RU2798701C1 - Method of conservative treatment of apical periodontitis - Google Patents

Abstract

FIELD: medicine; dentistry.

SUBSTANCE: invention is intended for use in endodontic treatment of apical periodontitis. The success rate of primary endodontic treatment of apical periodontitis is about 70.7%, with repeated treatment, bone tissue regeneration can be achieved in 65.2% of cases. During the first visit, the tooth is isolated with a latex scarf, instrumental and medical treatment of the root canal of the tooth is carried out. Next, a complex antimicrobial nanopreparation is made as follows: Kupral® calcium hydroxocuprate paste and NanArgol® silver nanoparticles hydrosol with a concentration of silver nanoparticles of 3 mg/l are mixed with a plastic spatula on a paper block in a ratio of 1:1. With the help of a canal filler or a K-file type hand tool, the complex preparation is introduced into the root canal for the entire working length and distributed along the walls of the canal. The medicinal product is delivered to the apical third of the canal at the tip of a calibrated gutta-percha pin. Then the mouth of the root canal is isolated with glass polyalkenate cement, the access cavity is closed with a temporary dressing, after 7 days, during the second visit, the temporary dressing and glass polyalkenate cement are removed, the therapeutic complex preparation is removed from the root canal by washing out with a sterile 0.9% sodium chloride solution, the canal is dried using paper absorbers of the appropriate size and sealed with gutta-percha and a sealer based on epoxy resins by lateral condensation in the apical third of the canal and by hot vertical condensation in the middle and orifice thirds of the canal.

EFFECT: method, due to a pronounced antimicrobial effect on deep microbial foci, namely, prolonged impregnation of the dentin of the tooth root with an antimicrobial agent based on GMC and silver nanoparticles to a depth of up to 500 microns, makes it possible to increase the effectiveness of treatment and save the teeth without the use of surgical methods.

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Description

The invention relates to medicine, namely to dentistry, and can be used in endodontic treatment of apical periodontitis in order to increase the effectiveness of such treatment and save teeth without the use of surgical methods.

Every year in Russia, more than 5 million people turn to dentists for the treatment of apical periodontitis. The prevalence of endodontic lesions of the teeth in persons aged 18 - 70 years is 79.4%. The success rate of primary endodontic treatment of apical periodontitis is 70.7%; during repeated treatment, bone tissue regeneration can be achieved in 65.2% of cases [Petrikas A.Zh., Zakharova E.L., Goreva L.A., Adkina G. IN. The prevalence of endodontic pathology / II International Periodontal Convention "Periodontology: from science to practice" (Proceedings of the convention) // Pod. ed. professor V.A. Rumyantseva.- Tver: RIC TSMU, 2019.- 40 p., S. 32-34]. Complications are caused by microbial associations that persist in the root canal system (RCS), which includes lateral branches, the apical delta region, and numerous dentinal tubules (DTs). DT is a reservoir of microorganisms, inaccessible for full-fledged mechanical and poorly accessible for drug treatment. A bacterial biofilm is found in the dentin of the tooth root at a depth of 300 - 1000 microns from the surface of the root canal wall [Faustov L.A., Leontiev V.K., Popkov V.L. Ultrastructural characteristics of hard tissues of the tooth root in pulpitis. The phenomenon of the formation of infected foci of destruction in the dentin // Scientific Bulletin of the Belgorod State University. Series: Medicine, pharmacy. 2011. No. 16-1. C. 93-99].

A prerequisite for effective endodontic treatment of periodontitis of any clinical form is the achievement of the maximum possible sterilization of all spaces of the tooth root. Known methods of conservative treatment (analogues) are temporary positioning of preparations with an antimicrobial effect in the root canals, if necessary, with the use of additional physico-chemical effects in order to initiate the penetration of active components into the dentin of the tooth root.

In particular, there is a method of depophoresis of a complex ionic antimicrobial drug of copper-calcium hydroxide (HMC, calcium hydroxocuprate), which is used in the endodontic treatment of apical periodontitis in teeth with obliterated or curved root canals [Knappvost A. Depophoresis of copper-calcium hydroxide // Clinical Dentistry . 1998. - No. 2. - S. 12-15]. The method is as follows: the treatment requires a generator of direct electric current of small size (1 μA) and pasty calcium hydroxocuprate (Cupral ^® , "Humanchemie GmbH", Germany). During the first visit, the root canal is filled with GMC paste, then an active electrode is inserted into the root canal. Under the influence of electric current, electroosmotic distribution of drug ions occurs in the SCC and DT of the tooth root. For dosed electrophoretic administration of "Cupral ^® " in the SCC, the devices "Original II", "Comfort", "ENDO 1.0", etc. are used. The procedure lasts from 3 to 10 minutes, is repeated 3 times - with an interval between visits from 7 to 14 days - and ends with a permanent filling of the root canals.

The disadvantage of the SMC depophoresis method is its duration: it involves at least three regular visits to the doctor, the course of treatment lasts 20-45 days. In addition, this technique is expensive, since it requires additional expensive equipment: electric current sources with electricity meters. In addition, the depophoresis procedure can be painful: during it, patients may experience discomfort caused by the passage of electric current through the tissues and their heating.

V.A. Rumyantsev et al. proposed a method of GMC galvanophoresis [Rumyantsev V.A., Bordina G.E., Olkhovskaya A.V., Opeshko V.V., Nekrasov A.V. Clinical and laboratory assessment and justification of the method of galvanophoresis of copper-calcium hydroxide in the endodontic treatment of apical periodontitis // Dentistry. 2015. - T. 94. - No. 1. - S. 14-19]. In this case, intracanal pin elements made of two metals that make up a galvanic pair, for example, copper and zinc, are positioned as current sources in the root canal. At the same time, a potential difference of 0.2-0.4 V occurs at the interface, due to which the charged nanoparticles from the calcium hydroxocuprate paste gradually move into the depth of the spaces of the dentin of the tooth root. The value of the galvanic current is about 0.1 mA. In this case, the process of galvanophoretic movement of the active ions of the GMC occurs.

The disadvantage of the calcium hydroxocuprate galvanophoresis method is that it requires additional equipment (galvanic pin cells), the production of which is not established on the territory of the Russian Federation. In addition, such treatment lasts a long time: depending on the clinical picture, the procedure is carried out on average within 7-10 days, but sometimes longer - up to 1-4 months. Regular visits to the dentist are required to replace the Kupral ^® paste in the root canals and galvanic pins, as well as for X-ray control of the process of bone tissue remodeling in the periapical region.

The most widely used in endodontic practice in the treatment of apical periodontitis is the method of temporary filling of the root canals of teeth with an aqueous paste of calcium hydroxide (HA) [Engar R.C. More on Calcium Hydroxide in Endodontics // Journal of the American Dental Association (1939). 2020. - T. 151. - No. 8. - S. 554]. HA has a wide spectrum of antimicrobial activity, tk. creates a high local pH level, which initiates the denaturation of bacterial cell wall components.

Flores B., Cruz A.G. One- versus two-visit endodontic treatment of teeth with apical periodontitis: a histobacteriologic study // J Endod. 2012. - Vol. 38. - №8. - P. 1040 - 1052].The disadvantage of this method is its insufficient efficiency, due to the fact that over time, during the leakage of inflammatory exudate, the HA suspension loses its activity. It has been experimentally established that the peak activity of the aqueous suspension of HA reaches the 14th day of exposure in the root canal, on the 18th day there is a decrease in pH to neutral values, which not only do not contribute to the elimination of microorganisms, but, on the contrary, create favorable conditions for the development of bacterial colonies [Sharma G ., Ahmed HMA, Zilm PS, Rossi-Fedele G. Antimicrobial properties of calcium hydroxide dressing when used for long-term application: A systematic review // Aust Endod J. 2018. - Vol. 44. - No. 1. - S. 60-65]. In addition, long-term exposure of HA preparations in root canals leads to a decrease in the bending strength of the tooth root and increases the risk of fractures under the influence of occlusal loads [Batur YB, Erdemir U., Sancakli HS The long-term effect of calcium hydroxide application on dentin fracture strength of endodontically treated teeth // Dent Traumatol. 2013. - Vol. 29. - No. 6. - S. 461-464]. In addition, due to the low ability to dissociate in aqueous solutions and weak diffusion, this antiseptic drug is not effective enough against microorganisms that persist in the slit-like areas of the root canal and deep in the DT [Vera J., Siqueira JF Jr, Ricucci D., Loghin S .,

Flores B., Cruz AG One- versus two-visit endodontic treatment of teeth with apical periodontitis: a histobacteriologic study // J Endod. 2012. - Vol. 38. - No. 8. - P. 1040 - 1052].

The prototype of the proposed method can be a method of temporary filling of root canals with an antimicrobial agent based on calcium hydroxide and 0.02% aqueous suspension of silver nanoparticles with a diameter of 10 nm [Balto H., Bukhary S., Al-Omran O., BaHammam A., Al -Mutairi B. Combined Effect of a Mixture of Silver Nanoparticles and Calcium Hydroxide against Enterococcus faecalis Biofilm // J Endod. 2020. - Vol. 46. - No. 11. - P. 1689-1694]. Immediately before entering into the root canals, the medicines are proposed to be mixed in a ratio of 1:1. It has been established that the optimal time for positioning the complex preparation is 4 weeks, during which time it is possible to achieve the destruction of 90.85% of bacterial cells in the test culture. After that, the drug is washed out of the root canals with a sterile phosphate buffer solution and the root canals are sealed with gutta-percha and a sealer.

The disadvantages of the prototype are the duration of exposure of the combined antimicrobial drug, the low diffusion capacity of microparticles, the inability to penetrate into the lumen of the DT and eliminate the microflora living there, the gradual weakening of antibacterial activity due to the neutralization of pH , as well as the lack of chemical affinity of silver nanoparticles to HA , which does not allow to achieve significant modification its particles.

To eliminate the lack of a prototype, a method of conservative treatment of apical periodontitis is proposed, which consists in the following. During the first visit, the tooth is isolated with a latex scarf, instrumental and medical treatment of the root canal of the tooth. Next, a new complex antimicrobial nanopreparation is made ex tempore. To do this, on a paper block with a plastic spatula, the paste of calcium hydroxocuprate "Kupral" ^® and the hydrosol of silver nanoparticles "NanArgol" ^® with a concentration of silver nanoparticles of 3 mg/l are mixed in a ratio of 1:1. With the help of a canal filler or a K-file type hand tool, the complex preparation is introduced into the root canal for the entire working length and distributed along the walls of the canal. The drug is delivered to the apical third of the canal at the tip of a calibrated gutta-percha pin. Then the mouth of the root canal is isolated with glass-polyalkelate restorative cement of chemical curing, the access cavity is closed with a temporary bandage.

After 7 days, during the second visit, remove the temporary dressing and glass polyalkelate cement. The therapeutic complex preparation is removed from the root canal by washing out with a sterile 0.9% sodium chloride solution. Re-irrigation of the canal with antiseptic solutions is not required. The canal is dried using paper absorbers of the appropriate size and sealed with gutta-percha and sealer based on epoxy resins using the lateral condensation method in the apical third of the canal, and the method of hot vertical condensation in the middle and orifice third of the canal.

The technical result of the proposed method is a pronounced antimicrobial effect on deep microbial foci that persist in the lateral branches of the main root canals, inaccessible for mechanical and drug treatment, the apical delta region and numerous microscopic dentinal tubules of the tooth root. The proposed method uses physicochemical phenomena occurring in the tissues of the tooth under the influence of diffusion of a new complex nanopreparation.

The scientific novelty of the proposed method lies in the fact that for the first time for the treatment of apical periodontitis a method based on the synergistic interaction of GMC nanoparticles and silver nanoparticles was used. The HMC preparation is represented by spherical particles 287±23.4 nm in size. Such large particles cannot penetrate into the DT of the tooth root and move into them even under the action of an electric field. However, an electron microscopic study of GMC preparations prepared on a hydrosol of silver nanoparticles showed that when diluting GMC with a hydrosol of silver nanoparticles, it is possible to achieve peptization of the system (Fig. 1-A) [Rumyantsev V.A., Frolov G.A., Blinova A. V., Karasenkov Ya.N., Bityukova E.V. Electron microscopic properties of a new antimicrobial nanopreparation based on copper-calcium hydroxide // Bulletin of Avicenna. 2021. - T. 23. - No. 4. - S. 532-541.]. When GMC is diluted with a hydrosol of silver nanoparticles, nanoparticles of the dispersed phase with a size of 0.5-3 nm penetrate into the surface layer of spherical particles of GMC, showing the properties of a surfactant (Fig. 1-B, 1-C).

In addition, large MMC particles accumulate the specific surface energy of silver particles and become able to penetrate deeper and more intensively into the depth of dentin along the concentration gradient (Fig. 1-D). Thus, when applying a new preparation, the main driving force is the osmotic pressure in the capillary system of the dentin. This is confirmed by the data of X-ray fluorescent elemental microanalysis of the transverse saw cuts of the roots of the teeth - after temporary filling of the root canal with a new preparation, after 7 days copper is found in the dentin at a distance of more than 400 microns (Fig. 2) [Rumiantsev V.A., Blinova A.V., Frolov G.A., Karasenkov Ya. N., Fedorova M.S., Cherdzhieva F.B. Improving The Efficiency of Endodontic Dental Treatment with The Use of New Nano-Impregnation Technology // Medicine, Science and Education. Scientific and Informational Journal. - 2020. - No. 30. – P. 108 – 112].

Examples

Example 1. Patient N.A.V., 56 years old, applied for the purpose of sanitation of the oral cavity and preparation for orthopedic treatment. On examination: generalized increased tooth wear in the anterior part of both jaws, percussion of teeth 1.1, 1.2, 1.3 is painless. On the intraoral radiograph in the area of the tops of the teeth 1.1, 1.2. and 1.3 there are foci of rarefied bone tissue up to 5 mm in diameter. The diagnosis was made: chronic apical granulomatous periodontitis of teeth 1.1, 1.2, 1.3. During the first visit, the working field was isolated using the “Opti Dam” system, access cavities were created, instrumental processing of the root canals of teeth 1.1, 1.2, 1.3 was carried out with their expansion to diameters 035, 035 and 040 according to ISO, respectively (Fig. 3- A). Conducted drug treatment of root canals with 3% sodium hypochlorite solution (three times with alternating washing with 17% EDTA solution and distilled water). The length of the root canals was measured, which was 18, 17 and 20 mm, respectively. For the manufacture of a new complex antimicrobial preparation ex tempore on a paper block, a plastic spatula was used to mix the paste of calcium hydroxocuprate "Kupral" ^® and the hydrosol of silver nanoparticles "NanArgol" ^® in a ratio of 1:1. With the help of a canal filler, the drug was introduced into the root canals for the entire working length and distributed along the walls; the drug was delivered to the apical third on calibrated gutta-percha pins (Fig. 3-B). In each tooth, the mouth of the root canal was isolated with chemically curing glass-polyalkelate cement "Kemfil" ^® , the access cavity was closed with a temporary dressing "Parasept" ((Fig. 3-B).

After 7 days, during the second visit, the temporary dressing and cement were removed, the medicinal preparation was washed out of the root canals with a sterile 0.9% sodium chloride solution. Then the root canals were dried and sealed using "AH+" sealer and gutta-percha pins by hot condensation method (Fig. 3-D). At the end of the treatment, the teeth were filled with Kemfil glass-polyalkenate light-curing cement. After 6 months, a control radiographic study was performed, which showed the absence of bone defects in the periapical zone (Fig. 3-D).

Example 2. Patient A.A.A., 48 years old, complained of recurrent pain in the area of tooth 4.6 when biting, swelling of the gums. On examination: tooth 4.6 under an extensive filling, the marginal fit is broken, percussion is moderately painful, palpation along the transitional fold in the tooth area is slightly painful, there is no fluctuation. On the cone-beam computed tomography, tooth 4.6 was previously depulped, there was no filling material in the apical third in the mesial root, a "step" was created during processing (Figure 4-A). In the area of the tops of the mesial and distal roots, there are foci of rarefied bone tissue about 4 mm in diameter. Based on the clinical and radiological picture, the diagnosis was made: chronic apical granulomatous periodontitis of tooth 4.6.

On the first visit, the working field was isolated using the Cofferdam system, the filling was removed from tooth 4.6, the root canals were unsealed in the mesial and distal roots: mesial-buccal, mesial-lingual, distal root canals were expanded to diameters 035, 030 and 040 according to ISO, respectively (Fig. 4-B). Conducted drug treatment of root canals with 3% sodium hypochlorite solution (three times with alternating washing with 17% EDTA solution and distilled water). The length of the root canals was measured, which was 16, 15 and 16 mm, respectively. To prepare a complex antimicrobial preparation ex tempore, on a paper block, a plastic spatula was used to mix the paste of calcium hydroxocuprate "Kupral" ^® and the hydrosol of silver nanoparticles "NanArgol" ^® in a ratio of 1:1. Using a K-file manual instrument, the preparation was introduced into the root canals to the full working length and distributed along the walls of the canal; the preparation was delivered to the apical third on calibrated gutta-percha pins (Fig. 4-B). The orifices of the root canals were isolated with Kemfil ^® chemically curing glass-polyalkelate cement, the access cavity was closed with a Parasept temporary bandage ((Fig. 4-D).

After 7 days, during the second visit, the temporary dressing and cement were removed, the medicinal product was washed out of the root canals with sterile 0.9% sodium chloride solution. Then the root canals were dried and sealed using AH+ sealer and gutta-percha pins using the lateral condensation method. At the end of the treatment, the teeth were filled with a light-hardening composite material "Filtec supreme". After 6 months, a control radiographic study was performed, which showed the absence of bone defects in the periapical zone (Fig. 4-D).

Example 3. Patient A.A.V., 33 years old, complained of discomfort in the area of tooth 2.6 when chewing solid food. On examination: tooth 2.6 is under a filling, the marginal fit is not disturbed, percussion is moderately painful, palpation along the transitional fold is painless. On the cone-beam computed tomography, tooth 2.6 was previously depulped, CCs were filled up to the physiological apex. In the region of the apex of the bucco-mesial root, there is a focus of bone tissue destruction about 4 mm in diameter (Fig. 5-B). Based on the clinical and radiological picture, the diagnosis was made: K04.5 chronic granulomatous apical periodontitis of tooth 2.6.

During the first visit, the working field was isolated using the Cofferdam system, the filling was removed, the root canals were unsealed, and an additional canal in the medial buccal root that had not been previously processed was found. Canals MB1, MB2, distal buccal and palatal canals were dilated to ISO diameters 035, 030, 035 and 040, respectively (Fig. 5-A). Conducted drug treatment with 3% sodium hypochlorite solution (three times with alternating washing with 17% EDTA solution and 0.9% sodium chloride solution). The length of the channels was measured, which was 19, 15, 18, and 20 mm, respectively. To prepare a complex antimicrobial preparation ex tempore, on a paper block, a plastic spatula was used to mix the paste of calcium hydroxocuprate "Kupral" ^® and the hydrosol of silver nanoparticles "NanArgol" ^® in a ratio of 1:1. Using a K-file hand instrument, the preparation was introduced into the canals for the entire working length; the preparation was delivered to the apical third on calibrated gutta-percha pins. The orifices were isolated with Kemfil ^® chemically curing glass-polyalkelate cement, the access cavity was closed with a Parasept temporary dressing (Fig. 5-B).

After 7 days, during the second visit, the temporary bandage and cement were removed, the medicinal product was washed out of the canals with a sterile 0.9% sodium chloride solution. Then the root canals were dried and sealed using AH+ sealer and gutta-percha pins using a combined method of lateral and vertical hot condensation (see above). At the end of the treatment, the teeth were filled with a light-hardening composite material "Filtec supreme". After 12 months, a control radiographic study was performed, which showed the absence of bone defects in the periapical zone (Fig. 5-D).

Claims (1)

The method of conservative treatment of apical periodontitis, which consists in the fact that during the first visit, the tooth is isolated using a latex scarf, instrumental and medical treatment of the root canal of the tooth, then a complex antimicrobial nanopreparation is made, hydroxocuprate paste is mixed on a paper block with a plastic spatula in a ratio of 1: 1 calcium "Cupral"® and hydrosol of silver nanoparticles "NanArgol"® with a concentration of silver nanoparticles of 3 mg/l, using a canal filler or a manual instrument of the "K-file" type, the complex preparation is introduced into the root canal for the entire working length and distributed along the walls of the canal, the drug is delivered to the apical third of the canal at the tip of a calibrated gutta-percha pin, then the mouth of the root canal is isolated with glass polyalkenate cement, the access cavity is closed with a temporary dressing, after 7 days, during the second visit, the temporary dressing and glass polyalkenate cement are removed, the therapeutic complex drug is removed from the root canal by washing with sterile 0.9% sodium chloride solution, the canal is dried using paper absorbers of the appropriate size and sealed with gutta-percha and sealer based on epoxy resins by lateral condensation in the apical third of the canal and by hot vertical condensation in the middle and orifice thirds of the canal.

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