|
 
 |
| REVIEW ARTICLE |
|
| Year : 2018 | Volume
: 9
| Issue : 2 | Page : 79-82 |
|
Lesion sterilization and tissue repair in pediatric dentistry
Suchetana Goswami
Department of Pedodontics and Preventive Dentistry, Dr. R Ahmed Dental College and Hospital, Kolkata, West Bengal, India
| Date of Web Publication | 18-Jun-2018 |
Correspondence Address:
Suchetana Goswami
Department of Pedodontics and Preventive Dentistry, Dr. R Ahmed Dental College and Hospital, 114, AJC Bose Road, Kolkata - 700 014, West Bengal
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/srmjrds.srmjrds_69_17
The success of endodontic treatment and restoration of teeth predominantly depend on disinfection or aseptic environment of the affected tissue. Some bacterial flora may also remain in spite of the conventional process of cleaning and irrigation, which may later cause reinfection and failure of treatment. The article reviews the usefulness of lesion sterilization and tissue repair procedure in pediatric dentistry, its indications, contraindications, advantages, disadvantages, clinical procedure, and related studies. Keywords: Lesion sterilization and tissue repair, regeneration, triple antibiotic paste
How to cite this article:
Goswami S. Lesion sterilization and tissue repair in pediatric dentistry. SRM J Res Dent Sci 2018;9:79-82 |
| Introduction | |  |
LSTR is an acronym for lesion sterilization and tissue repair. It is a process which allows the use of a combination of antibiotics (metronidazole, ciprofloxacin, and minocycline) for controlling of oral infections such as dentinal, pulpal, and periapical lesions.[1] This therapy aims to eliminate causative bacteria from the diseases by disinfecting the lesions and promoting tissue regeneration by the host's natural tissue recovering process. Three types of antibiotics are combined to ensure complete removal of all pathogenic microorganisms in pulpal and periapical lesions.[2]
The triple antibiotic paste (TAP) contains 1 part of ciprofloxacin and 3 parts of metronidazole and 3 parts of minocycline by weight. Ciprofloxacin is a synthetic fluoroquinolone and has a bactericidal effect. Metronidazole is a nitroimidazole compound having a broad spectrum of activity against protozoa and other anaerobic bacteria. Minocycline is a synthetic derivative of tetracycline with a similar spectrum of action. This procedure of disinfecting oral lesion was first invented by the Cariology Research Unit of Nigata University School of Dentistry.[3],[4],[5],[6]
| Some Studies Involving Triple Paste | | |
Sato et al. experimented with these drug combination in vitro to show its effectiveness in the deep caries, necrosed pulp, and infected root canals of primary teeth and found to be very effective.[5]
Few years later, Hoshino et al. found that a combination of ciprofloxacin, metronidazole, and minocycline with a dilution 25 gm/ml of paste has ability to decontaminate infected root canal in vitro.[7] Proceeding further, Banchs and Trope suggested that this method may not be suitable for determining whether combinations of drugs can kill all the bacteria in a flora.[8] On the other hand, Ozan and Er reported endodontic treatment of a large cyst like periradicular lesion using a combination of antimicrobial drugs.[9]
Akgun(2009) advocated the use of TAP for a traumatized immature tooth with a periapical lesion.[10] Literature also reveals that non vital teeth with immature roots were treated with antibiotic pastes.[11]
Jaya et al.[12] evaluated and compared the clinical and radiographic effectiveness of metronidazole and tinidazole in two groups of patients with primary teeth and found to be very effective with no significant difference between the two groups.
Tinidazole is a second-generation synthetic nitroimidazole group of drug and is more effective than metronidazole in anaerobic infections and produces fewer and milder side effects.[12]
Divya and Retnakumari conducted a study of 3 cases to determine the capability of the TAP to eliminate causative bacteria from lesions and to augment the host's natural recovery process to repair the damaged tissue. In the treatment process, both softened dentin and carious dentin can be intentionally left so that an inflamed pulp with spontaneous pain will recover after LSTR treatment.[13]
Nanda et al.[14] selected forty necrosed primary molars from healthy children and divided them into two groups. The first group was treated with metronidazole paste and the second group with ornidazole paste. The result showed that both the antibacterial pastes can be used effectively in endodontic treatment of necrosed primary teeth.
| The Clinical Indications for Lesion Sterilization and Tissue Repair | | |
- Primary teeth affected with pain and tender on percussion
- Teeth with Grade I and II mobility
- Presence of abscess
- Presence of sinus tract
- Presence of radiolucency in furcation area
- Pulpless primary teeth in hemophilic patient
- Immature primary teeth with necrotic pulp and incompletely formed roots.
Contraindications of lesion sterilization and tissue repair
- Patient sensitive or allergic to ciprofloxacin, minocycline, or metronidazole
- Radiographic evidence of excessive internal or external root resorption
- Primary tooth nearing exfoliation
- Perforated pulpal floor
- Excessive bone loss in furcation area involving underlying tooth germ
- Non restorable crown of permanent tooth where postplacement and core buildup are not possible.
| The Clinical Procedure | | |
According to Nanda et al.,[14]
- Isolation with rubber dam
- Administration of Local anaesthetic (optional)
- Removal of caries
- Preparation of access cavity
- Extirpation of necrotic coronal pulp
- Irrigation with normal saline (0.9%) and drying with cotton pellet
- Enlargement of canal orifices. It should be 1 mm in diameter and a depth of 2 mm to receive medication
- The cavity is then filled with 3 antibiotic mix and teeth restored with glass ionomer cement, and stainless steel crown is given.
Advantages of lesion sterilization and tissue repair
The advantages of LSTR include the following:
- The technique is easy and simple
- Treatment time is short
- Economical
- Relatively painless
- No instrumentation is needed
- No obturation is required
- Materials used are nonirritating to periapical tissues
- There is no need to use formocresol.
Disadvantages of lesion sterilization and tissue repair
- Minocycline has discoloration effect on hard tissues of the oral cavity. This discoloration may be due to photo-induced reaction. The drug binds to calcium ion by chelation and forms an insoluble compound with bluish gray hue. The problem can be solved by replacing minocycline with clindamycin
- The original mixture of antibiotics is radiolucent in radiograph which can be overcome by adding iodoform.
Method of preparation
The antibiotic paste should be freshly prepared before use. A clean mortar pestle is used for mixing. The three antibiotics ciprofloxacin, metronidazole, and minocycline powder are dispensed and mixed with a ratio of 1:3:3. Then, equal amount of propylene glycol is added to form a creamy paste. Extra paste can be stored in air-tight container for future use. However, the loss of translucency of the paste indicates contamination and it should be discarded.[6],[7],[14],[15]
Method of application
A 20 G needle is placed 1–2 mm short of root apex and medicaments are introduced into the canal using a backfill approach. Alternatively, lentulospirals can be used for filling.[15]
| Discussion | | |
It is always better to prevent disease rather than to cure it. When preventive approaches fail, more complicated procedures such as surgical interventions and restorations are required. The success of nonsurgical endodontic treatment depends on adequate cleaning, biomechanical preparation, asepsis, and filling of root canal with perfect apical sealing. Number of case reports have been published describing nonsurgical management of pulpless teeth with persisting sinus tract using TAP.[16],[17],[18],[19],[20],[21]
TAP was successful in decreasing the number of microbial load and promotes normal healing process of the host. When antibiotics are systemically administered, it reaches the infected tissue through circulatory system. Therefore, the infected area should have sufficient blood supply. However, local administration of antibiotics does not depend on these factors and can be a more effective mode of applying the drug directly on infected tissue.[22],[23]
The conventional process of apexification in immature tooth with necrotic pulp uses calcium hydroxide (Ca [OH)2) or mineral trioxide aggregate (MTA) and does not increase root length or does not cause further thickening of dentinal wall. Dentin smear layer can also have an inhibitory effect on bactericidal action of intracanal medicaments such as Ca (OH)2. Moreover, Ca (OH)2 can also have certain disadvantages such as multiple appointments and recontamination of root canal system during intratreatment period. The root dentin may also become brittle and could lead to cervical root fracture in future. MTA can also be used, but it also does not increase root length. Moreover, MTA also causes root closure at the length of root that is already present. Regenerative endodontics and revascularization are probably more helpful in such cases. Teeth with vital pulp could provide favorable result when aseptic condition is created. The inflammatory process could reverse, and tissues may proliferate.[24]
The success of treatment of immature tooth with periapical lesion depends on disinfection of canal, introduction of matrix (blood clot) within the canal for tissue growth, and a hermetic seal of access cavity. As the root canal infection is generally polymicrobial, a combination of drugs is always useful to cover aerobic, anaerobic, and facultative anaerobic infections.
TAP contains both bactericidal components (metronidazole and ciprofloxacin) and bacteriostatic component (minocycline) to allow for successful endodontic treatment. TAP is biocompatible. Tetracycline inhibits collagenase and matrix metalloproteinases. It also increases the level of interlukin-10, an anti-inflammatory cytokine. Metronidazole and ciprofloxacin are capable of increasing fibroblast production for regeneration purpose. However, one problem with antibiotics is that it can cause bacterial resistance. Besides, minocycline can cause tooth discoloration. Replacement of minocycline with clindamycin can overcome this problem. Furthermore, some scientists advocated use of dentin-bonding agent before placement of TAP to reduce discoloration.[21],[25],[26]
| Conclusion | | |
Success of endodontic treatment predominantly depends on aseptic conditions. Residual microorganisms can cause reinfection and failure of endodontic treatment. This causes waste of time, money, and energy and frustrating condition for the patient and dental surgeons. Moreover, pediatric patients usually have a short attention span and do not like long treatment duration and repeated visits. Therefore, TAP may be used for treatment of immature vital tooth.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Vijayaraghavan R, Mathian VM, Sundaram AM, Karunakaran R, Vinodh S. Triple antibiotic paste in root canal therapy. J Pharm Bioallied Sci 2012;4:S230-3.  [ PUBMED] |
| 2. | Kim JH, Kim Y, Shin SJ, Park JW, Jung IY. Tooth discoloration of immature permanent incisor associated with triple antibiotic therapy: A case report. J Endod 2010;36:1086-91. [ PUBMED] |
| 3. | Tripathi KD. Essentials of Medical Pharmacology. 6 th ed. New Delhi: Jaypee Brothers Medical Publishers; 2013. |
| 4. | Fuks AB. Pulp therapy for the primary and young permanent dentitions. Dent Clin North Am 2000;44:571-96, vii. [ PUBMED] |
| 5. | Sato T, Hoshino E, Uematsu H, Noda T. In vitro antimicrobial susceptibility to combinations of drugs on bacteria from carious and endodontic lesions of human deciduous teeth. Oral Microbiol Immunol 1993;8:172-6. [ PUBMED] |
| 6. | Anila B, Murali H, Cheranjeevi J, Kapil RS. Lesion sterilization and tissue repair (LSTR): A review. J Sci Dent 2014;4:49-55. |
| 7. | Hoshino E, Kurihara-Ando N, Sato I, Uematsu H, Sato M, Kota K, et al. In-vitro antibacterial susceptibility of bacteria taken from infected root dentine to a mixture of ciprofloxacin, metronidazole and minocycline. Int Endod J 1996;29:125-30. [ PUBMED] |
| 8. | Banchs F, Trope M. Revascularization of immature permanent teeth with apical periodontitis: New treatment protocol? J Endod 2004;30:196-200. [ PUBMED] |
| 9. | Ozan U, Er K. Endodontic treatment of a large cyst-like periradicular lesion using a combination of antibiotic drugs: A case report. J Endod 2005;31:898-900. [ PUBMED] |
| 10. | Akgun OM, Altun C, Guven G. Use of triple antibiotic paste as a disinfectant for a traumatized immature tooth with a periapical lesion: A case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:e62-5. [ PUBMED] |
| 11. | Varalakshmi R, Parasuraman L, Muljibhai BS. 3Mix-MP in endodontics – An overview. J Dent Med Sci 2012;3:36-45. |
| 12. | Jaya AR, Praveen P, Anantharaj A, Venkataraghavan K, Rani PS. In vivo evaluation of lesion sterilization and tissue repair in primary teeth pulp therapy using two antibiotic drug combinations. J Clin Pediatr Dent 2012;37:189-91. [ PUBMED] |
| 13. | Divya S, Retnakumari N. Lesion sterilization and tissue repair in primary teeth with periapical pathosis – A case series. J Dent Med Sci 2014;3:7-11. |
| 14. | Nanda R, Koul M, Srivastava S, Upadhyay V, Dwivedi R. Clinical evaluation of 3 mix and other mix in non-instrumental endodontic treatment of necrosed primary teeth. J Oral Biol Craniofac Res 2014;4:114-9. [ PUBMED] |
| 15. | Takushige T, Cruz EV, Asgor Moral A, Hoshino E. Endodontic treatment of primary teeth using a combination of antibacterial drugs. Int Endod J 2004;37:132-8. [ PUBMED] |
| 16. | Taneja S, Kumari M, Parkash H. Nonsurgical healing of large periradicular lesions using a triple antibiotic paste: A case series. Contemp Clin Dent 2010;1:31-5. [ PUBMED] [Full text] |
| 17. | Pinky C, Shashibhushan KK, Subbareddy VV. Endodontic treatment of necrosed primary teeth using two different combinations of antibacterial drugs: An in vivo study. J Indian Soc Pedod Prev Dent 2011;29:121-7. [ PUBMED] [Full text] |
| 18. | Windley W 3 rd, Teixeira F, Levin L, Sigurdsson A, Trope M. Disinfection of immature teeth with a triple antibiotic paste. J Endod 2005;31:439-43. |
| 19. | Grossman LI. Polyantibiotic treatment of pulpless teeth. J Am Dent Assoc 1951;43:265-78. [ PUBMED] |
| 20. | Portenier I, Haapasalo H, Rye A, Waltimo T, Ørstavik D, Haapasalo M, et al. Inactivation of root canal medicaments by dentine, hydroxylapatite and bovine serum albumin. Int Endod J 2001;34:184-8. |
| 21. | Manuel ST, Parolia A, Kundabala M, Vikram M. Non-surgical endodontic therapy using triple-antibiotic paste. Kerala Dent J 2010;33:88-90. |
| 22. | Athanassiadis B, Abbott PV, Walsh LJ. The use of calcium hydroxide, antibiotics and biocides as antimicrobial medicaments in endodontics. Aust Dent J 2007;52:S64-82. [ PUBMED] |
| 23. | Agarwal M, Das UM, Vishwanath D. A comparative evaluation of non-instrumentation endodontic techniques with conventional ZOE pulpectomy in deciduous molars: An in vivo study. World J Dent 2011;2:187-92. |
| 24. | Shabahang S, Torabinejad M, Boyne PP, Abedi H, McMillan P. A comparative study of root-end induction using osteogenic protein-1, calcium hydroxide, and mineral trioxide aggregate in dogs. J Endod 1999;25:1-5. [ PUBMED] |
| 25. | Bansal R, Bansal R. Regenerative endodontics: A state of the art. Indian J Dent Res 2011;22:122-31. [ PUBMED] [Full text] |
| 26. | Prabhakar AR, Sridevi E, Raju OS, Satish V. Endodontic treatment of primary teeth using combination of antibacterial drugs: An in vivo study. J Indian Soc Pedod Prev Dent 2008;26 Suppl 1:S5-10. [ PUBMED] |
|
Search Pubmed for