ANTIBACTERIAL EFFECTIVENESS OF RAMANIA LEAVES EXTRACT GEL (BOUEA MACROPHYLLA GRIFFITH) AGAINST THE GROWTH PSEUDOMONAS AERUGINOSA

ABSTRACTPreserving the natural dentition in its normal form and function is one of the major goals of endodontic treatment. Re-establishing the lost vitality and development of root maturation in immature permanent teeth with pulp necrosis/apical periodontitis is quiet challenging clinically. The very basis of regenerative endodontics relies on the concept of tissue engineering using stem cells, biomimetic scaffold, and bioactive growth factors to regenerate the pulp tissue damaged by microbial infection, injury, or developmental defects. In clinical endodontics, this approach is referred to as a “paradigm shift.” Even though repair instead of true regeneration is achieved with current protocols, it is hoped that further research in the area of stem-cell-based tissue engineering will allow for true regeneration and improved treatment outcomes. The aim of this review is to discuss about the various aspects of regenerative endodontics, current clinical protocols, and the future of pulp regeneration techniques.

Evidence-based endodontics: The one-visit treatment idea

Background: One of the most common microorganisms found in infected teeth after root canal treatment is Enterococcus faecalis (E. faecalis). This bacteria can cause failure in root canal treatment, so it is necessary to provide intracanal medicament, such as calcium hydroxide, which can increase antibacterial effectiveness by adding a mixing agent. One of the calcium hydroxide mixing ingredients is chlorhexidine (CHX) digluconate gel 2%, which can increase the activity of hydroxyl ions in calcium hydroxide. A natural mixing ingredient is 25% propolis, which contains flavonoids with an antibacterial effect. Objective: The aim is to determine the difference in antibacterial effectiveness between a combination of calcium hydroxide with 2% CHX digluconate or 25% propolis as an intracanal medicament against E. faecalis (in vitro) bacteria. Methods: This research used an experimental in vitro laboratory test with 18 teeth that had a single root canal. Teeth were sterilized, had root canal treatment, and cut off at the crown. Antibacterial efficacy was calculated by measuring optical density (OD) values with spectrophotometry. The data were analyzed using the Kruskal–Wallis test followed by the Mann–Whitney test. Results: The largest OD difference group was in the calcium hydroxide mixture 25% propolis than calcium hydroxide mixture 2% CHX gel. Conclusion: There was a difference in the antibacterial power of the intracanal medicament, calcium hydroxide combination with 2% CHX digluconate gel or 25% propolis. The combination of calcium hydroxide with propolis 25% more effective than the mixture of calcium hydroxide with 2% CHX digluconate as root canal medicament against E. faecalis bacteria.

Objective: The successful management of necrotic pulps and apical periodontitis poses a tough challenge in endodontic therapy, as it involves addressing compromised tooth vitality and microbial invasion of root canal systems. Failure to effectively treat these conditions can lead to persistent infection and severe patient discomfort. The efficacy of double antibiotic paste (DAP), a mixture of ciprofloxacin and metronidazole, was evaluated and compared to calcium hydroxide (CH) by assessing radiographic and clinical outcomes of nonsurgical endodontic treatment in cases with necrotic pulps and the presence of apical periodontitis. Methods: Thirty maxillary anterior teeth with necrotic pulps and apical periodontitis (periapical index [PAI] = 5) were divided randomly into two experimental groups. The first group received CH dressing, while the other group filled with DAP as intracanal medicament. After 3 weeks, medicaments were removed, and teeth were obturated in both groups. Teeth were assessed clinically and radiographically at 6-month and 12-month follow-ups. A chi-square test was performed to compare the outcome between the groups. Results: None of the teeth showed complete healing in a 6-month follow-up. At the 12-month follow-up, six samples in the DAP group showed complete healing of the periapical (PA) lesion, while none of the samples in the CH group were completely healed. The PA healing outcome was as follows: in the DAP group, 40% of cases were healed, 60% healing, and 0% diseased, while in the CH group, 0% healed, 93.3% healing, and 6.7% diseased. The results of the two experimental groups in 12 months differed significantly (p < 0.05). Conclusion: DAP group has shown significantly better outcomes compared to CH as intracanal medicament in the treatment of teeth with PA lesions. This finding suggests that DAP may offer a more effective therapeutic approach in managing necrotic pulps and apical periodontitis, potentially improving patient outcomes and treatment success rates. Trial Registration: Clinical Trial Registry identifier: IRCT2015060822615N1.

The purpose of this study was to compare to evaluate the post operative pain with different calcium hydroxide formulations when used as intracanal medicament in root canal which was evaluated by VAS scale.The 150 subjects were randomly assigned to four groups and one control group depending upon the intracanal medicament: Group 1: Calcium hydroxide paste (Ivoclar) was used as intracanal medicament, Group 2: Calcium hydroxide paste with iodoform (Metapex) was used as intracanal medicament, Group 3: Calcium hydroxide points (Hygenic) was used as intracanal medicament, Group 4: Calcium hydroxide paste using chitosan (0.2%) as vehicle was used as intracanal medicament, Group 5: Control group containing dry sterile cotton. The incidence and intensity of preoperative pain and experienced post operative pain (on 6, 12, 24 hour and 48 hour) after first visit of treatment were assessed according to patient’s recordings in visual analogue scale.The medicament causing least operative pain are ranked according to superiority as Calcium hydroxide paste &amp;#62; Calcium hydroxide points &amp;#62; Calcium hydroxide with chitosan &amp;#62; calcium hydroxide with iodoformAt 6 postoperative hour, least post operative pain was recorded by the calcium hydroxide points and high post operative pain in calcium hydroxide with iodine (Metapex). At 12th, 24th, 48 postoperative hour least post operative pain was recorded by calcium hydroxide paste (Apexcal).

Introduction:This study compared the root canal microbial count of necrotic teeth after irrigation with 6% sodium hypochlorite (NaOCl) (single session treatment) and two-session root canal treatment with two-week application of calcium hydroxide (CH) mixed with 0.2% chlorhexidine (CHX) as intracanal medicament. Methods and Materials:In this randomized clinical trial, single-rooted necrotic teeth were divided into two groups. Root canal was irrigated with 2 mL of 6% NaOCl in one group, and a mixture of 0.2% CHX and CH powder as an intracanal medicament for two weeks, in the other group. Root canal samples were obtained before and after the intervention and number of colony forming units (CFUs) was counted in each phase. Results: The reduction of Enterococcus faecalis CFU was not significantly different between the two groups (P=0.233) but the CFU of aerobic and anaerobic bacteria was significantly lower in CH+CHX group (P<0.001). Conclusion:Two-week application of CH+CHX caused significant reduced the aerobic, anaerobic and E. faecalis colony counts. Thus, it may be beneficial to carry out primary root canal treatment of necrotic teeth with endodontic lesions in two sessions with intracanal medicaments to achieve predictable results.

Root canal medicaments

Introduction Successfulendodontic treatment relies upon the microbial debridement of the root canal system. This can be achieved to a great extent by using intracanal medicaments, which inhibit the microbes growing in the root canal. Evaluating the capacity of oxidants in the saliva is a crucial parameter for assessing the antioxidant capacity of any individual, which decreases in inflammatory conditions. An effective intracanal medicament can increase the total antioxidant capacity of saliva, which comes down because of inflammatory conditions. Aim To evaluate the effect of two intracanal medicaments on the antioxidant capacity of saliva. Materials and methods In a randomized prospective clinical trial, 42 patients with a mean age of 18-70 years were selected based on exclusion and inclusion criteria, and the baseline value of the total antioxidant capacity of saliva was recorded. The patients were categorized into two groups as per the block randomization method (Group I: calcium hydroxide (Maarc, New Delhi, India) intracanal medicament; Group II: Hekla lava (SBL Pvt. Ltd., Germany) intracanal medicament). Access opening, working length determination, and cleaning and shaping were conducted using hand K-files and ProTaper Gold rotary files. Intracanal medicaments were placed according to the groups assigned, and temporary restoration was placed. The patients were recalled after seven days. If the tooth was asymptomatic, obturation was completed, and a saliva sample was collected to assess thetotal antioxidant capacity. Results The total antioxidant capacity of saliva was increased afterusing intracanal medicaments and endodontic therapy, and there was a statistically significant difference before and after using both the medicaments (p=0.0005; i.e., calcium hydroxide and Hekla lava. When both medicaments were compared, there was no significant difference in the antioxidant capacity of salivaamong medicaments (p=0.384). Conclusion The total antioxidant capacity ofsaliva was increased after using both the intracanal medicaments. Hence, Hekla lava can be potentially used as an alternativeintracanal medicament.

BackgroundCandida has been associated with cases of secondary and persistent root canal infections. The purpose of this study was to evaluate and compare the effectiveness of commonly used intracanal medicament against Candida biofilms found in root canals of human primary teeth with necrotic pulp.Materials and methodsPulp canals of 45 single-rooted primary maxillary anterior teeth with pulp necrosis in 34 children were included in the study. They were divided into three groups of 15 samples each - group I: Ca(OH)2 (calcium hydroxide); group II: 1% chlorhexidine gel (CHX); and group III: 1% metronidazole gel. Bacterial count was obtained from each tooth at two different stages: (1) after instrumentation, and (2) after placement of the medication. Statistical analysis using the Statistical Package for the Social Sciences version 10.0 software program (Inc., Chicago, IL, USA) with Wilcoxon signed rank test after grouping the samples was performed.ResultsCa(OH)2, 1% CHX gel, and 1% metronidazole gel were ineffective in completely eliminating Candida biofilms from root canal of human primary teeth with necrotic pulp.ConclusionNone of the commonly used intracanal medicaments, i.e., Ca(OH)2, 1% CHX gel, and 1% metronidazole gel, was effective in completely eliminating Candida biofilm from root canal of human primary teeth with necrotic pulp. Ineffectiveness of these medicaments against Candida has opened new door of research regarding the use of suitable intracanal medicaments against single and multispecies biofilms.How to cite this articlePaikkatt JV, Sreedharan S, Philomina B, Kannan VP, Santhakumar M, Kumar TVA. Efficacy of Various Intracanal Medicaments in Human Primary Teeth with Necrotic Pulp against Candida Biofilms: An in vivo Study. Int J Clin Pediatr Dent 2017;10(1):45-48.

Background:The goal for placement of intracanal medicament during pulpal therapy procedures is to eradicate the bacteria and the exotoxins from the infected root canal, thereby preventing and controlling pulpal and periradicular infections. Chemo-mechanical preparation is considered an essential step in root canal disinfection; but to accomplish the total elimination of bacteria in highly complex root canal anatomy is difficult. Intracanal medicaments help eliminate bacteria by remaining in the root canal, and calcium hydroxide has been recommended as one of the most effective antimicrobial dressings during endodontic therapy. The herbal agents offer an alternative to synthetic compounds. They have been considered either non-toxic or less toxic. The rapid increase in antibiotic-resistant strains and side effects caused by synthetic drugs have prompted researchers to look for herbal alternatives.Aim and Objective:The in vitro study aims to evaluate and compare the antibacterial activity of triphala and calcium hydroxide against Enterococcus faecalis as an intracanal medicamentMaterials and Methods:The antimicrobial efficacy of triphala and calcium hydroxide was evaluated against E. faecalis cultured and incubated for various time frames in 42 intact, caries-free, human, single-rooted teeth with straight roots and mature apices. The comparison of the number of counted colonies after each incubation time and based on the type of drug used inside the canal is evaluated using non-parametric Kruskal–Wallis test and Mann–Whitney U test, respectively. Statistical analysis was done using SPSS version 14.0.Results:Efficacy of calcium hydroxide against Enterococcus faecalis was best in the first 72-hr time duration compared with triphala. Triphala showed significant antimicrobial activity against Enterococcus faecalis that was closely parallel to the calcium hydroxide group in one week. Calcium hydroxide and triphala had complete eradication of Enterococcus faecalis in a given one-month time duration.

Background: Enterococcus faecalis (E. faecalis) is the bacteria most commonly resulting from failed root canal treatment. Intracanal medicament is used to enhance the success of root canal treatment. A material widely used for this purpose is calcium hydroxide. However, its ineffectiveness in eliminating E. faecalis requires the addition of other antibacterial substances, such as iodoform which has the disadvantage of having toxic effects on tissues. Pineapple peel has antibacterial properties because it contains chemical compounds, such as flavonoid, saponin, tannin, as well as the enzyme bromelain. Purpose: The aim of the study was to determine the antibacterial activity of a mixture of pineapple peel extract at 6.25% and 12.5% concentrations and calcium hydroxide paste at a ratio of 1:1 compared to100% calcium hydroxide and a mixture of calcium hydroxide and iodoform paste against E. faecalis. Methods: The research was laboratory-based experiment in nature. Sample groups were divided into two control groups (one featuring100% calcium hydroxide paste and a second featuring a mixture of calcium hydroxide and iodoform paste) and two treatment groups (mixture of pineapple peel extract and calcium hydroxide paste in 6.25% and 12.5% concentrations with ratio 1:1). The method was using agar diffusion. The result data were analyzed by One Way Anova test. Results: The highest average of the inhibitory zone occurred in group with a mixture of pineapple peel extract 12.5% and calcium hydroxide paste while the smallest average was that of group with a mixture of calcium hydroxide and iodoform paste. Conclusion: Mixture of pineapple peel extract in 6.25% and 12.5% concentrations and calcium hydroxide paste ratio 1:1 has higher antibacterial activity than paste of 100% calcium hydroxide and mixture of calcium hydroxide and iodoform paste againts E. faecalis.

The role of intracanal medication as a root canal dressing is re-examined. In pulpectomy and some root canal treatments, where the root canal contains vital pulp tissue, it is doubtful whether a routine intracanal medicament is needed. In infected root canals, intracanal medication has been advocated for many purposes. An intracanal medicament is used to: (i) eliminate any remaining bacteria after canal instrumentation; (ii) reduce inflammation of periapical tissues and pulp remnants; (iii) render canal contents inert and neutralize tissue debris; (iv) act as a barrier against leakage from the temporary filling; (v) help to dry persistently wet canals. However, most of the indications for intracanal medicaments are questionable. Intracanal medicaments should only be used for root canal disinfection as part of controlled asepsis in infected root canals, and their role is secondary to cleaning and shaping of the root canal. Thorough canal debridement and adequate canal preparation are more pertinent, and their importance is emphasized. Bacteriological sampling may be necessary if a tooth does not respond to treatment, to help in the choice of intracanal medicament.

Regenerative endodontic therapy (revascularization) for immature permanent teeth with pulp necrosis and/or apical periodontitis is an effective treatment to promote root maturation. Previous histological studies have reported the formation of cementoid or osteoid tissue and periodontal ligament-like tissue within the root canals. This case report presents the histopathological findings of a human immature permanent tooth with pulp necrosis following revascularization.A 11-year-old male patient presented with tenderness on biting and the formation of a sinus tract in the mandibular right second premolar (tooth #29), diagnosed as pulp necrosis with symptomatic apical periodontitis. Revascularization was performed using calcium hydroxide as an intracanal medicament, with reference to the American Association of Endodontists (AAE) 2018 Position Paper on Regenerative Endodontics. At the 12-month follow-up, radiographs showed thickening of the canal walls, apical narrowing, root elongation, and recovery of pulp sensibility. The tooth was later extracted for orthodontic reasons at 42 months and processed for histological examination.Histological evaluation revealed cementum-like hard tissue continuous with the existing dentin in the apical region, suggesting apical closure. In contrast, the coronal portion showed less mature cementum-like tissue accompanied by loose connective tissue and neovascularization. These findings indicate that revascularization with calcium hydroxide can induce the formation of cementum-like and dentin-like tissues with vascular regeneration in immature permanent teeth with pulp necrosis.

Regenerative endodontic treatment options for immature permanent teeth: a case report with 21-month follow-up

Background: The interest in herbal extracts as antimicrobial agents has increased over the past few years in endodontic therapy. Nasturtium officinale (watercress) is a promising plant with great medicinal values. This study aimed to investigate the antifungal activity of watercress oil in combination with calcium hydroxide against Candida albicans as intracanal medicament. Materials and Methods: Candida albicans was isolated from patients with necrotic root canal or failed root canal treatment. The sensitivity of Candida albicans to different concentrations of watercress oil extract was determined by using the agar well diffusion method in comparison with calcium hydroxide paste. The agar plate method was used to determine the minimum fungicidal concentration (MFC) of the tested oil against the fungus. The combination of the oil extract of Nasturtium officinale with calcium hydroxide was evaluated and compared to calcium hydroxide paste with iodoform by using the agar well diffusion method. Results: The oil extract exhibited antifungal activity against Candida albicans, this activity was found to be increased as the concentration of extract increased. The tested combination of watercress oil extract with calcium hydroxide revealed larger inhibition zones than the ones formed by each tested agent individually. Conclusion: The oil extract of Nasturtium officinale is active against Candida albicans suggesting its potential to be used as an intracanal medicament alone or in combination with calcium hydroxide.