journal club neonatal osteomyelitis

1. Presented by:
Dr.Louis Solaman
Simon
PGT 2nd year
Department of Pedodontics and Preventive
Journal club

2. Evaluation of Antibacterial
Efficacy of Fungal-Derived Silver
Nanoparticles
against Enterococcus faecalis
. Halkai KR, Mudda JA, Shivanna V, Rathod V, Halkai R
Contemporary Clinical Dentistry | Volume 9 | Issue 1 | January - March
2018.

3. Introduction
 Complete elimination and prevention of bacteria
from the root canal system is an essential
element for the successful endodontic
treatment
 However, it has been shown that, even after
meticulous root canal instrumentation, thorough
root canal disinfection, and obturation, microbiota
still persist in the root canal system
 eliminate the bacteria prevent persistent or
reinfections

4. Enterococcus faecalis
persistent periradicular lesions.
 Why it is resistant cytolysin,
Lytic enzymes,
Aggregation
substance,
Lipoteichoic acid.
invade dentinal tubules and
cementum.

5. nanoparticles (NPs)
 Various nanoparticles (NPs) have been used as
root canal irrigants and intracanal medicaments.
 unique mode of action,
potent antimicrobial activity, and
provide a long-term and effective
treatment
smaller doses

6. silver NPs (AgNPs)
 Broad spectrum of activity and are biocompatible.
 certain drawbacks such as high cost,
 chemicals involved in
synthesis,
 Therefore, biosynthesized AgNPs have
emerged alternative to synthetic
nanoparticles
 Why Fungi need simple nutrients for
growth, cost-effective, and
simple process involved,

7. To evaluate the antibacterial
efficacy of fungal-derived AgNPs
against E.faecalis

8. Materials and Methods
Isolation of Fungus
AgNPs were produced biosynthetically using
fungi isolated from the fresh leaves of Withania
Somnifera (Ashwagandha).
 The fungi were identified based on microscopic
and morphological features as Fusarium
semitectum.
 inoculated in malt glucose yeast peptone broth at
28°C for 72 h.
 The filtered biomass washed using distilled water
and then transferred into flasks containing 100
ml of distilled water and incubated for 48 h.

9. .
 The filtrate was mixed with aqueous
solution of silver nitrate of 1 mM
concentration,
 Thus get reduced and show the color change
from colorless to reddish-brown
producing the
AgNPs.

10. E. faecalis
 E. faecalis strains (ATCC-29212)
 (American Type Culture Collection, Manassas,
VA, USA) were used for the study

11. .
 Bacteria were subcultured from the stock culture
on trypticase soy agar (TSA) plates incubated at
35°C for 24 h.
 The colonies were confirmed by Gram staining.
 Inoculum was prepared by transferring the
colonies from the TSA plates with a sterilized
inoculation loop to the trypticase soya broth and
incubated for 6–7 h.
 The density = 0.5 McFarland constant was
adjusted to 1.5 × 108 CFU/mL.

12. .
 Antibacterial efficacy against E. faecalis was
evaluated by
agar well diffusion method
 BiosynthesizedAgNPs of different concentrations
20, 40, 60, 80,and 100 μl.
CONTROL GROUPS
 Chlorhexidine digluconate (CHX) of 0.2%and 2%,
 Ampicillin, and
 Sterile distilled water were used as antibacterial
agents.

13. .
 E. faecalis strains were evenly swabbed on the
solidified 20 ml of Mueller-Hinton Agar plates
using a sterile swab (HiMedia, Mumbai, India.)
 The plates around 60° in between streaking for
even distribution.
 Using a sterile punching device, wells of 5 mm
diameter were prepared in the agar plate

14. .
. A (20 μl),
B (40 μl),
C (60 μl),
D (80 μl),
E (100 μl) of AgNPs,
F (0.2% CHX),
G (2% CHX),
H (ampicillin), and
I (sterile distilled water)
The Petri plates were incubated for 24–48 h
at 37°C.

15. .
 The experiment was carried out in six replicates
for each agent used.
 The plates were read only when the lawn of
growth was confluent.
 Vernier calipers were used to measure the
diameter of inhibition to the nearest whole
millimeter and the data were tabulated.

16. Results
 AgNPs exhibited effective antibacterial efficacy.
 AgNPs E (100 μl), D (80 μl) , C (60 μl), B (40 μl) and
A (20 μl)
19.55 mm, 18.37 mm, 15.4 mm, 13.59 mm
and 10.32 mm
( zones of inhibitions)
Chlorhexidine2% and 0.2% 20.02 mm and 14.52
mm.
maximum inhibition zone was seen for control group H
(Ampicillin)
20.5 mm
no zones for I (sterile distilled water)

17. Statistical Analysis
One-way ANOVA (P < 0.0001) and post hoc Tukey
multiple comparison test
 shows no significant difference between E
(AgNPs 100 µl) and G (CHX 2%) and between G
(CHX 2%) and H (ampicillin)
 indicating AgNPs are as effective as 2% CHX
against E. faecalis

18. Mean, standard deviation, and one-way
analysis
of variance of zone of inhibition
 Groups Zone of inhibition ANOVA
P
(mm), mean±SD F
 AgNPs 598.11
<0.0001
 A (20 ml) 10.32±0.40
 B (40 ml) 13.59±0.10
 C (60 ml) 15.40±0.32
 D (80 ml) 18.37±0.29
 E (100 ml) 19.55±0.50
 Chlorhexidine
 F (0.2%) 14.52±0.04
 G (2%) 20.02±0.47
 Ampicillin H 20.5±0.54
 Distilledwater I Resistant
 SD: Standard deviation; ANOVA: Analysis of variance;AgNPs: Biosynthesized
silver nanoparticles

19. Discussion
 Bacterial adaptation to the root dentin and
cementum determines the pathogenicity of the
microorganisms.
 Ability to form biofilm, structure of biofilm,
physiological modification of bacteria within
biofilm, stress response, and
growth of microorganisms influence the bacterial
adaptation and survival even in
nutrient-depleted environment
 E. faecalis produces the collagen-binding proteins
such Adhesin, Ace, and serine protease, which
help to adhere to collagen present in dentin and
cementum

20. Wu et al
evaluated antibacterial efficacy of AgNPs in gel
and solution form as irrigant and intracanal
medicament against E. faecalis and reported as
AgNPs gel form are more effective as irrigant

21. Dong et al
reported 0.1% and 0.2% nanosilver gel is more
effective on E. Faecalis biofilm compared to
other disinfectants such as CHX and
camphorated phenol.
 However, no studies have been reported
employing biosynthesized AgNPs derived from
fungi as antibacterial agents against E. faecalis.

22. Limitations of Study
 Agar well diffusion method has been commonly employed
for studying antibacterial efficacy against microorganisms.
 However, factors apart from the actual antibacterial activity
of the agents tested might affect the accuracy and
reproducibility of agar well diffusion method
 such as, diffusion and solubility of the antimicrobial agent
through the agar medium,
 thickness of the gel,
 viscosity of the agar base,
 storage conditions of agar plates,
 incubation time, and methods employed for application.
 However, further in vitro and in vivo studies employing
different techniques should be carried out for the effective
use of these nanoparticles for endodontic disinfection.

23. Conclusion
 Biosynthesized AgNPs emerge as novel
antimicrobial agents for endodontic disinfection
with effective antibacterial efficacy against most
resistant endodontic pathogen E. faecalis.

24. Neonatal osteomyelitis:
An unusual complication of natal tooth
extraction
Esha Chandresh Vora, Jasmin Winnier, Rupinder Bhati
Department of Pediatric and Preventive Dentistry, D.Y. Patil University, School of
Dentistry, Navi Mumbai, Maharashtra, India
Journal of Indian Society of Pedodontics and Preventive Dentistry |
Volume 36 | Issue 1 | January-March 2018 |

25. Introduction
 Osteomyelitis is an uncommon but important
neonatal infection with recognized morbidity and
mortality.
 Douglas, in British Medical Journal 1898,
reported the first case of osteomyelitis in infants.
 The incidence of neonatal osteomyelitis is 1–7
per 1000 hospital admissions.
 However, with the advent of modern antibiotics
and better health-care protocols, it is rarely
encountered nowadays.

26. .
 A 52-day-old female infant
 complaint of painful swelling and abscess in the
lower anterior region of jaw for 1 month
 Prenatal history was noncontributory.???
Delivered in another hospital through normal
delivery, at 32-week gestation.
The birth weight was 1.5 kgs,
Baby was admitted in the Neonatal intensive
care unit (NICU) for 10 days.

27. .
 At birth, a natal tooth was observed in the lower
anterior region
 Extracted on the 11th day in the same hospital.
What made them to come Dental OPD
From the 12th day onwards, parents gave a
history of Difficulty in suckling,
Intermittent Fever,
Inflammation,and Pus Discharge from the
extraction site which relieved on medications but
recurred

28. intraoral examination
 Inflammation in the lower anterior region with a
pointing abscess of about 2 mm × 2 mm in size
Provisional diagnosis
 Infected extraction socket and a differential
diagnosis of osteomyelitis were made.

29. .
 The patient was started on amoxicillin 125 mg
thrice daily and metronidazole 100 mg thrice
daily.
 Blood investigations
 axial tomography (CT) scan, and
 culture tests were advised, the patient was
recalled the next day.

30. Intraoral picture at the 52nd-day showing
abscess form
Intraoral picture at 55th day of birth
showing draining sinus
Healing seen at the 3rd week of admissio

31. At 24 hr recall
 The condition of the infant worsened.
 The CT scan revealed destruction of the bone
involving right inferior border of the mandible
without signs of pathologic fracture.
 Elevated erythrocyte sedimentation rate (ESR)
and C-reactive protein (CRP).
 Blood and pus culture revealed
Staphylococcus aureus.

32. Based on the reports,
 Final diagnosis chronic suppurative
osteomyelitis
 Vancomycin 15 mg/kg/day intravenous (IV) was
administered 12 hourly.
 Over the next 24 h, the child developed an extraoral
draining sinus in the lower anterior border of the mandible
and presented with respiratory depression
 Vancomycin 15 mg/kg IV was now administered 6 hourly.
 After 3 weeks of medications, extraoral and intraoral
healing was satisfactory
 As per the recommendations and clinical considerations in
the present case,
 IV Vancomycin was continued for another 1 week and then
orally for a week.

33. .
 Parents were advised quarterly recall and to
report immediately if any signs of recurrence were
observed.
 They were educated to look for early signs of
ankylosis.???
 The possibility of future facial deformity was also
discussed???

34. Discussion
 The neonatal period is susceptible to
osteomyelitis due to several iatrogenic
predisposing factors.
 However, there are no cases till date reported in
the literature
Etiology is natal tooth extraction.

35. .
 The pathogenesis of osteomyelitis in infants could be
hematogenous or contiguous focus.
 Hematogenous osteomyelitis occurs due to bacterial
seeding from
the bloodstream
 Contiguous focus occurs due to direct inoculation of
microorganisms into the bone at the time of trauma.
 In our case, the osteomyelitis was considered to be
of the contiguous focus type as the infant had
suffered trauma at the time of natal tooth extraction.
 Trauma to tissues leads to decrease in blood supply
resulting in necrotic areas where bacteria bind and
infection begins its course

36. .
 The severity of tissue injury and inherent
susceptibility of the patient should also be
considered since the presence of bacteria in a
wound alone is not sufficient to cause osteomyelitis.
 Initially, the clinical signs and symptoms are
nonspecific and mild, including temperature instability
and feeding intolerance.
 These children will present with irregular temperature,
frequent convulsions, marked anorexia and will have
difficulty in nursing due to the pus in the nostril
 As the disease progresses, more specific signs
maybe present such as, disability, local swellings or

37. Early diagnosis of neonatal
osteomyelitis is often challenging
 Radiography may not be helpful since destructive
bone changes do not appear until 7–14 days of
disease.
 CT was a more practical option
Other methods for diagnosis of acute osteomyelitis are
 Ultrasound, which detects lesions earlier than
radiographs,
 Magnetic resonance imaging, which detects within 3
to 5 days after onset of infection
 Three-phase bone imaging, which allows detection
within 24–48 h after onset of symptoms.

38. .
Laboratory findings frequently show
Normal leukocytic count,
ESR,
Elevated CRP
Blood cultures are recommended when
osteomyelitis is suspected, though they are often
negative except in cases of
hematogenous osteomyelitis. If patient presents
with ulcers or draining wounds, it should be
cultured

39. Differential diagnosis of chronic
osteomyelitis
 Neoplasms such as, Ewing’s sarcoma,
 Langerhans cell histiocytosis,
 Bone metastases,

40. On confirmation of the diagnosis of
osteomyelitis
 Antimicrobial therapy should be administered against the
most common bacterial isolates responsible depending on
the age group.
 In infants, the predominant pathogen is Staphylococcus
species, hence it is recommended to begin a regimen that
includes antistaphylococcal agent.
 For neonates and infants at risk for hospital-acquired
infection (methicillin-resistant S. aureus [MRSA]),
vancomycin instead of amoxicillin should be preferred.
 Intravenous drug administration is recommended for 2–3
weeks followed by oral medication.
 Delay in therapy and presence of MRSA infection
increases the risk for complications including pathologic
fractures, temporomandibular joint disorders and if
systemic complications persist, it leads to death.

41. .
 In the present case also, the infant had the
history of swelling and abscess formation for 1
month which was undiagnosed.
 Late presentation and presence of
hospital-acquired infection were probably the
reasons why patients did not respond to initial
antibiotics, and extraoral draining sinus was
encountered in spite of appropriate antibiotics;
 Thus, a more aggressive therapy was
administered with which the patient showed
satisfactory recovery.

42. Conclusion
 Neonatal osteomyelitis is a rare complication that
offers a diagnostic and therapeutic challenge.
 Osteomyelitis should be considered in infants with
clinical signs of
sepsis, but no obvious focus, to facilitate early
diagnosis
and initiation of appropriate therapy.
There is no single test that can confirm or rule out
osteomyelitis
Thus, a combination of careful history,
physical examination,
imaging,
laboratory tests, and PROPER
DIAGNOSIS &

43. THANK
YOU