Effectiveness (amoxicillin, cefaclor, cefroxadine, fosfomycin or rokitamycin) were

Effectiveness of
antibiotics used in REPs against bacteria causing infection of the root canal

The use of ciprofloxacin, metronidazole and
minocycline in REPs has it experimental support in the researches carried out
by Hoshino et al. i in 1988,
who studied the bactericidal efficacy of metronidazole against bacteria in
carious dentin, concluding that metronidazole effectively disinfected the
carious dentin. Posteriorly, in 1993 Sato et
al. ii
demonstrated that different mixture of ciprofloxacin, metronidazole, plus a
third antibiotic (amoxicillin, cefaclor, cefroxadine, fosfomycin or
rokitamycin) were effective in sterilizing cultured of samples taken from
carious dentin and infected pulpal tissues. It was found that no bacteria could
be recovered after treatment with 100 mg/mL of each antibiotic (300 mg/mL of
mixture). Nygaard-Østby et al. iii
assessed the efficacy of ciprofloxacin, metronidazole and minocycline in dentin
penetration and eradication of bacteria from infected dentin. It was found that
there were no recovered bacteria after 48 h. In 1996, the experiments of Sato et al. iv and Hoshino et al. v revealed the bactericidal efficacy
of a mixture of ciprofloxacin, metronidazole and minocycline to eradicate
bacteria from the infected dentine of root canals. Since then, triple
antibiotic paste has been used widely in REPs, becoming the most popular
intracanal medicaments in pulp regenerative therapy. Takushige et al. vi used TAP to disinfect 87 infected
deciduous teeth, resulting in the resolution of symptoms within days, with
teeth remaining asymptomatic until exfoliation and eruption of successor
permanent teeth. They found that concentrations of 100 mg/mL of each drugs
completely eradicate cultivable bacteria from infected root canals in clinical
samples. Ordinola-Zapata et al. vii
evaluated the antimicrobial activity of calcium hydroxide, 2% chlorhexidine
gel, and TAP by using an intraorally infected dentin biofilm model, concluding
that TAP paste was most effective at killing the bacteria in the biofilms on
the intraorally infected dentin model in comparison with 2% chlorhexidine gel
and calcium hydroxide.

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Antibiotics used in REPs not only have direct
antibacterial effects. DAP (5 mg/mL) exhibited significant residual
antibacterial effects against bacterial biofilms from an infected root canal of
an immature tooth viii.


Clinical and
experimental studies on efficacy of antibiotics in REPs

After the experimental confirmation of the high
efficacy of the combination of ciprofloxacin, metronidazole and minocycline against
endodontic bacteria, Banchs & Trope 6 used, for the first time, a paste containing
these three antibiotics in a case of regenerative endodontics. The three
antibiotics have been mixed either with water, saline, or propylene glycol
until a thick creamy mixture was formed and certain physical consistency was
achieved that was deemed ideal by clinicians 2. Windley et
al. ix
assessed the efficacy of TAP in the disinfection of immature dog teeth with
apical periodontitis. The canals were sampled before (S1) and after (S2)
irrigation with 1.25% NaOCl and after dressing with the triple antibiotic paste
(S3). Reductions in mean CFU counts between S1 and S2 (p < 0.0001) as well as between S2 and S3 (p < 0.0001) were statistically significant, indicating the effectiveness of a triple antibiotic paste in the disinfection of immature teeth with apical periodontitis. Recently, a modified triple antibiotic paste dressing (ciprofloxacin, metronidazole and cefixime, a third generation broad spectrum cephalosporin) (mTAP) at concentration of 20 mg of each antibiotic, has been shown to improve the success rate of the revascularization procedure in immature dog teeth with AP x. However, the results of some studies concluded that the use of intracanal antibiotics might not be necessary in REPs in immature dogs' teeth with apical periodontitis. A study carried out by Da Silva et al. xi found that teeth treated with sodium hypochlorite irrigation with the EndoVac system alone, presented more exuberant mineralized formations, more structured apical and periapical connective tissue, and a more advanced repair process than teeth treated with sodium hypochlorite irrigation with the EndoVac system and TAP. Similarly, Cohença et al. xii analyzed samples collected from inmature dog's teeth root canals with pulp necrosis and apical periodontitis, seeded in a culture medium for anaerobic bacteria, determining colony-forming unit counts. There was no significant difference between the groups with or without TAP. Likewise, it has been demonstrated in REP carried out in immature dog teeth with AP, that TAP dressing during two weeks provides the same level of disinfection than irrigation with 5.25% sodium hypochlorite alone in only one session xiii. Recently, the ESE position statement on revitalization procedures advocates the use of calcium hydroxide instead of antibiotics xiv, considering that there is no strong evidence supporting the use of antibiotics in REPs xv. The ESE position statement on the use of antibiotics in endodontics comes to the same conclusion xvi.


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