Lesion sterilization and tissue repair (LSTR) method in irreversible dental pulp changes of primary teeth

Abstract

Background/Aim: Deep carious lesions on primary teeth usually have been causing infectious dental pulp changes. If indicated, traditional endodontic root canal treatment for these kinds of pulpal infections in primary teeth usually should involve the performing of pulpectomy methods, but often with questionable prognosis. The lesion sterilization and tissue repair (LSTR) approach is one of the good endodontic therapeutic alternatives for affected primary teeth with a poor prognosis, which could otherwise be condemned to premature extraction. Aim was to evaluate the medium-term clinical success in everyday practice of the LSTR method applied in affected primary teeth with irreversible pulpal tissue infections by observation of reduction/absence of their clinical symptoms. Material and methods: The study sample included child patients who had one or more of their affected primary molars with irreversible pulpal tissue changes of poor prognosis treated with the LSTR method. For each patient whose primary molar tooth was endodontically treated with the LSTR method a clinical evaluation of treated tooth was performed at intervals of 1 and 12 months afterwards. Results: Study sample was consisted of 40 child patients aged 4 to 9 years, with 45 primary molars included in total. It was obvious that the symptoms related to affected sample teeth have already been decreased almost immediately after initial action of triple antibiotic paste. Final outcome after 12-months follow-up period was success of applied LSTR method in 43 (95.6%) affected sample teeth in a way that initial clinical symptoms completely decreased and disappeared. Conclusions: LSTR method has been shown as successful pulpotomy technique for noninstrumental endodontic approach in non-vital pulp treatment of primary molar teeth in a 12-months follow-up period.

Full text

SUMMARY
Background/Aim: Deep carious lesions on primary teeth usually
have been causing infectious dental pulp changes. If indicated, traditional
endodontic root canal treatment for these kinds of pulpal infections
in primary teeth usually should involve the performing of pulpectomy
methods, but often with questionable prognosis. The lesion sterilization and
tissue repair (LSTR) approach is one of the good endodontic therapeutic
alternatives for affected primary teeth with a poor prognosis, which could
otherwise be condemned to premature extraction. Aim was to evaluate the
medium-term clinical success in everyday practice of the LSTR method
applied in affected primary teeth with irreversible pulpal tissue infections by
observation of reduction/absence of their clinical symptoms. Material and
methods: The study sample included child patients who had one or more
of their affected primary molars with irreversible pulpal tissue changes
of poor prognosis treated with the LSTR method. For each patient whose
primary molar tooth was endodontically treated with the LSTR method a
clinical evaluation of treated tooth was performed at intervals of 1 and 12
months afterwards. Results: Study sample was consisted of 40 child patients
aged 4 to 9 years, with 45 primary molars included in total. It was obvious
that the symptoms related to affected sample teeth have already been
decreased almost immediately after initial action of triple antibiotic paste.
Final outcome after 12-months follow-up period was success of applied
LSTR method in 43 (95.6%) affected sample teeth in a way that initial
clinical symptoms completely decreased and disappeared. Conclusions:
LSTR method has been shown as successful pulpotomy technique for non-
instrumental endodontic approach in non-vital pulp treatment of primary
molar teeth in a 12-months follow-up period.
Keywords: Paediatric Dentistry, Endodontics, Primary Teeth, LSTR
Amila Zukanović1, Elmedin Bajrić1, Nina
Marković1, Damir Duratbegović2, Elma
Katana2, Emina Čengić2, Senka Serhatlić2,
Hasan Pejak2
1 Department for Preventive Dentistry and
Pedodontics, Faculty od Dentistry with Clinics,
University of Sarajevo, Bosnia and Herzegovina
2 Clinic for Preventive and Paediatric Dentistry,
Faculty od Dentistry with Clinics, University of
Sarajevo, Bosnia and Herzegovina
ORIGINAL PAPER (OP)
Balk J Dent Med, 2023;15-20
BALKAN JOURNAL OF DENTAL MEDICINE
ISSN 2335-0245
Lesion Sterilization and Tissue Repair (LSTR)
Method in Irreversible Dental Pulp Changes of
Primary Teeth
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Introduction
Deep carious lesions on primary teeth usually have
been causing infectious dental pulp changes, due to
thinner and more permeable mineralized dentine tissue,
and weaker defensive potential of its dentin-pulp complex
as well. The most common diagnoses of dental pulp
diseases included purulent, necrotic, chronic hypertrophic
and/or gangrenous forms1-5.
If indicated, traditional endodontic root canal
treatment for these kinds of pulpal infections in
primary teeth usually should involve the performing
of pulpectomy methods, but often with questionable
prognosis. Furthermore, cooperation in child patients
has often been absent, which usually made it impossible
to perform these kinds of more demanding endodontic
treatments in dental office. So, it often happens that the
indicated procedures were abandoned and premature
extraction was only possible therapeutic choice in
everyday practice. Furthermore, the extractions by
10.5937/bjdm2301015Z

16 Amila Zukanović et al. Balk J Dent Med, Vol 27, 2023
of Sarajevo, and conducted according to the Helsinki
Declaration28. Informed consent was requested from the
parents of the minor respondents, and the content of the
study was briefly explained to the child patients and their
parent’s prior conduction of the study research.
Clinical sample
The study sample included child patients, who
visited the Clinic for Preventive and Paediatric Dentistry
of the Faculty of Dentistry with Clinics of the University
of Sarajevo, who had one or more of their affected
primary molars with irreversible pulpal tissue changes
treated with the LSTR method in the period from October
2020 until June 2021. Child patients had to be of good
general health without diagnosed chronic systemic
diseases, and also without diagnoses of allergies of any
kind to the materials or medicals used for LSTR method.
The method was performed on affected teeth following
clinical diagnoses of irreversible pulpitis, pulp necrosis
or chronic pulp infection with/without haemorrhage,
suppuration or purulence, and with/without signs of pain,
sensitivity to percussion, swelling, appearance of fistula
and/or pathological mobility. The crowns of affected teeth
had to be in restorable conditions. Radiographic inclusive
criteria were: presence/absence of root resorptions (if
resorption existed, only those of exfoliation up to the
one third of root size were acceptable), and with/without
apical periodontal lesions. Non-restorable teeth, teeth with
clinical or radiographic signs of perforated root furcation,
presence of extensive external (more than one third of root
size) and/or internal root resorption, and/or presence of
apical radicular cysts were excluded from the study27,29.
Clinical procedure
After clinical examination and radiographic
evaluation and diagnosis, the LSTR method included
the following clinical protocol during the first visit.
If the therapeutic procedure was painful for the child
patient, local anaesthesia in the vestibular gingival area
of affected tooth root was administered (Orabloc®,
Pierrel S.P.A., Italy; with articaine hydrochloride 40mg/L
and 1:100,000 adrenaline 0.01mg/L). After removal
of carious dentine, followed with removal of infected
pulpal tissue from chamber and root canal entrances of
indicated affected primary molar, pulpotomy was finally
performed. The pulp chamber was then irrigated with
3% Na-hypochlorite and saline solution afterwards and
dried with cotton pellets. Then the triple antibiotic paste
was placed at the entrances of the root canals. The paste
had the following antibiotic composition: amoxicillin
(Amoksicilin HF® capsules a 500 mg; Hemofarm
AD, Vršac, Srbija), doxycycline (Doksiciklin HF®
capsules a 100 mg; Hemofarm AD, Vršac, Srbija) and
metronidazole (Metrozol® tablets a 500 mg; Bosnalijek,
Sarajevo, Bosnia and Herzegovina). Antibiotic powders
from capsules and tablets were properly pulverized and
themselves could not always be the proper solutions, but
often could only open more problems for those children
with behaviour problems in dental office. These situations
were the most stressful paths which enormously in long
term could interfere with child oral and general health,
and with their quality of life as well1-6.
In endodontics of primary teeth, the treatment of
irreversibly changed dental pulp tissue with antibiotic
pastes has been present in the last more than 30 years.
Endodontic treatment of irreversibly changed pulp
of primary teeth, with the use of paste composed of a
combination of antibiotics, was first presented by Hoshino
and Sato et al. back in 1990 and 1992, respectively5,8-10.
Over time, therapeutic approaches have been changed
in terms of partial or complete removal of irreversibly
changed pulpal tissue, with the use of combinations of
different kinds of antibiotics, in order to improve the
prognosis of these procedures as much as possible11-15. The
therapeutic approach was described as lesion sterilization
and tissue repair (LSTR) method and was based on the
reparation of pulpal and/or periodontal tissue of primary
teeth under the action of the applied antibiotic combination.
Validation of the LSTR method on multi-rooted primary
teeth has shown very good prognostic results so far,
with the reduction and/or disappearance of previously
present clinical and radiographic symptoms, without any
interference with the eruption of permanent replacement
teeth. Also, considering the fact that the LSTR method
showed equally good results whether it was performed
within pulpotomy, high amputation or pulpectomy, it
greatly facilitated the treatment of affected primary teeth
with a poor prognosis. When used within pulpotomy form,
LSTR method also greatly facilitated and simplified the
process of endodontic treatment, made it faster and feasible
even for very young child patients, with reduced number
of visits. This have given the LSTR method a significant
advantage over conventional pulpectomy methods,
especially in child patients with a poor level of cooperation
in dental office. Thus, the LSTR approach is one of the
good endodontic therapeutic alternatives for affected
primary teeth with a poor prognosis, which could otherwise
be condemned to premature extraction16-27.
The goal of this study was to evaluate the medium-
term clinical success in everyday practice of the LSTR
method applied in affected primary teeth with irreversible
pulpal tissue infections by observation of reduction/
absence of their clinical symptoms.
Material and Methods
Ethical considerations
This longitudinal observational non-randomized
clinical study was approved by the Ethics Committee of
the Faculty of Dentistry with Clinics of the University

Balk J Dent Med, Vol 27, 2023 LSTR Method in Dental Pulp Therapy 17
analyses were performed with IBM SPSS statistical
software package v. 17. for Windows operative system.
Results
Study sample was consisted of 40 child patients aged
4 to 9 years (M=6.66 years, SD= ± 1.49 years), with 45
primary molars included in total (Table 1).
Table 1. Affected primary molars treated with LSTR method in
study sample
Primary Tooth n %
maxillar first right molar 5 11.1
maxillar second right molar 2 4.4
maxillar first left molar 5 11.1
maxillar second left molar 7 15.6
mandibular first left molar 3 6.7
mandibular second left molar 10 22.2
mandibular first right molar 4 8.9
mandibular first right molar 9 20.0
Total 45 100.0
stored in as described previously17. The powders were
mixed together in 1:1:1 ratio and prepared together with
glycerine vehicle in paste form immediately prior to
its use. The tooth is then temporarily closed with a Zinc
Oxide Eugenol (ZOE) cement filling for 10 days.
After 10 days, the ZOE temporary filling was
removed altogether with the contents of the antibiotic
paste from the chamber. The chamber was washed with
saline solution and dried with cotton pellets. ZOE cement
was then placed on the bottom of the chamber and the
entrances of the root canals, followed by placing of a
permanent filling.
Clinical follow-up
For each patient whose primary molar tooth was
endodontically treated with the LSTR method a clinical
evaluation of treated tooth was performed at intervals
of 1 and 12 months afterwards. During these visits, the
presence/absence of following clinical parameters was
monitored: pain, sensitivity to percussion, swelling,
appearance of fistula and/or pathological mobility.
Statistical analyses
Obtained results were analysed descriptively and
presented in absolute and relative values in tables. Data
Table 2. Presentation of recorded clinical symptoms in affected primary molars during applying of LSTR method
first visit second visit
presence absence total presence absence total
recorded symptoms n (%) n (%) n (%) n (%) n (%) n (%)
pain 23 (51.1) 22 (48.9) 45 (100) 3 (6.81) 41 (93.18) 44 (100)
percussion sensitivity 25 (55.6) 20 (44.4) 45 (100) 4 (9.09) 40 (90.90) 44 (100)
swelling 5 (11.1) 40 (88.9) 45 (100) 2 (4.54) 42 (95.45) 44 (100)
fistula 12 (26.7) 33 (73.3) 45 (100) 4 (9.09) 40 (90.90) 44 (100)
mobility 10 (22.2) 35 (77.8) 45 (100) 5 (11.36) 39 (88.63) 44 (100)
Table 3. Presentation of recorded clinical symptoms in affected primary molars during follow-up periods
after 1 month after 12 months
presence absence total presence absence total
recorded symptoms n (%) n (%) n (%) n (%) n (%) n (%)
pain 2 (6.1) 31 (93.9) 33 (100) 0 (0) 41 (100) 41 (100)
percussion sensitivity 1 (3.0) 32 (97.0) 33 (100) 2 (4.9) 39 (95.1) 41 (100)
swelling 0 (0) 33 (100) 33 (100) 0 (0) 41 (100) 41 (100)
fistula 1 (3.0) 32 (97.0) 33 (100) 0 (0) 41 (100) 41 (100)
mobility 0 (0) 33 (100) 33 (100) 4 (9.8) 37 (90.2) 41 (100)
Clinical symptoms recorded during clinical
examination of affected teeth while applying LSTR
method were presented in Table 2. It was obvious that the
symptoms related to affected sample teeth have already
been decreased almost immediately after initial action of
triple antibiotic paste. But, in the final second visit (after
10 days) of clinical procedure there were 39 patients and
44 teeth included, due to extraction of one tooth from
sample on child parent’s request.
After clinical follow-up recorded symptoms related
to affected sample teeth were presented in Table 3.
Further continuous decrease and disappearance
of previously recorded clinical symptoms were noted.
Twenty-eight patients (70% out of total sample) with 33
affected teeth treated initially with LSTR method were
present in the first follow-up period after 1 month. LSTR
method was considered as successful in 26 patients (92%)
and 29 teeth. One more child had symptoms of persistent

18 Amila Zukanović et al. Balk J Dent Med, Vol 27, 2023
root canals of primary molars during 12-months follow-up
period.
LSTR method was substantially based on the idea of
regenerative endodontics in permanent teeth, where, after
performed pulpectomy, temporarily applied antibiotic
paste root fillings intended to disinfect remained root canal
space and root dentin, and at the same time to re-initiate
the potential of surrounding soft and/or hard dental tissues
to regenerate. The idea of not removing infected pulpal
tissue from the root canals of affected tooth was only
present in primary teeth for a long time, but with various
kinds of therapeutic approaches applied. They all intended
to minimize or exclude further infectious pulpal tissue
potential to apical direction. Otherwise, these non-vital
pulpotomy procedures were judged to failure, and, with
endangering of local, oral and general health, could only
lead to premature extraction5-8, 39.
In paediatric dentistry there are several basic
indications for every kind of dental treatment related
to its invasiveness, and also to child general and mental
health regarding their capabilities for understanding and
cooperate during planned dental treatments. The more
invasive the treatment was, in combination with the
more invasive dental treatment could be, would result in
uncooperative dental behaviour. That is why everyday
paediatric dental practice needs those kind of therapeutic
solutions, even in situations that usually would have poor
prognosis, in order to preserve and improve poor oral
health. Otherwise, in everyday oral pathology in children
of preschool and young middle childhood age, where
indications for non instrumental endodontic non-vital
treatment in primary teeth were numerous, we usually
could have consequent disturbed orofacial development
and developed dental fear and anxiety in child patients
as long-term outcomes. These outcomes could have
great potential to be pretty reduced with LSTR method
applied1-5, 24, 27.
LSTR method basically used combination of
three antibiotics in order to cover and eliminate as
much bacterial strains and types that were present in
infected pulpal tissue. Some of these antibiotics, like
nitroimidazoles and macrolides classes, could have
various side-effects in their more usual non-dental use in
adults. Furthermore, there were also some doubts present
regarding their profound long-term disinfection and
sterilization potential, which could result in microbial
recolonization and therapeutic failures, and consequent
harm to oral and general health of child patients. But,
proper specific antibiotic usage in LSTR method within
determined indications could result in several evidence
based benefits only, which would eliminate these
opponent opinions for their dental use. Although LSTR
method was first introduced in Japan pretty long time
ago, and mostly applied sporadically afterwards, the
American Academy of Paediatric Dentistry have adopted
it recently and included in the guidelines of non vital pulp
pain and fistula related to affected sample tooth, which
had to be extracted upon parent’s request.
In the final follow-up after 12 months there were
38 patients (95%) present with 41 affected sample teeth.
Percussion sensitivity and mobility were only recorded
in affected sample teeth which were within the process
of exfoliation. Furthermore, primary teeth were regularly
exfoliated by their permanent successors in another 2
patients, with sound enamel and no clinical signs of any
kind regarding developmental disturbances on their
crowns.
Final outcome after 12-months follow-up period
was success of applied LSTR method in 38 patients and
43 (95.6%) affected sample teeth in a way that initial
clinical symptoms completely decreased and disappeared.
In 2 patients with 2 (4.4%) affected sample teeth applied
LSTR method was considered as unsuccessful and ended
up with extractions upon their parents’ requests.
Discussion
Application of LSTR method as non-
instrumentational form of endodontic treatment for non-
vital pulp in primary teeth has been shown as successful
technique in most of the reported related papers so far.
Indeed, the success rates in the last five years were high
but variable (mainly higher than 80%), as for the method
itself, and compared to the other performed pulpotomy
techniques23, 29-34. Furthermore, this method was even
more time consuming than some of other methods35.
Pretty high success rate in our study sample corresponded
to these results.
When compared to the pulpectomy, LSTR approach
as more convenient method was more successful in
affected teeth with root resorption in the first 12 months
after its application25,26. Our final clinical follow up
period was up until 12 months and without clinical
findings to compare these claims due to the fact that our
observational period was not longer than a year.
LSTR method itself has experienced many
modifications regarding the antibiotic compositions
and concentrations with intention to cover as much of
different kinds of microorganisms as possible within
infected pulp tissue and surrounding dentinal walls of
root canals. The idea was to disinfect those affected soft
and hard dental tissues in order to sterilize them from
microorganisms, and to consequently let the surrounding
tissues to regenerate36-38. The combination of antibiotics
in our study included specific members of penicillins,
macrolides and nitroimidazoles with their equal ratio,
and the final form of paste was prepared with glycerine
vehicle. It seemed that this antibiotic paste has enabled
profound penetration rate for disinfection and sterilization
of infected soft and hard dental tissues within affected

Balk J Dent Med, Vol 27, 2023 LSTR Method in Dental Pulp Therapy 19
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teeth was to show if its application could interfere normal
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There were several limitations of this study. First of
all, intention of this paper was to show cases with LSTR
method applied from our everyday practice, which have
resulted in observational non-randomized study, where
control and/or other comparative experimental groups
of patients were not established. Also, study protocol
followed our everyday clinical routine in the dental
office, where final restorations after second visit usually
were not stainless steel crowns (SSC), but rather mostly
glass-ionomer cement fillings. This fact could have more
potential to compromise the sealing after final restoration
than SSC. But, our follow-up results did not show
these potential filling microleakage problems. Various
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combination and dosage of used antibiotics, follow-up
periods and outcomes. These facts should be considered in
the future studies, in order to avoid potential problems in
establishing the strictest evidence based clinical guidelines
for LSTR method in primary teeth for everyday practice.
Conclusions
LSTR method has been shown as successful
pulpotomy technique for non-instrumental endodontic
approach in non-vital pulp treatment of primary molar
teeth in a 12-months follow-up period. This method
proved as the most convenient and time consuming
technique for the affected primary molars with irreversible
pulp infections of poor prognosis, which enabled delay/
cancellation of their premature extractions, and decrease
of appearance of dental fear and anxiety and behaviour
problems in child patients in the dental office.
Acknowledgements. We would like to acknowledge
the great efforts of the stuff of the Clinic for Preventive
and Paediatric Dentistry of the Faculty of Dentistry with
Clinics of the University of Sarajevo, for this study to be
successfully accomplished.

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Received on August 18, 2022.
Revised on September 2, 2022.
Accepted on September 20, 2022.
Conflict of Interests: Nothing to declare.
Financial Disclosure Statement: Nothing to declare.
Human Rights Statement: All the procedures on humans were
conducted in accordance with the Helsinki Declaration of 1975,
as revised 2000. Consent was obtained from the patient/s and
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Correspondence
Amila Zukanović
Department for Preventive and Paediatric Dentistry
Faculty od Dentistry with Clinics
University of Sarajevo, Bosnia and Herzegovina
e-mail: amila.zukanovic@hotmail.com
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