regenerative endodontics , leading to a better
understanding of the nature and behavior of the revitalized tissue within the root canal,
as well as factors associated with favorable and unfavorable treatment outcomes.
 The widely used terms “revascularization” and “revitalization”
refer to regenerative endodontic procedures (REPs), which aim to
facilitate ingrowth of new, vascularized tissue within the
disinfected root canal space.
 The blood clot also contains several blood-derived growth
factors capable of attracting other stem cells from periapical
tissues that can initiate ectopic deposition of mineralized
tissues (ie, bone, cementum) within the root canal, and cause
progressive narrowing of the canal space, which might
complicate future endodontic treatment, if needed.
 Histologic data from both animal studies and human teeth following
traditional REPs using blood clot as a scaffold have shown histologic
evidence of a new repair tissue, rather than a newly regenerated pulp-dentin
complex.

 The relatively more recent introduction of REPs using autologous platelet

concentrates (eg, platelet-rich plasma, platelet-rich fibrin) as biologic
scaffolds have also resulted in similar histologic findings of repair tissue
containing mineralized and fibrous connective tissues rather than a newly
regenerated pulp.
 Altogether, these outcomes have led authors to describe this
traditional treatment approach as “guided endodontic
repair” or “cell-free regenerative endodontic therapy”.
 Recently, dental pulp autotransplantation has been
described as a new regenerative endodontic treatment
approach.

 Transplanted pulp can serve as an optimal scaffold, owing

to its feasibility and great potential for cell growth and
differentiation without the risk of host rejection.
 Deciduous tooth pulp, which is a rich source of highly proliferative stem
cells and growth factors in a natural scaffold containing vasculature.

 Deciduous teeth are readily available as a biologic scaffold in young

individuals suffering pulp necrosis in immature permanent teeth as a
consequence of trauma and dental caries.

 Moreover, the donor deciduous tooth can be successfully preserved by

endodontic treatment until natural exfoliation.
 The present case series demonstrates the clinical and
radiographic outcomes of a novel RET using deciduous pulp
autotransplantation in traumatized, necrotic young permanent
incisors of five previously traumatized maxillary incisors of
four 8- to 11.5-year-old patients.
 CASE 1
 10.5-year-old boy experienced a fall accident 5 months earlier, but
refused to visit a dentist.
 Clinical examination
i) Complicated crown fractures of left central and lateral incisor
ii) Absence of pain on palpation and percussion, swelling, sinus tracts,
and mobility.
iii) Did not respond to cold test or electric pulp tests (EPTs)
 CASE 2
 An 11.5-year-old girl, had a fall accident that led to a crown fracture 8
months earlier, and the local dentist performed emergency treatment with
mineral trioxide aggregate (MTA) pulpotomy and resin composite
restoration.

 Over time, the patient had several episodes of spontaneous pain, but did
not visit the dentist.

 Clinically, the tooth was free of mobility, pain, and swelling, and did not
respond to cold and EPTs. There was no pain on palpation and percussion.
 CASE 3

 An 8-year-old boy with a history of untreated complicated crown

fracture of a maxillary right central incisor due to a fall accident 6
months earlier.

 Showed the same clinical and radiographic findings as case 1, with

slight periapical radiolucency.
 CASE 4
 An 8-year-old boy with a history of complicated crown fracture after
being hit by a swing 4 months earlier.

 Reportedly, the local dentist tried to remove the pulp, but could not
complete the procedure because of low patient compliance and scheduled
the patient for root canal therapy, but the patient refused to attend further
treatment.

 The clinical and radiographic findings and diagnosis were the same as
with case 3
 A regenerative endodontic treatment protocol using deciduous pulp
auto transplantation was planned.

 Informed consent was obtained from all patients and parents after
explaining and discussing the possible outcomes of treatment and the
treatment plan in case of failure.
 AUTOTRANSPLANTATION PROTOCOL
 FIRST APPOINTMENT
1. Incisors requiring treatment were isolated with a rubber dam
2. Endodontic access was obtained with water-cooled high-speed diamond
burs.
3. The root canal length was estimated by conventional radiographic
method.
4. The root canals were gently irrigated with 20 mL freshly prepared 2.5%
NaOCl using closed-end and side-vented needles placed 2 to 3 mm
below the apex and without any instrumentation.
 Following copious irrigation with sterile saline, the root canals were dried with
sterile paper points, and a calcium hydroxide paste was loosely packed into the
root canal approximately 2 mm below the apex.

 The access cavities were sealed with approximately 4 mm of conventional

glass ionomer cement and the patients were recalled after 4 weeks.
 Second appointment
 The patients first rinsed with 0.12% chlorhexidine mouthwash for 30 seconds.
 A thick rubber dam sheet, previously disinfected by thorough scrubbing with 10%
povidone iodine for 2 minutes was placed on the permanent incisor and primary
canine.
 The interface of the tooth and rubber dam were sealed with light-cured resin barrier.
 The isolated crown surfaces were polished with a with a presterilized medium-grit
pumice in sterile saline, followed by scrubbing with 2% chlorhexidine for 2 minutes,
and 5,25% NaOCl for 2 minutes
 The permanent incisors were reaccessed and the calcium hydroxide dressing was
removed by gentle irrigation with 10 mL sterile saline.

 The irrigation was completed with a 60-second application of passive ultrasonic

irrigation (PUI) using an Endoultra Ultrasonic activator (Vista Apex, Racine, WI)
with the tip of the ultrasonic activator placed 2 mm below the apical level.

 Followed by a final flush with saline to remove the remnants of calcium

hydroxide loosened by PUI.

 The root canals were dried with sterile paper points, and then gently irrigated with
20 mL of 17% EDTA. No apical bleeding was induced before autotransplantation.
 A mechanical pulp exposure, in the size of an endodontic access cavity, was created
on the donor primary maxillary canine crown.

 A new, presterilized barbed broach was used to remove the whole pulp (coronal 1
radicular pulp), to provide enough pulp volume to fill the permanent root canal.

 Thereafter, the whole pulp was quickly released from the broach using a sterile
tweezer, and gently inserted into the recipient root canal using disinfected
guttapercha cones, lubricated with the blood volume from the primary canine root
canal.
 A non-staining MTA coronal barrier (Neo MTA 2.0; NuSmile, Houston, TX) was
placed over the deciduous pulp scaffold and sealed with a thin layer of flowable
light-cured glass ionomer cement.

 The access cavities were restored with acid-etch resin composite (Filtek Ultimate; 3
M/ ESPE, St Paul, MN).

 Before removal of the rubber dam, the primary root canal was filled with a calcium
hydroxide paste with iodoform (Calciplast Forte; Cerkamed, Stalowa Wola,
Poland).
 No medications were prescribed.

 Following oral hygiene instructions, the patients were scheduled for

clinical and radiographic follow-up visits at 3 and 6 months, and
thereafter, every 6 months.
 Result
 Cases 1, 2, and 3 were followed for 24 months and case 4 for 12 months. All teeth showed
complete periradicular healing in the absence of clinical symptoms.

 All teeth showed complete periradicular healing in the absence of clinical symptoms.

 Cases 1, 2, and 3 showed a slight increase in root wall thickness, with the resultant canal
space being similar in size to that of adjacent vital teeth.

 There was no visible sign of root canal narrowing or obliteration .

 Compared with cases 1, 2, and 3, case 4 showed greater thickening of the apical half of root
walls, but the pulp space was similar to the adjacent vital incisor as with cases 1, 2, and 3
(Fig. 1)
 There was no visible sign of root canal narrowing or obliteration .

 Compared with cases 1, 2, and 3, case 4 showed greater thickening of the apical half of
root walls, but the pulp space was similar to the adjacent vital incisor as with cases 1, 2,
and 3.

 All teeth showed a blunt narrowing of the apical region (with case 3 to a lesser extent),
rather than a typical, conical apical closure pattern.

 All 3 teeth in case 1 and case 2 responded to cold test at 12 and 24 months, respectively,
whereas the remaining teeth did not respond to cold test or EPTs at any recall period
 The donor primary canines were free of clinical symptoms and
showed radiographic evidence of physiologic root resorption along
with resorption of the calcium hydroxide-iodoform paste.
 DISCUSSION
 Although current REPs using the so-called revascularization or revitalization
techniquewith induced apical bleeding cannot regenerate lost pulp tissue, they have
been used widely because they induce periapical healing, tooth survival and function,
and radiographic root development.

 Teeth receiving REPs with induced apical bleeding may require retreatment much
earlier than those receiving apexification treatment, and their failure rates increase
more rapidly over the time.

 These findings call for an urgent switch to REPs that do not use the blood clot from
induced apical bleeding as a scaffold.
 Autologous platelet concentrates might seem to be the most suitable alternative
scaffold to the blood clot, and when used without prior apical bleeding, platelet
concentrates can induce root growth and innervation with significantly less risk for
progressive root canal obliteration.

 However, platelet concentrates are costly and less patient-friendly, especially in

children and adolescents.
 Deciduous pulp autotransplantation may offer several benefits in children and young
patients, because it is readily available and does not require apical bleeding or
burdensome collection of peripheral blood to obtain platelet-derived scaffolds.

 The entire treatment can be accomplished in the clinical setting without the need for
additional equipment and/or laboratory procedures.

 As a biologic scaffold, deciduous pulp contains a rich population of stem cells that
have a higher proliferation rate than those from adult human teeth.
 Deciduous pulp also contains multiple growth factors, such as transforming growth
factor-beta, fibroblast growth factor-2 platelet-derived growth factor, and vascular
endothelial growth factor in a natural microenvironment.

 Growth factors naturally present in the pulp autotransplant with high potential to
promote dentinogenesis, guide the phenotypic expression of odontoblast progenitors,
and facilitate differentiation.

 In the presence of an open apical foramen, deciduous dental pulp stem cells may help
establish vasculature to ensure sufficient nutrient supply for tissue regeneration.
 In the case series, cases 3 and 4 did not respond to cold test at recall periods.

 It may not be detected in every case owing to the absence of nerve regeneration.

 In such cases, it is more appropriate to demonstrate pulp vitality by Doppler

ultrasound evaluation, which provides proof of revascularization.

 In the present case series, the 1- and 2- year radiographic observation of the increase
in root wall thickness was markedly slow and modest compared with a routine case
of conventional revascularization.
 For the autotransplantation procedure, maxillary deciduous canines were used as a
source for primary tooth pulp, because they offer a reasonably large pulp volume that
can be easily harvested from a single root canal.

 In our cases, the bleeding was initiated by the apical separation of primary pulp tissue,
and not by instrumentation beyond the apex, as would be typically performed in
conventional revascularization.

 In situations in which the pulp volume is not enough or when the pulp does not entirely
fit the root canal of a permanent tooth, the pulp transplants can be positioned near the
apex for better nutrient supply and the remaining canal space can be filled with the blood
from the donor primary tooth.
 Finally, in deciduous pulp autotransplantation, the donor primary teeth can be
successfully retained with endodontic therapy until natural exfoliation, with the
frequently encountered, progressive resorption the root-filling paste having no
significant effect on treatment outcomes.
 Chemical agents used for the treatment of immature necrotic teeth should be
selected not only based on their antimicrobial properties, but also on their ability to
provide stable and safe environment for stem cell survival at the periradicular area.
CROSS REFERENCE
 The aim of this study was to develop a novel method of endodontic therapy, which we refer to as dental pulp
autotransplantation. Three patients (2 males and 1 female) were selected for endodontic treatment of a
uniradicular premolar and extraction of a third molar (without odontosection). Electric assessment of pulp
vitality and computed tomographic imaging were undertaken followed by endodontic access and
instrumentation using triantibiotic solution for irrigation in the host tooth. A few minutes before the transplant
procedure, the third molar was extracted, the tooth was sectioned with a diamond blade in a low-speed
handpiece, and the pulp was carefully removed. After premolar instrumentation, the harvested and preserved
pulp tissue was reinserted into the root canal followed by direct pulp capping performed using Biodentine
(Septodont, Saint-Maur-des-Fosses, France), a liner of resin-modi fied glass ionomer cement and composite
resin restoration. The teeth were followed up for at least 12 months after the procedures and were analyzed
using computed tomographic imaging, electric pulp vitality testing, and Doppler ultrasound examination. At
the 3- and 6-month follow-ups, positive pulp vitality and regression of periapical lesions were verified. After
9– 12 months, all teeth were revascularized as determined by Doppler imaging, and the tooth vitality was
reestablished with no signs of endodontic/periodontal radiolucency or complications.
The study investigated allogenic pulp transplantation as an innovative method of regenerative endodontic
therapy. Three patients were selected for the endodontic treatment of single-root teeth, who also had a
son/daughter with deciduous teeth or third molars scheduled for extraction. Receptor teeth were
endodontically instrumented and irrigated using a tri-antibiotic solution. During the transplant procedures, the
teeth from the son/daughter were extracted, sectioned, and the pulp was carefully removed. The harvested
pulp from the donor was inserted into the root canal of the host tooth (father/mother), followed by direct pulp
capping and resin composite restoration. The teeth were followed-up with for 2 years and were surveyed with
computed tomography, the electric pulp vitality test, and Doppler ultrasound examination. At the 6-month
follow-up, positive pulp vitality and the formation of periapical lesions were verified in cases 1 and 2. Case 3
showed remarkable periapical radiolucency before transplantation, but after 1 year, such lesions disappeared
and there was positive vitality. All teeth were revascularized as determined by Doppler imaging after 2 years
with no signs of endodontic/periodontal radiolucency. In conclusion, although this was a case series with only
three patients and four teeth treated, it is possible to suppose that this allogenic pulp transplantation protocol
could represent a potential strategy for pulp revitalization in specific endodontic cases.
 Background: Experiments have previously demonstrated the therapeutic potential of mobilized dental
pulp stem cells (MDPSCs) for complete pulp regeneration. The aim of the present pilot clinical study is
to assess the safety, potential efficacy, and feasibility of autologous transplantation of MDPSCs in
pulpectomized teeth. Methods: Five patients with irreversible pulpitis were enrolled and monitored for up
to 24 weeks following MDPSC transplantation. The MDPSCs were isolated from discarded teeth and
expanded based on good manufacturing practice (GMP). The quality of the MDPSCs at passages 9 or 10
was ascertained by karyotype analyses. The MDPSCs were transplanted with granulocyte colony-
stimulating factor (G-CSF) in atelocollagen into pulpectomized teeth. Results: The clinical and laboratory
evaluations demonstrated no adverse events or toxicity. The electric pulp test (EPT) of the pulp at 4
weeks demonstrated a robust positive response. The signal intensity of magnetic resonance imaging
(MRI) of the regenerated tissue in the root canal after 24 weeks was similar to that of normal dental pulp
in the untreated control. Finally, cone beam computed tomography demonstrated functional dentin
formation in three of the five patients. Conclusions: Human MDPSCs are safe and efficacious for
complete pulp regeneration in humans in this pilot clinical study.
 CONCLUSION
 The present case series suggests that deciduous pulp may have a potential for
use as a biologic scaffold in the regenerative endodontic treatment of necrotic,
open-apex and nearly closed-apex young permanent teeth, by using a patient
friendly, uncomplicated autotransplantation protocol without the need to extract
the donor deciduous tooth. However, these early observations must be
supported by longterm randomized trials before its routine use can be
advocated.