Minimizing Concentration of Sodium Hypochlorite in Root Canal Irrigation by Combination of Ultrasonic Irrigation with Photodynamic Treatment

Antimicrobial photodynamic therapy against oral biofilm: influencing factors, mechanisms, and combined actions with other strategies

Oral biofilms are a prominent cause of a wide variety of oral infectious diseases which are still considered as growing public health problems worldwide. Oral biofilms harbor specific virulence factors that would aggravate the infectious process and present resistance to some traditional therapies. Antimicrobial photodynamic therapy (aPDT) has been proposed as a potential approach to eliminate oral biofilms via in situ-generated reactive oxygen species. Although numerous types of research have investigated the effectiveness of aPDT, few review articles have listed the antimicrobial mechanisms of aPDT on oral biofilms and new methods to improve the efficiency of aPDT. The review aims to summarize the virulence factors of oral biofilms, the progress of aPDT in various oral biofilm elimination, the mechanism mediated by aPDT, and combinatorial approaches of aPDT with other traditional agents.

Ultrasonic irradiation enhanced the efficacy of antimicrobial photodynamic therapy against methicillin-resistant Staphylococcus aureus biofilm

Antimicrobial photodynamic therapy (aPDT) is a non-pharmacological antimicrobial regimen based on light, photosensitizer and oxygen. It has become a potential method to inactivate multidrug-resistant bacteria. However, limited by the delivery of photosensitizer (PS) in biofilm, eradicating biofilm-associated infections by aPDT remains challenging. This study aimed to explore the feasibility of combining ultrasonic irradiation with aPDT to enhance the efficacy of aPDT against methicillin-resistant staphylococcus aureus (MRSA) biofilm. A cationic benzylidene cyclopentanone photosensitizer with much higher selectivity to bacterial cells than mammalian cells were applied at the concentration of 10 μM. 532 nm laser (40 mW/cm², 10 min) and 1 MHz ultrasound (500 mW/cm², 10 min, simultaneously with aPDT) were employed against MRSA biofilms in vitro. In addition to combined with ultrasonic irradiation and aPDT, MRSA biofilms were treated with laser irradiation only, photosensitizer only, ultrasonic irradiation only, ultrasonic irradiation and photosensitizer, and aPDT respectively. The antibacterial efficacy was determined by XTT assay, and the penetration depth of PS in biofilm was observed using a photoluminescence spectrometer and a confocal laser scanning microscopy (CLSM). In addition, the viability of human dermal fibroblasts (WS-1 cells) after the same treatments mentioned above and the uptake of P3 by WS-1 cells after ultrasonic irradiation were detected by CCK-8 and CLSM in vitro. Results showed that the percent decrease in metabolic activity resulting from the US + aPDT group (75.76%) was higher than the sum of the aPDT group (44.14%) and the US group (9.88%), suggesting synergistic effects. Meanwhile, the diffusion of PS in the biofilm of MRSA was significantly increased by 1 MHz ultrasonic irradiation. Ultrasonic irradiation neither induced the PS uptake by WS-1 cells nor reduced the viability of WS-1 cells. These results suggested that 1 MHz ultrasonic irradiation significantly enhanced the efficacy of aPDT against MRSA biofilm by increasing the penetration depth of PS. In addition, the antibacterial efficacy of aPDT can be enhanced by ultrasonic irradiation, the US + aPDT treatment demonstrated encouraging in vivo antibacterial efficacy (1.73 log₁₀ CFU/mL reduction). In conclusion, the combination of aPDT and 1 MHz ultrasound is a potential and promising strategy to eradicate biofilm-associated infections of MRSA.

Enhanced antimicrobial activity through the combination of antimicrobial photodynamic therapy and low-frequency ultrasonic irradiation

The rapid increase of antibiotic resistance in pathogenic microorganisms has become one of the most severe threats to human health. Antimicrobial photodynamic therapy (aPDT), a light-based regimen, has offered a compelling nonpharmacological alternative to conventional antibiotics. The activity of aPDT is based on cytotoxic effect of reactive oxygen species (ROS), which are generated through the photosensitized reaction between photon, oxygen and photosensitizer. However, limited by the penetration of light and photosensitizers in human tissues and/or the infiltration of oxygen and photosensitizers in biofilms, the eradication of deeply located or biofilm-associated infections by aPDT remains challenging. Ultrasound irradiation bears a deeper penetration in human tissues than light and, sequentially, can promote drug delivery through cavitation effect. As such, the combination of ultrasound and aPDT represents a potent antimicrobial strategy. In this review, we summarized the recent progresses in the area of the combination therapy using ultrasound and aPDT, and discussed the potential mechanisms underlying enhanced antimicrobial effect by this combination therapy. The future research directions are also highlighted.

Biofilm models in endodontics-A narrative review

The knowledge of biofilm and its eradication from the root canal system are of utmost importance in the clinical practice of an endodontist. Various treatment strategies and protocols have been demonstrated and discussed by numerous clinicians and researchers, on these models, that play an important role in the treatment outcome . Once a biofilm model is developed by considering various factors, several methods can be used to assess the biofilms formed on these models. This review discusses the importance of biofilm models in endodontics, types of biofilm models and factors associated with developing and the methods to evaluate these models.

Pretreatment of Root Canal with Photodynamic Therapy Facilitates Adhesion, Viability and Differentiation of Stem Cells of the Apical Papilla

This study was to test the hypothesis that root canal pretreated with photodynamic therapy (PDT) would promote stem cells from the apical papilla (SCAP) adhesion, proliferation and differentiation without affecting smear layer removal and microhardness of root canal. Standardized root canals were randomized into four groups (n = 30/group): (1) sodium hypochlorite(NaOCl) group, (2) NaOCl + ethylene diaminetetraacetic acid (EDTA) group, (3) NaOCl + PDT group, (4) NaOCl + EDTA + PDT group. After treatments, smear layer removal and microhardness of root canal were evaluated. SCAP with hydroxyapatite-based scaffolds were seeded into root canals for 7 days. SCAP adhesion was observed by scanning electron microscope (SEM), and viable cells were calculated by CellTiter-Glo Luminescent kit. Platelet-derived growth factor (PDGF) and vascular endothelial growth factor (VEGF) expression of SCAP were evaluated by Quantitative Reverse Transcriptase-Polymerase Chain Reaction. There was no significant difference in the smear layer removal and microhardness of root dentin between the groups with and without PDT treatment (P > 0.05). SCAP with elongated cytoplasmic processes and cell-cell contact were observed on the dentin surfaces treated with PDT. Elevated cell viability, PDGF and VEGF expression were found in root canal treated with PDT (P < 0.05). Under the experimental conditions, PDT could provide positive microenvironment for SCAP growth.

Nanoparticles for the Treatment of Oral Biofilms: Current State, Mechanisms, Influencing Factors, and Prospects

Due to their excellent size, designability, and outstanding targeted antibacterial effects, nanoparticles have become a potential option for controlling oral biofilm-related infections. However, the formation of an oral biofilm is a dynamic process, and factors affecting the performance of antibiofilm treatments are complex. As such, when examining the existing literature on the antibiofilm effects of nanoparticles, attention should be paid to the specific mechanisms of action at different stages of oral biofilm formation, as well as relevant influencing factors, in order to achieve an objective and comprehensive evaluation. This review is intended to detail the antibacterial mechanisms of nanoparticles during the four stages of the formation of oral biofilms: 1) acquired film formation; 2) bacterial adhesion; 3) early biofilm development; and 4) biofilm maturation. In addition, factors influencing the antibiofilm properties of nanoparticles are summarized from the aspects of nanoparticles themselves, biofilm models, and host factors. The limitations of current research and possible trends for future research are also discussed. In summary, nanoparticles are a promising antioral biofilm strategy. It is hoped that this review can serve as a reference and inspire ideas for further research on the application of nanoparticles for effectively targeting and treating oral biofilms.

Composite-derived monomers affect cell viability and cytokine expression in human leukocytes stimulated with Porphyromonas gingivalis

OBJECTIVES

Dental composites release unreacted resin monomers into the oral environment, even after polymerization. Periodontal cells are, therefore, exposed to substances that potentially elicit the immune inflammatory response. The underlying molecular mechanisms associated with the interaction between resin monomers and human immune cells found in the gingival crevicular fluid are not fully understood yet. This study investigated the ability of bisphenol A-glycidyl methacrylate (BISGMA), urethane dimethacrylate (UDMA) and triethylene glycol dimethacrylate (TEGDMA) to induce apoptosis and cytokine release by human leukocytes stimulated with a periodontal pathogen.

METHODOLOGY

Peripheral blood mononuclear cells (PBMC) from 16 healthy individuals were included in this study. To determine the toxicity, the PBMC were incubated for 20 hours, with monomers, for the analysis of cell viability using MTT assay. To evaluate cell death in the populations of monocytes and lymphocytes, they were exposed to sub-lethal doses of each monomer and of heat-inactivated Porphyromonas gingivalis (P. gingivalis) for 5 hours. Secretions of IL-1β, IL-6, IL-10 and TNF-α were determined by ELISA after 20 hours.

RESULTS

UDMA and TEGDMA induced apoptosis after a short-time exposure. Bacterial challenge induced significant production of IL-1β and TNF-α (p<0.05). TEGDMA reduced the bacterial-induced release of IL-1β and TNF-α, whereas UDMA reduced IL-1β release (p<0.05). These monomers did not affect IL-10 and IL-6 secretion. BISGMA did not significantly interfere in cytokine release.

CONCLUSIONS

These results show that resin monomers are toxic to PBMC in a dose-dependent manner, and may influence the local immune inflammatory response and tissue damage mechanisms via regulation of bacterial-induced IL-1β and TNF-α secretion by PBMC.

Antimicrobial photodynamic therapy using a plaque disclosing solution on Streptococcus mutans

OBJECTIVES

Photodynamic therapy with a bactericidal action is called antimicrobial photodynamic therapy (aPDT),which is a method of staining an object with a photosensitizing dye and then sterilizing by irradiating the dye at it's excitation wavelength. In this study, we aimed to investigate a caries pathogenic bactericidal method in a site difficult to mechanically remove, by examining aPDT effect on Streptococcus mutans (S. mutans), which is a typical caries pathogenic bacteria by applying the plaque disclosing solution as photosensitizing dye.

METHODS

The absorption wavelength spectrum of irradiating plaque staining agent phloxine B (PB) was analyzed using UV-vis. Reactive oxygen species (ROS) generated by photo excitation with blue LED irradiation was measured by electron spin resonance technique. S. mutans was cultured according to a conventional method and the effect of aPDT after PB staining was evaluated by a Colony Forming Unit (CFU). In addition, protein carbonyl (PC), an oxidative stress marker, was also measured by western blotting.

RESULTS

Singlet oxygen was generated by PB with blue light. As a result of aPDT treatment on S. mutans under this condition, it was recognized that CFU was suppressed dependent on irradiation intensity of blue light. In addition, the expression of PC was enhanced by aPDT.

CONCLUSIONS

aPDT is demonstrated by staining S. mutans with PB and irradiating blue light used for resin polymerization and tooth bleaching to generate ROS. Therefore, plaque-disclosing solution-based aPDT against S. mutans might represent a new method for cleaning pit and fissure grooves.

Role of extracellular DNA in Enterococcus faecalis biofilm formation and its susceptibility to sodium hypochlorite

Objective

This study investigated the role of extracellular deoxyribonucleic acid (eDNA) on Enterococcus faecalis ( E. faecalis ) biofilm and the susceptibility of E. faecalis to sodium hypochlorite (NaOCl).

Methodology

E. faecalis biofilm was formed in bovine tooth specimens and the biofilm was cultured with or without deoxyribonuclease (DNase), an inhibitor of eDNA. Then, the role of eDNA in E. faecalis growth and biofilm formation was investigated using colony forming unit (CFUs) counting, eDNA level assay, crystal violet staining, confocal laser scanning microscopy, and scanning electron microscopy. The susceptibility of E. faecalis biofilm to low (0.5%) or high (5%) NaOCl concentrations was also analyzed by CFU counting.

Results

CFUs and biofilm formation decreased significantly with DNase treatment (p<0.05). The microstructure of DNase-treated biofilms exhibited less structured features when compared to the control. The volume of exopolysaccharides in the DNase-treated biofilm was significantly lower than that of control (p<0.05). Moreover, the CFUs, eDNA level, biofilm formation, and exopolysaccharides volume were lower when the biofilm was treated with DNase de novo when compared to when DNase was applied to matured biofilm (p<0.05). E. faecalis in the biofilm was more susceptible to NaOCl when it was cultured with DNase (p<0.05). Furthermore, 0.5% NaOCl combined with DNase treatment was as efficient as 5% NaOCl alone regarding susceptibility (p>0.05).

Conclusions

Inhibition of eDNA leads to decrease of E. faecalis biofilm formation and increase of susceptibility of E. faecalis to NaOCl even at low concentrations. Therefore, our results suggest that inhibition of eDNA would be beneficial in facilitating the efficacy of NaOCl and reducing its concentration.

Biofilm model systems for root canal disinfection: a literature review

The aim of this review was to present an overview of laboratory root canal biofilm model systems described in the endodontic literature and to critically appraise the various factors that constitute these models. The electronic databases MEDLINE, Web of Science and EMBASE were searched up to and including December 2016 to identify laboratory studies using endodontic biofilm models. The following search terms were used in various combinations: biofilm, root canal, in vitro, endodontic, bacteria, root canal infection model, colony-forming unit. Only English papers from journals with an impact factor were selected. The records were screened by two reviewers, and full-text articles were assessed according to pre-defined criteria. The following data were extracted from the included studies: the microbial composition of the biofilm, the substrate, growth conditions, validation and quantification. Seventy-seven articles met the inclusion criteria. In the majority (86%) of the studies, a monospecies biofilm was cultured. In two studies, a dual-species biofilm was grown; others cultivated a multispecies biofilm, containing at least three species. Enterococcus faecalis was the most frequently used test species (in 79% of all studies, 92% of the monospecies studies). Four studies used an inoculum derived directly from the oral cavity. Human dentine was the most frequently used substratum (88% of the studies). Incubation times differed considerably, ranging from one to seventy days. The most common quantification method (in 87% of the studies) was bacterial culturing, followed by microscopy techniques. The variation in laboratory root canal biofilm model systems is notable. Because of substantial variation in experimental parameters, it is difficult to compare results between studies. This demonstrates the need for a more standardized approach and a validated endodontic biofilm model.

Antimicrobial Photodynamic Therapy against Endodontic Enterococcus faecalis and Candida albicans Mono and Mixed Biofilms in the Presence of Photosensitizers: A Comparative Study with Classical Endodontic Irrigants

Endodontic biofilms eradication from the infected root canal system remains as the primary focus in endodontic field. In this study, it was assessed the efficacy of antimicrobial Photodynamic Therapy (aPDT) with the Zn(II)chlorin e6 methyl ester (Zn(II)e₆Me) activated by red light against monospecies and mixed biofilms of Enterococcus faecalis and Candida albicans. The results were compared with the ones obtained with Rose Bengal (RB), Toluidine Blue-O (TBO), the synthetic tetracationic porphyrin (TMPyP) as well as classical endodontic irrigants (3% NaOCl, 17% EDTA and 2% CHX). The antimicrobial efficacy of aPDT toward monospecies and mixed biofilms was quantified resorting to safranin red method. The changes of biofilm organization and of cellular ultrastructure were evaluated through several microscopy techniques (light, laser confocal and transmission electron microscopy). Zn(II)e₆Me once activated with light for 60 or 90 s was able to remove around 60% of the biofilm’s biomass. It was more efficient than TBO and RB and showed similar efficiency to TMPyP and classical irrigants, CHX and EDTA. As desirable in a PS, Zn(II)e₆Me in the dark showed smaller activity than TMPyP. Only NaOCl revealed higher efficiency, with 70–90% of the biofilm’s biomass removal. The organization of biofilms and the normal microbial cell ultrastructure were extensively damaged by the presence of Zn(II)e₆Me. aPDT with Zn(II)e₆Me showed to be an efficient antimicrobial strategy deserving further studies leading to a future clinical usage in endodontic disinfection.

Photodynamic Antimicrobial Chemotherapy for Root Canal System Asepsis: A Narrative Literature Review

Aim. The aim of this comprehensive literature review was to address the question: Does photodynamic therapy (PDT) improve root canal disinfection through significant bacterial reduction in the root canal system? Methodology. A comprehensive narrative literature review was performed to compare PDT effect with sodium hypochlorite as the comparative classical irrigant. Two reviewers independently conducted literature searches using a combination of medical subject heading terms and key words to identify relevant studies comparing information found in 7 electronic databases from January 2000 to May 2015. A manual search was performed on bibliography of articles collected on electronic databases. Authors were contacted to ask for references of more research not detected on the prior electronic and manual searches. Results. The literature search provided 62 titles and abstracts, from which 29 studies were related directly to the search theme. Considering all publications, 14 (48%) showed PDT to be more efficient in antimicrobial outcome than NaOCl (0.5-6% concentration) used alone and 2 (7%) revealed similar effects between them. Toluidine blue and methylene blue are the most used photosensitizers and most commonly laser has 660 nm of wavelength with a 400 nm diameter of intracanal fiber. Conclusions. PDT has been used without a well-defined protocol and still remains at an experimental stage waiting for further optimization. The level of evidence available in clinical studies to answer this question is low and at high risk of bias.