Clinical have suggested that the discoloring effect

Clinical implications
of the use of antibiotics in REPs

The use of antibiotics as intracanal dressing in
REPs may cause some side effects. A problem that often accompanies the
intracoronal use of TAP containing minocycline is dentin discoloration 24,25,30,i,ii. Reynolds et al. iii have suggested that the discoloring
effect of the minocycline can be minimized by coating the dentinal tubules in
the pulp chamber with a bonding agent. Thibodeau & Trope iv
reported substituting minocycline for cefaclor in the tri-antibiotic formula to
avoid dentin discoloration, and Miller et
al. 38 has confirmed that the incorporation of cefaclor
in the TAP, instead of minocycline, avoids discoloration. The review carried
out by Kahler & Rossi-Fedele v have
analyzed the tooth discoloration in 80 studies of REPs, including 379 treated
teeth. Results demonstrate a strong association of discoloration with the use
of TAP containing minocycline. Authors suggest that either calcium hydroxide or
the double antibiotic paste of metronidazole and ciprofloxacin should
substitute the use of TAP with minocycline in REPs. Sealing the pulp chamber
walls before insertion of TAP decreased coronal discoloration following REP but
did not prevent it vi.
Dental bleaching was able to recover, at least partially, the tooth crown’s
color vii. The
ESE position statement on the use of antibiotics in endodontics concludes that,
taking into account the absence of strong evidence to support the use of antibiotics
in REPs, their use should be avoided 36.

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Other concern associated with intracanal use of
antibiotics is the possibility of promoting antibiotic resistance in some root
canal bacteria viii,ix. The results of Sedgley et al. x, who
analyzed the horizontal exchange of antibiotic resistance between different
bacterial species in root canals, suggest that antibiotic resistance could be already
developing in bacteria recovered from endodontic infections.

The third concern in the use of antibiotics as
intracanal dressing in REPs is the risk of precipitating an allergic reaction
in a sensitive patient or inducing sensitivity in a patient who has never been
sensitive 39, 45. The need for a thorough and complete medical
and dental history of the patient before REP must be highlighted, regardless of
the method of administering the antibiotic during the course of treatment 45.

i Kim JH,
Kim Y, Shin SJ, et al.Tooth discoloration of immature permanent incisor
associated with triple antibiotic therapy: a case report. J Endod 2010;36:1086–91.

ii Miller EK, Lee JY,
Tawil PZ, et al. Emerging therapies for the management of traumatized immature
permanent incisors. Pediatr Dent 2012;34:66–9.

iii Reynolds K, Johnson
JD, Cohenca N. Pulp revascularization of necrotic bilateral bicuspids using a
modified novel technique to eliminate potential coronal discolouration: a case
report. Int Endod J 2009;42:84–92.

iv Thibodeau
B, Trope M. Pulp revascularization of a necrotic infected immature permanent
tooth: case report and review of the literature. Pediatr Dent 2007;29:47–50.

v Kahler B,
Rossi-Fedele G. A review of tooth discoloration after regenerative endodontic
therapy. J Endod 2016;42:563-9.

vi Shokouhinejad N, Khoshkhounejad M, Alikhasi M et al. Prevention of
coronal discoloration induced by regenerative endodontic treatment  in an ex vivo model. Clin Oral Investig. 2017
Oct 31. doi: 10.1007/s00784-017-2266-0. Epub ahead of print PubMed PMID:
29090391.

vii Santos LG, Felippe WT, Souza BD et al.
Crown discoloration promoted by materials used in regenerative
endodontic procedures and effect of dental bleaching: spectrophotometric
analysis. J Appl Oral Sci. 2017;25:234-242.

viii Huang GT, Sonoyama
W, Liu Y, et al. The hidden treasure in apical papilla: the potential role in
pulp/dentin regeneration and bioroot engineering. J Endod 2008;34:645-51.

ix Wigler R,
Kaufman AY, Lin S et al. Revascularization: a treatment for permanent teeth
with necrotic pulp and incomplete root development. J Endod 2013;39:319-26.

x Sedgley
CM, Lee EH, Martin MJ et al. Antibiotic resistance gene transfer between
Streptococcus gordonii and Enterococcus faecalis in root canals of teeth ex
vivo. J Endod 2008;34:570-4.