Concentration-dependent Effect of Sodium Hypochlorite on Stem Cells of Apical Papilla Survival and Differentiation

Introduction

Intracanal disinfection is a crucial step in regenerative endodontic procedures. Most published cases suggest the use of sodium hypochlorite (NaOCl) as the primary irrigant. However, the effect of clinically used concentrations of NaOCl on the survival and differentiation of stem cells is largely unknown. In this study, we tested the effect of various concentrations of NaOCl on the stem cells of the apical papilla (SCAPs) survival and dentin sialophosphoprotein (DSPP) expression.

Methods

Standardized root canals were created in extracted human teeth and irrigated with NaOCl (0.5%, 1.5%, 3%, or 6%) followed by 17% EDTA or sterile saline. SCAPs in a hyaluronic acid–based scaffold were seeded into the canals and cultured for 7 days. Next, viable cells were quantified using a luminescence assay, and DSPP expression was evaluated using quantitative real-time polymerase chain reaction.

Results

There was a significant reduction in survival and DSPP expression in the group treated with 6% NaOCl compared with the untreated control group. Comparable survival was observed in the groups treated with the lower concentrations of NaOCl, but greater DSPP expression was observed in the 1.5% NaOCl group. In addition, 17% EDTA resulted in increased survival and DSPP expression partially reversing the deleterious effects of NaOCl.

Conclusions

Collectively, the results suggest that dentin conditioning with high concentrations of NaOCl has a profound negative effect on the survival and differentiation of SCAPs. However, this effect can be prevented with the use of 1.5% NaOCl followed by 17% EDTA. The inclusion of this irrigation regimen might be beneficial in regenerative endodontic procedures.     

Effect of Different Dentin Conditioning Agents on Growth Factor Release,Mesenchymal Stem Cell Attachment and Morphology

IntroductionEDTA has been considered the gold standard in regenerative endodontic treatments. The aim of this study was to evaluate the effects of different dentin conditioning agents other than EDTA on released growth factors, mesenchymal stem cell attachment, and morphology.MethodsTransforming growth factor beta 1, vascular endothelial growth factor, bone morphogenetic protein 2, and fibroblast growth factor 2 release from prepared dentin discs conditioned with 17% EDTA, 10% citric acid, 1% phytic acid (IP6), or 37% phosphoric acid were quantified using the enzyme-linked immunosorbent assay after final irrigation and after 3 days of adipose-derived mesenchymal stem cell (adMSC) seeding. Forty root fragments were prepared from extracted single-rooted teeth. The morphology and attachment of adMSCs on the conditioned root fragments were observed using a scanning electron microscope. Data for growth factor quantification were analyzed using 1-way analysis.ResultsThe highest transforming growth factor beta 1 release was observed after citric acid treatment followed by phosphoric acid; there was no significant difference between them, but compared with EDTA and 1% IP6, there were significant differences observed. The enzyme-linked immunosorbent assay detected a very minor exposure of vascular endothelial growth factor and fibroblast growth factor 2 after dentin conditioning, but there were no significant differences between the groups. The greatest bone morphogenetic protein 2 release was observed in the 1% IP6 group, but there were no significant differences between the groups. Three days of adMSC seeding after dentin conditioning has made a dramatic increase in all of the growth factors, and phosphoric acid appeared to be the most effective agent with significant differences compared with the remaining groups. Scanning electron microscopic observations showed that none of the conditioning solutions had an adverse effect on stem cell proliferation and attachment to root dentin. Different cell morphologies like round, oblong, flat, and well-attached cells with developed filopodia were observed in the dentin-conditioned groups.ConclusionsPhosphoric acid conditioning could be useful and may have beneficial effects in regenerative endodontic treatments.     

The Effect of Octenidine on Proliferation,Migration, and Osteogenic Differentiation of Human Dental Pulp and Apical Papilla Stem Cells

IntroductionThe research for alternative irrigating solutions is ongoing, since no “ideal” solution has yet been found. Octenidine dihydrochloride (OCT) has been indicated as an endodontic irrigant because it has adequate antimicrobial and biological properties. The present study aimed to assess the effects of OCT on proliferation, migration, and induction of the osteogenic phenotype of stem cells from human dental pulp and apical papilla.MethodsCells were collected from human third molars and exposed to different doses of OCT, chlorhexidine (CHX), sodium hypochlorite (NaOCl), and ethylenediaminetetraacetic acid (EDTA) to determine cell viability by alamarBlue assay; proliferation by bromodeoxyuridine incorporation; migration by the Transwell assay; alkaline phosphatase activity by thymolphthalein release; and production of mineralized nodules by alizarin red staining. The results were analyzed by 1- or 2-way analysis of variance and Tukey (α = .05).ResultsCHX promoted lower cell viability, followed by OCT, NaOCl, and EDTA, especially at intermediate doses (P < .05). Cells exposed to CHX had less proliferation than the other groups (P < .05). The Transwell assay revealed no differences among OCT, EDTA, and culture medium (control group) (P > .05). OCT and EDTA induced greater migration than CHX and NaOCl (P < .05). OCT and EDTA induced higher alkaline phosphatase activity than NaOCl and CHX (P < .05). No difference was detected among the groups using alizarin red staining (P > .05).ConclusionsOCT induced high migration, proliferation, and alkaline phosphatase activity of stem cells from human dental pulp and apical papilla, which could be advantageous for regenerative endodontic procedures.     

Dentin Conditioning Protocol for Regenerative Endodontic Procedures

IntroductionThis study focused on the optimization of sodium hypochlorite–EDTA irrigation in terms of the viability and morphology of dental pulp stem cells (DPSCs) and the effects of an optimized EDTA protocol alone or prepared with nanobubble (NB) water on cell behavior.MethodsIn the first part, human dentin discs were conditioned with the following protocols:(1) Sodium hypochlorite followed by phosphate-buffered saline (PBS),(2) Irrigation protocol from group 1 followed by EDTA,(3) Irrigation protocol from group 2 followed by PBS,(4) Sodium hypochlorite followed by EDTA,(5) Irrigation protocol from group 4 followed by PBS. DPSC viability and morphology were determined. In the second part, dentin discs were conditioned with the (1) optimized protocol in the first part, (2) EDTA prepared using NB water, (3) ultrasonic-activated EDTA, or (4) ultrasonic-activated EDTA prepared using NB water. Transforming growth factor beta release and DPSC viability, morphology, and migration were determined using the enzyme-linked immunosorbent assay, the water-soluble tetrazolium salt-1 cell viability assay and live-dead assay, and the transwell migration assay, respectively. Data were analyzed using Kruskal-Wallis or one-way analysis of variance and post hoc tests.ResultsThe highest cell viability was observed in group 3 followed by group 5 (P < .05) in which PBS was used as a final rinse. Irrigation protocol from group 3 was used for the subsequent experiments. Ultrasonic-activated EDTA improved transforming growth factor beta release, viability, and migration of the cells compared with EDTA (P < .05). The preparation of EDTA with NBs did not change the biological properties of the EDTA-conditioned dentin (P > .05).ConclusionsRemoving the residual EDTA using PBS improved the cell viability on the dentin surface. Ultrasonic activation enhanced the growth factor release and biological properties, whereas the preparation of EDTA with NBs showed a similar effect to regular EDTA without compromising the cellular effect.     

Direct and Indirect Effect of Chlorhexidine on Survival of Stem Cells from the Apical Papilla and Its Neutralization

Introduction

Several irrigants have been used for disinfection in regenerative endodontic procedures including chlorhexidine (CHX). In this context, the antibacterial properties of disinfectants are mainly in focus of research even though they may have an undesirable impact on the fate of stem cells. In this study, we hypothesized that CHX has both a direct effect when applied to stem cells of the apical papilla (SCAPs) and an indirect effect when SCAPs are exposed to dentin previously conditioned with CHX.

Effects of Intracanal Antimicrobials on Viability and Differentiation of Stem Cells From the Apical Papilla: An In Vitro Study

BackgroundRecent studies have indicated that intracanal antimicrobials used to disinfect the root canal in regenerative endodontic therapies (RETs) may be cytotoxic to stem cells from the apical papilla (SCAP), leading to inconsistent treatment outcomes. However, the effects of intracanal antimicrobial agents on the odontogenic differentiation capacity of SCAP at sub-lethal concentrations have not been investigated. The aim of this study was to determine the effects of intracanal antimicrobials on SCAP viability and odontogenic differentiation capacity using a clinically relevant concentration range (0.1–0.8 mg/mL).MethodsImmature human third molars were collected from 71 patients and the apical papillae were harvested to form single-cell suspensions. The cytotoxic effects of intracanal antimicrobials including double antibiotic paste (DAP), triple or modified-triple antibiotic paste (TAP or MTAP), and calcium hydroxide (Ca(OH)₂) on STRO-1⁺ SCAP were assessed using AlamarBlue and Live/Dead assays after exposing cells to treatment groups for 7 days at 0.1 to 0.8 mg/mL. The odontogenic differentiation potential of STRO-1⁺ SCAP was evaluated by immunocytochemistry staining of dentin matrix protein-1 and dentin sialophosphoprotein expression.ResultsAll concentrations of TAP significantly reduced STRO-1⁺ SCAP viability and odontogenic differentiation (P < .001), whereas no DAP concentrations were significantly cytotoxic. Ca(OH)₂ and MTAP concentrations below 0.4 mg/mL and 0.2 mg/mL, respectively, did not significantly reduce viability. The DAP, MTAP, and Ca(OH)₂ did not significantly impact the odontogenic differentiation capacity of STRO-1⁺ SCAP.ConclusionThe varying effects of intracanal antimicrobials on STRO-1⁺ SCAP in vitro suggest amendments to the current root canal disinfection protocol may improve the success of RETs.     

Effect of Irrigants on the Survival of Human Stem Cells of the Apical Papilla in a Platelet-rich Plasma Scaffold in Human Root Tips

Introduction

Intracanal disinfection is a crucial step in regenerative endodontic procedures. However, this novel endodontic treatment lacks standardization, and numerous treatment protocols have been reported without knowledge of the effect of disinfection protocols on the survival of stem cells. The aim of this study was to test the hypothesis that different root canal irrigation protocols alter survival of stem cells from the apical papilla (SCAP).

Methods

SCAP were isolated from immature human third molars, and a subpopulation of STRO-1 expressing cells was selected and expanded in vitro. Standardized human root segments (n = 5/group) were irrigated with 1 of 4 protocols: (1) 17% ethylenediaminetetraacetic acid (EDTA), (2) 6% NaOCl/17% EDTA/6% NaOCl, (3) 17% EDTA/2% chlorhexidine (CHX), or (4) 6% NaOCl/17% EDTA/6% NaOCl/isopropyl alcohol/2% CHX. Subsequently, STRO-1-enriched SCAP were mixed with platelet-rich-plasma, seeded into the root tips, and cultured for 21 days. Roots were then decalcified, processed for immunohistochemistry, and stained for vimentin and TO-PRO-3. The proportion of viable (vimentin-positive) cells was calculated on the basis of the total cell counts (TO-PRO-3) for each group.

Results

Irrigation with 17% EDTA best supported cell survival (89% viability; P < .001 versus all other groups), followed by irrigation with 6% NaOCl/17% EDTA/6% NaOCl (74%; P < .001 versus the 2 groups containing 2% CHX). Conversely, protocols that included 2% CHX lacked any viable cells.

Conclusions

Collectively, the results suggest that irrigants alone greatly affect the survivability of STRO-1-enriched SCAP within the root canal environment and that inclusion of EDTA in irrigation protocols might be beneficial in regenerative procedures.     

Human Stem Cells from the Apical Papilla Response to Bacterial Lipopolysaccharide Exposure and Anti-inflammatory Effects of Nuclear Factor I C

IntroductionStem cells from the apical papilla (SCAPs) are important for tooth root development and may be candidates for regenerative endodontic procedures involving immature teeth. The potential use of SCAPs for clinical applications requires a better understanding of their responses to bacterial challenge. We have investigated the effects of exposure of these cells to lipopolysaccharide (LPS). Inflammatory responses arising from bacterial challenges can constrain postinjury tissue regeneration and the effects of nuclear factor I C (NFIC), which plays a critical role in tooth root development. NFIC has been explored for its anti-inflammatory action in the context of endodontic treatment of immature teeth where continued root development is an important outcome.MethodsSCAPs were exposed to LPS, and the expression of Toll-like receptor-4 (TLR4), interleukin (IL)-6, IL-8, and tumor necrosis factor (TNF-α) were assessed by real-time polymerase chain reaction (RT-PCR). The pLenti6.3/v5-NFIC plasmid encoding the full-length NFIC or NFIC silencing by si-RNA (small interfering RNA) in SCAPs were measured by Western blotting or RT-PCR; the effects of NFIC on IL-6, IL-8, and TNF-α were analyzed by RT-PCR. The protein levels were subsequently measured by enzyme-linked immunoassay.ResultsLPS induced the synthesis of IL-6, IL-8, and TNF-α in SCAPs in a time-dependent manner. Pretreatment with a TLR4 inhibitor significantly inhibited LPS-induced IL-6, IL-8, and TNF-α expression. Knockdown of NFIC increased the expression of IL-6, IL-8, and TNF-α, whereas the overexpression of NFIC resulted in the suppression of the inflammatory response stimulated by 1 μg/mL LPS, especially for IL-8. Together, these data show that LPS is recognized by the transmembranous receptor TLR4 to mediate inflammatory responses in SCAPs and NFIC overexpression can suppress LPS-initiated innate immune responses.ConclusionsThe anti-inflammatory effects of NFIC overexpression provide a valuable target to dampen inflammatory responses in the infected pulp to allow tissue regeneration to occur.     

Effect of Bioceramic Materials on Proliferation and Odontoblast Differentiation of Human Stem Cells from the Apical Papilla

Introduction

In regenerative endodontic treatment (RET), practitioners favor the placement of bioceramics as sealing materials over blood clots. It is important to understand the interaction between sealing material and cells in the root canal. The purpose of this study was to compare the effectiveness of various bioceramic materials (ProRoot MTA [Dentsply, Tulsa, OK], Biodentine [Septodont, Saint-Maur-des-Fossés, France], and RetroMTA [BioMTA, Seoul, Korea]) as sealing materials in RET for the proliferation and differentiation of stem cells from the apical papilla (SCAPs).

A Comparative Evaluation of Concentrated Growth Factor and Platelet-rich Fibrin on the Proliferation,Migration, and Differentiation of Human Stem Cells of the Apical Papilla

Introduction

Concentrated growth factor (CGF) is considered to be a natural biomaterial that is better than platelet-rich fibrin (PRF) in bone regeneration, but there is little information acquired in regenerative endodontics. Therefore, the purpose of this study was to evaluate their effects on the proliferation, migration, and differentiation of human stem cells of the apical papilla (SCAPs).

Effects of Lipopolysaccharide on the Proliferation and Osteogenic Differentiation of Stem Cells from the Apical Papilla

Introduction

Stem cells from the apical papilla (SCAPs) were suggested as the stem cell source in regenerative endodontic procedures. However, bone and/or cementum-like structure were observed in root canals. Lipopolysaccharide (LPS) in infected root canals might alter SCAPs' osteogenic differentiation pattern. The objectives of this study were to investigate the effects of LPS on SCAPs' proliferation and osteogenic differentiation.

Engineering a Novel Stem Cells from Apical Papilla-Macrophages Organoid for Regenerative Endodontics

IntroductionA 3-dimensional (3D) tissue construct with a heterogeneous cell population is critical to understand the interactions between immune cells and stem cells from the apical papilla (SCAPs) in the periapical region for developing treatment strategies in regenerative endodontics. This study aimed to develop and characterize a 3D tissue construct with a binary cell system for studying the interactions between SCAPs and macrophages in the presence of lipopolysaccharide (proinflammatory) and interleukin 4 (anti-inflammatory) environments.MethodsSCAPs and macrophages were seeded in the 3D-printed dumbbell-shaped molds to generate tissue constructs with a binary cell population. Two experimental (lipopolysaccharide and interleukin 4) and control (non-stimulation) conditions were applied to the tissue constructs to determine the characteristics of the tissue construct, the volume of viable cells, and their morphology using confocal laser scanning microscopy from a 0- to 7-day period. Experiments were conducted in triplicate, and data were analyzed with trend analysis and 2-way analysis of variance at a significance of P < .05.ResultsThe tissue constructs revealed distinct SCAP-macrophage interaction in pro/anti-inflammatory environments. SCAPs displayed characteristic self-organization as a cap-shaped structure in the tissue construct. The growth of cells and cell-to-cell and cell-to-matrix interactions resulted in 70% and 30% decreased dimension of the tissue graft on the SCAP side and macrophage side, respectively, at day 7 (P < .0001). The tissue environments influenced SCAP-macrophage interactions, resulting in an altered viable cell volume (P < .05), morphology, and structural organization.ConclusionsThis study developed and characterized an apical papilla organoid in a 3D collagen-based tissue construct for studying SCAP-macrophage crosstalk in tissue regeneration as well as repair.     

牙本质支架体外诱导兔骨髓干细胞分化

目的：探讨将人牙本质作为组织工程支架的可行性,采用不同的方式处理牙本质片,观察牙本质片处理后诱导兔骨髓基质干细胞贴壁附着生长的规律及成骨分化潜能。方法：将兔的骨髓基质干细胞分别接种于经机械去除前期牙本质加EDTA-柠檬酸脱矿处理（A组）,标准根管预备-EDTA处理（B组）的牙本质片上,体外培养1周,扫描电镜观察细胞与牙本质片的附着情况,碱性磷酸酶、茜素红及Vonkossa染色观察兔骨髓基质干细胞成骨分化。结果：兔骨髓基质细胞附着在2种方式处理的牙本质片上生长良好,贴附紧密。B组牙本质片上细胞碱性磷酸酶表达阳性率高达80％,茜素红、Vonkossa染色观察到钙结节数量多于A组。结论：经标准根管预备一EDTA处理的人牙本质能有效促进骨髓基质干细胞增殖及成骨分化,可能成为一种理想的成骨生物支架,并为牙体牙髓疾病的治疗提供了新的思路。广西科学研究与技术开发计划项目（桂科攻1012400lA一42）     

Comparative Effects of Concentrated Growth Factors on the Biological Characteristics of Periodontal Ligament Cells and Stem Cells from Apical Papilla

IntroductionDuring cell-free regenerative endodontic therapy, both stem cells from apical papilla (SCAPs) and periodontal ligament cells (PDLCs) are possible cell sources because of their proximity. Nonetheless, the regenerative ability of PDLCs and SCAPs under the induction of concentrated growth factors (CGFs) remains unclear.MethodsPDLCs and SCAPs were treated with various concentrations of CGF-conditioned medium (CCM). The effects of CCM with or without Porphyromonas gingivalis lipopolysaccharide (LPS) on cell migration, odonto/osteogenic differentiation, and the expression of inflammatory cytokines were assessed. Dentin matrix transplants composed of PDLCs or SCAPs cell sheets coupled with CGF were put subcutaneously in immunocompromised mice for 8 weeks to explore their regenerative characteristics in vivo.ResultsCCM dose dependently enhanced the migration, proliferation, and odonto/osteogenic differentiation of PDLCs and SCAPs. CCM alleviated LPS-inhibited odonto/osteogenic differentiation of PDLCs and SCAPs as well as the LPS-induced up-regulation of inflammatory cytokines. In vivo, the newly regenerated tissue and microvessels formed by PDLCs and SCAPs were significantly increased under the induction of CGF. SCAPs mainly regenerated pulp/dentinlike tissues and a large number of microvessels, whereas PDLCs mainly formed bone/cementumlike structures.ConclusionsOverall, PDLCs excelled in cell proliferation, migration, and osteogenic differentiation, whereas SCAPs outperformed PDLCs in terms of angiogenic and odontogenic differentiation. The biological differences between PDLCs and SCAPs provided a possible theoretical basis for the formation of bone/cementum/periodontal ligament–like tissues after cell-free regenerative endodontic therapy.     

Effect of EDTA on Attachment and Differentiation of Dental Pulp Stem Cells

Introduction

In regenerative endodontics, it is believed that EDTA induces odontoblast differentiation by releasing growth factors from the dentin matrix. The aim of this study was to evaluate the effect of EDTA on the attachment and differentiation of dental pulp stem cells (DPSCs). We also investigated whether the behavioral changes of DPSCs could be caused by biochemical components released from EDTA-treated dentin.

Methods

Cells were obtained from human third molars, and the stem-like nature of the cells was investigated by flow cytometric analysis. DPSCs were seeded on EDTA-treated and untreated dentin slices. After 3 days of culture, cell attachment was evaluated by cell density, fibronectin 1 gene expression level using quantitative real-time polymerase chain reaction, and scanning electron microscopy. After 21 days of culture, the expression of differentiation genes was investigated by quantitative real-time polymerase chain reaction, and calcification was observed using alizarin red S staining. To investigate the EDTA-induced growth factor release, DPSCs were cultured with or without direct contact with the EDTA-treated dentin surface.

Results

After 3 days of culture, both the cell density and fibronectin expression level were significantly higher in the EDTA-treated dentin group. After 3 weeks, the DPSCs on the EDTA-treated dentin surfaces showed higher expression levels of dentin sialophosphoprotein and dentin matrix protein 1, whereas the DPSCs cultured without direct contact with the EDTA-treated dentin surfaces did not exhibit these findings.

Conclusions

Our results showed that EDTA induced cell attachment and odontoblastic/osteoblastic differentiation, which was observed only in the group in which the DPSCs were placed in direct contact with the EDTA-treated dentin surfaces. These findings suggest that EDTA is beneficial for achieving successful outcomes in regenerative endodontics.     

Angiotensin II Regulates Proliferation and Function of Stem Cells of Apical Papilla

IntroductionStem cells of apical papilla (SCAP) may be affected by inflammatory mediators released by activation with lipopolysaccharide (LPS) from infected pulpal cavities of necrotic immature teeth. Therefore, this study aimed to investigate the presence of a local renin-angiotensin system (RAS) and the role of angiotensin II (Ang II) on the modulation of SCAP in vitro.MethodsPrimary cultures of SCAP were incubated with LPS (0.1–10 μg/mL) for cell viability and quantification of the chemokine CCL2. Components of RAS were searched by gene expression of angiotensinogen (AGTN), angiotensin converting enzyme (ACE), renin, angiotensin receptor 1 (AT1) and 2 (AT2), and Mas receptor. Ang II was investigated in SCAP supernatants. Immunofluorescence was used to detect AGTN and AT1. Next, cells were treated with Ang II for viability/proliferation assessment, quantification of CCL2 and interleukin 6, and mineralization assay. Data were evaluated by analysis of variance using Tukey post hoc comparisons or the Student t test. P values <.05 were considered to be significant.ResultsLPS increased CCL2 production at 1 and 10 μg/mL. The gene expression of AGTN, renin, ACE, and AT1 was detected, but only ACE was increased by LPS. Ang II peptide was found in SCAP supernatants but unaltered by LPS. Both AGTN and AT1 proteins were detected by immunostaining. Ang II significantly induced SCAP proliferation, increased CCL2 production, down-regulated IL-6 release, and reduced the SCAP mineralization rate.ConclusionsA local RAS was found at the apical papilla, and Ang II was able to modulate SCAP function in vitro.     

Antibacterial Efficacy of Triple Antibiotic Medication With Macrogol (3Mix-MP), Traditional Triple Antibiotic Paste,Calcium Hydroxide,and Ethanol Extract of Propolis: An Intratubular Dentin Ex Vivo Confocal Laser Scanning Microscopic Study

IntroductionThis study aimed to assess the effectiveness of antibacterial activity of medications used in regenerative endodontic treatment.MethodsSixty-seven dentin cylinders of single-rooted teeth were contaminated with a culture of Enterococcus faecalis (ATCC 29212; American Type Culture Collection, Manassas, VA) for 5 days. Samples were divided into 1 control group and the following experimental groups according to the medication applied: traditional triple antibiotic paste (TAP), clindamycin-modified TAP (mTAP), triple antibiotic medication with macrogol (3Mix-MP), clindamycin-modified 3Mix-MP (m3Mix-MP), calcium hydroxide (CH), and ethanol extract of propolis (EEP). After 14 days, the medications were removed, and the samples were submitted to confocal laser scanning microscopic analysis to quantify the percentage of viable bacteria. The distribution of data was confirmed by the Shapiro-Wilk test. The Kruskal-Wallis and Dunn tests were used for intergroup comparisons, and the Wilcoxon test was used for comparison between superficial and deep antibacterial efficacy for the same medication. The level of significance was set at P < .05.Results3Mix-MP and m3Mix-MP presented significantly higher antibacterial efficacy compared with the other tested medications (P < .05), except for mTAP. mTAP was more effective than TAP (P < .05). The antibacterial efficacy of EEP and CH did not differ significantly from TAP and mTAP (P > .05). All medications showed effective antibacterial action compared with the control group (P < .05).Conclusions3Mix-MP and m3Mix-MP, which present extremely high concentrations of antibiotics (1500 mg/mL), were not more effective than mTAP at the concentration recommended by the American Association of Endodontists (5 mg/mL). Moreover, CH and EEP were as effective as TAP and mTAP.