Antimicrobial effectiveness of intracanal medicaments against Enterococcus faecalis in endodontics: a systematic review with structured domain-based interpretative synthesis and exploratory meta-analysis.

BACKGROUND

Persistent endodontic infections are frequently associated with Enterococcus faecalis, a pathogen capable of biofilm formation and dentinal tubule penetration, contributing to treatment failure.

OBJECTIVES

This systematic review aimed to evaluate the antimicrobial effectiveness of intracanal medicaments against E. faecalis, compare different formulations, and explore patterns of bacterial resistance and tolerance using a structured domain-based interpretative synthesis and exploratory meta-analysis.

METHODS

A systematic review was conducted following PRISMA 2020 guidelines. Searches were performed in PubMed/MEDLINE, Scopus, and Embase. Eligible studies included in vitro, ex vivo, and clinical investigations reporting quantitative antimicrobial outcomes. A structured domain-based interpretative synthesis was performed across key domains, and meta-analysis was conducted when feasible.

RESULTS

Twelve studies were included. Antibiotic-based medicaments, particularly triple antibiotic paste, generally showed comparatively stronger antimicrobial performance, especially in studies assessing bacterial reduction and biofilm-related outcomes. Calcium hydroxide showed variable and generally lower efficacy, especially in deeper dentinal regions, though combination therapies improved performance. Novel agents, including nanoparticle-based systems and bioactive compounds, showed promising but heterogeneous results. Quantitative pooling was limited to two studies and revealed extreme heterogeneity with imprecise estimates. Overall certainty of evidence ranged from low to moderate.

CONCLUSIONS

Intracanal medicaments exhibit consistent antimicrobial activity against E. faecalis, with comparatively stronger performance observed for antibiotic-based formulations in the available experimental evidence. However, substantial heterogeneity and limited high-quality clinical evidence constrain definitive conclusions. These findings suggest potential improvements in intracanal disinfection strategies, pending further standardized and clinically robust investigations.

SYSTEMATIC REVIEW REGISTRATION: https://www.crd.york.ac.uk/PROSPERO/recorddashboard, identifier CRD420261345958.