Antifungal effects of endodontic medicaments

Nicolau Syndrome after Endodontic Treatment: A Case Report

Calcium hydroxide has been used successfully in root canal therapy for many years. However, it can cause serious damage if it is inadvertently displaced into surrounding vital structures, resulting in thrombosis if displaced into blood vessels, damaging connective tissue, and causing skin necrosis. These adverse reactions are known as Nicolau syndrome (NS) or embolia cutis medicamentosa. Very few case reports have been published about these adverse effects of injecting calcium hydroxide beyond the apex during root canal therapy. A 16-year-old female patient was referred to the endodontic department of Hamad Dental Center for assessment after treatment by the maxillofacial surgery department for swelling and tissue necrosis that occurred after endodontic treatment in another clinic. When the patient initially attended the maxillofacial surgery department, she presented with swelling on the left side in the region of the maxillary left first permanent molar. On examination, there was a change in the color of the skin of the left cheek in that area along with some reported paralysis of the left side of her lips. Analgesics and antibiotics had already been prescribed at the referring clinic. Two weeks later, the patient developed a necrotic patch of skin on the same area. Subsequent evaluation at the endodontic department of Hamad Dental Center led to a diagnosis of NS. NS is a very rare iatrogenic condition. Displacing calcium hydroxide beyond the apex might increase the chance of NS. Clinicians should avoid overinstrumentation and forced injection of calcium hydroxide to prevent NS.

Update of the therapeutic planning of irrigation and intracanal medication in root canal treatment. A literature review

Background

The success of endodontic treatment derives from the complete elimination of microorganisms capable of causing an intraradicular or extraradicular infection. To achieve a more effective eradication of these microorganisms, endodontic instrumentation must always be implemented with abundant irrigation, which has to achieve chemical, mechanical and biological effects. The irrigators most used today are NaOCl, CHX and EDTA, released into the ducts through different techniques such as syringe, manual agitation, positive or negative apical pressure, sonic or ultrasonic activation, PIPS and PDT. The objective of this review is to update the different irrigating solutions and intracanal disinfection drugs, as well as to establish an irrigation protocol in the endodontic treatment.

Material and Methods

Systematic search of scientific articles in the databases PubMed, Medline and Google Scholar, with the following keywords Endodontic, Infection, Failure, Irrigation, Retreatment and Irrigation protocol. The exclusion criteria were “case report” articles and articles with a publication date prior to 2000.

Results

48 articles that met the inclusion criteria were analyzed. Comparing the different articles it can be seen that the NaOCl is the “gold standard” in terms of immediate antimicrobial efficacy, followed by the CHX that has a long-term antibacterial effect. As an intra-conductive drug it is advisable to use the combination of Ca(OH)2 with CPMC.

Conclusions

The most adequate irrigation protocol consists of using 2.5% NaOCl activated with ultrasound followed by a final wash with 7% MA or 0.2% CTR combined with 2% CHX.

Key words:Endodontic failure, endodontic infection, enterococcus faecalis, endodontic retreatment, irrigation, sodium hipoclorite, irrigation protocol.

[Efficacy of sodium hydroxide at 2.5 %, chlorhexidine gluconate at 0.5 % and calcium hydroxide against Candida albicans]

INTRODUCTION

Endodontic flora is dominated in the apical part of the channels by strict anaerobic and some facultative anaerobic bacteria but also by Candida yeasts, especially Candida albicans species that are involved in the maintenance and persistence of endodontic infections. Their elimination of the canal system in practice by chemo-mechanical methods of disinfection is not always guaranteed. Thus, this in vitro study was performed to determine the sensitivity of C. albicans with sodium hypochlorite (NaOCl) dosed at 2.5 %, the chlorhexidine digluconate 0.5 % and calcium hydroxide used in inter-session medication.

METHODS

The diffusion method was used initially to test the sensitivity of C. albicans strains with the above products. Then a dilution technique has allowed us to determine the minimum inhibitory concentration of these active products on C. albicans.

RESULTS

Strains from infected pulp teeth of patients showed a sensitivity of C. albicans to sodium hypochlorite to a minimum inhibitory concentration less than 70μg/mL and 30μg/mL for chlorhexidine.

CONCLUSION

This study demonstrated a sensitivity of C. albicans to sodium hypochlorite and chlorhexidine.

Antimicrobial efficacy of chlorhexidine as a root canal irrigant: a literature review

Use of an appropriate root canal irrigant is essential during endodontic treatment, due to the complex and unpredictable anatomy of the root canal system and limitations in the mechanical instrumentation techniques used to obtain a clean, bacteria-free canal. Several irrigants, such as sodium hypochlorite, chlorhexidine, hydrogen peroxide, and normal saline, have been proposed as canal system irrigants in endodontic treatment. The widely used endodontic irrigant chlorhexidine is a positively charged lipophilic/hydrophobic molecule that interacts with phospholipids and lipopolysaccharides on the bacterial cell membrane. In endodontics, its mode of antibacterial activity is determined by its concentration (0.2% or 2%). This article reviews findings from available endodontic studies on the antibacterial, antifungal, and antibiofilm activities of chlorhexidine.

Antimicrobial peptide-based treatment for endodontic infections--biotechnological innovation in endodontics

The presence/persistence of microorganisms in the pulp and periapical area corresponds to the maintenance of an exacerbated immune response that leads to the start of periradicular bone resorption and its perpetuation. In endodontic treatment, the available intracanal medications do not have all the desirable properties in the context of endodontic infection and apical periodontitis; they need to include not only strong antimicrobial performance but also an immunomodulatory and reparative activity, without host damage. In addition, there are various levels of resistance to root canal medications. Thus, antimicrobial agents that effectively eliminate resistant species in root canals could potentially improve endodontic treatment. In the emergence of new therapies, an increasing number of studies on antimicrobial peptides (AMPs) have been seen over the past few years. AMPs are defense biomolecules produced in response to infection, and they have a wide spectrum of action against many oral microorganisms. There are some studies that correlate peptides and oral infections, including oral peptides, neuropeptides, and bacterial, fish, bovine and synthetic peptides. So far, there are around 120 published studies correlating endodontic microbiota with AMPs but, according to our knowledge, there are no registered patents in the American patent database. There are a considerable number of AMPs that exhibit excellent antimicrobial activity against endodontic microbiota at a small inhibitory concentration and modulate an exacerbated immune response, down-regulating bone resorption. All these reasons indicate the antimicrobial peptide-based endodontic treatment as an emerging and promising option.

Comparative antifungal efficacy of light-activated disinfection and octenidine hydrochloride with contemporary endodontic irrigants

The aim of this study was to evaluate the antifungal effects of light-activated disinfection (LAD) in comparison with contemporary root canal irrigation solutions: sodium hypochlorite and 2% chlorhexidine gluconate and a new wound antiseptic, octenidine hydrochloride. Seventy extracted teeth having single root canals were contaminated with Candida albicans for 14 days. The samples were divided into five experimental (n = 10) and two control (positive and negative) groups (n = 10): (1) LAD with toluidine blue O, (2) octenidine hydrochloride (OCT), (3) 2.5% sodium hypochlorite (2.5% NaOCl), (4) 5.25% sodium hypochlorite (5.25% NaOCl) and (5) 2% chlorhexidine. Five millilitres of each test solution was applied for 3 min, and irradiation time used for LAD was 30 s. After treatment, the dentin chips were collected from inner canal walls into vials containing phosphate buffered saline, vortexed, serially diluted, seeded on Tryptic Soy Agar plates and incubated (37 °C, 48 h). The number of colony-forming units was then counted. Differences between LAD group and positive control group were statistically significant (P < 0.05). All Candida cells were totally eliminated in root canals irrigated with OCT, 2.5% NaOCl, 5.25% NaOCl and 2% chlorhexidine groups (CFU = 0). Within the limitations of this ex vivo study, LAD had minimal antimicrobial effect on C. albicans when used 30 s, and further modifications in LAD protocol are required to improve its antifungal capability. A new wound antiseptic, octenidine hydrochloride, demonstrated better potential than LAD in elimination of Candida albicans cells and may be a promising alternative to NaOCl and chlorhexidine solutions in future.

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.

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.

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.

Elimination of Candida albicans infection of the radicular dentin by intracanal medications

Fungi have been associated with cases of secondary or persistent root canal infections. The purpose of this study was to evaluate the effectiveness of four intracanal medications in disinfecting the root dentin of bovine teeth experimentally infected with Candida albicans. Infected dentin cylinders were exposed to four different medications: calcium hydroxide/glycerin; calcium hydroxide/0.12% chlorhexidine digluconate; calcium hydroxide/camphorated paramonochlorophenol/glycerin; and 0.12% chlorhexidine digluconate/zinc oxide. Specimens were in contact with the medications for 1 h, 2 days, and 7 days. The viability of C. albicans after exposure was evaluated by specimen incubation in culture medium to compare the effectiveness of the medications in disinfecting dentin. Results showed that the specimens treated with calcium hydroxide/camphorated paramonochlorophenol/ glycerin paste or with chlorhexidine/zinc oxide paste were completely disinfected after 1 h of exposure. Calcium hydroxide/glycerin paste only consistently eliminated C. albicans infection after 7 days of exposure. Calcium hydroxide mixed with chlorhexidine was ineffective in disinfecting dentin even after 1 week of medication exposure. Among the medications tested, the calcium hydroxide/camphorated paramonochlorophenol/glycerin paste and chlorhexidine digluconate mixed with zinc oxide were the most effective in eliminating C. albicans cells from dentinal specimens.