Triple Antibiotic Paste (TAP) in Pediatric Endodontics: Current Clinical Evidence

Triple Antibiotic Paste (TAP) has gained significant attention in pediatric endodontics, particularly in the management of necrotic primary teeth and immature permanent teeth.

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Its broad-spectrum antimicrobial activity has made it a key intracanal medicament in regenerative endodontic procedures (REPs) and complex pulpal infections.

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Despite its effectiveness, concerns regarding tooth discoloration, cytotoxicity, and antibiotic resistance have prompted ongoing research and clinical debate.

✅ What Is Triple Antibiotic Paste (TAP)?
TAP is a combination of three antibiotics:

▪️ Metronidazole
▪️ Ciprofloxacin
▪️ Minocycline
This formulation targets both aerobic and anaerobic microorganisms, making it particularly effective against polymicrobial endodontic infections.
TAP is primarily used as an intracanal medicament rather than a permanent filling material.

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✅ Clinical Applications in Pediatric Endodontics
TAP is commonly indicated in:

▪️ Necrotic primary teeth with periapical pathology
▪️ Immature permanent teeth with open apices
▪️ Regenerative endodontic procedures
▪️ Persistent endodontic infections resistant to conventional irrigation

Clinical studies show a significant reduction in bacterial load when TAP is used short-term.

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✅ Advantages of TAP

▪️ Broad-spectrum antimicrobial efficacy
▪️ Effective against Enterococcus faecalis and anaerobic species
▪️ Enhances canal disinfection prior to regenerative procedures
▪️ Improves clinical and radiographic healing outcomes

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✅ Limitations and Safety Concerns
Despite its benefits, TAP presents important limitations:

▪️ Minocycline-induced tooth discoloration
▪️ Potential cytotoxic effects on stem cells
▪️ Risk of antibiotic resistance
▪️ Not recommended for long-term intracanal use

These concerns have led to the development of modified formulations such as Double Antibiotic Paste (DAP) and antibiotic-free alternatives.

📊 Comparative Table: Benefits of Pastes Used in Pulp Therapy

Aspect	Advantages	Limitations
Triple Antibiotic Paste (TAP)	Broad-spectrum antimicrobial action; effective in regenerative procedures	Tooth discoloration; cytotoxicity; antibiotic resistance risk
Double Antibiotic Paste (DAP)	Reduced discoloration risk; effective bacterial control	Still involves antibiotic exposure; limited long-term data
Calcium Hydroxide	High biocompatibility; promotes hard tissue formation	Less effective against resistant bacteria
Ledermix Paste	Anti-inflammatory and antibacterial properties	Contains corticosteroids; limited pediatric indication
Iodoform-Based Pastes	Resorbable; suitable for primary teeth	Limited antimicrobial spectrum

💬 Discussion
Current evidence supports the short-term use of TAP as an effective intracanal medicament, particularly in regenerative endodontics. However, lower concentrations and limited exposure times are strongly recommended to reduce adverse effects.
Recent guidelines emphasize balancing antimicrobial efficacy with biocompatibility, especially in pediatric patients where tissue healing and tooth development are critical.

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✍️ Conclusion
Triple Antibiotic Paste remains a valuable tool in pediatric endodontics when used judiciously. While highly effective in infection control, clinicians must consider its limitations and adhere to evidence-based protocols to ensure safety and long-term success.

🔎 Clinical Recommendations
▪️ Use TAP at low concentrations (≤1 mg/mL)
▪️ Limit intracanal placement to 1–4 weeks
▪️ Avoid use in esthetic zones when possible
▪️ Consider DAP or calcium hydroxide as alternatives
▪️ Follow updated regenerative endodontic guidelines

📚 References

✔ Hoshino, E., Kurihara-Ando, N., Sato, I., Uematsu, H., Sato, M., Kota, K., & Iwaku, M. (1996). In-vitro antibacterial susceptibility of bacteria taken from infected root dentine to a mixture of ciprofloxacin, metronidazole and minocycline. International Endodontic Journal, 29(2), 125–130. https://doi.org/10.1111/j.1365-2591.1996.tb01173.x
✔ American Association of Endodontists. (2023). Clinical considerations for regenerative endodontic procedures. https://www.aae.org/specialty/clinical-resources/regenerative-endodontics/
✔ Diogenes, A., Ruparel, N. B., Shiloah, Y., & Hargreaves, K. M. (2016). Regenerative endodontics: A way forward. Journal of the American Dental Association, 147(5), 372–380. https://doi.org/10.1016/j.adaj.2016.01.018
✔ Ruparel, N. B., Teixeira, F. B., Ferraz, C. C., & Diogenes, A. (2012). Direct effect of intracanal medicaments on survival of stem cells of the apical papilla. Journal of Endodontics, 38(10), 1372–1375. https://doi.org/10.1016/j.joen.2012.06.018

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