Asheesh Sawhny et al IJRD ISSUE 1, 2013

CASE REPORT

Non Surgical Endodontic

Management of immature root
with a large periapical lesion
using tri-Antibiotic paste & MTA: A Case Series
Asheesh Sawhny*MDS, D. Arunagiri *MDS, Pushpa.S*MDS, Irfana Khursheed*MDS, Abhishek
Singh*Post Graduate Student.
* Department of Conservative dentistry & Endodontics Rama Dental College, Hospital & Research Centre,
Kanpur, Uttar Pradesh, INDIA
Address for correspondence: Dr. Asheesh Sawhny, Reader, Department of Conservative dentistry and Endodontics , Rama Dental
College, Hospital & Research Centre, A-1/8, Lakhanpur, Kanpur-208024, Uttar Pradesh.
E-mail : [email protected]
Abstract : The immature tooth with apical periodontitis presents numerous challenges that inhibit our ability to provide a predictable
long-term treatment outcome. Past efforts have been aimed at eliminating the bacterial challenge and creating an environment conducive
to the placement of a root canal filling. The infection of the root canal system is considered to be polymicrobial infection, consisting of
both aerobic and anaerobic bacteria. Because of the complexity of the root canal infection, it is unlikely that any single antibiotic could
result in effective sterilization of the canal. A combination of antibiotic drugs (metronidazole, ciprofloxacin and minocycline) is used to
eliminate target bacteria, which are possible sources of endodontic lesions. Two case reports describe the nonsurgical endodontic
treatment of teeth with large periradicular lesions. During treatment procedure, 2.5% sodium hypochlorite was used for irrigation and a
combination of antibiotic drugs was used for the intracanal dressing. Periapical healing was observed 3-month after initial treatment and
continued at the 7-month review. Apical closure was done with MTA plug.
Keywords: Tri-antibiotic paste, sodium hypochlorite, LSTR therapy, periapical healing, periapical lesion, MTA.
INTRODUCTION includes the initial use of non-surgical root canal
treatment (1). When this treatment is not successful
Traumatic injuries of teeth are a frequent occurrence in resolving the periradicular pathosis, additional
and usually involve the anterior teeth of young treatment options should be considered. Such
patients. Pulpal necrosis is a frequent sequel of treatment may include non-surgical retreatment to
trauma and if microbial infection occurs, this will rule out morphological abnormalities or treatment
result in the development of a periapical lesion(1). inadequacies. Surgery may occasionally be required.
The immature tooth with apical periodontitis Surgical treatment of persistent extensive
presents numerous challenges that inhibit our ability periradicular lesions most often involves curettage
to provide a predictable long-term treatment and apical resection. Some clinical studies have
outcome. Past efforts have been aimed at eliminating confirmed that simple nonsurgical treatment with
the bacterial challenge and creating an environment proper infection control can promote healing of
conducive to the placement of a root canal filling large lesions(1,3). In recent years, The Cariology
(2). Research Unit of the Niigata University has
developed the concept of ‘Lesion sterilization and
Treatment options to manage large periapical lesions
tissue repair, LSTR therapy(5,6), that employs the
range from non-surgical root canal treatment and/or
use of a combination of antibacterial drugs for
apical surgery to extraction. Current philosophy in
disinfection of oral infectious lesions, including
the treatment of teeth with large periapical lesions
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 Asheesh Sawhny et al IJRD ISSUE 1, 2013
dentinal, pulpal, and periradicular lesions. Repair of clinically detected. The tooth was slightly tender to
damaged tissues can be expected if lesions are percussion with probing and exhibited normal
disinfected(7). mobility. Periapical radiograph demonstrated a large
radiolucent lesion with a well-defined margin
The infection of the root canal system is considered around the apex of the maxillary left lateral incisor
to be a polymicrobial infection, consisting of both (Fig. 1). The lesion was approximately 3.5cm in
aerobic and anerobic bacteria(8,9). Because of the maximum diameter. This tooth gave negative
complexity of the root canal infection it is unlikely response to electric pulp and cold tests. The access
that any single antibiotic could result in effective cavity was prepared, and a rubber dam was applied.
sterilization of the canal. More likely a combination A clear, straw-colored fluid was exuded from the
would be needed to address the diverse flora canals. Necrotic pulp tissue was extirpated and the
encountered. A combination of antibiotics would working length was estimated as being 1 mm short
also decrease the likelihood of the development of of the radiographic apex. The canal was
resistant bacterial strains. The combination that instrumented with size 80 K-file.
appears to be most promising consists of
metronidazole, ciprofloxacin, and minocycline (2).

Though the goals of eliminating the bacterial

challenge and creating an environment conductive to
the placement of a root canal filling have been
adequately met, but the problem of thin root walls
and susceptibility to fracture still remain. The usual
treatment procedure proposed for such cases is the
repeated intracanal placement of calcium hydroxide
in order to induce an apical hard tissue barrier.
However, the calcium hydroxide apexification has
some inherent disadvantages such as prolonged
treatment time, unpredictability of apical closure,
difficulty in patient follow up, susceptibility to Fig.1: Preoperative radiograph showing
coronal micro leakage, weakens the root structure by
maxillary left lateral incisor with large
neutralizing the acidic components of dentin. To
overcome all these limitations a single visit periapical lesion
apexification technique using mineral trioxide
aggregate (MTA) was adapted.

The following case report describes the endodontic

treatment of a large cyst-like periradicular lesion
using a combination of antibiotic drugs followed by
apical closure with mineral trioxide aggregate
(MTA).

Case 1: A 16 year old male presented to the

department of conservative dentistry and
Endodontics in the college for treatment of
maxillary left lateral incisor tooth. On clinical
examination of soft tissue an intra oral sinus tract
was present. No discoloration and caries were Fig.2: Radiograph showing placement of MTA

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Asheesh Sawhny et al IJRD ISSUE 1, 2013
no sensitivity to percussion or palpation and the soft
tissues were healthy.

Case 2: A 19 year old female reported to the

department of conservative dentistry and
Endodontics with a chief complaint of pain and
swelling in maxillary anterior region. There was a
history of trauma to maxillary left central incisor 1
year back due to fall while playing. But the patient
did not seek any treatment for the same at that time.
Extraoral examination revealed no swelling.
Intraoral examination revealed fracture of maxillary
Fig.3: Follow-up 7 months after completion of
left central incisor involving enamel and dentin.
endodontic treatment. Periapical radiograph shows
Two periapical radiographs at different vertical
healing of the periapical lesion.
angulations were made but showed no root fracture.
During the instrumentation, the canal was irrigated Periapical radiographic examination revealed a well
copiously with 2.5% sodium hypochlorite solution defined radiolucent area involving maxillary left
using a 27-gauge endodontic needle after each central and lateral incisors, measuring around 3cm in
instrument. Drainage was performed until discharge diameter (Fig 4). Electric pulp and cold tests elicit
through the canal ceased. When the drainage ceased, negative response with maxillary left central incisor
the root canal were finally instrumented and copious and lateral incisor. The clinical and radiographic
irrigation with 2.5% sodium hypochlorite solution findings were suggestive of periapical pathology in
under rubber dam isolation was done. After drying relation to central and lateral incisor. Hence
with sterile paper points, and a mixture of endodontic treatment was proposed with patient’s
ciprofloxacin, metronidazole, and minocycline paste consent. A rubber dam was applied, and the access
as described by Takushige et al. (7) was prepared cavities were prepared. The drainage of pus was
into a creamy consistency and spun down the canal noted from both teeth. Both teeth were instrumented
with a lentulo spiral instrument into the canal. The to ISO size 60 by using the step-back technique.
paste was further condensed using sterile cotton During instrumentation, the canals were irrigated
pellets before sealing the coronal access. The with 2.5% sodium hypochlorite and dried, triple
compounding of antibiotic paste was standardized antibiotic paste was placed, and the teeth were
for all two cases. The patient was recalled after 3 temporized. The paste was changed every month for
months when radiographic examination revealed a period of 3 months until the teeth displayed no
significant healing (Fig. 2). The antibiotic paste symptoms. After 3 months the canals were irrigated
removed after irrigation with 3% sodium with 2.5% sodium hypochlorite and apical closure
hypochlorite, the white MTA was mixed to a paste was done with MTA plug in the same appointment
consistency with saline and delivered to the canal (Fig 5). Next day rest of the canal was obturated
using plugger in about 4 mm thickness and with gutta-percha and the restoration was
remainder of canal was obturated next day using a accomplished with composite resin (Fig 6). The
lateral condensation technique. Access cavity was patient returned to the department for the 7 month
sealed with composite. The patient returned to the follow-up examination and was asymptomatic.
department for 7 month follow-up examination and Radiographic examination showed progressive
was asymptomatic. Radiographs showed that the healing of lesion.
radiolucent area was absent and that trabecular bone
was forming (Fig 3). Clinical examination showed

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Asheesh Sawhny et al IJRD ISSUE 1, 2013
provide a good nutritional supply for pathogenic
bacteria, which must be present for the development
of a periapical lesion. The treatment options
available to manage large cysts range from
nonsurgical root canal treatment and/or apical
surgery to extraction. In some instances, nonsurgical
treatment may be ineffective or difficult; those cases
may be treated by surgery. In the present study,
radiographs revealed that the involved teeth had
large periradicular lesion with uniformly dense
radiolucency and well-defined margins around the
Fig.4: Preoperative radiograph showing apices.
maxillary left cental & lateral incisor
with large periapical lesion. The infection of the root canal system is considered
to be a polymicrobial infection, consisting of both
aerobic and anerobic bacteria (8,9). 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. A combination of antibiotics would
also decrease the likelihood of the development of
resistant bacterial strains. The combination that
appears to be most promising consists of
metronidazole, ciprofloxacin, and minocycline. Sato
et al. investigated this drug combination in vitro and
found it to be very effective in the sterilization of
Fig.5: Radiograph showing placement of MTA carious lesions, necrotic pulps, and infected root
dentin of deciduous teeth (10). Hoshino et al.
performed an in vitro study testing the antibacterial
efficacy of these drugs alone and in combination
against the bacteria of infected dentin, infected
pulps, and periapical lesions. Alone, none of the
drugs resulted in complete elimination of bacteria.
However, in combination, these drugs were able to
consistently sterilize all samples (11). Metronidazole
is a nitroimidazole compound that exhibits a broad
spectrum of activity against protozoa and anaerobic
bacteria. Known for its strong antibacterial activity
against anaerobic cocci, as well as gram-negative
Figure 6: Radiograph taken after obturation with and gram-positive bacilli it has been used both
gutta-percha. systemically and topically in the treatment of
periodontal disease. Tetracyclines, which include
DISCUSSION
doxycycline and minocycline, are a group of
The response to trauma can be varied. Some pulps bacteriostatic antimicrobials. They have a broad
remain apparently normal with no adverse effects, spectrum of activity against both gram-positive and
whereas others became necrotic. Necrotic pulps gram-negative microorganisms. Tetracyclines are
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 Asheesh Sawhny et al IJRD ISSUE 1, 2013
effective against most spirochaetes, and many obturation after short canal disinfection with calcium
anaerobic and facultative bacteria. Minocycline is a hydroxide could be performed. In agreement with
semisynthetic derivative of tetracycline with a other studies, MTA appeared to show good sealing
similar spectrum of activity. It is available in many ability, good marginal adaptation, a high degree of
topical forms ranging from gel mixtures to sustained biocompatibility and a reasonable setting time
release microspheres, and has also been used (about 4 h). From a practical point of view, MTA
extensively in periodontal therapy. Ciprofloxacin can be used in the presence of moisture in the root
has very potent activity against gram-negative canal. This property is important in teeth with
pathogens but very limited activity against gram- necrotic pulps and inflamed periapical lesions
positive bacteria. Most anaerobic bacteria are because one of the problems found in these cases is
resistant to ciprofloxacin, therefore, it is often the presence of exudate at the apex of the root (16).
combined with metronidazole in the treatment of
mixed infections (2). Side effects of ciprofloxacin The clinical case reported here demonstrates that
have been reported, however, Black et al. found the when MTA is used as an apical plug in necrotic
drug to be clinically safe when applied in low doses teeth with immature apices, the canal can be
(12). When applied as an intra-canal medicament in effectively sealed.
low doses, adverse systemic side effects should be
CONCLUSION
minimized. It was further suggested that no single
antimicrobial agent can be used appropriately for the Root canal treatment using a combination of
treatment of mixed infections. Thus a combination antibiotic drugs as an antibacterial dressing was
of medicaments must be considered. Knowing the successful in healing large cyst-like periradicular
concern over the potential for the development of lesions. The use of MTA apical plug after calcium
resistant flora when using certain topical antibiotics, hydroxide disinfection showed a positive initial
Slots advocated the use of metonidazole because of clinical outcome for the immature tooth.
the unlikelyhood of inducing bacterial resistance
(13). It was demonstrated in this case report that the REFERENCES
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