Effect of Calcium Hydroxide Versus Double Antibiotic Paste on Endodontic Treatment Outcomes

Teeth with necrotic pulps undergoing endodontic treatment require the elimination of as many bacteria as possible from the root canal system. Chemo-mechanical preparation plays a crucial role in removing bacteria, infected dentin, and devitalized tissue. However, it cannot reliably achieve bacteria-free canals.

Achieving complete disinfection in teeth with necrotic pulps and apical periodontitis is challenging due to the polymicrobial nature of infections and the complex anatomy of the root canal system. Therefore, intracanal medicaments are used to ensure complete bacterial elimination after chemo-mechanical preparation in multi-visit endodontic treatments for necrotic teeth.

Common Intracanal Medicaments

Calcium hydroxide (CH): A common inter-appointment medicament, but its limited antimicrobial effectiveness against certain microorganisms raises concerns.

Triple Antibiotic Paste (TAP): Offers broad-spectrum antibacterial activity by combining three antibiotics: minocycline, metronidazole, and ciprofloxacin. However, minocycline may cause tooth discoloration.

Double Antibiotic Paste (DAP): A mixture of ciprofloxacin and metronidazole, DAP provides effective antimicrobial properties without the risk of tooth discoloration associated with TAP.

Study Objective

The present research aimed to evaluate and compare the efficacy of DAP and CH as intracanal medicaments in treating necrotic pulps with apical periodontitis. Radiographic and clinical outcomes of non-surgical endodontic treatment were assessed.

Study Design

A triple-blinded, randomized clinical trial was conducted to compare DAP and CH as intracanal medicaments in anterior maxillary teeth with apical periodontitis.

Participants:

• 30 patients aged 18–30 years, referred to the Endodontic Department, Shahid Beheshti University of Medical Sciences, between March 2018 and March 2020.

• Inclusion criteria: One non-vital anterior maxillary tooth with apical periodontitis, lesion size >5 mm, and PAI = 5.

The exclusion criteria were defined as follows:

1. Allergy to the antibiotics (metronidazole or ciprofloxacin) 

2. Patients not able to take oral NSAIDs 

3. Pregnancy or nursing 

4. Vertical root fractures 

5. Calcified canals 

6. Internal/external root resorptions 

7. Roots with open apices 

8. Non restorable teeth 

9. Patients with masticatory parafunctions 

Each tooth was clinically examined for sensitivity to palpation, percussion, presence of sinus tract, or intra-/extraoral swelling and abscess. Preoperative radiographs were taken.

After local anesthesia and proper rubber dam isolation, access cavities were prepared, and the working length was established. the root canals were prepared with 10 cc irrigation with 2.5% sodium hypochlorite. The canals were dried and filled with intracanal medication plugged into the canal by using Lentulo spiral. A layer of 4-mm interim restoration material was used to obtain a tight coronal seal.  

After 3 weeks of medication, the canals were re-entered under rubber dam isolation, and the intracanal medications were removed using 5 mL of NaOCl 2.5% and circumferential filing with a Hedstrom file. The canals were dried and obturated with gutta-percha and AH 26 sealer.  

The patients were recalled for evaluation 6 and 12 months after treatment. Clinical and radiographic examinations were performed in follow-up sessions.

Based on clinical and radiographic presentations, the outcome was defined as healed/healing/diseased. 

The “healed” category defined both normal clinical and radiographic presentations.  

The “healing” category defined normal clinical presentation with a reduced PA radiolucency size. 

The “diseased” category stands for unchanged or emerged PA radiolucency with/without clinical signs/symptoms. 

Results - At 6-month follow-up, no teeth in either group showed complete healing. 

Reference

1. Wiley Online Library. "Journal of Medical Virology." Accessed January 16, 2025. https://onlinelibrary.wiley.com/journal/6164.

(Input from various sources)

(Rehash/Dr. Puja Devi/MSM)