www.ijohrr.

com
77
I
J
O
H
R
R

ENDODONTIC TREATMENT OF A LARGE PERIRADICULAR LESION USING
A COMBINATION OF ANTIBIOTIC DRUGS : A CASE REPORT
Dr. Amit Bhagat
1
, Dr. Ripu Daman Singh
2
1
Senior Lecturer, Dept of Conservative Dentistry and Endodontics, BRS Dental College and
Hospital, Panchkula
2
Reader, Dept of Conservative Dentistry and Endodontics, SGRD College and Hospital,
Amritsar


ABSTRACT

Microorganisms are the possible source of endodontic lesions. The polymicrobial infection makes
the sterilization of the root canal difficult. Elimination of microbial contamination from the root
canal system is a precondition for successful root canal treatment. This case report describes the
non-surgical endodontic treatment of maxillary central incisors with large periradicular lesion,
which did not heal with calcium hydroxide dressing. The treatment protocol was changed to an
intracanal dressing of triple antibiotic paste for 3 months. Periapical healing was observed 3-month
after initial treatment and continued at the 7-month review. On follow up, teeth were clinically
asymptomatic and radiographically showed healing of the periradicular lesion. The result of the
case show that when most commonly-used medicaments fail in eliminating the symptoms, a triple
antibiotic paste (metronidazole, ciprofloxacin, and minocycline) can be used clinically in the
treatment of teeth with large periradicular lesions.
Keywords- non vital, calcium hydroxide, triple antibiotic paste, periraradicular lesion.
INTRODUCTION
Apical periodontitis is caused, primarily, by bacteria in the root canal space. Therefore, a logical
treatment aim is to remove as many of these bacteria as possible. Root canal therapy is an
invaluable measure to preserve teeth that would otherwise need to be extracted1. However, bacteria
inside the root canal system have a significant impact on this success rate. When a tooth is infected
before treatment, the success rate of root canal therapy drops to 79% as compared to 93% success
rate of root canal treated teeth without periapical periodontitis2, therefore, improving the cleaning
and disinfection phase of treatment is of crucial importance and has been the impetus for the
advancement of instrumentation and irrigation.
The infection of the root canal system is considered to be a polymicrobial infection, consisting of
both aerobic and anaerobic bacteria
3
. Past efforts have been aimed at eliminating the bacterial
challenge and creating an environment conducive to the placement of a root canal filling. Because
International Journal of Oral Health Research & Review 78
I
J
O
H
R
R

of the complexity of the root canal infection, it is unlikely that any single antibiotic could result in
effective sterilization of the canal. More likely, a combination would be needed to address the
diverse flora encountered. The combination that appears to be most promising consists of
metronidazole, ciprofloxacin, and minocycline (Sato et al. 1993)
4

The following case report describes the endodontic treatment of a large cyst-like periradicular
lesion using a combination of antibiotic drugs.
CASE REPORT
A 20-yr-old boy presented to the Department of conservative dentistry and Endodontics, SGRD
Amritsar with a chief complaint of dull continous pain and discoloration with respect to his upper
anterior teeth (Figure 1).

Figure 1. Discolored Central Incisors

Figure 2. Preoperative radiograph Figure.3 Access opening under isolation
.
www.ijohrr.com
79
I
J
O
H
R
R


Patient gave history of trauma to his front teeth seven years prior to his visit. The past medical
history of the patient was noncontributory. Patient was already undergoing root canal treatment by a
local practitioner. The maxillary central incisors were tender on percussion and exhibited normal
mobility. Peri apical radiographic examination revealed a ill defined radiolucent area involving
maxillary right and left central incisors (Figure 2). Radiographically there was no sign of root
fracture. The clinical and radiographic findings were suggestive of periapical pathology in relation
to 11 and 21. Hence non-surgical endodontic therapy maxillary central incisors was planned.
At the same appointment, root canal treatment was initiated, access cavity modified, and rubber
dam was applied (Figure .3). Working length was estimated as being 1 mm short of the
radiographic apex. The canal was instrumented with size 15-40 K-files using a step-back technique.
During the instrumentation, the canal was irrigated copiously with 3 % sodium hypochlorite
solution using a 27-gauge endodontic needle after each instrument.

Figure.4 Triple antibiotic paste mixture
Initially Calcium hydroxide was given as a intracanal medicament for three weeks, but patient
showed no signs of pain relief. The treatment plan was changed. After removing smear layer using
17% EDTA and 3% sodium hypochlorite solution, canal was dried using paper points. Triple
antibiotic paste (Figure .4) was placed in the canals, patient showed signs of relief in one week.
Paste was changed every 15 days for a period of 3 months.
The canals were irrigated with 3% sodium hypochlorite followed by normal saline and obturated
with gutta-percha and AH plus by using a lateral compaction technique. The restoration was
accomplished with composite. After 7 months , the radiographs showed bony healing with well-
defined trabeculae (Figure.5). Composite build up was done after non vital bleaching.

International Journal of Oral Health Research & Review 80
I
J
O
H
R
R




Figure.5 Post operative Follow Up radiograph (8 months)



Figure. 6 Post operative Photograph

DISCUSSION

www.ijohrr.com
81
I
J
O
H
R
R

In infected teeth, disinfection is carried out with a combination of instrumentation, irrigation, and
the placement of an intracanal medicament. Though complete disinfection is not achieved through
mechanical instrumentation alone, it is a very important step in the disinfection process, resulting in
an approximate 20 to 40% reduction in bacterial counts
5
.
The infection of the root canal system is considered to be a polymicrobial infection, consisting of
both aerobic and anerobic bacteria
6
. Because of the complexity of the root canal infection it is
unlikely that any single antibiotic could result in effective sterilization of the canal. More likely a
combination would be needed to address the diverse flora encountered.
A combination of antibiotics would also decrease the likelihood of the development of resistant
bacterial strains
4
. The combination that appears to be most promising consists of metronidazole,
ciprofloxacin, and minocycline. Sato et al. investigated this drug combination in vitro and found it
to be very effective in the sterilization of carious lesions, necrotic pulps, and infected root dentin of
deciduous teeth.
Hoshino et al.
7
performed an in vitro study and found, alone none of the drugs resulted in complete
elimination of bacteria. However, in combination, these drugs were able to consistently sterilize all
samples. Takushige et al.
8
evaluated the efficacy of poly-antibiotic paste consisted of ciprofloxacin,
metronidazole, and minocycline, on the clinical outcome of so-called Lesion Sterilization and
Tissue Repair, LSTR, therapy in teeth with periradicular lesions. Results showed that in all cases,
clinical symptoms such as gingival swelling, sinus tracts, induced dull pain, spontaneous dull pain,
and pain on biting disappeared after treatment, although in four cases clinical signs and symptoms
were finally resolved only after retreatment using the same procedures. Thus, gingival abscesses
and fistulae, if present, disappeared after a few days.

In this study, calcium hydroxide was used, but the symptoms were not relieved. The treatment
protocol was changed, and a triple antibiotic paste was used instead. After its application, the
symptoms resolved. Since the overwhelming majority of bacteria in the deep layers of the infected
dentine of the root canal wall consist of obligate anaerobes
9
, metronidazole was selected as the first
choice among antibacterial drugs. It is reported that metronidazole can penetrate the deep layers of
carious lesions and disinfect the lesions in vivo

and diffuse throughout the dentine.

As the bacterial
flora of the root canal with a periradicular lesion is complex in nature,

metronidazole alone cannot
kill all bacteria

indicating that other drugs may be necessary to sterilize the infected root dentine.
Thus, ciprofloxacin and minocycline, in addition to metronidazole were required to sterilize the
infected root dentine.
CONCLUSION
When the most commonly used medicament fail to eliminate the symptoms, then a triple antibiotic
paste can be used as an alternative material. The periradicular lesion in this case showed progressive
International Journal of Oral Health Research & Review 82
I
J
O
H
R
R

healing after using a triple antibiotic paste in the canal. Every effort should be made to treat such
lesions irrespective of size by a nonsurgical endodontic treatment method. Periapical surgery may
be the only alternative when the tooth with periapical lesion fails to respond to non surgical
treatment.

REFERENCES
1. Melker KB, Vertucci FJ, Rojas MF, Progulske-Fox A, Blanger M. Antimicrobial efficacy of
medicated root canal filling materials. J Endod. 2006 Feb;32(2):148-51.
2. Farzaneh M, Abitbol S, Lawrence HP, Friedman S Treatment outcome in endodontics-the
Toronto Study. Phase II: initial treatment. J Endod. 2004 May;30(5):302-9.
3. Windley W 3rd, Teixeira F, Levin L, Sigurdsson A, Trope M. Disinfection of immature teeth
with a triple antibiotic paste. J Endod. 2005 Jun;31(6):439-43.
4. Sato T, Hoshino E, Uematsu H, Noda T. In vitro antimicrobial susceptibility to combinations of
drugs on bacteria from carious and endodontic lesions of human deciduous teeth. Oral Microbiol
Immunol. 1993 Jun;8(3):172-6.
5. Bystrm A, Sundqvist G. Bacteriologic evaluation of the efficacy of mechanical root canal
instrumentation in endodontic therapy. Scand J Dent Res. 1981 Aug;89(4):321-8.
6. Fabricius L, Dahln G, Ohman AE, Mller AJ. Predominant indigenous oral bacteria isolated
from infected root canals after varied times of closure. Scand J Dent Res. 1982 Apr;90(2):134-44.
7. Hoshino E, Kurihara-Ando N, Sato I, Uematsu H, Sato M, Kota K, Iwaku M. In-vitro
antibacterial susceptibility of bacteria taken from infected root dentine to a mixture of ciprofloxacin,
metronidazole and minocycline. Int Endod J. 1996 Mar;29(2):125-30.
8. Takushige T, Cruz EV, Asgor Moral A, Hoshino E. Endodontic treatment of primary teeth using
a combination of antibacterial drugs. Int Endod J. 2004 Feb;37(2):132-8.
9. 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 Mar;29(2):118-24