Indian Journal of Public Health ResearchDOI Number: 10.

37506/v11/i1/2020/ijphrd/193845
& Development, January 2020, Vol. 11, No. 01 363

Regenerative Endodontics-The Future?

A Questionnaire Based Study

Farhan Ariwala1, Mahalaxmi Yelapure2, Mithra N. Hegde3, Darshana Devadiga4, Upasana5

1II-MDS, 2Reader, 3Headof the Department, 4Reader, 5Lecturer,
Department of Conservative Dentistry and Endodontics, ABSMIDS, Mangaluru

Abstract
Introduction: Regenerative Endodontics is a fast growing field in dentistry showing highly favourable
clinical outcomes. It encompasses various procedures that serve as a better alternative to traditional root
canal therapy as well as more aggressive treatments such as surgical endodontics. The knowledge and skill
of the practitioner plays a pivotal role in the success of any regenerative procedure.

Aim: The purpose of this survey is to evaluate knowledge, attitudes and practice of regenerative endodontics
among the dental Interns, dental postgraduates and dental practitioners in mangaluru.

Materials and Method: An online questionnaire comprising of 20 questions was distributed amongst the
dental professionals of Manguluru. A total of 448 dental professionals responded over a period of 1 month.
Their responses were collected and tabulated to interpret the data and obtain the results.

Results: A total of 448 replies were received, with the majority of the correspondents belonging to the
dental post graduates (41.5%). The majority (97%) of the participants of this survey had come across the
term ‘Regenerative Endodontics’, but only 41 out of the 448 had reported performing any regenerative
endodontic procedure.

Conclusion: Regenerative endodontic Procedures have shown favourable results in various studies. It can
be used as a valuable tool for any dental professional. But, as seen in this study, the knowledge levels as well
as attitudes amongst the dental fraternity needs to improve so as to allow the incorporation of regenerative
endodontics into clinical practice.

Keywords: Regenerative, Survey, Knowledge.

Introduction apexification procedures amongst researchers and

clinicians.[1]
Regenerative endodontic procedures(REP’s) were
proposed to overcome the drawbacks related to the Regenerative endodontic procedures can be defined
clinical management of necrotic immature permanent as biologically based procedures designed to replace
teeth and are gaining prominence over traditional damaged structures, including dentin and root structures,
as well as cells of the pulp-dentin complex.[2]

In other words, regenerative endodontics is a broad

Corresponding Author:
term encompassing various procedures such as pulp
Dr. Farhan Ariwala
revascularisation, apexogenesis, pulp implantation,
II MDS, Department of Conservative Dentistry and
three-dimensional cell printing etc.[2]
Endodontics, ABSMIDS, Mangaluru
Address: 301, Plama Citius, University Road, The success of regenerative endodontics, like any
Deralakatte, Mangalore-575018 other dental procedure, depends upon the knowledge
e-mail: imranariwala@gmail.com and skill of the practitioner. Although, regenerative
364 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
procedures are highly technique sensitive and require a of mangaluru digitally. This was done by distributing the
systematic protocol to be followed. link to the questionnaire. https://docs.google.com/forms/
d/e/1FAIpQLScxYl8XLC4yK2PsDovd4hQHqSQMcY
Hence, the knowledge of the practitioner regarding tTULLYucTErJCZ_buKiQ/viewform#start=openform
these procedures is of paramount importance. Since
very few studies have been conducted in this regard Printed copies of the questionnaire were also
and little information about this is available, the aim used and were circulated individually amongst the
of this survey is to evaluate knowledge, attitudes and practitioners. Only dental interns, dental post graduates
practice of regenerative endodontics among the dental and dental practitioners were provided with the
Interns, dental postgraduates and dental practitioners in questionnaire. Responses to both the online form as well
mangaluru. as the hard copy of the questionnaire were accepted for
a period of 1 month.
Materials and Method
All the data was then collected and tabulated. This
The study undertaken was a questionnaire- was later analysed to obtain the results of the survey.
based survey to evaluate the awareness and attitudes
towards regenerative endodontics, with a questionnaire Results
comprising of 20 questions. Out of this, 15 questions
were framed to evaluate the knowledge and awareness A total of 448 replies were received for the
of dental professionals towards REP’s, while 5 were survey, both online and offline. Out of this, most of the
framed to reveal their attitudes towards the same. correspondents were the dental postgraduates (41.5%),
followed by the dental practitioners (31.9%) and then
The questions were arranged systematically to the dental interns (26.6%).
evaluate the awareness, knowledge and attitudes of the
dental practitioners in the region of Mangaluru, towards The age of the participants ranged from 21 to 52
regenerative endodontic procedures. years, with an average age of 27 years. Amongst the
dental practitioners, the average number of years of
Using ‘Google Docs’, an online questionnaire was practice was 7.5 years.
created to be distributed amongst the dental professionals

Table 1: Questions drafted so as to determine the knowledge levels of the various participants in the field of
regenerative endodontics

Response
Question
Yes No Not Sure
Do you think Regenerative procedures can serve as a practical and
292(65.2%) 66(14.7%) 90(20.1%)
feasible replacement for more aggressive treatment protocols?
Do you think regenerative procedures can serve as an alternative to
128(28.6%) 186(41.5%) 134(29.9%)
implants?
Single visit procedure is recommended for regenerative endodontic
26(5.8%) 338(75.4%) 84(18.8%)
treatment.
Leaching of Sodium Hypochlorite (NaOCl) into the periapical space has
289(64.5%) 42(9.4%) 117(26.1%)
a detrimental effect on revascularisation procedures.
The use of Ethylene-Diamine-Tetra-acetic acid (EDTA) is
recommended along with Sodium Hypochlorite (NaOCl) during 161(35.9%) 108(24.1%) 179(40%)
revitalisation procedures.
Revascularisation procedures performed on teeth with a large apical
foramen diameter are more successful than teeth with a small apical 172(38.4%) 102(22.8%) 174(38.8%)
foramen.
Should revascularisation be performed on deciduous teeth? 30(6.7%) 288(64.3%) 130(29%)
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 365
Table 2: The technical aspects of regenerative procedures was inquired with these following questions.

Table 3: The scope and future aspects of REP’s, according to the participants, was Questioned.

Discussion Endodontics. Few of the correspondents also believed

direct pulp capping (20.2%) and apexification (9.6%) to
In this survey, 97% (435) of the correspondents
be regenerative procedures, but, even though they fulfil
had come across the term ‘Regenerative Endodontics’.
the criteria stipulated for regenerative procedures of
This showed a high awareness amongst the population
growth of tooth structures, they are not considered under
of dentists in mangaluru. In a similar study conducted
the umbrella of regenerative endodontics.
amongst dental residents in selected hospitals within
Nigeria, 91.2% (114) of the participants had come across A total of 41(9.1%) respondents reported practicing
the term regenerative endodontics.[3] regenerative procedures, with apexogenesis (18) and pulp
revascularisation (14) the most practiced procedures.
Pulp revascularisation and apexogenesis were the 2
procedures (88.2% & 78.3% respectively) most recognised A total of 292(65%) of the respondents believed
in this study to fall under the term of Regenerative that REP’s can replace more aggressive treatment
366 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
modalities. This is supported by available literature, Sodium hypochlorite has a detrimental effect on
displaying a high success rate for procedures such as the stem cells. [12,16] The majority of the correspondents
pulp revascularisation and apexogenesis. A cohort study were aware of this fact, with 289(64.5%) believing that
investigated 20 cases of regenerative endodontic therapy leaching of sodium hypochlorite into the periapical
for immature permanent teeth with necrotic pulps and space is harmful for the regenerative procedure. Out of
showed that the success or survival rate of treated teeth those who did not agree to the same, the majority of the
was 100% in terms of regression of clinical symptoms/ correspondents belonged to the group of dental interns.
signs and resolution of apical periodontitis or retention
of teeth. [4] In a study conducted by martin et al. (2014), the
use of 17% EDTA resulted in increased survival and
But, it is also important to view the failures for DSPP expression, partially reversing the deleterious
REP’s. A study conducted by song et.al (2017) showed effects of NaOCl. [12] This study showed that the highest
the presence of Revascularisation Associated Intra-Canal awareness regarding this information existed amongst
Calcifications in 62% of the cases under the study.[5] the post graduates. As the speciality of the participants
were not recorded, the awareness amongst the various
When it came to REP’s serving as an alternative specialities could not be determined.
to implants, the majority of the correspondents (71%)
were sceptical towards it’s ability for the same. The Teeth with pre-operative apical diameters wider
current philosophy in tissue engineering is developing/ than 1 mm have been reported to show a greater increase
regenerating a whole new organ. This can be achieved in root thickness, length, and apical narrowing. This
either by seeding tooth germ cells in a tooth shaped finding suggests that revascularization of necrotic
scaffold or recreating the tooth germ from detached pulps with fully formed (closed) apices might require
mesenchymal and epithelial cells.[6] But, this technology instrumentation of the tooth apex to approximately 1 to
is still in its infancy. This may also explain why 332 2mm in apical diameter to allow systemic bleeding into
of the total correspondents believed that it would take root canal systems. [13]There was reduced knowledge
atleast 20 years for a tooth developed in a lab to be regarding this fact, as only 154(35%) correspondents
implanted in the oral cavity. were aware of it. Again, the post graduates showed the
highest awareness regarding the same.
A multiple visit protocol using a tri-antibiotic paste
may be a better treatment option for teeth with complete The most recognised scaffold, in this survey, to be
pulpal necrosis, during revascularisation procedures.[7] used during REP’s was Platelet Rich Fibrin. A study
338(75.4%) of the respondents also believed the same, comparing platelet rich plasma (PRP), platelet rich
as they did not believe single visit endodontics is fibrin (PRF) and blood clot, showed that PRF had a
recommended for regenerative procedures. Shin et al. huge potential to accelerate the growth characteristics in
had proposed a single visit procedure using an intra immature necrotic permanent teeth as compared to PRP
canal medicament,but it showed limited success.[7] and blood clot. [14]

Disinfection of the root canal space is paramount 227(50.7%) of the correspondents believed that the
towards the success of any Regenerative procedure. higher cost factor for regenerative procedures would be
Both irrigants as well as intra canal medicaments can its biggest obstacle.In a similar survey conducted by
be used.[8] The most recognised irrigant in the survey Utneja et al (2012), 74% of the participants believed that
was sodium hypochlorite and the most recognised intra the higher cost factor would be the biggest obstacle to
canal medicament was the triple antibiotic paste (TAP). regenerative procedures. [15]
Although TAP has been shown to be more effective
in eradicating bacteria,[9] it has the potential for tooth For those believing that complicated procedures
disco-loration, which results from contact between are the biggest obstacle for regenerative endodontics,
minocycline and the root canal walls during the REP.[10] the majority belonged to the practicing dentists (40%),
Exclusion of minocycline (known as double antibiotic which may indicate a lack of trust in such procedures by
paste) or substitution of minocycline by amoxicillin, practitioners.
doxycycline, clindamycin, tetracycline or cefaclor has
been reported to solve this problem.[11]
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 367

Conclusion Mahilod study 1: Comparison of radiographic and

survival outcomes of immature teeth treated with
Traditional root canal therapy of necrotic pulps is
either regenerative endodontics or apexification
mechanically and materially based. But, Regenerative
method—A retrospective study. J. Endod. 2012,
endodontic therapy is biologically based and intended
38, 1330–1336.
to promote the host’s natural wound healing process to
restore vitality, immunity, and sensitivity of tissue in the 5. Song M, Cao Y, Shin S, Shon W, Chugal N, Kim
canal space, that was destroyed by infection or trauma. R et al. Revascularization-associated Intracanal
Calcification: Assessment of Prevalence and
In order to harness this potential, the dental Contributing Factors. Journal of Endodontics.
practitioners need to be aware and well informed 2017;43(12):2025-2033.
regarding the same. This will allow the introduction of a 6. C U V, George J, John M, Nair M, S A. regenerative
new era in clinical endodontic dentistry, that will help in endodontics- treatment options and challeges to
preserving the vitality of the tooth. success. International Journal Of Oral Care and
In this study, the dental interns lacked knowledge Research. 2015;3(4):89-95.
regarding certain aspects of the regenerative endodontic 7. Shin SY, Albert JS, Mortman RE. One step
procedures. Training regarding the same can be done pulp revascularization treatment of an immature
so as to facilitate the incorporation of regenerative permanent tooth with chronic apical abscess: a case
endodontics in dental clinics. report. Int Endod J. 2009;42(12):1118–26.
8. Velmurugan N. Revascularisation of necrotic
A wider study group, incorporating a larger region
immature permanent teeth: An update. J Oper Dent
could be done in the future to analyse the trend of REP’s
Endod 2016;1(1): 18-24.
in today’s environment.
9. Windley W, Teixeira F, Levin L, Sigurdsson A,
Limitations: The study did not differentiate Trope M. Disinfec-tion of immature teeth with a
between the various specialities of the post graduates triple antibiotic paste. J Endod 2005;(6):439—43.
as well as the practitioners. Hence, knowledge levels 10. Reynolds K, Johnson JD, Cohenca N. Pulp
regarding REP’s between each speciality could not be revascularization of necrotic bilateral bicuspids
determined. The study also did not differentiate between using a modified novel technique to eliminate
general practitioners and dental specialists. potential coronal discolouration: a case report. Int
Endod J 2009;42(1):84—92.
Source of Funding: Self
11. Conde MC, Chisini LA, Sarkis-Onofre R, Schuch
Ethical Clearance: Not required HS, No¨r JE, Demarco FF. A scoping review of
root canal revascularization: relevant aspects for
Conflict of Interest: None
clinical success and tissue formation. Int Endod
J)2016;(October 22).
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