A silent revolution is brewing in endodontic clinics, promising to turn root canals from a static procedure into a dynamic process of biological healing.
And What Dental Residents Think
For decades, the standard approach to a necrotic immature permanent tooth involved a procedure called apexification—creating an artificial barrier to seal the root—which although effective, had a significant drawback: it could not restore the tooth's vitality or allow for continued root development2 7 .
Regenerative Endodontic Procedures (REPs) represent a paradigm shift. This biologically-based approach uses the concept of tissue engineering to restore the root canal to a healthy state, allowing for continued development of the root and surrounding tissue3 .
But how prepared is the next generation of dentists to embrace this innovation? A look into the knowledge and attitudes of dental residents reveals a fascinating landscape of optimism, challenges, and evolving practices.
Regenerative endodontics doesn't rely on a single magic bullet but on the sophisticated interplay of three key components, much like building a house requires both materials and blueprints.
These are the raw building materials. The most crucial source in immature teeth is the Stem Cells from the Apical Papilla (SCAP), a specialized tissue at the tip of a developing root7 . Remarkably, these stem cells can remain viable even when the pulp is necrotic, thanks to collateral circulation near the apex7 .
This is the supportive framework that allows cells to grow. In many clinical procedures, a scaffold is created by intentionally inducing bleeding into the cleansed root canal, forming a natural fibrin clot that stem cells can adhere to4 . Researchers are also developing advanced biomimetic scaffolds, such as electrospun nanofibers and injectable hydrogels, that can provide more controlled environments for tissue growth2 .
These are the architectural blueprints that direct the stem cells. They include growth factors and proteins present in the blood clot or released from the dentin walls that signal the cells to differentiate into the desired specialized tissues, such as odontoblasts (dentin-forming cells) or vascular cells2 7 .
The theory comes to life in clinical practice. A detailed case report illustrates the step-by-step process and its potential for remarkable outcomes4 .
Periradicular radiolucency completely resolved
Tooth apex showed signs of continued development
Radiographic evidence confirmed dentinal walls had thickened and root apex had closed. The tooth also responded positively to pulp testing, indicating restoration of sensory function.
This case demonstrates that conservative revascularization can promote complete root maturation by preserving the vitality of dental pulp stem cells and providing a conducive environment for regeneration4 .
Embracing a new paradigm requires not just technical skill but also a shift in mindset. Research into the attitudes of dental residents, particularly in India, offers encouraging insights.
Source: Adapted from Shah et al.5
This enthusiasm is also reflected in clinical practice, with over half (52.6%) of the residents reporting they were already using some form of regenerative therapy, though often limited to membranes, scaffolds, or bioactive materials5 .
This lack of homogeneity in protocols is a major hurdle. As one study concluded, "Since it's an evolving science there is a need to bring about a uniformity in practices to increase the evidences to support the causal effect relation of regenerative endodontics"1 .
The following table details essential materials and their functions in a typical REP.
| Reagent/Material | Function | Key Considerations |
|---|---|---|
| Low-concentration Sodium Hypochlorite (NaOCl) | Irrigation; disinfects the canal and dissolves necrotic tissue4 . | Concentration is critical (e.g., 1.5%). High concentrations are toxic to stem cells2 . |
| Ethylenediaminetetraacetic Acid (EDTA) | Irrigation; removes the smear layer, exposes dentinal growth factors, and promotes stem cell recruitment4 7 . | Often used as a final rinse after NaOCl. |
| Calcium Hydroxide or Triple Antibiotic Paste | Intracanal medicament; provides sustained disinfection between visits1 4 . | Antibiotic pastes must be used at low, non-cytotoxic concentrations to avoid harming stem cells2 . |
| Biocompatible Scaffolds | Provides a 3D matrix for cell attachment and growth. Can be a natural blood clot or advanced hydrogels (e.g., GelMA)2 4 . | Advanced scaffolds can be engineered to release growth factors or antimicrobials in a controlled manner2 . |
| Calcium Silicate Cements (MTA, Cold Ceramic) | Used as a coronal seal above the scaffold. Creates a bacteria-tight seal to prevent reinfection4 . | Some materials may cause tooth discoloration; new formulations are being developed to address this2 . |
The journey of regenerative endodontics is still unfolding. Current procedures, while promising, often result in "repair" with the formation of bone- and cementum-like tissues in the canal, rather than a perfect regeneration of the native pulp-dentin complex2 . The future lies in leveraging tissue engineering to achieve functional restoration—including the return of neural sensation and immune competence7 .
For dental residents in Puducherry and around the world, the path is clear. The foundation of enthusiasm is strong. The next steps involve standardizing education, honing clinical skills through practice, and contributing to research—for instance, by reporting cases to databases like the one maintained by the American Association of Endodontists3 .
As the science evolves from a promising concept to a clinical reality, the next generation of dentists will be the ones to truly bring the revolution to life, moving beyond simply saving teeth to actively making them live again.