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What is the LSTR Therapy?
LSTR stands for Lesion Sterilization and Tissue Repair. LSTR 3Mix-MP therapy is a novel caries, pulpal and root canal treatment system. Using an anti-bacterial drug combination, the therapy aims to eliminate causative bacteria from lesions, and after sterilization, the lesions are repaired or regenerated by the host’s natural tissue recovery process.
After sterilization, softened dentin will re-calcify, so both softened dentin as well as carious dentin can be intentionally left. An inflamed pulp, even with spontaneous pain, will recover after LSTR treatment. In root canal treatment, complete root canal preparation or root canal obturation is not essential due to the medication of 3Mix-MP which can successfully eliminate the causative bacteria from dentin walls of the root canals.. The principle and clinical procedures of LSTR 3Mix-MP therapy are quite different from the conventional endodontic treatment procedures, so it is necessary for to follow the specific and proper procedures for LSTR 3Mix-MP therapy. This procedure should not combined together with conventional procedures.
What are the benefits to use LSTR 3Mix-MP therapy?
This treatment medicates and treats caries, pulpitis and root canal infection. The concept of this therapy is 'do not remove', 'Do not touch' and ‘Leave it' as much as possible.’ In caries treatment, carious dentin including softened dentin is intentionally left without removing it. In pulptitis cases, the inflamed pulp is disinfected without pulpotomy or pulpectomy, and in root canal treatment root canal preparation or root canal obturation is not essential. In most cases, the treatment can be completed in one visit. So the treatment is simple, painless, time-saving, and with less of a burden to patients physically and mentally. Thus, patient compliance and cooperation of patients is predicable, even in pediatric treatment.
How to prepare 3Mix-MP
3Mix-MP should be prepared (mixed) on the day of treatment. However, in advance, each drug can be powdered and stocked in a desiccated and tight-capped device/container.
The powdered drug should be used up within a month, and kept under dehumidified conditions if possible. When or if the powder becomes wet, it should be discarded.
The preparation would be better done by yourself (operating dentists) to be sure when and how the preparation was performed. To ensure the antibacterial efficiency of the prepared 3Mix, you should be sure the drugs are potent enough even after powdering, after stock of respective drugs, and after preparation of the 3Mix. The clinician should know how to pulverize the drugs properly, how to stock the powdered drugs under the suitable conditions, and how to make 3Mix-MP correctly. Again, an important point is that the powder of drugs should be mixed on the day of treatment. 3Mix (mixed 3 drugs) is mixed with MP to make up 3Mix-MP.
1. Powdering drugs.
1) Tablets/ Metronidazole and Ciprofloxacin.
Metronidazole may be coated with sugar coating, and if so, remove it. The Drug component is located in the cores.
The Film coating of the Ciprofloxacin, and capsule materials of Minocycline are also removed.
You may check the components of each tablet and capsule. For example, if a tablet is a 100mg tablet, and after removal of sugarcoat/film coating /capsule materials, is 100mg, which means the tablet contains 100 mg drug (100% purity). If the actual weight is 200mg, it means there is only 50% purity. If a tablet is a 200mg tablet as the potency, and the actual weight is 200mg, there is 100% purity. The same amount of powder contains the same potency. Thus, the labeled potency (100mg tablet or 200mg tablet) does not necessarily equal the purity. If the prepared powder is of 50% purity, then 2-times the amount would be equivalent potency to the powder of 100% purity.
2) Mortar and pestle for powdering the drugs.
3) Clean burs with engine, knives or other instruments to remove sugar coating and film coating.
4) 4 Ceramic devices with tight caps to keep each drug separately from moisture and light. Put Silica gel inside the ceramic devices to desiccate.
Purchase Metronidazole, Minocycline, and Ciprofloxacin.
These may be in forms of tablets or capsules, or in pure powder form.
One tablet/capsule may be enough for a one-month supply(3 patient x 25 days).
If so, you will prepare each of 3Mix drugs once per month, and the other remaining tablets/capsules are kept in original packages to avoid efficiency losses.
1) Take one tablet of Metronidazole, which may be sugar coated. Using burs or others, sugar-coating layers will be removed.
If you use Asuzol tablets, pink line indicates the boundary of the sugar coating layer. Remove the side-edge partly to make the pink line clear, and then remove out the outer layers of tablets according to the guidance of pink line. The core is used.
2) Crush, smash and grind the tablet core to obtain a fine powder.
3) Transfer this to a ceramic device, and cap tightly. You may use paraffin coated drug-rapping paper to rap powder. Keep dry with desiccates.
4) Wash and dry all the instruments used for Metronidazole powdering to avoid mixing with the other drug. You may use ethanol to dry mortar up, if necessary.
5) Take one tablet of Ciprofloxacin. It may have film-coating. Use a knife, scissors or others devices to take off the coating. Do 2). Un-removed film fractions may be found in this procedures, and if so, take those out. Do 3) and 4). This clean-up step should not be omitted.
6) Take one capsule of Minocycline. This may be capsule form. Open capsule and place the content onto mortar. Do 2) to break micro-capsule structure and make a fine powder. Do 3) and 4).
Now you have fine powders of Metronidazole, Minocycline, and Ciprofloxacin in separate ceramic devices. The fine powder should be used up within a month.
2. 3Mix-MP preparation
On the day of treatment, you will do this procedure, and 3Mix-MP preparation can be used on that day. Any unused 3Mix-MP should be discarded at the end of the clinic day.
1) Three devices with the drug-powder. If you stock these devices in a refrigerator, you should wait to open the caps for a while until it reaches room temperature to avoid any condensation drops.
2) A clean and dry kneading glass slab/mixing pad with a spatula.
3) A Fourth device to keep the prepared 3Mix-MP.
1) Using a spatula, take the Metronidazole (MN) drug-powder onto a kneading paper/glass pad. Wipe and make clean the spatula to avoid contamination of MN with the next drug-powder. Place the MN device away after capping it tightly, not to use it again. Use all 3 drugs, and not 2 or 1 kind because this is the most effective combination to kill all the types of bacteria in endodontic infections.
2) Using a clean and dry spatula, place the same amount of Minocycline (MINO) drug-powder onto kneading pad. Wipe and clean the spatula to avoid contamination of CIPRO with the next drug-powder. Place the MINO device away after capping tightly so not to use it again.
3) Using a clean and dry spatula, place the same amount of Ciprofloxacin (CIPRO) drug-powder onto kneading pad.
4) Mix those to make up the 3Mix.
Metronidazole : Minocycline : Ciprofloxacin=1 : 1 : 1
(original ratio was 3;3;1, but 1:1:1 is adequate)
5) At the other end of the mixing pad/glass slab, take one part Propylene glycol (P) and the same volume of Macrogol (M). Mix well to make up the MP. The texture and appearance will be like 70% whipped cream. Only one part of MP to 7 parts of 3Mix is needed to make an effective preparation of 3Mix-MP.
6) For standard preparation, mix one-part of MP and 7-part of 3Mix.
Standard preparation: 3Mix : MP=7 : 1
7) The final preparation will be a soft ball-like structure of 1mm diameter. If you cannot produce a rounded ball-like structure using spatula because it is too soft, add more 3Mix powder to this. If your preparation becomes flakey and dry, the preparation is too hard so you can add more MP in this case.
8) Use the 3Mix-MP preparation immediately and the remaining 3MixMP can be stored in the fourth device. If you leave 3Mix-MP on the pad (this may be also acceptable, if covered by another mixing paper or pad), the Mix-MP may become dried with time, and if so, add more MP.
9) It is quite simple and easy to prepare 3Mix-MP. Ideally it is better to prepare 3Mix-MP for each patient immediately before the start of treatment (or during the treatment), and discard it after the treatment.
Any remaining 3Mix-MP should be discarded at the end of the day.
One of important points for clinical successes is place enough antibacterial potency of 3Mix-MP on dentin. To avoid losing efficiency before use, stock and prepare of each component in correct and proper ways, and to avoid flowing 3Mix-MP out of cavities place and seal it tightly in correct and proper ways.