reatments for immature teeth with pulp necrosis may include calcium hydroxide apexification, mineral trioxide aggregate (MTA) apical barrier technique or regenerative endodontic treatment. While the advantage of regenerative treatment includes potential for future root maturation with increased canal wall thickness, root length and apical closure, a recent study with an average follow-up of 25 months revealed a high incidence of revascularization-associated intracanal calcification that progressed over time.

Clinical considerations published by the American Association of Endodontists (AAE) in 2016 for regenerative endodontic procedures define 3 outcome measures (ranked from most to least essential):

  • Primary: elimination of symptoms and evidence of bony healing
  • Secondary: increased root wall thickness and/or increased root length
  • Tertiary: positive response to vitality testing

The AAE also noted possible adverse effects, e.g., staining of crown/root, lack of response to treatment and pain/ infection. However, the clinical considerations make no mention of intracanal calcification or ingrowth of bone.

Kahler et al from the University of Queensland Oral Health Centre, Australia, reported the case of an 11-year-old girl who underwent regenerative endodontic treatment in 2 mandibular premolar teeth after a diagnosis of an infected root canal system, pulp necrosis and symptomatic apical periodontitis.

The root canal widths of the teeth increased by 72.1% and 39.7%, respectively, at 18 months after surgery. Annual follow-ups over 8 years showed complete calcification with a 100% increase in canal width and no substantive change in root length, along with no evidence of pathosis. Both teeth remained unresponsive to electric pulp testing until the 8-year recall, at which time both teeth had become responsive.


In this case, along with complete revascularization-associated intracanal calcification, all 3 treatment goals established by the AAE clinical considerations were achieved in the 2 treated teeth, although both teeth required internal bleaching to alleviate discoloration. Revascularization-associated intracanal calcification carries with it the potential to cause complications in subsequent endodontic treatment. Because most studies of regenerative endodontic treatment have had comparatively short follow-up times, larger long-term studies are required to enable the AAE to update its clinical considerations and include the potential for revascularization-associated intracanal calcification following regenerative endodontic treatment.

Kahler B, Kahler SL, Lin LM. Revascularization-associated intracanal calcification: a case report with an 8year review. J Endod 2018;44:1792-1795.