Successful nonsurgical retreatment of resected teeth associated with ...

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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

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

ENDODONTOLOGYENDODONTOLOGYENDODONTOLOGYENDODONTOLOGYENDODONTOLOGY Volume: 25 Issue 2 December 2013 Case Report

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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.

SUMANTHINI.M.V., VANITHA.U.SHENOY, RUPALI DESHMUKH, RAHUL KUMAR

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presented, a diagnosis of acute exacerbation of

chronic alveolar abscess was arrived at. Non-

surgical retreatment of the involved teeth was

planned. Patient’s medical history was

noncontributory.

All the clinical steps were performed under

rubber dam isolation (Hygienic Dental Dam,

Colténe Whaledent, Germany). The coronal

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

the absence of an apical stop, MTA (ProRoot,

Dentsply Maillefer, Ballaigues, Switzerland) apical

plug was placed. MTA was mixed with sterile water

as per manufacturer’s instructions and placed in

small increments using prefitted modified finger

Fig 2a: Intraoral photograph showing no discoloration due tominocycline in maxillary left central and left lateral incisor

Fig 2b: Intraoral periapical radiograph of MTA apical plug placed inmaxillary left lateral incisor and obturation of maxillary central incisor

pluggers and the butt end of gutta-percha to a

thickness of 5mm. A radiograph was taken to

confirm the dense placement of MTA plug [Fig 2b].

A moist sterile cotton pledget was placed in the

canal and access cavity sealed with a zinc oxide

eugenol temporary filling. After 24 hours, the

temporary filling and cotton pellet were removed.

Set of MTA was checked gently with a K-file and

the remaining pulp space was obturated with AH

Plus and gutta-percha by lateral compaction

technique [Fig 2c]. Post endodontically, the access

Fig 2c: Immediate post obturation radiograph

Fig 2d: 3month recall radiograph


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cavities of 21, 22 and the mesial angle fracture in

11 were restored with light cured resin composite

restoration. Patient was recalled for checkup at

regular intervals of 3, 6, 12 and 24 months.

Radiographs and clinical photographs revealed

complete healing and patient has been symptom

free [Fig 2d, 3a, b, c, d].

DiscussionInadequate cleaning and obturation of root

canals is the major cause of endodontic failure. As

with the present case, the intra oral radiograph

revealed that canal preparation and the orthograde

Fig 3a: 6 month recall radiograph

Fig 3b: 12 month recall radiograph

obturation was unsatisfactory hence nonsurgical

retreatment was opted though the teeth had

undergone surgical resection. In such canals

significant portions of root canal walls probably are

left untouched and this might have jeopardized

optimal healing of the periradicular tissues.

Complete elimination of bacteria by instrumentation

alone is unlikely to occur. Therefore some form of

root canal disinfection is necessary to eliminate

residual microorganisms. CH is an effective

intracanal medicament, owing to its high alkalinity.

We chose to place CH medicament as symptoms

did not resolve, probably due to limited antibacterial

spectrum10 and the reduced efficacy of CH in

retreatment cases11, the treatment protocol was

changed and TAP was used instead after obtaining

patient consent.

Fig 3c: 24 month recall radiograph revealing healing of periapical tissues.

Fig 3d: 24 month photograph demonstrates no discoulortation postoperatively and satisfactory soft tissue healing, mesial angle fracture

of 11 restored with resin composite restoration


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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

have demonstrated its successful application in

regenerative endodontic treatment13, retreatment14,

root fracture15 and in healing of large periradicular

lesions.16 Nevertheless, caution has to be exercised

when we attempt to locally apply systemic

antibiotic drugs as this may cause development of

resistant species of microbes. Though there have

been no reports of any side effects, care should be

taken if patients are sensitive to chemicals or

antibiotics.

Various agents such as saline, sterile distilled

water and macrogol combined with propylene

glycol have been used as a vehicle for preparing

the antibiotic mixture. The antibiotic paste used in

the presented case consisted of 100mg of each of

the three drugs namely ciprofloxacin, metronidazole

and minocycline in a total volume of 0.5 ml of

pharmaceutical carrier propylene glycol. Propylene

glycol is a clear colourless, odourless liquid. Its

wide application in endodontics as a vehicle for

intracanal medicaments is attributed to its well

documented antibacterial action against

microorganism and its consistency which improves

the handling qualities of the paste. Also propylene

glycol, though viscous, has a low surface tension

which enables it to penetrate through dentinal

tubules when used as a vehicle.17

Of the three antibiotics, minocycline is often

reported to cause green-grey or blue-grey intrinsic

tooth discoloration. Minocycline is a semi synthetic

derivative of tetracycline and is a broad spectrum

antibiotic, effective against gram positive and

negative bacteria. The literature shows no theory

that conclusively illustrates the mechanism of

minocycline staining. Discolouration may be due

to minocycline binding to calcium ions via chelation

to form an insoluble complex and is incorporated

into tooth matrix causing discoloration.18 According

to ‘intrinsic theory’ minocycline is bound only by

those tissues with a high affinity for it such as dental

pulp, dentin, and bone which are collagenous.

Once in the tissues, the minocycline is oxidized

and subsequently transformed to a coloured

product. Pigment deposits from discoloured teeth

when examined microscopically and histologically

suggest the presence of iron and hemosiderin, a

minocycline degradation product, chelates with iron

to form an insoluble complex. The pigment contains

a quinone –like structure which is the main

contributor to its colour.19 Minocycline cannot stain

the tooth matrix unless it comes in contact with

coronal dentin.9The discolouration caused by

minocycline cannot be rectified satisfactorily by

bleaching techniques alone, depending on the

severity of cases the clinician may have to resort to

indirect veneers or even crowns. Inspite of its

potential draw back minocycline is incorporated

in the antibiotic mixture since it (minocycline) is

the most effective component of the antibiotic

mixture against E.faecalis.20

The discoloration can be best prevented by

bonding the pulp chamber with a two-step etch and

rinse dentin bonding system and composite resin


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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.


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1. Stéphane S and Wihelm-Joseph P. Clinical Success inEndodontic Retreatment. Paris: Quintessence Int, 2007.p.122.

2. Ingle IJ, Bakland KL, Baumgartner C J. Ingle’sEndodontics6th edition. Ontario: BC Decker Inc,2008: 1337.

3. Andreasen JO, Munksgaard EC, Bakland KL. Comparisonof fracture resistance in root canals of immature sheep teethafter filling with calcium hydroxide or MTA. DentTraumatol2006; 22:154-6.

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9. Kim J, Kim Y, Shin S, Park J, Jung I. Tooth Discoloration ofimmature permanent incisor associated with triple antibiotictherapy: A Case Report. J Endod 2010;36:1086-91.

10. Siqueira JF, Loupes HP. Mechanisms of antimicrobialactivity of calcium hydroxide: A Critical Review. Int Endod J1999;32:361-9.

11. Ingle IJ, Bakland KL, Baumgartner C J. Ingle’sEndodontics6th edition. Ontario:BC Decker Inc,2008; 1201.

12. Sato I, Kurihara-Ando N, Kota K, Iwaku M, Hoshino E.Sterilization of infected root canal dentine by topicalapplication of a mixture of ciprofloxacin, metronidazole andminocycline in situ. Int Endod J 1996;29:118-24.

13. Akgun OM, Atlun C, Guven G.Use of triple antibioticpaste as a disinfectant for a traumatized immature tooth witha periapical lesion: a case report. Oral Surg Oral Med OralPathol Oral Radiol Endod 2009;108:e62-e65.

14. Kusgoz A, Yildirim T, Er K, Arslan I. Retreatment of aresected tooth associated with a large periradicular lesion by

using a triple antibiotic paste and mineral trioxide aggregate:a case report with a thirty month follow-up. J Endod 2009;35:1603-6.

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16. Özan Ü, Er K. Endodontic treatment of a large cyst- likeperiradicular lesion using a combination of antibiotic drugs:A case report. J Endod 2005; 31:898-900.

17. Cruz EV, Kota K, Huque J, Iwaku M, Hoshino E.Penetration of propylene glycol into dentine. Int Endod J.2002;35: 330–336.

18. Tanase S, Tsuchiya H, Yao J, Ohmoto S, Takagi N, YoshidaS. Reversed-phase ion-pair chromatographic analysis oftetracycline antibiotics: application to discolored teeth. JChromatogr B Biomed Sci Appl. 1998;706:279–285.

19. Cheek CC, Heymann OH. Dental and Oral DiscolorationsAssociated with Minocycline and Other Tetracycline Analogs.J of Esthetic Dent 1999;11:43-48.

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