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Where knowledge of antibiotics was highly valued, participants stated that their most utilized sources of information were medical textbooks, pharmaceutical company representatives PCRs , and allopathic doctors in the case of informal health providers. All four groups of participants were asked whether antibiotics were useful for viral infections and whether antibiotics were indicated to reduce the symptoms of pain and inflammation as part of the knowledge assessment.
As Fig 2 below indicates, the levels of knowledge of allopathic doctors contrasted strongly with the other three groups as expected. A few senior doctors who responded incorrectly later qualified their answers by suggesting that a lack of follow-up opportunities and the likelihood of developing a secondary infection occasionally required the use of antibiotics even during viral infections.
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Similar sentiments were expressed by allopathic doctors when they were asked whether antibiotics were indicated to alleviate the symptoms of pain and inflammation: a few doctors explicitly stated that inflammation can be caused by a bacterial infection, which would necessitate the use of antibiotics even in the absence of confirmation from laboratory testing. Most allopathic doctors confidently completed the survey questionnaire without much hesitation. However, the most challenging question for allopathic doctors inquired which antibiotic was contraindicated in pregnancy, with three possible single-select options: Amoxicillin, Ciprofloxacin, and Gentamicin.
The U. By contrast, Ciprofloxacin is classified as a Category C drug, which indicates that there are no adequate and controlled studies in humans despite animal reproduction studies indicating adverse effects. The correct answer Gentamicin was selected by a mere Only Informal health providers and nurses similarly had little idea about Gentamicin and its links to potential birth defects, even though we frequently observed IHPs providing Gentamicin during field observations.
As Fig 3 below demonstrates, an overwhelming proportion of all respondents either strongly disagreed or disagreed with the practice of stopping a full course before it was complete. However, this also reflected a sharp dissonance between knowledge and practice, as we found that all four groups of respondents frequently disbursed shorter, 3-day courses of antibiotics rather than a full course. Our team conducted a more detailed analysis of the knowledge, attitudes, and practices by creating a composite KAP score for each respondent in the survey, which has been presented as average percentage scores for ease of comparison below in Table 2.
One-way ANOVA testing determined that there was a statistically significant difference in average scores of knowledge, attitude and practice questions between the four occupational groups. As evidenced in Table 2 , allopathic doctors scored highest in questions assessing knowledge Allopathic doctors performed most poorly We also conducted a multivariate logistic regression analysis, adjusting for age and gender, and found that the odds of having a low composite score in non-allopathic practitioners was Thus, our study found that non-allopathic practitioners were significantly more likely to perform poorly on the survey.
Our study represents one of the few attempts in the literature to assess the knowledge, attitudes, and practices of all providers interacting with antibiotics in the Indian context, including allopathic doctors, nurses, pharmacy shopkeepers, and informal health providers. While doctors outperformed other formal and informal healthcare providers in the knowledge and attitudes components of the survey, their comparatively poor performance in the practice section of the survey is concerning.
This may be due to the fact that many doctors across India prescribe antibiotics in PHC settings as a precautionary measure to compensate for diagnostic uncertainty due to lack of availability of point-of-care diagnostic tests, poor infection control, and inadequate sanitation practices [ 26 ]. Additionally, informal practitioners, nurses, and pharmacy shopkeepers are not legally entitled to prescribe antibiotics, which may have prompted them to answer less candidly on practice-related questions in comparison to doctors.
Other studies [ 11 — 13 , 18 — 20 ] have focused predominantly on the KAP of medical students or clinicians in tertiary care hospitals, which address a limited part of the antibiotic dispensing pathway and leave out the crucial role played by informal providers. These studies generally report poor practices even among medical students and allopathic practitioners: for instance, Khan et al.
Another study by Gautham et al. The study documents not just wide variations in knowledge, but also interesting and mutually beneficial referral links with private doctors. While the presence of informal providers is particularly salient in India, such providers can be found in every health system, according to the WHO [ 28 ].
A systematic review conducted by Sudhinaraset et al. The authors found that inappropriate prescription practices were linked to a multitude of factors, including clinical factors, demographic characteristics of patients, severity of illness, previous infection history, compromised immune response, geographic region, among others [ 30 ]. Multi-center studies conducted across the United States, Scotland, Switzerland, Sweden, Slovenia, Spain, France, and England examined knowledge, attitudes, and practices related to antibiotic use among medical students and found that the vast majority wished to acquire more knowledge about choosing appropriate antibiotic treatment [ 32 — 34 ].
Moreover, many relied on Wikipedia more than formal peer-reviewed sources or textbooks for guidance on antimicrobial use [ 33 ].ediscoverynutsandbolts.com/wp-content/mawor-come-spiare-un.php
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In our context, many providers relied on pharmaceutical company representatives as a source of information regarding new antibiotics and associated uses. This may stem from an inadequate focus on antibiotics and drivers of antibiotic resistance in the medical curriculum. Our findings further indicate that there is poor knowledge and awareness of antibiotic uses and functions among informal providers and a strong dissonance between knowledge and practices among formal healthcare providers. This is supported by other studies as well: Das et al.
Similarly, Scaioli et al used the original questionnaire adapted in our study on a convenience sample of students from medical, dental, nursing, and other health professions in Italy and found that health professionals do not practice what they know: in other words, high levels of knowledge do not translate into appropriate attitudes and practices with respect to antibiotic use [ 36 ].
We found that allopathic doctors treated common illnesses such as cold, cough, fever, and watery loose stools with antibiotics without clinical indication, largely due to risk aversion in the context of diagnostic uncertainty and lack of robust follow-up. As for informal providers, Bloom et al. This may explain the high rates of antibiotic use among informal providers in our context, since many areas of the district are inadequately covered by existing public facilities. However, the evidence on training programs is uncertain: Das et al.
Rather than focusing solely on training, future efforts must work to strengthen the existing public health infrastructure. The Government of India has also embraced this idea and announced a Bridge Program in Community Health for Nurses and Ayurveda practitioners under the flagship National Health Mission in order to enhance the capacity of mid-level care providers [ 41 ]. Initiatives like this can be scaled up to improve the capacity of the existing public health infrastructure to meet patient demands.
We argue that these kinds of initiatives provide a unique opportunity to enhance awareness around antibiotic resistance while ensuring equitable access to antibiotics when required. Balancing the demands between access and overuse of antibiotics is the big challenge for policy makers at present.
In order to better tackle the growing threat of resistance, India also adopted the National Action Plan on Antimicrobial Resistance —21 in April [ 42 ]. The objectives include reducing infections, enhancing awareness, strengthening surveillance, improving rational use, promoting research and supporting neighboring countries in the collective fight against infectious diseases. However, the National Plan does not account for the role of PCRs and informal providers with respect to antibiotic use. Trainings should be initiated for PCRs who have been largely ignored in the scientific literature around antibiotic resistance.
In Paschim Bardhaman district, the vast majority of participants surveyed indicated that they relied on pharmaceutical company representatives as a source of medical knowledge. Future efforts to curb antibiotic resistance should involve advocacy with pharmaceutical firms in order to tap into the strong, pre-existing networks of PCRs and reorient their efforts to promote a more responsible message around antibiotics; regulation may also be useful in addressing the issue.
These efforts to involve PCRs and informal health providers can form a critical community-level component of antibiotic stewardship programs moving forward, in addition to emphasizing antibiotic resistance in the curriculum for continued medical education, increasing access to cost-effect point-of-care diagnostics to aid doctors in decision making, increasing the use of prescription audits in primary care settings, and enforcing the legal framework around over-the-counter use of antibiotics.
Current initiatives to tackle ABR in Asia aim to set up surveillance systems, regulate the sale of antibiotics, and introduce national guidelines for antibiotic use, but fail to take into account patient perceptions and expectations from health providers as a major driver for ABR. Any effort to tackle antibiotic resistance must also include patient education and counseling, as patient demands are a major driver for overuse of antibiotics among formal and informal health providers alike. Several recent studies demonstrate that the Internet and social media, in particular, can be an effective resource for disseminating high quality health information to improve antibiotic stewardship in the community [ 43 — 44 ].
Future interventions must consider social media within their communication strategy to promote appropriate use for antibiotic-related information seeking in the general population. This study had several limitations due to resource constraints. Firstly, given the use of convenience sampling in the survey design, our findings must be interpreted with caution when generalized to Paschim Bardhaman district despite the sample size of participants.
The use of convenience sampling limits the generalizability of the results at the study population level and may introduce the potential for selection bias in the study. Finally, self-reported data always comes with limitations. We were unable to cross-check survey responses with actual prescription practices, and social desirability bias may have played a role in undermining the credibility of our results.
Given the vastly limited literature from this region of India, we believe the study adds value in understanding the scope of the problem, but we recommend that future studies should be undertaken with a robust study design in mind. Browse Subject Areas? Click through the PLOS taxonomy to find articles in your field. Abstract Introduction Antibiotic misuse is widespread and contributes to antibiotic resistance, especially in less regulated health systems such as India.
Objectives This quantitative study systematically examines the knowledge, attitudes, and practices of informal and formal providers with respect to antibiotic use. Methods We surveyed a convenience sample of participants 96 allopathic doctors, 96 nurses, 96 informal providers, and 96 pharmacy shopkeepers over a period of 8 weeks from December to February using a validated questionnaire developed in Italy. Results Doctors scored highest in questions assessing knowledge Conclusions Our findings indicate poor knowledge and awareness of antibiotic use and functions among informal health providers, and dissonance between knowledge and practices among allopathic doctors.
Introduction Antibiotics have been a crucial development in the evolution of medical treatment, effectively reducing the morbidity and mortality from bacterial diseases that were previously left untreated [ 1 ]. Materials and methods A self-administered question KAP survey tool was provided to allopathic doctors, informal healthcare providers, nurses, and pharmacy shopkeepers, in order to establish the knowledge, attitudes, and practices related to antibiotic use in Paschim Bardhaman district of West Bengal.
Recruitment and sampling The study team adopted a convenience sampling methodology to recruit participants for the KAP survey due to resource limitations. Data collection and analysis Data collection took place over a period of approximately 8 weeks from December to February following an initial one month period of planning and field mapping. Download: PPT. Table 1. Demographic characteristics of health provider sub-groups.
Antibiotics & analgesics dentistry
Trials in the outpatient setting made use of expert panel discussions, educational feedback on previous acts of prescribing, the dissemination of guidelines and the establishment of internal guidelines. However, most studies were confounded by a high risk of selection bias, selective outcome reporting and high variance across study groups.
In particular, information relating to study design and methodology was insufficient. Only three studies related the prescriptions to the number of patients treated with antibiotics. This systematic review was able to offer conclusions which took the limitations of the investigated studies into account. Unfortunately, few studies could be included and many of these studies were confounded by a low quality of scientific reporting and lack of information regarding study methodology.
High-quality research with objective and standardised outcome reporting, longer periods of follow-up, rigorous methodology and adequate standard of study reporting is urgently needed. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: The articles and study registrations screened for eligibility are accessible online.
The manuscript contains a full list of search terms for each webpage searched. Competing interests: We have read the journal's policy and the authors of this manuscript have the following competing interests: We are engaged in an intervention study focusing on optimizing antibiotic prescribing in general dental care. Results of the study are not published yet and are not included in this review. Today, appropriate prescription of antibiotics is a challenge in most health care systems. Presently, antibiotic resistance is one of the biggest threats to global health and results in less effective therapies for a growing number of infections, longer hospital stays, higher medical costs and increased mortality.
Supranational bodies are starting to address this challenge. Although the inappropriate use of antibiotics rose across Europe between and , there has been no significant increase from to However, we found abundant evidence, particularly from the UK, that a high number of antibiotics were provided despite being incompatible with guidelines in dentistry. For many years, the prophylactic prescription of antibiotics has been important for the prevention of infective endocarditis among at-risk patients undergoing invasive dental treatment. Surprisingly, antibiotic misuse is rarely addressed publically or scientifically in dentistry, which is in contrast to the practice found in general medicine.
So far, only a small number of interventional trials have been conducted in this field. Most of these trials made use of cognitive elements such as clinical audits, educational outreach visits or feedback. However, there was no systematic evidence, whether these interventions were able to produce sustained changes in the prescription of antibiotics. The present systematic review aimed at investigating whether the interventions were associated with changes in the prescription reduction of the number of prescriptions or changes in accuracy in general dental care and in specialized dental care.
In particular, this review addressed three objectives: Firstly, which types of interventions aiming to optimise the prescription of antibiotics were reported in dentistry? Secondly, what was the effect of these types of interventions and which types were most effective? And last but not least, what were the specific strengths and limitations of the studies included and what was their impact on data validity aspects?
Literature search methodology, data extraction, synthesis and reporting were based on the Cochrane handbook for systematic reviews of interventions[ 54 ] and the PRISMA statement for preferred reporting items for systematic reviews and meta-analyses. The search included studies investigating the effect of all types of interventions aiming to optimise acts of prescribing antibiotics in dentistry, such as clinical audits, educational outreach visits, feedback, patient education and communication training.
Studies investigating effects in primary dental care and specialised dental care were included. Since only few studies have addressed the optimisation aiming to impact on acts of prescribing antibiotics in dentistry so far, all quantitative studies were included in this review. This was necessary, as this review could not be limited to randomised controlled trials. Databases were searched for English and German entries dated January and later with no restrictions on their geographical focus. Search terms included synonyms as well as major subject headings and subheadings that had been adjusted to the database.
Search concepts were based on "antibiotic prescribing", "dentistry" and "intervention".
See Table 1 for full search terms by database. To manage literature entries the software program EndNote was used. Both reviewers independently determined the eligibility of studies, assessed the methodology of the included studies and extracted the data. Studies that met the inclusion criteria were included in the review.
A piloted data extraction sheet formed the basis for data extraction from these studies. Among other items, this sheet included information about study objective, design, participants, intervention s , outcome s and result s. Authors were contacted in order to resolve open questions. A narrative synthesis is provided within this review which summarises the study results with respect to their objectives, settings, interventions and effects. Particular emphasis is given to the guidelines used to determine the accuracy of the prescription for an antibiotic. A combination of the Cochrane Collaboration's tool for assessing the risk of bias[ 54 ] and the STROBE statement for reporting of observational studies in epidemiology[ 56 ] was employed to assess the risk of bias in each study.
A risk of bias sheet including eleven domains was developed and piloted. Information on each domain was extracted from the publications, obtained from personal correspondence or was based on our judgement. The narrative synthesis of all studies is presented alongside the summary table and figure.
Databases were searched on the 20 th of June in and a sum of 7. A total of 17 potentially relevant publications were retrieved for full paper review. Reasons for excluding papers from the review comprised a lack of intervention[ 57 , 58 ], wrong outcome measures[ 59 , 60 ] and wrong study design ecological studies [ 52 , 53 ]. One debate paper[ 61 ], early-stage trials and those without published findings were also excluded. PLoS Med 6 7 : e All studies had been conducted within the UK, apart from one study which had been administered in Nepal.
Within those studies assessing practice in primary dental care, four trials included all medical conditions[ 63 , 65 , 66 , 68 , 69 ], whereas one study exclusively investigated acute dental pain. For example, these guidelines involved considerations about the clinical indication for a prescription of an antibiotic, the recommended antimicrobial agent, dose, frequency and duration of intake Table 2. Prior to randomisation, the participating practices were stratified by their previous level of prescribing antibiotics. They compared practices randomised to individualised graphical audit and feedback with and without a written behaviour change message arm 1 and 2, respectively against care as usual arm 3.
Among both intervention arms, participating practices were randomly allocated to receive audit and feedback: i with or without a health board comparator and ii at zero, six months or at zero, six and nine months into the study. Four trials were comparatively large and included up to some thousand prescriptions or patients. Audit, feedback, education, local consensus and the dissemination of guidelines were the elements most often used and combined in the studies.
Three studies collected outcome data on the number of the prescribed antibiotics and the act of prescribing antibiotics as a measure of adherence to local or national guidelines. Comparing the number of prescribed antibiotics across studies was challenging as only three studies related the prescriptions to the number of patients treated. Only Elouafkaoui et al. These included the number of antibiotic items dispensed per treatment claims, the number of prescriptions for antimicrobial agents, the number of antimicrobial agents and average of antimicrobial agents per prescription.
Bearing these limitations in mind, within those studies following the pre-post design, interventions were associated with a reduction of prescriptions for antibiotics ranging between In the large studies by Palmer et al. Smaller trials, mostly conducted in outpatient departments, showed higher levels. The other studies did not report p-values or significance levels Fig 2. In their three-arm RCT, Seager et al. Specifically, 8. The overall adjusted effect size of 0.
Relative to the control group this is a reduction of 5. Note: Chopra et al. Instead of reporting figures, odds ratios are reported in Seager et al. Three months after the intervention these prescriptions were at 63 among patients and at prescriptions among patients six months after the intervention. A postoperative reduction of prescriptions for antibiotics was not intended. Interventions most strongly associated with reducing the number of prescriptions for antibiotics include the establishment of internal guidelines[ 71 ] and educational feedback on previous acts of prescribing antibiotics.
The combination of audit, education, local consensus and dissemination of guidelines showed less pronounced but still high levels of reductions. The audit and feedback intervention involving all NHS general dental practices in Scotland showed the weakest reduction in the number of prescriptions. As far as adherence to guidelines is concerned, studies vary by the type of guidelines used. Whereas four trials relied on national guidelines[ 65 , 66 , 69 , 70 ], three studies established local guidelines.
Although most studies made use of guidelines, merely five trials used adherence to guidelines as an outcome measure.
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Among the pre-post studies, three papers provided detailed information on adherence to guidelines. Note: Palmer et al. Seager et al. Here, expert panel discussions and the dissemination of guidelines had been entered as interventions. Additionally, the trials reported on clinical and medical conditions related to the prescription of the antibiotic as outcome measures.
Most studies did not investigate adverse effects owing to the reduction in prescriptions of antibiotics. By contrast, Thomas and Hill, who focused on the prescription of antibiotics for third molar surgery, reported the presence of a postoperative infection at one week, the number of postoperative visits and the attendance at practitioners outside the hospital. The study was not able to identify negative effects on these parameters.
All studies included in this review successfully reduced the number of prescription for antibiotic drugs and increased the accuracy of the prescription. Studies conducted in the outpatient setting usually included a lower number of patients and were more successful in reducing the number of prescriptions than interventions in primary dental care. A combination of the Cochrane Collaboration's tool for assessing the risk of bias[ 54 ] and the STROBE statement for reporting of observational studies in epidemiology[ 56 ] was employed in order to assess the risk of bias in RCTs and trials with a pre-post designs.
Risk of bias was categorised into low, moderate, high and unknown risk. The latter category was used when publications did not provide enough information to pass judgment. Unfortunately, this was the case for a number of domains in most publications and most frequently studies from the ies were affected by this lack of information Fig 4.
The highest methodological standard was witnessed in the study by Elouafkaoui and colleagues[ 63 ]: All NHS dental practices in Scotland prescribing antibiotics were included, practices were randomly allocated to groups, outcome measures were based on routinely collected NHS data and the trial statistician was blinded to allocation. These methodological features minimised the potential risk of bias. The risk of selective reporting by dentists was high in the study by Seager et al. It remained unclear to what extent dental practitioners complied with these data collection procedures since compliance of dentists was not monitored and information on group differences in reporting was not included.
Furthermore, there was high variance across study groups: Firstly, the attrition level differed between control, guideline and academic outreach group. Secondly, there were significant differences in the proportion of privately registered patients and in the proportion of patients with a symptom indicative of spreading infection across groups, consequently, the risk of selection bias was high.
Last but not least, the trial registration provided very limited information which rendered the evaluation of outcome reporting difficult. Note: Low risk of bias is indicated by green colour, moderate risk of bias by yellow colour and high risk of bias by red colour. The question mark indicates an unknown risk. The studies by Palmer et al.
In both studies, a major risk of bias arose from the fact that dentists participating in the trial were critically involved in the design and conduct of the audit: Dentists were aware of the primary outcome measure, discussed the anonymous baseline findings and set their own goals and standards in the second audit period.
Additionally, the dentists were asked to use a proforma every time they prescribed an antibiotic. In consequence, there might have been a high risk of prescribing antibiotics differently than usually Hawthorne effect and of selective reporting. Furthermore, information upon the dropout of a dentist from the trial was not collected. The authors of these affected studies could not reconstruct if and when a dentist stopped providing information on prescribing antibiotics. This might have led to a high risk of selection bias as those dentists not complying with study goals or standards or those under time pressure might have left the audit prematurely.
Quantitatively this is problematic as prescriptions for antibiotics were compared longitudinally before and after the audit. This way, dentist attrition in the second data collection period would have automatically reduced the total number of prescriptions, insinuating a successful audit. In the study by Steed and Gibson[ 68 ] seven dental practitioners out of 15 participating practices formed the audit group, secured funding for the project, collected own prescribing data and performed the data analyses.
The remaining participating dentists collaborated with the former in the same practices. Based on this strong involvement of audit participants in the audit, dentists might have influenced outcomes sub consciously, for example by prescribing antibiotics differently than usually Hawthorne effect , by influencing definitions, procedures or analyses. There was also a high risk of selective reporting. Finally, it remains unclear whether there were any differences in patients and prescriptions before and after the audit, consequently, any of these variances might have distorted the comparisons.
In the study by Zahabiyoun et al. However, compared to other studies, the risk of selective reporting was low as the internal computer software was used to obtain the data on prescriptions. The external validity of the study by Chopra et al. In particular, it was unclear whether there were any differences between patients included before the audit and those investigated after the audit, for example in demographic variables such as age and sex.
In Raunair et al. This study failed to state how the baseline data were collected from participating dentists and the authors did not explain how the data collected on prescriptions related to dentists. It appears it is important to use a concentration of TAP, which can disinfect the root canal completely and remove the bacterial biofilm on one hand and does not damage the stem cells in the area on the other hand because in the treatment of immature necrotic teeth it is necessary to achieve regeneration and continue maturation of the root. An in vitro study by Ruparel et al 11 , in which 0.
Therefore, a balance between antibacterial effects and cytotoxicity should be considered. On the other hand, in addition to minocyclin,s positive effects on modulating host responces by inhibiting collagenases and matrix metaloproteinases, impeding osteoclastogenesis, regulating angiogenesis and substantivity, it binds calcium ions through chelation and produces an unfavorable compound which discolors teeth.
Therefore, it appears that with lower concentrations of TAP there are no concerns about tooth discoloration due to minocycline. The time necessary for TAP dressing in root canal has been reported to be several days to several months; it has also been reported that the treatment procedure can continue after removal of TAP from the root canal in the absence of symptoms and signs of periradicular conditions.
Based on a study by Chuensombat et al 12 the cytotoxic effects of TAP are time- and dose-dependent and the effects increase with an increase in exposure duration; therefore, it seems that, time, too, is an important factor in the use of this medication. The results of the present study showed that the effect of 1-week use of this paste is not different from those of 2-, 3- and 4-week. However, more in vivo studies are necessary to validate these findings.
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The results of the present study suggest that use of lower concentrations of TAP might decrease tooth discoloration potential and at the same time increase the potential of regeneration due to a decrease in the negative effects on the stem cells in the area; it is possible that 1-week use of this medication might be able to eradicate bacterial biofilms from the root canal space.
National Center for Biotechnology Information , U. Published online Sep Author information Article notes Copyright and License information Disclaimer. Received May 27; Accepted Mar This article has been cited by other articles in PMC. Abstract Background and aims.
Keywords: Anti-bacterial agents, Enterococcus faecalis, root canal medicaments, triple antibiotic paste. Introduction Enterococcus faecalis is the chief colonizing microorganism in endodontic infections and the most important bacterial species in refractory infections of the root canal system.
Materials and Methods Selection and Preparation of Samples A total of extracted one-rooted human central incisors with closed apices were selected. Open in a separate window. Figure 1. Preparation of Medications To prepare TAP, at first equal amounts weight of metronidazole, minoycline and ciprofiloxacin were mixed with a mixed base of glycerine, mannitol and colloidal silicone dioxide and diluted serially to achieve the desired concentrations.
Figure 2. Effect of antibacterial approach against Enterococcus faecalis. Discussion Treatment of immature necrotic teeth is a challenge in endodontics and requires special disinfection procedures to achieve regenerative aims. References 1. A comparison between the antimicrobial effects of triple antibiotic paste and calcium hydroxide against Entrococcus faecalis. Iran Endod J. Sodium hypochlorite accident: inadvertent injection into the maxillary sinus. J Endod.
Trope M. Treatment of the immature tooth with a nonvital Pulp and apical periodontitis. Dent Clin North Am. Garcia- Godoy F, Murray E. Recommendations for using regenerative endodontic proced ures in permanent immature traumatized teeth. Dent Traumatol. A comparative study of root- end induction using osteogenic protein — 1, calcium hydroxide, and mineral trioxide aggregate in dogs. Pulp revascularization of immature teeth with apical periodontitis: a clinical study. Platelet-rich fibrin-mediated revitalization of immature necrotic tooth.
Contemp Clin Dent. Banches F, Trope M. Revascularization of immature permanent teeth with apical periodontitis: new treatment protocol. Biologically based treatment of immature permanent teeth with pulpal necrosis: a case series.