Meschi Nastaran, Palma Paulo J, Cabanillas-Balsera Daniel
Department of Oral Health Sciences, Endodontology, KU Leuven & Dentistry, University Hospitals Leuven, Leuven, Belgium.
Center for Innovation and Research in Oral Sciences (CIROS) I Institute of Endodontic, Faculty of Medicine, University of Coimbra, Coimbra, Portugal.
Int Endod J. 2023 Oct;56 Suppl 3:510-532. doi: 10.1111/iej.13778. Epub 2022 May 31.
Revitalization procedures primarily aim to eliminate clinical symptoms and heal periapical lesions.
The objective of the study was to elucidate the effectiveness of revitalization in treating apical periodontitis in necrotic mature and immature permanent teeth based on the following PICO question: In patients with permanent immature or mature teeth and pulp necrosis with or without signs of apical periodontitis (P) what is the effectiveness of revitalization (I) in comparison with calcium hydroxide apexification, apical plug and root canal treatment (C) in terms of tooth survival, pain, tenderness, swelling, need for medication (analgesics and antibiotics), radiographic evidence of reduction of apical lesion size, radiographic evidence of normal periodontal ligament space, radiographic evidence of increased root thickness and length (not for mature teeth), tooth function (fracture and restoration longevity), need for further intervention, adverse effects (including exacerbation, restoration integrity, allergy and discolouration), oral health-related quality of life (OHRQoL), presence of sinus tract and response to sensibility testing (O). (T) = Defined as a minimum of 1 year and maximum of as long as possible for all outcome measures, except 'pain, tenderness, swelling, need for medication (analgesics)', which is a minimum of 7 days and maximum of 3 months and OHRQoL which is minimum of 6 months and a maximum of as long as possible.
Three databases (PubMed, Embase and Cochrane Library) were searched for human, experimental and observational studies in English, complemented with hand search, until 31/10/2021. Studies recruiting teeth with pulp necrosis (with/without apical periodontitis), with minimum 10 teeth/arm at the end of the study and with a follow-up of at least 1 year, were included. Records without an abstract and a full text were excluded. The qualitative analysis of the included (non-) randomized controlled clinical trials was performed with the Revised Cochrane risk-of-bias tools (RoB 2 and ROBINS-I). Meta-analysis for survival and success (including a subgroup analysis for mature/immature permanent teeth) was performed using the Mantel-Haenszel method. The certainty of evidence was assessed using GRADE (Grades of Recommendation, Assessment, Development and Evaluation).
From the 365 identified records, five met the inclusion criteria. The 12 months survival rate was 100% for all (im)mature permanent teeth in all groups (3 studies). The success rate at 12 months was 100% for immature permanent teeth for I and C (1 study), however, reduced to 92% and 80% for mature teeth in I and C respectively (1 study, p > .05). The risk of bias for the most critical outcome (survival) was high for two studies and low for one. For the critical outcome success, all assessed studies were highly biased. Meta-analyses provided pooled relative risk with no statistically significant difference between I and C for both survival (RR = 1.00, 95%CI = 0.96-1.04, p = 1.00) and success (RR = 1.06; 95%CI = 0.83-1.35, p = .66). The evidence level for survival was kept 'low' and for success was downgraded to 'very low' due to inconsistency and imprecision.
The survival and success rates were favourable in all included studies and for all groups; however, these outcomes are not reliable due to the low certainty level. Clinically, the most reported adverse event was tooth discolouration, hence the application of bismuth oxide containing calcium silicate cements should be avoided in revitalization. Radiographically, caution is needed when assessing periapical bone healing and further root development with periapical radiographs, due to multifactorial inaccuracies of this imaging technique. Methodological and assessment concerns need to be addressed in future clinical trials. Long-term results are necessary for studies reporting revitalization of mature permanent teeth, as they seem to be experimental so far.
No robust evidence was discovered to support that revitalization is effective to treat apical periodontitis in (im)mature permanent teeth. The success and survival rates of revitalized and fully pulpectomized (im)mature permanent teeth did not differ significantly.
Prospero: CRD42021262466.
牙髓再血管化治疗主要目的是消除临床症状并治愈根尖周病变。
本研究的目的是基于以下PICO问题阐明牙髓再血管化治疗坏死成熟恒牙和未成熟恒牙根尖周炎的有效性：在患有恒牙未成熟或成熟且牙髓坏死伴或不伴根尖周炎体征的患者中（P），与氢氧化钙根尖诱导成形术、根尖屏障术和根管治疗相比（C），牙髓再血管化治疗（I）在牙齿留存率、疼痛、压痛、肿胀、用药需求（镇痛药和抗生素）、根尖病变大小缩小的影像学证据、牙周膜间隙正常的影像学证据、牙根厚度和长度增加的影像学证据（成熟恒牙不涉及）、牙齿功能（折断和修复体寿命）、进一步干预需求、不良反应（包括病情加重、修复体完整性、过敏和牙齿变色）、口腔健康相关生活质量（OHRQoL）、窦道存在情况以及牙髓活力测试反应方面的有效性如何（O）。（T）=所有结局指标的定义为最短1年，最长尽可能长，但“疼痛、压痛、肿胀、用药需求（镇痛药）”为最短7天，最长3个月，OHRQoL为最短6个月，最长尽可能长。
检索了三个数据库（PubMed、Embase和Cochrane图书馆），查找英文的人体实验性和观察性研究，并辅以手工检索，截至2021年10月31日。纳入的研究为招募牙髓坏死（伴/不伴根尖周炎）患者的研究，研究结束时每组至少有10颗牙齿，且随访至少1年。排除无摘要和全文的记录。使用修订后的Cochrane偏倚风险工具（RoB 2和ROBINS - I）对纳入的（非）随机对照临床试验进行定性分析。使用Mantel - Haenszel方法对留存率和成功率进行Meta分析（包括对成熟/未成熟恒牙的亚组分析）。使用GRADE（推荐分级、评估、制定和评价）评估证据的确定性。
从365条识别记录中，有5项符合纳入标准。所有组中所有（未）成熟恒牙12个月的留存率均为100%（3项研究）。未成熟恒牙组中，牙髓再血管化治疗组和对照组12个月时的成功率均为100%（1项研究），然而，成熟恒牙组中牙髓再血管化治疗组和对照组的成功率分别降至92%和80%（1项研究，p＞0.05）。两项研究中最关键结局（留存率）的偏倚风险高，一项研究中偏倚风险低。对于关键结局成功率，所有评估研究的偏倚均很高。Meta分析得出的合并相对风险显示，牙髓再血管化治疗组和对照组在留存率（RR = 1.00，95%CI = 0.96 - 1.04，p = 1.00）和成功率（RR = 1.06；95%CI = 0.83 - 1.35，p = 0.66）方面均无统计学显著差异。由于存在不一致性和不精确性，留存率的证据水平维持为“低”，成功率的证据水平降至“极低”。
所有纳入研究和所有组的留存率和成功率都较好；然而，由于确定性水平低，这些结果并不可靠。临床上，最常报告的不良事件是牙齿变色，因此在牙髓再血管化治疗中应避免使用含氧化铋的硅酸钙水门汀。在影像学方面，由于根尖片这种成像技术存在多因素不准确性，在通过根尖片评估根尖周骨愈合和牙根进一步发育时需谨慎。未来的临床试验需要解决方法学和评估方面的问题。对于报告成熟恒牙牙髓再血管化治疗的研究，长期结果是必要的，因为目前这些研究似乎还处于实验阶段。
未发现有力证据支持牙髓再血管化治疗对（未）成熟恒牙根尖周炎有效。牙髓再血管化治疗的（未）成熟恒牙与完全牙髓摘除术的（未）成熟恒牙的成功率和留存率无显著差异。
Prospero：CRD42021262466
