|Year : 2022 | Volume
| Issue : 5 | Page : 463-480
|Antibacterial efficacy of antibiotic pastes versus calcium hydroxide intracanal dressing: A systematic review and meta-analysis of ex vivo studies
Mohammadreza Vatankhah1, Kamyar Khosravi1, Nazanin Zargar2, Armin Shirvani1, Mohammad Hossein Nekoofar3, Omid Dianat4
1 Iranian Center for Endodontic Research, Research Institute of Dental Sciences, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2 Department of Endodontics, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran
3 Department of Endodontics, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran
4 Department of Advanced Oral Sciences and Therapeutics, School of Dentistry, University of Maryland, Baltimore, Maryland, USA
Click here for correspondence address and email
|Date of Submission||02-Apr-2022|
|Date of Decision||15-May-2022|
|Date of Acceptance||20-May-2022|
|Date of Web Publication||05-Jul-2022|
| Abstract|| |
Background: Conflicting findings on the potency of antibiotic pastes versus calcium hydroxide (CH) have been evident in the literature.
Aims: To compare the antibacterial efficacy of single antibiotic paste (SAP), double antibiotic paste (DAP), triple antibiotic paste (TAP), and modified TAP (mTAP) with CH on bacterial biofilms.
Methods: PubMed, Scopus, and Embase were comprehensively searched until August 23, 2021. The study protocol was registered in the PROSPERO. Ex vivo studies performed on Enterococcus faecalis or polymicrobial biofilms incubated on human/bovine dentin were selected. The quality of the studies was assessed using a customized quality assessment tool. Standardized mean difference (SMD) with a 95% confidence interval (CI) was calculated for the meta-analysis. Meta-regression models were used to identify the sources of heterogeneity and to compare the efficacy of pastes.
Results: The qualitative and quantitative synthesis included 40 and 23 papers, respectively, out of 1421 search results. TAP (SMD = −3.82; CI, −5.44 to −2.21; P < 0.001) and SAPs (SMD = −2.38; CI, −2.81 to − 1.94; P < 0.001) had significantly higher antibacterial efficacy compared to the CH on E. faecalis biofilm. However, no significant difference was found between the efficacy of DAP (SMD = −2.74; CI, −5.56–0.07; P = 0.06) or mTAP (SMD = −0.28; CI, −0.82–0.26; P = 0.31) and CH. Meta-regression model on E. faecalis showed that SAPs have similar efficacy compared to TAP and significantly better efficacy than DAP. On dual-species (SMD = 0.15; CI, −1.00–1.29; P = 0.80) or multi-species (SMD = 0.23; CI, −0.08–0.55; P = 0.15) biofilms, DAP and CH had similar efficacy.
Conclusions: Ex vivo evidence showed that antibiotic pastes were either superior or equal to CH. The studied SAPs had considerably higher or similar antibacterial effectiveness compared to DAP, CH, and TAP. Hence, combined antibiotic therapy was not necessarily required for root canal disinfection ex vivo.
Keywords: Antibiotic paste; bacterial biofilm; calcium hydroxide; intracanal medicament
|How to cite this article:|
Vatankhah M, Khosravi K, Zargar N, Shirvani A, Nekoofar MH, Dianat O. Antibacterial efficacy of antibiotic pastes versus calcium hydroxide intracanal dressing: A systematic review and meta-analysis of ex vivo studies. J Conserv Dent 2022;25:463-80
|How to cite this URL:|
Vatankhah M, Khosravi K, Zargar N, Shirvani A, Nekoofar MH, Dianat O. Antibacterial efficacy of antibiotic pastes versus calcium hydroxide intracanal dressing: A systematic review and meta-analysis of ex vivo studies. J Conserv Dent [serial online] 2022 [cited 2022 Sep 25];25:463-80. Available from: https://www.jcd.org.in/text.asp?2022/25/5/463/349908
| Introduction|| |
Endodontic treatments must strive to eliminate as many bacteria as possible from the root canal system. Chemomechanical preparation plays an essential role in removing bacteria, necrotic tissues, and infected dentin for this aim. Different instrumentation systems leave an unpredictable range of 2.6%–80% of the root canal walls untouched., Hence, instrumentation, irrigation, and obturation cannot predictably render canals bacteria-free, and residual bacteria may reside in unaffected areas., Most of these species may not survive after the treatment or may persist in low virulence and numbers, insufficient to sustain the periapical inflammation. The microbial etiology of these persistent lesions was reported to comprise different community profiles or single robust species such as Enterococcus faecalis.
E. faecalis is commonly identified in persistent endodontic infections., The presence of E. faecalis in secondary infections is of particular relevance since it is seldom discovered in infected but untreated root canals. There are several unique characteristics for E. faecalis, such as inherent antimicrobial resistance, and ability to withstand extreme environmental conditions. It could sustain viability for 12 months and might serve as a long-term nidus for future infection.
Intracanal medicament (ICM) aids further bacterial elimination after chemomechanical preparation in multivisit endodontic treatments of necrotic teeth. Calcium hydroxide (CH) is the most commonly used ICM in the literature. However, both in vitro and in vivo studies have shown that CH has limited antibacterial efficacy.,, For instance, CH favors the population of E. faecalis in multi-species biofilms, as E. faecalis survives the high pH of CH.,
Antibiotic therapy in various formulations is vastly used in medical-related professions to prevent and treat bacterial infections. Given the insufficient spectrum of action of available commercial antibiotic pastes, various antibiotic formulations were developed. It is critical to sterilize the root canal and radicular area during endodontic regenerative procedures since tissue repair and healing are best achieved in a relatively aseptic environment., However, the need for a potent antibacterial agent does not solely limit to regenerative procedures. Antibiotic pastes could be used in the treatment of large/persistent periapical lesions, before/parallel with surgical interventions. A systematic review of 16 articles concluded that even when CH cannot reduce symptoms and heal the periapical lesions, TAP could be effective.
Although numerous studies have compared the antibacterial efficacy of antibiotic pastes with CH, the results are inconsistent.,,, Furthermore, clinical evidence on this issue is limited. The present systematic review and meta-analysis aimed to compare the antibacterial efficacy of single antibiotic paste (SAP), double antibiotic paste (DAP), triple antibiotic paste (TAP), and modified TAP (mTAP) with CH as an ICM on bacterial biofilms from the available ex vivo studies.
| Materials and Methods|| |
Protocol and registration
The protocol of this systematic review was registered in the PROSPERO database (registration number: CRD42021184650), and its report adhered to the preferred reporting items for systematic review and meta-analysis statement.
Formulating the review question
The review question was developed using the PICOS framework: In human/bovine extracted permanent teeth or dentin samples infected with bacterial biofilm (Population), does antibiotic paste (Intervention) provide higher antibacterial efficacy (Outcome) compared to CH (Comparison) in ex vivo settings (Study type)?
Ex vivo studies with the following criteria were included: (1) performed on human/bovine extracted permanent teeth or dentin slabs, (2) in press and published papers with full-text available, (3) comprising at least two experimental groups of CH and an antibiotic paste, (4) performed on E. faecalis mono-species or polymicrobial (i.e., composed of more than one species) biofilms.
In vivo studies, animal studies, review articles, expert opinions, cross-sectional studies, clinical trials, case reports, and case series were excluded. Furthermore, studies with the following criteria were excluded: (1) assessing the residual antimicrobial efficacy of the medicaments, (2) conducted on immature/deciduous teeth, (3) performed on endotoxins, fungal species, and mono-species bacteria other than E. faecalis, and (4) using substrates other than sound dentin.
A combination of medical search heading, Emtree, and free text terms was piloted during the preliminary electronic searches. The search strings were formulated using Boolean operators “OR” and “AND” in three databases: MEDLINE, Scopus, and Embase. No language or date restrictions were applied. The search was last updated on August 23, 2021. The references of the included studies were manually searched for eligible articles. [Supplementary Table 1] presents the search queries.
Search results were exported to EndNote x9 software (Clarivate, Philadelphia, PA, United States), and the duplicates were automatically removed. Two authors (K.K., M.V.) independently screened titles and abstracts of the identified publications according to the inclusion/exclusion criteria. Potentially appropriate studies were further assessed for eligibility by full-text screening. Disagreements were negotiated with a third author (N.Z.) and resolved.
The same authors (K.K., M.V.) performed the data extraction from the full-text papers covering: (1) general information: first author, year, and country; (2) methodology: bacterial strain, incubation period, type of the teeth, sample dimensions, total sample size, medicament ingredients, concentration, and retention period, outcome measuring technique, depth of dentin, and sampling technique/instrument [Supplementary Table 2]; (3) results of culture plate counts, biofilm structural alterations visualized by scanning electron microscopy, colony-forming unit (CFU) counts, viable/dead bacterial cells discovered by confocal laser scanning microscopy, optical density (OD) values, and DNA amounts detected by quantitative polymerase chain reaction.
A third author (O.D.) verified the data sheets and discussed any disagreement between the two authors during the data extraction to achieve consensus. An e-mail was sent to the corresponding author if the desired data were not appropriately mentioned in a manuscript during the data extraction, risk of bias assessment, and meta-analysis. In response, a total of 11 authors supplied the requested information.,,,,,,,,,,
Risk of bias assessment
A specified bias assessment table was provided inspired by the modified Cochrane risk of bias tool and the tool for before–after studies. The table consisted of 11 items particularly selected for this review to critically assess the studies' methodology.
Two reviewers (K.K., M.V.) independently rated low risk for items that were done and reported accurately, high risk for domains that were not performed/imprecisely reported, not applicable, and not mentioned (NM). In case of disagreement, a third author (N.Z.) was consulted for deliberation. The same authors independently assessed the overall risk of bias. Cohen's Kappa was used to measure the agreement between the two authors using SPSS 25 (IBM corp. Released 2017. IBM Statistics for Windows, Ver. 25.0. Armonk, NY, USA).
Data synthesis and statistical analysis
Standardized mean difference (SMD) with 95% confidence intervals (CIs) was calculated to compare the continuous data on the number of CFUs, percentage of live/dead bacteria, and OD values between the antibiotic and CH groups. Due to the small sample sizes in the studies, the SMDs were computed using Hedges' g statistic. Mean values were calculated from the median in some studies, based on the method proposed by Wan et al. The summary estimates were computed using a random-effects model. Statistical heterogeneity in the pooled results was calculated via Chi-square and I2 statistics, with a P = 0.05 significance threshold.
If heterogeneity significantly influenced the summary estimate, random-effects multivariable meta-regression analysis was applied to explore potential sources. When no statistical heterogeneity was observed in the pooled estimate, no further analysis was performed. The first meta-regression model included the variables that were most likely to have an effect on the pooled meta-analytic outcomes: ICM concentration, retention time, and dentin depth. Moreover, the second model compared the efficacy of different antibiotic pastes, while variables of the first model were adjusted. Galbraith plot was employed to display the potential outliers visually. Sensitivity analysis was performed by excluding the outlier study.
Each type of analysis was conducted individually for mono-, dual-, and multi-species biofilm groups, with a restricted maximum likelihood method, using STATA 16 (StataCorp. 2019, College Station, TX, USA).
| Results|| |
Literature search and study selection
[Figure 1] displays the flow diagram of the studies. The search resulted in 1417 studies from different databases. Four more articles were added by manual searching. After duplicate removal, 959 records were identified, 46 of which were subjected to full-text screening. Forty and twenty-three studies were included in the qualitative and quantitative synthesis, respectively. Reasons of the exclusion for each synthesis are presented in [Table 1].
|Figure 1: Flow diagram of the identified studies based on The Preferred Reporting Items for Systematic Reviews and Meta-Analyses|
Click here to view
|Table 1: Reasons for and the number of excluded studies in each synthesis|
Click here to view
Characteristics of the included studies
[Table 2] represents a synopsis of included studies. Thirty-five studies (87.5%) were merely conducted on mature/immature E. faecalis, 2 (5%) on dual-species mature, and 3 (7.5%) on multi-species mature/immature biofilms. TAP and DAP were the most frequently used antibiotics in 23 (57.5%) and 13 (32.5%) studies, respectively. Out of 40 studies, 3 (7.5%) used spectrophotometry/colorimetry to assess optical density values, 8 (20%) implemented the CLSM approach to quantify the percentage of live/dead bacterial cells, 21 (52.5%) performed culture methods to calculate CFUs, and 8 (20%) used a combination of ≥2 different methods.
Risk of bias assessment
Totally, 20 studies (50%) were considered as low overall risk, 6 (15%) were deemed as moderate overall risk, and 14 (35%) were rated as high overall risk of bias. The appraisal of the risk of bias for each study is presented in [Table 3]. Two authors agreed on 88.86% of the items (391/440) with a Cohen's Kappa of 0.82. They were in agreement in 87.5% of the overall scores, yielding a Cohen's Kappa of 0.75.
Meta-analysis and meta-regression on Enterococcus faecalis biofilm
Triple antibiotic paste versus calcium hydroxide
In 31 incorporated comparisons from 13 studies, TAP had significantly higher antibacterial efficacy compared to the CH [[Figure 2]a, SMD = −3.82; 95% CI, −5.44 to −2.21; P < 0.001]. The effect sizes, however, were statistically heterogeneous (I2 = 98.27%, P < 0.001). One study was excluded from the meta-regression model as an outlier. This model, which is presented in [Table 4], showed that concentration (P = 0.136), retention time (P = 0.150), and depth of dentin (P = 0.642) were not significant predictors for the antibacterial efficacy of TAP.
|Figure 2: (a) Forest plot comparing the efficacy of TAP and CH on E. faecalis biofilm (negative interval favors antibiotic). (b) Forest plot comparing the efficacy of DAP and CH on E. faecalis biofilm. (c) Forest plot comparing the efficacy of mTAP and CH on E. faecalis biofilm. (d) Forest plot comparing the efficacy of SAPs and CH on E. faecalis biofilm (negative interval favors antibiotic).|
Click here to view
|Table 4: Meta-regression model comparing the efficacy of antibiotic pastes with calcium hydroxide|
Click here to view
Double antibiotic paste versus calcium hydroxide
There was no statistically significant difference between the DAP and CH in 17 integrated comparisons from 7 studies [[Figure 2]b, SMD = −2.74; 95% CI, −5.56–0.07; P = 0.06]. However, the pooled data analysis was significantly influenced by heterogeneity (I2 = 98.90%, P < 0.001). The same study was excluded from the meta-regression model. Moreover, another study was dropped so that the model could precisely determine the influence of the variables. The model revealed a strong association between the concentration (P = 0.021) and the higher antibacterial efficacy of DAP. In contrast, retention time (P = 0.167) and dentin depth (P = 0.702) were not significant predictors of efficacy [Table 4].
Modified triple antibiotic paste versus calcium hydroxide
No significant difference between mTAP (metronidazole, ciprofloxacin, and clindamycin) and CH was seen in three integrated comparisons from two studies [[Figure 2]c, SMD = −0.28; 95% CI, −0.82–0.26; P = 0.31] with no statistical heterogeneity (I2 = 0.00%, P = 0.48).
Single antibiotic pastes versus calcium hydroxide
In 26 incorporated comparisons from 5 studies, SAPs (including ciprofloxacin, clindamycin, doxycycline, oxytetracycline, erythromycin, metronidazole, and co-amoxiclav) were considerably more effective than CH [[Figure 2]d, SMD = −2.38; 95% CI, −2.81 to −1.94; P < 0.001] with substantial heterogeneity among effect sizes (I2 = 81.16%, P < 0.001). One study was dropped due to the collinearity, and the rest of the comparisons fit the meta-regression model [Table 4]. Higher concentration (P = 0.036) or retention time (P = 0.021) of SAPs was strongly associated with higher antibacterial efficacy. However, the antibacterial efficacy of SAPs was significantly reduced in deeper dentin (P = 0.002).
Multiple meta-regression analyses comparing antibiotic pastes with adjusted variables are presented in [Table 5]. All investigated SAPs showed better efficacy compared to DAP (P < 0.05). Nonetheless, when compared to mTAP, only clindamycin (P = 0.034), erythromycin (P = 0.021), and metronidazole (P = 0.021) had significantly higher efficacy. Compared to oxytetracycline (as the weakest SAP), metronidazole, erythromycin, and ciprofloxacin were all substantially superior (P < 0.05); however, clindamycin, doxycycline, and co-amoxiclav were not (P > 0.05). Moreover, the differences between SAPs and TAP were not statistically significant (P > 0.05). TAP had significantly higher efficacy than DAP (P = 0.034). Nevertheless, there was no significant difference between TAP or DAP compared to mTAP (P > 0.05).
|Table 5: Meta-regression analysis comparing the efficacy of antibiotic pastes used on Enterococcus faecalis biofilm with adjusted covariates (concentration, retention time, depth)|
Click here to view
Meta-analysis and meta-regression on dual-species biofilm
No statistically significant difference in antibacterial efficacy was seen between the DAP and CH in 5 integrated comparisons from 2 studies [[Figure 3]a, SMD = 0.15; 95% CI, −1.00–1.29; P = 0.80]. Effect sizes were considerably heterogeneous (I2 = 81.58%, P < 0.001). The meta-regression model indicated that both higher concentration (P = 0.035) and retention time (P < 0.001) could contribute to increased antibacterial efficacy of DAP. However, in deeper dentin, DAP offered a significantly lower antibacterial efficacy (P = 0.005).
|Figure 3: (a) Forest plot comparing the efficacy of DAP and CH on dual-species biofilm (negative interval favors antibiotic). (b) Forest plot comparing the efficacy of DAP and CH on multi-species biofilm|
Click here to view
Meta-analysis on multi-species biofilm
In 10 incorporated comparisons from 2 studies, the difference between the CH and DAP was not statistically significant [[Figure 3]b, SMD = 0.23; 95% CI, −0.08–0.55; P = 0.15], with negligible statistical heterogeneity among the data (I2 = 12.67%, P = 0.27).
The Galbraith plots associated with the studies on E. faecalis biofilm are depicted in [Figure 4]a, [Figure 4]b, [Figure 4]c. Despite the abundance of outliers, only one study was excluded, and the rest were not removed due to their symmetrical distribution around the regression line. The results of the sensitivity analysis are shown in [Figure 4]d and [Figure 4]e. No significant change in the pooled estimate findings or the degree of heterogeneity was detected, confirming the pooled results' robustness.
|Figure 4:. (a) Galbraith plot comparing antibacterial efficacy of SAP and CH on E. faecalis biofilm. (b) Galbraith plot comparing antibacterial efficacy of DAP and CH on E. faecalis biofilm. (c) Galbraith plot comparing antibacterial efficacy of TAP and CH on E. faecalis biofilm. (d) Sensitivity analysis by excluding the outlier from the comparison of DAP and CH. (e) Sensitivity analysis by excluding the outlier from the comparison of TAP and CH|
Click here to view
| Discussion|| |
The present systematic review compared the antibacterial efficacy of various antibiotic pastes versus CH on different bacterial strains incubated on human/bovine dentin structure from available ex vivo studies. As an overview of the results, TAP and SAPs were significantly superior to CH on E. faecalis biofilm, while mTAP and CH displayed similar efficacy. No statistical difference was noticed between DAP and CH in terms of antibacterial potency on mono-, dual-, and multi-species biofilms.
On Enterococcus faecalis biofilm
The superiority of TAP compared to CH was in agreement with the results of a recently published systematic review, including both clinical and in vitro studies. The antibacterial efficacy of CH directly lies within the diffusion of alkaline hydroxyl ions. After a week of CH introduction inside the canal, pH reaches its maximum values, and then begins to drop. As the pH falls, the residual bacteria may regrow in the canals treated with CH, while the samples treated with antibiotics may not get affected. However, there was no superiority for DAP/mTAP compared to CH in our review. This unusual phenomenon warrants more investigation as TAP and SAPs were more effective against E. faecalis than CH.
Our findings revealed that SAPs were more potent antibacterial agents than CH. One of the included studies employed antibiotics with a minimum inhibitory concentration. Another included study assessed the antibacterial efficacy after only 5 and 10 min of ICM retention. Surprisingly, in both studies, antibiotic groups were significantly more effective than CH. This may indicate a turning point for future research to examine the efficacy of different SAPs, with lower concentrations and reduced retention times.
The comparison of antibiotic pastes with adjusted covariates revealed that each kind of SAPs could reduce E. faecalis as effectively as TAP while showing significantly better efficacy than DAP. Combination antibiotic therapy has been used to improve treatment efficacy, broaden the antibiotic range of activity, slow the evolution of drug resistance, and minimize toxicity by lowering the dosage of each active component. However, synergistic effects will not always occur as antibiotics may exhibit inhibitory interactions. The combination of bacteriostatic and bactericidal agents is less effective than the bactericidal agent alone. TAP is a mixture of two bactericides and a bacteriostatic antibiotic. Hence, the probable interactions between minocycline and the bactericidal agents may be responsible for such results obtained comparing the efficacy of SAPs and TAP. Altogether, the underlying philosophy behind most antibiotic interactions is yet to be understood.
Furthermore, the polymicrobial nature of the persistent endodontic infection, with the most predominant species being E. faecalis and Porphyromonas gingivalis, is different from that of primary infection. Different SAPs, such as metronidazole, could have notable antibacterial efficacy against these species; obligate and facultative anaerobic bacteria. Furthermore, metronidazole is suggested for topical use since it is unlikely to develop resistance. Based on our findings, using combination antibiotic therapy may not be necessary as SAPs could effectively reduce E. faecalis colonies.
The ability of an ICM to disperse into the root canal system appears to be critical for its successful antibiofilm efficacy. Based on the findings by Abbott et al., the diffusion of a drug across dentinal tubules is directly related to its concentration, retention time, and the area of the inner canal exposed to the agent.
On polymicrobial biofilms
Of the two studies conducted on dual-species biofilms, one was performed on the E. faecalis and Prevotella intermedia, while the other one was on E. faecalis and Streptococcus gordonii combined biofilms. These species were chosen for their capacity to coexist in a biofilm. However, the difference in the bacterial combination could presumably account for part of the heterogeneity of the pooled results. On the other hand, the two studies on the multi-species biofilms were performed on isolated bacteria from mature/immature teeth with necrotic pulps, which were believed to have a similar bacterial population according to a clinical study. Moreover, these two studies had more methodological characteristics in common (DAP as antibiotic, 7-day retention time, evaluating CFU/mL at the dentin surface), which resulted in low heterogeneity of the pooled results.
Hypothetically, the overall better efficacy of antibiotics compared to CH on E. faecalis biofilm might be related to the functioning proton pumps of the bacteria. These pumps maintain cell survival by acidifying the cytoplasm. However, this function might be hindered in polymicrobial biofilms to some extent. Therefore, CH could appear with equal efficacy as antibiotics in such biofilms. Clinical studies have proved this claim by showing equal efficacy of TAP or moxifloxacin compared to CH., However, DAP was the only antibiotic investigated on polymicrobial biofilms in this review. Hence, based on the difference between the mono- and polymicrobial biofilms, studying different antibiotic pastes on polymicrobial biofilms is recommended.
In our review, the outcomes of meta-analyses were mostly influenced by substantial heterogeneity. The high degree of statistical heterogeneity was probably explained by focusing on the intrinsic methodological aspects of the studies. The potential confounding factors included bacterial strain, incubation period, type of the teeth, sample dimensions, sample size, cementum removal, ICM vehicle, biofilm development confirmation, sampling technique, and outcome measure technique.
Methodological appraisal of studies
E. faecalis has been reported to be the most prevalent species isolated from root-filled teeth with apical periodontitis. This bacterium, however, is no longer in the spotlight as the only cause of persistent infections, as it is not identified in 100% of the secondary infection cases. E. faecalis is simply cultured in the laboratory with little sensitivity to different conditions. Hence, the regular selection of E. faecalis by different studies could be explained. Polymicrobial biofilms are also favored for ex vivo biofilm investigations, as they more precisely mimic clinical infection. Therefore, this paper systematically reviewed the effect of ICMs on the polymicrobial biofilms as well as the mono-species of E. faecalis.
Since single-rooted human and bovine teeth are alike in terms of dentin structure, both were included in this review. Moreover, mature biofilms behave differently than single bacterial strains since they are composed of a complex microbial community. As a result, studies with immature biofilms were excluded from the final meta-analysis in this review.
Antibiotics' retention time in root canals is vital to eradicate as many bacteria as possible. According to the quantitative results of the included studies, the antibacterial efficacy of SAP and DAP increased with time after application. However, when applied for more than 48 h, antibiotic pastes could induce cytotoxicity and genotoxicity on human stem cells. This issue raises an essential question: Could we benefit from antibiotic pastes in shorter application times? Addressing this question, we included all reported retention times in the meta-analysis to analyze its influence.
Similar to most ex vivo systematic reviews, this study used a modified tool for quality assessment. Based on the published evidence, randomization and operator blinding are not regularly performed/reported in ex vivo settings. Likewise, no study reported the operator blinding in the present review, and very few reported the randomization procedure or sample size calculation rationale. As performing these steps increases the generalizability of evidence, authors are strongly recommended to use/mention them in their studies.
Four processes should be considered while simulating clinical infection within the dentinal tubules ex vivo. First, the smear layer should be removed. This layer seals the tubules' entrance; hence, leaving it intact may decrease the penetration of bacteria and the diffusion of ICMs through the tubules. Second, experiments should be conducted on mature bacterial biofilms, defined as ≥3-week-old incubated biofilm wherein bacteria develop more resistance to the disinfectants., All included studies in the meta-analysis followed these two criteria. Third, the cementum layer should be eliminated. Its removal permits easier infiltration of bacteria into the dentinal tubules, resulting in noticeable infection. Fourth, biofilm formation after the incubation period should be verified since ex vivo biofilm development depends on various laboratory steps. Cementum removal was NM by most studies, while biofilm development confirmation was rather well performed by the majority of the studies included in the meta-analysis.
Recommendations for the future research
- Ex vivo studies are encouraged to test ICMs on polymicrobial infections. The most acceptable source of such biofilm would be an obturated root canal with a persistent lesion
- Clinical studies, especially randomized clinical trials, are recommended for testing antibiotic pastes on endodontic outcomes
- Ex vivo studies are suggested to examine new ICMs with minimum concentration and retention time parameters chosen reasonably.
Strengths and limitations
To date, no systematic review has been conducted to compare the antibacterial efficacy of the two commonly-used ICMs via meta-analytic pooling of data. Concerning the limited number of clinical evidence, the abundance of existing ex vivo studies, and the lack of consensus toward selecting the proper ICM, only ex vivo articles were included.
As strength, a meta-regression analysis was conducted to ascertain the sources of heterogeneity. Moreover, sensitivity analysis indicated the stability of the results.
In addition, data on ICM efficacy against polymicrobial biofilms were obtained and pooled; however, the number of studies on this subject was restricted. Therefore, it is not proper to draw generalized conclusions about polymicrobial biofilms.
Although it has been demonstrated that greater concentrations of CH have enhanced bactericidal activity, it was not possible to calculate/convert the concentrations in all studies. Therefore, as an important limitation, dosage differences for CH were neglected in the meta-analysis.
| Conclusions|| |
Within the constraints of this review, antibiotic pastes were either superior or comparable to CH in terms of overall effectiveness. SAPs, while having the same potency as TAP, exerted significantly better antibacterial efficacy compared to DAP or CH against E. faecalis biofilm. Considering the overall superiority of SAPs to other medicaments, a combination of antibiotics (as in DAP, mTAP, or TAP) seems not to be a necessity for root canal disinfection.
This study was financially supported by the Iranian Center for Endodontic Research, Research Institute of Dental Sciences, Dental School, Shahid Beheshti University of Medical Sciences, Tehran, Iran. The authors would like to thank Dr. Venkateshbabu Nagendrababu for providing technical assistance to this study.
Financial support and sponsorship
This study was financially supported by the Iranian Center for Endodontic Research, Research Institute of Dental Sciences, Dental School, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Karataş E, Baltacı MÖ, Uluköylü E, Adıgüzel A. Antibacterial effectiveness of calcium hydroxide alone or in combination with Ibuprofen and Ciprofloxacin in teeth with asymptomatic apical periodontitis: A randomized controlled clinical study. Int Endod J 2020;53:742-53.
Gagliardi J, Versiani MA, de Sousa-Neto MD, Plazas-Garzon A, Basrani B. Evaluation of the shaping characteristics of ProTaper Gold, ProTaper NEXT, and ProTaper universal in curved canals. J Endod 2015;41:1718-24.
Lopes RM, Marins FC, Belladonna FG, Souza EM, De-Deus G, Lopes RT, et al.
Untouched canal areas and debris accumulation after root canal preparation with rotary and adaptive systems. Aust Endod J 2018;44:260-6.
Gazzaneo I, Vieira GC, Pérez AR, Alves FR, Gonçalves LS, Mdala I, et al.
Root canal disinfection by single- and multiple-instrument systems: Effects of sodium hypochlorite volume, concentration, and retention time. J Endod 2019;45:736-41.
Siqueira JF Jr., Pérez AR, Marceliano-Alves MF, Provenzano JC, Silva SG, Pires FR, et al
. What happens to unprepared root canal walls: A correlative analysis using micro-computed tomography and histology/scanning electron microscopy. Int Endod J 2018;51:501-8.
Vera J, Siqueira JF Jr., Ricucci D, Loghin S, Fernández N, Flores B, et al.
One- versus two-visit endodontic treatment of teeth with apical periodontitis: A histobacteriologic study. J Endod 2012;38:1040-52.
Nair PN, Henry S, Cano V, Vera J. Microbial status of apical root canal system of human mandibular first molars with primary apical periodontitis after “one-visit” endodontic treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99:231-52.
Zakaria MN, Takeshita T, Shibata Y, Maeda H, Wada N, Akamine A, et al.
Microbial community in persistent apical periodontitis: A 16S rRNA gene clone library analysis. Int Endod J 2015;48:717-28.
Stuart CH, Schwartz SA, Beeson TJ, Owatz CB. Enterococcus faecalis
: Its role in root canal treatment failure and current concepts in retreatment. J Endod 2006;32:93-8.
Barbosa-Ribeiro M, De-Jesus-Soares A, Zaia AA, Ferraz CC, Almeida JF, Gomes BP. Antimicrobial susceptibility and characterization of virulence genes of Enterococcus faecalis
isolates from teeth with failure of the endodontic treatment. J Endod 2016;42:1022-8.
Zargar N, Marashi MA, Ashraf H, Hakopian R, Beigi P. Identification of microorganisms in persistent/secondary endodontic infections with respect to clinical and radiographic findings: Bacterial culture and molecular detection. Iran J Microbiol 2019;11:120-8.
Sundqvist G, Figdor D, Persson S, Sjögren U. Microbiologic analysis of teeth with failed endodontic treatment and the outcome of conservative re-treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85:86-93.
Lins RX, de Oliveira Andrade A, Hirata Junior R, Wilson MJ, Lewis MA, Williams DW, et al.
Antimicrobial resistance and virulence traits of Enterococcus faecalis
from primary endodontic infections. J Dent 2013;41:779-86.
Portenier I, Waltimo TM, Haapasalo M. Enterococcus faecalis
– The root canal survivor and 'star' in post-treatment disease. Endod Topics 2003;6:135-59.
Sedgley CM, Lennan SL, Appelbe OK. Survival of Enterococcus faecalis
in root canals ex vivo
. Int Endod J 2005;38:735-42.
Chong BS, Pitt Ford TR. The role of intracanal medication in root canal treatment. Int Endod J 1992;25:97-106.
Kim D, Kim E. Antimicrobial effect of calcium hydroxide as an intracanal medicament in root canal treatment: A literature review – Part I. In vitro
studies. Restor Dent Endod 2014;39:241-52.
Kim D, Kim E. Antimicrobial effect of calcium hydroxide as an intracanal medicament in root canal treatment: A literature review – Part II. In vivo
studies. Restor Dent Endod 2015;40:97-103.
Sathorn C, Parashos P, Messer H. Antibacterial efficacy of calcium hydroxide intracanal dressing: A systematic review and meta-analysis. Int Endod J 2007;40:2-10.
Evans M, Davies JK, Sundqvist G, Figdor D. Mechanisms involved in the resistance of Enterococcus faecalis
to calcium hydroxide. Int Endod J 2002;35:221-8.
van der Waal SV, Connert T, Crielaard W, de Soet JJ. In mixed biofilms Enterococcus faecalis
benefits from a calcium hydroxide challenge and culturing. Int Endod J 2016;49:865-73.
Chu FC, Leung WK, Tsang PC, Chow TW, Samaranayake LP. Identification of cultivable microorganisms from root canals with apical periodontitis following two-visit endodontic treatment with antibiotics/steroid or calcium hydroxide dressings. J Endod 2006;32:17-23.
Wigler R, Kaufman AY, Lin S, Steinbock N, Hazan-Molina H, Torneck CD. Revascularization: A treatment for permanent teeth with necrotic pulp and incomplete root development. J Endod 2013;39:319-26.
Parhizkar A, Nojehdehian H, Asgary S. Triple antibiotic paste: Momentous roles and applications in endodontics: A review. Restor Dent Endod 2018;43:e28.
Ozan U, Er K. Endodontic treatment of a large cyst-like periradicular lesion using a combination of antibiotic drugs: A case report. J Endod 2005;31:898-900.
Taneja S, Kumari M, Parkash H. Nonsurgical healing of large periradicular lesions using a triple antibiotic paste: A case series. Contemp Clin Dent 2010;1:31-5.
] [Full text]
Diwan A, Bhagavaldas MC, Bagga V, Shetty A. Multidisciplinary approach in management of a large cystic lesion in anterior maxilla – A case report. J Clin Diagn Res 2015;9:D41-3.
Kumar NK, Brigit B, Annapoorna BS, Naik SB, Merwade S, Rashmi K. Effect of triple antibiotic paste and calcium hydroxide on the rate of healing of periapical lesions: A systematic review. J Conserv Dent 2021;24:307-13. [Full text]
Pereira TC, Vasconcelos LR, Graeff MS, Duarte MA, Bramante CM, Andrade FB. Intratubular disinfection with tri-antibiotic and calcium hydroxide pastes. Acta Odontol Scand 2017;75:87-93.
Devaraj S, Jagannathan N, Neelakantan P. Antibiofilm efficacy of photoactivated curcumin, triple and double antibiotic paste, 2% chlorhexidine and calcium hydroxide against Enterococcus fecalis in vitro. Sci Rep 2016;6:24797.
Madhubala MM, Srinivasan N, Ahamed S. Comparative evaluation of propolis and triantibiotic mixture as an intracanal medicament against Enterococcus faecalis
. J Endod 2011;37:1287-9.
Tilakchand M, Hegde S, Naik B. Evaluation of the efficacy of a novel antibiotic-steroid paste versus conventionally used intracanal antibiotic pastes and irrigating solutions against a 3-week-old biofilm of Enterococcus faecalis
. J Conserv Dent 2020;23:436-40. [Full text]
Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al
. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. Br Med J 2021;372:n71.
Alfadda S, Alquria T, Karaismailoglu E, Aksel H, Azim AA. Antibacterial effect and bioactivity of innovative and currently used intracanal medicaments in regenerative endodontics. J Endod 2021;47:1294-300.
Athanassiadis M, Jacobsen N, Nassery K, Parashos P. The effect of calcium hydroxide on the antibiotic component of Odontopaste and Ledermix paste. Int Endod J 2013;46:530-7.
Chai WL, Hamimah H, Abdullah M. Evaluation of antimicrobial efficacy of antibiotics and calcium hydroxide against Enterococcus faecalis
biofilm in dentine. Sains Malays 2013;42:73-80.
Cunha Neto MA, Coêlho JA, Pinto KP, Cuellar MR, Marcucci MC, Silva EJ, et al.
Antibacterial efficacy of triple antibiotic medication with macrogol (3Mix-MP), traditional triple antibiotic paste, calcium hydroxide, and ethanol extract of propolis: An intratubular dentin ex vivo
confocal laser scanning microscopic study. J Endod 2021;47:1609-16.
Panyakorn T, Makeudom A, Kangvonkit P, Pattamapun K, Wanachantararak P, Charumanee S, et al.
Efficacy of double antibiotics in hydroxypropyl methylcellulose for bactericidal activity against Enterococcus faecalis
and Streptococcus gordonii
in biofilm. Arch Oral Biol 2021;129:105210.
Plutzer B, Zilm P, Ratnayake J, Cathro P. Comparative efficacy of endodontic medicaments and sodium hypochlorite against Enterococcus faecalis
biofilms. Aust Dent J 2018;63:208-16.
Zancan RF, Calefi PH, Borges MM, Lopes MR, de Andrade FB, Vivan RR, et al.
Antimicrobial activity of intracanal medications against both Enterococcus faecalis
and Candida albicans
biofilm. Microsc Res Tech 2019;82:494-500.
Zancan RF, Canali LC, Tartari T, Andrade FB, Vivan RR, Duarte MA. Do different strains of E. faecalis
have the same behavior towards intracanal medications in in vitro
research? Braz Oral Res 2018;32:e46.
Zancan RF, Cavenago BC, Oda DF, Bramante CM, Andrade FB, Duarte MA. Antimicrobial activity and physicochemical properties of antibiotic pastes used in regenerative endodontics. Braz Dent J 2019;30:536-41.
Sterne JA, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al.
RoB 2: A revised tool for assessing risk of bias in randomised trials. BMJ 2019;366:l4898.
Wan X, Wang W, Liu J, Tong T. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol 2014;14:135.
Baker WL, White CM, Cappelleri JC, Kluger J, Coleman CI; Health Outcomes, Policy, and Economics (HOPE) Collaborative Group. Understanding heterogeneity in meta-analysis: The role of meta-regression. Int J Clin Pract 2009;63:1426-34.
Athanassiadis B, Abbott PV, George N, Walsh LJ. In vitro
study of the inactivation by dentine of some endodontic medicaments and their bases. Aust Dent J 2010;55:298-305.
Moradi Eslami L, Vatanpour M, Aminzadeh N, Mehrvarzfar P, Taheri S. The comparison of intracanal medicaments, diode laser and photodynamic therapy on removing the biofilm of Enterococcus faecalis
and Candida albicans
in the root canal system (ex-vivo
study). Photodiagnosis Photodyn Ther 2019;26:157-61.
Ghabraei S, Bolhari B, Sabbagh MM, Afshar MS. Comparison of antimicrobial effects of triple antibiotic paste and calcium hydroxide mixed with 2% chlorhexidine as intracanal medicaments against Enterococcus faecalis
biofilm. J Dent (Tehran) 2018;15:151-60.
Kim AR, Kang M, Yoo YJ, Yun CH, Perinpanayagam H, Kum KY, et al. Lactobacillus plantarum
lipoteichoic acid disrupts mature Enterococcus faecalis
biofilm. J Microbiol 2020;58:314-9.
Valverde ME, Baca P, Ceballos L, Fuentes MV, Ruiz-Linares M, Ferrer-Luque CM. Antibacterial efficacy of several intracanal medicaments for endodontic therapy. Dent Mater J 2017;36:319-24.
Padmavathy K. Evaluation of irrigant-intracanal medicament regimen against Enterococcus faecalis
biofilm count. Eur J Mol Clin Med 2020;7:1219-24.
Adl A, Hamedi S, Sedigh Shams M, Motamedifar M, Sobhnamayan F. The ability of triple antibiotic paste and calcium hydroxide in disinfection of dentinal tubules. Iran Endod J 2014;9:123-6.
Lakhani AA, Sekhar KS, Gupta P, Tejolatha B, Gupta A, Kashyap S, et al.
Efficacy of triple antibiotic paste, moxifloxacin, calcium hydroxide and 2% chlorhexidine gel in elimination of E. faecalis
: An in vitro
study. J Clin Diagn Res 2017;11:C06-9.
Ravi K. Antimicrobial efficacy of various intracanal medicaments against Enterococcus faecalis
. J Pharm Sci Res 2017;9:1861-3.
Shaik J, Garlapati R, Nagesh B, Sujana V, Jayaprakash T, Naidu S. Comparative evaluation of antimicrobial efficacy of triple antibiotic paste and calcium hydroxide using chitosan as carrier against Candida albicans
and Enterococcus faecalis
: An in vitro
study. J Conserv Dent 2014;17:335-9.
] [Full text]
de Freitas RP, Greatti VR, Alcalde MP, Cavenago BC, Vivan RR, Duarte MA, et al.
Effect of the association of nonsteroidal anti-inflammatory and antibiotic drugs on antibiofilm activity and pH of calcium hydroxide pastes. J Endod 2017;43:131-4.
Saha S, Nair R, Asrani H. Comparative evaluation of propolis, metronidazole with chlorhexidine, calcium hydroxide and curcuma longa extract as intracanal medicament against E. faecalis
– An in vitro
study. J Clin Diagn Res 2015;9:C19-21.
Sapra P, Patil AC, Bhat K, Kullar AS. Comparative evaluation of the antibacterial efficacy of two different formulations of calcium hydroxide as intracanal medicaments against Enterococcus faecalis
: An in-vitro
study. J Clin Diagn Res 2017;11:ZC26-30.
Subbiya A, Gayathri K, Venkatesh A, Padmavathy K, Mahalakshmi K, Mitthra S. Evaluation of the antibacterial efficacy of daptomycin, gentamicin, and calcium hydroxide – Antibiotic combinations on Enterococcus faecalis
dentinal biofilm: An in vitro
study. J Contemp Dent Pract 2021;22:128-33.
Dewi A, Upara C, Krongbaramee T, Louwakul P, Srisuwan T, Khemaleelakul S. Optimal antimicrobial concentration of mixed antibiotic pastes in eliminating Enterococcus faecalis
from root dentin. Aust Endod J 2021;47:273-80.
Khoshkhounejad M, Sharifian M, Assadian H, Afshar MS. Antibacterial effectiveness of diluted preparations of intracanal medicaments used in regenerative endodontic treatment on dentin infected by bacterial biofilm: An ex vivo
investigation. Dent Res J (Isfahan) 2021;18:37.
Ordinola-Zapata R, Bramante CM, Minotti PG, Cavenago BC, Garcia RB, Bernardineli N, et al.
Antimicrobial activity of triantibiotic paste, 2% chlorhexidine gel, and calcium hydroxide on an intraoral-infected dentin biofilm model. J Endod 2013;39:115-8.
Pavaskar R, de Ataide Ide N, Chalakkal P, Pinto MJ, Fernandes KS, Keny RV, et al.
An in vitro
study comparing the intracanal effectiveness of calcium hydroxide- and linezolid-based medicaments against Enterococcus faecalis
. J Endod 2012;38:95-100.
Sabarathinam J, Muralidharan NP, Pradeep S. Antimicrobial efficacy of four different intracanal medicaments on contaminated extracted teeth: In vitro
study. Drug Invent Today 2018;10:3026-9.
Rastegar Khosravi M, Khonsha M, Ramazanzadeh R. Combined effect of levofloxacin and N-acetylcysteine against Enterococcus faecalis
biofilm for regenerative endodontics: An in vitro
study. Iran Endod J 2019;14:40-6.
Abbaszadegan A, Dadolahi S, Gholami A, Moein MR, Hamedani S, Ghasemi Y, et al.
Antimicrobial and cytotoxic activity of Cinnamomum zeylanicum
, calcium hydroxide, and triple antibiotic paste as root canal dressing materials. J Contemp Dent Pract 2016;17:105-13.
Asnaashari M, Eghbal MJ, Sahba Yaghmayi A, Shokri M, Azari-Marhabi S. Comparison of antibacterial effects of photodynamic therapy, modified triple antibiotic paste and calcium hydroxide on root canals infected with Enterococcus faecalis
: An in vitro
study. J Lasers Med Sci 2019;10:S23-9.
Balto H, Bukhary S, Al-Omran O, BaHammam A, Al-Mutairi B. Combined effect of a mixture of silver nanoparticles and calcium hydroxide against Enterococcus faecalis
biofilm. J Endod 2020;46:1689-94.
Carbajal Mejía JB, Aguilar Arrieta A. Reduction of viable Enterococcus faecalis
in human radicular dentin treated with 1% cetrimide and conventional intracanal medicaments. Dent Traumatol 2016;32:321-7.
Jacobs JC, Troxel A, Ehrlich Y, Spolnik K, Bringas JS, Gregory RL, et al.
Antibacterial effects of antimicrobials used in regenerative endodontics against biofilm bacteria obtained from mature and immature teeth with necrotic pulps. J Endod 2017;43:575-9.
Krithikadatta J, Indira R, Dorothykalyani AL. Disinfection of dentinal tubules with 2% chlorhexidine, 2% metronidazole, bioactive glass when compared with calcium hydroxide as intracanal medicaments. J Endod 2007;33:1473-6.
Latham J, Fong H, Jewett A, Johnson JD, Paranjpe A. Disinfection efficacy of current regenerative endodontic protocols in simulated necrotic immature permanent teeth. J Endod 2016;42:1218-25.
McIntyre PW, Wu JL, Kolte R, Zhang R, Gregory RL, Bruzzaniti A, et al.
The antimicrobial properties, cytotoxicity, and differentiation potential of double antibiotic intracanal medicaments loaded into hydrogel system. Clin Oral Investig 2019;23:1051-9.
Mozayeni MA, Haeri A, Dianat O, Jafari AR. Antimicrobial effects of four intracanal medicaments on Enterococcus faecalis
: An in vitro
study. Iran Endod J 2014;9:195-8.
Saber Sel-D, El-Hady SA. Development of an intracanal mature Enterococcus faecalis
biofilm and its susceptibility to some antimicrobial intracanal medications; an in vitro
study. Eur J Dent 2012;6:43-50.
Shokraneh A, Farhad AR, Farhadi N, Saatchi M, Hasheminia SM. Antibacterial effect of triantibiotic mixture versus calcium hydroxide in combination with active agents against Enterococcus faecalis
biofilm. Dent Mater J 2014;33:733-8.
Tagelsir A, Yassen GH, Gomez GF, Gregory RL. Effect of antimicrobials used in regenerative endodontic procedures on 3-week-old Enterococcus faecalis
biofilm. J Endod 2016;42:258-62.
Verma R, Fischer BI, Gregory RL, Yassen GH. The radiopacity and antimicrobial properties of different radiopaque double antibiotic pastes used in regenerative endodontics. J Endod 2018;44:1376-80.
Zargar N, Rayat Hosein Abadi M, Sabeti M, Yadegari Z, Akbarzadeh Baghban A, Dianat O. Antimicrobial efficacy of clindamycin and triple antibiotic paste as root canal medicaments on tubular infection: An in vitro
study. Aust Endod J 2019;45:86-91.
Makandar S, Noorani T. Triple antibiotic paste – Challenging intracanal medicament: A systematic review. J Int Oral Health 2020;12:189-96. [Full text]
Chandwani ND, Maurya N, Nikhade P, Chandwani J. Comparative evaluation of antimicrobial efficacy of calcium hydroxide, triple antibiotic paste and bromelain against Enterococcus faecalis
: An in vitro
study. J Conserv Dent 2022;25:63. [Full text]
Siqueira JF Jr., Lopes HP. Mechanisms of antimicrobial activity of calcium hydroxide: A critical review. Int Endod J 1999;32:361-9.
Mori GG, Ferreira FC, Batista FR, Godoy AM, Nunes DC. Evaluation of the diffusion capacity of calcium hydroxide pastes through the dentinal tubules. Braz Oral Res 2009;23:113-8.
Cai M, Abbott P, Castro Salgado J. Hydroxyl ion diffusion through radicular dentine when calcium hydroxide is used under different conditions. Materials (Basel) 2018;11:E152.
Cottarel G, Wierzbowski J. Combination drugs, an emerging option for antibacterial therapy. Trends Biotechnol 2007;25:547-55.
Ocampo PS, Lázár V, Papp B, Arnoldini M, Abel zur Wiesch P, Busa-Fekete R, et al.
Antagonism between bacteriostatic and bactericidal antibiotics is prevalent. Antimicrob Agents Chemother 2014;58:4573-82.
Sullivan GJ, Delgado NN, Maharjan R, Cain AK. How antibiotics work together: Molecular mechanisms behind combination therapy. Curr Opin Microbiol 2020;57:31-40.
Barbosa-Ribeiro M, Arruda-Vasconcelos R, Louzada LM, Dos Santos DG, Andreote FD, Gomes BP. Microbiological analysis of endodontically treated teeth with apical periodontitis before and after endodontic retreatment. Clin Oral Investig 2021;25:2017-27.
Slots J. Selection of antimicrobial agents in periodontal therapy. J Periodontal Res 2002;37:389-98.
Abbott PV, Heithersay GS, Hume WR. Release and diffusion through human tooth roots in vitro
of corticosteroid and tetracycline trace molecules from Ledermix paste. Endod Dent Traumatol 1988;4:55-62.
Nagata JY, Soares AJ, Souza-Filho FJ, Zaia AA, Ferraz CC, Almeida JF, et al.
Microbial evaluation of traumatized teeth treated with triple antibiotic paste or calcium hydroxide with 2% chlorhexidine gel in pulp revascularization. J Endod 2014;40:778-83.
Ghahramani Y, Mohammadi N, Gholami A, Ghaffaripour D. Antimicrobial efficacy of intracanal medicaments against E. faecalis
bacteria in infected primary molars by using real-time PCR: A randomized clinical trial. Int J Dent 2020;2020:6669607.
Tirukkolluru C, Thakur S. Comparative evaluation of triple antibiotic paste, propolis with moxifloxacin, and calcium hydroxide as intracanal medicaments against Streptococcus
spp. and Enterococcus faecalis
in type II diabetes mellitus patients: A randomized clinical trial. Contemp Clin Dent 2019;10:191-6. [Full text]
Siqueira JF Jr., Rôças IN. Polymerase chain reaction-based analysis of microorganisms associated with failed endodontic treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97:85-94.
Swimberghe RC, Coenye T, De Moor RJ, Meire MA. Biofilm model systems for root canal disinfection: A literature review. Int Endod J 2019;52:604-28.
Rolph HJ, Lennon A, Riggio MP, Saunders WP, MacKenzie D, Coldero L, et al.
Molecular identification of microorganisms from endodontic infections. J Clin Microbiol 2001;39:3282-9.
Yassen GH, Platt JA, Hara AT. Bovine teeth as substitute for human teeth in dental research: A review of literature. J Oral Sci 2011;53:273-82.
Bacali C, Vulturar R, Buduru S, Cozma A, Fodor A, Chiş A, et al.
Oral microbiome: Getting to know and befriend neighbors, a biological approach. Biomedicines 2022;10:671.
Jamshidi D, Ansari M, Gheibi N. Cytotoxicity and genotoxicity of calcium hydroxide and two antibiotic pastes on human stem cells of the apical papilla. Eur Endod J 2021;6:303-8.
Tran L, Tam DN, Elshafay A, Dang T, Hirayama K, Huy NT. Quality assessment tools used in systematic reviews of in vitro
studies: A systematic review. BMC Med Res Methodol 2021;21:101.
Watters MP, Goodman NW. Comparison of basic methods in clinical studies and in vitro
tissue and cell culture studies reported in three anaesthesia journals. Br J Anaesth 1999;82:295-8.
Drake DR, Wiemann AH, Rivera EM, Walton RE. Bacterial retention in canal walls in vitro
: Effect of smear layer. J Endod 1994;20:78-82.
Foster KH, Kulild JC, Weller RN. Effect of smear layer removal on the diffusion of calcium hydroxide through radicular dentin. J Endod 1993;19:136-40.
Stojicic S, Shen Y, Haapasalo M. Effect of the source of biofilm bacteria, level of biofilm maturation, and type of disinfecting agent on the susceptibility of biofilm bacteria to antibacterial agents. J Endod 2013;39:473-7.
Wang Z, Shen Y, Haapasalo M. Effectiveness of endodontic disinfecting solutions against young and old Enterococcus faecalis
biofilms in dentin canals. J Endod 2012;38:1376-9.
Haapasalo M, Orstavik D. In vitro
infection and disinfection of dentinal tubules. J Dent Res 1987;66:1375-9.
Gautam S, Rajkumar B, Landge SP, Dubey S, Nehete P, Boruah LC. Antimicrobial efficacy of metapex (calcium hydroxide with iodoform formulation) at different concentrations against selected microorganisms – An in vitro
study. Nepal Med Coll J 2011;13:297-300.
Dr. Omid Dianat
Division of Endodontics, Department of Advanced Oral Sciences and Therapeutics, School of Dentistry, University of Maryland, Baltimore, 650 West Baltimore Street, 4th Floor, Baltimore, MD 21201
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
| Article Access Statistics|
| Viewed||352 |
| Printed||39 |
| Emailed||0 |
| PDF Downloaded||28 |
| Comments ||[Add] |