Treatment of Chronic Apical Periodontitis Using Depotphorese: A Clinical Trial

Headnote

Abstract

Aim: Chronic apical periodontitis is caused by irritants continually entering the periapical tissues from a necrotic pulp. However in certain instances non surgical treatment may be ineffective or difficult. In these cases a new technique called depotphorese has been used widely. The aims of this study were to diagnose patients with chronic apical periodontitis and to treat the patients with chronic apical periodontitis using standardized step back technique and copper calcium hydroxide as an intracanal medic-ation with the use of depotphorese.

Materials and methods: In this clinical study 30 cases were selected by simple random sampling. Both men and women bet- ween age group 25 to 40 years were selected. Follow-up of the cases was done for a minimum period of 12 months to assess the prognosis. Statistical interpretation was done using Chi-square test.

Results: The parameters fixed for the assessment of cases were success, incomplete and failure. From the findings of the study it was concluded that non surgical root canal treatment using copper calcium hydroxide (med calci) and Depotphorese in teeth wi- th chronic periapical lesions can be an alternative treatment to surgical therapy.

Conclusion: Based on the mode of presenting complaints, clinical and radiological findings inference was made that depotpho- rese is effective in the treatment of chronic apical periodontitis.

Keywords: Depotphorese; chronic apical periodontitis; copper calcium hydroxide.

Introduction

The dental pulp in its unique environment has been a mys- tery since ages.1 Lots of authors consider micro-organisms for primary etiologic agents in endodontic diseases.2 Bacteria may still be detected in the root canal system after chemomechanical preparation.3 Numerous studies have re- ported the bacteria may remain viable in ramifications, ist- hmian and dentinal tubules of root canal system.4 It reacts to bacterial infection or to other stimuli by an inflammatory response.5 As the pulp is entirely enclosed within an unyie- lding chamber of dentin, hence it has no space to swell unl- ike other soft tissues and this leads to cell death. Moreover lack of collateral blood supply of coronal pulp makes it hi- ghly compromised in its ability to defend itself from severe irritation.1 Because of inter relationship between the pulp and peri-radicular tissues pulpal inflammation causes infl- ammatory changes in the periodontal ligament. Egress of these irritants from infected root canals into peri-radicular tissues can initiate the formation and perpetuation of peri- radicular lesions.The general task in endodontic treatment of infected root canals is destruction and complete elimin- ation of micro-organisms and protection from reinfection. This aim is accomplished by using mainly antimicrobial agents through different methods of irrigation, application, ultrasonic preparation of root canals, iontophoresis.7 Chro- nic apical periodontitis is a low grade infection and one of the most common of all sequelae of pulpitis and acute api- cal periodontitis.8 As chronic apical periodontitis often de- velops without subjective symptoms the radiological diag- nosis is particularly important. The lesion is usually detec- ted on routine radiographic examination.9 One of the major reasons for the low efficiency of the treatment of chronic apical periodontitis is poor sterilization of the root canal system especially of teeth with hard to reach channels.10 Usually the treatment consists of extraction of the involved tooth or root canal treatment with or without apicoectomy.8 However, in certain instances non surgical treatment may be ineffective or difficult and hence, a technique called de- potphorese has been widely used.10 Therefore, the current study has been taken up to assess the effectiveness of depo- tphorese in the treatment of chronic periododntitis.

Materials and methods

In this clinical study 30 cases were selected by simple ran- dom sampling. Study was conducted at Department of Co- nservative Dentistry and Endodontics, Kharkiv Medical Academy, Ukraine. Both men and women between age gr- oup 25 to 40 years irrespective of socio economic status, cultural, educational and literacy background were selec- ted. Inclusion criteria were known cases of chronic apical periodontitis confirmed by clinical and radiographic exa- mination, cases with deep caries involving pulp and peria- pical lesion and sinus opening, cases with unsuccessfid ro- ot canal treatment with periapical lesion. Patients with con- ditions like acute abscess, apical periodontitis, osteomyeli- tis, malignant lesions ,fractured teeth with trauma, grossly decayed teeth, medically compromised subjects like HIV, prevailing oral infections- Herpes Simplex Vims (HSV) type II, candida albicans, tuberculosis, haematologic fac- tors- bleeding/clotting disorders, known history of valvu- lar heart disease were excluded. Cases were followed up for a minimum period of 12 months. The procedure was ex- plained to the patients and consent was taken. Of these 30 cases selected, 12 were anterior, 8 premolars and 10 mo- lars. Previous endodontic therapy was already performed on 12 teeth. Periapical radiographs demonstrated large rad- iolucent lesions with well defined margins with a diameter varying from 1 -6mm (21 patients had 1 to 3 mm and 9 pat- ients had 4 to 6 mm diameter). 20 patients had mild pain and remaining were asymptomatic. All cases were treated by one operator using standardized step back technique al- ong with depotphorese. The null hypothesis was formed as use of Depotphorese in the treatment of chronic apical pe- riodontitis is not effective. The results were statistically an- alyzed by Chi-square test.

Procedure

Depotphorese is a gentle painless holistic method of treat- ment for root canal in which the root canal is filled with copper calcium solution and then a weak electrical current is sent through a fine probe. Technically it is same as iont- ophoresis except that the amount of electric current applied is 5mA in depotphorese as compared to iontophoresis. This technique uses the Original II apparatus along with med calci. This apparatus consists of 4 pieces of 9 volt batteries which are put from the opposite side of apparatus. It consi- sts of 2 screens on showing mA (quantity of current) and other showing the time for which the current has passed. It consists of a handle with probe which carries the cathode (- electrode). The connecting wire consists of 2 ends, a black and a red end. The black end is connected to the negative electrode on the other side of handle and the red end is co- nnected to the anode or positive electrode which is placed on the cheek of the patient on opposite side. However, care should be taken to place moistened cotton on the inner met- allic surface ofpositive electrode.

After isolating the operating field med calcii is carried into the canals and the negative electrode with fine probe is pl- aced upto 3 -4 mm within the canal and the apparatus is sw- itched on and current is increased slowly until a warm sens- ation is felt by he patient. The amount of current for one ca- nal must not be less than 5mA/5 minutes. However, if pa- tient feels excessive pain the current can be decreased upto 1mA. To avoid excessive irritation of apical tissues the tre- atment is carried out in 3 settings at a time interval of 1 we- ek. After carrying out the depotphorese procedure 3 times the canals were dried with paper points and were obturated with atasamit sealer with gutta percha points. The patients were recalled at every 3 months interval to assess the stage of periapical healing. The treatment was considered to be successful when the tooth was found to be clinically symp- tomless and the radiograph showed reduction in the pre ex- isting radiolucency. If expansion or no change in size of the pre existing lesion or no reduction in symptoms was obser- ved the treatment was recorded as failure.

Results

Caries and bacteria were considered the most common eti- ological factors in pulp death and development of periapi- cal lesions followed by pulp less teeth or those previously root filled. Pain was eliminated in 1-3 days in 20 sympto- matic teeth. Complete healing was observed in 21 teeth (70%) and incomplete healing was observed in further 7 te- eth (23.33%). Failure was observed in 2 teeth (6.67%). Su- ccessful healing occurred within 4-14 months of treatment (Table 1). Lesions of l-3mm diameter (21 teeth) healed in 21 cases (100%) consisting of 16 complete healing cases (76.20%) and 5 healing incompletely (23.80%). The length of time required for healing in these cases ranged from 3-9 months.

Lesion with diameter ranging from 3 -6mm (7 teeth) healed in 7 cases (100%) including 5 (71.43%) cases of complete healing and 2 (28.57%) of incomplete healing (Table 2, Gr- aph 1). The period for complete healing in these cases rang- ed from 4-14 months (Figure 1, 2). Healing of periapical lesions around pa-rtially resorted calcium hydroxide paste had occurred in 6-12 months in 3 of 4 accidentally overfill- ed cases. Root canal treatment failed in 2 teeth. Possible ca- uses of therapy failure included advanced periodontal dise- ase (2 cases). The value of yl at degree of freedom 2 was 5.991, which imply that the calculated value was more than observed value and hence, null hypothesis was rejected which states that use of depotphorese in the treatment of ch- ronic apical periodontitis is not effective. The alternative hypothesis, use of depotphorese in the treatment of chronic apical periodontitis is effective, was accepted.

Discussion

Micro-organisms in the dentinal tubules may constitute a reservoir from which root canal and surrounding tissue infection and reinfection may occur. Treatment strategies designed to eliminate this reservoir should include agents that can penetrate the dentinal tubules and destroy these micro-organisms.11 In these cases depotphorese has been widely used with success. This depotphorese process is capable of dissolving the content of the entire root canal system by alkaline proteolysis and removing the oligopeptides formed from the canal system via the apical foramen. The canal is then freed from all organic residues. In this way majority of roots which cannot be prepared mechanically are fundamentally treatable.12 The process that takes place during depotphorese is as follows :

1 ) During the first sitting the hydroxyapatite ions Cu(OH)4 and hydroxide ions OH from hydroxide med calci Cu[Ca (OH),] pass through the canal and settle inside. Then there is breakdown of hydroxyapatite ions and transformation into solution of hydroxide med Cu(OH),. Also the project- ing acidity from the periapical tissues is seen as a froth exu- date in the tooth cavity which is removed with the help of cotton rolls.

2 ) During the second visit the contents of the canal continue to undergo proteolysis and there is destruction of more sm- all portions of acid in the periapical region. Also there is precipitation of hydroxide med calci in the periapical regi- on. Also there is movement of colloidal small particles of med calci. They also transfer in apical direction and settle on the walls of the canal already liberating proteolytic orga- nic contents.

3) During the third visit the ions incoming in the compo- sition of med calci get embedded in the dentinal tubules and disinfect them. They also start ossification in the periapical region and hence there is gradual reduction in periapical di- scomfort.13 In a study conducted by Sachdeva et al., in 2011 on iontophoresis it was found useful for antibacterial treat- ment of infections and for effective pain control of teeth du- ring endodontics allowing dentin and pulp tissue remov- al.14 Also a study conducted by Zhandov et al., in 2002 us- ing depotphorese with copper calcium hydroxide showed good results with 93% of cases.13 As depotphorese is simi- lar to iontophoresis the current study showed good results with the use electrically activated copper calcium hydrox- ide. Calcium hydroxide has a lasting antibacterial activity in the root canal space due to its high pH however, it has poor solubility and its bactericidal effect on penetration in- to the dentinal tubules is unsatisfactory. The best results were obtained with the addition of copper to calcium hydr- oxide and with the use of an electrical current according to the method described by Knappvost. The depth of compl- ete disinfection was at least 500pm.11 Electrophoretically activated copper improves efficacy in bovine dentinal tub- ules.15 Studies have shown that the hydroxocuprate contai- ned in copper calcium hydroxide is 100 times more bacteri- cidal than calcium hydroxide and does not loose its effect over time. In addition it also remains on the apical entrance and there transforms into long term bactericide copper hy- droxide. Also it completely covers the surface of the canal and sterilizes it. Traces of copper ions enhance the quick physiological reossification and sealing of foramina.14 It is generally accepted that the choice of intracanal medicame- nt should balance antibacterial potency with tissue toxicity, a balance that is often difficult to achieve because medica- ments that are bactericidal usually exhibit some toxicity.11

Conclusion

From the study taken up to know the utility of depotphorese with copper calcium hydroxide in the treatment of chronic apical periodontitis, this may be concluded that the favor- able results of this study demonstrates that non surgical ro- ot canal treatment using copper calcium hydroxide (med calci) and depotphorese in teeth with chronic periapical le- sions can be an alternative treatment to surgical therapy.

This process not only stops the progression of the lesion but also attains sterility of the canals treated thereby preventi- ng further recurrence.

This study helped to get better idea and varied experience in treating individuals with chronic apical periodontitis. The limitations of this study were sample design was small and the literature available for depotphorese was limited. This kind of study requires longer period and large sample size to make an in depth observation to understand the role of depotphorese with copper calcium hydroxide. Therefore it is recommended to take up a long term study to fill the sh- ort comings ofthis study.

References

References

1. Bailoor D, Nagesh KS. Fundamentals of oral medicine and radiology. Jaypee Brothers. New Delhi, 2005:381.

2. Lin Y, Mickel AK, Chogle S. Effectiveness of selected ma- terials against Enterococcus Faecalis. Part 3. The antibacte- rial effect of calcium hydroxide and Chlorhexidine on Entero- coccus faecalis. J Endod 2003;29:565-66.

3. Morder JJ. Antimicrobial activity of Ca(OH)2 dental cem- ents: an in vitro study. JEndod2003;29:51-54.

4. Cobankara FK. In vitro antibacterial activities of root canal sealers by using 2 different methods. J Endod 2004;4:57-60.

5. Grossman L. Oliet S, Del Rio CE. Endodontic practice 11th edn. Varghese Publishing House; Mumbai, 1991:78.

6. Ingle J, BaklandL. Endodontics S'^edn. Elsevier; New Delhi; reprinted2006;175,180.

7. Kalchinov V, Dimitov S, Belcheva M. In vitro study of bact- ericidal effect of antimicrobial agents used in modern endod- ontics. JIMAB 2009;2:79-83.

8. Shafer, Hine, Levy. Shafer's Textbook of oral pathology 5'11 edn. Reed Elsevier. New Delhi; reprinted 2006;65.668,670, 676.

9. Huiunonen S, Orstavik D. Radiological aspects of apical per- iodontitis. Endodontic topics 2002;1:3-25.

10. Knappvost A. Depotphorese copper calcium hydroxide evid- ence based alternative in endodontics. Clinical Dentistry 1998;2:12-15.

11. Mizrahi FZ, Lin S, Cherniak O, Weiss EL A Laboratory study of the effect of calcium hydroxide mixed with iodine or ele- ctrophoretically activated copper on bacterial viability in de- ntinal tubules. Int Endod J2002;35:522-26

12. Knappvost A, Gura E. Preparation of not completely access- ible root canals by means of depot iontophoresis with an ex- terior iontophoresis device. DtschZahnarztl Z 1979;34:477- 79

13. Zhandov EV. The use of depotphoresis of copper calcium hydroxide for the treatment of impassable and hard to reach root canals. Stomatologia (Mosk) 2002;81:61-32

14. Sachdeva S, Gupta R, Gupta G. Iontophoresis and Dentistry. JIndDent Assoc 2011;5:46-48

15. Lin S, Tsesis I, Zukermann O, Weiss E J, Fuss Z. Effect of ele- ctrophoretically activated calcium hydroxide on bacterial vi- ability in dentinal tubules-In vitro. Dent Traiunatol 2005;21: 42-45