Year : 2008 | Volume
: 26 | Issue : 5 | Page : 5--10
Endodontic treatment of primary teeth using combination of antibacterial drugs: An in vivo study
AR Prabhakar, E Sridevi, OS Raju, V Satish
Department of Pedodontics and Preventive Dentistry, Bapuji Dental College and Hospital, Davangere - 577 004, Karnataka, India
A R Prabhakar
Department of Pedodontics and Preventive Dentistry, Bapuji Dental College and Hospital, Davangere - 577 004, Karnataka
Background and Objectives: The purpose of this study was to evaluate clinical and radiographic success of endodontic treatment of infected primary teeth using combination of ciprofloxacin, metronidazole, and minocycline.
Meterials and Methods: The treatment was performed on selected 60 teeth, which were randomly divided into two groups, viz. Group A and B with 30 teeth in each group. In Group A, only the necrotic coronal pulp was removed, whereas in Group B both necrotic coronal as well as all accessible radicular pulp tissue was extirpated. The orifice of the canal was enlarged in both the groups and was termed as źDQ╗Medication cavity.źDQ╗ The medication cavity was half-filled with antibacterial mix, sealed with glass-ionomer cement and reinforced with composite resin. Resolution of clinical signs and symptoms was evaluated within a month after the treatment. At every subsequent visit, clinical and radiographic evaluation was done once in 6 months for a period of one year.
Results: Both the groups showed considerable clinical and radiographic success, but Group B showed greater clinical and radiographic success than Group A.
|How to cite this article:|
Prabhakar A R, Sridevi E, Raju O S, Satish V. Endodontic treatment of primary teeth using combination of antibacterial drugs: An in vivo study.J Indian Soc Pedod Prev Dent 2008;26:5-10
|How to cite this URL:|
Prabhakar A R, Sridevi E, Raju O S, Satish V. Endodontic treatment of primary teeth using combination of antibacterial drugs: An in vivo study. J Indian Soc Pedod Prev Dent [serial online] 2008 [cited 2020 May 29 ];26:5-10
Available from: http://www.jisppd.com/text.asp?2008/26/5/5/41746
The teeth with infected root canals, particularly those in which infection has reached the periradicular tissues are a common problem in primary dentition.  Early loss of primary teeth can cause number of problems, such as - ectopic eruption, disturbance of eruption sequence, drifting of erupted teeth, space loss for the successor permanent teeth, development of aberrant habits such as tongue thrusting, alterations in speech, and impairment of function. , Thus it is important that primary dentition should be maintained in the dental arch, provided it can be restored to function and remain free from the disease. An intact tooth successfully disinfected and restored clinically is a superior spacemaintainer than an appliance.  To accomplish this many treatment procedures have been proposed such as indirect pulp capping, direct pulp capping, partial pulpotomy, pulpotomy, and pulpectomy. ,
Endodontic therapy plays an important role in removing bacteria, their by-products and their substrates, by disrupting and destroying the microbial ecosystem through chemical and mechanical methods.  Different drugs and medicaments have also been suggested to accompany these techniques with varying success rate. Besides the use of nonspecific antiseptics, application of antibacterial drugs represents one of the methods of eradicating bacteria in the root canal treatment. ,
In recent years, the Cariology Research Unit of Niigata University School of Dentistry has developed the concept of lesion sterilization and tissue repair (LSTR) therapy that employed a mixture of antibacterial drugs for disinfection. Repair of damaged tissues can be expected if lesions are disinfected. 
Metronidazole has a wide spectrum of bactericidal action against oral obligate anaerobes. , It has been found that obligate anaerobes form majority of isolates from carious lesions, infected root dentin, and from nonexposed pulp tissue. However, metronidazole even at higher concentrations could not eradicate all the bacteria from carious lesions, indicating the necessity of some additional drugs to sterilize these lesions. Thus, it was seen that a mixture of antibacterial drugs, i.e. ciprofloxacin, metronidazole, and minocycline can sterilize carious lesions, necrotic pulps, and infected root dentine of deciduous teeth. ,,
Hence the present study was undertaken to evaluate the success rate of endodontic treatment of primary teeth using a combination of ciprofloxacin, metronidazole, and minocycline.
A total of 41 children aged between 4 and 10 years who were having 60 infected primary molars were selected from the out patient clinic of the Department of Pedodontics and Preventive dentistry, Bapuji Dental College and Hospital, Davangere. A general examination of the children was done prior to beginning of the study, the children who were free of any medical condition that would contraindicate the pulp therapy were included in the study.
Ethical committee clearance was obtained from concerned authorities. An informed written consent was taken from patient's parents prior to start of the study.
The teeth were selected following the clinical and radiographic examination  [Table 1]. Teeth with perforated pulpal floor, radiographic evidence of excessive internal root resorption, excessive bone loss in the furcation area which involves the underlying developing tooth germ and nonrestorable teeth were excluded from the study [Figure 1]. 
Preparation of antibacterial mix
Commercially available chemotherapeutic agents such as ciprofloxacin, metronidazole, and minocycline were used in this study. After removal of enteric coating the drugs were pulverized, kept separately in tightly capped porcelain containers to prevent exposure to light and moisture. This was stored in refrigerator. These powdered drugs were taken in the ratio of 1:3:3 (one part of ciprofloxacin, three parts of metronidazole and minocycline), mixed with propylene glycol and macrogol to form an ointment just before use.
The selected 60 teeth were randomly divided into two Groups of A and B with 30 teeth each. A thorough history followed by clinical examination and preoperative radiograph was taken for every patient. Anesthesia for the tooth to be treated was achieved by inferior alveolar nerve block using 2% lignocaine hydrochloride with adrenaline 1:80,000. Isolation was achieved using rubber dam. The cavity was prepared depending on the extent of the lesion. The carious dentin was excavated with the help of a spoon excavator and with a large round bur [Figure 2]. Access to the pulp chamber was gained; roof of the pulp chamber was removed, making sure that all overhanging edges were eliminated.
In Group A only coronal ref 11 necrotic pulp was removed with a sharp spoon excavator and pulp chamber was thoroughly irrigated with saline. To visualize the orifices clearly the pulp chamber was dried using cotton pellets.
In Group B after removal of the necrotic coronal pulp, all ref 11 accessible radicular pulp was also extirpated.
Then in both the groups the orifices of the canals were enlarged with straight bur to receive the medicament; which was termed as "medication cavity." Then the medication cavity was half-filled with antibacterial mix as shown in [Figure 3]. The teeth were then restored with Glass Ionomer cement (GIC) [Figure 4],[Figure 5],[Figure 6],[Figure 7] and further reinforced with composite resin [Figure 3].
The whole procedure was completed in one visit. Resolution of clinical signs and symptoms was evaluated within a month after the treatment.[Figure 8] At every subsequent visit, once in 6 months for a period of 1 year clinical and radiographic evaluation was done.
The treated cases were considered clinically successful if there was absence of spontaneous pain, tenderness to percussion, abnormal mobility and signs of pathology like intraoral and/or extraoral abscess, whereas, treated cases were considered successful radiographically, when radiolucency decreased compared to preoperative status or remained same. Increase in the radiolucency at the subsequent visits was considered as radiographic failure ,, [Table 2].
Catagorical data are presented as numbers and percentages and are analyzed by Fisher's exact test.
P 0.05 - Significant
A P -value of 0.05 or less was considered for statistical significance.
Fisher's exact test:
The observations were based on clinical and radiographic evaluation; the data were tabulated and subjected to statistical analysis using Fisher's exact test. The results were summarized as follows.
Preoperative clinical and radiographic findings [Table 3] and [Table 4]
In Group A out of 30 teeth selected, all the teeth (100%) exhibited pain and tenderness, 29 teeth (96.7%) had intraoral abscess, 2 teeth (6.7%) had extraoral abscess and 27 teeth (90%) exhibited abnormal mobility, and 23 teeth (76.7%) showed presence of inter-radicular radiolucency. Whereas in Group B out of 30 teeth selected, all the teeth (100%) exhibited pain, tenderness and intraoral abscess, 2 teeth (6.7%) had extraoral abscess and 29 teeth (96.7%) exhibited abnormal mobility, and 29 teeth (96.7%) showed the presence of inter-radicular radiolucency.
Postoperative clinical and radiographic findings [Table 3] and [Table 4]
One-month postoperative clinical evaluation
One month post-operatively there was complete resolution of clinical findings, such as pain, tenderness, mobility, and abscess in both the groups.
Six-month postoperative clinical and radiographic evaluation
In Group A one tooth showed presence of intraoral abscess, abnormal mobility, and tenderness, 11 teeth (36.7%) showed increase in furcation radiolucency, 9 teeth (30%) showed bone regeneration, and 9 teeth (30%) demonstrated no change. Whereas in Group B, all the teeth remained asymptomatic, 24 teeth (80%) showed bone regeneration, and 6 teeth (20%) demonstrated no change.
Twelve-month postoperative clinical and radiographic evaluation
In Group A, one more tooth (3.3%) showed presence of pain, intraoral abscess, abnormal mobility, and tenderness for which it was extracted, 5 teeth (16.7%) showed increase in the radiolucency, 11 teeth (36.7%) showed bone regeneration, and 12 teeth (40%) demonstrated static bone morphology. Whereas in Group B, all the teeth remained asymptomatic, 25 teeth (83.3%) showed bone regeneration, 5 teeth (16.7%) demonstrated no change, and no single tooth exhibited increase in the radiolucency.
A statistically significant difference was found between the two groups with respect to bone regeneration, static bone morphology, and increase in the bone loss.
Endodontic management of primary teeth with severe pulpal necrosis is evidenced by nonvital pulp tissue, fistula, and loss of alveolar bone is generally discouraged. Though several reasons have been cited for this, the main one being morphology of the primary teeth which is not suitable for biomechanical preparation. 
Sterilization of the root canal and periradicular region results in good healing of the periradicular region.  Bacteria which are present mainly in the root canals and superficial layer of infected root canal wall may be easily removed by conventional root canal treatment. But the bacteria, which remain in the deep layers of root canal dentin, may leak out to periapical region and cause complications. Application of antibacterial drugs to endodontic lesions is one of the clinical procedures that can be used to sterilize such lesions. 
To sterilize such lesions, a single antibacterial drug may not be effective, even if it is a broad spectrum antibiotic. Reason being the bacterial composition of the infected root canals is complex. In addition, bacteria may also invade root canals from other oral sites, e.g. dental plaque, saliva and from carious dentin which may also smear the root canal during endodontic treatment. All such bacteria should be targeted by antibacterial drugs. 
Since the overwhelming majority of bacteria in the deep layers of infected dentine of the root canal wall consist of obligate anaerobes, metronidazole was selected as first choice among the antibacterial drugs. Metronidazole even at high concentrations cannot kill all the bacteria indicating the necessity of other drugs. Thus, ciprofloxacin and minocycline, in addition to metronidazole were added to sterilize infected root dentin. 
To sterilize deep layers of infected root dentin, root canal medicaments should penetrate root canal dentin. The penetration ability of these drugs was improved by mixing these drugs with propylene glycol and macrogol to form ointment base.  The penetration ability of propylene glycol was clearly demonstrated by Cruz et al . 
The procedure performed in Group A was similar to the one performed by Takushige et al ,  whereas, the procedure performed in Group B was similar to the standard pulpectomy procedure. The experimental medicament was placed and teeth were restored. These two groups were compared for the clinical and radiographic success.
However, in Group A observations of this study were different from those made by Takushige et al ,  who reported 100% success rate. This difference may be attributed to the fact that they have reported retreatment of few cases which were clinically symptomatic after the treatment.  In our study, we have not performed retreatment for those teeth which exhibited clinical failure. On radiographic evaluation 16.7% cases showed increase in the radiolucency, this can be attributed to the fact that radiolucent areas were often seen in the areas of erupting succedaneous teeth at the time of root resorption and it was difficult to differentiate the cause of the radiolucency.  In the study mentioned by Takushige et al , there was no data available regarding the radiographic evaluation at subsequent visits.
The difference in the success rate between the two groups can be attributed to the fact that, in Group A the infected radicular pulp tissue was not removed. The more the infected tissue removed the greater are the ultimate chances of the success.  Another reason could be in Group A medicament was placed directly over the radicular pulp tissue. Though it was stated by Hoshino et al ,  that the placement of these drugs on the human pulp does not caused pathological reactions, the exact reaction of these drugs on the pulp is not known.
Therefore, some histological studies revealing the effects of these medicaments on the pulpal tissue are required. Hence within the limitations of this study, the primary teeth with the periradicular lesions, including those at various stages of physiological root resorption, can be conserved by the lesion sterilization and tissue repair (LSTR) therapy.
The following conclusions were drawn within the limitations of this study:
Endodontic treatment using antibacterial mix (a combination of ciprofloxacin, metronidazole, and minocycline mixed with propylene glycol and macrogol) in primary teeth has shown good clinical and radiographic success.All the treated cases were clinically and radiographically successful with removal of necrotic coronal and accessible radicular pulp tissue when compared with only coronal pulp removal.
However, we advocate further clinical and histological studies with longer follow-up till the period of tooth exfoliation to ascertain the efficacy of this novel treatment modality.
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