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| Title |
Triple Antibiotic Solution Promotes Similar Antibacterial Effects as Calcium Hydroxide/2% Chlorhexidine When Used as an Intracanal Medicament |
| Clinical Question |
In patients undergoing non-surgical therapy in a tooth diagnosed with pulpal necrosis, does the use of triple antibiotic paste as an intracanal medicament have better antibacterial efficacy than a calcium hydroxide/chlorhexidine formulation? |
| Clinical Bottom Line |
Triple antibiotic solution (1 mg/mL) promoted similar antibacterial effects as calcium hydroxide/2% chlorhexidine when used as an intracanal medicament. This is based on several randomized clinical trials in which intracanal medicaments were placed for 7 to 21 days in primary and immature/mature permanent teeth. Triple antibiotic solution provides endodontic practitioners with a viable canal disinfection option for conventional nonsurgical root canal therapy or pulp revascularization. |
| Best Evidence |
(you may view more info by clicking on the PubMed ID link) |
| PubMed ID |
Author / Year |
Patient Group |
Study type
(level of evidence) |
| #1) 30144986 | Arruda/2018 | 48 subjects (23 females/25 males, age 13-71 years) with pulpal necrosis and asymptomatic apical periodontitis | Randomized controlled trial | | Key results | This study compared the disinfection efficacy of triple antibiotic solution (metronidazole, minocycline, and ciprofloxacin in a combined 1 mg/mL concentration) to calcium hydroxide powder/2% chlorhexidine gluconate. The study used quantitative real-time polymerase chain reaction (qRT-PCR) assay on DNA extracts of clinical samples taken from the canal at baseline, after initial cleaning and shaping, and after 7-10 days of intracanal disinfection in mature teeth. There was no significant difference in microbial reduction between the two medicaments from the pre-operative samples to the final samples taken immediately before obturation. However, triple antibiotic solution showed a significant reduction (97%) in bacterial load compared to calcium hydroxide/chlorhexidine (39%) during the medicament treatment between the second (before medicament placement) and third samples (after medicament removal), and a greater number of cases negative for detection of bacterial DNA (P<0.01). | | #2) 24862703 | Nagata/2014 | 15 subjects (age 7-17 years) with immature teeth with pulpal necrosis | Randomized controlled trial | | Key results | This research compared the disinfection efficacy of triple antibiotic paste to calcium hydroxide/2% chlorhexidine gluconate using a polymerase chain reaction assay after initial chemical debridement and after 21 days of intracanal disinfection as part of a pulp revascularization protocol in immature teeth. Both medicaments significantly reduced bacteria by the final sample (P<0.05), but there was no significant difference in disinfection between the two medicaments (P=0.99). The best antibacterial efficacy came from initial irrigation of the canal system with sodium hypochlorite. In addition, the bacterial profile of infected immature teeth was similar to that found in primarily infected mature permanent teeth. | | #3) 29104387 | Dutta/2017 | 48 subjects (age 4-6 years) with primary teeth with pulpal necrosis | Randomized controlled trial | | Key results | This study compared the antibacterial efficacy of calcium hydroxide, triple antibiotic paste, calcium hydroxide/2% chlorhexidine, and triple antibiotic paste/2% chlorhexidine by the quantification of colony-forming units (CFUs) of cultivable bacteria sampled from canals after initial chemomechanical debridement and 7 days of intracanal disinfection in primary teeth. All four medicaments showed significant reduction of microbes. Triple antibiotic paste, calcium hydroxide/2% chlorhexidine, and triple antibiotic paste/2% chlorhexidine were significantly more effective than calcium hydroxide alone (P<0.001). There was no significant difference between triple antibiotic paste, calcium hydroxide/2% chlorhexidine, and triple antibiotic paste/2% chlorhexidine (P>0.05). | | #4) 30144986 | Nagata/2014 | 23 immature teeth (subjects age 7-17 years) with pulpal necrosis | Randomized controlled trial | | Key results | This study with relatively small sample size (n=11-12/group) compared clinical radiographic data of traumatized immature teeth treated with triple antibiotic paste to those treated with calcium hydroxide/2% chlorhexidine gluconate after initial chemical debridement and after 21 days of intracanal disinfection as part of a pulp revascularization protocol. Teeth treated with triple antibiotic paste had significantly reduced incidence of spontaneous pain (P=0.01), pain on percussion (P=0.007), and pain on palpation (P=0.03). Similarly, teeth treated with calcium hydroxide/2% chlorhexidine demonstrated significantly reduced pain on vertical percussion (P=0.03), and both treatment regimens showed significant apical closure (P<0.05). As an adverse effect of its use, teeth treated with triple antibiotic paste also showed significantly greater incidence of crown discoloration (83.3%) compared to teeth treated with calcium hydroxide/chlorhexidine (P<0.002). | |
| Evidence Search |
“nonsurgical root canal therapy” AND “intracanal medicament” OR “triple antibiotic paste” AND “calcium hydroxide” |
Comments on
The Evidence |
Validity: All studies cited used the same chemomechanical or chemical debridement protocols to prepare teeth for the intracanal medicaments and demonstrate the paramount importance of initial debridement in reducing bacteria. The studies show that intracanal medicaments, when combined with canal instrumentation and/or irrigation, are effective in canal disinfection. The intracanal antimicrobial efficacy of triple antibiotic formulation is shown to be superior to calcium hydroxide alone, or at least comparable to calcium hydroxide combined with 2% chlorhexidine when assessing antibacterial efficacy and clinical outcomes.
Perspective: Randomized clinical trials are currently the highest available evidence comparing use of triple antibiotic paste against other canal medicaments in primary teeth and immature and mature permanent teeth. While these studies delineate triple antibiotic solution as another option for interappointment disinfection, its use may be precluded by cost, availability of ingredients, concern over possible bacterial resistance, or the tendency of minocycline to discolor coronal tooth structure. |
| Applicability |
Eliminating bacteria in teeth with pulpal necrosis and apical periodontitis is of predominant importance in root canal therapy and pulp revascularization. The research presented emphasizes the importance of chemomechanical disinfection and supports use of triple antibiotic formulations as an effective intracanal medication for use during conventional nonsurgical root canal therapy or regenerative endodontic procedures. |
| Specialty/Discipline |
(Endodontics) |
| Keywords |
triple antibiotic, calcium hydroxide, root canal medicament
|
| ID# |
3361 |
| Date of submission: |
11/20/2018 |
| E-mail |
smithb2@livemail.uthscsa.edu |
| Author |
Bracken G. Smith, DMD |
| Co-author(s) |
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| Co-author(s) e-mail |
|
| Faculty mentor/Co-author |
Anibal Diogenes, DDS, MS, PhD |
| Faculty mentor/Co-author e-mail |
diogenes@uthscsa.edu |
Basic Science Rationale
(Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?) |
post a rationale |
| None available | |
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Comments and Evidence-Based Updates on the CAT
(FOR PRACTICING DENTISTS', FACULTY, RESIDENTS and/or STUDENTS COMMENTS ON PUBLISHED CATs) |
post a comment |
| None available | |
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