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 Table of Contents  
Year : 2017  |  Volume : 29  |  Issue : 1  |  Page : 78-81

Nonsurgical retreatment of a very large periapical lesion using triple antibiotic paste, calcium hydroxide and intracanal aspiration technique

1 Department of Conservative Dentistry and Endodontics, Seema Dental College, Rishikesh, Uttarakhand, India
2 Department of Periodontics, Seema Dental College, Rishikesh, Uttarakhand, India

Date of Web Publication25-May-2017

Correspondence Address:
S Dixit
1/3, Semal Road, Shipra Suncity, Indirapuram, Ghaziabad - 201 014, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/endo.endo_111_16

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This article presents a case with a very large periapical lesion in relation to mandibular right first and second molars. A nonsurgical approach was taken into consideration for the management of the lesion. The treatment included nonsurgical root canal treatment with the aspiration of fluid through the root canal and placement of triple antibiotic paste for 2 weeks followed by metapex for 3 months. Complete periapical healing was observed at 2 years recall. This report suggests that surgical removal of the large periapical lesion is not mandatory and that irrespective of the size of the lesion, every effort should be made to treat such lesion by conservative means.

Keywords: Healing; nonsurgical treatment; peri-apical lesion; sodium hypoclorite; triple antibiotic paste.

How to cite this article:
Dixit S, Dixit A. Nonsurgical retreatment of a very large periapical lesion using triple antibiotic paste, calcium hydroxide and intracanal aspiration technique. Endodontology 2017;29:78-81

How to cite this URL:
Dixit S, Dixit A. Nonsurgical retreatment of a very large periapical lesion using triple antibiotic paste, calcium hydroxide and intracanal aspiration technique. Endodontology [serial online] 2017 [cited 2022 May 22];29:78-81. Available from: https://www.endodontologyonweb.org/text.asp?2017/29/1/78/206994

  Introduction Top

Root canal system anatomy plays a significant role in endodontic success and failure. These systems contain branches that communicate with periodontal attachment apparatus furcally, laterally and often terminate apically into multiple portals of exit.

Endodontic failures can be attributable to inadequacies in cleaning, shaping, and obturation, iatrogenic events or re-infection of root canal system when the coronal seal is lost after completion of root canal treatment. Regardless of all the initial cause, the sum of all causes is leakage.[1]

Periapical lesions generally represent an inflammatory response to the invasion of the root canal system by micro-organisms and their by-products.[2] Most periapical lesions can be classified as dental granulomas, radicular cysts, or abscesses.[3],[4] There is clinical evidence that as the peri-apical lesions increase in size, the proportion of cyst increases. However, some large lesions have shown to be granulomas. The definitive diagnosis can be made only by a histological examination.[5]

The rationale for nonsurgical re-treatment is to remove the root canal space as a source of irritation to the attachment apparatus.

Various nonsurgical methods technique has been proposed to reduce the large size of the periapical lesion such as decompression technique [6] and aspiration through the root canal system.[7] Elimination of the periapical lesions has been a challenge for the clinician. The polymicrobial infection makes sterilization of the root canal system difficult.

Various medicaments have been widely used to help eliminate bacteria, reduce periapical inflammation, and induce healing. Calcium hydroxide (Ca(OH)2) has been commonly used as an intracanal medicament; however, it is not effective in cases with persistent endodontic infection.[8] Triple antibiotic been shown to be very effective in eliminating endodontic pathogens. It is a mixture of ciprofloxacin, metronidazole, and minocycline.[9]

This case report describes the nonsurgical retreatment of a very large periapical lesion by aspiration of fluid through the root canal space and subsequent use of triple antibiotic paste as an intracanal medicament.

  Case Report Top

A 38-year-old male patient came with severe pain and swelling in lower right back tooth region. A thorough medical and dental history was taken. Medical history was noncontributory. The patient gave a history of dental treatment in mandibular posterior teeth 15 years back. He had undergone root canal treatment in 46.

Intraoral examination revealed a diffuse swelling in buccal mucosa in relation to right mandibular posterior teeth. Crowns were placed in 46 and 47. 46 was extremely tender to percussion and 47 was asymptomatic. On radiographic examination, poorly obturated 46 was revealed. 47 did not show root canal treatment. There was a very large radiolucent lesion involving apices of 46 and 47 [Figure 1].
Figure 1: Preoperative orthopantomograph

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A provisional diagnosis of the periapical cyst was established. Nonsurgical endodontic retreatment was planned to treat the involved teeth as the patient was unwilling to go for surgery.

Following removal of crowns from 46 and 47, amalgam restorations were revealed. 47 had a large Class II restoration. On pulp testing, 47 gave delayed response. After careful examination, root canal treatment was planned for 47 and retreatment for 46. Under local anesthesia, access cavities were prepared in 46 and 47 after removal of amalgam restorations. Once the gutta-percha was removed from 46 using H-files, there was drainage of large amount of straw-colored fluid into the pulp chamber providing immediate relief to patient from pain and swelling. The fluid was aspirated using 5 ml syringe. Aspirated fluid was sent for histopathological examination. When the drainage ceased, the root canal preparation was performed using rotary protaper files till No. F2. 47 was also prepared till F2, there was no drainage of fluid from 47. Apical patency was maintained throughout the procedure in 46. During preparation, the canals were irrigated with 3% hypochlorite and saline. After preparation Ca(OH)2 powder mixed with saline was placed as an intra-canal medicament into 46 and 47 and access cavities sealed with Cavit-G. The patient was prescribed analgesics and antibiotics for 5 days and recalled after 1 week.

The patient reported back in 2 days with recurrence of pain and swelling. After removal of intracanal dressing from 46, there was drainage of a large amount of fluid from the pulp chamber. The fluid was aspirated using 5 ml syringe and pulp chamber left open till the drainage ceased. Again, the canals were thoroughly irrigated and Ca(OH)2 placed for 1 week. 47 was asymptomatic.

At next appointment, there was slight relief in pain and swelling. On removal of temporary restoration, again there was massive fluid drainage. The fluid was again aspirated using syringe. This time, it was decided to use triple-antibiotic paste as intracanal medicament. The patient reported after 1 week with the absence of swelling and pain but a slight discomfort on palpation in buccal mucosa. There was no drainage of fluid from the pulp chamber. The intracanal dressing with triple-antibiotic paste repeated for the second time and recalled after 1 week. Since lesion was very big, it was decided to obturate 47 as it remained asymptomatic and to place metapex in 46 for 3 months to check the progress of healing. The procedure was completed, and patient recalled after 3 months. However, the patient turned up after 6 months. The clinical examination revealed 46 asymptomatic and radiograph showed signs of healing of lesion. The metapex was removed from 46 using K-files and copious amount of irrigation with 3% NaOCl and saline after which 46 was obturated [Figure 2] and [Figure 3].
Figure 2: Intraoral periapical after obturation

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Figure 3: Orthopantomograph after obturation

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The patient was recalled after 3 months intervals. Orthopantomographs (OPGs) were taken after 1 year [Figure 4] and 2 years [Figure 5] that revealed proper integrity of the periodontal tissues.
Figure 4: Orthopantomograph 1 year postoperative

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Figure 5: Orthopantomograph 2 years postoperative

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The histopathological report of the aspirated fluid revealed a lesion suggestive of inflammatory nature [Figure 6]. Few cholesterol crystals were also reported.
Figure 6: Histopathological picture

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  Discussion Top

The definitive diagnosis of the type of periapical lesion can only be made by a histological examination. A preliminary clinical diagnosis of a periapical cyst can be made if all of the following conditions exist:

  • Peri-apical lesion involves one or more teeth with necrotic pulp
  • Lesion is >200 mm 2 in size
  • A straw-colored fluid is produced on aspiration or on drainage through an access
  • The fluid contains cholesterol crystals.[10]

In the present case, OPG revealed a very large periapical lesion involving apices of 46 and 47 and extending toward the base of mandible [Figure 1]. The aspiration of the fluid sample was easy to carry out as 46 had adequate drainage through the root canal. On histological examination of fluid, cholesterol crystals were observed. On observing a radiographically large periapical lesion and a straw colored fluid containing cholesterol crystals, a presumptive diagnosis of a periapical cyst can be made. The treatment options available can be nonsurgical root canal treatment, apical surgery, decompression, and at last extraction.[11]

When treating the large periapical lesions by nonsurgical retreatment method, establishment of drainage is very important. In the present case after removal of gutta-percha, drainage was established by extending No. 25 K-file 1–2 mm beyond the apex in distal canal. The aspiration-drainage was performed using 25-gauge needle inserting into the distal canal of 46. The procedure was performed for three consecutive appointments due to persistent exudation. Bhaskar 1972 suggested that if instruments are extended 1 mm beyond the apical foramen, the inflammatory reaction that develops destroys the cyst lining and converts the lesion into granuloma. Once the causative factors are eliminated the granuloma heals spontaneously.[12]

In the past, it was considered that surgery was always required for the treatment of cyst. However nowadays, with the development of newer instruments, techniques, and materials, it is possible to stimulate the immunological system to induce repair, even in the cystic lesion, if the lesion is effectively evacuated off the inflammatory exudates and the microbial load is reduced with an effective intra-canal medicament.[13]

The first intra-canal medicament used in this case was Ca(OH)2. Ca(OH)2 has been widely used as an intra-canal medicament for disinfecting the root canals.[14] In the present case, swelling and pain did not respond to Ca(OH)2 dressing. The reason might be bacteria associated with persistent apical infections have the ability to invade the dentinal tubules and buffer the high pH produced by Ca(OH)2.[15] The triple-antibiotic paste was used as an alternative to Ca(OH)2. In the present case, there was a drastic reduction in symptoms after use of triple antibiotic paste. The intracanal dressing of triple antibiotic paste was placed for 1 week. The swelling did not recur, and no pus discharge was observed. The dressing was again replaced for 1 week for proper disinfection of root canals.

Taking into account:

  • The disadvantage of triple antibiotic paste, tooth discoloration induced by minocycline [16]
  • Very large size of periapical lesion.

It was decided to place metapex into 46 and 47. Later on, observing the periapical healing on the radiograph, the root canal obturation was performed and observation continued for 24 months. OPGs were taken at 1 year [Figure 4] and 2 years [Figure 5] interval.

During the removal of the gutta percha filling, a small amount had extruded out of the apex; however, it did not interfere with the healing.

Radiographic findings in later OPGs, such as density change within the lesion, trabecular reformation and lamina dura formation confirmed healing associated with clinical findings of teeth being asymptomatic and soft tissue healthy.

  Conclusion Top

In this case report, root canal treatment proved successful in promoting the healing of a large periapical lesion. This confirms that even large periapical lesions can respond favorably to nonsurgical treatment and therefore, it must always be the first treatment of choice.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Ruddle CJ. Non-surgical endodontic retreatment. In: Cohen S., Burns RC, editors. Pathways of Pulp. 8th ed. St. Louis, Mosby 2002. p. 875-6.  Back to cited text no. 1
Nair PN. New perspectives on radicular cysts: Do they heal? Int Endod J 1998;31:155-60.  Back to cited text no. 2
Bhaskar SN. Oral surgery – Oral pathology conference No. 17, Walter Reed Army Medical Center. Periapical lesions – Types, incidence, and clinical features. Oral Surg Oral Med Oral Pathol 1966;21:657-71.  Back to cited text no. 3
Lalonde ER, Luebke RG. The frequency and distribution of periapical cysts and granulomas. An evaluation of 800 specimens. Oral Surg Oral Med Oral Pathol 1968;25:861-8.  Back to cited text no. 4
Natkin E, Oswald RJ, Carnes LI. The relationship of lesion size to diagnosis, incidence, and treatment of periapical cysts and granulomas. Oral Surg Oral Med Oral Pathol 1984;57:82-94.  Back to cited text no. 5
Martin SA. Conventional endodontic therapy of upper central incisor combined with cyst decompression: A case report. J Endod 2007;33:753-7.  Back to cited text no. 6
Hoen MM, LaBounty GL, Strittmatter EJ. Conservative treatment of persistent periradicular lesions using aspiration and irrigation. J Endod 1990;16:182-6.  Back to cited text no. 7
Leonardo MR, Hernandez ME, Silva LA, Tanomaru-Filho M. Effect of a calcium hydroxide-based root canal dressing on periapical repair in dogs: A histological study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:680-5.  Back to cited text no. 8
Ozan U, Er K. Endodontic treatment of a large cyst-like periradicular lesion using a combination of antibiotic drugs: A case report. J Endod 2005;31:898-900.  Back to cited text no. 9
Caliskan MK. Prognosis of large cyst-like periapical lesions following nonsurgical root canal treatment: A clinical review. Int Endod J 2004;37:408-16.  Back to cited text no. 10
Stavropoulou AF, Koidis PT. A systematic review of single crowns on endodontically treated teeth. J Dent 2007;35:761-7.  Back to cited text no. 11
Bhaskar SN. Nonsurgical resolution of radicular cysts. Oral Surg Oral Med Oral Pathol 1972;34:458-68.  Back to cited text no. 12
Dhillon JS, Amita, Saini SK, Bedi HS, Ratol SS, Gill B. Healing of a large periapical lesion using triple antibiotic paste and intracanal aspiration in nonsurgical endodontic retreatment. Indian J Dent 2014;5:161-5.  Back to cited text no. 13
  [Full text]  
Caliskan MK, Türkün M. Periapical repair and apical closure of a pulpless tooth using calcium hydroxide. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:683-7.  Back to cited text no. 14
Haapasalo HK, Sirén EK, Waltimo TM, Ørstavik D, Haapasalo MP. Inactivation of local root canal medicaments by dentine: An in vitro study. Int Endod J 2000;33:126-31.  Back to cited text no. 15
Kim JH, Kim Y, Shin SJ, Park JW, Jung IY. Tooth discoloration of immature permanent incisor associated with triple antibiotic therapy: A case report. J Endod 2010;36:1086-91.  Back to cited text no. 16


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]


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