|Year : 2019 | Volume
| Issue : 2 | Page : 185-191
Comparative evaluation of clinical and radiographic success of three different lesion sterilization and tissue repair techniques as treatment options in primary molars requiring pulpectomy: An in vivo study
Amolkumar Lokade, Seema Thakur, Parul Singhal, Deepak Chauhan, Chiranjeevi Jayam
Department of Pediatric and Preventive Dentistry, HP Government Dental College and Hospital, Shimla, Himachal Pradesh, India
|Date of Web Publication||26-Jun-2019|
Dr. Amolkumar Lokade
Room No. 301, Department of Pedodontics and Preventive Dentistry, HP Government Dental College, Shimla - 171 001, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Paediatric endodontics is part of paediatric dental practice. Teeth with infected root canals, particularly those in which the infection has spread around the apical foramen and furcation area, is a common problem in primary dentition for such conditions pulpectomy is the procedure. Pulpectomy procedure proves to be long and complicated and has remained controversial for a number of reasons. Lesion sterilization and tissue repair therapy (LSTR) is a relatively new biologic approach for carious lesions with or without pulpal and periapical involvement using a mixture of antibiotics. Objectives: The aim of this study was to evaluate clinical and radiographic success of three different LSTR techniques as treatment options in primary molars requiring pulpectomy. Methods: Sixty-three primary molars of fifty children aged between 4 and 8 years with primary molars requiring pulpectomy were treated with modified 3Mix-MP antibiotic paste without removal of accessible radicular pulp (Group I), modified 3Mix-MP with removal of accessible radicular pulp (Group II) and Chloramphenicol, tetracycline and zinc oxide eugeno (CTZ) paste (Group III). The subjects were followed up clinically at one, six, and twelve months whereas radiographically at six and twelve months, respectively. Results: The results showed that clinical success rates of Group I, Group II and Group III were 90%, 90.5% and 81.8% respectively and radiographical success rates were 75%, 76.2% and 63.6% respectively after twelve months observation. Conclusion: On the basis of the overall success rates of all the three LSTR techniques, following order of performance can be inferred clinical success and radiographical success: – 3Mix-MP without removal of radicular pulp = 3Mix-MP with removal of radicular pulp >CTZ paste.
Keywords: CTZ paste, lesion sterilization and tissue repair, modified 3Mix-MP paste, noninstrumentation endodontic treatment, primary teeth
|How to cite this article:|
Lokade A, Thakur S, Singhal P, Chauhan D, Jayam C. Comparative evaluation of clinical and radiographic success of three different lesion sterilization and tissue repair techniques as treatment options in primary molars requiring pulpectomy: An in vivo study. J Indian Soc Pedod Prev Dent 2019;37:185-91
|How to cite this URL:|
Lokade A, Thakur S, Singhal P, Chauhan D, Jayam C. Comparative evaluation of clinical and radiographic success of three different lesion sterilization and tissue repair techniques as treatment options in primary molars requiring pulpectomy: An in vivo study. J Indian Soc Pedod Prev Dent [serial online] 2019 [cited 2019 Nov 17];37:185-91. Available from: http://www.jisppd.com/text.asp?2019/37/2/185/261358
| Introduction|| |
Endodontic treatment in primary teeth is aimed primarily to remove all bacterial infection by endodontic instrumentation and proper irrigation and to obturate the root canals with a filling material. The success of pulpectomy determined by resolution of the clinical and radiological signs and symptoms, normal exfoliation of treated primary tooth, and unimpeded eruption of succedaneous tooth.
Pulp therapy has been suggested since 1932 as a method for maintaining primary teeth, which would otherwise be lost. Pulpectomy procedure proves to be long and complicated and has remained controversial for a number of reasons. Mainly, the perceived difficulty of behavior management in the pediatric population and uncertainty about the effects of root canal filling material and instrumentation on the succedaneous teeth. Anatomic situations like the often complicated curved and tortuous shape of root canals and the closeness of the advancing tooth buds make the treatment more difficult. Another limitation is the apparent connection between the coronal floor with the intraradicular area with the presence of multiple accessory canals and ramifications as well as the difficulty in obtaining hermetic seal due to lack of apical closure following physiologic root resorption have surely added reluctance among dentists to use this procedure. Hence, the use of such procedure should be discouraged.
A relatively new biologic approach, lesion sterilization and tissue repair therapy (LSTR) were introduced in the treatment of carious lesions with or without pulpal and periapical involvement using a mixture of three broad spectrum antibiotics, namely, metronidazole, ciprofloxacin, and minocycline (3Mix). Modification of 3Mix by using cefaclor in place of minocycline and ornidazole in place of metronidazole has better clinical results., The rationale of LSTR is that mixture of three antibiotics (3Mix) can sterilize necrotic pulps and infected root dentine of primary teeth. Repair of damaged tissues can be expected if lesions are disinfected. In the primary dentition, LSTR has shown high rate of clinical success as a substitute for pulpectomy., However, radiographic success is questionable in long-term follow up.
In this research to find an alternate treatment option for tooth requiring pulpectomy, the present study was undertaken to evaluate and compare clinical and radiographic success of three different LSTR techniques.
| Methods|| |
The study consisted of patients in the age group of four–eight years in which ethical approval from the Institutional Ethical Committee and consent from the parents/guardians were obtained. The criteria for selection of teeth include first and second primary molars (maxillary and mandibular) showing signs and symptoms indicating pulpectomy: (a) Spontaneous pain or tender to percussion, (b) Deep carious with pulp exposure, (c) Uncontrolled hemorrhage after removal of coronal pulp tissue, (d) Presence of chronic apical abscess or sinus tract (e) The tooth should be restorable and radiographic characteristics: (a) Coronal radiographic evidence of a deep carious lesion involving pulp. (b) Radicular–(i) discontinuity of lamina dura (ii) Furcation involvement less than or equal to half of shortest root in vertical dimension.
The teeth were excluded when nonrestorable or presented with physiologic root resorption more than a third of its length or if they had the presence of obliteration of the root canal, excessive internal resorption, internal calcifications, perforation into the bifurcation, or any underlying dentigerous cysts. Patients with any systemic illness or with previous history of allergy to the antibiotics used in the study were also excluded.
Clinical and radiographic information before treatment was recorded by an operator. The enrollment of teeth to either group was done randomly by envelope draw method. All treatments were performed by same operator.
- Group one: Only the coronal pulp was removed and the pulp chamber half filled with modified 3Mix antibiotic paste, sealed with glass ionomer cement (GIC) and reinforced with stainless crown after 15 days (20 teeth)
- Group two: Both coronal as well as all accessible radicular pulp tissue was extirpated and the medication cavity half-filled with modified 3Mix antibiotic paste, sealed with GIC and reinforced with stainless crown after 15 days (21 teeth)
- Group three: Only coronal pulp tissue was removed and the pulp chamber half filled with CTZ paste, sealed with GIC and reinforced with stainless crown after 15 days (22 teeth).
Clinical procedure for all three groups
Clinical procedure for Group I
Administration of local anesthesia and rubber dam application [Figure 1]a
Initially topical anesthetic was applied at the site of injection followed by nerve block for adequate anesthetization of selected tooth [Figure 1]a. All cases were treated under rubber dam.
|Figure 1: (a) Application of rubber dam, (b) Access opening and pulp extirpation, (c) Showing freshly mixed 3Mix-MP paste, (d) showing freshly mixed CTZ paste, (e) Showing placement of modified 3Mix-MP in cavity, (f) Restoration of teeth with stainless steel crown|
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Access opening and pulp extirpation [Figure 1]b
Access to the pulp chamber was gained with a round bur and proper access cavity was made using straight fissure and tapering fissure bur. Spoon excavator was used to remove bulk of the pulp or necrotic debris from the pulp chamber.
Preparation of modified 3Mix-MP paste [Figure 1]c
The chemotherapeutic agents used were ornidazole tablets 500 mg (Ornida, Aristo pharmaceuticals, India), ciprofloxacin tablets 500 mg (Ciplox®, Alchemist Ltd., India), and cefaclor tablets 250 mg (Distaclor™ DT, Baroque pharmaceuticals, India). After the removal of enteric coating of tablets with the help of B.P blade, the drugs are pulverized into fine powder using sterilized mortar pestle. The powered drugs were kept separately in amber colored air tight containers. The fine powder was used up within a month. 3Mix-MP paste was freshly prepared for each use. The same amount of each powdered drug (1:1:1) was mixed to form modified 3Mix powder. One part of propylene glycol (P) and the same volume of macrogol (M) were mixed to make MP. For standard preparation, one part of MP and 7 parts of modified 3Mix powder were mixed.
Placement of modified 3Mix-MP in cavity [Figure 1]e
Modified 3Mix-MP was then placed into pulp chamber.
Restoration of the tooth [Figure 1]f
After the placement of modified 3Mix-MP paste, the cavity was filled with GIC restoration in same visit. The patient was then recalled after 15 days and the tooth was then restored with stainless steel crown.
Clinical procedure for Group II
Same clinical procedure followed as Group I only difference is (The canals orifices were enlarged using round bur to form medication cavity) medication cavity is prepared at root canal orifice. Medication cavity is a cavity with diameter one mm and depth two mm and it acts as receptacle for medication and accessible radicular pulp is extripated using H-files and filled with 3Mix-MP paste, the cavity was filled with GIC restoration in same visit. The patient was then recalled after 15 days and the tooth was then restored with stainless steel crown.
Clinical procedure for CTZ paste: (Group 3)
Same clinical procedure followed as Group 1 but pulp chamber is filled with CTZ paste.
Preparation of modified CTZ paste [Figure 1]d
The chemotherapeutic agents used were tetracycline (Tetracycline capsules, Resteclin® abbott healthcare pvt.ltd), chloramphenicol (Chloramphenicol capsule, 500 mg Paraxin® abbott healthcare pvt.ltd.) After the removal of enteric coating of capsules, the drugs are pulverized one by one into fine powder using sterilized mortar pestle. The powered drugs were kept separately in amber-colored air tight containers. The fine powder was used up within a month. CTZ paste was freshly prepared for each use before or during treatment. Same amount of both powdered drugs along with two parts of zinc oxide powder (Zinc oxide powder, DPI, Mumbai, India) and drop of eugenol (DPI, Mumbai, India) were dispensed on clean glass slab and mixed to form CTZ paste. The ratio of the mixture was tetracycline: chloramphenicol: zinc oxide (1:1: 2). Along with One drop of eugenol.
Clinical and radiographic evaluation
After treatment, clinical evaluation was done at one, six and twelve while radiographic evaluations were performed at six and twelve months. Blinded clinical evaluations were performed by the operator. The preoperative and follow up radiographs are shown in [Figure 2] for the three groups. The radiographic evaluations were carried out by two coinvestigators. The intraexaminer reliability and interexaminer reliability of the first and the second coinvestigators were calculated by Cohen's kappa statistic, i.e., 0.90 and 867, respectively, which indicates excellent level of agreement. The criteria for clinical success include the absence of pain, presence of healthy soft tissue, and absence of abnormal mobility. The criteria for radiographic success include static/reduction in size of intra-radicular radiolucency, evidence of bone regeneration/continuity of lamina dura, and the absence of internal/external resorption. The treatment was judged to be successful when both clinical and radiographic criteria were fulfilled. P < 0.05 was considered statistically significant.
|Figure 2: Radiographic success of all three groups preopratively and at six and twelve months follow up|
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| Results|| |
Postoperative, follow up clinical examinations at one, six and twelve months are shown in [Table 1], [Table 2], [Table 3]. Postoperative radiographic followup at six and twelve months are shown in [Table 4] and [Table 5].
Postoperative clinical findings
All teeth of three groups were clinically checked at one month postoperatively and 100% success observed. At six months, in group I and group II showed 100% clinical success while in group III showed 90.9% of clinical success. At 12 clinical follow up in group I there was 90% success observed while in group II and group III the clinical success were 90.5% and 81.8% respectively. No statistically significant difference between the three groups was observed for the clinical success at 1, 6 and 12 months respectively [Graph 1] and [Graph 2].
Postoperative radiological findings
At 6 months of radiological followup in all groups that is group I, group II and group III there was 95%, 95.2% and 90.9% success were observed however it was fell to 75%, 76.2% and 63.6% at twelve months evaluation respectively [Graphs 1], [Graphs 2] and [Figure 2]. No statistically significantn difference between the three groups was observed for the radiologicaal success at six and twelve months respectively.
| Discussion|| |
In group I, there was 100% success observed at 1 month and at six months clinical evaluation, whereas it was 90% at twelve months follow up. This result is comparable with Prabhakar et al. (93.3%), Pinky et al. (90%) and Doneria et al. (89.5). However, its lesser than Takushige et al. (100%) and Nakornchai et al. (100%) and more than Agarwal et al. (28%) and Trairatvorakul and Detsomboonrat (75%). Radiographically there was 95.0% success observed at six months evaluation however it fell to 75.0% at twelve months followup. The radiological success rate of 75.0% is comparable with Nakornchai et al. (76%). However, it is lesser than as reported by Pinky et al. (90%) and Doneria et al. (80.95%) but higher than that of Prabhakar et al. (63.3%) and Agarwal et al. (28%). These reported variations in success rates may be attributed to differences in sample selection, evaluation criteria and techniques employed.
Internal resorption and increase in intraradicular radiolucency was found to be the most common cause of radiological failure in group I. A total of two teeth showed internal resorption while three teeth were present with increase in radioluceny, PDL enlargement, Discontinuity of lamina dura. Previous investigations have also reported increase in radiolucency and internal resorption as the most frequent postoperative radiological failures observed in primary molars after LSTR. Prabhakar et al. and Pinky et al. noted increase in bone loss in five teeth and two teeth out of 30 and 20 teeth respectively. Trairatvorakul and Detsomboonrat reported total 38 failure cases when observed for 24 months. Out of these failures, six teeth showed static radiolucency, 26 teeth showed increase in radiolucency and six teeth showed internal resorption.
A study by Prabhakar et al. of 3Mix-MP with radicular pulp extripation group which showed 100% clinical and radiographic success at six and twelve months respectively however in the present study group II there is 100% clinical success at six months which is in accordance with above study but there is 95.2% radiological success at 6 months which is lesser than the above study. However, in our study, at twelve months clinical success is 90.5% and the failures were due to pain and abscess in one tooth and other tooth presented with pain and mobility and radiologically there is success of 76.6% and failure were due to four teeth showing internal resorption along with increase in interradicular radiolucency and other four teeth showed only increase in interradicular radiolucency. Comparative lesser success rate observed in our group II as compared to study conducted by Prabhakar et al. May be due to radiological success/failure criteria for assessment taken.
The search of dental literature showed published reports by Moura et al. (2016 and 2018), in which CTZ paste was used as LSTR agent in primary molars. In our study CTZ paste is used in group III and no clinical failure was observed on one month follow up. Whereas at 6 months clinical as well as radiological follow up there was 90.9% success. The failure were due to pain, gingival swelling, sinus tract formation clinically and radiologically there was periodontal ligament (PDL) enlargement, increase in interradicular radiolucency, internal resorption, discontinuity of lamina dura in both the cases. At twelve months clinical and radiographic follow up there was 81.8% and 63.6% success observed respectively. Clinically main reasons for clinical failure was pain, gingival swelling and sinus tract formation in all four teeth and radiologically four teeth presented with internal resorption along with increase in interradicular radiolucency and other four teeth showed PDL enlargement, Increase in interradicular radiolucency and discontinuity of lamina dura. The twelve months success rate of CTZ in our study was lesser as compared to de Deus Moura Lde et al. (100% clinical and 93% radiographic). This may be due to difference in evaluation criteria.
Clinical evaluation at six months follow up showed two failure in group III as compared to none in other two groups, whereas at twelve months interval number of clinical failures in first two groups augmented to two each and in group III it was four. However statistically there was no significant difference between the three groups for clinical success of treatment P = 0.146 (6 months) and P = 0.632 (12 months).
Radiologically Group I and II showed one failure in each and two failures were seen in group III at six months interval. Furthermore, at twelve months interval failures increased in all three groups to five each in first two groups and eight in Group III. However statistically there was no significant difference between the three groups for Radiological success of treatment P = 0.807 (6 months) and P = 0.603 (12 months).
Although the comparative results in the present study at six and twelve months interval were statistically insignificant, Group I and II showed slightly better results than Group III.
The findings of our investigation indicate that modified 3Mix-MP and CTZ LSTR therapies hold potential to be used as an effective alternative option in endodontic treatment of primary teeth. In the present study, although all three materials have shown clinically as well as radiographically, comparable and acceptable results, yet further studies with a larger sample size with a longer period of follow-up is required. Investigations are also required to understand the reaction of periapical tissues to drugs as well as the amount of drug absorption into the systemic circulation. Ultrastructural, histological and microleakage studies may be helpful to further determine the suitability of 3Mix-MP Paste and CTZ Paste in future LSTR studies.
| Conclusion|| |
Within the limits of the presentin vivo study, we conclude that all three LSTR techniques used in respective groups can be used effectively as alternative to pulpectomy in primary teeth. It can also concluded that modified 3Mix-MP antibiotic with and without removal of radicular pulp treatment and CTZ paste treatment can be a substitute of pulpectomy procedure in primary molars requiring pulpectomy.
I would like to express my appreciation to the Department of Pedodontics and Preventive dentistry staff and junior residents and Department of Plastic Surgery staff. Without their valuable assistance, this work would not have been complete.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
American Academy of Pediatric Dentistry. Guidelines on pulp therapy for primary and young permanent teeth. Reference manual 2006-2007. Pediatr Dent 2007;28:144-8.
Kubota K, Golden BE, Penugonda B. Root canal filling materials for primary teeth: A review of the literature. ASDC J Dent Child 1992;59:225-7.
Holan G, Fuks AB. A comparison of pulpectomies using ZOE and KRI paste in primary molars: A retrospective study. Pediatr Dent 1993;15:403-7.
Moss SJ, Addelston H, Goldsmith ED. Histologic study of pulpal floor of deciduous molars. J Am Dent Assoc 1965;70:372-9.
Mathewson RJ, Primoch RE, Morrison JT. Fundamentals of Pediatric Dentistry. 3rd
ed. Chicago, Berlin, London, Tokyo, Sao Paulo, Moscow, Prague, Warsaw: Quintessence Publishing Co Inc.; 1995. p. 257-84.
Sato I, Ando-Kurihara N, Kota K, Iwaku M, Hoshino E. Sterilization of infected root-canal dentine by topical application of a mixture of ciprofloxacin, metronidazole and minocycline in situ
. Int Endod J 1996;29:118-24.
Sato I, Hoshino E, Uematsu H, Kota K, Iwaku M, Noda T. Bactericidial efficacy of a mixture of ciprofloxacin, metronidazole, minocycline and rifampicin against bacteria of carious and endodontic lesions of human deciduous teeth in vitro
. Microb Ecol Health Dis 1992;5:171.
Pinky C, Shashibhushan KK, Subbareddy VV. Endodontic treatment of necrosed primary teeth using two different combinations of antibacterial drugs: Anin vivo
study. J Indian Soc Pedod Prev Dent 2011;29:121-7.
] [Full text]
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.
Prabhakar AR, Sridevi E, Raju OS, Satish V. Endodontic treatment of primary teeth using combination of antibacterial drugs: Anin vivo
study. J Indian Soc Pedod Prev Dent 2008;26 Suppl 1:S5-10.
Trairatvorakul C, Detsomboonrat P. Success rates of a mixture of ciprofloxacin, metronidazole, and minocycline antibiotics used in the non-instrumentation endodontic treatment of mandibular primary molars with carious pulpal involvement. Int J Paediatr Dent 2012;22:217-27.
Doneria D, Thakur S, Singhal P, Chauhan D. Comparative evaluation of clinical and radiological success of zinc oxide-ozonated oil, modified 3mix-mp antibiotic paste, and vitapex as treatment options in primary molars requiring pulpectomy: Anin vivo
study. J Indian Soc Pedod Prev Dent 2017;35:346-52.
] [Full text]
Nakornchai S, Banditsing P, Visetratana N. Clinical evaluation of 3Mix and vitapex as treatment options for pulpally involved primary molars. Int J Paediatr Dent 2010;20:214-21.
Agarwal M, Das UM, Vishwanath D. A comparative evaluation of noninstrumentation endodontic techniques with conventional ZOE pulpectomies in deciduous molars: Anin vivo
study. World J Dent2011;2;187-92.
de Deus Moura Lde F, de Lima Mde D, Lima CC, Machado JI, de Moura MS, de Carvalho PV, et al.
Endodontic treatment of primary molars with antibiotic paste: A Report of 38 cases. J Clin Pediatr Dent 2016;40:175-7.
Moura LF, Lima MD, Lima CC, Bandeira AV, Moura MS, Conde Júnior AM, et al.
Cellular profile of primary molars with pulp necrosis after treatment with antibiotic paste. Int J Exp Pathol 2018;99:264-8.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]