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ORIGINAL ARTICLE
Year : 2019  |  Volume : 9  |  Issue : 1  |  Page : 34-39

Triple antibiotic paste versus propolis: A clinical quest for the reliable treatment of periapical lesions in primary molars


Department of Pedodontics and Preventive Dentistry, St. Joseph Dental College, Eluru, Andhra Pradesh, India

Date of Web Publication8-Jan-2019

Correspondence Address:
Dr. Ambati Naga Radhakrishna
Department of Pedodontics and Preventive Dentistry, St. Joseph Dental College, Eluru, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sej.sej_42_18

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  Abstract 

Background: Teeth with infected root canals, particularly those in which the infection has reached the periradicular tissues, require effective treatment interventions to save the tooth. Lesion sterilization concept (lesion sterilization and tissue repair [LSTR]) was successful in treating periapical polymicrobial infection, but this poses a risk of development of antimicrobial resistance.
Aim: The present study evaluated and compared both clinically and radiographically the healing abilities of Propolis liquid (natural therapeutic agent)-mixed Endoflas powder with LSTR (allopathic combination) for the management of periapical lesions in primary molars.
Materials and Methods: A total of 30 selected primary molars were randomly divided into two groups of 15 each: Group 1 – Propolis liquid-mixed Endoflas powder and Group 2 – LSTR (3Mix). Follow-up after 3, 6, and 12 months was done to evaluate progress in clinical and radiographic parameters. The obtained data were subjected to statistical analysis. McNemar's test was applied between the time points in each group. Comparison of Group 1 with Group 2 was done using Chi-square test.
Results: At the end of 12th-month follow-up, the overall clinical and radiographic success rate for Group 1 was 100%, whereas for Group 2, it was 93% and 60%, respectively. The difference in the radiographic success rate between the two groups was statistically significant (P < 0.05).
Conclusion: In the present study, Propolis liquid-mixed Endoflas powder combination has shown better results than LSTR. This novel combination of Propolis liquid-mixed Endoflas powder can, therefore, be considered as the material of choice for pulpectomy in deciduous molars with extensive involvement of pulp and periradicular tissues.

Keywords: Dental caries, periapical lesion, primary teeth, pulpectomy, triple antibiotic paste


How to cite this article:
Divya D V, Prasad MG, Radhakrishna AN, Sandeep RV, Reddy SP, Santosh Kumar K V. Triple antibiotic paste versus propolis: A clinical quest for the reliable treatment of periapical lesions in primary molars. Saudi Endod J 2019;9:34-9

How to cite this URL:
Divya D V, Prasad MG, Radhakrishna AN, Sandeep RV, Reddy SP, Santosh Kumar K V. Triple antibiotic paste versus propolis: A clinical quest for the reliable treatment of periapical lesions in primary molars. Saudi Endod J [serial online] 2019 [cited 2019 Feb 21];9:34-9. Available from: http://www.saudiendodj.com/text.asp?2019/9/1/34/249594


  Introduction Top


Teeth with infected root canals, particularly those in which the infection has reached the periradicular tissues, are a common problem in primary dentition; efforts have to be made to preserve these compromised teeth as early loss of primary teeth can cause a number of problems, including space loss for successor permanent teeth.[1] However, conventional pulp therapy is not preferred in teeth with extensive pulp involvement because microorganisms in fins and isthmuses can remain viable despite ultrasonic irrigation and sodium hypochlorite (NaOCl) irrigation, largely contributing to endodontic failure.[2]

Lesion sterilization and tissue repair (LSTR) therapy aims to eliminate causative bacteria from lesions by sterilizing the lesions, thereby promoting tissue repair and regeneration by the host's natural tissue recovery process.[2] However, even though various studies[3],[4],[5],[6] have reported the effectiveness of triantibiotic paste, Trairatvorakul and Detsomboonrat suggested that noninstrumentation endodontic treatment using 3Mix-MP (antibiotic [3Mix]: ratio 1:1:1 –ciprofloxacin 200 mg, metronidazole 500 mg, and minocycline 100 mg; carrier [MP]: ratio 1:1 – macrogol ointment and propylene glycol) cannot replace conventional root canal filling material as a long-term therapy in primary teeth.[7]

The rationale of the present study was to find an alternative to 3Mix-MP, and for this purpose, a novel combination of Endoflas powder and Propolis liquid was chosen. Propolis has been known to be a natural antibiotic containing flavonoids which have been proven to have antimicrobial activity against Streptococcus mutan s and polymicrobial cultures collected from necrotic root canals.[8],[9] As in the current scenario, Endoflas which is a mixture of calcium hydroxide, zinc oxide eugenol, and iodoform has a high success rate and can be considered as an effective root canal filling material in primary teeth due to its healing ability, bone regeneration characteristics, and its resorption of excess material without washing within the roots,[10],[11] but the disadvantage of this material is its eugenol content which causes periapical irritation.[12],[13] The hypothesis of the present study was that by replacing the liquid eugenol with Propolis, favorable healing results could be achieved, thereby improving the treatment success rate of periapically involved deciduous molars.

The present study aimed to evaluate the treatment outcomes of LSTR and Propolis liquid-mixed Endoflas powder in primary molars with extensive pulpal and periapical involvement by comparing them both clinically and radiographically.


  Materials and Methods Top


The present study was carried out on a group of 17 children who attended the Outpatient Department of Pedodontics and Preventive Dentistry, St. Joseph Dental College, West Godavari, Andhra Pradesh, India. Children with good general health and no history of systemic illness or hospitalization were selected. A total of 30 primary molars from 17 children aged 4–9 years with the mean age of 6.25 years meeting inclusion criteria were selected. The sample included 15 mandibular first molars, 12 mandibular second molars, 1 maxillary first molar, and 2 maxillary second molars. The teeth were randomly divided into two groups of 15 each and treated either with Group 1 – Propolis liquid-mixed Endoflas powder or Group 2 – LSTR (3Mix). Written informed consent was obtained from the patients/guardians of children who required to undergo the treatment. The present study was approved by the ethics committee of the institution. The institutional ethical committee approval number: cec/032/14-17.

Clinical criteria

  • History of spontaneous pain with deep carious lesion
  • Presence of pathologic mobility
  • Presence of abscess or fistula.


Radiographic criteria

  • Presence of radiolucency in the interradicular/periradicular area without involving permanent tooth bud
  • Adequate bone support, i.e., coverage by the bone of minimum two-thirds of at least one root
  • Absence of internal resorption and pathologic external root resorption.


Exclusion criteria

  • Pulpal involvement requiring pulp therapy but not involving the periradicular tissues
  • Tooth with root caries
  • Children with a history of systemic illness
  • Periapical lesions with poor prognosis indicated for extraction
  • Presence of radiolucency in the interradicular and periradicular area involving permanent tooth bud
  • Retreatment of failed pulpectomies.


Preparation of Propolis liquid-mixed Endoflas powder mixture

Propolis liquid (Brazilian Green Bee Propolis Liquid Extract, Uniflora®) and Endoflas powder (Sanlor and Cia. S. En C. S., Colombia) were mixed on a glass slab with the help of a stainless steel spatula. The mixing ratio of Endoflas powder and Propolis liquid was 2:1.

Preparation of 3Mix (lesion sterilization and tissue repair)

Commercially available chemotherapeutic agents such as ciprofloxacin, metronidazole and minocycline were used in the study. After removal of enteric coating, these drugs were pulverized, using sterile porcelain mortar and pestle.

  • These powdered drugs were mixed in the ratio of 1:3:3, i.e., being one part of ciprofloxacin, three parts of metronidazole, and three parts of minocycline, kept separately to prevent exposure to light and moisture[4],[5],[6]
  • One increment of powdered drugs was mixed with saline to get paste-like consistency just before use.


Clinical procedure for Propolis liquid-mixed Endoflas powder (Group 1)

Local anesthesia was given for the selected tooth followed by isolation using rubber dam, after access cavity preparation coronal pulp was removed with a spoon excavator followed by chemomechanical preparation using K files (Mani Inc., Tochigi, Japan) and irrigation with 3% NaOCl followed by normal saline. All the canals were dried using paper points and were obturated with Propolis liquid-mixed Endoflas powder mixture using incremental technique. Radiographic confirmation was done. Then, access cavity was restored with Type IX glass ionomer cement followed by stainless steel crown.

Lesion sterilization and tissue repair (3Mix) clinical procedure (Group 2)

Local anesthesia was given for the tooth to be treated, followed by isolation using rubber dam. Access opening was performed and the necrotic pulp was removed with a spoon excavator. Hemorrhage, if present, was controlled by applying cotton pellets immersed in 3% NaOCl. The pulpal floor was covered with 3Mix. Then, the access cavity was filled with Type IX glass ionomer cement (GC Corporation, Tokyo, Japan) followed by stainless steel crown.

All cases were performed by a single operator and were evaluated both clinically and radiographically at a period of 3, 6, and 12 months' interval.

Treated teeth were inspected clinically for any signs of failure that included:

  • Reports of spontaneous pain
  • Presence of swelling
  • Sinus tract
  • Mobility and premature exfoliation.


Radiographic signs of pathosis were also checked and compared with preoperative radiograph to assess:

  • Whether any increase/decrease of periapical and furcation radiolucencies
  • Deviation in the path of eruption of succedaneous teeth
  • Internal root resorption had decreased or increased following treatment
  • Resorption of over-pushed material
  • Resorption of filling material with respect to root resorption.


The observed data were subjected to statistical analysis. Data analysis was done using Statistical Package for the Social Sciences (SPSS) software Version 20 (Chicago, IL, USA). McNemar's test was applied between the time points in each group. Comparison of Group 1 with Group 2 was done using Chi-square test.


  Results Top


The preoperative and postoperative clinical signs and symptoms were tabulated [Table 1]. Statistically significant difference (P = 0.0001) was seen between the preoperative and postoperative clinical signs and symptoms in both the groups at postoperative 3, 6, and 12 months. There were no extractions or failures in Group 1. However, one tooth had to be extracted in Group 2 during the 12th-month follow-up and the clinical success of LSTR was 93% owing to the one postoperative failure, whereas it was 100% clinical success for Propolis liquid-mixed Endoflas powder group.
Table 1: Group 1 and Group 2 clinical findings

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Radiographically, the teeth were assessed for changes in the interradicular radiolucency. In Group 1, 80% decrease in the size of interradicular radiolucency was observed at the end of 3 months, 93% at the end of 6 months, and 100% at the end of 12 months' review. In Group 2, 80% decrease in the size of interradicular radiolucency was observed at the end of 3 months' follow-up and 86.6% at the end of both 6 and 12 months' review. In Group 1, there was neither internal resorption nor deviated path of eruption of succedaneous teeth, and complete healing of furcation radiolucency in 100% of cases was noted at the end of 12 months. Whereas, in Group 2, internal resorption and deviated path of eruption of succedaneous tooth was noted in one case which was extracted at the end of 12 months' follow-up and there was complete healing of furcation radiolucency in 60% of cases at the end of 12 months [Table 2].
Table 2: Group 1 and Group 2 radiographic findings

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Radiographic assessment of the overfilled material in Group 1 revealed that of the 5 overfilled canals, resorption of the excess material was seen in two canals at the 3rd-month follow-up and four canals at the end of the 6th-month follow-up. However, retention of the material was found in one canal at the end of the 12th-month evaluation period. Eighty percentage success was observed in teeth with overfilled Propolis liquid-mixed with Endoflas powder [Table 3].
Table 3: Resorption of overfilled material in Group 1

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The resorption of the filling material in Group 1 was equal to the physiological resorption of the root in 93.3% of cases. Whereas, in 6.6%, that is, in 1 case of 15, it was noted that the resorption of the root was faster than filling material [Table 4].
Table 4: Comparison of postoperative relative resorption of filling material with respect to root resorption in Group 1

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The overall clinical and radiographic findings in this study revealed 100% clinical success in Group 1 compared with 93% success in Group 2. Whereas, radiographically success reported was 100% with Group 1 and 60% with Group 2 at the end of 12 months' follow-up [Table 5]. The difference in the radiographic success rate between the two groups was statistically significant (P < 0.05).
Table 5: Group 1 and Group 2 overall success

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  Discussion Top


Endodontic management of primary teeth with severe pulpal necrosis which was evidenced by nonvital pulp tissue, fistula, and loss of alveolar bone is generally discouraged. The main reason behind was the morphology of the primary teeth which is not suitable for biomechanical preparation.[3] Application of antibacterial drugs to endodontic lesions is one of the clinical procedures that can be used to sterilize such lesions.[14] The present study intended to evaluate the prognosis of primary molars with severe pulpal necrosis by comparing both allopathic and natural therapeutic agents.

As it is universally known that LSTR procedure requires removal of coronal pulp only, pulpectomy procedure requires removal of coronal as well as radicular pulp. There was a considerable amount of literature supporting the efficiency of LSTR technique which disinfects the severely infected deciduous teeth and allows them to function as a space maintainer until the eruption of its permanent successor.[15] However, LSTR has shortcomings such as the development of antibiotic-resistant strains and lack of good long-term prognosis.[7] Nowadays, LSTR technique is being widely practiced in pediatric dentistry, especially in the management of primary teeth with furcation involvement and severe bone loss, where the prognosis of conventional pulpectomy procedure is considered to be poor.[16]

One study tested the efficiency of ciprofloxacin, minocycline, and metronidazole combination in vitro and established it to be very effective in the decontamination of necrosed pulp and infected root canals of primary teeth.[17] Later, many in vivo studies had also reported success with the same regimen and technique.[3],[4],[5],[6] The same drug regimen was used in the present study.

In the present study, all reported and recorded clinical signs and symptoms resolved in LSTR group (3Mix) and also there was a reduction in the periapical radiolucency in almost all the cases within 3 months and these observations noted in the present study were similar to the results reported in a previous study done using the same drug regimen.[18]

Although LSTR was effective, many authors had cited that further research is needed for comparing this technique with the conventional root canal treatment.[4],[5] However, the indiscriminate use of antibiotics has led to increase in resistant strains and their adverse effects have prompted the researchers to look for an herbal alternative.[19] In this context, as literature till date indicates no other clinical study compared the credibility of LSTR with an herbal alternative till date in the management of periapical lesions in primary molars for which the present study intended to do so.

Endoflas possesses most of the qualities of an ideal obturation material.[10],[11] However, the main disadvantage with Endoflas is eugenol which is known to cause periapical irritation.[12],[13] Hence, in the present study, alternative liquid formulation, Propolis, was used.

Propolis was used in the present study because previous studies had reported that when compared with triantibiotic mixture as intracanal medicament, the ethanolic extract of Propolis was more effective against Enterococcus faecalis.[19] And also, the antimicrobial effect of Propolis was equally efficacious as NaOCl on E. faecalis and Candida albicans when used as irrigating solution.[20],[21]

A study assessing the antimicrobial effect of three intracanal propolis containing pastes against polymicrobial cultures collected from primary molars, having necrotic root canals, inferred that the addition of propolis to metapex and zinc oxide eugenol could potentiate the antimicrobial effect of each other.[21] Therefore, in the present study, after summarizing the available literature[8],[9],[20],[21],[22],[23] on Propolis which had been proved to be a potent root canal disinfectant had been used as liquid component with Endoflas powder for obturation of primary molars with severe pulpal necrosis.

Overall clinical and radiographic findings in this study revealed 100% success rate in Group 1 at the end of 3 months' follow-up and maintained until 6 and 12 months' follow-up. Contrary to these results, a retrospective study had reported that in 42% of the overfilled teeth, the pathologic lesions remained unchanged or increased, leading to a success rate of 58% using Endoflas alone. Lack of resorptive ability can be attributed mainly to the presence of eugenol in the liquid.[22] In the present study, as the liquid component was replaced with propolis, 80% of treated cases displayed complete resorption of the overfilled material. And also, 100% of treated primary molars demonstrated complete healing of periapical radiolucency in Group 1 at 12th month follow-up which can be attributed to the phagocytic activity with potent tissue repair ability of the flavonoids present in Propolis. Furthermore, flavonoids support the immune system by promoting phagocytic activities, stimulating cellular immunity, and augmenting healing effects. In addition, Propolis contains elements such as iron and zinc which are important for the synthesis of collagen.[7]

As we had targeted the management of primary teeth with breakdown of periradicular tissues in the present study, lack of uniformity of treatment procedures in both the groups can be considered as a limitation. For future studies, inclusion of a standard control group treated with most common obturating material to compare the treatment outcomes of new filling material, such as Propolis liquid-mixed Endoflas powder in primary molars with apical lesions, with an objective way or tool to observe the changes of resorption and also an increase in sample size can be recommended.


  Conclusion Top


The observations noted in the present study give a new array in the form of Endoflas and Propolis combination for overcoming the pitfalls of LSTR technique at the same time saving the primary tooth, thereby maintaining the arch integrity. Propolis liquid-mixed Endoflas powder obturating material can also be used in primary teeth after conventional pulpectomy procedure as it has been improvised with the combination of formulations having both disinfective and regenerative potential capabilities.

Acknowledgments

We thank Fr. Nelli George and Dr. Sleeva Raju for their support throughout the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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