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CASE REPORT
Year : 2014  |  Volume : 5  |  Issue : 3  |  Page : 146-150

Nonsurgical healing of large periradicular lesions using a triple antibiotic paste


Department of Pedodontics and Preventive Dentistry, College of Dental Sciences, Davangere, Karnataka, India

Date of Submission08-Mar-2013
Date of Acceptance08-Mar-2013
Date of Web Publication12-Nov-2014

Correspondence Address:
Shilpa S Sasalawad
Assistant Professor, Department of Pedodontics and Preventive Dentistry, College of Dental Sciences, Davangere, Karanataka - 577 004
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0976-6944.144539

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  Abstract 

The success of the endodontic treatment depends on the microbial suppression in the root canal and periapical region. The infection of the root canal system is considered to be a polymicrobial in nature. Because of the complexity of the root canal infection, it is unlikely that any single antibiotic could result in effective sterilization of the canal. Triple antibiotic paste (TAP) containing metronidazole, ciprofloxacin, and minocycline has been reported to be a successful regimen in controlling the root canal pathogen. Two case reports describe the nonsurgical endodontic treatment of teeth with large periradicular lesions. A triple antibiotic paste was used for 8 months, the follow-up radiograph of two cases showed progressive healing of periradicular lesion. The results of these cases show that when most commonly used medicaments fail in eliminating the symptoms, then a triple antibiotic paste can be used clinically in the treatment of teeth with large periradicular lesions.

Keywords: Ciprofloxacin, metronidazole, minocycline, nonsurgical root canal treatment, periradicular lesion, triple antibiotic paste


How to cite this article:
Sasalawad SS, Naik SN, Poornima, Shashibhushan K K. Nonsurgical healing of large periradicular lesions using a triple antibiotic paste . Indian J Oral Sci 2014;5:146-50

How to cite this URL:
Sasalawad SS, Naik SN, Poornima, Shashibhushan K K. Nonsurgical healing of large periradicular lesions using a triple antibiotic paste . Indian J Oral Sci [serial online] 2014 [cited 2018 Nov 17];5:146-50. Available from: http://www.indjos.com/text.asp?2014/5/3/146/144539


  Introduction Top


The role of microorganisms in the development and perpetuation of pulp and periapical diseases has clearly been demonstrated in animal models and human studies. [1] The development and progression of endodontically induced periapical lesion is clearly associated with the presence of microorganisms in the root canal system. [2] Bacteria in infected root canals and periradicular tissues are capable of invading and residing deeply within dentin and in cementum around the periapex. Endodontic therapy is aimed at elimination of bacteria from the infected root canal and at the prevention of infection. [3] Because of the complexity of the root canal infection, it is unlikely that any single antibiotic could result in effective sterilization of the canal. More likely, a combination would be needed to address the diverse flora encountered. The combination that appears to be most promising consists of metronidazole, ciprofloxacin, and minocycline. [4] Some clinical studies have confirmed that simple nonsurgical treatment with proper infection control can promote healing of large lesions. [5] When this treatment is not successful in resolving the periradicular pathosis, additional treatment options should be considered. Surgery may occasionally be required.

In recent years, the Cariology Research Unit of the Niigata University has developed the concept of 'Lesion sterilization and tissue repair LSTR' therapy, [6] that employs the use of a combination of antibacterial drugs (metronidazole, ciprofloxacin, and minocycline) for the disinfection of oral infectious lesions, including dentinal, pulpal, and periradicular lesions. In studies, [7] oral lesions have been analyzed with strict anaerobic conditions to understand the target bacteria in endodontic treatment and on this basis, antibacterial drugs have been selected. Metronidazole has a wide spectrum of bactericidal action against oral obligate anaerobes, [8] even against isolates from infected necrotic pulps and, in fact, more than 99% of bacteria found in carious lesions and infected root dentine were not recovered in the presence of 10 μg per ml metronidazole in in vitro experiments. However, metronidazole, even at a concentration of 100 μg per ml, could not kill all the bacteria, [9] indicating that other drugs may be needed to sterilize the infected root dentine. It has been reported that a mixture of antibacterial drugs, that is, metronidazole, ciprofloxacin, and minocycline, can sterilize the root dentine. [10]

The following case reports describe the endodontic treatment of a large periradicular lesion using a combination of antibiotic drugs.


  Case Reports Top


Case 1

A 13-year old boy reported to the Department of Pedodontics and Preventive dentistry, college of dental sciences, Davangere, with a complaint of pain and pus discharge in lower left and right back tooth region. His medical status was noncontributory. According to the patient's clinical records, he reported a history of repeated pain and swelling in the lower left and right side since 6 months, which was associated with fever.

On extra oral examination, there were enlarged, palpable and tender bilateral submandibular lymph nodes. On intraoral examination, there was deep occlusal caries associated with 36 and 46 teeth, which were slightly tender to percussion, with probing exhibited normal mobility. The electronic pulp test was negative for both teeth. An intraoral periapical radiograph with 36 and 46 showed a well-circumscribed radiolucent lesion located around the apex of both the mesial and distal root of teeth [Figure 1] and [Figure 2], just above the mandibular canal. The lesion around the distal and mesial root of both the teeth measured approximately 10 and 6 mm in diameter respectively along with involvement of furcation and interradicular bone. After evaluating all the data, a root canal treatment of the both the molars was planned. At the same appointment, the root canal treatment was initiated for both the teeth. A rubber dam was applied and the access cavity was prepared. A hemorrhagic, purulent exudate was found from the canals of the teeth 36 and 46. In the next appointment, the working length was estimated using radiographic method. The distal canals were instrumented with size 15-40 K-files and mesial canals with size 15-30 K-files using a step-back technique for both the teeth. During the instrumentation, the canals were irrigated copiously with 2.5% sodium hypochlorite solution using a 27-gauge endodontic needle after each instrument. Drainage was performed until the discharge through the canal ceased. The canals were dried with sterile paper points and then dressed with calcium hydroxide. A sterile cotton pellet was inserted into the access cavity before sealing it with a temporary filling material. The calcium hydroxide dressing was changed every 1 week for three times. After 3 weeks, the discharge from the canals did not cease completely. The treatment procedure was changed. The canals were dried, and a triple antibiotic paste consisting of ciprofloxacin, metronidazole, and minocycline (100 mg of each drug in 0.5-ml of total volume in propylene glycol base) was placed with the help of a lentulo spiral. The paste was changed 3 weeks for a period of 8 months until the roots of the teeth displayed complete healing of the lesion. After 8 months, when the teeth 36 and 46 showed no symptoms, no pain on percussion, soft tissues were found healthy, and the canals were dry, the canals were irrigated with 2.5% sodium hypochlorite followed by normal saline and obturated with gutta-percha and Zinc oxide eugenol as a sealer by using a lateral compaction technique [Figure 3] and [Figure 4]. The restoration was accomplished with glass ionomer cement. After 1 month, the teeth 36 and 46 were given full coverage restoration using stainless steel crowns. At 16 months [Figure 5] and [Figure 6], the radiographs showed complete bony healing with well-defined trabeculae.
Figure 1: Preoperative intraoral radiograph showing large periapical lesion with roots of tooth 46

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Figure 2: Preoperative intraoral radiograph showing large periapical lesion with roots of tooth 36

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Figure 3: IOPA illustrating complete healing of periapical lesion with tooth 46 after 8 months and obturation

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Figure 4: IOPA illustrating complete healing of periapical lesion with tooth 36 after 8 months and obturation

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Figure 5: IOPA after 16 months showing complete bony healing with well-defined trabeculae with tooth 46

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Figure 6: IOPA after 16 months showing complete bony healing with well-defined trabeculae with tooth 36

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Case 2

A 12-year-old girl reported to the Department of Pedodontics and Preventive dentistry, College of dental sciences, Davangere, with a complaint of pain in his upper front region. Her medical status was noncontributory. According to history, 3 years earlier she had a fall during playing and had broken her maxillary left central incisor. It was left untreated for many years. Three years later, the patient developed pain and pus discharge with the fractured teeth. An intraoral periapical radiograph showed a well-circumscribed radiolucent lesion extending from the apex of tooth 21 [Figure 7]. The lesion was approximately 15 mm in diameter.
Figure 7: Preoperative intra oral radiograph showing large periapical lesion with root of tooth 21

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Thermal and electronic pulp testing was negative for tooth 21. After evaluating all the data, nonsurgical endodontic root canal treatment of tooth 21 was planned. Tooth was isolated with rubber dam and access opening was done. Upon access, a thick purulent discharge exuded from the orifice of the canal. After ensuring the presence of a clean root canal, a working length radiograph was taken. The canal was instrumented up to size 60 K-file for the central incisor by using the step-back technique. During the instrumentation, the canal was irrigated copiously with a 3% sodium hypochlorite solution. The canals were irrigated and dried, a triple antibiotic paste was placed, and the teeth were temporized.

The patient was called after a 3 weeks interval for refreshing the triple antibiotic paste in the canal. After 8 months, when the root of the tooth displayed complete healing of the lesion showed no symptoms, no pain on percussion, soft tissues were found healthy, and the canal was dry [Figure 8], the canal was irrigated with 2.5% sodium hypochlorite and obturated with gutta-percha and Zinc oxide eugenol. The patient returned to the department for the 12-month follow-up examination and was asymptomatic. Radiographic examination [Figure 9] showed progressive healing of lesion.
Figure 8: IOPA illustrating complete healing of periapical lesion with tooth 21after 8 months

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Figure 9: IOPA illustrating complete bony healing with well-defined trabeculae with tooth 21 and obturation

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  Discussion Top


Modern concept of dentistry emphasizes prevention and reversal of the diseases. Only when these attempts fail, we would take on the unfavorable approaches, that is, surgical intervention and restoration with artificial prostheses. [11] The development and progression of endodontically induced periapical lesions is clearly associated with the presence of microorganisms in the root canal system. [2] Ideally, a nonsurgical method should initially be done especially in cases where lesions are in close proximity to important anatomical landmarks. The success of nonsurgical endodontic treatment method is based on appropriate cleaning, shaping, asepsis, and filling of the root canal. It has been reported that the sterilization of the root canal and periradicular region results in good healing of periapical diseases in adults. [12] In order to sterilize the infected root dentine, especially the deep layers, antibacterial medicaments are useful. These compounds should reach the deeper layers of the infected dentine. Several case reports have been published on nonsurgical management of tooth with a nonvital pulp and persisting sinus tract using TAP. TAP was successful in promoting the healing and repair of the periapical tissue. The systemic administration of antibiotics relies on patient compliance with the dosing regimens followed by absorption through the gastrointestinal tract and distribution via the circulatory system to bring the drug to the infected site. Hence, the infected area requires a normal blood supply which is no longer the case for teeth with necrotic pulps and for teeth without pulp tissue. Therefore, local application of antibiotics within the root canal system may be a more effective mode for delivering the drug. [11]

Calcium hydroxide is the most commonly used medicament for the asepsis of the root canal because of its high alkalinity and antibacterial activity. The antimicrobial effects of calcium hydroxide have also been evaluated by clinical studies where calcium hydroxide has been shown to successfully disinfect root canals following 1-month dressing in 97% of treated cases. [13] In this study, calcium hydroxide was used for the first case, but the symptoms were not relieved. The treatment protocol was changed, and a triple antibiotic paste was used instead. After its application, the symptoms resolved. Since the overwhelming majority of bacteria in the deep layers of the infected dentine of the root canal wall consist of obligate anaerobes, [14] metronidazole was selected as the first choice among antibacterial drugs. As the bacterial flora of the root canal with a periradicular lesion is complex in nature, metronidazole alone cannot kill all bacteria indicating that other drugs may be necessary to sterilize the infected root dentine. Thus, ciprofloxacin and minocycline, in addition to metronidazole were required to sterilize the infected root dentine. [15]

The compounding of the triple antibiotic paste was standardized in this series of cases. Each batch of the triple antibiotic paste was compounded within 24 h of use and was removed from the canals after every 3 weeks of placement for 8 months.

Caution should be taken in general when giving local or systemic drugs. Although the volumes of the drugs applied in this therapy were small and there were no reports of side effects, care should be taken if patients are sensitive to chemicals or antibiotics.


  Conclusion Top


Success of the endodontic treatment relies upon the elimination of bacteria from the root canal. Microorganisms in the periapical region can cause re-infection and failure. When the most commonly used medicament fail to eliminate the symptoms, then a triple antibiotic paste can be used as an alternative material. From the existing literature, it is clear that TAP can be effectively used for sterilization of canals and healing of periapical pathology. The periradicular lesion in two cases was large but showed progressive healing after using a triple antibiotic paste in the canal. Every effort should be made to treat such lesions irrespective of size by a nonsurgical endodontic treatment method. TAP seems to be promising medicament in the sterilization and healing.

 
  References Top

1.
Sundqvist G. Ecology of the root canal flora. J Endod 1992;18:427-30.  Back to cited text no. 1
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2.
Taneja S, Kumari M, Prakash H. Nonsurgical healing of large periradicular lesions using atriple antibiotic paste: A case series. Contemp Clin Dent 2010;1:31-5.  Back to cited text no. 2
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3.
Pinky C, Shashibhushan KK, Subbareddy VV. Endodontic treatment of necrosed primary teethusing two different combinations of antibacterial drugs: An in vivo study. J Indian Soc Pedod Prev Dent 2011;29:121-7.  Back to cited text no. 3
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Windley W 3 rd , Teixeira F, Levin L, Sigurdsson A, Trope M. Disinfection of immature teethwith a triple antibiotic paste. J Endod 2005;31:439-43.  Back to cited text no. 4
    
5.
Caliºkan MK. Prognosis of large cyst-like periapical lesions following nonsurgical root canaltreatment: A clinical review. Int Endod J 2004;37:408-16.  Back to cited text no. 5
    
6.
Hoshino E, Takushige T. LSTR 3Mix-MP method-better and efficient clinical procedures oflesion sterilization and tissue repair (LSTR) therapy. Dent Rev 1998;666:57-106.  Back to cited text no. 6
    
7.
Hoshino E, Ando N, Sato M, Kota K. Bacterial invasion of non-exposed dental pulp. Int Endod J 1992;25:2-5.  Back to cited text no. 7
    
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Ingham HR, Selkon JB, Hale JH. The antibacterial activity of metronidazole. J Antimicrob Chemother 1975;1:355-61.  Back to cited text no. 8
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Hoshino E, Kota K, Sato M, Iwaku M. Bactericidal efficacy of metronidazole against bacteria of human carious dentin in vitro. Caries Res 1988;22:280-2.  Back to cited text no. 9
    
10.
Sato T, Hoshino E, Uematsu H, Kota K, Iwaku M, Noda T. Bactericidal efficacy of a mixture of ciprofloxacin, metronodazole, minocycline and rifampicin against bacteria of carious andendodontic lesions of human deciduous teethin vitro. Microb Ecol Health Dis 1992;5:171-7.  Back to cited text no. 10
    
11.
Manuel ST, Parolia A, Kundabala M, Vikram M. Non-surgical endodontic therapy using triple-antibiotic paste. Kerala Dent 2010;33:88-91.  Back to cited text no. 11
    
12.
Soares J, Santos S, Silveira F, Nunes E. Nonsurgical treatment of extensive cyst-like periapical lesion of endodontic origin. Int Endod J 2006;39:566-75.  Back to cited text no. 12
    
13.
Bystrom A, Claesson R, Sundqvist G. The antibacterial effect of camphorated paramonochlorophenol, camphorated phenol and calcium hydroxide in the treatment of infected root canals. Endod Dent Traumatol 1985;1:170-5.  Back to cited text no. 13
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Ando N, Hoshino E. Predominant obligate anaerobes invading the deep layers of root canal dentine. Int Endod J 1990;23:20-7.  Back to cited text no. 14
    
15.
Csukás Z, Ferenczi I, Nász I, Bánóczy J. Diffusion of metronidazole through the dentinaltubules of extracted teeth. Acta Microbiol Hung 1987;34:121-4.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]


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