81 81 Successful nonsurgical retreatment of resected teeth associated with persistent periapical lesion by placing triple Antibiotic paste and mineral trioxide aggregate apical plug - A case report Sumanthini.M.V. # Vanitha.U.Shenoy # Rupali Deshmukh # Rahul Kumar # ABSTRACT This article describes the nonsurgical management of traumatized teeth that had undergone apisectomy and associated with a large periapical lesion. A combination of antibacterial drugs consisting of metronidazole, ciprofloxacin and minocycline was used for root canal disinfection. The common problem encountered with this drug combination is tooth discoloration due to minocycline. Adhesive restoration was used to address this problem. Mineral trioxide aggregate apical plug was placed in the lateral incisor that had undergone unsuccessful root resection. On two year follow up the patient was asymptomatic and intraoral periapical radiograph showed successful healing with complete resolution of the periradicular lesion. Key words: Discolouration, mineral trioxide aggregate, retreatment, triple antibiotic paste. # Department of Conservative Dentistry and Endodontics, MGM Dental College and Hospital, Navi Mumbai Introduction Endodontic surgery with root end resection often leaves a canal with an apex that is large in diameter creating an open apex. 1 In the event of failure subsequent orthograde retreatment may be indicated. It is difficult to obtain a fluid tight apical seal in such teeth with open apices by using the conventional endodontic treatment methods due to absence of an apical barrier, against which obturation material can be compacted. Traditionally, multiple-visit apexification with calcium hydroxide (CH) was the treatment of choice in teeth with open apex, which would induce formation of an apical hard tissue barrier. Although successful, it takes anywhere from 3 to 18 months for the creation of physiologic hard tissue barrier. 2 The disadvantages of this technique is multiple treatment appointments, coronal leakage, and increased susceptibility of tooth fracture. 3,4 An alternative technique for apexification with CH is to seal the open apical foramen with mineral trioxide aggregate (MTA) apical plug. Considerable success has been reported recently with this technique in treating permanent teeth with immature apices which is attributed to its ability to induce periradicular tissue regeneration, biocompatibility, good sealing ability and enables treatment to be completed in a short frame of time. 5 MTA has been found to be an appropriate material for apical sealing of mature root canals with open apex as a result of over instrumentation, resorption or former apisectomy. 6,7 The major causative role of microorganisms in the pathogenesis of persistent periapical diseases is well documented and considered to be ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY ENDODONTOLOGY Volume: 25 Issue 2 December 2013 Case Report
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Successful nonsurgical retreatment of resected teethassociated with persistent periapical lesion by placing tripleAntibiotic paste and mineral trioxide aggregate apical plug- A case report
immature apices which is attributed to its ability to
induce periradicular tissue regeneration,
biocompatibility, good sealing ability and enables
treatment to be completed in a short frame of time.5
MTA has been found to be an appropriate material
for apical sealing of mature root canals with open
apex as a result of over instrumentation, resorption
or former apisectomy.6,7
The major causative role of microorganisms
in the pathogenesis of persistent periapical diseases
is well documented and considered to be
ENDODONTOLOGYENDODONTOLOGYENDODONTOLOGYENDODONTOLOGYENDODONTOLOGY Volume: 25 Issue 2 December 2013 Case Report
8282
polymicrobial. A combination of antimicrobial
drugs consisting of metronidazole, ciprofloxacin and
minocycline has been shown to be very effective in
eliminating endodontic pathogens in vitro and in
vivo. In combination, these drugs were able to
consistently sterilize all samples.8Among the
components of the mixture, minocycline, a
semisynthetic derivative of tetracycline has the
potential to induce tooth discolouration.9
Anticipating this, as a precaution, adhesive
restorative techniques need to be adopted from the
beginning of commencement of treatment in order
to prevent discolouration from occurring.
The following case report describes nonsurgical
endodontic retreatment of teeth that had undergone
apical root resection and was associated with a
persistent large periradicular lesion.
Case ReportA 26 year old female patient was referred to
Department of conservative dentistry and
endodontics, with a chief complaint of pain and
swelling in maxillary left central incisor (21) and
maxillary left lateral incisor (22) since one month.
The patient gave a history of root canal treatment in
the 21, 22 and maxillary left canine (23) followed
by surgical root resection in 21 and 22. Clinical
examination revealed an intraoral, labial swelling
and sinus tract at the apex of 21 [Fig 1a]. The access
cavities were restored with tooth coloured
restorations. Tooth number 22 was tender on
percussion and 23 were asymptomatic. Maxillary
right central incisor (11) had a mesial angle fracture
involving enamel and tested vital. Intraoral
periapical radiograph revealed large periapical
rarefactions in 21 and 22, obturation in both teeth
were below acceptable standards and the root ends
were resected [Fig 1b]. A Gutta percha cone is
radiographically seen tracing the source of infection
to 21[Fig 1c]. In view of the signs and symptoms
Fig 1a: Preoperative intraoral picture of maxillary left central andlateral incisors with swelling and sinus tract apical to maxillary leftcentral incisor, mesioangle fracture in maxillary right central incisor.
Fig 1b: Preoperative intraoral periapical radiograph revealing largeperiapical lesion in relation to maxillary left central and lateral incisors,obturation not meeting acceptable standards and resected root apex
Fig 1c: Intraoral periapical radiograph showing gutta-percha conetracing the sinus tract to the root apex of 21.
restorations and gutta-percha root canal filling was
removed from 21 and 22. Pus exuded through the
canal of 22, canal was irrigated with normal saline
to facilitate drainage. A loose sterile cotton pledget
was placed in the pulp chambers of both teeth
followed by thin closed dressing of zinc oxide
eugenol (DPI, Mumbai, India). Patient was recalled
the following day; her acute symptom of pain had
subsided. Canals were re-entered, working length
established by radiographic method [Fig 1d]. Root
canals were cleaned and shaped with hand files by
step back technique to a #60 ISO size K file (Mani
INC, Japan). During instrumentation, the canals
were copiously irrigated with 5% sodium
hypochlorite (NaOCl) (Trifarma, Thane, India)
intermittently. A thick paste of CH (Deepashree
Fig 1d: Working length radiograph, note the lack of apical stop inmaxillary left lateral incisor
Products, Ratnagiri, India) and saline was packed
within the canal and temporized with zinc oxide
eugenol cement. The CH dressing was changed
every week for 3 weeks.
As the symptoms of pain and swelling were
not alleviated, triple antibiotic paste (TAP) was
considered for the intracanal dressing, consisting
of ciprofloxacin 250mg (Ciplox, Cipla Ltd, Mumbai,
India) metronidazole 400mg (Flagyl, Abbott Health
care private limited, Thane, Maharashtra, India ) and
minocycline 100mg (Minoz, Ranbaxy Laboratories
Limited, India) after obtaining patient’s consent.
Prior to the placement of the paste (TAP), adhesive
restoration was placed in the pulp chamber. The
root canal orifices of teeth 21 and 22 were blocked
with a large gutta percha point. The pulp chamber
was etched with 37 %phosphoric acid (SS White,
Dental Pvt.Ltd. England) for 15 seconds and rinsed
with water. A total etch adhesive (Tetric N-Bond,
Ivoclar Vivadent, Liechtenstien) was applied
according to manufacturer’s instructions, followed
by placement of composite resin( Tetric N-Ceram,
Ivoclar Vivadent, Schaan, Liechtenstien) on the
internal walls of the pulp chamber and light cured.
Hundred milligrams of each drug was obtained
after removal of the enteric coating. The drugs were
pulverized in sterile mortar and pestle separately
and mixed in 0.5 ml of propylene glycol (Desmo
exports limited, Mumbai, India) in a sterile dappen
dish. The TAP was freshly prepared just prior to
insertion in the canal. It was placed in the canals
using lentulospirals (Mani INC, Japan) 1mm short
of the working length and 2 mm short of the canal
orifice. A cotton pledget was placed and the access
cavity sealed with Glass ionomer cement (Type II
GC Universal restorative, Tokyo, Japan). The paste
SUCCESSFUL NONSURGICAL RETREATMENT OF RESECTED TEETH ASSOCIATED WITH PERSISTENT PERIAPICALLESION BY PLACING TRIPLE ANTIBIOTIC PASTE AND MINERAL TRIOXIDE AGGREGATE APICAL PLUG : A CASE REPORT
8484
was changed every month for a period of three
months, after which the symptoms of pain and
swelling resolved. On examination, sinus tract had
healed, soft tissues were healthy and the teeth
showed no signs of discoloration due to
minocycline (Fig 2a). The antibiotic medication was
removed with K- files and irrigation with
5%NaOCl. Root canal of tooth 21was dried with
sterile paper points (Dentsply Maillefer Ballaigues,
Switzerland), obturated with gutta-percha (Dentsply
Maillefer Ballaigues, Switzerland) and AH Plus
(Dentsply Detrey Konstanz, Germany) sealer by
lateral compaction technique (Fig 2b). In 22, due to
Fig 3d: 24 month photograph demonstrates no discoulortation postoperatively and satisfactory soft tissue healing, mesial angle fracture
of 11 restored with resin composite restoration
SUCCESSFUL NONSURGICAL RETREATMENT OF RESECTED TEETH ASSOCIATED WITH PERSISTENT PERIAPICALLESION BY PLACING TRIPLE ANTIBIOTIC PASTE AND MINERAL TRIOXIDE AGGREGATE APICAL PLUG : A CASE REPORT
8686
The local application of antibacterial drugs
represents one of the means of eradicating bacteria
in root canal treatment. A study by Sato et al found
that combination of antibacterial drugs comprising
of metronidazole, ciprofloxacin and minocycline
was effective in killing bacteria in the deep layers
of root canal dentine, capable of sterilizing carious
lesions, necrotic pulp and infected root dentin of
deciduous teeth.12 Several reports in recent times
restoration, there by sealing the dentinal tubules.9, 21 This prevents contact between the antibiotic
medicament and the dentin. Following the above
method, in the present study, discolouration due to
minocycline was prevented in the treated teeth, 21
and 22 (fig 2a, 3d). The paste application should
terminate to a level cervical to the canal orifice and
completely removed from the access cavity. Also
the access cavity should be adequately sealed with
a suitable adhesive restoration, else moisture
contamination could lead to leaching of the paste
and subsequent discoloration of the tooth. After the
placement of triple antibiotic paste, we chose to
restore access cavity with type II Glass ionomer
cement as an intermediate restoration between the
appointments. Glass ionomer cement being truly
chemically bonded to the tooth structure could have
played a significant role in preventing discoloration
of the coronal tooth structure.
In this case, the resected 22 presented an
abnormally large diameter or misshapen apical
foramen due to the retrograde preparation
previously completed. Endodontic obturation
techniques rely on the presence of an apical barrier
against which obturation material can be placed.
In these cases placement of an apical plug of MTA
followed by conventional obturation is the current
treatment of choice.1 The results of the retrospective
study of treatment outcome conducted by Mente et
al suggest placing 4mm apical MTA plug in open
apical foramina yielded a predictable outcome at
par with outcomes expected in conventionally root
filled teeth with undisturbed apical constriction.7
In the case presented a 5mm thick MTA apical
plug was placed which is the recommended
thickness to provide adequate apical seal against
bacterial microleakage .22 MTA is has excellent
sealing properties in the presence of moisture,
induces regeneration of cementum, periodontal
ligament and bone.5,23The favorable biologic
properties of MTA in human periapical tissues are
attributed to the production of bone morphogenic
protein-2 and transforming growth factor beta-
1.24The release of hydroxyl ions, sustained high
pH of 12.5 for extended periods of time, formation
of a mineralized interstitial layer might contribute
to its antibacterial properties.23 MTA inhibits the
growth of Enterococcous faecalis and yeasts such
as Candida albicans prevalent in root canal failures
and refractory endodontic disease.25,26
In the case presented, considering all the merits
of MTA, we concluded that placing an apical plug
of MTA would best address the problem of lack of
apical constriction secondary to root resection. The
6, 12 and 24 month follow up radiographs
demonstrated complete healing of the periapical
lesion and new hard tissue formation in the apical
area.
ConclusionThe outcome in this case suggests that failing
surgically resected teeth can be successfully
retreated nonsurgically by using a combination of
antibiotic drugs for canal disinfection. In order that
no tooth discoloration occurs, adhesive restorative
materials should be used to seal the dentine surface
while applying the minocycline based intracanal
medicament.
MTA apical plug can be considered a viable
option in resected teeth that can possibly reduce
the indications for endodontic resurgery.
SUCCESSFUL NONSURGICAL RETREATMENT OF RESECTED TEETH ASSOCIATED WITH PERSISTENT PERIAPICALLESION BY PLACING TRIPLE ANTIBIOTIC PASTE AND MINERAL TRIOXIDE AGGREGATE APICAL PLUG : A CASE REPORT
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