DOI: 10.1111/j.1365-263X.2011.01181.
Success rates of a mixture of ciprofloxacin, metronidazole,
and minocycline antibiotics used in the non-instrumentation
endodontic treatment of mandibular primary molars with
carious pulpal involvement
CHUTIMA TRAIRATVORAKUL1 & PALINEE DETSOMBOONRAT2
1
Department of Pediatric Dentistry, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand, and 2Department of
Community Dentistry, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand
International Journal of Paediatric Dentistry 2012; 22:
217–227
Objective. To evaluate the clinical and radio-
graphic success rates of three mixed antibiotics in
the non-instrumentation endodontic treatment of
primary mandibular molars at 24–27 months post-
operatively.
Methods. Eighty cariously involved lower primary
molars from 58 children (ages 3–8 years) received
a 3Mix medicament by non-instrumentation endo-
dontic treatment and were then sealed with
glass-ionomer cement and composite resin before
permanent restoration with stainless steel crowns.
The patients received a clinical and radiographic
assessment every 6 months over a 2-year follow-
Introduction
Despite efforts to prevent dental caries
among children, premature loss of primary
teeth because of rampant caries, particularly
when involving the pulp, is common. Impor-
tantly, primary teeth are considered natural
space maintainers. Hence, they should be
retained until their exfoliation is chronologi-
cally appropriate. The primary aim of end-
odontic treatment in primary teeth is to
remove all bacterial infection by endodontic
instrumentation and to apply a permanent
root canal filling such as zinc oxide-eugenol
(ZOE), calcium hydroxide (Ca(OH)2), calcium
hydroxide ⁄ iodoform paste (Vitapex), or Kri
paste1.
Correspondence to:
P. Detsomboonrat, Department of Community Dentistry,
Faculty of Dentistry, Chulalongkorn University,
34 Henri-Dunant Road, Patumwan, Bangkok 10330,
Thailand. E-mail: palinee.d@chula.ac.th
 2011 The Authors
International Journal of Paediatric Dentistry  2011 BSPD, IAPD and Blackwell Publishing Ltd
up period with an intra-examiner reliability of
0.83–1.00 (j value).
Results. In 60 cases at 24- to 27-month follow-up,
the success rates as determined by clinical and
radiographic evaluation were 75% and 36.7%,
respectively; however, the overall success rate of
3Mix non-instrumentation endodontic treatment
was 36.7% with 15.8% of cases demonstrating a
pulpal response of internal resorption.
Conclusions. Non-instrumentation endodontic
treatment using 3Mix-MP showed good clinical
success but had a low success rate based on radio-
graphic evaluation at 2-year follow-up. Hence,
3Mix antibiotic treatment cannot replace a conven-
tional root canal treatment agent as a long-term
therapy.
Currently, the majority of Thai children are
covered by universal health insurance pro-
grams, i.e., the Civil Servant Medical Benefit
Scheme (CSMBS) and the Universal Coverage
Scheme (UCS). Both schemes provide compre-
hensive oral health care comprising restora-
tions, extractions, pulp treatment, scaling and
prophylaxis, and preventive treatments such
as fluoride application for high-risk groups and
sealants. Studies have revealed Thai children
receive endodontic treatment in primary teeth
at a low rate, and there is disparity in such
treatment across socioeconomic status groups,
i.e., lower socioeconomic children received
endodontic treatment less frequently than
their higher socioeconomic counterparts2. Also
reports on the decisions of dentists in the pub-
lic sector showed they preferred extraction of
infected primary teeth instead of performing
endodontic treatment because of the difficult
and time consuming procedure3.Thus, there is
a need for a simple and less time consuming
technique to treat these teeth.
217
218 C. Trairatvorakul & P. Detsomboonrat
The concept of ‘‘lesion sterilisation and tis-
sue repair’’ (LSTR), therapy has become
widespread, using a mixture of antibacterial
drugs to eliminate oral bacteria in dentin and
pulp tissue by non-instrumentation endodon-
tic treatment. This paradigm also infers that
repair of damaged tissues occurs subsequent
to the lesions being treated4.
Although metronidazole is considered as the
antibacterial drug of choice because it has a
broad bactericidal spectrum against anaerobes,
which are commonly found in infected oral
tissue5–10, metronidazole even in high concen-
tration cannot eradicate all bacteria from cari-
ous lesions11. Hence, some additional drugs to
sterilise the lesions are necessary. A mixture
of antibacterial drugs consisting of ciprofloxa-
cin, metronidazole, and minocycline, which
can sterilise carious lesions, necrotic pulps,
and infected root dentin, has been introduced.
Both in vitro and in situ studies revealed these
three mixed antibiotic drugs are effective in
eliminating oral bacteria and in healing lesions
of infected primary teeth11–13.
The bactericidal efficacy of a mixture of
antibiotics is also corroborated by the success
of its use in the treatment of immature per-
manent teeth. After removing and disinfect-
ing the necrotic coronal pulp by antibiotics in
an infected immature permanent tooth with
periapical involvement, there is the potential
for the remaining vital pulp cells to proliferate
and develop new pulp tissue into the coronal
pulp chamber, the so-called pulp revasculari-
sation14–16.
There are few reports of investigations with
long-term follow-up into the use of this three
mix antibiotic paste to improve the results of
clinical treatment of infected pulp in primary
teeth17–19. Given the limitations in previous
studies such as undefined radiographic evalua-
tion criteria used to determine the success of
the treatment etc17–19, this study aimed to
investigate the success rates of three mixed
antibiotics in the non-instrumentation endo-
dontic treatment of primary molars under
more rigorous evaluation criteria and to exam-
ine whether there were statistically significant
differences in success rates of using 3Mix-MP
among different levels of severity of the preop-
erative radicular pathology and tooth type.
International Journal of Paediatric Dentistry  2011 BSPD, IAPD and Blackwell Publishing Ltd
Materials and methods
This study was approved by the Ethics Com-
mittee of Chulalongkorn University, Bangkok,
Thailand. Informed consent was obtained
from all participating parents or legal guard-
ians. Cariously involved lower primary molars
were selected according to both clinical and
radiographic inclusion criteria as follows: (1)
clinical characteristics that indicated pulpecto-
my, i.e., the presence of a deep carious lesion
with pulpal exposure, bleeding after removing
of all the coronal pulp tissue from vital
inflamed pulp, spontaneous pain and ⁄ or
chronic apical abscess, or abnormal mobility;
(2) The radiographic characteristics were cate-
gorised into four groups: no pathology (P1),
discontinuity of lamina dura (P2), furcation
involvement less than or equal to half the
length of the shortest root (P3), and furcation
involvement more than half the length of the
shortest root (P4)20. Primary mandibular
molars with radiographic characteristics of
P2–P4 met the inclusion criteria of this study.
Study exclusion criteria included teeth with
obliteration of the root canal, internal resorp-
tion, and physiologic root resorption more
than one-third of the root length.
According to the clinical and radiographic
criteria established, 80 affected primary man-
dibular molars from 58 healthy children, age
range from 3 years 11 months to 8 years
7 months (mean ± SD age of 6.18±0.96
years), were included in the study. Of those
teeth, 33 of 80 (41.25%) fell into the P2
pathology class, 5 of 80 (6.25%) belonged to
the intermediate P3 group, whereas 42 of 80
(52.5%) were in the more severely affected
P4 group. The sample group was somewhat
skewed towards primary second molars at 47
of 80 (58.75%). Table 1 shows the distribu-
tion of sample teeth by tooth type and radio-
graphic pathology at baseline.
The preparation of 3Mix-MP
The chemotherapeutic agents used, cipro-
floxacin (Ciproxan, Bayer-Japan, Osaka,
Japan), metronidazole (Metronidazole, GPO,
Bangkok, Thailand) and minocycline (Mino-
mycine, Ledeale-Japan, Tokyo, Japan), were
 2011 The Authors
 Success rates of three mixed antibiotics in the non-instrumentation endodontic treatment
Table 1. Distribution of teeth according to tooth type and
radiographic pathology rating at baseline.
Tooth (N)
Level #74 #75 #84 #85
P2 6 10 9 8
P3 0 1 2 2
P4 10 12 6 14
Total 16 23 17 24
P2, Discontinuous lamina dura; P3, Furcation involvement less
than or equal to half the length of the shortest root in vertical
measurement; P4, Furcation involvement more than half the
length of the shortest root in vertical measurement.
pulverised into powder after the removal of
the enteric coating on the drugs. The drugs
were kept separately in tightly capped porce-
lain containers to prevent exposure to light
and moisture. These powdered drugs were
used in a ratio of 1 : 1 : 1 as the 3Mix18. A
mixture of macrogol (M) and propylene gly-
col (P) was used as a carrier (MP; Meiji,
Tokyo, Japan) to facilitate better diffusion of
medicament through root canal dentin and
the surrounding periradicular tissues21. The
drug mixture and carrier were thoroughly
mixed to form 3Mix-MP22.
Clinical procedure of non-instrumentation
endodontic treatment of primary molars
The procedure of non-instrumentation endo-
dontic treatment used in this study followed
the standard pulpotomy procedure. In each
case, treatment was delivered and completed
in one visit by the same paediatric dentist.
Access opening was performed and the necro-
tic pulp and previous restoration, if any, were
removed with a straight high speed No. 9
bur. The walls of the access cavity were
chemically cleaned with ethylenediamine tetra-
acetic acid (EDTA; CU-Dent product, Bang-
kok, Thailand), a chelating agent, which is
used to improve chemo-mechanical debride-
ment in root canal treatment because of its
ability to remove the smear layer and act on
the dentinal wall to produce a clean surface
and patent dentinal tubules allowing anti-
biotics to penetrate into dentinal tubules23.
Before applying 3Mix-MP, the orifice of each
root canal was enlarged to create medication
 2011 The Authors
International Journal of Paediatric Dentistry  2011 BSPD, IAPD and Blackwell Publishing Ltd
219
receptacles with a diameter of 1 mm and
2 mm depth for the standardisation of medi-
cament delivery. Haemorrhage, if present,
was controlled by applying cotton pellets
Total immersed in 10% sodium hypochlorite to
33 stop bleeding, remove both organic and inor-
5 ganic components of the smear layer, and to
42 eliminate bacteria efficiently at the dentin
80
surface23,24. The pulpal floor was covered
with the 3Mix-MP and then sealed with
glass-ionomer cement (Fuji II LC; GC,
Tokyo, Japan) covered by composite resin
(Z250; 3M ESPE, St Paul, MN, USA) using
self-etch adhesive (Adper prompt; 3M-
ESPE). All teeth were restored with stainless
steel crowns (3M ESPE) as a permanent res-
toration and cemented with glass-ionomer
cement (Hy-Bond GI CX; Shofu, Kyoto,
Japan). Radiographic examination was per-
formed to check the marginal adaptation of
the stainless steel crown before permanent
cementation.
Post-treatment evaluation criteria
Patients were re-evaluated after 1 month
(clinical follow-up) and a clinical ⁄ radiographic
evaluation at 6, 12, 18–21, and 24–27 months
post-treatment. The clinical criteria indicating
successful treatment consisted of the absence
of pain, the presence of healthy soft tissue
(defined as the absence of swelling, redness,
or sinus fistula), and the absence of abnormal
mobility. The evaluation criteria for radio-
graphic success were radiographic continuity
of the lamina dura, a reduction in the size of
any pathologic inter-radicular and ⁄ or periapi-
cal radiolucencies, or evidence of bone regen-
eration. The overall success of treatment was
indicated when both clinical and radiographic
criteria were fulfilled. Absence of change in
discontinuity of the lamina dura or in size of
any radiolucent area was considered as
‘‘Observed’’ status at the 6-month evaluation.
The same condition would be classified as
failure at the 12-month recall. Radiographic
examination was performed by one other
paediatric dentist, and the blinded investiga-
tor was assessed for intra-examiner reliability
at every 6-month follow-up. Cohen’s kappa
statistic indicated excellent reproducibility both
220 C. Trairatvorakul & P. Detsomboonrat
of the clinical and radiographic evaluation
with a measurement agreement of 1.0 and
0.83–0.95, respectively.
Results
Of the 80 primary mandibular molars receiv-
ing treatment, 79 (98.75%), 72 (90%), 59
(73.75%), and 60 (75%) teeth were available
for evaluation at 6, 12, 18–21, and 24–27
months, respectively. Based on clinical evalu-
ation, out of 52 teeth that presented for the
24- to 27-month re-evaluation, we found 43
teeth (82.7%) to be asymptomatic, 7 teeth
(13.5%) having abnormal mobility, and none
with spontaneous pain (Table 2). Although
all cases with pre-operative gingival swelling
or fistula had completely resolved by 1 month
postoperatively, we found slight gingival
swelling of the buccal gingiva in two cases at
the 24- to 27-month recall.
A representative example of a clinical success
case of a treated primary mandibular second
molar is shown in Fig. 1. Photographed imme-
diately after treatment and restoration with a
stainless steel crown, a fistula was present and
the buccal gingiva at the affected tooth is
observed to be erythematous and quite swollen
(Fig. 1a). Seen 1 month later, the gingiva has
regained its normal colour and architecture
(Fig. 1b). Radiographic evaluation showed
caries extending into the pulp chamber with a
large inter-radicular radiolucency seen pre- and
immediately postoperatively (Fig. 1c,d). At the
6-month re-evaluation, the inter-radicular
radiolucency is largely resolved; however, a
small radiolucent point at the root bifurcation
was noted (Fig. 1e). By 12, 18, and 24 months,
external root resorption at the distal root was
Table 2. Clinical findings of primary molars treated with three mixed antibiotics and non-instrumentation endodontic
treatment.
No symptom Gingival
Clinical examination (%) swelling ⁄ Fistula (%) mobility (%) pain (%)
Preoperative 66 (82.5)
Postoperative (6 months) 75 (94.9)
Postoperative (12 months) 69 (95.8)
Postoperative (18–21 months) 48 (84.2)
Postoperative (24–27 months) 43 (82.7)
International Journal of Paediatric Dentistry  2011 BSPD, IAPD and Blackwell Publishing Ltd
markedly increased showing evidence of a
radiographic and thus overall case failure
(Fig. 1f–h).
An indication for the use of 3Mix therapy is
when there is external root resorption and end-
odontic treatment cannot be rendered. An
example of such a case is seen in Fig. 2 where
the distal root of a primary mandibular first
molar is seen to be largely resorbed on both pre-
and post-treatment radiographs (Fig. 2a,b).
Seen at 6, 12, 18, and 24 months, the distal
defect shows progressive resolution by fill with
bone tissue, and the observed resorption can be
attributed to the erupting premolar beneath it
(Fig. 2c–f). Another indication for the use of
3Mix therapy is in cases where the tortuousness
of the tooth roots makes them less amenable to
biomechanical preparation. A primary second
mandibular molar with this clinical presenta-
tion requiring treatment is shown in Fig. 3.
Carious pulpal exposure is evident pre-opera-
tively (Fig. 3a) as is a furcation radiolucency
(Fig 3a,b). By 6 months, this radiographic
defect appears to be resolved (Fig. 3c), and at
12, 18, and 24 months, this tooth showed no
signs of radiographic pathology (Fig. 3d–f).
The radiographic evaluation did not corre-
late well with the clinical findings, showing
radiographic success in only 36.7% (22 of 60)
of teeth. The remaining 63.3% of cases (38 of
60) were considered as failures whereas the
clinical success was higher at 75% (45 of 60).
Overall clinical and radiographic success rate
was 36.7% at the 24- to 27-month recall.
This result is broken down by pathological
group in Table 3. Of the 38 failed teeth, 20
teeth (52.6%) were in the P4 category that
was the group with the most severe radio-
graphic pathology, 1 tooth (2.6%) in P3
Abnormal Spontaneous Abnormal Normal
Exfoliation (N) Exfoliation (N)
11 (13.8) 6 (7.5) 3 (3.8)
0 4 (5.1) 0
0 3 (4.2) 0
1 (1.8) 8 (14.0) 0 2
2 (3.8) 7 (13.5) 0 6 2
 2011 The Authors
 Success rates of three mixed antibiotics in the non-instrumentation endodontic treatment 221

(a) (b)

(c) (d)

(e) (f)

(g) (h)

Fig. 1. Clinically successful case of 3Mix-MP NIET. A fistula is present at the buccal gingiva of the primary mandibular second
molar in the immediate post-treatment image (a). At recall 1 month later, the gingiva has regained its normal colour and
architecture (b). Radiographic appearance shows evidence of caries extending into the pulp chamber, with a large inter-
radicular radiolucency, seen pre- and immediately postoperatively (c and d). At the 6-month re-evaluation, the inter-radicular
radiolucency is largely resolved; however, a small radiolucent point at the root bifurcation was noted (arrow; e). At 12, 18,
and 24 months, there was evidence of case failure with markedly increased external root resorption of the distal root (arrows
f–h).

category, and 17 teeth (44.8%) in the P2
category; however, there was no significant
difference between different levels of severity
of the preoperative radicular pathology
(Chi-square, P-value = 0.249), but there was
statistically significant difference between
the first and second molar with clinical and
radiographic success. (Chi-square, P-value =
0.003).
A detailed analysis of the failed cases at the
24- to 27-month recall is shown in Table 4.
Out of 38 teeth failing to respond to the 3Mix
treatment, 6 (15.8%) showed no change from
their preoperative state, whereas 26 (68.4%)
exhibited an increase in inter-radicular radio-
lucent areas. Some teeth (15.8%) demon-
strated a pulpal response of internal
resorption. Figure 4 shows the radiographic
image of a primary mandibular second molar
revealing a large carious lesion on its distal
aspect penetrating the pulp with discontinuity
of the lamina dura preoperatively and

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International Journal of Paediatric Dentistry  2011 BSPD, IAPD and Blackwell Publishing Ltd
222 C. Trairatvorakul & P. Detsomboonrat

(a) (b)

(c) (d)

(e) (f)

Fig. 2. Successful case of 3Mix-MP NIET. Preoperative and postoperative radiographs of a mandibular first molar that
presented with an inter-radicular radiolucency and external root resorption (a and b). At 6 and 12 months, the distal defect is
seen radiographically to be filled by bone tissue (c and d). By the 18- and 24-month recalls, note the consistent radiopacity of
the furcation area and root resorption because of the eruption of the first premolar (e and f).

immediately post-treatment (Fig 4a,b). At the
6-month recall, some internal resorption in
the mesial pulp canal was seen (Fig. 4c).
At the 12-, 18-, and 24-month re-evaluations,
the mesial canal resorption was markedly
increased, leading this case to be deemed a
treatment failure (Fig. 4d).
Discussion
This study examined the association between
success rates with radicular pathology severity
and tooth type. Our result showed no statisti-
cally significant difference between success
rates and radicular pathology severity (P1–P4);
however, cases having excessive root resorp-
tion had the least success, and most of the
failures were found in the most severe group
when treated with pulpectomy and either
ZOE or Vitapex20. Comparing first and second
lower molars, we found less success in first
primary molars, even though the most severe
pathology (P4) was present in 55% (26 of 47)
of second molars and 48.5% (16 of 33) in
first molars. Ozalp reported success rates that
were not statistically different between first
and second primary molars25.
At 24–27 months postoperatively, the non-
instrumentation endodontic treatment with
3Mix-MP performed in this study revealed a
clinical success rate of 75% consistent with
previous studies (Annex 1); however, when
considering both clinical and radiographic
characteristics as the determinant of the over-
all success rate, this study had a success rate
at 36.7% consistent with the study of Prabha-
kar et al.17, using a similar procedure i.e.,
non-instrumentation with radicular pulp
extirpation. Their extirpated pulp group
showed much higher success (83.3%). There-
fore, instrumentation for radicular pulp extir-
pation treatment may be advocated for
further studies to ascertain the efficacy of this
novel treatment modality.
The success rate we found here is lower than
other studies18,19, which reported an overall

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International Journal of Paediatric Dentistry  2011 BSPD, IAPD and Blackwell Publishing Ltd
 Success rates of three mixed antibiotics in the non-instrumentation endodontic treatment 223

(a) (b)

(c) (d)

(e) (f)

Fig. 3. Successful case of 3Mix-MP NIET. A primary mandibular second molar presented with a large carious lesion involving
the pulp with an inter-radicular radiolucency, seen pre- and immediately postoperatively (a and b). A radiograph exposed
6 months postoperatively shows improvement of the furcation radiolucency with bone regeneration (c) and the complete
resolution of the rarefied area and restoration of the borders of the follicle of the second premolar at the 12-, 18-, and 24-
month follow-up (d–f).

Table 3. Clinical, radiographic, and overall success of treatment evaluated at 6, 12, 18–21 and 24–27 months.

Overall (clinical and radiographic)

Clinical successes Radiographic successes successes

Follow-up Success (%) Failure (%) Success (%) Failure (%) Observe (%) Success (%) Failure (%) Observe (%) Total (N)

6 months
P2 33 (100) 0 (0) 13 (39.4) 5 (15.2) 15 (45.5) 13 (39.4) 5 (15.2) 15 (45.5) 33
P3 4 (100) 0 (0) 3 (75) 0 (0) 1 (25) 3 (75) 0 (0) 1 (25) 4
P4 38 (90.5) 4 (9.5) 27 (64.3) 5 (11.9) 10 (23.8) 26 (61.9) 7 (16.7) 9 (21.4) 42
Total 75 (94.9) 4 (5.1) 43 (54.4) 10 (12.7) 26 (32.9) 42 (53.2) 12 (15.2) 25 (31.6) 79
12 months
P2 32 (100) 0 (0) 17 (53.1) 15 (46.9) – 17 (53.1) 15 (46.9) – 32
P3 4 (100) 0 (0) 2 (50) 2 (50) – 2 (50) 2 (50) – 4
P4 33 (91.7) 3 (8.3) 14 (38.9) 22 (61.1) – 14 (38.9) 22 (61.1) – 36
Total 69 (95.8) 3 (4.2) 33 (45.8) 39 (54.2) – 33 (45.8) 39 (54.2) – 72
18–21 months
P2 24 (88.9) 3 (11.1) 10 (37) 17 (63) – 10 (37) 17 (63) – 27
P3 4 (100) 0 (0) 3 (75) 1 (25) – 3 (75) 1 (25) – 4
P4 20 (71.4) 8 (28.6) 11 (39.3) 17 (60.7) – 11 (39.3) 17 (60.7) – 28
Total 48 (81.4) 11 (18.6) 24 (40.7) 35 (59.3) – 24 (40.7) 35 (59.3) – 59
24–27 months
P2 20 (80) 5 (20) 8 (32) 17 (68) – 8 (32) 17 (68) – 25
P3 3 (100) 1 (25) 3 (75) 1 (25) – 3 (75) 1 (25) – 4
P4 22 (71) 9 (29) 11 (35.5) 20 (64.5) – 11 (35.5) 20 (64.5) – 31
Total 45 (75) 15 (25) 22 (36.7) 38 (63.3) – 22 (36.7) 38 (63.3) – 60

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International Journal of Paediatric Dentistry  2011 BSPD, IAPD and Blackwell Publishing Ltd
224 C. Trairatvorakul & P. Detsomboonrat

Table 4. Radiographic appearance of failure cases at 6.5 years). These differences make it difficult
24–27 months of evaluation.
to compare their results with ours. Moreover,
Stasis of Increase of their study had differences in postoperative
radiolucent radiolucent Internal root radiographic evaluation criteria in comparison
Level area (%) area (%) resorption (%) Total with Nakornchai et al.19, which categorised
P2 3 10 4 17 the static group as a success group at the 12-
P3 1 0 0 1 month follow-up. In this study, we categor-
P4 2 16 2 20 ised cases showing no change at 6 months
Total 6 (15.8) 26 (68.4) 6 (15.8) 38
into a ‘‘further observation group’’ and con-
sidered them as failures with unchanged
success rate at 100% and 76%, respectively, pathology at the 12-month follow-up. This is
as seen in Annex 1. This may be due, in part, in accord with the American Academy of Pae-
to the differences in sample selection. For diatric Dentistry’s guideline on pulp therapy
example, other studies included maxillary stating radiographically evident pathology of
and mandibular primary molars and anterior pulpectomised teeth should resolve in
teeth, with some cases near exfoliation. This 6 months. Another difference is the final res-
made them difficult to evaluate radiographi- toration. We used stainless steel crowns,
cally, as physiologic root resorption may have whereas Takushige et al. used composite
confounded the radiographic interpretation. inlays. This, however, should not contribute
Takushige et al.18 did not outline pre-deter- to our higher failure rate because we filled
mined postoperative radiographic evaluation the pulp chamber with 2 to 3-mm thick
criteria and had a non-uniform ⁄ random fol- composite resin for leakage control before
low-up schedule (average of 2 months up to stainless steel crown restoration.

(a) (b)

(c) (d)

(e) (f)

Fig. 4. Failure case of 3Mix-MP NIET. The pre-operative radiograph of a primary second molar reveals a large carious lesion
on its distal aspect with discontinuity of the lamina dura (a) and immediately post-treatment (b). Some internal resorption in
the mesial pulp canal are seen at 6 months (arrow; c), and by the 12-, 18-, and 24-month follow-up, the mesial canal
resorption was markedly increased (d–f).

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International Journal of Paediatric Dentistry  2011 BSPD, IAPD and Blackwell Publishing Ltd
 Success rates of three mixed antibiotics in the non-instrumentation endodontic treatment
This study is noteworthy in that both clini-
cal and radiographic criteria were taken into
account for the sample selection and evalua-
tion, using defined recall periods. Our ratio-
nale for selecting only lower molars was to be
able to identify radiographic pathology and
healing more precisely given the reduced
overlap of lower permanent tooth buds and
primary molar roots and ⁄ or furcations in
radiographic examination compared with
other studies17–19. This may have contributed
to a higher degree of pathology observed than
in other studies and in turn may have con-
tributed to a higher failure rate.
‘‘Observed’’ status was included as one cat-
egory of this study’s outcome ratings. This is
because of data from previous studies show-
ing, at 6–12 months, there were cases of
unchanged pathology that fulfilled neither
the success nor the failure criteria but could
be classified by success ⁄ failure criteria at the
longer follow-up periods26,27. In comparison
to other materials, the success rate of conven-
tional pulpectomy using ZOE or Vitapex (at
12 months, the overall success rates were
85% and 89%, respectively)20 was higher
than our overall success rate of the 3Mix-MP
non-instrumentation endodontic treatment
(36.7%), whereas 3Mix-MP with radicular
pulp extirpation yielded similar success
(83.3%)17. Further study on the success of
3Mix-MP with radicular pulp extirpation
should be conducted.
Radiographic failures in the current study
were cases of internal root resorption similar to
those found in previous studies of pulpotomy
treatment28,29. Some of our findings of internal
resorption could be a result of an inflammatory
response of the residual pulp. The 3Mix medi-
cament can produce a vascular change in the
pulp involving inflammation and the forma-
tion of granulation tissue with an accompany-
ing metaplasia of connective tissue and
macrophages to form osteoclast-like multinu-
cleated giant odontoclasts30,31. Internal resorp-
tion seen in this study may have resulted from
coronal pulp amputation without gentle
technique, heat generation at the tip of the
bur, pressure from placing the medicament,
incomplete pulp amputation, or residual
inflamed pulp tissue. In these teeth, if internal
 2011 The Authors
International Journal of Paediatric Dentistry  2011 BSPD, IAPD and Blackwell Publishing Ltd
225
resorption was found at the initial evaluation,
the tooth was categorised into the observe
group until the resorption progressed. It was
then classified as a failure similar to Smith
et al.28
Conclusions
Non-instrumentation endodontic treatment
using 3Mix-MP has shown good clinical suc-
cess (75%) but the overall (clinical and radio-
graphic) success rates at 24–27 months were
lower (36.7%). The authors suggest that the
use of 3Mix antibiotic treatment cannot
replace conventional root canal treatment
over the long term.
What this paper adds
• The 3Mix-MP has shown good clinical success but a
low success rate in radiographic evaluation.
• The use of 3Mix-MP cannot replace a conventional
root canal treatment agent in a long term.
Why this paper is important for paediatric dentists
• We found the low success rate of 3Mix-MP at the
2-year evaluation to be contradictory to previous
reports of 1-year studies. Rigorous criteria for evalua-
tion and case inclusion of our study contributed to the
differences in findings. This technique, therefore, is not
recommended as a long-term treatment modality.
Conflict of interest
The authors declare no conflict of interest.
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 Success rates of three mixed antibiotics in the non-instrumentation endodontic treatment 227

Annex 1: Characteristics of included studies

Success rate

Maxillary/mandibular Permanent Follow-up Clinical Radiographic Overall success

Study N teeth restoration (months) (%) (%) rate (%)

Takushige 87 Maxillary or mandibular Composite 22.6 (mean) 100 NA 100

et al.18 molar or anterior teeth inlay (2 months–6.5
years)
Prabhakar 30 (Group A)* Maxillary or mandibular Composite 12 93.3 36.7 36.7
et al.17 30 (Group B)** molar teeth resin 100 83.3 83.3
Nakornchai 25 Maxillary or mandibular SSC 12 96 76 76
et al.19 molar teeth
This study 80 Only mandibular molar SSC 24–27 75 36.7 36.7
teeth

*Group A: the infected radicular pulp tissue was not removed.

**Group B: the infected radicular pulp tissue was removed.

 2011 The Authors

International Journal of Paediatric Dentistry  2011 BSPD, IAPD and Blackwell Publishing Ltd