LESION STERLIZATION

&TISSUE REPAIR

By

Ahmed Mohsen Fawzy

Dentist in

Zagazig General HospitalEgypt

a-mohsen2040@hotmail.com

Dental caries is the greatest challenge to

the oral health of children especially

among low socioeconomic status

population.

Dental caries leads to irreversible damage

of pulp by exposing of the dental pulp to

microorganisms results in the

development of pulpal and periradicular

pathosis.

How do we fight back caries

invaded the pulpal tissues

..??

Pulpotomy

Pulpectomy

RCTExtraction

Is that an equivalent war ?!

No

What is LSTR ?Lesion Sterilization & Tissue Repair is simply

placing of antibiotic combination inside the

infected pulp chamber.

The therapy aims to eliminate causative bacteria

from lesions by sterilizing the lesions promoting

tissue repair & regeneration by the host's natural

tissue recovery process.

The Antiabiotic Combination 3 types of antibiotics are combined together to

ensure the complete eradication of all pathogenic

microbes in the periapical lesions.

The triple antibiotic paste (TAP) is formed by

mixing the powder of the antibiotics with

Macrogol & Propylene glycol which act as a

vehicle for the antimicrobial compound by their

penetrating ability to control the infection as far

as it extend.

So, it’s also called 3 Mix-MP

Triple Antibiotic Paste

TAP

Ciprofloxacin

Metronidazole

Minocycline

Nitroimidazole

compound that

exhibits a broad

spectrum of

activity against

protozoa and

anaerobic bacteria.

Synthetic

fluoroquinolone

& has

a bactericidal

mode of action.

Semisynthetic

derivative of

tetracycline

with a similar

spectrum of

activity.

Ratio 1 : 3 : 3 by wt

The Clinical Proceduresaccording to Rishi Nanda

Rubber dam Isolation

LA is not required as the pulp is necrotic

Caries Removal

Access Cavity

Extirpation of necrotic coronal pulp

Irrigation with normal saline (0.9%) and drying with cotton pellets to ensure visualization

Enlarging the canal orifices 1 mm in diameter and 2 mm deep to receive medicament (Medication Cavity)

Fill the medication cavities with 3 Mix and teeth restored with Glass Ionomer cement

S.S Crown

a: Primary tooth b: Permanent successor

1: Superficial restoration 2: Glass Inomer cement

3: Medication cavity filled with 3 Mix

The Cariology Research Unit of the Niigata University

School of Dentistry was the first to introduce the concept

in 1988.

In Vitro evaluation of 3-Mix - Ibrahim Khalil et al

(2012) proved that the 3Mix (Ciprofloxacin, Minocycline, Metronidazole) has the best results when compared with each one alone & Ca(OH)2 againstEnterococcus faecaliswhich is considered as the most resistant strain in the radicular colonies.

In Vivo Studies on LSTR

Jaya et al (2012) evaluated and compared the clinical

and radiographic effectiveness of Ciprofloxacin,

Minocycline, Metronidazole combination with

Ciprofloxacin, Minocycline and Tinidazole

combination in primary teeth.

Tinidazole a second generation synthetic

nitroimidazole, is more effective than metronidazole

and produces fewer and milder side-effects and is

recommended as drug of choice in single dose therapy

and is preferred to metronidazole.

Jaya et al2012

Method:- 25 healthy children, aged between 6 – 9 years who were having

30 infected primary teeth with pain, tenderness &

symptoms of abscess were selected and divided into 2 groups.

- In Group A a mixture of 3mix-MP (Ciprofloxacin,

Metronidazole and Minocycline) was placed on the floor

of the pulp chamber covering the root canal orifices.

- In Group B a mixture of Ciprofloxacin, Tinidazole and

Minocycline was placed as a layer on the floor of the pulp

chamber.

- The procedure was completed in a single visit.

Jaya et al2012

- Post operative clinical evaluation was done after 1,6,12 and 24

months.

- Postoperative radiographic evaluation was done at 6,12 and 24

months.

- Both Groups showed :

Absence of pain & Tenderness

subsidence of Abscess

- They observed no significant difference between both the

groups and thus a combination of Ciprofloxacin, Minocycline

and Tinidazole antibacterial drugs can be used on teeth

pulpally involved with physiologic root resorption.

Divya et alMar. 2014

Conducted a study on 3 cases to ensure the

capability of the TAP to eliminate causative

bacteria from lesions, assuming that lesions will

be repaired or regenerated by the host's natural

tissue recovery process & softened dentin will re-

calcify, so both softened dentin as well as carious

dentin can be intentionally left so, an inflamed

pulp, even with spontaneous pain, will recover

after LSTR treatment.

Divya et alCase 1 :

- A 6-year old female child

with the chief complaint

of increasing pain in the

lower left back tooth

region for past two

weeks.

- On clinical examination

deep proximal caries

with pulpal exposure

was seen in the lower

left D.

- Patient had severe pain

on percussion on first

molar when compared to

the second molar.

- The radiograph showed

periapical radiolucency

Case 2:

- A six and a half year old male child with the chief complaint of pain and swelling in the lower left back tooth region & history of swelling for past two days.

- On clinical examination, patient had dentoalveolar abcsessrelated to the lower left E.

- The periapical radiograph showed radiolucencyinvolving the furcationand circumscribing the mesial root of the second primary molar

Case 3 :

- A five year old male

child with the chief

complaint of pain in

the lower left back

tooth region for 2

weeks.

- On clinical

examination left lower

D had caries with

pulpal exposure.

There was

dentoalveolar abscess

related to the same

tooth.

- The radiograph

showed mild furcation

involvement.

Divya et al

Preoperative After 3 months

Case 1

Divya et al

Preoperative After 3 months

Case 2

Divya et al

Preoperative After 3 months

Case 3

Divya et alConclusion:

The Lesion sterilization and tissue repair therapy is simple,

painless, time-saving, and with less burden to patients

physically and mentally.

Thus, patient compliance and cooperation of patients is

predicable which is of great concern in the management of

Pediatric patients.

This procedure might disinfect the severely infected

deciduous teeth and allow it to function as a space

maintainer until the eruption of its permanent successor.

Burrs et al

Children’s Hospital of Wisconsin

They published 2-case report in May 2014 to provide dental practitioners an ensured alternative treatment to pulpectomies and extractions for nonvital pulp therapy in primary teeth.

Modifications on 3-Mix have been acquired in this case report.

CHW’s 3-Mix 2-part system

- 1. Dry powder :

Metronidazole

Ciprofloxacin

Clindamycin (To avoid

discoloration of the tooth

and gums induced by

Minocycline)

Iodoform (To make the

product radiopaque)

- 2. Liquid component :

Polyethylene Glycol 300

MW liquid

Propylene Glycol

- That is mixed with the

powder in the dentist’s

office immediately prior to

use

Case 1 Vestibular abscess with fluctuant swelling adjacent to lower

right E

Radiograph shows a furcation radiolucency.

Case 14 Months postoperative patient continues to be symptom free.

Furcal bone shows continued healing and increase in

trabeculation.

Case 2- Vestibular abscess with fluctuant swelling adjacent to the

lower right D.

- Clinically the tooth was depressible and class III mobile.

- Radiograph shows a furcation radiolucency.

Case 2- 3 Months postoperative patient is asymptomatic.

- Soft tissue showed complete healing.

- The tooth was negative to percussion and palpation and had

normal mobility.

- Radiograph demonstrates increased trabeculation in furcation

area.

Rishi Nanda et alAug. 2014

- Conducted a study on 40 teeth of healthy children were

randomly divided into two groups.

- In Group A 20 teeth, using (ciprofloxacin, metronidazole,

and minocycline) 3 Mix

- Group B 20 teeth, using (ciprofloxacin, ornidazole, and

minocycline) Other Mix.

- Ornidazole has been reported to have a longer

duration of action, with better efficacy and slower

metabolism compared with metronidazole.

Rishi Nanda et al2014

Clinical and radiographic evaluation was done at 3, 6 and 12

months.

Both of the groups showed 100% clinical success

Radiographic success rate was 81% with 3 Mix and

92% with Other Mix.

Rishi Nanda et al2014

Using Ciprofloxacin, Minocycline, Metronidazole (3mix)

A: preoperative B: after 3 months

C: after 6 months D: after12 months

Rishi Nanda et al2014

Using Ciprofloxacin, Minocycline, Ornidazole (other mix)

A: preoperative B: after 3 months

C: after 6 months D: after12 months

Rishi Nanda et al2014

Wang et al2011

Performed 2 case report to present

conservative treatment for immature

premolars with apical periodontitis

using triple antibiotic paste (TAP) to

disinfect the root canal systems for

revascularization.

Wang et al2011

Case 1 :

- 11-year-old boy

- Swelling on the buccal

vestibule related to the lower

right 5

- Sensitive to palpation and

percussion.

- Radiograph : immature open

apex.

Case 2 :

- 14-year-old girl.

- sinus tract on the buccal

gingiva of the mandibular

right second premolar.

- Percussion sensitivity existed.

- 5 mm of probing depth on the

mesial surface of the root.

- Radiograph : immature open

apex.

Wang et al2011

Case Management :

- Rubber dam isolation

- Access cavity preparation without anesthesia.

- Hemorrhage observed.

- A gutta-percha cone size # 30 was gently inserted into

the canal and the patient reported sensitivity,

potentially indicating the survival of residual vital

pulp tissue.

Wang et al2011

- Irrigation with 10 mL of 3% NaOCl, without

instrumentation.

- The canal was dried with paper points.

- 3 mix placed into the canal with an endodontic plugger to

a depth of 10 mm.

- The access cavity was sealed with 4-mm thickness of

intermediate restorative materials (IRM)

- After 21 days no clinical symptoms.

- The tooth was then re-opened & the canal irrigated with

10 mL of 3% NaOCl.

Wang et al2011

- An endodontic explorer was introduced into the canal until apical tissue was detected.

- The explorer was used to irritate the tissue gently to create some bleeding into the canal.

- The bleeding was stopped at a level of 3 mm apical to the CEJ and left for 10 minutes.

- 3 mm thickness of MTA was carefully placed over the blood clot followed by a wet cotton pellet & IRM.

- 3 days later the IRM and cotton pellet were removed and replaced with bonded composite resin restoration.

Wang et alCase1

(A)Radiolucent lesion at the periapical area of the second premolar.

(B) A gutta-percha cone being introduced into the canal without local

anesthesia, which stopped when the patient felt sensitivity.

(C)Radiograph presenting the mineral trioxide aggregate placement.

(D)Radiograph presenting composite resin restoration.

Wang et al

(A)6 month follow-up radiograph showing complete resolution of radiolucency.

(B)One-year follow-up radiograph revealing an increase in the thickness of the

root canal wall and continual development of the apex.

(C)17 month follow-up radiograph depicting continual root development.

Wang et al2011

Crown discoloration was noted

Wang et alCase 2

(A) A sinus tract on the alveolar mucosa between 1st & 2nd premolars.

(B) Periradicular radiolucency of 2nd premolar with a wide open apex.

(C) Radiograph showing the sinus tract tracing to the periradicular radiolucency of

the affected tooth.

Wang et al

(D) Gutta-percha cone, which was introduced

into the canal without local anesthesia and

stopped when the patient felt sensitivity.

(E) 25 days after TAP placement, showing that

the sinus tract had disappeared and crown

discoloration.

(F) The mineral trioxide aggregate placement.

(G) Coronal sealing with composite resin

LSTR indications1- All indications of pulpectomy

2- 1ry affected teeth associated with pain &

tender to percussion

3- Presence of mobility (grade I, II)

4- Presence of abscess

5- Presence of sinus tract

6- Presence of radiolucency in furcation area

LSTR indications7- Restorable crown

8- Pulpless 1ry teeth in hemophilic patient

9- Strategic importance for space

maintaining especially when space

maintainer fabrication is difficult (e.g.:

Handicapped & uncooperative patients)

10- Immature permanent tooth with

incomplete root formation

LSTR contraindication

1- Sensitive & allergic patient to any of the antibiotic componants

2- Radiographic evidence of excessive internal or external root resorption

3- Primary tooth about to exfoliate

4- Perforated pulpal floor

5-Excessive bone loss in furcation area involving underlying tooth germ

6- Unrestorable crown of permanent tooth as post placement & core build up are not allowed in revitalized pulp

Advantages of LSTR1- Easy & simple technique

2- One short visit technique

3- Economic

4- Painless

5- No instrumentation needed

6- No irritation of periapical tissues

7- No obturation needed

8- No use of formocresol

Disadvantages of LSTR1- Minocycline discoloration effect

(Solved by replacing Minocycline with

Clindamycine) by CHW

2- Radiolocent in radiograph

(Solved by adding Iodoform) by CHW

3- Inability of post placement & core build up in

badly destructed permanent teeth

Thank You