Lesion Sterilization Tissue Repair: A Review

ABSTRACT

As part of lesion sterilization and tissue restoration (LSTR), treatment for primary molars affected by extensive periapical pathosis and extreme resorption entails the use of a triple antibiotic mixture in an appropriate medium. In-depth explanation of all components of LSTR is the main focus of this review of the literature.

INTRODUCTION

Pulpotomy/pulpectomy is the recommended course of treatment for infected and pulpally involved primary teeth. However, in other cases, such as when there has been a major root resorption and/or there is furcal radiolucency, a pulpectomy may not be an option and extraction would then be the only solution. A space maintainer should be given in the event of extraction to prevent any potential space loss. For primary teeth where pulpectomy has been contraindicated, LSTR appears to be a suitable option.[1] The clinician should have a thorough awareness of the history of the idea and its justification before carrying out the procedure. The purpose of this review of literature is to discuss the various aspects of LSTR in detail.

Lesion sterilization and tissue repair

Hoshino invented the idea for LSTR therapy at the Cariology Research Unit of Niigata University School of Dentistry in 1990, and Takushige popularized it. The LSTR is an endodontic treatment method that includes minimal or no instrumentation, followed by the administration of an antibiotic mix in a propylene glycol vehicle to disinfect periapical lesions and root canals.[2]

For the management of pulpal and periapical lesions, LSTR combines the antibiotics metronidazole, ciprofloxacin, and minocycline. By disinfecting the lesions and encouraging tissue regeneration through the host’s natural tissue recovery process, this therapy tries to eradicate the pathogenic bacteria that cause the disorders. To ensure that all pathogenic bacteria in pulpal and periapical lesions are completely eradicated, three different antibiotics are mixed.[3]

Hoshino et al. blended antibiotics in 1990 that included metronidazole 500 mg, ciprofloxacin 200 mg, and minocycline 100 mg in a 1:1:1 ratio.[4] The aforementioned antibiotics were used by Takushige et al. in 1998 in a 1:3:3 ratio.[1]

Both gram-positive and gram-negative anaerobes are hampered in their growth by metronidazole, a member of the nitroimidazole group. Ciprofloxacin, which blocks DNA gyrase and helps eradicate gram-negative bacteria, is a member of the fluoroquinolone group. By inhibiting the synthesis of fresh proteins, collagenases, and matrix metalloproteinases, the broad-spectrum antibiotic minocycline destroys both gram-positive and gram-negative bacteria, as well as spirochetes. Due to their greater penetration into the dentinal tubules, different vehicles like macrogol or propylene glycol are specifically utilized.[5,6]

Triple antibiotic paste preparation

Making triple antibiotic paste is an essential step in LSTR. The most well-liked combination is minocycline, ciprofloxacin, and metronidazole.[7] The outer covering of the medicines is removed by scraping with a blade, and the external capsular substance of the capsule is also removed. Then, each part is pounded separately in a brand-new mortar and pestle. The powder should not be wetted, thus care must be taken. The powder can be kept separately in ceramic containers with tight lids and maintained in a dark place to avoid exposure to light and moisture during storage. Each ingredient is well pulverized before being added to a clean glass mixing pad or slab to make an antibiotic paste.[6,7] Advantages and Disadvantages of LSTR are listed in Table 1.

Table 1.

Advantages and disadvantages of LSTR[1,2,3,13]

Advantages	Disadvantage
Less technique sensitive	Need to evaluate systemic absorption and drug resistance of the drugs used in LSTR therapy.
Reduce chairside time	Chance of discoloration
Easy to perform	The original 3-mix paste appears radiolucent in radiographs.
Economical
Well accepted by patients and parents

Clinical step for LSTR[2]

• Access is opened, and then the previous restoration and any necrotic pulp are removed.

• 37% phosphoric acid was used to treat the walls of the access cavity.

• A medicine cavity is made that is 1 mm wide and 2 mm deep to help with the implantation of 3-mix paste.

• Cotton pellets dipped in 10% sodium hypochlorite are used to control hemorrhage if it is present.

• When it is not possible to prepare a medication cavity (due to significant physiologic resorption), the entire pulpal floor is filled with 3-mix paste.

• Glass ionomer cement is used for postoperative restoration before a stainless-steel crown.

DISCUSSION

LSTR appears to be the only feasible method for giving the damaged tooth a good prognosis, assisting the clinician and the care provider in overcoming such difficult situations.[8]

TAP, a “intra-canal medicament,” is a combination of three antibiotics—metronidazole, ciprofloxacin, and minocycline—at a precise ratio of 1:1:1. Since no single antimicrobial medicine has the ability to entirely eliminate the polymicrobial flora, TAP is employed to provide the best results and thoroughly clean the area. TAP, a trio of antibiotics, offers strong antibacterial effects during endodontic treatment. Since it considerably reduces the risk of bacterial resistance, the three medications combined in a single mixture are particularly effective.[9]

LSTR therapy does not rely on mechanical techniques; instead, it tries to remove germs from the root canals. As a result, the clinical treatment is straightforward and does not call for a lot of chair time or frequent visits.[10] Numerous studies back the use of LSTR as a successful alternative to the traditional pulpectomy technique in primary teeth. When compared to typical obturating materials, these in vivo experiments demonstrated a significant success of triple antibiotic paste utilized as an LSTR approach, with its success being higher than another counterpart.[10,11]

Tooth discoloration is one of the biggest issues with TAP. Studies have shown that TAP is more significantly connected with discoloration when compared to other antibiotic pastes such as ledermix, polyantibiotic paste, and septomixine forte. Because of this, using double antibiotic paste (DAP), which only contains ciprofloxacin and metronidazole, has been suggested in certain situations.[9]

Concerns over the overuse of antibiotics have led to ongoing research to develop a single therapy to replace the triple antibiotic paste and CHX, two routinely used intracanal medications, in root canal-resistant microorganisms. Currently, moxifloxacin and nitrofurantoin have been used as a single drug replacement for LSTR.[12]

Indication of LSTR

LSTR can be used to treat a range of clinical issues, including uncooperative children, grossly carious teeth, extensive root resorption, severe bone loss and mobility, furcal radiolucency, parents unwilling for extraction, and similar issues.[6]

Contraindication of LSTR

Aside from patients with perforated pulpal floors and primary teeth that are on the verge of exfoliating, known allergies to medicine used and radiographic appearance of internal and external resorption should not be given the choice of the LSTR. LSTR is not indicated in kids affected by infective endocarditis.[6]

CONCLUSION

Based on currently available literature, it can be said that LSTR therapy, which involves the use of 3-mix paste, has been effective in treating compromised primary teeth with pulp–periapical lesion.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.