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5-2014

Treatment of Abscessed Primary Molars Utilizing Lesion

Sterilization and Tissue Repair: Literature Review and Report of
Three Cases
David Burrus

Lori Barbeau
Children's Hospital of Wisconsin

Brian D. Hodgson
Marquette University, brian.hodgson@marquette.edu

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Part of the Dentistry Commons

Recommended Citation
Burrus, David; Barbeau, Lori; and Hodgson, Brian D., "Treatment of Abscessed Primary Molars Utilizing
Lesion Sterilization and Tissue Repair: Literature Review and Report of Three Cases" (2014). School of
Dentistry Faculty Research and Publications. 49.
https://epublications.marquette.edu/dentistry_fac/49
 ..
PEDI ATRIC DEN TISTRY V 36 I NO 3 M AY JU N 14

Treatment of Abscessed Primary Molars Utilizing Lesion Sterilization and Tissue Repair:
Literature Review and Report of Th ree Cases
David Burrus, DDS1 • Lori Barbeau, DDS2 • Brian Hodgson, DDS'

Abstract: Purpose: The purpose of this report was to review an emerging alternative treatment to pulpectomies and extractions for nonvital primary
teeth called lesion sterilization and tissue repair (LSTR) and provide the results of three clinical case applications. LSTR is a noninstrumentotion endodont
treatment that involves a triantibiotic mixture in a propylene glycol vehicle, which is used to disinfect root canol systems. This concept ~s develope
by the coriology research unit of the School of Dentistry. Niigata University. Niigata, Niigata Prefecture, japan. This article reviews the development G,
the technique, clinical procedures required for the technique, three clinical applications and radiographic documentation and follow-up, and a sho!
literature review of the current evidence supporting its application in clinical practice. (Pediatr Dent 2014;36:240-4) Received january 18, 2013 I La"
Revision june 5, 20/3 I Accepted june 19. 2013

KEYWORDS: DECIDUOUS TOOTH, NONV1TAl TOOTH. 3-MIX OINTMENT

Pediatric d enti sts are often fa ce d with th e m anage ment of
primary teeth that show sig ns of irrevers ible pulpitis or ne-
cros is. l Traditionally accepted treatment options for teeth with
infec ted roOt canal s/ pe riradi cular ti ss ue s are pulpectomy or
extraction. 1 Although extraction with space maimenance re-
mains a' viable treatment option, a successfull y restored primary
toorh is a far superior space maintainer than an appliance. 2,J
With pulpecromy treatm ent, necrotic o r abscessed primary
teeth have acceptable o urco m es approximately 85 percent of
th e time", but the te chniqu e ca n be ver y challenging given
the continu ous changes in the apical for ame n as a res ult of
ph ys iolog ic and path o logic resorption. Overinstrumentation
may injure the developing per mane nt tOoth bud.4.{i Sjogren et
aL found that, eve n after thorough mechani ca l and chemical
cleanin g of the canals, up to 40 percent of the canals may still
exhibit positive bacterial culturesJ - radio lucencies on radiographs, 52 had gingival swell ings, an ,'
These findings led researchers to inves ti ga te antibiotic
options for disinfecting root ca nal sys tems. As a result. the
cariol ogy resea rch unit of the Sc hool of Dentistry, Niigata
University, Niigata, Ni igata Prefec ture, Japan , develo ped the
co ncep t of lesion ste rilization and tissue repair (LSTR) therapy,
which is a nonin str um entatio n endodontic trea tm ent that
employs a mixture of antibacterial drugs in a propylene glycol
vehicle for the di sinfec tion of dentinal, pulpal. and periapical
lesions. If lesions are co mpletely disinfected, tissue repai r ca n
be expected. S
Bacterial co nstitu en ts of intraoral pathology have bee n
analyzed under strict anaerobic co nditions to understand the
targe t bacteria in LSTR endodontic treatment. S- 17 M etroni - '
dazo le was chose n initially for its wide bacter icidal spectrum
aga inst anaerobes commo nly found in o ral s ites. Howeve r,
eve n high concentrations of metro nidazol e could nOt eliminate
all the bacteria in the lesio ns. Therefore, two additional antibac-
terial drugs. ci proAoxacin and minocycline, were added in an
! Dr. Burrus is a pedia t ric dentist in private practice. Bend. Ore. ; l Dr. Barbeau is
effort to full y eradicate all of the bacteria. 18 Wind ley et ,11
noted that this combination of antibiotics would also d ecreas
the likelihood of the development of resistant bacterial s train s. l ~
Ex tensive in vitro and in si tu studies have shown tha t th
mi xture (3-Mix) of metronidazo le, ciprofloxacin, and mi no
cyeli ne is effective against oral bacteria, including those in t h l
endodontic lesio ns of primary teeth .8•13 ,19"J l Furthermore, th i
same antibiotic combination has been successful in perman en
tOoth disin fection and regenerative endodontic treatments. J2 -:I
Cruz et aL showed that the addition of propylene glycol an<"
macrogol (M P) as a carrier vehicle greatly improved the pene
tration ability of these medications. 35
Takushige et ai. ' clinically applied this LSTR theory in
trial involving 87 infected primary molars in 56 four to 18-
yea r-o lds. Fifty-four of the infected primary molars showe{
22 had fistulas. Their resu lts showed that 83 of th e 87 case
d emonstrated healing after o ne application of th e 3-Mix- M ~
Dental Paste. In those 83 cases, pain, swelling, and fistulas re-
so lved within one week of therapy. The four nonrespondi n:
teeth were retreated due to continued swellin g, and, co nst'
quenrly, all symproms reso lved . The mean function tim e 0
the treated primary teech in this study was 680 d ays. Succes ~
was d escribed as follows: no mobil ity, functional tooth, an t"
no pain or infection.
The purpose of this literature review and report of caSt'"
was to info rm dental practitioners of lesion sterilizatio n a n (~
tissue repai r therapy for nonvital pulp therapy in primary teeth .
Methods
Modification ofTakushige et al,'s techniqu e. A compoun d -
in g ph arm acist was en listed to revi ew and suggest an alte r-
native antibiotic to min ocycline. because minocycline has been
sho wn in (he permanem delllilioll to ca u ~e black staini ng
and discoloration of the tooth and gum s. 22 .2J .J6 C lindamyci n
was chose n due to its effectiveness against streptococci and
anaerobes Y Iodoform was also added to th e 3·Mix-MP d ental

medical director, Pediatric Dental m idency program. Ch ildren's Hospitol of Wisconsin; paste (3-Mix-MP-R), makin g it radiopaque and allowin g
and JDr. Hodgson is a n associate prof essor, Division of Pediatric Dentistry. Marquette radiogra phic confirmation of proper pas te placement. As
Un ivers itr &hool ofOentislry. both in Milwaukee. WlS .. USA. prov ided by the compounding pharmacist, th e 3-Mix-M P-R
Co rrespond with Dr. Burrus at davidburrusdds@gma ii. com is suppli ed as a two-part syste m. The dry powder co mponen t

240 TRE ATMEN T OF ABSCESS ED PRIMARY ~ OlA R S


contains mecronidazole US P, ciprofloxacin H e l US P. c1i nd a-
myc in HC I USP, and iodoform (rriiodomerhane) US P. The
liquid co mpo nent comains polyethylene glycol 300 and macro-
gol. Th e two components are mixed immedi ately prior to use.
Clinical procedure of LSTR using 3-Mix-MP-R. The
foll owin g is a desc ription of the clinical proced ure of LSTR
a nd fin al restoradon performed on each of the thue cases pre-
senred here. A d enr~ 1 ex~ mination with app ropriate rad iographs
was com pleted , an d a clinical diagnosis was deter min ed. After
di scuss ion of the ri s ks, benefits. an d a lternatives, info rm ed
conse nt was obtained. The teeth were anes thetized and isolated
with a rubber dam and pu lpal access was ob ta ined . The necro-
tic tissues were removed from the co ronal portion of the pulp
chamber, and th e canal orifices enlarged wi th a ro und bur
(on e mm di ameter and tWO mm depth) {Q crea te medi ca tion
receptacl es. T he walls of th e chamber were clea nsed with 35
p ercent phosphoric acid (Ulna Etch, Ultraden t, South Jordan,
Utah, USA), rinsed , and dried usi ng an air and water syrin ge.
Phosphoric acid was llsed for its bacteri cidal properties. Any re-
fracto ry hemorrhage was cO lUrolied by applyi ng a cotto n peller
soaked in 10 perce nt NaOCI (Pure Bright. KIK Internatio nal
Inc. Concord, Ontario. Canada) until hemostasis was ach ieved .
The 3-M ix-MP- R was placed in the medi cation receptacles
and over rh e pul pa l Aoor. The access opening was sealed with
a glass ionom er cement ( Fugi IX, GC Ame ri ca, Alsip, IlL ,
USA), and th e rooth was restored with a stainl ess steel crown
[(SSC); 3M ESPE Unirek Srainless Sreel C rowns, Sr, Paul,
Minn ., USA], rhe most effective long-term resroratio n for pulp-
ally treat ed prim ary teeth . l The additiona l use of sys te mi c
antib iotics was considered jf significant ves tibular swellin g was
noted or if a large furca tion rad iolucency was present.
Case descriptions
Case 1. A seven-yea r-old Ca ucasian male, wirh a medi cal histo ry
positi ve for neurofibromatosis type I and a stable optic glioma,
p resen ted to the pedi atri c dental residency cl inic at the C hil -
dren's H ospital of Wisconsin, Milwaukee, \'(lis, fo r the evalua-
t ion and treatment of a mandibular right posterior swell ing in
associatio n with his primary mandibular ri ght seco nd molar
and a one-week histo ry of pain. Based o n the parenr's descrip-
tion of th e swelling via a phone interview the week prior, the
p ati ent was p rescribed a cou rse of syste mi c ant ibiotics. T he
Figure h .. Inilial periapical radiogra ph show- Figure lb. Eleven months posl-op. a periapical
ing a furcal ion rad iol ucency. radiograph showed continued stability and
furcal ion bone he:!.ling.
..
PEDIATRIC DENTISTRY V 36 I NO 3 MAY I JUN 14
demal histo ry revealed that the patient had previously received
opera tive treatment on thi s too th by a co mmu nity pediatric
dentist. .
C lin ical examination revealed a vestibu lar abscess adjacent
to the prima ry mandibular right second molar. Sensiti vity was
documented with percussion, and the rooth had grea ter than
physiologic mo bility. On palpation, there was pai n and ex udate.
A peri apical radiograph revea led bo ne al tera tio ns and a fur-
catio n radio lucency of the primary man dibular right second
molar (Figure 1a). An existing co mpos ite res in restoration was
in place and in dose proximity to the mes ial pulp horn. Consi-
deri ng rhe hi story, sympto ms, and clinica l and radiographic
fin din gs, the primary mandibular right second molar was di-
ag nosed with a ne croti c pulp and ac ute furcal dentoalveo lar
abscess.
T he clinical proced ure of LSTR using 3-Mix-MP-R was
co mpleted. The pulp chamber contai ned on ly necroric ti ss ue,
and no hemorrhage was present. The patient was asymptomatic
when he return ed for his four-week fo ll ow- up. Clinical evalu-
at io n showed compl ete soft tissue healing of the abscess. The
roo th had normal mobilicy and was nega tive to percuss ion and
palpatio n. In creased furca ti o n radiodensity and trabeculation
were detected on a radiograph.
T he pati ent was sy mptOm -free when he returned four
months late r and again for examination of the primary mandi-
bular right seco nd molar 11 months post-LSTR. Radi ographic
findings demonstrated co ntinued stability and furcatio n bone
heali ng (Figure I b),
Case 2. A six-year-old African -American femal e presented
to the C hild ren's Hospital of Wis consin pedi atric dental re-
sidency program for an emerge ncy pain assess ment appoint-
ment with th e chief co mpl aint o f a toothache o n th e lower
right sid e for one week. The pariem had neve;:r rel.:t:ivt:J dt:IHal
care. The pat ient reported spomaneous waking pain and elicited
pain wi th eating and drinking. No significant medical or family
histo ry was repo rted, and she otherwise appeared heruthy. '
A clinical examination revealed a large, purulent, vestibular
abscess adjace nt to the primary mandibular right first molar.
The tooth exhibited pathologic mob ili cy and was depressi ble to
occl usal forces. The patient was hi gh ly sensitive to percussion,
a nd on pa lpa ti o n th ere was pain and ex ud ate. A p eri apical
radiog raph revealed distal-occlusal ca ri es extend ing into the
Figu re 2a. Initi:!.1 pe riapical radiograph showed
dental caries extend ing 10 the d is tal pulp horn
and a furcadon rad iol ucency.
TREATMENT OF ABSCESSED PRIMARY MOLARS 241
PEDIATRIC DE NTISTRY V 36 NO 3 MAY JUN 14

Case 3. A four-year-o ld Hispani c female without a sign i-

Fig u re 2b. Twelve
mo mhs poSt-op. pe-
ri~pi(al ud iographs
revealed bone stabi-
l ity. ca lcific mC'u·
mo rph osis of the
TOOl C1Inal space. and
norm ~ l ph ysiologic
rOOt reso rption by
t he pcrm:tnC' nt m ~ n ­
d ib u la r right fi rs t
prC'molar.
di s tal pulp horn of th e primary mandibular right fi rst mola r
(F igu re 2a). A furcati o n radi ol ucency and loss of lamina dura
were noted . The tooth was d iagnosed with necroti c pulp and
an ac ute apica l d entoalveo lar abscess. The pat ient was pre-
sc rib ed sys temi c antibi o ti cs and scheduled fo r a treatment
appoincmenr.
Following a o ne-week course of a sys temic amibiodc, the
clinical procedure of LSTR using 3-Mi x-MP-R was completed .
Th e pulp chamber was found to co ntain on ly dr y nec rotic
(iss ue. A( th e th ree- mo nth follow-up appo intment, no sy mp-
toms were reported. On c1inicaJ exam , the primary mandibular
ri g ht first molar was negat ive to percuss io n and palp ation
and had phYS iologic mobility. The soft tiss ue showed co mple te
healin g of th e abscess. A periapical radiog raph was ta ken and
de mo nstrated in creased d epos ition of bone in th e furcafio n
area and the rerum of the lamina dura.
Th e pati ent was asy mp co mati c 12 month s pos t- LSTR
and showed nothing remarkable during a clinical exam. Rad io-
graphic findings revealed bone stability, calcific metamorphosis
of th e rOO t ca na l s pace, and no rmal ph ys io logic rOOt re-
sorp t io n by th e perm a nent mandi b ul ar ri ght first p remolar
(Figure 2b).
ficant medical and famH y history was referred to the C hildren's
H ospi tal of Wisconsi n's ped iatri c dental res idency program fo r
evaluation and dental care. The patient reponed severe roo th
pa in on her lower ri ght sid e. On clinical exam inat ion , a large
cario us les io n was no ted o n th e occlusal surface of th e pri-
mary mandibular right second molar along with a buccal ves
tibular abscess . The tooth had no rm al phys io logic mobili ry
bu t was pos iti ve to percuss ion a nd palp ari o n. A lower ri gh e
peri apical radiograph revealed a fu rcat ion radiolucency ove r-
lying the succedan eous tooth bud (Fig ure 3a) . Based on ciw
clinical and radiographic findin gs, th e tooth was diagno sed
wirh a necroti c pulp / irreversible pulpjtis w ith acute api ca J
dentoalveolar infection.
During th e clinical procedure, nec rotic ti ss ue was fou ne
in th e mesial canal and hemorrhage was present in th e disral
ca nal. Necrotic ti ss ue was re m oved a nd th e chamb er wa
clea nsed wi th 3 5 percent phos phoric acid. Hemos tas is in th·
di stal canal was achieved by applyin g press ure wi th a corto r
pellet sa turated with 10 perce nt NaOC L The remai nder of th
pro tocol was then complered .
The pa tient was asy mptom a ti c wh en she rerurn ed for
o ne- monrh follow- up visit. C lin ical evalu ati o n showe d so l
dssue healin g of the abscess. The tooth co ntinued to have ph}
siologic mobi li ty and res ponded no rmall y to palpati o n an l
percuss ion.
At th e four- month and l O-m o nth visi t pos t-LSTR, th t
patient continued to be asy mpto mat ic. Th e soft ti ss ue re
main ed healthy. Periapical radiographs d emon strated increase . .
trabeculation and radi od ensity in th e furcation are a. Sli gh,
internal resorp tion of th e di stal cana l was noted at rhe fo ur-
month follow-up ; however, the radiog raph from th e lO-mon ti
fo llow-up showed reversal of th is intern al resorption. (Figure 3\-
and 3c).
Discussion
To date, there have been limited evide nce- based clinical srud ie:-.
of 3-Mix-MP-R employed in LSTR th era py. The techniq u,"
have varied sli ghtl y, and th e res ults have bee n incon sisten t
Nakorn chai et al. J8 compared the clinical and radiographic sue
cess of 3-M ix- MP a nd Vi ta pex (pre m ixed calcium hydroxid ·

Figure 3. (a) Inili ~1 pC'riapkal radiograph showing occlusal cariC's extendi ng imo thC' pulp chambC' r with a furcuion radioluctncy ovC'rlying t he permanent too t h bud .
(b) Fou r months pOSt ·op. the periapical radiograph dC' mo nst ra ted increa!C'd trabC'cula tion in t hC' furcation a re~. Slight internal resorptio n nOted in t hC' di na l canal.
(c) Ten months post-o p. radiographic findings demonstrated s t~bility of the inter-radic ular and periapical struc tu rC's and ~ l1 orm~1 periodonral lig~ ment 5p~CC' . Internal
resorp tion in thC' dinal canal has resolved.

242 TREATMENT OF ABSCESSED PRIMARY MOLARS


and iodofo rm root ca nal medicam ent; Neo D enral Interna -
tional, Federal Way, Wash ., USA) for roOt canal treatment on
pulpally involved primary mola rs usin g 2.5 percenr NaO C I as
a cleans in g age nr. No sign ificanr d ifferences were found clini-
call y or radiographically between th e twO groups at 12 month s,
and they concluded that both 3-Mi x-MP and Vitapex can be
used as root can al treatme nt age nts in pulpall y involved pri-
mary teeth. They su m mar ized that th e simple and shorr pro-
cedures of 3-Mix-M P may be sup erior to other mate ri als used
for root canal treat m en t in ch ild ren a nd more ad vantageous
in teeth with p reoperative root reso rption.
Prabhakar er al. 19 evaluated t he success of 3-M ix-M P
LSTR in two g roups usin g no bac te ri cidal cleansing agent,
only salin e. In th e fi rst gro up , onty the necrotic coro nal pulp
was removed. whi ch was simila r to the procedure perfo rm ed
by Takushige et al. tI In the seco nd group , both the necrotic
co ronal and accessib le radicula r pulp (issue were exti rp ated .
Both groups were treated with the 3-M ix- MP Dental Paste and
restored with co mposite resin. T hey fo und that both groups
s howed considerable clinical and radiographic success. Statis-
tical Significance was fo und between the [\110 groups concern ing
rad iograph ic evaluation. -The seco nd group showed mo re bo ne
regeneration , less static bone mor phology, and no increase in
lesio n size when co mpared to (he first gro up. This find ing can
likel y be attrib uted to the fact chat the seco nd group had more
infected tiss ue removed with (he ext ir pat io n of the radicul ar
pu lp, possibly increasing the chances for success.
Trairarvorakul er .l 40 evaluated th e success rates of 3-M ix-
MP LSTR t reatments in primary mandibular molars using
ethylenediami ne tetraacetic acid (CU- Denc , Ba ngkok, Thailand)
as th e cl eanSing agent at 24 to 27 month s post-operation.
They found sati sfactOry clin ical success with LSTR but low
success rates based on rad iographic eva luation, which may be
attrib uted to their radiographic criteria. Nakorn chaio et al. JtI
and Prabhakar et al. ~9 defi ned rad iograp hic success as a decrease
in the rad iol ucency compared to the preo perative statu s or an
un changed radiolu cent State in a static rel ation ship; however,
Tra iratvoraku l cr al. 40 categorized stat ic cases that showed no
change at six month s inro a "fu rther obse rva tion group" and
co nsidered them as failures with unc han ged pathology at the
12-momh follow-up.
Agarwa l et al. 41 evaluated (h e success of 3-Mix-MP LSTR,
Pulpotec (a m ixture of polyoxymethylene, iodoform , dexam-
ethasone ace tate, formalde hyde, phenol, and guaiacol, Produits
D enraires SA, Vevey, Switzerl and) pulpotom y, and trad itiona l
z in c ox ide euge nol p ulpecto my of prim ary molars wit h vita l
ca ri ous ex pos ure tha t showed no clin ical or rad iographic signs
of pathology. They foun d th at 3-Mix- MP using fi ve perce m
NaO C I immersed in co[[on to co ntro l rhe hemorrhage had
significan tly lower success rates with vital pu lps. This study did
not add ress necrotic pri mary molars.
The three cases completed lIsing th e C hildren's H os pital
of Wisco ns in's 3-M ix-MP-R appear promisin g and support the
cl in ical find ings of Takushige et a!. 8 It was found th at LSTR
therapy provided an exce ll enc altern ati ve ro pulpectomi es and
extractions fo r nonvi tal pri mary teeth. Howevet, ca ution sho uld
be taken when dent is ts adm inister local or sys temi c medi ca-
tions. Takushi ge et al. 8 repo rted no side effects with the delivery
of copical ant ibiotics, bur LST R should be avoi ded if a child
is sensitive or all erg ic to any of th e ant ibiotics or chem ical s
invo lved.
If clinical sympwOl s d o nor improve o r reappear, ret reat-
ment is warra nted w ith spec ial attention to a fresh preparation
of 3-Mix-MP- R and a tigh t seal that prevents m icro leakage.
PEDIATRIC DENTISTRY Y 36 NO 3 MAY JUN 14
To the bes t of our knowledge. no re search has been com -
pl eted co compare t he effec ti veness of the original and new
formu lations, but theoretica l em pir ical eviden ce suggests th at
th e substitution of c1 ind amyc in for the minocycline wou ld
be simila rl y effective as th e o ri g inal for mul a studi ed by
Takushige et al. s
Given the positive res ults of the th ree com pleted cases,
furth er controlled clinical trials are warranted with long-ter m
fo ll ow-up to assess th e exfo li ation of the treated teeth and to
determ ine the implications, if an y, to th e succedaneo us reeth.
Additiona lly, for LSTR to become a rel iable treat ment o ption,
th e selecti o n c riteria an d protocol need to be continu all y re-
defined and updated to yield the best predictable outco mes.
C lini cal cases of LSTR therapy show exci dn g and pro-
mi sing resul ts for the fut ure of pediatric dentistry. LSTR ther-
apy is particularly favotab le for you ng patients because it can
potentially avoid ex tractio n and is rel at ively no n trau ma ti c to
the parient. In addition, the restored tooth is more stable in the
dental arch rhan a space maintainer and (h e procedure time is
shortened. W ith continued research an d co nsistenr favorab le
results. LSTR certainl y has the potential to be a revo lutionary
thera py for th e treatm ent of abscessed primary molars.
Acknowledgment
The aut hors wis h to (hank th e compound ing p harm ac ist,
Jacob O lson , PharmD, presidem and CEO of Skywalk Phar-
macy and Carli DiGioia, DMD. attend in g pediatric dentist,
both at (he C hildren's Hospi tal of Wisco nsin, for their guid ance
in th e preparation of this manuscript. This paper is dedicated
to the memory of Dr. Charl es POS t, DDS, devoted direcco r of
C hildren's Hospital of Wisconsin pediarric dental resid ency
program , mentor, and friend.
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