Comparative evaluation of antimicrobial efficacy of triple antibiotic paste, calcium hydroxide, and a proton pump inhibitor against resistant root canal pathogens

Comparative evaluation of antimicrobial efficacy of triple antibiotic paste and amoxicillin clavulanate paste as an intracanal medicament against Enterococcus faecalis: An in vitro study

Background

Triple antibiotic paste (TAP) is the commonly used intracanal medicament against Enterococcus faecalis. Amoxicillin clavulanate paste (ACP) is recommended as a "fall-back" antibiotic when traditional dental antibiotics fail. Literature comparing the antimicrobial efficacy of TAP and ACP in eradicating E. faecalis from the root canal system is sparse; hence, this in vitro study was conducted to evaluate and compare the antimicrobial efficacy of TAP and ACP as an intracanal medicament for endodontic treatment of single-rooted permanent teeth against E. faecalis.

Materials and Methods

This in vitro, experimental study evaluated 60 root samples obtained from extracted single-rooted human permanent teeth. The canal diameter was enlarged and subsequently infected with E. faecalis for 21 days. Four groups of the contaminated samples were treated with TAP, ACP, calcium hydroxide (positive control), and saline (negative control), respectively. Dentinal shavings were collected at the end of the 1st, 7th, and 10th day and inoculated in agar plates. The number of colony-forming units was determined, and the data were statistically analyzed using the Kolmogorov-Smirnov and Shapiro-Wilks test. P <0.05 was considered statistically significant.

Results

The mean number of E. faecalis colony counts across all 3 test days demonstrated that TAP exhibited the highest inhibition of bacterial growth, followed by ACP which is not statistically significant (P = 1.00).

Conclusion

Considering the limitations of this in vitro study, the findings suggest that ACP could be an effective alternative intracanal medicament to TAP for endodontic therapy.

Comparative Analysis of Photosensitizer Penetration Depth in Root Canal Debridement for Endodontic Disinfection

Introduction

Microbial agents play a crucial role in periapical lesions and despite mechanical preparation, presence of persistent bacteria in root canal system is a challenge. Photodynamic therapy offers a debridement method, utilizing photosensitizers such as Curcumin, Indocyanine Green (ICG), and Methylene Blue (MB). This study aimed to assess and compare the penetration depth of these photosensitizers on the lateral surface of the root canal.

Materials and Methods

The crown of 30 single-rooted teeth were separated by a diamond disc. The canals were prepared using a rotary system and were rinsed with 10 mL of 2.5% NaOCl. In order to remove the smear layer debris, 17% EDTA was placed in the root canal for 1 min, then rinsed with NaOCl and saline. The teeth were sterilized by autoclave and randomly assigned to three groups that filled with curcumin, ICG, or MB. Subsequently, they were incubated for 10 min and dried up by paper. Longitudinal sections were cut, and penetration depth of the photosensitizers in coronal, middle, and apical sections were measured using a stereomicroscope.

Results

Curcumin demonstrated a higher average penetration depth (3000 µm) than MB, and MB showed higher penetration depth than ICG. Significantly different penetration depths were observed in pairwise comparisons among all three groups (P<0.005).

Conclusion

Curcumin with its superior average penetration depth, emerges as a promising choice for effective root canal disinfection in endodontic treatments. Consideration of these findings may enhance the selection of photosensitizers in clinical applications.

Comparative evaluation of antibacterial efficacy of nonsteroidal anti-inflammatory medications and proton-pump inhibitor against Enterococcus faecalis: An in vitro study

Aim

The present in vitro experimental study was undertaken to evaluate and compare the antimicrobial activity of triple antibiotic paste (TAP), diclofenac, and proton-pump inhibitor (PPI) against the microorganism Enterococcus faecalis.

Materials and Methods

Three medicaments were selected for the study, TAP, diclofenac, and PPI. The experimental groups for the test were as follows: Part 1 - Group 1: TAP, Group 2: diclofenac, and Group 3: PPI; Part 2 - Group 1: TAP + PPI and Group 2: diclofenac + PPI. An agar well diffusion test was used to determine the efficacy of the experimental medicaments against E. faecalis (ATCC 29212). The diameter of inhibition zones was measured in millimeters using an inhibition zone measuring scale and the results were recorded.

Statistical Analysis

The statistical analysis was done using an analysis of variance and an unpaired t-test. P value was set at < 0.05.

Results

There was a significant difference in the diameter of growth inhibition zones, with the greatest diameter noted for TAP + PPI followed by diclofenac sodium (DS) + PPI, TAP, DS, and PPI.

Conclusions

The antimicrobial effectiveness of TAP + PPI was found to be superior to all other medicaments (DS + PPI, TAP, DS, and PPI).

Stability Evaluation of Lyotropic Liquid Crystalline Precursor for the Co-delivery of Chlorhexidine and Silver Nanoparticles

Sealing the therapeutic agents in the root canal is considered to be an essential step in root canal therapy. The lyotropic liquid crystalline precursor (LLCP) incorporated with chlorhexidine (CHX) and silver nanoparticles (Ag-NPs) has been confirmed as a promising candidate for root canal therapy in the previous study. Importantly, the stability of the LLCP system was a significant determinant for its therapeutic effect and further application. The objective of this study was to comprehensively investigate the stability of the LLCP incorporated with CHX and Ag-NPs. The oil-water partition coefficient of CHX and Ag-NPs was measured. The water absorption and the physical stability of drug-loaded LLCP solution were studied. Stability under high temperature, high humidity, and strong light irradiation was also investigated. The results demonstrated that CHX and Ag-NPs could be entrapped in the water channel of LLCP, indicating the low tendency of drugs leakage. The drug-loaded LLCP was a pseudoplastic fluid and it showed an excellent physical stability with a sedimentation rate of 0.981 and a settling time of 26~28 h. The payload of LLCP was confirmed to weaken the water absorption behavior, which facilitated its transformation to cubic liquid crystal. The stress testing under high temperature, high humidity, and strong light irradiation also manifested that the LLCP was stable when stored under moisture-proof condition. In conclusion, the developed LLCP incorporated with CHX and Ag-NPs was highly stable during storage and qualified for further application.

Antimicrobial action of photodynamic therapy on Enterococcus faecalis biofilm using curing light, curcumin and riboflavin

The aim of this study was to assess the effect of antimicrobial photodynamic therapy (aPDT) with curcumin and riboflavin on three-week Enterococcus faecalis biofilm. At first the 15-mm root canals of 65 single rooted extracted human teeth (including maxillary incisors, mandibular and maxillary canines and mandibular premolars) were separated from the crown and were prepared with ProTaper instruments. After autoclave sterilisation, samples were inoculated with E. faecalis suspension, and incubated for three weeks. After ensuring biofilm formation by scanning electron microscopy (SEM) in two teeth, the remaining 63 teeth were randomly divided into seven groups (n = 9): aPDT + curcumin, aPDT + riboflavin, LED, curcumin, riboflavin, 5.25% NaOCl (positive control) and no intervention (negative control). For light source a LED unit with 390-480 nm wavelength (peak of 460 nm), power density of 1000 ± 100 mW cm^-2 and mean energy density of 60 J cm^-2 was used. The roots were horizontally sectioned into coronal, middle and apical thirds each with 5 mm thicknesses. Dentin chips with equal weight (1 ± 0.005 g) were collected from the root canal walls with Gates Glidden drills and were transferred into microtubes containing 1 mL of sterile saline and vortexed for 30 s. Next, 10 µL of the contents of each tube was serially diluted and eventually, 10 µL of each solution was cultured on BHI agar. The number of colony-forming units was determined. Data were analysed using the Kruskal-Wallis and Friedman tests. The colony reduction was not significantly different between NaOCl and either riboflavin + LED or Curcumin + LED. The 5.25% NaOCl group showed maximum reduction in colony count, compared with the negative control (P = 0.00). Groups with aPDT with Curcumin + LED (P = 0.005), and with riboflavin + LED (P = 0.011) showed significant reduction in colony count in all three canal thirds (P < 0.05) without any difference with one another. With significant reduction of E. faecalis colony count, aPDT with Curcumin and riboflavin can serve as an adjunct to routine root canal disinfection method.

Antibacterial effect of silver nanoparticles mixed with calcium hydroxide or chlorhexidine on multispecies biofilms

The purpose is to evaluate the antibacterial effects of the silver nanoparticles (AgNPs) (Nanografi, METU Teknokent, Ankara, Turkey) mixed with calcium hydroxide (Ca(OH)₂) (Ultracal XS, Ultradent, St Louis, US) or chlorhexidine gel (CHX) (Gluco-Chex, Cerkamed, Stalowa Wola, Poland) against a multispecies biofilm, by confocal laser scanning microscopy (CLSM) and culture-based analysis. Dentine blocks were inoculated with Enterococcus faecalis, Streptococcus mutans, Lactobacillus acidophilus and Actinomyces naeslundii for 1 week. Infected dentine blocks were randomly divided into groups according to medication; saline solution (SS), Ca(OH)₂, Ca(OH)₂ + AgNP, 2%CHX gel and 2%CHX gel + AgNP and time of application: 1 and 7 days (all groups, n = 5). Bacterial samples were collected before and after medication to quantify the bacterial load. Biofilm elimination was quantitatively analyzed by Live/Dead BacLight Bacterial Viability staining and CLSM. The addition of AgNPs to Ca(OH)₂ increased the effectiveness of medicament in terms of bacterial reduction in both application times (1 and 7 days) (p < 0.05: ANOVA, Tukey's test) according to culture-based analysis. The CLSM images revealed that mixture of AgNP with CHX killed significantly more bacteria when compared with all other medicaments at 1- and 7-day application times (p < 0.05 and p > 0.05, respectively: Kruskal-Wallis, Dunn post hoc tests). The efficacy of Ca(OH)₂ mixed with AgNPs was superior to Ca(OH)₂ used alone in both application times (p < 0.05) according to CLSM analysis. The present study put forth the potential use of AgNPs mixed with Ca(OH)₂ or CHX on multispecies (Enterococcus faecalis, Streptococcus mutans, Lactobacillus acidophilus and Actinomyces naeslundii) biofilm in 1 and 7day application periods.

Comparative evaluation of the concentration-dependent effect of proton-pump inhibitor in association with calcium hydroxide and chlorhexidine on Enterococcus faecalis: An in vitro study

Background

Enterococcus faecalis is the most persistent organism in the root canal which resists most of the intracanal medicaments. There is always a constant attempt to eliminate this endodontic pathogen from the root canal system.

Aim

The aim of this study was to evaluate the efficacy of the association of different concentrations of proton-pump inhibitor (PPI) (Lansoprazole) with calcium hydroxide (CH) and chlorhexidine (CHX) against E. faecalis using a broth dilution method.

Materials and Methods

E. faecalis was inoculated into brain-heart infusion broth at 37°C for 5 h. The master broth was then treated with CH (Group 1); CH + 2% CHX (Group 2); CH + PPI 6.25 μg/ml (Group 3A); CH + PPI 25 μg/ml (Group 3B); 2% CHX + PPI 6.25 μg/ml (Group 4A); 2% CHX + PPI 25 μg/ml (Group 4B); CH + 2% CHX + PPI 6.25 μg/ml (Group 5A), and CH + 2% CHX + PPI 25 μg/ml (Group 5B). The groups were spectrophotometrically analyzed at 630 nm at 24 h to determine the group with the least optical density.

Statistical Analysis

Comparison between the groups was done by the one-way analysis of variance and Kruskal-Wallis test for multiple comparisons.

Results

The mean percentage inhibition of E. faecalis by Group 5A (CH + 2% CHX + PPI 6.25 μg/ml) was the highest compared to other groups. The lowest mean value was observed in Group 3A (CH + PPI 6.25 μg/ml) indicating least efficiency.

Conclusion

There was a concentration-dependent effect of PPI on CH and CHX against E. faecalis. The maximum efficacy was found when the lower concentration of PPI was associated with CH/CHX mixture.

Evaluation of the Cytotoxicity and apoptotic effect of Nano triple antibiotic paste with Nano anti-inflammatory drug as an intracanal medicament

Objective:

The aim of this study is to compare the cytotoxicity of triple antibiotic paste (TAP) with an anti-inflammatory drug (TAP+Catafast-TAPC) in nano and regular formulations versus calcium hydroxide as intracanal medicaments.

Methods:

The TAPC drugs extraction were made in cell culture media MEM-E (Eagle’s minimal essential medium) using concentration of 10 mg/mL of each sample for seven days. Inhibitory concentrations (IC50 values) were determined for each extract. A human fibroblasts cell line was used to evaluate the cytotoxicity of different concentrations (10, 0.625 and 0.07 mg/mL) using MTT essay. The cell viability was measured after 24 h, 48 h and 7 days for all concentrations of the drugs. Flow cytometry analysis was carried out to identify the effect of materials on apoptosis/necrosis. Statistical analysis for the obtained results was done by one-way ANOVA.

Results:

The results revealed that cell viability was inversely proportional to the duration of treatment in all of the groups. Calcium hydroxide (Control group) demonstrated a significantly greater cytotoxic effect, followed by Nano Triple Antibiotic Paste with Catafast as an anti-inflamatory drug (Nano TAPC), while Triple Antibiotic Paste with Catafast (TAPC) had the least cytotoxic effect. Nano TAPC has the greatest apoptotic value, while TAPC had the least when compared with the reference group, with no significant difference between groups (P<0.05).

Conclusion:

The cytotoxic effect of Nano TAPC was lower than that of calcium hydroxide and higher than that of TAPC. Although Nano TAPC has the highest apoptotic value when compared to TAPC and calcium hydroxide but still there is no statistically significant difference between them.

Evaluation of tissue inflammatory response of four intracanal medicament - An animal study

Aim:

The aim of the study was to evaluate the tissue inflammatory response of origanum vulgarae, omeprazole, triple antibiotic paste (TAP), and calcium hydroxide in an animal model.

Materials and Methods:

Seventy Five male Wistar rats were randomly divided into four experimental groups and one control group: Group 1: control (n = 15), Group 2: 0.25 mg origanum vulgarae/1 ml of cellulose (n = 15), Group 3: 2 mg omeprazole/1 ml of distilled water (n = 15), and Group 4: 1 mg TAP/1 ml of distilled water (n = 15), Group 5: 16 mg calcium hydroxide/1 ml of distilled water (n = 15). A trough was made in the periapical bone and the medicament of the respective groups was placed. After the 7^th, 14^th, 28^th and days, the animals were euthanized and tissue specimen was prepared for histological examination.

Results:

The results were analyzed statistically. On the 7^th and 14^th days, all the experimental groups showed severe inflammatory response with no statistical significance, whereas on the 28^th day, the inflammatory response was graded based on the mean value, in which omeprazole showed moderate inflammatory cells followed by TAP. Mild inflammatory response was seen in calcium hydroxide and origanum vulgarae, showing no statistical significance.

Conclusion:

Within the limitation of the study, severe inflammatory response was reported on the 7^th and 14^th days in all experimental groups, whereas on 28^th day, there was a moderate inflammatory response seen in omeprazole, followed by TAP. Calcium hydroxide and origanum vulgarae showed a mild inflammatory response.

Evaluation of Antimicrobial Efficacy of Calcium Hydroxide along with Proton Pump Inhibitor against Enterococcus Faecalis

Aim:

The aim of this study was to evaluate in vitro the efficacy of pantoprazole, a proton pump inhibitor, alone, and in combination with calcium hydroxide against Enterococcus faecalis, a star survivor in endodontic pathology.

Materials and Methods:

Teeth were inoculated with E. faecalis strains MTCC 439 and were divided into groups. Group 1 used saline as the negative control, Group 2 used calcium hydroxide, Group 3 used pantoprazole alone, and Group 4 used calcium hydroxide along with pantoprazole. They were incubated and dentine harvesting was performed. Colonies were counted using a digital counting machine. Data were statistically analyzed.

Results:

Group 4 was found to be the most effective against the pathogen.

Discussion:

This study indicates that the association of calcium hydroxide with the proton pump inhibitor pantoprazole can be successfully used as an intracanal medicament against E. faecalis.

Endodontic irrigants: Different methods to improve efficacy and related problems

Shaping and cleaning a root canal system along with the preservation of the surrounding periodontal tissues are the principal goals of an endodontic treatment. While most of the attention is paid to the mechanical aspects of a root canal treatment, an essential feature of it is the irrigation. All over the years, many materials have been used to clean the root canal of a tooth, and certainly, the sodium hypochlorite (NaOCl) and ethylenediaminetetraacetic acid solutions are the most used and most reliable ones. Putting them inside of a canal is mostly done using a normal syringe, but many techniques have been involved in this process, including the use of sonic/ultrasonic instruments, the use of shaping files, and even laser, to increase the efficacy of irrigant solutions, especially of NaOCl one. Each one of this technique faces some disadvantages, just as the vapor lock effect and the apical extrusion, and has a different action on features such as the reaction rate and the shear stress of an endodontic irrigant solution. In this narrative review, we describe the different features of many irrigant solutions and the different ways of upgrading their efficacy in the cleaning of a root canal system, with the use of tables to summarize the entire description, and drawing the readers' attention to a photographic illustration for a better understanding of the topic.

Postoperative pain of patients with necrotic teeth with apical periodontitis following single visit endodontic treatment versus multiple visit endodontic treatment using triple antibiotic paste: a randomized clinical trial

Background: A randomized clinical trial was conducted to compare the postoperative pain following endodontic treatment of necrotic teeth with apical periodontitis. Treatments were performed in multiple visits with application of triple antibiotic paste interappointment dressing or single visit without interappointment dressing. Methods: In total 44 participants were assigned randomly into two groups. Group A: multiple visit endodontic treatment with triple antibiotic paste interappointment dressing; group B: single visit endodontic treatment without interappointment dressing. Postoperative pain of participants was assessed after 24, 48, 72 hours and one week using numerical rating scale. Results: No statistically significant difference was found in postoperative pain after 24, 48, 72 hours and one week between the two groups. Conclusion: Triple antibiotic paste as an interappointment dressing in multiple visits endodontic treatment was not proved to reduce the postoperative pain compared to a single visit in patients with necrotic teeth with apical periodontitis who did not have an interappointment dressing. Trial registration: clinicaltrials.gov, NCT02947763. Date: 28th October 2016.

Comparative Evaluation of Triple Antibiotic Paste, Propolis with Moxifloxacin, and Calcium Hydroxide as Intracanal Medicaments against Streptococcus spp. and Enterococcus faecalis in Type II Diabetes Mellitus Patients: A Randomized Clinical Trial

AIMS

The antimicrobial efficacy of intracanal medicaments such as calcium hydroxide, propolis with moxifloxacin, and triple antibiotic paste (TAP) was assessed against Streptococcus spp. and Enterococcus faecalis in chronic apical periodontitis (AP) patients with Type II diabetes mellitus (DM).

SETTINGS AND DESIGN

This study design was a randomized clinical trial.

SUBJECTS AND METHODS

Forty-five Type II DM patients with single-rooted teeth diagnosed as AP were instrumented, randomly divided into three groups, and medicated with either TAP, propolis with moxifloxacin, or calcium hydroxide. Bacteriological samples obtained from the root canals after instrumentation (S1) in the first treatment session, and after medication (S2) in the second session 1 week later, were assessed for bacterial growth of E. faecalis and Streptococcus spp., by viable colony-forming unit counts.

STATISTICAL ANALYSIS USED

Intragroup, intergroup, and pair-wise comparisons were done by Wilcoxon's signed ranked test, Kruskal-Wallis test, and Mann-Whitney test, respectively (P > 0.05).

RESULTS

The microbiological analysis showed a significant reduction in microbial count from (S1) to (S2) in all the study groups. However, intergroup comparisons revealed no significant difference in decrease of microbial load between all three groups at the end of 1 week.

CONCLUSIONS

Within the limitations of the study, it was concluded that antimicrobial efficacy of TAP, propolis with moxifloxacin, and calcium hydroxide were comparable.

A liquid crystalline precursor incorporating chlorhexidine acetate and silver nanoparticles for root canal disinfection

Lyotropic liquid crystals (LLC) have received increasing attention as a drug delivery system. In this study, a novel intra-canal disinfectant based on the glycerol monooleate (GMO) LLC precursor incorporation with chlorhexidine (CHX) and silver nanoparticles (Ag-NPs) was designed and evaluated. The LLC precursor with excellent fluidity was able to penetrate deeply into the complex tiny collateral branch root canals. The transformation of cubic LLC in root canals upon coming into contact with water provided long-lasting disinfection against multidrug-resistant bacteria to avoid the endodontic reinfection and follow-up visits. The GMO-ethanol-water (48% : 12% : 40%, w/w) formulation containing 0.5% CHX and 0.02% Ag-NPs was selected for further studies. The low viscosity of the precursor presented excellent injectability and flowabilities. From the in vitro release test, the release behaviours were found to be influenced by CHX and Ag-NP contents, allowing the optimized precursor to obtain a 28-day release profile. The CHX-Ag-NP containing LLC precursor exhibited an excellent and sustained sterilization effect on Enterococcus faecalis for more than one month with a bacterial inactivation rate of ≥98.5%, which was far more than the minimum clinical requirement (7 days). Furthermore, no in vitro toxicity was observed in the cytotoxicity evaluation. The CHX-Ag-NP containing LLC precursor was proved to be a promising intra-canal disinfectant in our study.