Regenerating Hope for the Hopeless Pulp 

For an endodontist, bringing a tooth back from the dead is the ultimate victory. And nowhere is this victory more important than in the case of pediatric patients. Currently, the most common treatment for managing permanent teeth with immature apices that show swelling or infection is extraction. But at this stage, the teeth are really just maturing. When you extract a permanent immature tooth, not only does it lend itself to malocclusion or alter how the teeth function, but it can be a cosmetic concern that leads to self-doubt. This is especially damaging in today’s selfie and social media culture.

The primary goal in my endodontic practice is to favor saving natural teeth. I began exploring regenerative endodontic procedures (REPs) as part of research for my endodontic residency over 10 years ago. Since then, the protocol has been central to my treatment approach.

Case in Point

In a ground-breaking 2004 case report,* 2 researchers used a protocol for revascularization, or REP, to treat an immature permanent premolar that was necrotic and presented with a localized draining abscess. What’s so amazing about this case is that not only did the abscessed gums in the surrounding bone and tissue heal but also dentin in the root itself became thicker, and the root reached full maturation—allowing structural formations to increase in size and minimizing the risk of fracture. So, basically, these researchers took a hopeless tooth that most clinicians would have extracted and reinstated its form and function— essentially bringing it back to life!

Eliminating Extractions

REPs are reproducible in most clinical settings; however, the literature does highlight nuances of technique—more specifically, the disinfectant protocol implemented to eliminate microbes, create a sterile environment, and promote stem cell survival and activity. The goal is to create a fertile environment for stem cells of the apical papilla (SCAP) to repopulate into the root canal, and then promote a scaffold that allows the regenerative process to continue.

There are a couple of ways that you can start exploring how to implement REPs in your practice whether you’re a general practitioner or a specialist:

• •Visit the AAE website
• If you visit the American Association of Endodontists website you’ll find a database of cases and treatment protocols that you can access to help you negotiate and manage a case from start to finish.
• •Talk to your colleagues
• Any endodontist or pediatric dentist within your community is a great resource. The pediatric profession has really taken to this procedure and adapted it into their discipline, so there’s a host of pediatric dentists to choose from who are well versed in managing these types of cases.

This technique is not new to dentistry, but it is starting to gain more traction as clinicians in residencies and private practice recognize the long-term value of saving a natural tooth. Although REPs are technique-sensitive and require multiple visits—not to mention, in this case, parent compliance— any time that we can save a natural tooth, it’s in the best interest of all parties involved.

About the Doctor

Dr. Marcus Johnson, a graduate of NYU College of Dentistry, continued his postgrad training in endodontics at Case Western Reserve University in Cleveland, OH. As a board-certified Diplomate of the American Board of Endodontics, he maintains a full-time private practice, City Endodontics in midtown Manhattan, and is the head endodontic attending for the GPR program at Interfaith Medical Center Hospital in Brooklyn, NY, where he also teaches pediatric residents. Dr. Johnson serves on the American Association of Endodontics Public and Professional Relations Committee, where he hosts an evidence-based endodontic podcast, Endo Voices.

*Banchs, Trope. J Endodontics. 2004 Apr;30(4):196-200.