Introduction- The aim of this study is to report the management of large periapical lesion using triple antibiotic paste as an alternative intra-canal medicament in non-surgical endodontic treatment. Case report- an 11 year old male patient with large periapical lesion in mandibular anterior region, treated using conservative non-surgical endodontic treatment. Calcium hydroxide-iodoform paste (Vitapex™) was used as an intracanal medicament, which did not lead to resolution of symptoms. Hence, triple antibiotic paste was used as an alternative intracanal medicament for 2 weeks. Obturation was completed with Nanohybrid composite as final restoration. Progressive healing was observed at subsequent follow up examinations, with almost complete resolution of the periapical lesion at 18 months. Conclusion- Endodontic cases resistant to routine intracanal medicaments should be treated with alternative medicaments which act against a wider spectrum of microorganisms, before opting for surgical procedures, especially while treating paediatric patients.

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Use of triple antibiotic paste as an intracanal
medicament in the non-surgical endodontic
treatment of a large periapical lesion: A case
report
Hemal Patel1
, Navneet Grewal2
, Sangeeta Aggarwal3
Department of Pedodontics and Preventive Dentistry, Government Dental College and Hospital
Department of Pedodontics and Preventive Dentistry, MDS student (Hemal Patel)
Department of Pedodontics and Preventive Dentistry, Prof. & HOD (Navneet Grewal)
Medical officer (Sangeeta Aggarwal)
Amritsar, India
ABSTRACT
Introduction- The aim of this study is to
report the management of large periapical
lesion using triple antibiotic paste as an
alternative intra-canal medicament in non-
surgical endodontic treatment.
Case report- an 11 year old male patient
with large periapical lesion in mandibular
anterior region, treated using conservative
non-surgical endodontic treatment.
Calcium hydroxide-iodoform paste
(Vitapex™) was used as an intracanal
medicament, which did not lead to
resolution of symptoms. Hence, triple
antibiotic paste was used as an alternative
intracanal medicament for 2 weeks.
Obturation was completed with
Nanohybrid composite as final restoration.
Progressive healing was observed at
subsequent follow up examinations, with
almost complete resolution of the
periapical lesion at 18 months.
Conclusion- Endodontic cases resistant to
routine intracanal medicaments should be
treated with alternative medicaments
which act against a wider spectrum of
microorganisms, before opting for surgical
procedures, especially while treating
paediatric patients.
Keywords- Antibiotics, Calcium
Hydroxide, Healing, Periapical Diseases,
Root Canal Medicaments.
INTRODUCTION
Pulp necrosis resulting from infection of
the root canals, initiates an inflammatory
response in the periapical region due to
ingress of the toxic by-products of
microorganisms. Failure to eradicate the
microbial load from the necrotic root
canals lead to the development of
periapical lesions that increase in size by a
variety of mechanisms [1].
In the past, large periapical lesions were
managed by root canal treatment of
involved teeth followed by surgical
excision. However, awareness of the
complex root canal morphology and
development of newer techniques and

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intracanal medicaments has led to the
paradigm shift of treating such lesions
conservatively [2]. Calcium hydroxide
(Ca(OH)2), commonly used as an
intracanal medicament, however, is
ineffective against all members of the
endodontic microbiota [3]. Use of a
combination of antibiotics- a mixture of
ciprofloxacin, metronidazole and
minocycline is reported to be very
effective in healing of large cyst-like
periradicular lesions [4,5].
This case report describes successful
management of a large periapical lesion
resistant to Ca(OH)2, treated with triple
antibiotic paste (TAP) containing
ciprofloxacin/cefaclor/metronidazole as an
alternative intracanal medicament with 18
months follow up.
CASE REPORT
An 11 year old male patient with non-
contributory medical and dental history
reported to the department of Pedodontics
and Preventive Dentistry with the chief
complaint of mild spontaneous pain in
mandibular anterior region since two days.
History revealed blunt trauma to chin by
banging against the bed 2 years ago.
Intraoral examination revealed an Ellis
Class IV fracture in relation to mandibular
right central incisor and grade 1 mobility
(Fig. 1). There was no displacement
noticed in the anterior teeth. The adjacent
soft tissue were clinically normal with no
redness or swelling in the affected area
with marginal gingivitis of mandibular
anterior region. Mandibular right central
incisor, right lateral incisor and left central
incisor were sensitive to percussion and
palpation and failed to respond to thermal
or electrical pulp sensibility testing,
compared to adjacent normal teeth.
Preoperative radiograph, revealed a well-
defined large periapical radiolucency
involving mandibular right central incisor,
right lateral incisor and left central incisor,
measuring approximately 14x15mm (Fig.
2). A software named AutoCAD 2017
version 2.0 (Autodesk, Calofornia, USA)
was used for measurements by digitalizing
the scanned standardized radiographic
images taken using Endo-ray film holder
and Fixott-Everett Lead grid. Based on
clinical and radiographic features, non-
surgical endodontic treatment was planned
in all three teeth with possible need for
complementary surgical intervention at a
later stage, if required.
Access cavity was prepared after rubber
dam isolation under local anaesthesia with
2% lignocaine with 1: 2,00,000 adrenaline.
Root canal preparation was done using a
step-back technique until an apical
preparation size #30 was achieved. During
the instrumentation, normal saline and
2.5% sodium hypochlorite was used to
irrigate the canals copiously with a 25-
gauge needle after each instrument action.
Vitapex (NEO Dental Chemical Products
Co., LTD. Tokyo, Japan) was placed into
the canals with a Lentulo spiral instrument.
The access cavity was sealed with a
temporary filling material (Cavit).
Two weeks later, the teeth were
symptomatic with exudate through the root
canals. Triple antibiotic mixture containing
ciprofloxacin (Cifran 500 mg, Ranbaxy
Laboratories Ltd., India), cefaclor
(Distaclor 375 mg, Pharmalink
Pharmaceuticals Pvt. Ltd., India) and
metronidazole (Metrogyl 400 mg, J.B.
Chemicals and Pharmaceuticals Ltd.,
India) was freshly prepared. Macrogol and
propylene glycol (vehicle) and drug
mixture (1:1:1) were thoroughly mixed to
form TAP containing 100 μg/ml of each

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drug [4]. The canals were irrigated with
sterile normal saline and the paste was
condensed using sterile cotton pellets on
the orifices of root canals and pulpal floor
and the coronal access was sealed with
glass ionomer cement as an interim
restoration.
The patient was asymptomatic when re-
examined after two weeks. In the next
operative appointment, i.e. one month
from the start of treatment, teeth were re-
entered and triple antibiotic paste was
removed using irrigating solutions and the
teeth were obturated with gutta-percha
(Dentsply Maillefer, Switzerland) and
resin based sealer (Resino Seal) using
lateral condensation technique. The final
restoration was a Nanohybrid composite
using sandwich technique with glass
ionomer cement as base. Post-operative
periapical radiograph revealed a decrease
in the size of the radiolucency with
progressive healing at 3 months follow-up
visit (Figs. 3a & 3b). Radiographic
examination after a follow-up of 18
months revealed almost complete
resolution of the periapical lesion (Fig. 3c).
DISCUSSION
Periapical cyst has been reported to occur
at an incidence rate of 6-55% within
periapical lesions. Two distinct classes of
radicular cyst exists i.e. true apical cyst
and bay cyst, with the incidence of true
apical cyst being <10%. It is difficult to
differentially diagnose radiographically a
bay cyst from a true cyst or granuloma.
Thus, it is judicious to favour a
conservative approach in treatment
planning [1]. Complete and partial healing
of peripaical lesions following nonsurgical
therapy has been reported in 94.4% cases
[6].
Possible damage to adjacent vital teeth,
damage to anatomical structures in the
vicinity of the lesion, pain and discomfort
associated with surgical procedures can be
eliminated by non-surgical methods. Also,
patient cooperation is an important factor
when using a surgical approach in
managing periapical lesions.
Chemo-mechanical preparation along with
disinfection with intra-canal medicaments
is necessary in anatomically complex teeth
like the mandibular central incisors, with
45% displaying second canal [2]. The
ability to diffuse into dentinal tubules is a
desired characteristic of an antibacterial
agent. Oily vehicles are non-water-soluble
substances leading to lowest solubility and
diffusion of the paste within the tissues
affecting the ionic dissociation and
conductivity of Ca(OH)2 solutions [7].
Vitapex had significantly smaller zones of
inhibition in an agar diffusion comparison
of the antimicrobial effect of calcium
hydroxide at five different concentrations
[8]. Moreover, Haapasalo et al. showed in
an in-vitro experiment that dentin powder
had inhibitory effect on all endodontic
medicaments tested, consequentially,
decreasing the ability to eliminate the
bacteria [9]. Considering the limited
effectiveness of Ca(OH)2, local application
of antibiotics may be a more effective
mode for delivery in endodontics.
Therefore, as Vitapex™
failed to resolve
the symptoms, TAP was introduced into
the root canal as an intracanal medicament.
This concept of ‘Lesion Sterilization and
Tissue Repair (LSTR)’ was developed by
the Cariology Research Unit of the Niigata
University, School of Dentistry, which
employs the use of a combination of
antibiotics (metronidazole, ciprofloxacin,
and minocycline). Propylene glycol was
used as a vehicle carrying the drug, since it

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has efficient penetration into the dentin
[10]. Cefaclor with similar antibiotic
effectiveness, was used to prevent
discoloration induced by minocycline [4].
Lengthy application was avoided to
prevent development of resistant bacterial
strains, although some have reported its
use for one to three months [11].
The periapical lesion in the above case
report showed an estimated repair rate of
4.5 mm2
after 1 month. The rate of repair
was calculated by dividing the size
differential between the initial and follow-
up visits by the number of elapsed months.
The calculated rate was in accordance to
the average rate of repair of 4 mm2
after 1
month as reported by Fernandes et al. [12].
The rate of repair is directly related to age,
with the highest rate in patients 19 years of
age or younger (58.8%) [13].
As reported by Orstavik, approximately
half of the lesions heal completely in one
year and the majority (86%) heal within
two years post-treatment. Radiographic
signs of definite, but incomplete, healing
were apparent at one year post-treatment in
89% of lesions that subsequently fully
healed indicating that observation of
healing on a radiograph is a strong
predictor of total healing [14].
Radiographic signs such as density change
within the lesion, trabecular reformation
and lamina dura formation confirmed
healing in the present case, particularly
when associated with the clinical finding
that the tooth was asymptomatic and the
surrounding soft tissue was healthy.
CONCLUSION
Patient co-operation, fear and anxiety and
damage to developing permanent teeth are
important factors to be considered when
using surgical approach in paediatric
patients, thus conservative approach
should be considered before opting for
invasive surgical procedures.
Conflict of interest: The authors declare
that they have no conflict of interest.
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Figure 1. Preoperative intraoral examination showing Ellis Class IV fracture in 41.

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Figure 2. Preoperative radiograph demonstrating large periapical lesion measuring 14x15mm
associated with osseous extension involving apices of teeth 41, 42 and 31.
a) b) c)
Figure 3. (a) Post-operative radiograph demonstrating a decrease in the size of the periapical
radiolucency to 12 x 13mm in diameter. (b) Radiograph after 3 months demonstrating a
decrease in size of the periapical radiolucency to 8 x 9mm. (c) Radiograph after follow-up of
18 months, showing almost complete resolution of the periapical lesion.