The use of calcium hydroxide, antibiotics and biocides as antimicrobial medicaments in endodontics

Bacteria have been implicated in the pathogenesis and progression of pulp and periapical diseases. The primary aim of endodontic treatment is to remove as many bacteria as possible from the root canal system and then to create an environment in which any remaining organisms cannot survive. This can only be achieved through the use of a combination of aseptic treatment techniques, chemomechanical preparation of the root canal, antimicrobial irrigating solutions and intracanal medicaments. The choice of which intracanal medicament to use is dependent on having an accurate diagnosis of the condition being treated, as well as a thorough knowledge of the type of organisms likely to be involved and. their mechanisms of growth and survival. Since the disease is likely to have been caused by the presence of bacteria within the root canal, the use of an antimicrobial agent is essential. Many medicaments have been used in an attempt to achieve the above aims, but no single preparation has been found to be completely predictable or effective. Commonly used medicaments include calcium hydroxide, antibiotics; non-phenolic biocides, phenolic biocides and iodine compounds. Each has advantages and disadvantages, and further research is required to determine which is best suited for root canal infections.

Antimicrobial Activity of Rosmarinus officinalis against Oral Pathogens: Relevance of Carnosic Acid and Carnosol

The in vitro inhibitory activity of crude EtOH/H(2)O extracts from the leaves and stems of Rosmarinus officinalis L. was evaluated against the following microorganisms responsible for initiating dental caries: Streptococcus mutans, salivarius, S. sobrinus, S. mitts 5 sanguinis, and Enterococcus faecalis. Minimum inhibitory concentrations (MIC) were determined with the broth microdilution method. The bioassay-guided fractionation of the leaf extract, which displayed the higher antibacterial activity than the stem extract, led to the identification of carnosic acid (2) and carnosol (3) as the major compounds in the fraction displaying the highest activity, as identified by HPLC analysis. Rosmarinic acid (1), detected in another fraction, did not display any activity against the selected microorganisms. HPLC Analysis revealed the presence of low amounts of ursolic acid (4) and oleanolic acid (5) in the obtained fractions. The results suggest that the antimicrobial activity of the extract from the leaves of R. officinalis may be ascribed mainly to the action of 2 and 3.

Impact of antimicrobial resistance on the treatment and outcome of patients with sepsis

Antimicrobial therapy is one of the main stones of sepsis therapy. A recent study of septic shock patients showed that each hour of delay in antimicrobial administration during the ensuing 6 h after the onset of hypotension was associated with a decrease in survival rates. However, many questions regarding the impact of infection caused by antimicrobial-resistant pathogens on the mortality of patients with sepsis still need to be clarified. There is a lack of fair studies in the literature. Most studies have had inadequate sample size, inadequate adjustment for predictors of adverse outcomes, and inadequate definition of appropriate antibiotic therapy. Despite the fact that appropriate therapy is essential to treat sepsis, it seems that severity of underlying diseases and comorbidities are more important than resistance, although the studies were not well designed to examine the real impact of resistance on outcome. Finally, new technologies such as microarray that can identify different microorganisms, genes of resistance, and virulence in a few hours might have a great impact on the treatment of sepsis due to antimicrobial-resistant pathogens in the future.

Antimicrobial Activities of Ethanol Extract and Coumestans from Eclipta alba (L.) Hassk (Asteraceae)

Ethanol extract and fractions from aerial parts of Eclipta alba (L.) Hassk (Asteraceae) were screened for the antibacterial and antifungal activities against different species of human pathogenic bacterial ATCC, antibiotic-resistant clinical isolates and strains of the dermatophyte Trichophyton rubrum (wild and mutant for TruMDR2 gene) using a microdilution method. Demethylwedelolactone/wedelolactone (DWL/WL) and only wedelolactone (WL), both in a high homogeneity degree, were efficient to inhibit the ATCC strains of Staphylococus aureus (Minimal Inhibitory Concentration MIC = 75 mu g/mL), Staphylococcus epidemidis (MIC = 125 mu g/mL) and Escherichia coli (MIC = 125 mu g/mL) as well as antibiotic-resistant clinical isolates of Enterococcus spp (MIC = 250 mu g/mL) and S. aureus (MIC = 125 mu g/mL). Ethanol extract was more effective than the purified fractions against Trichophyton rubrum strains (MIC = 125 mu g/mL), suggesting that anti-fungal activity is not only related to demethylwedelolactone and wedelolactone, but also to a synergistic action between these coumestans and other compounds found in that extract. Thus, this work suggests that E. alba possesses a significant antimicrobial activity, including that against multi-drug resistant microorganisms, which could be of relevance for the treatment of infectious diseases.

Antimicrobial Activities of Indole Alkaloids from Tabernaemontana catharinensis

Tabernaemontana catharinensis root bark ethanol extract, EB2 fraction and the MMV alkaloid (12-methoxy-4-methylvoachalotine) were evaluated for their antimicrobial activities. T. catharinensis ethanol extract was effective against both strains of the dermatophyte Trichophyton rubrum at concentrations of 2.5 mg/mL (wild strain) and 1.25 mg/mL (mutant strain), while the EB2 fraction and MMV alkaloid showed a strong antifungal activity against wild and mutant strains with MIC values of <0.02 and 0.16 mg/mL, respectively. The EB2 fraction showed a strong antibacterial activity against ATCC strains of S. aureus, S. epidermidis, E. coli and P. aeruginosa with MICs from <0.02 to 0.04 mg/mL, as well as against resistant clinical isolates species of Enterococcus sp, Klebsiella oxytoca, Citrobacter, K. pneumoniae, P. mirabilis, S. aureus, S. epidermidis, E. coli and P. aeruginosa with MIC values ranging from 0.04 to 0.08 mg/mL. The MMV alkaloid presented a MIC of 0.16 mg/mL against the strains of S. aureus and E. coli ATCC. For the resistant clinical isolates Enterococcus sp, Citrobacter, S. aureus, S. epidermidis, E. coil and P. aeruginosa the MIC of MMV ranged from 0.08 to 0.31 mg/mL. The chromatography analysis of the EB2 fraction revealed the presence of indole alkaloids, including MMV, possibly responsible for the observed antimicrobial activity.

Influence of dentin on pH of 2% chlorhexidine gel and calcium hydroxide alone or in combination

The aims of endodontic treatment in cases of apical periodontitis are to reduce as much as possible the number of microorganisms inside the root canal system and to inactivate toxins produced by them. Most of the times, these objectives are not achieved solely by chemomechanical preparation, and intracanal dressing may be necessary. In these cases, calcium hydroxide is used as a root canal dressing due to its well-known and recognized antimicrobial activity. Chlorhexidine has a wide spectrum of antimicrobial activity and its association with calcium hydroxide has been recommended in an attempt to amplify antimicrobial effects of calcium hydroxide. It is also known that dentin exerts a buffering effect under wide pH variations, and may be responsible for decreasing the antimicrobial activity of drugs inside the root canal. The objectives of this study were to assess the pH of 2% chlorhexidine gel and calcium hydroxide alone or in combination, as well as the influence of dentin on the pH of these compounds. Dentin powder was obtained from bovine teeth and added as 1.8% to the volume of the medications. All substances were individually stored in plastic flasks, in triplicate. A pH meter was used at five different moments to assess pH in viscous medium: immediately after preparation and after 24 h, and 7, 14, and 21 days. Results were analyzed by paired Student`s t-test. Statistically significant differences were observed in the 2% chlorhexidine gel group alone or associated with calcium hydroxide and added of dentin powder (P < 0.05). Mean pH values indicated the influence of dentin powder because of a significant increase in pH. Calcium hydroxide with propylene glycol as the vehicle always showed high pH, demonstrating that this compound was not affected by the presence of dentin.

Bacterial leakage in obturated root canals-part 2: a comparative histologic and microbiologic analyses

Objective. In this study, presence of dentin infection in root canals, obturated with 4 techniques submitted to the bacterial leakage test, was evaluated using histologic methods. Study design. The canals of palatal roots of 160 molars were instrumented and divided into different groups, according to the obturation technique used (lateral condensation, MicroSeal system, Touch `n Heat + Ultrafil, and Tagger`s hybrid technique) and extent of the remaining obturation material (5 mm and 10 mm). Ten additional roots were used as control samples. The roots were sterilized in ethylene oxide and mounted on a device for evaluation of bacterial leakage using the bacteria Enterococcus faecalis for 120 days. After the leakage test, roots were microscopically analyzed for the presence of dentin infection in the root canals and dentinal tubules. Results. A total of 154 specimens were analyzed using both methodologies in the experimental groups; 50 root canals (32.4%) showed bacterial leakage at the end of the experimental period, and 118 (76.6%) showed the presence of bacteria in the root canals using the histologic criteria. The lateral condensation technique allowed lower penetration of bacteria in the root canals and dentinal tubules, followed by Touch `n Heat + Ultrafil, MicroSeal, and Tagger`s hybrid technique, which allowed significantly greater penetration of bacteria. Root canals with 10 mm of remaining obturation material presented similar bacterial penetration as root canals with 5 mm. Conclusions. Even when an adequate seal of the apical foramen was shown by the absence of turbidity in the bacterial leakage test, E. faecalis dentin infection was present in a high percentage of the root canals after 120 days of root filling exposure to the bacteria. Tagger`s hybrid technique presented greater quantity of bacteria in histologic sections than root canals obturated with the other techniques. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010; 109: 788-794)

Biofilm Dissolution and Cleaning Ability of Different Irrigant Solutions on Intraorally Infected Dentin

Introduction: The aim of this study was to evaluate the biofilm dissolution and cleaning ability of different irrigant solutions on intraorally infected dentin. Methods: One hundred twenty bovine dentin specimens were infected intraorally by using a removable orthodontic device. Thirty samples were used for each irrigant solution: 2% chlorhexidine and 1%, 2.5%, and 5.25% sodium hypochlorite (NaOCl). The solutions were used for 5, 15, and 30 minutes and at 2 experimental volumes, 500 mu L and 1 mL. The samples were stained by using acridine orange dye before and after the experiments and evaluated by using a confocal microscope. The percentage of biofilm, isolated cells, and noncolonized dentin was measured by using a grid system. Differences in the reduction or increase of the studied parameters were assessed by using nonparametric methods (P < .05). Results: The higher values of biofilm dissolution and noncolonized dentin were found in the 30-minute NaOCl group and in the 5-minute and 15-minute groups of 5.25% NaOCL. The use of 2% chlorhexidine solution did not improve the biofilm dissolution or increase the cleaning of the dentin in comparison with the NaOCl solutions (P < .05). Conclusions: Two percent chlorhexidine does not dissolve the biofilms. Thirty minutes of NaOCl are necessary to have higher values of biofilm dissolution and to increase the cleaning of the dentin independently of the concentration in comparison with the 5-minute and 15-minute contact times. (J Endod 2011;37:1134-1138)

Depth and percentage of penetration of endodontic sealers into dentinal tubules after root canal obturation using a lateral compaction technique: A confocal laser scanning microscopy study

Objective. The aim was to compare the percentage and depth of sealer penetration into dentinal tubules during obturation using Sealer 26, GuttaFlow, or Sealapex in root canals filled with the lateral compaction technique. Study design. Thirty root canals filled with the lateral compaction technique using GuttaFlow (n = 10), Sealapex (n = 10), or Sealer 26 (n = 10) were analyzed using confocal microscopy. The teeth were sectioned at 3 and 5 mm from the apex, and statistical analyses was performed using analysis of variance-Tukey test (P < .05). Results. Sealapex showed the deepest sealer penetration at both levels evaluated (P < .05). No statistically significance was found between Sealer 26 and GuttaFlow at the 3 mm and 5 mm levels. No statistical significance was found in the percentage of penetration around the root canal wall among the 3 sealers evaluated at both levels. Conclusions. Although Sealapex displayed deeper penetration into the dentinal tubules there was no difference in the percentage of adaptation to the root canal walls among the 3 sealers evaluated. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009; 108: 450-457)

The influence of cone-beam computed tomography and periapical radiographic evaluation on the assessment of periapical bone destruction in dog`s teeth

Objective. The aim of this study was to determine the influence of periapical radiographs, cone beam computed tomography (CBCT) sections, and cone beam volumetric data on the determination of periapical bone destruction in endodontically treated distal root canals of premolar canine teeth. Nontreated mesial roots were used as controls. Study design. Enterococcus faecalis strain (ATCC 29212) was inoculated into 30 root canals of 2 mongrel dogs to induce apical periodontitis. After 60 days, the root canals of the distal roots of the 11 mandibular and 4 maxillary premolars were endodontically treated (n = 15). The mesial root canals were used as controls (no treatment). The bone destruction was evaluated after 6 months by 5 evaluators using periapical radiographs and by CBCT (coronal and sagittal sections). After the experimental period, the area of the lesions in periapical radiographs and CBCT sections were measured in mm(2) using the ImageTool software. A single evaluator measured the volumetric data using the OsiriX software. The comparison between the diagnosis methods in treated root canals and controls was performed using parametric and nonparametric criteria. The Pearson correlation coefficient was computed between radiographic values and CBCT volumetric data in treated root canals and controls. Results. The results showed the presence of chronic apical periodontitis in every inoculated tooth. After 6 months, periapical radiographs, coronal CBCT sections, and volumetric data showed lower bone destruction in endodontically treated teeth in comparison with the control group (P < .05). The 5 evaluators found no differences between the apical periodontitis area of treated teeth and controls when CBCT sagittal sections were used (P > .05). No correlation was found between x-ray and CBCT volumetric values in treated root canals. Conclusions. Although selected CBCT sagittal sections showed similar values of bone destruction in endodontically and nontreated root canals, volumetric CBCT data showed that periapical lesions of endodontically treated root canals had half of the volume of periapical lesions in nontreated root canals. No relationship could be found between the periapical values of bone destruction and volumetric data found in CBCT of treated rood canals. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011; 112: 272-279)

Bacterial leakage in root canals obturated by different techniques. Part 1: microbiologic evaluation

Objective. This study compared the coronal bacterial leakage of root canals obturated by different techniques and with different lengths of obturation. Study design. The canals of palatal roots of 160 maxillary molars were instrumented and divided into different groups according to the obturation technique used (lateral condensation, Microseal system, Touch `n Heat + Ultrafil system, or Tagger`s hybrid technique) and the length of obturation (5 mm or 10 mm). The roots were impermeabilized, sterilized in ethylene oxide, and mounted on a device for evaluation of the bacterial leakage. Results. Tagger`s hybrid technique produced a statistically greater number of specimens with coronal leakage than the other techniques. There was no statistically significant difference between the lateral condensation, Touch `n Heat + Ultrafil, and Microseal groups. Root canals with 10 mm of obturation produced a statistically significantly smaller number of specimens with leakage than root canals with 5 mm of obturation. Conclusion. Tagger`s hybrid technique produced a greater number of specimens with coronal leakage than the other techniques, and a greater number of root canals with 5 mm of obturation leaked than root canals with 10 mm of obturation.

Direct and transdentinal antibacterial activity of chlorhexidine

Purpose: To evaluate the antibacterial effect of different chlorhexidine (CHX) concentrations against Streptococcus mutans using the agar-diffusion method with and without human dentin discs placed between the bacteria and the test substances. Methods: For the direct application (agar-well technique), a base layer containing 15 mL of BHI agar and 300 mu L. of S. mutans inoculum (10(9) cfu/mL) was prepared in Petri dishes. Six wells per dish were made at equidistant points and immediately filled with CHX gels (0.12%, 0.2%, 1% and 2%), 35% phosphoric acid and pure natrosol (n=6 wells/substance). Paper discs soaked in sterile distilled water served as control group (n=6). For the indirect application (transdentinal diffusion), 0.2 mm- and 0.5 mm-thick human dentin discs (36 discs/thickness) had the hydraulic conductance determined, which allowed the homogeneous allocation of them to the experimental and control groups. The discs were placed at equidistant points on the Petri dishes containing BHI with the S. mutans inoculum (six discs per dish; one per substance) with the pulpal side in contact with the bacteria. In the discs treated with CHX gels, dentin surface was etched with H(3)PO(4) and rinsed with distilled water before CHX gel application for 1 minute. After both direct and indirect application, the dishes were incubated for 24 hours and the bacterial growth inhibition zones formed around the wells and dentin discs were measured. Data were analyzed statistically by the non-parametric Kruskal-Wallis and Mann-Whitney tests at 5% significance level. Results: In the direct test, all CHX concentrations presented a dose-dependent antibacterial activity against S. mutans. In the indirect test, there were statistically significant differences (P< 0.05) among all groups and the largest microbial growth inhibition zones were observed when 2% CHX was applied on 0.2 mm-thick discs (P< 0.05). It was concluded that all evaluated CHX gels exhibited both direct and transdentinal antibacterial activity against S. mutans. This effect of CHX was strongly influenced by the CHX concentration as well as the dentin barrier thickness. (Am J Dent 2010;23:255-259).

Bacterial leakage evaluation of root canals filled with different endodontic sealers

Objective. The objective of this study was to evaluate the sealing ability of AH Plus, Epiphany, Acroseal, Endofill, and Polifil after active lateral condensation technique, by using a bacterial test, during 64 days. Study design. One hundred bovine incisors were cleaned and shaped; then they were filled with the endodontic sealers and adapted into a microcentrifuge tube. The setup root/microcentrifuge tube was added to glass flasks containing Brain Heart Infusion broth. A culture of Enterococcus faecalis was inserted into the upper chamber of each assembly. Daily leakage was evaluated through the broth turbidity. Results. The results were submitted to statistical analysis (Kaplan-Meier method, Kruskal-Wallis and Dunn tests). Conclusions. AH Plus and Endofill had the worst sealing ability when compared with Polifil, which showed the least leakage. Acroseal and Epiphany showed a tendency toward having an intermediate behavior; however, there was no significant difference among Acroseal, Epiphany, and the other sealers. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009; 108: e56-e60)

Evaluation of pH and Calcium Ion Release of Calcium Hydroxide Pastes Containing Different Substances

Introduction: The objective of this study was to evaluate the pH and calcium ion release of calcium hydroxide pastes associated with different substances. Methods: Forty acrylic teeth with simulated root canals were divided into 4 groups according to the substance associated to the calcium hydroxide paste: chlorhexidine (CHX) in 2 formulations (1% solution and 2% gel), Casearia sylvestris Sw extract, and propylene glycol (control). The teeth with pastes and sealed coronal accesses were immersed in 10 mL deionized water. After 10 minutes, 24 hours, 48 hours, and 7, 15, and 30 days, the teeth were removed to another container, and the liquid was analyzed. Calcium ion release was measured by atomic absorption spectrophotometry, and pH readings were made with a pH meter. Data were analyzed statistically by analysis of variance and Tukey test (alpha = 0.05). Results: Calcium analysis revealed significant differences (P < .05) for 1% CHX solution and 2% CHX gel at 10 minutes. After 24 hours, 2% CHX gel x Control and 2% CHX gel x 1% CHX solution differed significantly (P < .05). After 48 hours, there were significant differences (P < .05) for 2% CHX gel x Control and Extract x Control. No differences (P > .05) were observed among groups in the other periods. Regarding the pH, there were significant differences (P < .05) for 2% CHX gel x Control and 2% CHX gel x 1% CHX solution after 48 hours and for 2% CHX gel x Control after 15 days. In the other periods, no differences (P > .05) were observed among groups. Conclusions: All pastes behaved similarly in terms of pH and calcium ion release in the studied periods. (J Endod 2009;35:1274-1277)

Determination of para-Chloroaniline and Reactive Oxygen Species in Chlorhexidine and Chlorhexidine Associated with Calcium Hydroxide

The aim of this study was to determine whether para-chloroaniline (PCA) and/or reactive oxygen species (ROS) are generated by chlorhexidine (CHX) alone or after CHX is mixed with calcium hydroxide at different time points. Mass spectrometry was performed to detect PCA in samples of 0.2% CHX and Ca(OH)2 mixed with 0.2% CHX. High-performance liquid chromatography was used to confirm the presence of CHX in the mixture with Ca(OH)2. The samples were analyzed immediately after mixing and after 7 and 14 days. During the intervals of the experiment, the samples were maintained at 36.5 degrees C and 95% relative humidity. PCA was detected in the 0.2% CHX solution after 14 days. The mixture of CHX with Ca(CH)2 liberated ROS at all time points, but no traces of CHX were present in the mixture as a result of immediate degradation of the CHX. (J Endod 2008;34:1508-1514)