8181

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

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.

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

8383

presented, a diagnosis of acute exacerbation of

chronic alveolar abscess was arrived at. Non-

surgical retreatment of the involved teeth was

planned. Patients medical history was

noncontributory.

All the clinical steps were performed under

rubber dam isolation (Hygienic Dental Dam,

Coltne 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 patients 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 manufacturers 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