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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 3  |  Issue : 4  |  Page : 284-287

An in vivo study evaluating lesion sterilization and tissue repair 3 MIX-MP noninstrumentation endodontic treatment as an alternative to conventional endodontic retreatment


1 Department of Conservative Dentistry and Endodontics, St. Joseph Dental College and Hospital, Eluru, Andhra Pradesh, India
2 Department of Prosthodontics, St. Joseph Dental College and Hospital, Eluru, Andhra Pradesh, India

Date of Web Publication14-Sep-2016

Correspondence Address:
Dr. Sohani Maroli
Department of Conservative Dentistry and Endodontics, St. Joseph Dental College and Hospital, Duggirala, Eluru - 534 003, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2348-3334.190579

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  Abstract 

Aim: To alleviate the patient's symptoms and promote periapical healing in teeth with failure of root canal treatment, without the removal of previous obturating material using lesion sterilization and tissue repair (LSTR) 3 MIX-MP noninstrumentation endodontic treatment (NIET). Materials and Methods: Fifteen single-rooted teeth with a history of root canal treatment 1–2 years previously, requiring retreatment, with pain, sinus tract, swelling and periapical lesions, and having acceptable obturation were included in the study. The previous coronal restoration was removed, and a medication cavity was prepared for placement of 3MIX MP; this was followed by lining with Glass ionomer cement and a coronal restoration with composite resin. Results: At 8 weeks, all patients did not have either pain, tenderness on vertical percussion, pain on biting, or swelling (asymptomatic). Radiographically, the periapical lesions had reduced by 1 mm in five cases. In six patients, the lesion size remained unchanged. Conclusion: LSTR NIET is an excellent, inexpensive, less traumatic, and least time-consuming alternative to treat symptomatic teeth requiring endodontic retreatment.

Keywords: Antibiotics, endodontic retreatment, lesion sterilization and tissue repair, noninstrumentation endodontic treatment


How to cite this article:
Dasari V, Maroli S, Chowdary L, Karukola R, Premakumar SH, Vusurumarthi V. An in vivo study evaluating lesion sterilization and tissue repair 3 MIX-MP noninstrumentation endodontic treatment as an alternative to conventional endodontic retreatment. CHRISMED J Health Res 2016;3:284-7

How to cite this URL:
Dasari V, Maroli S, Chowdary L, Karukola R, Premakumar SH, Vusurumarthi V. An in vivo study evaluating lesion sterilization and tissue repair 3 MIX-MP noninstrumentation endodontic treatment as an alternative to conventional endodontic retreatment. CHRISMED J Health Res [serial online] 2016 [cited 2019 Nov 20];3:284-7. Available from: http://www.cjhr.org/text.asp?2016/3/4/284/190579


  Introduction Top


The success of root canal treatment can be evaluated by considering three different perspectives: The dentist, the patient, and the tooth.[1] It has been estimated that the percentage of success of root-filled teeth is 92.6% and the failure rate is 7.4%.[2] Many factors such as degree of microbial invasion, site of the infection, and the immune response of host, play a vital role in the success of the root canal treatment and also in making the decision whether to retreat a case surgically or address it nonsurgically.[3]

A complete elimination of bacteria cannot always be achieved; the bacteria which are present in the isthmuses, ramifications, dentinal tubules, and the irregularities of the root canal may be uninterrupted by the endodontic procedures. This is owing to the complexity of the root canal system. These undisturbed bacteria egress into the periapical area causing inflammation and conclusively lead to an endodontic failure.[4]

Traditionally, the treatment options available for failed root canal treatment have been endodontic retreatment, surgical intervention, and extraction. In 1988, the Cariology Research Unit, Niigata University School of Dentistry, Japan, developed the concept of lesion sterilization and tissue repair (LSTR) which is also known as noninstrumentation endodontic treatment (NIET). It now offers an innovative line of treatment which is less traumatic, less expensive, and also less time-consuming. This employs the use of antibacterial drugs for the disinfection of the oral infectious lesions including the dentinal, pulpal, and periapical lesions. The expected repair of these lesions can be aimed at by disinfecting it.[5]

It employs the use of 3 MIX-MP which consists of three antibacterial drugs, namely, metronidazole, ciprofloxacin, and minocycline. These 3 antibiotic combinations when mixed with propylene glycol or macrogol show a good penetration into the dentinal tubules and the periapical lesions which promote disinfection. The aim of the present study was to treat the patients' symptoms and promote periapical healing without the removal of previous obturating material using LSTR NIET.


  Materials and Methods Top


Among the patients presenting to the Department of Conservative Dentistry and Endodontics, 15 patients who had undergone root canal treatment 1–2 years previously but were advised retreatment due to symptoms such as pain, swelling, pain on biting, abscess, sinus tract formation, and periapical lesion in their single-rooted teeth were selected. The cases were screened radiographically to confirm the adequacy of the previous obturation. An informed written consent from the patients and approval from the Institutional Ethical Committee was obtained before the commencement of the study. Triple antibiotic paste (3MIX-MP) was used in this study which consisted of three chemotherapeutic agents: Ciprofloxacin - 500 mg, metronidazole - 400 mg, and minocycline - 100 mg.

The capsule coverings of these pills were removed, and the contents were pulverized in a porcelain mortar and pestle. The powders were stored separately in airtight containers till just before placement into the root canal. All the three types of powders were mixed freshly in the ratio of 1:3:3 by volume with propylene glycol into an ointment consistency. The paste can be used for up to 30 days.

The previous coronal restoration was removed completely and a medication cavity of the size 1 mm diameter × 2 mm depth was made at the canal orifice. It was then irrigated with 3% sodium hypochlorite and dried with a cotton pellet. The antibiotic paste was mixed, and a 1 mm diameter of a ball-like material of 3 MIX MP was placed at the bottom of the prepared cavity. The cavity was then sealed with a layer of Glass ionomer cement (GIC), and permanent restoration was done using composite resin. The patients were recalled for postoperative follow-up at 4, 6, and 8 weeks.


  Results Top


Before LSTR, among the fifteen patients included in the study, 13 patients had presented with pain. Pain on biting was experienced by ten patients. Three patients complained of spontaneous pain. None of the patients reported pain on exposure to hot/cold stimuli. One patient (with uncontrolled diabetes) had swelling. One patient reported with a sinus tract. Periapical lesion was observed radiographically in all the patients. At the first recall (after 4 weeks), pain was completely relieved in ten patients, the severity of pain decreased in three patients, and it persisted in two patients. There was a reduction in swelling in one case (uncontrolled diabetes). Pain on biting was relieved in four cases, whereas six cases continued to complain of the same. No change was noted radiographically in the size of the periapical lesions in all the cases. Two patients did not report for follow-up.

At second recall (after 6 weeks), pain was relieved completely in all the patients including those who had pain in the first recall. The swelling had resolved, and none of the patients had pain on biting. Radiographically, the periapical lesions had reduced by up to 0.5 mm in three patients. Another two patients did not report for follow-up. After 8 weeks (third recall), all the patients were completely asymptomatic. Radiographically, the periapical lesions had reduced by 1 mm in nine cases and in six patients, the lesion size remained unchanged. They continue to be under observation.

The patients were divided into four groups after 8 weeks (third recall):

  • Group 1 – Good clinical outcome: Five patients showed a reduction in pain as well as the size of periapical lesion [Figure 1], [Figure 2], [Figure 3]
  • Group 2 – Continued observation: 11 patients reported with an improvement in the clinical symptoms but no reduction in the size of the periapical lesion [Figure 4] and [Figure 5]
  • Group 3 – Failure: None of the patients reported worsening of clinical symptoms such as abscess formation, pain, and increased size of the periapical lesions
  • Group 4 – Two patients dropped out before the first recall (4 weeks), whereas two other patients did not attend the second recall at 6 weeks [Figure 6].
Figure 1: Periapical lesion in relation to 11 (good clinical outcome)

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Figure 2: Periapical lesion in relation to 21 (good clinical outcome)

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Figure 3: Periapical lesion in relation to 11 and 21 (good clinical outcome)

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Figure 4: Periapical lesion in relation to 31 and 41 (continued observation)

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Figure 5: Periapical lesion in relation to 21 and 22 (continued observation)

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Figure 6: Bar diagram

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  Discussion Top


This study was undertaken with a null hypothesis, and it was found that symptoms were alleviated in all the patients, and periapical healing was evident radiographically in five cases. Therefore, it may be assumed that there is a penetration of the 3 MIX-MP through the obturating material to the periapical lesion (in accordance with the study performed with phides).[6] It is likely that this transport of antibiotics alleviated the symptoms in all the patients and promoted periapical healing. The repair of damaged lesions can be expected when lesions are fully disinfected. It has been proved that even soft caries that is clinically softened upon probing could be recalcified upon disinfection.

One important prediction of LSTR hypothesis is that the local delivery of effective antibiotics in an appropriate vehicle to endodontic lesions may lead to the healing of recurrent endodontic cases without the need for conventional re-instrumentation and re-obturation.[7] The infection in the root canal system is said to be polymicrobial. It is more likely that a combination of antibiotics is needed to address the diverse flora in the root canal system. Among the anaerobes recovered from carious dentin, 80% were obligate anaerobes. From infected pulp, obligate anaerobes recovered were 92%, while 80% obligate anaerobes are found in the root canal.

3 MIX-MP is bactericidal to aerobic bacteria and is resistant to obligate anaerobes. Obligate anaerobes are sensitive to metronidazole.[4] Ciprofloxacin, a synthetic fluoroquinolone, has a bactericidal mode of action. This bactericidal activity persists not only during the multiplication phase but also during the resting phase. Ciprofloxacin is proven to be very effective against Gram-negative bacteria but has a limited effect on Gram-positive bacteria. Most of the anaerobic bacteria are resistant to ciprofloxacin, and hence, it is combined with metronidazole.[8] Tetracyclines, which include doxycycline and minocycline, are a group of bacteriostatic antimicrobials. They have a broad spectrum of activity against both Gram-positive and Gram-negative microorganisms. Its mode of action is inhibition of protein synthesis.[8] While doxycycline is reputed to cause staining of the tooth structure, minocycline causes less or minimal tooth discoloration. Hence, minocycline was used in the present in vivo study.

The main purpose of propylene glycol is to prevent a product from drying. A dihydric alcohol is a vehicle that has the potential for use in root canal treatment. It has been used in endodontics as a vehicle for calcium hydroxide. Studies have proven that propylene glycol can quickly and effectively travel through the root canal system, and hence, it was used as a vehicle. Propylene glycol when mixed with 3 MIX-MP can effectively eliminate the microorganisms present in the infected canals particularly those residing in the areas that cannot be reached even by irrigation.[9]

LSTR proposes the removal or disinfection of bacteria present in these lesions, by the local application of the above-mentioned antibacterial drug combination. This leads to the resolution of dentinal, pulpal, and periapical lesions. It was noted that the lesions in the periapical area had resolved in size approximately 1 mm in diameter (recall at 8 weeks) which proves that if the lesions were disinfected, they underwent repair.

It is crucial to have an impervious coronal seal. Conventional root canal treatment may not be successful in sealing bacteria within the root canal system and prevent the migration of bacteria into the periapical spaces. This may be due to minute air bubbles and boundary problems between the root canal wall dentin and the obturation. GIC as the first sealing material and overlying composite resin as the next restorative material to complete the treatment may provide an excellent seal to maintain the sterile environment created within the root canal system. After 8 weeks, all patients were asymptomatic and responded positively toward the treatment. The patients continue to be recalled every 3 months for a regular follow-up to evaluate the progress in periapical healing radiographically.


  Conclusion Top


Retreatment cases are notorious for continued failure. Probably, it is caused by failure to remove or kill the refractory bacteria responsible for the lesion in the first place. LSTR is an excellent alternative method to set new dimensions of successful treatment without the removal of previous obturating material.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Estrela C, Holland R, Estrela CR, Alencar AH, Sousa-Neto MD, Pécora JD. Characterization of successful root canal treatment. Braz Dent J 2014;25:3-11.  Back to cited text no. 1
    
2.
Schaeffer MA, White RR, Walton RE. Determining the optimal obturation length: A meta-analysis of literature. J Endod 2005;31:271-4.  Back to cited text no. 2
[PUBMED]    
3.
Doyle SL, Hodges JS, Pesun IJ, Law AS, Bowles WR. Retrospective cross sectional comparison of initial nonsurgical endodontic treatment and single-tooth implants. J Endod 2006;32:822-7.  Back to cited text no. 3
[PUBMED]    
4.
Ahmad AS. Lesion sterilization tissue repair as an adjunct to conventional root canal treatment of periodontic-endodontic cases. World J Dent 2014;5:47-52.  Back to cited text no. 4
    
5.
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.  Back to cited text no. 5
[PUBMED]    
6.
Phides NP, Hoshino E. MP penetration through obturated root canals – A basis for LSTR 3Mix-MP NIET retreatment. J LSTR Ther 2009;8:1-2.  Back to cited text no. 6
    
7.
Takushige T. Endodontic retreatment using 3mix MP without the removal of previous obturation. J LSTR Ther 2009;8:3-7.  Back to cited text no. 7
    
8.
Windley W 3rd, Teixeira F, Levin L, Sigurdsson A, Trope M. Disinfection of immature teeth with a triple antibiotic paste. J Endod 2005;31:439-43.  Back to cited text no. 8
    
9.
Blackwell S, Cruz EV. Penetration of propylene glycol into dentine. Int Endod J 2002;35:330-6.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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