JICDRO is a UGC approved journal (Journal no. 63927)

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CASE REPORT
Year : 2010  |  Volume : 2  |  Issue : 1  |  Page : 36-39

Apexification in a non-vital tooth: By control of infection


Department of Pediatric Dentistry, Dr. D. Y. Patil Dental College, Pune, India

Date of Web Publication18-Nov-2011

Correspondence Address:
Basgauda R Patil
Department of Pediatric Dentistry, Dr. D. Y. Patil Dental College, Pune
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2231-0754.89995

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   Abstract 

Endodontic management of immature non-vital permanent teeth in young pediatric patients is a great challenge to dentists. When the pulp of an incompletely formed tooth loses its vitality, then the entire root system has also lost its ability to continue to develop. The walls of the root canals are frequently divergent and open apices make debridement and obturation difficult. Thus, closure of the root apex is very essential for the success of endodontic treatment. Many different materials are used for the apexification procedure, for apical barrier formation and healing. However, in this present case the apical closure was achieved only by means of infection control.

Keywords: Central incisor, Infection control, Apexification


How to cite this article:
Patil BR, Patil PB, Patil AN. Apexification in a non-vital tooth: By control of infection. J Int Clin Dent Res Organ 2010;2:36-9

How to cite this URL:
Patil BR, Patil PB, Patil AN. Apexification in a non-vital tooth: By control of infection. J Int Clin Dent Res Organ [serial online] 2010 [cited 2019 Oct 22];2:36-9. Available from: http://www.jicdro.org/text.asp?2010/2/1/36/89995


   Introduction Top


Anterior teeth in children are more prone to trauma. This trauma may cause loss of vitality of the pulp. The stage of development of the tooth in which trauma occurs is important because the growth of roots may be hampered and may result in an open apex. A devitalized tooth should be treated endodontically to remove any infection and to achieve an apical seal. Therefore, it is essential to achieve apical closure in the traumatized tooth; and this is only possible if the conditions are made conducive for the growth of the roots, by removal of the non-vital tissue and infection. Pulpectomy and filling with calcium hydroxide paste has been suggested until the apex is completed. [1],[2] This is a routinely performed dental procedure. Perhaps only the eradication of infection may be sufficient for apexification. This following case has occurred accidentally, but it raises the question about the necessity of any filling in the canal for apexification.


   Case Report Top


A 12-year-old Indian girl was seen in the clinic on an emergency basis. She had an acute alveolar abscess in the region of the maxillary right central incisor. When examined, the tooth was mobile and tender to touch. The incisal edge was fractured. The patient's history disclosed that trauma occurred approximately six years earlier. There had been no discomfort and the patient had not sought treatment at that time.

A periapical radiograph taken at the current visit [Figure 1] showed arrested formation of roots in this tooth, as compared to the left central incisor. The patient was in acute distress, and there was much swelling and the tooth was tender to touch. Oral antibiotics and analgesics were prescribed for the relief of the acute symptoms. By the third day, the pain and swelling had reduced considerably. The pulp chamber was exposed and the root canal was cleaned and irrigated with sodium hypochlorite solution (3%) and the canal was left open for drainage [Figure 2].
Figure 1: Periapical radiograph showing incomplete root end development and Radiolucency at the apex

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Figure 2: Periapical radiograph showing root canal acess opening

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After two days, the canal was irrigated again, A fresh cotton pellet was placed and the canal opening was closed with zinc oxide-eugenol paste [Figure 3].
Figure 3: Periapical radiograph showing placement of cotton pellet with zinc oxide eugenol closed dressing

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Although the patient was asked to return within two days, she did not come for the next visit for approximately five months. At this visit, there were no symptoms and clinical examination showed that the tooth was normal. A radiograph taken at that time showed resolution of the apical radiolucency simultaneously with apical closure. Immediately root canal treatment was done [Figure 4].
Figure 4: Periapical radiograph showing calcific callus formation and closure of apex

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   Discussion Top


The growth of the roots depends on a vital pulp and Hertwig's epithelial root sheath formed by the inner and outer enamel epithelium. [3] The sheath induces the differentiation of the odontoblast, and when dentin is deposited the sheath disintegrates and brings the connective tissue in contact with the dentin. This induces the formation of cementoblasts, which lay down the cementum. Thus, the root consists of dentin and cementum.

In cases in which the pulp is devitalized, formation of roots has been noticed to continue under favorable conditions. Some clinicians advocate the filling of the root canal with calcium hydroxide paste.

In this case, the formation of the root occurred without any filling. Vojinovic [4] says that the basic target should be stimulation and preservation of the granulation tissue cells in the apical part of the canal, to allow the possibility of a calcified callus forming in the wide apical fora­men. Torneck [5],[6],[7] and others think this may be the product of residual odontogenic cells of the pulp and the cells growing into the pulp space from the periapical tissue. However, in some cases, they have found the growth of roots despite pulpal or periapical inflammation. It is reported that teeth that were instrumented more during cleaning of the root canal showed a lesser degree of root formation when compared with teeth that were instrumented less. This is attributed to mechanical injury to the periapical tissue and the formative cells therein. This may be one of the reasons for the quick growth of roots in this case as virtually no instrumentation was done. The tissues forming this portion of the root may not be dentin covered with cementum; however, our main concern is to have a closed apex.

In the apexification procedure the apical repair can be of four types (Frank, 1966): [8]

  1. The apex is closed, with definite, although minimum recession of the canal
  2. The apex is closed with no change in root space
  3. A radiographically apparent calcific bridge forms just coronal to the apex
  4. There is no radiographic evidence of apical closure, but upon clinical instrumentation there is a definite stop at the apex, indicating some calcific repair


This apical calcification occurs mostly in a horizontal fashion rather than vertical, that is why the term 'apical repair' is preferred to 'apical closure'.

Simple disinfection and minimal instrumentation seem to be conducive for this procedure. The non-vital teeth with open apices should be given a chance for apexification by removal of infection and minimum handling, and permanent filling should be delayed until the root apex is closed. Irrigation during endodontic treatment aids in removing the pulp tissue.

Antibacterial effect of sodium hypochlorite

The use of sodium hypochlorite (NaOCl) for treating wounds was introduced in World War I by a physician named Dankins. [9] NaOCl is a powerful, inexpensive irrigant that has been shown to nearly dissolve the pulp tissue. [10] NaOCl can be used clinically in various concentrations, for its ability to destroy all microorganisms on direct contact and its ability to dissolve the pulp tissue from all aspects of the root canal system. [11] Warming of the NaOCl at approximately 60 o C increases the rate and effectiveness of tissue dissolution. [12]


   Summary Top


Incomplete formation of roots in permanent dentition because of the death of pulps is fairly common. Various pastes are used in apexification procedures. It has been suggested that minimum mechanical intervention and removal of infection alone may be sufficient. A case is reported in which this was observed.

 
   References Top

1.Holloway PJ, Swallow JN, Slack GL. Child dental health. Bristol: John Wright and Sons Ltd; 1969. p. 120.  Back to cited text no. 1
    
2.Feldman G, Solomon C, Notaro P, Moskowitz E. Endodontic treatment of vital and non-vital teeth with open apices. NY State Dent J 1973;39:277-80.   Back to cited text no. 2
    
3.In Orban's oral histology. St. Louis: C. V. Mosby Co; 1976. p.28-48.   Back to cited text no. 3
    
4.Vojinovic O. Induction of apical forma­tion in immature teeth by different endodontic methods of treatment. Experimental pathohis­tological study. J Oral Rehabil 1974;1:85-97.  Back to cited text no. 4
[PUBMED]    
5.Tomeck CD, Smith JS, Grindall P. Biologic effects of- endodontic procedures on developing incisor teeth. Effect of pulp injury and oral contamination. Oral Surg Oral Med Oral Pathol 1973;35:378-88.   Back to cited text no. 5
    
6.Tomeck CD, Smith JS, Grindall P. Biologic effects of endodontic procedures on developing incisor teeth. Effect of debridement and disinfection procedures in the treatment of experimentally induced pulp and periapical disease. Oral Surg Oral Med Oral Pathol 1973;35:532-40.   Back to cited text no. 6
[PUBMED]    
7.Tomeck CD, Smith JS, Grindall P. Biologic effects of endodontic procedures on developing incisor teeth. Effect of debridement procedures and calcium hydroxide­camphorated parachlorphenol paste in the treatment of experimentally induced pulp and periapical disease. Oral Surg Oral Med Oral Pathol 1973;35:541-54.   Back to cited text no. 7
    
8.Kennedys Paediatric Operative Dentistry. 4 th ed. Bristol, England: Wright publication; 1996. p.189.   Back to cited text no. 8
    
9.Dankins HD. On the use of certain antiseptic substances in the healing of infected wounds. Br Med J 1915;2:318-20.  Back to cited text no. 9
    
10.Hasselgren G, Olsson B, Cvek M. Effect of CaOH and NaOCl on the dissolution of necrotic porcine muscle tissue. J Endod 1988;14:125-7.  Back to cited text no. 10
[PUBMED]  [FULLTEXT]  
11.Sirqueira JR Jr, Batista MM, Fraga RC, de Uzeda M. Antibacterial effects of endodontics irrigants on black pigmented gram-ve anaerobes and facultative bacteria. J Endod 1998;24:414-6.  Back to cited text no. 11
    
12.Gambarini G, De Luca M, Gerosa R. Chemical stability of heated NaOCl endodontic irrigants. J Endod 1998;24:432-4.  Back to cited text no. 12
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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