|Year : 2017 | Volume
| Issue : 2 | Page : 123-127
Management of long-standing perforation with mineral trioxide aggregate using metronidazole-containing collagen as an internal matrix
Sidhartha Sharma, Vijay Kumar, Ajay Logani
Division of Conservative Dentistry and Endodontics, Centre for Dental Education and Research, All Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||25-Apr-2017|
Division of Conservative Dentistry and Endodontics, Centre for Dental Education and Research, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
The time elapsed from the development of the perforation is a critical factor influencing the posttreatment prognosis. Long-standing perforations usually show a worse prognosis than fresh perforations. Mineral trioxide aggregate (MTA) is widely used to seal perforations because of its biocompatibility and sealing ability in the presence of blood and moisture. Metrogene sponge is a metronidazole-containing absorbable collagen having significant antibacterial activities. It can be an added advantage when used as an internal matrix for long-standing perforation repair. Three cases of long-standing perforation were selected and were sealed with MTA using metrogene sponges as an internal matrix. Finally, the teeth were endodontically treated and coronally restored. The absence of periradicular radiolucent lesions, pain, and swelling along with functional tooth stability at follow-up indicated a successful outcome of sealed perforations. To conclude, MTA with metrogene sponges as a matrix provides an effective seal of root perforations and clinical healing of the surrounding periodontal tissue.
Keywords: Collagen, long-standing perforation, mineral trioxide aggregate, perforation repair
|How to cite this article:|
Sharma S, Kumar V, Logani A. Management of long-standing perforation with mineral trioxide aggregate using metronidazole-containing collagen as an internal matrix. Saudi Endod J 2017;7:123-7
|How to cite this URL:|
Sharma S, Kumar V, Logani A. Management of long-standing perforation with mineral trioxide aggregate using metronidazole-containing collagen as an internal matrix. Saudi Endod J [serial online] 2017 [cited 2022 May 17];7:123-7. Available from: https://www.saudiendodj.com/text.asp?2017/7/2/123/205127
| Introduction|| |
Perforation is defined as “a mechanical or pathological communication between the root canal system and the external tooth surface.” Factors that affect the treatment prognosis include size and location of the perforation, biocompatibility of the sealing material, and time elapsed between the injury and repair. Sterility of the perforation site is an important criterion that dictates treatment success, particularly in long-standing cases. The following materials have been utilized for sealing perforations: Cavit, silver amalgam, calcium hydroxide, super ethoxy benzoic acid cement, hydroxyapatite, calcium phosphate cement, light-cured glass ionomer, and decalcified freeze-dried bone. None of these perforation sealing materials is adequately biocompatible to ensure a good treatment outcome when it comes into direct contact with bone tissue. Mineral trioxide aggregate (MTA) has the properties of the ideal material for perforation repair. The biocompatibility of MTA, ability to seal root perforations effectively, and its setting properties in the presence of moisture and even blood are important characteristics that may result in greater success rates when used for treating root perforations. Animal studies, case reports, and case series are available on the successful use of MTA as a perforation sealing material.,, Use of a biocompatible matrix has been recommended to achieve hemostasis as well as control placement of the material. Collagen is often the matrix of choice because of its biocompatible, hemostatic, handling, and resorbable properties. Metrogene sponge is a resorbable collagen fiber containing 4.5 mg metronidazole and thus having antibacterial properties.
The purpose of this report was to present three long-standing cases of perforation repair using metronidazole-containing collagen as an internal matrix.
| Case Reports|| |
A 30-year-old male presented with pain and swelling associated with the maxillary left first molar. The tooth was root canal treated by a private practitioner 8 months before this visit. On examination, a draining sinus tract on the swollen buccal mucosa at about the mid-root level was found. On reentering the access cavity, a diagnosis of complete furcal perforation was confirmed. After discussing the treatment options, written consent was obtained from the patient. A treatment plan of repairing the perforation with MTA (ProRoot ™ MTA, Dentsply Tulsa Dental, Tulsa, OK, USA) and collagen (Metrogene, Septodont, Saint-Maur-des-Fosses, France) sponge was decided. After providing the local anesthesia (xylocaine, lidocaine HCl injection, USP), the access cavity was modified followed by canal orifice location. The canals were filled with poorly compacted Gutta-percha. Gutta-percha was removed with a Hedstrom file. The perforation site was cleaned using ultrasonic diamond-coated CPR 3 tips (Spartan, Fenton, MI, USA), irrigated copiously with 2.5% sodium hypochlorite (NaOCl) (Cmident, New Delhi, India), and dried. Following this, a radiopaque dye incorporated metrogene collagen was placed through the perforation as an internal matrix. The canal orifices were blocked with absorbant paper points. Since the defect was large, a two-step repair technique was followed. In the primary step, the perforation was sealed with MTA mixed in 3:1 proportion which was delivered by an MTA gun (MAP System, Dentsply Tulsa Dental, OK, USA). A hand plugger was used to accommodate the MTA inside the defect with minimal pressure. A moist cotton pellet was placed into the pulp chamber, and the access cavity was sealed with Cavit (3M ESPE, Seefeld, Germany). A radiographic examination was undertaken to confirm the correct MTA positioning. According to operator's experience, primary repair is not sufficient in large defects. At the next visit, the material should be checked to determine if it has set hard and remains positioned in the perforation site. Hence, after 72 h, the seal was reassessed and a secondary repair step was performed in a similar way. Working length was determined using an apex locator (Tri Auto ZX, J Morita USA Inc., California, USA) and a #15 K-file. Biomechanical preparation was completed using rotary ProTaper files (Dentsply Maillefer; Ballaigues, Switzerland) and copious 2.5% NaOCl irrigation. Final irrigation was completed with 2% chlorhexidine (R4, Septodont, Saint-Maur-des-Fosses, France). This was followed by calcium hydroxide dressing (Prevest Denpro Limited, Jammu, India) as an intracanal medicament. After a week, the canals were obturated by warm Gutta-percha vertical compaction technique using AH Plus (Dentsply Detrey, Konstanz, Germany) sealer. The tooth was restored with composite material. The clinical findings at 2-year after treatment were absence of a periodontal defect in the area of perforation, pain, swelling, and sinus. The radiographic criteria for healing were absence of radiolucency adjacent to the repair site and periradicular lesions [Figure 1].
|Figure 1: (a) Preoperative intraoral periapical, (b) furcal perforation, (c) collagen placement, (d) intraorifice barrier, (e and f) first stage mineral trioxide aggregate repair, (g and h) second stage mineral trioxide aggregate repair, (i) postoperative intraoral periapical, (j) followup|
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A 25-year-old male presented with pain associated with the left mandibular first molar. The tooth was previously root canal initiated 6 months before this visit. After clinical and radiographic examinations, a diagnosis of furcal perforation involving the distal root was established. After access cavity modification, the perforation site was cleaned with ultrasonics and 2.5% NaOCl. The defect was repaired with MTA under dental operating microscope (PROergo, Carl Zeiss Meditec, Jena, Germany) in two steps after finding the primary repair insufficient. Metrogene sponge was used as a matrix. Moist cotton pellet was placed for 72 h and the access was sealed temporarily. The endodontic therapy was completed in two visits using ProTaper rotary files and calcium hydroxide was used as an interim medication. Obturation was accomplished with warm vertical compaction technique. The access cavity was sealed with composite restoration. The clinical and radiographic findings at 2 years after treatment suggested adequate healing of the tooth supporting structures [Figure 2].
|Figure 2: (a) Preoperative intraoral periapical, (b) canal location, (c) furcal perforation seen under dental operating microscope, (d and e) mineral trioxide aggregate repair with collagen, (f) postoperative, (g) follow up|
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A 42-year-old male presented with pain and swelling associated with a previously root canal initiated mandibular left second molar. A diagnosis of furcal perforation (on the lingual aspect) of 1-month duration was established. After redefining the access cavity, the repair procedure was performed with MTA and metrogene sponge as mentioned earlier. In this case, only primary MTA repair was sufficient since the defect was small. After setting of MTA, biomechanical preparation was completed using ProTaper rotary files. Calcium hydroxide was used as an intracanal medicament. Obturation was done with warm vertical compaction technique. This was followed by a composite restoration. The clinical and radiographic findings at 1 year after treatment suggested adequate healing of the tooth supporting structures [Figure 3].
|Figure 3: (a) Preoperative intraoral periapical, (b and c) mineral trioxide aggregate repair with collagen, (d) postoperative intraoral periapical, (e) 1-year follow-up|
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| Discussion|| |
The control of inflammation in the defect area represents one of the main goals of the perforation repair in addition to promoting the health of the surrounding tissue. In long-standing cases, the chronic inflammatory reaction provokes periodontal attachment loss and compromising tooth stability. This makes long-standing perforations, a real treatment challenge. The goal to reestablish tissue attachment was extremely difficult to achieve before the advent of MTA. MTA induces osteogenesis and cementogenesis which is unique and had not been demonstrated with any other material.
The protocol for cleansing and repairing perforation has been described by Arens and Torabinejad. Although the periradicular tissues provide some moisture from the external surface of the material, the use of a moist cotton pellet has been recommended to assure proper setting. Allowing the MTA to set undisturbed for 72 h or longer prior to placement of a coronal restoration has also been reported to decrease the chance of MTA displacement in furcation perforation repairs.
In cases of long-standing large perforation, the use of biocompatible matrices such as calcium sulfate, hydroxyapatite, or HAPSET has been recommended to control the extrusion of the material. In addition, its placement also helps achieving hemostasis. Al-Daafas and Al-Nazhan reported that the use of calcium sulfate did not aid bone regeneration or prevent epithelium migration into the defected perforation area. They concluded that using calcium sulfate as an internal matrix for MTA is not recommended. A study reported the use of “modified internal matrix” concept in which collagen was used as a completely resorbable barrier material and MTA for sealing of the perforation. Small pieces of collagen were used to push the granulation tissue out of the perforation and keep it in place outside the root.
The management of bacterial infection of the perforation site dictates the success of the attempted repair in long-standing cases. Pitt Ford, et al. demonstrated that in the group with delayed repair, more specimens were associated with inflammation, which appeared to be linked to the presence of infection in spite the use of MTA as perforation repair material. Thus, the successful outcome of long-standing perforations seems to be attributed to removal of contaminants as well as cleansing of the pulp chamber and perforation before repairing under aseptic conditions. Most of the floras seen during long-standing perforation cases are anaerobic in nature. Metronidazole covers most of the flora responsible for periodontal disease, for example, Bacteroides fragilis, Bifidobacterium, Fusobacterium, Peptostreptococcus, Prevotella, and Porphyromonas. Hence, the use of a resorbable collagen matrix containing metronidazole may provide additional antimicrobial activities in long-standing cases. The antibacterial property is due to fast release of metronidazole from sponges, i.e., approximately 6.5–58 mg/L in 0–30 min and 1 mg/L for period of 5–7 days after laying.
| Conclusion|| |
The outcome of the furcal perforations treated with MTA and metrogene sponge in the study showed radiographic and clinical healing in all the cases. This is the first case report/series to report the benefit of using metronidazole-containing collagen matrix in long-standing perforation repair cases. This not only results in repair of the defect but also promotes healing of the periodontal ligament due to its antibacterial efficacy. Further clinical studies are necessary to investigate the predictability of the outcome of the technique.
We would like to thank the patients who participated in the treatment.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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