Efficacy of triantibiotic paste in endodontics: antibacterial activity against resistant strains of Enterococcus faecalis. An exhaustive review
Article Sidebar
Published:
Jul 28, 2025
Keywords:
Enterococcus faecalis, triantibiotic paste, resistance, strains, endodontics, root canal treatment.
Main Article Content
Abstract
Introduction: Enterococcus faecalis is one of the main microorganisms associated with endodontic treatment failures due to its ability to form biofilms, survive in harsh conditions, and exhibit antimicrobial resistance, particularly to vancomycin. In response to this clinical challenge, the Triple Antibiotic Paste (TAP), composed of ciprofloxacin, metronidazole, and minocycline, has shown promising results due to its synergistic antibacterial activity against persistent bacteria in root canal systems. Objective: To evaluate the antibacterial efficacy of triple antibiotic, paste against resistant strains of Enterococcus faecalis through an exhaustive review. Methodology: An exhaustive review was conducted following the PRISMA guidelines. A total of 138 scientific articles were identified and analyzed from indexed databases (PubMed, Scopus, and ScienceDirect), using MeSH and DeCS descriptors combined with Boolean operators AND/OR. Results: Most included studies demonstrated that TAP exhibits high antimicrobial effectiveness against E. faecalis, including strains resistant to conventional antibiotics. Both in vitro and vivo investigations revealed a significant reduction in bacterial load and disruption of radicular biofilms, outperforming other intracanal medications such as calcium hydroxide and chlorhexidine. Conclusions: Triple antibiotic paste is an effective therapeutic option in regenerative endodontics and retreatment procedures, particularly in persistent infections caused by Enterococcus faecalis. Its rational and standardized use can improve clinical outcomes in complex cases, making it a relevant tool in managing antimicrobial resistance within the root canal system. General area of study: Health Sciences. Specific area: Dentistry. Study type: Literature review.
Downloads
Download data is not yet available.
Article Details
How to Cite
Cevallos Fernández, E. P., & Cuenca León, K. de los Ángeles. (2025). Efficacy of triantibiotic paste in endodontics: antibacterial activity against resistant strains of Enterococcus faecalis. An exhaustive review. Anatomía Digital, 8(3.1), 88-104. https://doi.org/10.33262/anatomiadigital.v8i3.1.3454
Section
Articulos de revisión bibliográfica
References
1. Parhizkar A, Nojehdehian H, Asgary S. Triple antibiotic paste: momentous roles and applications in endodontics: a review. Restorative Dentistry & Endodontics [Online]. 2018 [cited 2025 May 15];43(3): e28. Available from: https://pubmed.ncbi.nlm.nih.gov/30135847/
2. Sabrah AHA, Yassen GH, Liu WC, Goebel WS, Gregory RL, Platt JA. The effect of diluted triple and double antibiotic pastes on dental pulp stem cells and established Enterococcus faecalis biofilm. Clinical Oral Investigations [Online]. 2015 [cited 2025 May 15]; 19(8):2059–2066. Available from: https://pubmed.ncbi.nlm.nih.gov/25689981/
3. Frough Reyhani M, Rahimi S, Fathi Z, Shakouie S, Salem Milani A, Soroush Barhaghi MH, et al. Evaluation of antimicrobial effects of different concentrations of triple antibiotic paste on mature biofilm of enterococcus faecalis. Journal of Dental Research, Dental Clinics, Dental Prospects [Online]. 2015 [cited 2025 May 15]; 9(3):138–143. Available from: https://pubmed.ncbi.nlm.nih.gov/26697145/
4. Hoshino E, Kurihara-Ando N, Sato I, Uematsu H, Sato M, Kota K, et al. In-vitro antibacterial susceptibility of bacteria taken from infected root dentine to a mixture of ciprofloxacin, metronidazole, and minocycline. International Endodontic Journal [Online]. 1996 [cited 2025 May 15]; 29(2):125-130. Available from: https://pubmed.ncbi.nlm.nih.gov/9206436/
5. Khan AM, Gangoo IKA, Ali NA, Khan M, Javed MQ, AlAttas MH, et al. The effect of calcium hydroxide, triple antibiotic pastes and chlorhexidine on pain in teeth with symptomatic apical periodontitis: a randomised controlled trial. International Journal of Environmental Research and Public Health [Online]. 2023 [cited 2025 May 15];20(4): 3091. Available from: https://pubmed.ncbi.nlm.nih.gov/36833788/
6. Asnaashari M, Eghbal MJ, Yaghmayi AS, 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. Journal of Lasers Medical Sciences [Online]. 2019 [cited 2025 May 15];10(suppl 1): S23–S29. Available from: https://pubmed.ncbi.nlm.nih.gov/32021669/
7. Prasad LK, Tanwar BS, Kumar KN. Comparison of Calcium Hydroxide and triple antibiotic paste as Intracanal medicament in emergency pain reduction: In vivo study. International Journal of Oral Care & Research [Online]. 2016 [cited 2025 May 15]; 4(4):244–246. Available from: http://www.ijocrweb.com/pdf/2016/October-December/10570_ORIGINAL%20ARTICLE.pdf
8. Mohammadi Z, Jafarzadeh H, Shalavi S, Yaripour S, Sharifi F, Kinoshita JI. A review on triple antibiotic pastes as a suitable material used in regenerative endodontics. Iranian Endodontic Journal [Online]. 2018 [cited 2025 May 15];13(1):1–6. Available from: https://pubmed.ncbi.nlm.nih.gov/29692827/
9. Guan L, Beig M, Wang L, Navidifar T, Moradi S, Motallebi Tabaei F, et al. Global status of antimicrobial resistance in clinical Enterococcus faecalis isolates: systematic review and meta-analysis. Annals of Clinical Microbiology and Antimicrobials [Online]. 2024 [cited 2025 May 15];23(1):80. Available from: https://pubmed.ncbi.nlm.nih.gov/39182092/
10. Sultan OS, Jonathan GCM, Lin SL, Davamani F, Sidhu P, Choudhury M. Management of Enterococcus faecalis associated endodontic infection using gold nanogel: An in-vitro study. The Saudi Dental Journal [Online]. 2025 [cited 2025 May 15];37(24):4-6. Available from: https://link.springer.com/article/10.1007/s44445-025-00019-w
11. Yang S, Meng X, Zhen Y, Baima Q, Wang Y, Jiang X, et al. Strategies and mechanisms targeting Enterococcus faecalis biofilms associated with endodontic infections: a comprehensive review. Frontiers in Cellular and Infection Microbiology [Online]. 2024 [cited 2025 May 15]; 14:1-15. Available from: https://www.frontiersin.org/journals/cellular-and-infection-microbiology/articles/10.3389/fcimb.2024.1433313/full
12. Hakim TA, Zaki BM, Mohamed DA, Blasdel B, Gad MA, Fayez MS, et al. Novel strategies for vancomycin-resistant Enterococcus faecalis biofilm control: bacteriophage (vB_EfaS_ZC1), propolis, and their combined effects in an ex vivo endodontic model. Annals Clinical Microbiology and Antimicrobials [Online]. 2025 [cited 2025 May 15];24(24). Available from: https://ann-clinmicrob.biomedcentral.com/articles/10.1186/s12941-025-00790-y
13. Manoil D, Cerit EE, Fang H, Durual S, Brundin M, Belibasakis GN. Profiling antibiotic susceptibility among distinct enterococcus faecalis isolates from dental root canals. Antibiotics [Online]. 2024 [cited 2025 May 15];13(1): 18. Available from: https://pubmed.ncbi.nlm.nih.gov/38247577/
14. Panchal KG, Virani K, Patel V, Ali Khan A, Pettiwala A, Puranik SS, et al. Triple antibiotic paste: a game changer in endodontics. Journal of Pharmacy and Bioallied Sciences [Online]. 2024 [cited 2025 May 15];16(Suppl 3): S1913-S1915. Available from: https://pubmed.ncbi.nlm.nih.gov/39346169/
15. Bains R, Tikku AP, Verma P, Pandey P. Antimicrobial efficacy of triple antibiotic pastes in teeth with primary endodontic infection: a systematic review. Asian Journal of Oral Health and Allied Sciences [Online]. 2021 [cited 2025 May 15]. Available from: https://ouci.dntb.gov.ua/en/works/40LEYoP4/
16. Lillygrace E, Kethineni B, Puppala R, Raichurkar HKL, Ambati S, Saikiran KV. Antimicrobial efficacy of triple antibiotic pastes and propolis as an intracanal medicament in young permanent teeth: an in vivo study. International Journal of Clinical Pediatric Dentistry [Online]. 2021 [cited 2025 May 15]; 14(2):243–248. Available from: https://pubmed.ncbi.nlm.nih.gov/34413600/
17. Maria do Couto A, Espaladori MC, Pereira Leite AP, Castro Mastins C, Ferreira de Aguiar MC, Guimarães Abreu L. A systematic review of pulp revascularization using a triple antibiotic paste. Pediatric Dentistry [Online]. 2019 [cited 2025 May 15];41(5):341-353. Available from: https://pubmed.ncbi.nlm.nih.gov/31648664/
18. Daffinee KE, O’Neill ET, Bleick CR, Williams G, Antoci V, Garcia D, et al. Staphylococcal biofilm: penetration and bioavailability of vancomycin with or without rifampin. Diagnostic Microbiology Infectious Disease [Online]. 2023[cited 2025 May 15];106(3): 115947. Available from: https://pubmed.ncbi.nlm.nih.gov/37116243/
19. Nikhade P, Agrawal P, Mahapatra J, Suryawanshi T, Bhopatkar J, Umate L. Efficacy of Triple Antibiotic Paste and Bromelain Paste as Intracanal Medicament Against Enterococcus faecalis: An In-Vivo Study. Cureus [Online]. 2023[cited 2025 May 15];15(11): e48098. Available from https://pubmed.ncbi.nlm.nih.gov/38046769
20. Mandal SS, Margasahayam SV, Shenoy VU. A comparative evaluation of the influence of three different vehicles on the antimicrobial efficacy of triple antibiotic paste against Enterococcus faecalis: An in vitro study. Contemporary Clinical Dentistry [Online]. 2020[cited 2025 May 15]; 11(2):150–157. Available from: https://www.researchgate.net/publication/343491372
21. Roy S, Aung MS, Paul SK, Khan NA, Nasreen SA, Hasan MS, et al. Isolation of vanA-Mediated Vancomycin-Resistant Enterococcus faecalis (ST1912/CC116) and Enterococcus faecium (ST80/CC17), optrA-Positive Linezolid-Resistant E. faecalis (ST32, ST1902) from Human Clinical Specimens in Bangladesh. Antibiotics [Online]. 2025 [cited 2025 May 15]; 14(3):261. Available from: https://www.mdpi.com/2079-6382/14/3/261
22. Sanapala S, Singh S, Patel S, Logesh, Ranjan R, Suneetha. Bactericidal effect of triple antibiotic pastes against enterococcus faecalis in dentinal tubules-an ex vivo study. European Journal of Cardiovascular Medicine [Online]. 2024 [cited 2025 May 15];14(5):632-636. Available from: https://healthcare-bulletin.co.uk/article/bactericidal-effect-of-triple-antibiotic-paste-against-enterococcus-faecalis-in-dentinal-tubules-an-ex-vivo-study-2490
23. Vaca Ayala CE, Guamán Hernández VA, Cabezas Abad CA, León Velastegui MA. Microfiltración corono apical de Enterococcus faecalis en dientes endodonciados. Anatomía Digital [Internet]. 2024[citado 15 de mayo de 2025]; 7(2):147-162. Disponible en: https://doi.org/10.33262/anatomiadigital.v7i2.3017
2. Sabrah AHA, Yassen GH, Liu WC, Goebel WS, Gregory RL, Platt JA. The effect of diluted triple and double antibiotic pastes on dental pulp stem cells and established Enterococcus faecalis biofilm. Clinical Oral Investigations [Online]. 2015 [cited 2025 May 15]; 19(8):2059–2066. Available from: https://pubmed.ncbi.nlm.nih.gov/25689981/
3. Frough Reyhani M, Rahimi S, Fathi Z, Shakouie S, Salem Milani A, Soroush Barhaghi MH, et al. Evaluation of antimicrobial effects of different concentrations of triple antibiotic paste on mature biofilm of enterococcus faecalis. Journal of Dental Research, Dental Clinics, Dental Prospects [Online]. 2015 [cited 2025 May 15]; 9(3):138–143. Available from: https://pubmed.ncbi.nlm.nih.gov/26697145/
4. Hoshino E, Kurihara-Ando N, Sato I, Uematsu H, Sato M, Kota K, et al. In-vitro antibacterial susceptibility of bacteria taken from infected root dentine to a mixture of ciprofloxacin, metronidazole, and minocycline. International Endodontic Journal [Online]. 1996 [cited 2025 May 15]; 29(2):125-130. Available from: https://pubmed.ncbi.nlm.nih.gov/9206436/
5. Khan AM, Gangoo IKA, Ali NA, Khan M, Javed MQ, AlAttas MH, et al. The effect of calcium hydroxide, triple antibiotic pastes and chlorhexidine on pain in teeth with symptomatic apical periodontitis: a randomised controlled trial. International Journal of Environmental Research and Public Health [Online]. 2023 [cited 2025 May 15];20(4): 3091. Available from: https://pubmed.ncbi.nlm.nih.gov/36833788/
6. Asnaashari M, Eghbal MJ, Yaghmayi AS, 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. Journal of Lasers Medical Sciences [Online]. 2019 [cited 2025 May 15];10(suppl 1): S23–S29. Available from: https://pubmed.ncbi.nlm.nih.gov/32021669/
7. Prasad LK, Tanwar BS, Kumar KN. Comparison of Calcium Hydroxide and triple antibiotic paste as Intracanal medicament in emergency pain reduction: In vivo study. International Journal of Oral Care & Research [Online]. 2016 [cited 2025 May 15]; 4(4):244–246. Available from: http://www.ijocrweb.com/pdf/2016/October-December/10570_ORIGINAL%20ARTICLE.pdf
8. Mohammadi Z, Jafarzadeh H, Shalavi S, Yaripour S, Sharifi F, Kinoshita JI. A review on triple antibiotic pastes as a suitable material used in regenerative endodontics. Iranian Endodontic Journal [Online]. 2018 [cited 2025 May 15];13(1):1–6. Available from: https://pubmed.ncbi.nlm.nih.gov/29692827/
9. Guan L, Beig M, Wang L, Navidifar T, Moradi S, Motallebi Tabaei F, et al. Global status of antimicrobial resistance in clinical Enterococcus faecalis isolates: systematic review and meta-analysis. Annals of Clinical Microbiology and Antimicrobials [Online]. 2024 [cited 2025 May 15];23(1):80. Available from: https://pubmed.ncbi.nlm.nih.gov/39182092/
10. Sultan OS, Jonathan GCM, Lin SL, Davamani F, Sidhu P, Choudhury M. Management of Enterococcus faecalis associated endodontic infection using gold nanogel: An in-vitro study. The Saudi Dental Journal [Online]. 2025 [cited 2025 May 15];37(24):4-6. Available from: https://link.springer.com/article/10.1007/s44445-025-00019-w
11. Yang S, Meng X, Zhen Y, Baima Q, Wang Y, Jiang X, et al. Strategies and mechanisms targeting Enterococcus faecalis biofilms associated with endodontic infections: a comprehensive review. Frontiers in Cellular and Infection Microbiology [Online]. 2024 [cited 2025 May 15]; 14:1-15. Available from: https://www.frontiersin.org/journals/cellular-and-infection-microbiology/articles/10.3389/fcimb.2024.1433313/full
12. Hakim TA, Zaki BM, Mohamed DA, Blasdel B, Gad MA, Fayez MS, et al. Novel strategies for vancomycin-resistant Enterococcus faecalis biofilm control: bacteriophage (vB_EfaS_ZC1), propolis, and their combined effects in an ex vivo endodontic model. Annals Clinical Microbiology and Antimicrobials [Online]. 2025 [cited 2025 May 15];24(24). Available from: https://ann-clinmicrob.biomedcentral.com/articles/10.1186/s12941-025-00790-y
13. Manoil D, Cerit EE, Fang H, Durual S, Brundin M, Belibasakis GN. Profiling antibiotic susceptibility among distinct enterococcus faecalis isolates from dental root canals. Antibiotics [Online]. 2024 [cited 2025 May 15];13(1): 18. Available from: https://pubmed.ncbi.nlm.nih.gov/38247577/
14. Panchal KG, Virani K, Patel V, Ali Khan A, Pettiwala A, Puranik SS, et al. Triple antibiotic paste: a game changer in endodontics. Journal of Pharmacy and Bioallied Sciences [Online]. 2024 [cited 2025 May 15];16(Suppl 3): S1913-S1915. Available from: https://pubmed.ncbi.nlm.nih.gov/39346169/
15. Bains R, Tikku AP, Verma P, Pandey P. Antimicrobial efficacy of triple antibiotic pastes in teeth with primary endodontic infection: a systematic review. Asian Journal of Oral Health and Allied Sciences [Online]. 2021 [cited 2025 May 15]. Available from: https://ouci.dntb.gov.ua/en/works/40LEYoP4/
16. Lillygrace E, Kethineni B, Puppala R, Raichurkar HKL, Ambati S, Saikiran KV. Antimicrobial efficacy of triple antibiotic pastes and propolis as an intracanal medicament in young permanent teeth: an in vivo study. International Journal of Clinical Pediatric Dentistry [Online]. 2021 [cited 2025 May 15]; 14(2):243–248. Available from: https://pubmed.ncbi.nlm.nih.gov/34413600/
17. Maria do Couto A, Espaladori MC, Pereira Leite AP, Castro Mastins C, Ferreira de Aguiar MC, Guimarães Abreu L. A systematic review of pulp revascularization using a triple antibiotic paste. Pediatric Dentistry [Online]. 2019 [cited 2025 May 15];41(5):341-353. Available from: https://pubmed.ncbi.nlm.nih.gov/31648664/
18. Daffinee KE, O’Neill ET, Bleick CR, Williams G, Antoci V, Garcia D, et al. Staphylococcal biofilm: penetration and bioavailability of vancomycin with or without rifampin. Diagnostic Microbiology Infectious Disease [Online]. 2023[cited 2025 May 15];106(3): 115947. Available from: https://pubmed.ncbi.nlm.nih.gov/37116243/
19. Nikhade P, Agrawal P, Mahapatra J, Suryawanshi T, Bhopatkar J, Umate L. Efficacy of Triple Antibiotic Paste and Bromelain Paste as Intracanal Medicament Against Enterococcus faecalis: An In-Vivo Study. Cureus [Online]. 2023[cited 2025 May 15];15(11): e48098. Available from https://pubmed.ncbi.nlm.nih.gov/38046769
20. Mandal SS, Margasahayam SV, Shenoy VU. A comparative evaluation of the influence of three different vehicles on the antimicrobial efficacy of triple antibiotic paste against Enterococcus faecalis: An in vitro study. Contemporary Clinical Dentistry [Online]. 2020[cited 2025 May 15]; 11(2):150–157. Available from: https://www.researchgate.net/publication/343491372
21. Roy S, Aung MS, Paul SK, Khan NA, Nasreen SA, Hasan MS, et al. Isolation of vanA-Mediated Vancomycin-Resistant Enterococcus faecalis (ST1912/CC116) and Enterococcus faecium (ST80/CC17), optrA-Positive Linezolid-Resistant E. faecalis (ST32, ST1902) from Human Clinical Specimens in Bangladesh. Antibiotics [Online]. 2025 [cited 2025 May 15]; 14(3):261. Available from: https://www.mdpi.com/2079-6382/14/3/261
22. Sanapala S, Singh S, Patel S, Logesh, Ranjan R, Suneetha. Bactericidal effect of triple antibiotic pastes against enterococcus faecalis in dentinal tubules-an ex vivo study. European Journal of Cardiovascular Medicine [Online]. 2024 [cited 2025 May 15];14(5):632-636. Available from: https://healthcare-bulletin.co.uk/article/bactericidal-effect-of-triple-antibiotic-paste-against-enterococcus-faecalis-in-dentinal-tubules-an-ex-vivo-study-2490
23. Vaca Ayala CE, Guamán Hernández VA, Cabezas Abad CA, León Velastegui MA. Microfiltración corono apical de Enterococcus faecalis en dientes endodonciados. Anatomía Digital [Internet]. 2024[citado 15 de mayo de 2025]; 7(2):147-162. Disponible en: https://doi.org/10.33262/anatomiadigital.v7i2.3017