Management of biofilm in endodontics. History, Classification, use of sodium hypochlorite, EDTA, Chlorhexidine, recent irrigants, LASERS, Ultrasonics, Natural agents, Nanoparticles and probiotics

1. MANAGEMENT OF BIOFILM IN
ENDDONTICS
DR. MRINALINI

2. Complexity and variability of the root canal system
Multi-species nature of biofilms
Disinfection challenging.

3. Reduce the bacterial load to a subcritical
level so that the patient’s immune
response will allow healing.

4. Secondary infections: survive harsh conditions like wide pH range
and nutrient-limited conditions.
Difference in microbial phenotypes in primary & secondary
infection, with latter being predominated by gram-positive bacteria.
Exposed pulp :similar to the oral flora (gram-positive cocci
predominate), apx 25% of the isolates are anaerobes.
Organisms associated with flare ups: similar composition as those
from asymptomatic root canals

5. “
Cleaning & Shaping:
(i) remove remnant vital or necrotic tissues
(ii) kill microbiota & disrupt the biofilm
(iii) remove accumulated hard tissue debris
that is formed during root canal
instrumentation

7. 7
In endodontics, 4 types of biofilms
(i) intracanal,
(ii) Extraradicular: Calculus and glycocalyx like deposits
(iii) periapical,
(iv) biomaterial-centered biofilms: Gm positive facultative
anaerobes

8. 8
P. N. Ramachandran Nair(1987): 1st to discuss biofilm concept in endodontics
Sen BH, Piskin B, Demirci T: Invasion in dentinal tubules, presence of yeast
cells

9. ⩥ Kishen et al,2006.:
ability of E. faecalis
to form such
calcified biofilm on
root canal dentin
may be a factor that
contributes to its
persistence.
9

10. Dissolve vital &
necrotic tissue+
antimicrobial
0.5-6%:
antimicrobial
activity
Ordinola-Zapata,
2014: tissue
dissolution &
biofilm disruption
is conc specific
Most studies:
Completely
disrupts the biofilm
Effectiveness:
Warming solution,
agitation, lowering
pH, increasing
volume
Ozdemir et al.:
17% EDTA+ 2%
Hypochlorite for
biofilm disruption
Rosen et al.:
induces a viable
but non-culturable
state of bacteria in
biofilms
This might
contribute to
bacterial
persistance
SODIUM
HYPOCHLORITE

11. 11
Caitlinn B. Lineback, 2018:
Sodium hypochlorite- irreversibly kill
bacterial cells in biofilms by denaturing
proteins in the biofilm matrix and inhibiting
major enzymatic functions in bacterial cells
Drawback: Monoculture biofilm

12. 12

13. 13

14. 14

15. CHLORHEXIDINE
• ALX:
Controver
sial
• Alexidine:
increased
permeabili
ty to cell
memb.
2% as
irrigant,
substantiv
ity
Baca et
al.,
2%CHX+
0.2%
Cetrimide
-Biofilm
CHX
alone:no
effect on
biofilm
CHX+
Cetrimide
: EPS
destructio
n
1% ALX
equivalent to
2% CHX
Octinidine
Hydrochloride:
C.albicans

16. 16

17. 17

18. 18
CHX: damage the bacterial cytoplasmic membrane and
subsequent leakage of cytoplasmic material.
Resistance: multidrug efflux pumps and cell membrane
changes.
Staphylococci: plasmid borne qac (“quaternary ammonium
compound”) genes encode Qac efflux proteins that recognize
cationic antiseptics as substrates.
 Pseudomonas stutzeri: changes in the outer membrane
protein and lipopolysaccharide profiles.

19. 19

20. Luiz Fernando Machado Silveira, 2003: E.fecalis
biofilm
Matilde Ruiz-Linares, 2004: S.mutans biofilm
Thaís M da Silva, 2018: Along with NaOCl eradicated
biofilm not alone

21. 21

22. EDTA+ NaOCl:
disruption of biofilm of
E.fecalis
EDTA alone: No
antimicrobial action
2.25% Paraacetic acid:
removal of monospecies
E.fecalis biofilm
Lottani S, 2009:
Paraacetic acid alone as
an irrigant
PAA: Demineralising
agent+ antibacterial
action

23. Hüseyin Ozgur Ozdemir, JOE,2010: EDTA+NaOCl-
significantly decreased the biofilm of E. faecalis, but
it did not totally eliminate all bacteria in the root
canals, root canals from elderly population are more
susceptible to canal infection

24. 24

25. 25

26. ⩥ MTAD: Controversial in terms of effect on biofilm.
⩥ QMIX: As effective as NaOCl in terms of antibacterial
property.
⩥ Mixture of 5% sodium hypochlorite +18% etidronic
acid: single proteolytic-antibacterial-demineralising
solution.
⩥ Continuous chelation: excellent antibiofilm activity
against biofilms of E. Fecalis (Arias Moliz et al., 2015)

27. 27
Yoo YJ,et
al. 2017;
Ahn KB,
2018; Lim
S M et
al,2017
HUMAN BETA DEFENSINS
HBD-3 is strongly
inhibitory, whereas
HBD-1, -2, and –
4 have weak
antimicrobial effects
on E. faecalis
Synthetic HBD-3:
C terminal 15 amino
acids: effective
against endodontic
biofilm including C.
albicans

28. 28

29. 29

30. NATURAL AGENTS
• Berberine, an
antimicrobial plant
alkaloid+ 1% CHX=
5.25% Hypo
Berberine
• Curcumin: effective
photosensitizer and brings
about antibiofilm activity
and dentinal tubule
disinfection
Curcumin

31. 31
Ethyl acetate fraction of Cocculus trilobus, Garlic:
said to reduce the adherence.
Cranberry components: destruction of the ECM,
inhibition of carbohydrate production, proteolytic
activities and prevents coaggregation which
involved in biofilm formation

32. 32

33. NANOPARTICLES BASED
DISINFECTION
Chitosan (CS-np), zinc oxide (ZnO-np) and silver (Ag-np)
nanoparticles: broad spectrum of antimicrobial activity, caused by
altering cell wall permeability resulting in cell death.
Rose bengal, a non-toxic dye, becomes cytotoxic when activated
with a low-intensity visible light and oxygen, targeting cells or
tissues
Chitosan conjugated with rose bengal: enhance the degradation
resistance of collagen

34. Silver nanoparticles (10–100 nm): powerful antibacterial
activity against gram-positive and gram-negative bacteria
Nanoparticles: very small sizes, a large surface-area-to-mass
ratio and very good reactivity
Limitations: can form some aggregates compromising
effective delivery to target areas
Not enough studies on biofilm disruption

35. 35
Generate reactive oxygen species (ROS) that are cytotoxic for
bacteria.
Higher surface area and more charge density: greater potential
for bacterial interactions.
Numerous positively charged nanoparticles accumulate on
negatively charged bacterial cell membranes, which increase
permeability to destroy cells.
Cationic nanoparticles: adhere to negatively charged dentin
surface to prevent biofilm formation

36. Niazi & coworker: 1% trypsin and
1% proteinase K+ Ultrasoncis:
disrupts biofilm , both aerobic &
anaerobic
D-leucine: E.fecalis biofilms
Miscellaneous

38. Intracanal
medicament
Limited action
on biofilm
Ability to
penetrate EPS:
Questionaible
Chitosan+
CaOH: better
TAP: Effective
against E.fecalis
biofilm
Concern:
resistance

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Brändle et al.(CaOH):
evaluated the effects of growth condition (planktonic, mono-
and multi-species biofilms) on the susceptibility of E. faecalis,
Streptococcus sobrinus, C. albicans, Actinomyces naeslundii,
and Fusobacterium nucleatum to alkaline stress.
Result:
Planktonic microorganisms were most susceptible.
E. faecalis and C. albicans survived in saturated solution for 10
minutes, and the latter also survived for 100 minutes

40. 40

41. 41
The positive charge of chitosan is expected to
react electrostatically with the negatively-charged
biofilm components such as EPS, proteins and
DNA, resulting in an inhibitory effect on bacterial
biofilm

42. 42

43. Sonic and
Ultrasonic: dis-
agglomeration
of the bacterial
biofilm, re-
suspending
bacteria in
planktonic form
Temporary
weakening of
the cell
membrane,
increases the
bacterial cell
permeability to
antimicrobial
irrigants
Shear stresses
that may cause
detachment of
the biofilms
from the root
canal walls

44. 44
Light: Non-Coherent (Photoactivated Disinfection) and
Coherent (Laser Activated Disinfection)
Erbium:YAG (Er:YAG) laser+ special tip to achieve the so-
called Photon-induced photoacoustic streaming (PIPS):
removal of debris and smear layer from the root canal system.
More effective than ultrasonic activation or syringe irrigation
method for removing E. fecalis biofilms

45. 45
PROBIOTICS:
Lactobacillus plantarum (L. plantarum):anti-inflammatory and anti-biofilm
effect.
Inhibit Streptococcus mutans (S. mutans), E. faecalis, and Staphylococcus
aureus (S. aureus) biofilm formation by controlling gene expression, quorum
sensing, and inhibiting exopolysaccharides production .
L. plantarum LTA also disrupted preformed biofilm of E. faecalis and S. aureus
Also effective against multi-species biofilm consisting of A. naeslundii, E.
faecalis, Lactobacillus salivarius, and S. mutans

46. 46
QUOROM
QUENCHING:
Dissociation of
biofilm not killing
BACTERIOPHAGE
SURFACE
BIOMODIFICATION
: Biocides
ENZYMES:
Deoxyribonucleases,
glycosidases, and
proteases

47. 47
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