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The opinions within this web page are not ours. Authors have been credited for the individual posts where they are. Photos courtesy Bilal - ROOTS
  Revascularization case

From: Fred Barnett
Sent: Sunday, June 21, 2009 5:02 AM
Subject: [roots] Revasc case

from a 1ts year resident.....

Subject: Fwd: Revasc case

Revascularization case started 1month ago.
10 y.o. pt presented with hx of trauma approx 2 years ago while playing. He fell on his face and chipped #9.
No signs/symptoms of other injury. Diagnosis #9: Necrotic pulp & Chronic periapical abscess with sinus

On first visit:
Tooth accessed, irrigated and ultrasonicated. Apical diameter >1.1mm.
Bimix paste placed consisting of Cirpofloxacin & Metronidazole, followed by triage temporary restoration.

Pt was asymptomatic with resolution of sinus tract.
Accessed tooth and ultrasonicated out bimix with endoactivator.
Induced a hemopoietic scaffold using a combo of the endo activator and #30 Hedstrom file.
This was a toughy to get the blood clot to rise up the canal to the CEJ.
Colla-plug was placed next at the level of the CEJ.
Thereafter, a MTA(white) seal, flowable composite base, etch & bond, luxa-core and composite final restoration
(perhaps the luxacore and composite was overkill).

I will follow-up with the patient in a months time. - Bilal

Thanks Fred for sharing another excellent clinical report and photos from your resident group. Iím also receiving in my residency some trauma cases were a successful regendo would be the best solution. Even though I havenít fond yet any sustained evidence to support such protocol. Of the literature review I made, here you are, the claimed rational and the evidence behinds it: Mechanism of action or role of TAP in revascularization technique. A) Antimicrobial effect: The incorporation of a antimicrobial agent in a clinical protocol should be sustained by: Increment of the overall spectum of action No evidence Increase the efficiency of the main irrigant Synergistic effect No evidence Reduce the potencial side effects of the main irrigant No evidence Increment of the overall rage of action Action on difficult access areas No evidence. B) Off targets properties: Differentiation effect of Triple/Double antibiotic paste -TAP- on mesenchymal stem cells Although there are some research groups developing protocols to verify in vitro the effect of antibiotics on survival and differentiation of SCAP there are any results published so far that proves it. Inhibition of MMPs and decalcification the outer layer of dentin, leading to exposure of embedded growth factors such as TGFb or Fibronectin Minocycline. (Terranova et al. J Periodontol 1989;60:293 301). Not present in Double mix And thatís all. As the antimicrobial benefit is highly unlikely otherwise we all would use it in conceptually more demanding jobs cleaning the apical 1/3 of a mature root; and even not consider the potential drawbacks of using antibiotics as a intracanal dressing in immature teeth sensitization (as it is not yet find in literature) and biofilm selection (Bacterial resistance); Arenít we relying only on this off target properties far to be proven or others not yet considered to sustain our clinical actions? Or there is any other evidence Iím missing? I sincerely hope this cases succeeded and Iím looking forward to see your recalls, but even if we have healing regendo case, can we honestly conclude that the key-healing factor are the antibiotics? Or, at the end, is just a matter of disinfection and the question is what do we need the double/triple mix for? - Ricardo Hi Ricardo , Thanks for your clear review. Last week I posted my concerns on the use of these antibiotics on ROOTS but did not get much response. Obviously because the mechanism of revascularisation is still a mystery. Bacterial resistance does not only result from the actual application, but also results from throwing the leftovers from the paste in the bin. Sensitization does not only occur in the patient, but also in the one that prepares and handles the stuff. Again should not we ask ourselves if the, yet not proven, benefits, outweigh the cost? - Suzette
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