Journal of Conservative Dentistry : JCD · 6 authors, 1 centre
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This in vitro study compared the antibacterial efficacy of triple antibiotic paste (TAP), diclofenac sodium (NSAID), and pantoprazole (PPI) against Enterococcus faecalis. The combination of TAP + PPI produced the largest inhibition zones, followed by diclofenac + PPI, TAP alone, diclofenac alone, and PPI alone. These findings suggest that combining nonantibiotic agents with antibiotics may enhance root canal disinfection and help reduce antibiotic resistance.
**Background:** Enterococcus faecalis is a Gram-positive facultative anaerobe commonly implicated in persistent endodontic infections and failed root canal treatments. Traditional intracanal medicaments such as calcium hydroxide have limited efficacy against E. faecalis biofilms. Triple antibiotic paste (TAP) — a combination of metronidazole, ciprofloxacin, and minocycline — is widely used but raises concerns about antibiotic resistance. Nonantibiotic drugs, including nonsteroidal anti-inflammatory drugs (NSAIDs) and proton-pump inhibitors (PPIs), have shown antibacterial properties in prior studies. This study aimed to evaluate and compare the antibacterial efficacy of TAP, diclofenac sodium (DS), pantoprazole (PPI), and their combinations against E. faecalis.
**Methods:** This in vitro study used E. faecalis ATCC 29212 cultured in brain-heart infusion broth, adjusted to 0.5 McFarland turbidity (1.58 × 10⁸ bacteria/ml). The study was conducted in two parts. Part 1 (n = 60) compared three groups: DS (400 mg/ml), PPI (12.5 μg/ml), and TAP (1 mg/ml each of metronidazole, ciprofloxacin, and minocycline). Part 2 (n = 80) compared two combination groups: TAP + PPI (1:1 w/v) and DS + PPI (1:1 w/v). Antibacterial activity was assessed using the agar well diffusion method on Mueller–Hinton agar plates with 5 mm diameter, 2 mm depth wells. Each well received 30 μl of test material. Plates were incubated aerobically at 37°C for 24 hours, and a blinded examiner measured inhibition zone diameters in millimeters. Statistical analysis used ANOVA (Part 1) and unpaired t-test (Part 2), with P < 0.05 considered significant.
**Key Results:** In Part 1, TAP showed the largest mean inhibition zone (36.00 mm, SD 0.918), followed by DS (30.15 mm, SD 0.813) and PPI (27.05 mm, SD 0.826) (F = 567.413, P < 0.001). In Part 2, TAP + PPI produced a significantly larger mean inhibition zone (39.68 mm, SD 0.474) compared to DS + PPI (36.53 mm, SD 0.506) (F = 28.732, P < 0.001). Intergroup post-hoc comparisons showed significant differences between all five groups (P < 0.001 for all pairwise comparisons). The overall ranking of inhibition zone diameters was: TAP + PPI > DS + PPI > TAP > DS > PPI.
**Clinical Implications:** The combination of TAP with PPI demonstrated superior antibacterial activity against E. faecalis compared to all other tested medicaments. The synergistic effect of combining antibiotics with nonantibiotic agents such as PPIs may offer a strategy to enhance root canal disinfection while potentially reducing the risk of antibiotic resistance. The authors recommend using combination medicaments rather than single agents in clinical endodontic practice. However, as an in vitro study, further clinical investigations are needed to confirm these findings in vivo. The use of nonantibiotic agents as intracanal medicaments may also reduce systemic complications and help combat antibiotic resistance.