RU2618424C1 - Dental intra-root paste for stimulation of reparative processes in periapical tissues in case of destructive forms of chronic periodontitis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to therapeutic dentistry. Dental paste for temporary filling of root canals of teeth in treatment of destructive forms of chronic periodontitis contains, wt %: calcium hydroxide - 40.0, ciprofloxacin - 10.0, minocycline - 10.0, metronidazole - 10.0, 2% solution of chlorhexidine bigluconate - the remaining part.

EFFECT: invention makes it possible to achieve optimisation of osteogenesis process in periapical tissues by elimination of pathogenic microflora from root canal system, produce efficient impact on main pathogenic mechanisms of development of destructive forms of chronic periodontitis in short term (14-21 days), and obtain stable therapeutic effect.

4 tbl, 2 ex, 4 dwg

Description

The present invention relates to medicine, namely to therapeutic dentistry, and can be used in the treatment of destructive forms of chronic periodontitis.

The problem of destructive forms of chronic periodontitis remains very urgent for dentists, since a long inflammatory process in the field of periapical tissues causes the development of acute inflammatory processes in the maxillofacial region, a focus of chronic infection that causes somatic diseases. Periodontal disease is a major medical and social problem due to the risk of losing permanent teeth and a deterioration in the quality of life. Destructive lesions in the periodontium are an indication for tooth extraction in 50% of patients under the age of 35 years and in 80% of cases in older people [1].

Modern researchers state that a long asymptomatic period of the formation of destructive lesions in the periodontium significantly changes the properties of the surrounding tissues, and the addition of a microbial factor causes tooth extraction and odontogenic complications. The greatest danger to humans is the destructive forms of chronic periodontitis, which are foci of odontogenic infection. Chronic granulating and granulomatous periodontitis are accompanied by destructive changes in the bone of the alveolar process, and the decay products of tissue proteins (biogenic amines) pose a great danger to the body, causing chronic intoxication and sensitization [2].

It was found that the destructive focus in the periodontium is a source of chronic infection. In case of impaired function of the immune system, the prolonged existence of a focus of chronic infection leads to a decrease in the level of nonspecific resistance of the organism and, as a result, to the development and complication of the course of focal diseases [3].

Numerous studies by domestic and foreign authors have established that the main source of bacterial colonization in periodontitis is in the root canal system. The results of microbiological studies showed that the root canals of teeth in patients with chronic forms of apical periodontitis were seeded in 100% of cases, 1074 strains were isolated. Microorganisms in the root canal system exist in the form of biofilms: with destructive forms of chronic periodontitis (granulating, granulomatous), their film-forming ability is 6.6 times higher than with compensated fibrous form [4].

The data of numerous studies confirm that the cause of the development and development of periodontal diseases is the persistence of periodontopathogenic microflora: mainly representatives of the obligate and facultative anaerobic flora. In the group of patients with chronic apical periodontitis, Streptococcus was isolated in 63.3% of the examined, and Enterococcus faecalis and Candida fungi were isolated in 30% and 23.3%, respectively. In the group of patients with periapical abscess, representatives of the group of facultative anaerobic streptococci dominated, which stood out in 61.2% of cases. It has been established that among the causes of inflammation of the periapical tissues, the main place is given to microorganisms and their toxins coming from the root canals to the periodontium. The morphological process in chronic granulating periodontitis is characterized by the growth of granulation tissue, causing intense resorption of tooth hard tissues (cement, dentin), cortical plate of the wall of the dental alveoli and spongy bone tissue. Thus, as a focus of infection and intoxication, periodontitis is a potential danger to the body. Modern literature data indicate that infection of periapical foci can cause odontogenic inflammatory processes of the maxillofacial region, sensitize the body and contribute to the development of diseases of the internal organs and systems of the human body, and also leads to a protracted and complicated course of acute and chronic processes [5].

This explains the relevance of the search for new methods and drugs to increase the effectiveness of treatment of acute apical periodontitis in the initial treatment of the patient. The question of optimizing the choice of methods and endodontic antibacterial agents for the most effective treatment of acute forms of periodontitis also remains unresolved.

A known method for the treatment of chronic periodontitis, including the preparation of the carious cavity, root canal treatment, introducing into the channel a mixture of preparations containing zinc oxide, pyramidone and retabolil (1: 1: 1) and filling the tooth with a permanent filling (AS No. 1409273, USSR MKI ⁴ A 6/03, 1989).

However, this mixture has the following disadvantages: the paste does not have an antiseptic effect, has a low osteogenesis-stimulating effect and, therefore, the rehabilitation periods of the tooth are lengthened, the infectious focus remains, which in the future can provoke new complications.

A known method of treating periodontitis, in which, after endodontic and drug treatment of the root canal, a mixture of an antibiotic (Cefazolin Sodium), an immunomodulating drug Viferon and a corticosteroid Dexamethasone in a ratio of 1: 1: 0.1 in a dose of 0.5-1 g, removing the mixture beyond the apical opening for 10-15 days (RF patent No. 2216303).

The disadvantage of using these drugs is the long duration of treatment. In addition, the use of a hormonal (glucocorticosteroid) drug can cause a violation of reparative processes in the periodontium due to the immunosuppressive effect.

The closest in essence to the claimed and accepted for the closest analogue is the intracanal treatment of apical periodontitis using pastes based on calcium hydroxide [7]. The method consists in introducing into the root canals of periodontitis teeth medical pastes containing calcium hydroxide - a substance with a non-specific antiseptic effect, attributable to the high pH value.

Advantages of the closest analogue: Calcium hydroxide, miscible with water or saline, is slightly soluble and has a ph of 12.5. Calcium hydroxide has an antimicrobial, healing and osteoblastic effect. Calcium hydroxide triggers the mechanisms of cementoblast integration, stimulating the formation of an “apical plug”, which further serves as a natural biological barrier from periodontal tissues during root canal obstruction.

The disadvantage of the closest analogue is that the paste based on calcium hydroxide does not allow to fully influence the entire spectrum of microflora of apical periodontitis, for example enterococcus. Yeast fungi withstand a high alkaline environment and are able to survive in the root canals, and because of this, the paste based on calcium hydroxide does not provide sanitation of the foci of infection, often leading to a protracted, recurrent course of the disease.

The objective of the invention is to increase the effectiveness of antimicrobial treatment of the root canal system in the treatment of destructive forms of chronic periodontitis.

The task is achieved by including in the composition of the combined medicinal paste, containing, in addition to calcium hydroxide, ciprofloxacin, minocycline, metronidozole, a 2% solution of chlorhexidine bigluconate is included as a binding agent in the preparation of this paste. Thus, the new temporary filling material contains the following components in the ratio, mass. %:

calcium hydroxide 40,0 ciprofloxacin 10.0 minocycline 10.0 metronidozole 10.0 2% solution of chlorhexidine bigluconate rest

The selection of mass fractions included in the components was carried out empirically. It was found that the use of components outside the specified interval does not make sense, because this does not improve the effect. The proposed paste for temporary filling of root canals in the treatment of destructive forms of chronic periodontitis is obtained by simple mechanical mixing. First, a powder is obtained in which there are 4 components (calcium hydroxide, ciprofloxacin, minocycline, metronidozole), and then it is kneaded with a 2% solution of chlorhexidine bigluconate to obtain a paste.

The choice of antimicrobial active substances is based on the suppression of the widest possible spectrum of pathogens, including aerobic gram-positive bacteria, aerobic gram-negative bacteria, anaerobic bacteria (spore- and non-spore-forming), protozoa, since Heling et al. (1992) found that the use of calcium hydroxide involved in physiological saline, widely used by dentists in the treatment of chronic destructive forms of periodontitis, does not show antibacterial activity against E. Faecalis ext three dentinal tubules and, in turn, does not prevent secondary infection. The combination of calcium hydroxide, ciprofloxacin, minocycline, metronidozole and a 2% solution of chlorhexidine bigluconate causes an increase in antimicrobial activity, especially against resistant microorganisms such as E. Faecalis. A 2% solution of chlorhexidine bigluconate has positive properties: antibacterial, low toxicity for periodontal tissues, a viscosity that keeps active substances in constant contact with the walls of the canal and dentinal tubules. Having contacted the surface of dentin, a 2% solution of chlorhexidine bigluconate prolongs its effect. The combined use of calcium hydroxide, ciprofloxacin, minocycline, metronidozole and a 2% solution of chlorhexidine bigluconate, previously not used as a temporary paste in the treatment of destructive forms of periodontitis in dentistry, can significantly increase the antimicrobial activity of the paste.

The proposed paste allows for a short time (14-21 days) to effectively influence the main pathogenetic mechanisms of development of destructive forms of chronic periodontitis, to obtain a persistent therapeutic effect.

The proposed paste is prepared as follows.

The number of components is given per 100 g of the finished product.

The mixture is prepared on a glass slide from calcium hydroxide powder (40 g), ciprofloxacin (10 g), minocycline (10 g), metronidozole (10 g) - in powder, then the mixture is thoroughly mixed until a homogeneous powder is added to the prepared powder 2% a solution of chlorhexidine bigluconate and mix the mixture at room temperature until a paste is obtained. The resulting paste is ready for use within 7-10 minutes after the start of kneading, then hardens and cannot be used. The resulting paste for root canal filling is a homogeneous paste of creamy consistency, from light yellow to light brown in color. The paste is applied immediately after kneading by introducing into the root canal using a canal filler for 14-21 days.

Within 18 months, the claimed paste was clinically tested (main group, 15 patients) and compared with the control group (15 patients) with a diagnosis of chronic granulating periodontitis, which included the use of the closest analogue - intracanal treatment of apical periodontitis using a paste based on calcium hydroxide [7 ].

After the treatment, the patients of the main and control groups were re-examined 6, 12 and 18 months after permanent filling.

The effectiveness of the treatment with x-ray examination was visually evaluated on a five-point scale proposed by Vorobyov Yu.I. and Maksimovsky Yu.M. [6]:

0 points - the destructive process is not stopped;

1 point - the absence of a decrease in the size of the periapical destructive lesion;

2 points - a decrease in the size of the periapical focus by 1/3;

3 points - a decrease in the size of the periapical foci from 1/3 to 1/2;

4 points - a decrease in the size of the periapical focus by more than 1/2;

5 points - complete restoration of the structure of bone tissue and the formation of a cortical plate.

When conducting an X-ray assessment of the quality of the treatment after 6 months, the progression of the pathological process was observed in one patient (6.6%) in the control group of patients. These data were consistent with complaints and dental examination data, which is why treatment in these patients was found to be ineffective. In the main group where the claimed paste was used, a decrease in the size of the periapical lesion by more than 1/2 was noted in 53.3% of cases in patients; in the control group, a decrease in the size of the periapical lesion by more than 1/2 was noted in 13.3% cases. A decrease in the size of the periapical focus by 1 / 3-1 / 2 of its initial size in patients of the main group was detected in 46.6% of cases, in patients of the control group 46.6%. Moreover, in 33.3% of patients in the control group, the size of the periapical lesion decreased by less than 1/3 (Table 1).

Thus, as shown by the results of a study conducted after six months, in the main group, where the claimed temporary paste was used, a decrease in the size of the periapical focus by more than 1/2 was noted in a larger number of cases compared with the control group. Moreover, in 33.3% of patients in the control group, the size of the periapical lesion decreased by only 1/3 or less, which was not observed in the main group.

When conducting an X-ray assessment of the quality of the treatment after 12 months, the following results were obtained. In the main group, complete recovery of the periapical focus was observed in 26.6% of cases in patients. There were no such observations in the control group. A reduction in the size of the periapical lesion by less than 1/3 of the initial parameters in the control group was detected in 13.3%, and there were no such observations in the main group (Table 2).

When conducting an X-ray assessment of the quality of treatment after 18 months, the following observations were obtained: in the main group, 66.6% of patients had complete recovery of the periapical focus, in the control group, 13.3%, which is significantly less than in the main group, where claimed temporary paste. A decrease in the size of the periapical focus from 1/3 to 1/2 of its initial size in patients of the control group was 13.3%, there were no such observations in patients of the main group, the best dynamics of restoration of the periapical focus in the main group from reducing the size of the focus by more than 1 was observed. / 2 in 33.3% and until the bone structure is completely restored and the cortical plate is formed in 66.6% of patients (Table 3).

The effectiveness of the antimicrobial activity of the applied temporary pastes in the main and control groups was carried out using a microbiological study, which included taking material from the root canals of the patients after opening the tooth cavity and after temporary insertion into the root canal (after 20 days), the biomaterial was delivered to the laboratory within one hour from the time of the fence. After thermostating, quantitative counting of the colonies of each type of microbes was carried out. The number of colonies obtained was used to determine the quantitative seeding of the studied biomaterial and the CFU / ml value, the colony forming unit, was established. The average sample values of quantitative attributes are given in the text in the form M ± m, where M is the average sample, m is the standard error of the mean. To test statistical hypotheses, nonparametric methods were used (Wilconson's test). The results of the study are presented in table No. 4.

An analysis of the microbiological results of the contents of the root canal in patients of the main group revealed a significant decrease in the frequency of microflora excretion in associations and a decrease in their concentration in the root canal of the tooth compared with the control group (Table 4).

Analyzing the results of testing, we can conclude that the proposed paste for temporary filling of the root canal of the tooth from the components of calcium hydroxide, ciprofloxacin, minocycline, metronidozole, 2% chlorhexidine bigluconate solution is convenient to use, available, well tolerated by patients, has no side effects and contraindications for use. The data obtained allow us to recommend the proposed paste for effective treatment in destructive forms of chronic periodontitis, both in terms of dosage and time of exposure, which is confirmed by specific clinical examples.

Example 1, treatment of a patient from the main group. Patient G., 39 years old, complained of periodic swelling and aching pain in the lower jaw on the right. According to the patient, 4.4 tooth was treated several years ago, according to orthopedic indications.

Objectively: 4.4 tooth has a stamped crown. Percussion 4.4 tooth painful. On the roentgenogram, the appendix (Fig. 1), at the apex of the root of the 4.4 tooth, the center of rarefaction of bone tissue of rounded shape with clear contours, size 5 × 10 mm.

Diagnosis: chronic granulating periodontitis 4.4 teeth.

Treatment: 4.4 tooth crown was removed, anchor pin was removed, 4.4 tooth cavity was opened, standard endodontic treatment using endodontic instruments, drug treatment of root canals with 5.25% sodium hypochlorite solution. The canals are sealed with the developed paste to the physiological tip 4.4 of the tooth, a provisional filling is placed. When re-examined after 3, 7 and 20 days, the patient has no complaints. On the 20th day, the provisional filling was removed, the claimed paste was removed from the root canal of the 4.4 tooth, the antiseptic treatment with 5.25% sodium hypochlorite was performed, the canal was sealed with AHplus material with gutta-percha by the lateral condensation method. On the control x-ray - a full obstruction of the root canal of 4.4 tooth. A stump insert was placed with subsequent prosthetics with a ceramic-metal crown 4.4 teeth. The results of an X-ray examination carried out after 18 months showed the complete elimination of the site of bone destruction in the apex of the 4.4 tooth, the absence of destructive changes in the periapical tissues, application (Fig. 2).

The results obtained indicate a complete relief of the inflammatory process, anti-inflammatory, antiseptic and reparative effects of the developed paste.

Example 2, control group. Patient K. asked for help with complaints about the presence of fistulous passage in the area of the projection of the apex of the root of the 3.6 tooth.

Objectively: 3.6 tooth is changed in color, there is a filling on its chewing surface. Percussion of 3.6 tooth is slightly painful. On the radiograph at the bottom of the cavity and in 1/3 of the distal canal of the root of the 3.6 tooth there is filling material, at the top of the anterior root of the 3.6 tooth there is a bone rarefaction site in the form of “tongues of flame” with fuzzy contours, sizes 6 × 7 mm, application (Fig. 3 )

Diagnosis: chronic granulating periodontitis 3.6 tooth.

Treatment: removal of a filling, opening of a cavity of a tooth 3.6, removal of material residues from the bottom of a tooth cavity. The passage of the 3.6 tooth channels under the baths from antiseptics was performed; the pulp decay was removed from the 3.6 tooth channels; drug treatment was performed. Channels are dried using paper cones. Temporary filling material of calcium hydroxide, mixed with sterile water, is introduced into the root canal of the 3.6 tooth when the canal filler is rotated at low speeds to the physiological opening of the root tip of the 3.6 tooth. A provisional seal was delivered. After 20 days, the patient did not complain, percussion of 3.6 tooth was painless, fistula was not detected, provisional filling was removed, the claimed preparation was removed from the root canal of 3.6 tooth, the antiseptic treatment was carried out with 5.25% sodium hypochlorite, the channels were sealed with AHplus material with gutta-percha by the lateral condensation method . On the control x-ray - a full obstruction of the root canal of 3.6 tooth. Permanent seal is delivered. The results of an X-ray examination, carried out after 18 months, showed incomplete elimination of the site of destruction of bone tissue in the region of the apex of the anterior root of the 3.6 tooth (Fig. 4). The root canals of the 3.6 tooth are sealed to the apex.

The studies were conducted at the Department of Therapeutic Dentistry of the State Budgetary Educational Institution of Higher Professional Education "Kuban State Medical University" of the Ministry of Health of the Russian Federation (GBOU VPO KubGMU of the Ministry of Health of Russia) and the dental clinic of GBOU VPO KubGMU of the Ministry of Health of Russia.

Thus, as the results of clinical testing have shown, the developed tool for temporary root canal filling in the treatment of destructive forms of chronic periodontitis has the technical result: a high anti-inflammatory, bacteriostatic, bactericidal, antiseptic effect, stimulating the repair of effects that allow optimization of the reparative process of osteogenesis in periapical tissues by eliminate pathogenic microflora from the root canal system.

Information sources

1. Borovsky EV How to improve the dental health of Russians? / E.V. Borovsky // Dentist. - 2006. - No. 12. - S. 5-10.

2. Mitronin A.V. Endodontic treatment of pulp and periodontal diseases. Part 1. Aspects of the use of antibacterial drugs / A.V. Mitronin, M.M. Gerasimova // Endodontics Today. - 2012. - No. 1. - S. 9-15.

3. Lukin L.M. Sensitivity to antimicrobial agents of microorganisms associated with root canal biofilms / L.M. Lukins, A.S. Kokunova, N.V. Tiunova // Endodontics Today. - 2013. - No. 1. - S. 67-70.

4. Kallagova D.E. Features of the microflora of the root canals of teeth in patients with chronic apical periodontitis in the case of ozone therapy / D.E. Kallagova, F.S. Kosakovsky // Dental Forum. - 2013. - No. 5 (51). - S. 18.

5. Features of the microflora of the root canals with different forms of periodontitis / S.D. Arutyunov, A.S. Nose, E.G. Margaryan [et al.] // Education, science and practice in dentistry: Sat. Proceedings of IV All-Russian. scientific-practical conf. - Moscow, 2007 .-- S. 192.

6. Clinical aspects of the use of ozone therapy in the treatment of complications of caries / L.N. Maksimovskaya, M.A. Kuprina, D.E. Kallagova, F.S. Kosakovsky // Endodontics Today. - 2015. - No. 1. - S. 32-37.

7. 3. Kontakiotis Ε. Nakopoulou H., Georgopoulou Η. In vitro study of indirect action of calcium hydroxide on anaerobic flora of the root channel. Int Endodontic J 28: 285-289, 1995.

Claims (2)

Dental paste for temporary filling of root canals in the treatment of destructive forms of chronic periodontitis, containing calcium hydroxide, ciprofloxacin, metronidazole, minocycline, characterized in that a 2% solution of chlorhexidine bigluconate is included in the composition in the following ratio, mass. %: calcium hydroxide 40,0 ciprofloxacin 10.0 minocycline 10.0 metronidozole 10.0 2% solution of chlorhexidine bigluconate rest

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