Effect of a Benzalkonium Chloride Surfactant-Sodium Hypochlorite Combination on Elimination of Enterococcus faecalis

INTRODUCTION

The purpose of this investigation was to determine the effect of a sodium hypochlorite-surfactant combination on the removal of Enterococcus faecalis from infected teeth.

METHODS

Sixty-four extracted human single canal anterior teeth were prepared with rotary instrumentation and sterilized. Teeth were divided into 4 groups, N = 16. Three experimental groups were inoculated with E. faecalis and cultured for 21 days before use: positive control group, no irrigation; NaOCl group, irrigated with 5 mL 6% NaOCl; and NaOCl/BAK group, irrigated with 5 mL 6% NaOCl/0.008% benzalkonium chloride (BAK). The negative control group received medium only and no inoculate. Paper point sampling of the canals was obtained before irrigation (S1) for all 4 groups and for 2 groups after irrigation (S2) to determine remaining colony-forming units. After sampling, all teeth were split in half and evaluated for bacterial viability colony-forming units and penetration of dentinal tubules by using fluorescent vital dye staining and confocal laser scanning microscopy.

RESULTS

Comparison of pre-irrigation and post-irrigation paper point samples from the 2 irrigated groups showed a significant reduction in bacterial canal load (P < .001, Kruskal-Wallis), with a significantly lower load in the NaOCl/BAK group than in the NaOCl group (P = .001, Mann-Whitney U test); 68.8% of the NaOCl/BAK samples gave no recoverable counts. In contrast, no significant difference between these groups was found for counts recovered from dentin. Confocal laser scanning microscopy showed no differences in tubule penetration.

CONCLUSIONS

The addition of BAK to NaOCl significantly reduced the number of remaining bacteria within the canal after irrigation compared with NaOCl alone.

Antibacterial activity of chlorhexidine after final irrigation with ethanol: CLSM and culture-based method analysis

This study investigated the effect of 95% ethanol on the antibacterial properties of 2% chlorexidine (CHX) over monospecies biofilm (Enterococcus faecalis) through a culture-based method, and over multispecies biofilm using confocal laser scanning microscopy (CLSM). For monospecies model, E. faecalis biofilm was induced in 40 root canals. The irrigation procedures were: S-saline solution; S/CHX-saline solution + CHX; E-ethanol; and E/CHX-ethanol + CHX. Microbial sampling was performed at three periods: before (S1), immediately after (S2), and 72 h after the final flush (S3). For multispecies biofilm model, 28 sterilized bovine dentin blocks were fixed on a removable orthodontic device to allow intraoral biofilm development. Seven samples were used in each group. Statistical analysis was carried out by using the Kruskal-Wallis test and Dunn's test for multiple comparisons. There was a significant reduction in CFUs count immediately after the final flush (S2) in all experimental groups (P < 0.05). However, only S/CHX, E and E/CHX groups had CFU counts close to zero, without differences among them (P > 0.05). After 72h (S3), the S/CHX and E/CHX groups had CFU counts near zero (P > 0.05). The CFU count increased in S3 for S and E groups (P < 0.05). CLSM showed that the percentages of remaining live cells were similar in S/CHX, E, and E/CHX groups (P > 0.05). The S group had the highest percentage of live cells (P < 0.05). The 95% ethanol did not interfere in the antibacterial properties of 2% CHX over mono- and multispecies biofilms.

Antibiofilm and Antimicrobial Activity of Polyethylenimine: An Interesting Compound for Endodontic Treatment

AIM

Bacteria levels of necrotic teeth are greatly reduced after endodontic treatment procedures but the presence of persisting microorganisms leads to continuous efforts to develop materials with antimicrobial properties. The purpose of the study was to determine the antimicrobial activity of polyethylenimine (PEI) against common bacteria and yeasts, regarding planktonic cells and biofilm, and to clarify its antimicrobial mechanism of action through flow cytometry.

MATERIALS AND METHODS

The antibiofilm and antimicrobial effect of PEI was determined against Enterococcus faecalis, Staphylococcus aureus, Escherichia coli and Candida albicans strains using reference protocols. The effect of PEI was evaluated regarding adhesion, biofilm formation and biofilm disaggregation. In order to understand PEI cellular effects flow cytometric analysis was performed with different fluorescent markers.

RESULTS

It was verified that minimal inhibitory concentrations (MIC) values and minimal lethal concentrations (MLC) obtained for PEI were similar and ranged between 50 and 400 mg/l, proving the microbicidal and fungicidal activity of this compound. Antibiofilm activity was also proved for all the microorganisms. Severe lesion of the membrane and cell depolarization was demonstrated.

CONCLUSION

Polyethylenimine showed antimicrobial and antibiofilm activity against microorganisms often associated with apical periodontitis.

CLINICAL SIGNIFICANCE

Theoretically, prolonging the antibacterial effects of materials used in endodontics may be interesting to help prevent reinfection and possibly to affect residual bacteria that survived the treatment procedures.

Photodynamic therapy: An adjunct to conventional root canal disinfection strategies

Although chemical-based root canal disinfectants are important to reduce microbial loads and remove infected smear layer from root dentin, they have only a limited ability to eliminate biofilm bacteria, especially from root complexities. This paper explores the novel photodynamic therapy (PDT) for antimicrobial disinfection of root canals. The combination of an effective photosensitizer, the appropriate wavelength of light and ambient oxygen is the key factor in PDT. PDT uses a specific wavelength of light to activate a non-toxic dye (photosensitizer), leading to the formation of reactive oxygen species. These reactive oxygen molecules can damage bacterial proteins, membrane lipids and nucleic acids, which promote bacterial cell death. In, addition PDT may enhance cross-linking of collagen fibrils in the dentin matrix and thereby improving dentin stability. The concept of PDT is plausible and could foster new therapy concepts for endodontics. The available knowledge should enable and encourage steps forward into more clinical-oriented research and development. This article discusses PDT as related to root canal disinfection, including its components, mechanism of action, reviews the current endodontic literature and also highlights the shortcomings and advancements in PDT techniques.

Effect of Nanosilver Gel, Chlorhexidine Gluconate, and Camphorated Phenol on Enterococcus faecalis Biofilm

Aim. To assess the effectiveness of nanosilver gel (NSG) in comparison to chlorhexidine gluconate (CHX) and camphorated phenol (CP) against Enterococcus faecalis (E.f) biofilm. Methods and Materials. Two tests were done, methyl thiazolyl tetrazolium (MTT) assay and confocal laser scanning microscopy (CLSM) analysis, to determine the effectiveness of NSG, CHX, and CP on E.f biofilm. Polystyrene microtiter 96- and 6-well plates were used for MTT and CLSM, respectively. Nanosilver gel was in three concentrations (0.05%, 0.1%, and 0.2%), chlorhexidine gluconate used was 2%, and camphorated phenol and normal saline were as control. Analysis was done using one-way ANOVA; the post hoc test was run for multiple comparisons. The level of statistical significance was set at P < 0.05. Results. One-way ANOVA showed significant differences among groups (0.05% NSG and CP, 0.1% NSG and CP, 0.2% NSG and CP, 0.1% NSG and 2% CHX, 0.2% and NSG and 2% CHX) (P < 0.001) and also showed significant difference between groups (P < 0.001), f-ratio 87.823. A post hoc Tukey's test revealed no significant difference between chlorhexidine gluconate and 0.05% nanosilver gel (P > 0.05). Conclusions. 0.1% and 0.2% nanosilver gel is more effective on Enterococcus faecalis biofilm as compared to chlorhexidine gluconate and camphorated phenol.

Antibiofilm activity of three irrigation protocols activated by ultrasonic, diode laser or Er:YAG laser in vitro

AIM

To investigate the impact of three irrigation protocols, activated by three different methods, on mature biofilms of Enterococcus faecalis in vitro.

METHODOLOGY

Root canals in 280 single-rooted teeth were instrumented using a rotary Ni-Ti system. Biofilms of E. faecalis were generated based on a previously established protocol. Samples were randomly divided into three experimental (n = 80) and one control (n = 40) group based on the irrigation protocol employed: group 1 (NaOCl + Etidronic acid), 1 : 1 mixture of 6% NaOCl and 18% etidronic acid; group 2 (NaOCl-EDTA), 3% NaOCl followed by 17% EDTA; group 3 (NaOCl-EDTA-NaOCl), 3% NaOCl followed by 17% EDTA and a final flush of 3% NaOCl. Saline served as the control. Samples were further divided into four subgroups (n = 20) based on the activation method: subgroup A, no activation; subgroup B, ultrasonic activation; group C, diode laser; group D, Er:YAG laser. Confocal laser scanning microscopy was used to assess bacterial viability in situ. Root dentine powder was obtained for determining the colony-forming units (CFU mL(-1) ). Data were analysed by appropriate statistical analyses with P = 0.05.

RESULTS

All experimental irrigation protocols caused complete destruction of the biofilm in the root canal lumen. Within the dentinal tubules, all groups had a significantly higher percentage of dead bacteria than the saline control (P < 0.05). There was no significant difference between NaOCl + etidronic acid and NaOCl-EDTA-NaOCl (P > 0.05), whereas both groups brought about more bacterial reduction than NaOCl-EDTA (P < 0.05). There was no significant difference between diode laser and Er:YAG laser in any of the groups (P > 0.05). Both diode and Er:YAG laser were more effective than ultrasonic activation and conventional syringe irrigation in reducing E. fecalis biofilms (P < 0.05).

CONCLUSIONS

The use of NaOCl after or in combination with a chelator caused the greatest reduction of E. faecalis. Diode laser and Er:YAG laser activation were superior to ultrasonics in dentinal tubule disinfection.

Traditional and contemporary techniques for optimizing root canal irrigation

Canal irrigation during root canal treatment is an important component of chemo-mechanical debridement of the root canal system. Traditional syringe irrigation can be enhanced by activating the irrigant to provide superior cleaning properties. This activation can be achieved by simple modifications in current technique or by contemporary automated devices. Novel techniques are also being developed, such as the Self-adjusting File (Re-Dent-Nova, Ra'anana, Israel), Ozone (Healozone, Dental Ozone, London, UK), Photoactivated Disinfection and Ultraviolet Light Disinfection. This paper reviews the techniques available to enhance traditional syringe irrigation, contemporary irrigation devices and novel techniques, citing their evidence base, advantages and disadvantages.

CLINICAL RELEVANCE

Recent advances in irrigation techniques and canal disinfection and debridement are relevant to practitioners carrying out root canal treatment.

Regeneration of the dentine-pulp complex with revitalization/revascularization therapy: challenges and hopes

The concept of regenerative endodontics has gained much attention in clinical endodontics in the past decade. One aspect of this discipline is the application of revitalization/revascularization therapies for infected and/or necrotic immature pulps in permanent teeth. Following the publication of a case report (Iwaya et al. ), investigators have been rigorously examining the types of tissues formed in the canals as well as exploring strategies to regenerate the pulp-dentine complex in revitalized teeth. This review will provide an update on the types of tissues generated in the canals after revitalization/revascularization therapy in both animal and human studies. The understanding of the role of stem cells and microenvironment in the process of wound healing resulting in either regeneration or repair will be thoroughly discussed. Stem cells and microenvironmental cues introduced into the canal during revitalization/revascularization procedures will be examined. In addition, requirement of a sterile microenvironment in the canal and vital tissue generation in revitalization/revascularization therapy will be emphasized. The challenges that we face and the hopes that we have in revitalization/revascularization therapy for regenerative endodontics will be presented.

Evaluation of the antibacterial efficacy of silver nanoparticles against Enterococcus faecalis biofilm

INTRODUCTION

The purpose of this study was to evaluate the antibacterial efficacy of silver nanoparticles (AgNPs) as an irrigant or medicament against Enterococcus faecalis biofilms formed on root dentin.

METHODS

Dentin sections were inoculated with E. faecalis for 4 weeks to establish a standard monospecies biofilm model. These biofilms were tested in 2 stages. In stage 1, the biofilms were irrigated with 0.1% AgNP solution, 2% sodium hypochlorite, and sterile saline for 2 minutes, respectively. In stage 2, the biofilms were treated with AgNP gel (0.02% and 0.01%) and calcium hydroxide for 7 days. The ultrastructure of one half of the specimens from each group was evaluated by using scanning electron microscopy, whereas the structure and distribution of viable bacteria of the other half of the specimens were assessed with confocal laser scanning microscopy combined with viability staining.

RESULTS

Syringe irrigation with 0.1% AgNP solution did not disrupt the biofilm structure, and the proportion of viable bacteria in the biofilm structures was not different from that of the saline group (P > .05) but was less than that of the control group (P < .05). The biofilms treated with 0.02% AgNP gel as medicament significantly disrupted the structural integrity of the biofilm and resulted in the least number of post-treatment residual viable E. faecalis cells compared with 0.01% AgNP gel and calcium hydroxide groups (P < .05).

CONCLUSIONS

The findings from this study suggested that the antibiofilm efficacy of AgNPs depends on the mode of application. AgNPs as a medicament and not as an irrigant showed potential to eliminate residual bacterial biofilms during root canal disinfection.

Antimicrobial activity of calcium hydroxide in endodontics: a review

The purpose of endodontic therapy is to preserve the patient's natural teeth without compromising the patient's local or systemic health. Calcium hydroxide has been included in several materials and antimicrobial formulations that are used in several treatment modalities in endodontics, such as inter-appointment intracanal medicaments. The purpose of this article was to review the antimicrobial properties of calcium hydroxide in endodontics. Calcium hydroxide has a high pH (approximately 12.5-12.8) and is classified chemically as a strong base. The lethal effects of calcium hydroxide on bacterial cells are probably due to protein denaturation and damage to DNA and cytoplasmic membranes. Calcium hydroxide has a wide range of antimicrobial activity against common endodontic pathogens but is less effective against Enterococcus faecalis and Candida albicans. Calcium hydroxide is also a valuable anti-endotoxin agent. However, its effect on microbial biofilms is controversial.

Synergistic effect of microbubble emulsion and sonic or ultrasonic agitation on endodontic biofilm in vitro

INTRODUCTION

Irrigation dynamics and antibacterial activity determine the efficacy of root canal disinfection. Sonic or ultrasonic agitation of irrigants is expected to improve irrigation dynamics. This study examined the effects of microbubble emulsion (ME) combined with sonic or ultrasonic agitation on irrigation dynamics and reduction of biofilm bacteria within root canal models.

METHODS

Two experiments were conducted. First, high-speed imaging was used to characterize the bubble dynamics generated in ME by sonic or ultrasonic agitation within canals of polymer tooth models. Second, 5.25% NaOCl irrigation or ME was sonically or ultrasonically agitated in canals of extracted teeth with 7-day-grown Enterococcus faecalis biofilms. Dentinal shavings from canal walls were sampled at 1 mm and 3 mm from the apical terminus, and colony-forming units (CFUs) were enumerated. Mean log CFU/mL values were analyzed with analysis of variance and post hoc tests.

RESULTS

High-speed imaging demonstrated strongly oscillating and vaporizing bubbles generated within ME during ultrasonic but not sonic agitation. Compared with CFU counts in controls, NaOCl-sonic and NaOCl-ultrasonic yielded significantly lower counts (P < .05) at both measurement levels. ME-sonic yielded significantly lower counts (P = .002) at 3 mm, whereas ME-ultrasonic yielded highly significantly lower counts (P = .000) at both measurement levels. At 3 mm, ME-ultrasonic yielded significantly lower CFU counts (P = .000) than ME-sonic, NaOCl-sonic, and NaOCl-ultrasonic.

CONCLUSIONS

Enhanced bubble dynamics and reduced E. faecalis biofilm bacteria beyond the level achieved by sonic or ultrasonic agitation of NaOCl suggested a synergistic effect of ME combined with ultrasonic agitation.

Streptococcus gordonii collagen-binding domain protein CbdA may enhance bacterial survival in instrumented root canals ex vivo

INTRODUCTION

The surface-associated collagen-binding protein Ace of Enterococcus faecalis has been implicated as a virulence factor that contributes to bacterial persistence in endodontic infections. The purpose of this study was to determine if proteins with amino acid sequence similarity to Ace found in more abundant oral streptococci could play a similar role in potentially enhancing endodontic infections.

METHODS

A Streptococcus gordonii gene similar to ace was identified by genome sequence searches in silico. An isogenic derivative of strain DL1 with a disruption in the identified gene was constructed by allelic replacement. Parent and mutant strains were characterized for their ability to bind immobilized collagen type 1 in a microtiter plate-binding assay. Survival of the strains in a human tooth ex vivo-instrumented root canal model was compared by inoculating canals with parental or mutant bacteria and determining the colony-forming units (CFUs) recovered at various time points over a 12-day period.

RESULTS

The S. gordonii gene, encoding a protein with a conserved collagen-binding domain similar to that of Ace, was designated cbdA. The cbdA-deficient cells were less able to bind collagen type 1 than parental cells (P < .0001). Genetic complementation of the cbdA-deficient strain restored the collagen-binding phenotype. By day 12, significantly fewer (P = .03) cbdA-deficient than parental CFUs were recovered from instrumented canals.

CONCLUSIONS

A gene encoding a putative collagen-binding protein was identified in S. gordonii. Fewer S. gordonii cbdA-deficient cells survived ex vivo compared with parental cells, suggesting that collagen-binding proteins may contribute to the persistence of oral streptococci in instrumented root canals.

The Application of Microencapsulation Techniques in the Treatment of Endodontic and Periodontal Diseases

In the treatment of intracanal and periodontal infections, the local application of antibiotics and other therapeutic agents in the root canal or in periodontal pockets may be a promising approach to achieve sustained drug release, high antimicrobial activity and low systemic side effects. Microparticles made from biodegradable polymers have been reported to be an effective means of delivering antibacterial drugs in endodontic and periodontal therapy. The aim of this review article is to assess recent therapeutic strategies in which biocompatible microparticles are used for effective management of periodontal and endodontic diseases. In vitro and in vivo studies that have investigated the biocompatibility or efficacy of certain microparticle formulations and devices are presented. Future directions in the application of microencapsulation techniques in endodontic and periodontal therapies are discussed.

Properties and applications of calcium hydroxide in endodontics and dental traumatology

Calcium hydroxide has been included within several materials and antimicrobial formulations that are used in a number of treatment modalities in endodontics. These include, inter-appointment intracanal medicaments, pulp-capping agents and root canal sealers. Calcium hydroxide formulations are also used during treatment of root perforations, root fractures and root resorption and have a role in dental traumatology, for example, following tooth avulsion and luxation injuries. The purpose of this paper is to review the properties and clinical applications of calcium hydroxide in endodontics and dental traumatology including its antibacterial activity, antifungal activity, effect on bacterial biofilms, the synergism between calcium hydroxide and other agents, its effects on the properties of dentine, the diffusion of hydroxyl ions through dentine and its toxicity. Pure calcium hydroxide paste has a high pH (approximately 12.5-12.8) and is classified chemically as a strong base. Its main actions are achieved through the ionic dissociation of Ca(2+) and OH(-) ions and their effect on vital tissues, the induction of hard-tissue deposition and the antibacterial properties. The lethal effects of calcium hydroxide on bacterial cells are probably due to protein denaturation and damage to DNA and cytoplasmic membranes. It has a wide range of antimicrobial activity against common endodontic pathogens but is less effective against Enterococcus faecalis and Candida albicans. Calcium hydroxide is also an effective anti-endotoxin agent. However, its effect on microbial biofilms is controversial.

Is endodontic re-treatment mandatory for every relatively old temporary restoration? A narrative review

OBJECTIVES AND BACKGROUND

In this review, the authors examine whether there is any decisive evidence to support the revision of root fillings that have been exposed to the oral environment for more than three months, undertaken solely because of suspicions of microleakage. Researchers in numerous endodontic studies have addressed the evaluation of coronal microleakage by using different tracers and techniques. The need to achieve a tight, permanent coronal seal as soon as possible after the completion of endodontic treatment is obvious. However, the clinical importance of microleakage studies recently has been questioned because of their wide range and even contradictory results, and findings from only a few clinical investigations have demonstrated a clear relationship between the endodontic success rate and failure rate owed to coronal microleakage in cases involving high-quality endodontic therapy.

METHODS

The authors analyzed commonly cited articles regarding the clinical relevance of microleakage studies and the success rate of teeth with compromised restorations.

CONCLUSIONS

In a review of the literature, the authors found no clear evidence to support immediate replacement of well-obturated endodontic treatment that has lasted more than three months solely because of suspicions of microleakage. It may be prudent in such cases to make a new coronal restoration immediately and to observe the tooth for at least three months before placing the permanent crown.

Resazurin metabolism assay for root canal disinfectant evaluation on dual-species biofilms

INTRODUCTION

Endodontic infections are caused by polymicrobial biofilms. Therefore, novel root canal disinfectants should be evaluated not only on single-species biofilms but also on dual- or mixed-species biofilms. A simple, high-throughput assay is urgently needed for this. In this study, the application of the resazurin metabolism assay was investigated for the evaluation of a root canal disinfectant on dual-species biofilms.

METHODS

Enterococcus faecalis with or without Streptococcus mutans in biofilms were formed in an active attachment biofilm model for 24 hours. Subsequently, the biofilms were treated with various concentrations of NaOCl for 1 minute. After resazurin metabolism by both organisms was confirmed, treatment efficacies using 0.0016% resazurin were evaluated.

RESULTS

During NaOCl treatments, resazurin metabolism displays a clear dose response, not only in single-species E. faecalis (or S. mutans) biofilms but also in dual-species biofilms. Notably, the assay revealed that the resistance of dual-species biofilms to NaOCl was 30-fold higher than in single-species E. faecalis biofilms. Viability counts on a selected NaOCl treatment (0.004%) confirmed this result and showed the increased resistance of E. faecalis in dual-species biofilms.

CONCLUSIONS

Clearly, the high-throughput and low cost resazurin metabolism assay has a great potential for testing novel root canal antimicrobial agents in mixed-species biofilms.

A model system to study antimicrobial strategies in endodontic biofilms

The purpose of this work was to develop a model system to study antimicrobial strategies in endodontic biofilms. Enterococcus faecalis suspension was colonized in 10 human root canals. Five milliliters of Brain Heart Infusion (BHI) were mixed with 5 mL of the bacterial inoculums (E. faecalis) and inoculated with sufficient volume to fill the root canal during 60 days. This procedure was repeated every 72 h, always using 24-h pure culture prepared and adjusted to No. 1 MacFarland turbidity standard. Biofilm formation was analyzed by scanning electron microscopy (SEM). E. faecalis consistently adhered to collagen structure, colonized dentin surface, progressed towards the dentinal tubules and formed a biofilm. The proposed biofilm model seems to be viable for studies on antimicrobial strategies, and allows for a satisfactory colonization time of selected bacterial species with virulence and adherence properties.

Antibacterial efficacy of intracanal medicaments on bacterial biofilm: a critical review

The purpose of this paper is to discuss critically the antibacterial efficacy of intracanal medicaments on bacterial biofilm. Longitudinal studies were evaluated by a systematic review of English-language articles retrieved from electronic biomedical journal databases (MEDLINE, EMBASE, CENTRAL) and handsearching records, using different matches of keywords for root canal biofilm, between 1966 and August 1st, 2007. The selected articles were identified from titles, abstracts and full-text articles by two independent reviewers, considering the tabulated inclusion and exclusion criteria. Disagreements were resolved by consensus. The search retrieved 91 related articles, of which 8.8% referred to in vivo studies demonstrating the lack of efficacy of endodontic therapy on bacterial biofilm. Intracanal medicaments were found to have a limited action against bacterial biofilm.

Chlorhexidine gluconate in endodontics: an update review

The major objective in root canal therapy is to disinfect the entire root canal system. This requires that the pulpal contents be eliminated as sources of infection. This goal may be accomplished using mechanical instrumentation and chemical irrigation, in conjunction with medication of the root canal between treatment sessions. Microorganisms and their by-products are considered to be the major cause of pulpal and periradicular pathosis. In order to reduce or eliminate bacteria, various irrigation solutions have been used during treatment. Chlorhexidine is a cationic molecule which can be used during treatment. It has a wide range antimicrobial activity. Furthermore, because of its cationic structure, chlorhexidine has a unique property named substantivity. The purpose of this paper is to review different aspects of the use of chlorhexidine gluconate in endodontics.