Combination of Ledermix Paste

and Calcium Hydroxide

A 50:50 mixture of Ledermix paste and calcium hydroxide has been advocated as an intracanal dressing in cases of infected root canals, pulp necrosis and infection with incomplete root formation (as an initial dressing prior to using calcium hydroxide alone for apexiÞcation), perforations, inßammatory root resorption, and inßammatory periapical bone resorption and for treatment of large periapical radiolucent lesions [70, 82]. It has been shown that the 50:50 mixture results in slower release and diffusion of the active components of Ledermix paste which makes the medicament last longer in the canal [72]. This in turn helps to maintain the sterility of the canal for longer and also maintains a higher concentration of all components within the canal [72] without affecting the function of each component of both medicaments [72, 73].

Taylor et al. [73] also showed that for two indicator microorganisms, Lactobacillus casei and Streptococcus mutans, the 50:50 mixture was marginally more effective than either paste used alone. However, Seow [83] showed that for Streptococcus sanguis and Staphylococcus aureus, the addition of only 25 % by volume of Calyxl (a calcium hydroxide in saline paste) (Otto and Co., Frankfurt, Germany) to Ledermix paste converted the zone of complete inhibition originally seen with Ledermix paste to one of only partial inhibition.

Triple Antibiotic Paste

Because of the complexity of the root canal infection, it is unlikely that any single antibiotic could result in effective sterilization of the canal. More likely a combination would be needed to address the diverse ßora encountered. A combination of antibiotics would also decrease the likelihood of the development of resistant bacterial strains. The combination that appears to be most promising consists of metronidazole, ciproßoxacin, and minocycline [84, 85]. Sato et al. [86] showed that no bacteria were recovered from infected dentin of the root canal wall 24 h after application of a

mixture of ciproßoxacin, metronidazole, and minocycline, except in one case in which a few bacteria were recovered. Hoshino et al. [87] investigated the antibacterial effect of a mixture of ciproßoxacin, metronidazole, and minocycline on bacteria taken from infected dentin of root canal walls and found that it was able to consistently sterilize all samples. Takushige et al. [88] evaluated the efÞcacy of a poly-antibiotic paste consisting of ciproßoxacin, metronidazole, and minocycline, on the clinical outcome of so-called Òlesion sterilization and tissue repair (LSTR)Ó therapy in primary teeth with periradicular radiolucencies. Their results showed that in all cases, clinical symptoms such as gingival swelling, sinus tracts, dull pain, spontaneous pain, and pain on biting disappeared after treatment. However, there were four cases where the clinical signs and symptoms were only Þnally resolved after further treatment using the same procedures. Windley et al. [32] assessed the efÞcacy of a triple antibiotic paste in the disinfection of immature dog teeth with apical periodontitis. The canals were sampled before (S1) and after (S2) irrigation with 1.25 % NaOCl and after dressing with a triple antibiotic paste (S3), consisting of metronidazole, ciproßoxacin, and minocycline. At S1, 100 % of the samples cultured positive for bacteria with a mean CFU count of 1.7 × 10. At S2, 10 % of the samples cultured bacteria-free with a mean CFU count of 1.4 × 10. At S3, 70 % of the samples cultured bacteria-free with a mean CFU count of only 26. Reductions in mean CFU counts between S1 and S2 as well as between S2 and S3 were statistically signiÞcant.

Conclusions

1.The local application of antibiotics within the root canal system may be a more effective mode for delivering such drugs than systemic routes of administration.

2.Tetracyclines have been used to remove the smear layer from instrumented root canal walls, for irrigation of retrograde cavities during periapical surgical procedures, and as intracanal medicaments.

3.Substantivity of tetracyclines has been shown for up to at least 12 weeks.

4.BioPure (MTAD) is effective in removing the smear layer. However, the antimicrobial efÞcacy against E. faecalis of 1.3 % NaOCl/MTAD compared with that of the combined alternate use of 5.25 % NaOCl and 15 % EDTA is still controversial.

5.Substantivity of MTAD has been shown to last for up to 4 weeks. Furthermore, application of MTAD to 1.3 % NaOCl-irrigated dentine may reduce its substantivity.

6.Tetraclean, a mixture of an antibiotic (doxycycline), an acid, and a detergent has a very low surface tension and a high degree of efÞcacy against bacterial bioÞlms.

7.Ledermix paste, a glucocorticosteroidantibiotic compound, has anti-inßamma- tory, antibacterial, and anti-resorptive properties, all of which help to reduce the periapical inßammatory reaction including clastic-cell-mediated resorption. This material has been shown to signiÞcantly lower the incidence of inßammatory and replacement resorption and thus promotes more favorable healing in replanted and luxated teeth.

8.A 50:50 mixture of Ledermix paste and calcium hydroxide has been advocated as an intracanal dressing in cases of pulpless infected root canals, pulp necrosis and infection with incomplete root formation (as an initial dressing prior to apexiÞcation), perforations, inßammatory root resorption, and inßammatory periapical bone resorption and for the treatment of large periapical radiolucent lesions.

9.A triple antibiotic paste consisting of metronidazole, ciproßoxacin, and minocycline has been reported to be very effective in the disinfection of the root canal system.

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