Introduction of DMS
irrigation to heal Endo–Perio lesions and Cysts
Darakshan Nabi Vakil, BDS
Abstract
Introduction: This article discusses the introduction of DMS
Irrigation Solution (Doxycycline, Metronidazole and Saline). It is an
antibiotic solution, which can be pushed beyond the Periapical region to treat
the Perio-Endo Lesions, Furcation, Fistula and even a big cyst of diameter 10
to 12 cm without causing any complications. Material
and Method: The case study has been done in Sabya General
Hospital, Jizan, Saudi Arabia in patients of the age group 18 to 55 after their
proper consent. Only female cases were taken up for the
study. Observation: Fifty cases were treated and followed up. Among them 20 cases had
periodontitis and all of these had history of diabetes. During this procedure the DMS irrigation is used which
directly flushes the microbes providing enough dilution, irrigation and
initiates the process of healing, revascularization, regeneration and epithelialization
of the wound. Conclusion: Delivery
system seems to be an efficient system in treating the lesions; even of bigger
diameters and DMS, as an irrigation seems to be the most appropriate additional
irrigation besides the conventional ones used in dentistry.
Introduction
A clinician needs efficiency and proper knowledge of the defect prior to
deciding any procedure. The latest evidences emphasize that an atraumatic
procedure is always a better option and single or multiple visits should not be
a reason to opt for the surgery. The relationship
between the periodontium and the pulp was first discovered by Simring and
Goldberg in 1964(1). The sequel of events, their
mixed anaerobic infections follow different pathways but lead to similar
consequences: the abscess, the furcation, the sinus-tract, fistula, denudement
of periodontal ligament and the bone destruction (periodontitis) and a more
accentuated form - the cyst, which has other etiological factors too. A cyst is
a challenge to treat non-surgically without enucleation. The pulpal and
periodontal infections at times co-exist together in the form of combined
lesions, showing different manifestations and following different patterns(2). The periapical endodontic lesions increase in size and enlarge in a
coronal direction, while at the same time a periodontal pocket progresses apically
and the two lesions subsequently join. These teeth require both root canal
therapy and aggressive periodontal treatment for their survival. Periodontitis
is normally considered to be a chronic process. The micro-organisms associated
with periodontitis may also be capable of producing necrosis of the pulp cells
through the action of their metabolic products, destructive enzymes or other
mechanics(3). Porphyromonas and prevotella species induce the
activation of macrophages which subsequently produces interleukin-1. This
mediator may enhance bone resorption and perpetuation of the combined
pulp-periodontal lesion. The larger the part of the lesion caused by root canal
infection or plaque infection, the favorable prognosis is once the regeneration
of attachment happens(4). Root canal procedure seems to
be the most appropriate treatment in draining the abscess produced by either of
the two routes, Endo or Perio. The presence of A. actinomycetemcomitans is a
major organism and the discovery that this organism penetrates the tissues
offered new hope for therapeutic success, namely antibiotics. Currently an
ideal such antibiotic does not exist, however a combination is necessary to
eliminate all putative pathogens. The currently used chemicals for irrigation
include NaOCL, (Sodium Hypochlorite) CHX (Chlorhexidene), EDTA (Ethylenediaminetetraaceticacid)
and MTAD (A mixture of doxycycline, citric acid and a detergent Tween80. None
of these possess all the characteristics of an ideal irrigation. Hence the need
to test the effectiveness of an easily prepared antibiotic solution for
irrigation.
Material
and Methods
Study Selection: The patients
selected were only females between the age group of 18 and 55 years. They
visited the OPD of Sabya General Hospital, Jizan, Kingdom of Saudi Arabia and
were diagnosed with various lesions. The surgical procedures were decided but
certain patients had preference for non-surgical procedures and some of the
patients when given options opted for the atraumatic line of treatment. This
whole procedure and follow up was done between May 2015 and January 2018.
Composition
of DMS: DMS irrigating solution
is used in the ratio of 1:5:5. One capsule of Doxycycline 100 mg, 5 ml of metronidazole and 5 ml of normal
saline. The concentration of the drug used in this research is 5ml from 500ml
of metronidazole which contains 500 mgs. This means the concentration used here
is minimal i.e. 5 mg of metronidazole and 100 mg of doxycycline with 5 ml of
normal saline. This combination has the least toxic complications and provides
significant results. DMS is used on weekly basis for first month and then
tapered in the second month. Local delivery: The use of local delivery method to administer antibiotics offers a
novel approach to localized periodontal infections but in perio-endo lesions,
all endo-irrigations have their limitations. Recently MTAD (a mixture of
tetracycline isomer, acid and detergent) has been introduced which is a
formulation of doxycycline, tween-80, and citric acid. Its effectiveness is
attributed to its anti-collagenase activity, low pH & ability to be
gradually released over time, however MTAD cannot be pushed beyond the canals
in the periapical region to treat the furcation or a cyst(5). DMS
solution follows the process of osmosis and works against concentration
gradient thereby reducing the acidic pH of the abscess at the site and
relieving the pain immediately. The RCT (Root Canal Treatment) is an initial
step done to relieve the pressure by providing the drainage. Tetracycline as a
mouth wash was used on these patients initially and the hygiene was taken care
of thoroughly. The mouthwash was not mandatory for other cases.  Observation:
All the
patients responded without any complication except one patient aged 45, who
developed sensitivity to doxycycline even after doing all her blood
investigations. She felt pain while injecting it through the access cavity
prepared in 41. She had a huge lesion, so after RCT apicectomy was considered
the best treatment. From the various studies done so far it has been seen that
there is a strong correlation between the periodontitis and diabetes. Any
significant medication in treating the periodontitis in diabetic patients can
become a motivational local delivery drug combination to treat the lesion. Meenavat et al(6) studied the effect of
periodontal therapy in diabetics and found that there was reduction in HbA1c in
patients who underwent periodontal therapy with systemic doxycycline and
chlorhexidine rinse. Diabetic
patients, their compromised bone structure and the excellent prognosis with
Doxycycline helped me launch the concept of DMS in treating the lesions.
The use of antibiotic in perio-endo lesion was first reported in 1951 by
Grossman(7) which was known as poly-antibiotic paste and was a
mixture of penicillin, bacitracin, streptomycin and caprylate-sodium. The potency and efficacy of medicaments used in DMS have been
separately been advocated by Jarmillo and Herrara(8). They
stated that antibiotic therapy should be taken into account in abscess
formation. The antimicrobial property of calcium
hydroxide and tetracycline has found a significant effect on enterococci(9). In 2012 the mixture of metronidazole,
ciprofloxacin and minocycline was added with macrogol propylene glycol and was
a powdered mix in a ratio of 1:3:3(10).
Ledermix was used as a therapeutic intracanal medicament. It had two active
components, triamicinolone a steroid (1 percent) and broad spectrum antibiotic
di-methylchlortetracycline 3:2 and 1 percent democycline(11).
The discoloration occurred due to minocycline packed for 2 weeks. Metronidazole
was used as a 1% solution or, more frequently, as a 0.75% or 0.80% gel. Two
reported adverse effects were skin irritation and a burning sensation. In a
study by Barker and Lockett it was found ineffective in eliminating
streptococcus viridans in root canal of dogs(12). Dogs were
administered metronidazole orally at doses of 0, 25 and 50 mg/kg for a period
of one month. They showed no physical or biological alteration and no tissue
modification(13). From the previous researches, it has been seen
that the peak concentrations of metronidazole in plasma and saliva were in the
same range, 8.7-13.8 micrograms/mL, and similar concentrations were found in
the gingival fluid samples. It is concluded that metronidazole taken orally has
similar pharmacokinetics in both saliva and plasma, and that a single oral dose
of 750 mg metronidazole leads to a concentration of the drug in the gingival
crevice fluid that exceeds the minimal inhibitory concentration for most
anaerobic oral micro-organisms(14). Generally, topical metronidazole
was reported to result in a reduction or eradication of wound odor, decrease in
wound drainage, improvement in wound appearance, decrease in surrounding
cellulitis, halting of tissue necrosis, and decrease in pain. Although nurses
report success with sprinkling crushed metronidazole pills on wounds, no
published reports of this method of topical application are available. Topical
metronidazole may be considered as an option for the management of malodorous
wounds. In all these years antibiotics were used in the form of powder and
mixtures but never as an irrigation.
The DMS Irrigating solution obeys the physical phenomenon of osmosis. It
is of great importance in biological processes. The transport of solute
molecules of doxycycline and metronidazole creates selective diffusion process
driven by the internal energy of solvent molecules. This attains enough
pressure for diluting the abscess incubated in the inaccessible furcation area,
or even a cyst henceforth increasing, the pH from an acidic consistency of 6.7
to 7. The initial response is the relief in pain. Grahms and Ficks Law of
Thermodynamics are profound in transportation and natural phenomenon. The drugs
used in this research have specific modalities like tetracyclines. They were
initially used as a mouthwash in the diabetic patients and finally got replaced
by doxycycline in DMS due to their chemically modified nature. Jens Ove
Andersen(15) in his studies showed that topically applied
tetracycline solution doubled the chance of pulp re-vascularization.
Tetracycline has some specific properties including low pH. Its acidic property
causes it to function as calcium chelator and demineralize enamel and dentin.
This mineralization is comparable by what is gained through citric acid.
Furthermore, tetracycline has retention property absorbed by dentin and
cementum and freed gradually. In high densities, tetracycline can have a
bactericidal impact. Among other specific properties of tetracycline is its
ability to decrease the root resorption by affecting the osteoclast activity
and reducing collagenase; although tooth color is a harmful side-effect of this
irrigant(16). Doxycycline has higher availability in gingival crevice. It's more significant
against A. actinomyetemcomitans and Enterobacter faecalis. It has host
modulating properties: antimicrobial, anti-collagenase, anti-inflammatory,
inhibition of bone resorption, and promotes re-attachment(17). Collagenase and gelatinase are matrix
metalloproteinases (MMPS) which play an important role in tissue destruction.
Doxycycline inhibits MMPS and prevents tissue destruction independent of their
anti-microbial activity. The molecular environment of chronic wounds like many
other chronic inflammatory diseases contains abnormally high levels of
pro-inflammatory cytokines, tumor necrosis factor (TNF)-alpha and interleukin
(IL-1beta) and MMPs which impair normal wound healing. The US Food and Drug
Administration (USFDA) approved antibiotic appears to inhibit members of the
MMP superfamily like MMPs and TNF-alpha converting enzyme (TACE). The use of
topical doxycycline enhances healing of chronic wounds. The favorable clinical
response may in part be due to inhibition of classical phagocytes, neutrophils
and mesenchymal collagenase/MMP8 activities produced by doxycycline. This
anti–collagenolytic doxycycline effect is mediated through inhibition of the
enzyme. Doxycycline scavenges hypochlorous acid and superoxide radicals
produced by phagocytes. Doxycycline increases the level of interleukin 34. It
is a cytokine which promotes the proliferation, survival and differentiation of
monocytes and macrophages. It promotes the release of pro-inflammatory
chemokine and thereby plays an important role in regulation of osteoclast
proliferation and bone resorption. Yagiela et al(18) explained the
mechanism of doxycycline as it is primarily bacteriostatic, inhibits bacterial
protein synthesis by binding to and interfering with ribosomes. This
bacteriostatic action may be advantageous because in the absence of bacterial
cell lysis, antigenic byproducts such as endotoxins are not released. The
research concluded that doxycycline administered at sub-antimicrobial doses led
to improvements in disease parameters with no apparent side effects and appears
to have significant potential as an oral adjunctive therapy in the long term
management of adult periodontitis(19). Metronidazole is the drug of choice for treating Actinomycetemcomitans and is more
effective when used in combination with other antibiotics. It's also effective
against P. gingivalis and Prevotella intermedia. Metronidazole rapidly enters
human gingival fibroblasts via simple diffusion. Metronidazole has a marked
anti-inflammatory action and as such leads to early regression of pain and
inflammatory edema and healing of ulcer(20). The ultimate goal of periodontal therapy has
been the regeneration of the supporting tissues lost as a consequence of
inflammatory periodontal diseases, various modalities are available to treat
the bone defects and achieve a goal in treating localized infra bony and class
2 furcation defects by using guided tissue regeneration GTR. Metronidazole
which is an anti –microbial drug helps in the management of infrabony bone
defects associated with periodontal defects, non–surgically when incorporated
with the doxycycline as an irrigation to reach the inaccessible areas and to
reduce the mobility(20) . Rao et al(21) used metronidazole and reported a significant
increase in the epithelialization in the wound. Normal saline (isotonic
solution of 0.9% sodium chloride) is used to flush wounds and is an effective
endo-irrigant. It acts as a vehicle to transport the doxycycline and
metronidazole granules, facilitating the reduction of pathogens and promoting
the antibiotics to work efficiently. It can be used safely in periapical area
when compared to 2.6 percent sodium hypochlorite which has its complications.
It leaves us no doubt that the DMS in the form of irrigation gains
accessibility without causing any side effects. Lastly calcium hydroxide is
packed in the canals. The hydroxyl group of calcium hydroxide is considered the
most important component which provides an alkaline environment thereby
encouraging repair and active calcification. It neutralizes the lactic acid
from osteoclasts, arrests inflammatory root resorption and stimulates healing.
The
clinical pictures and the radiographic presentations of few patients are
depicted below showing the healing of lesions atraumatically and demonstrating the effects of DMS.
A patient aged 25 years with an old composite restoration and a pyogenic
granuloma in the lingual sulcus in relation to 36 is shown in the picture
below.
Iopa (Intra-oral peri-apical) X-ray reveals radiolucency in
relation to tooth 36, mobility grade 2, vitality negative; Periodontal
examination depicts the depth of 4-7mm and class 2 furcation involvement (measured with Naber’s probe).
B)A 10-year-old patient with Swelling and pain is diagnosed a Fistula
related to 41.
C) Represents
a 25 year old patient with radicular cyst based on clinical and radiological
diagnosis. Differential diagnosis should include dentigerous cyst,
ameloblastoma, odontogenic keratocyst, periapical cementoma and Pindborg tumor.
The patient was treated on the same lines as the previous cases. Success was attained
within 2 months of treatment and the patient was kept on follow up. It was a
challenge to treat such a big radiolucency without enucleation. In the first
two sessions the pain and the huge swelling was reduced. Slowly and gradually
the huge radiolucency got replaced remarkably by bone and tissue epithelialization
started filling up the empty space. There were many speculations regarding its
recurrence, however the reduction of a cyst non-surgically was remarkable. The
patient was kept on follow up and even after 8 months there was no recurrence.
 

 
Serial evaluations showed remarkable outcome and the irrigation varied as
per the patient’s lesion and its severity. Oral hygiene was one of the most
important factor and a priority in treating these lesions.
DISCUSSION
Infections are associated with the usual symptoms but if they are related
to a tooth they are encased inside a closed structure thereby exaggerating all
those symptoms resulting in severe intolerable pain. In all kinds of infections
of any origin, antibiotics are prescribed systemically. These antibiotics reach
a peak level and start combating all manifestations of the disease. In case of
a tooth these antibiotics play a major role too but to relieve the pressure
build up inside the tooth we adopt RCT for drainage and use irrigating
solutions. The infection in the tooth leads to lesions which can be seen as radiolucency of various diameter on x-rays. The
radiolucency in the perio-endo lesions are difficult to treat due to
inaccessible position e.g the furcation, aggregate of microbes. Seven bacterial
species can be found in oral cavity leading to various perio-endo lesions and
destruction of tissue. Collagenase and gelatinase are matrix metalloproteinases
(MMPS) which play an important role in tissue destruction. During all these years, surgical procedures
are being done on the lesions of various types. They are invasive procedures
done every now and then It takes time for bone regeneration and epithelialization
of wounds, but when we think of non-surgical techniques they seem difficult and
time consuming. In other words we can opt for these techniques only if the
patients are co-operative and we have profound knowledge of the procedures we
are doing. The best achievement is when both the techniques provide the same
results non-invasively without scarring or suturing. In both these techniques
we use irrigations. During surgery we use normal saline and while opting for
non-surgical techniques we opt for RCT and use various irrigating solutions.
Since 1920 Sodium hypochlorite has been used and is one of the most frequently
used endo-irrigation to treat the lesions. Its bactericidal and proteolytic efficacy is quite known but NaOCL
causes haemolysis and necrosis if injected beyond peri-apical region(22).
Many
studies in the literature indicate that combined periodontal and endodontic
therapy is essential for successful healing of a periodontal-endodontic lesion.
It has been said that either endodontic or periodontic treatment alone would
not lead to a satisfactory prognosis, if both disease entities are present and
that both must be considered together. Hiatt and Amen(23) claimed
that persistent periodontal disease may clear up only after definitive
periodontal therapy is followed by successful endodontic treatment. Simring and Goldberg(1) postulated
that endodontic therapy is indicated in the treatment of terminal periodontal
disease that does not respond to periodontal therapy. The localized nature of
the periodontal infection and the easy access of the teeth, has prompted the
development of delivery systems which release the antimicrobial agent directly
into the periodontal pocket. The first of these delivery systems that is
commercially available is a tetracycline impregnated cord which can be wrapped
around the tooth below gingival margin. The cord releases over 100 μg of
tetracycline per ml of gingival crevicular fluid during the entire period that
it is in situ(24). In this manner, patient compliance is assured
and the plaque microbes are constantly exposed to therapeutic levels of the
agent. The double-blind metronidazole studies indicate that EOP (Early onset
periodontitis) and AP (Adult periodontitis) respond to treatment as if they
were anaerobic infections and would seem to presage the more frequent usage of
anti-anaerobic agents, such as metronidazole(25). In the future
treatment of periodontal disease, further developments of delivery systems
which release antimicrobials directly into the periodontal pocket should assure
that most periodontal infections will be medically managed(26).
Directly
infusing antibiotics into the infected area maintains a high local
concentration level while minimizing systemic toxicity. Work has been done no
doubt in orthopedic implant surgery, however it also suggests that this method
avoids the potential for growth of antibiotic resistant strains of bacteria.
Locally applied antibiotics concentration is 1000 times higher and causes major
reduction in infection, therefore it can be applied in the peri-apical lesions
too(27).
The local drug delivery devices, which have been approved for the
treatment of periodontal diseases, are Perio chip®, Jerusalem,
Israel (2.5 mg chlorhexidine gluconate, thin solid chip system), Atridox®,(Atridox is a FDA approved 10% doxycycline in 1 a gel
system using a syringeFort) Collins, Colo, USA
(10% doxycycline hyclate, flowable polymer syringe), Actisite®, Palo
Alto CA, USA (25% tetracycline fibers) and Arestin®, Warminster,
Pennsylvania (1 mg minocycline hydrochloride, microspheres syringe)(28).
Metronidazole: Elyzol is a topical medication containing an oil-based
metronidazole 25% dental gel , applied in viscous 1 consistency to the pocket(29).
USFDA has approved these drugs and are being used individually but if these
drugs are combined their efficacy becomes better and that is what has been
attained with DMS irrigation.
CONCLUSION
We
recommend that DMS can be used as an ideal irrigation in the treatment of
endo-perio lesions. We know that at a junction the two maladies (endo or perio)
lead to the same sequence of destruction. If endodontically we acquire a
hermetic seal in the canals, the elimination of microbes, epithelialization of
tissues and healing of lesions can be easily attained by the combination of
anti-microbial agents like DMS. However, the delivery system should be advanced
and the irrigation should be made in the refined and modern manner.
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Author Information: Dr. Darakshan Nabi Vakil, BDS worked as General Dentist in Sabya
General Hospital, Jizan, Kingdom of Saudi Arabia. She is Member, Saudi
Commission for Health Specialities and Member CBAHI Guidelines for Dental
Department. She is also Member Saudi Dental Society. Email: pinkeynabi@gmail.com
Disclosure: The
contents of the paper are solely the responsibility of the author.
How to cite this article: Vakil DN. Introduction of DMS irrigation to heal Endo–Perio
lesions and Cysts. Physicians Academy 2018; 12(4): 43-51
Source of support: NIL.
Conflict of interest: None declared. To Get This Article in PDF CLICK HERE |