E. faecalis Role in Root Canal Treatment Failure

Enterococcus faecalis: Its Role in Root
Canal Treatment
Failure and Current Concepts in
Retreatment
Charles H. Stuart et.al Vol 32, No.2, Feb2006
1
GUIDED BY:
DR.RAHUL MARIA
PRESENTED BY:
DR. ANUBHUTI
Conservative Dentistry & Endodontics
DENTAL INSTITUTE
RIMS

 Enterococcus faecalis is a
microorganism commonly detected in
asymptomatic, persistent endodontic
infections.
 it is able to survive in the root canal
as a single organism or as a major
component of the flora 3
INTRODUCTION

Bacteria are
the primary
etiologic
agents of apical
periodontitis
Enterococcus faecalis Adhesin, Ace, Mediates Attachment to Particulate Dentin William J. Kowalski et.al JOE—Volume 32,
Number 7, July 2006 4

Enterococcus faecalis
It’s a gram positive
cocci & is facultative
anaerobe that until
1984 were classified
as Group D
Streptococci
Ingle’s 6th EDITION PAGE NO 258
5

E. faecalis is infrequently found in necrotic
dental pulp tissue , but it is frequently cultured
from endodontically treated teeth with
persistent apical periodontitis
Studies have shown E. faecalis prevalence in
root filled teeth with apical periodontitis to
range from 29 to 64%
6
Number 7, July 2006

It is likely that the
bacteria that cause
endodontic infections
must first adhere to root
canal dentin.
Type I collagen is a main
component of dentin,
comprising
approximately 90% of
the organic phase.
The E. faecalis collagen
binding protein, Ace,
targets the extracellular
matrix proteins of host
cells and allows
adherence to type I
collagen
7
Number 7, July 2006

JOE- Vol 32, No.2, Feb2006 8
E. faecalis (large colonies in the middle) produces
substances that can inhibit the growth and even kill
other bacteria.

Factors that may
contribute to
persistent
periradicular
infection
Intra-radicular
infection
extra-radicular
infection
Foreign body
reaction
cysts containing
cholesterol crystals
JOE- Vol 32, No.2, Feb2006 9
Lymphocytes,
macrophages,
plasma cells that
die in great
numbers and
disintegrate in
chronic periapical
regions

Major cause of failure is the survival of microorganisms
in the apical portion of the root-filled tooth
JOE- Vol 32, No.2, Feb2006 10

Unlike Primary endodontic infections,
which are poly microbial in nature and
dominated by gram-negative anaerobic
rods
11

The microorganisms involved in
secondary infections are composed of
one or a few bacterial species .
Enterococcus faecalis is a persistent organism
that, despite making up a small proportion of
the flora in untreated canals, plays a major role
in the etiology of persistent periradicular
lesions after root canal treatment.
12

E. faecalis Characteristics and Strains
 Gram positive cocci that can occur singly, in pairs, or
as short chains.
 Facultative anaerobes, possessing the ability to
grow in the presence or absence of oxygen.
 Enterococcus species live in vast quantities [105-108
colony-forming units (cfu) per gram of feces] in the
human intestinal lumen and under most
circumstances cause no harm to their hosts.
 They are also present in human female genital tracts
and the oral cavity in lesser numbers
13

Catabolize a variety of energy
sources including carbohydrates,
glycerol, lactate, malate, citrate,
arginine, agmatine, and many keto
acids.
survive very harsh
environments including
extreme alkaline pH (9.6)
and salt concentrations
They resist bile salts,
detergents, heavy metals,
ethanol, azide,and
desiccation.
Can grow in the range of 10
to 45°C and survive at
temperature of 60°C for 30
min
JOE- Vol 32, No.2, Feb2006 14

There are
currently 23
Enterococci
species
these are
divided into
five groups
based on their
interaction
with mannitol,
sorbose, and
arginine.
These five
species form
acid in mannitol
broth and
hydrolyze
arginine;
however, they
fail to form acid
in sorbose broth
JOE- Vol 32, No.2, Feb2006 15

Group Species
Group I
(+) acid formation in mannitol broth
(-) acid formation in sorbose broth
() arginine hydrolysis
E. avium
E. gilvus
E. malodoratus
E. pallens
E. pseudoavium
E. raffinosus
E. saccharolyticus
JOE- Vol 32, No.2, Feb2006 16

JOE- Vol 32, No.2, Feb2006 17
Group Species
Group II
(+) arginine hydrolysis
E. faecalis
E. faecium
E. casseliflavus
E. gallinarum
E. mundtii
Lactococcus sp.
E. faecalis can normally be identified by further testing with arabinose, tellurite, and pyruvate.
E. faecalis is arabinose negative and except for some atypical variants, is the only member of
the group to utilize pyruvate and to tolerate tellurite

JOE- Vol 32, No.2, Feb2006 18
Group Species
Group III
(-) acid formation in mannitol broth
(+) arginine hydrolysis
E. dispar
E. durans
E. hirae
E. porcinus
(E. villorum)
E. ratti

JOE- Vol 32, No.2, Feb2006 19
Group Species
Group IV
(-) acid formation in mannitol broth
(-) arginine hydrolysis
E. asini
E. cecorum
E. sulfureus

JOE- Vol 32, No.2, Feb2006 20
Group Species
Group V
(-) arginine hydrolysis
E. columbae
Vagococcus sp.

Identification of the bacteria
1.Gram’s Stain
2.Culture
Liquid(broth)
Solid(agar)
Semisolid
3.Molecular diagnostic methods
DNA-DNA hybridization
Polymerase chain reaction (PCR)
21NISHA GARG 2ND EDITION PAGE NO 54 55

• More recently, molecular techniques have been developed
that have the capability to rapidly and accurately identify
the Enterococcus species.
• Techniques involving DNA-DNA hybridization, Sequencing
of the 16S rRNA genes, whole-cell protein (WCP) analysis
and gas liquid chromatography of fatty acids have been
used for taxonomic purposes.
• Most of these methods are nucleic acid-based involving
PCR amplification assays that are followed by
electrophoretic analysis of the PCR products, probing,
sequencing, or both
JOE- Vol 32, No.2, Feb2006 22

DNA-DNA hybridization
• This method uses DNA probes which target
genomic DNA or individual genes
• This helps in simultaneous determination of the
presence of multitude of bacterial species
• It’s the process of annealing the complimentary
bases of two single-stranded DNA molecules
• Ingle’s 6th edition page no 223
23

Disadvantage
Cross reaction
can occur on
non-target
microorganisms
Identify only
cultivable
microorganisms
Does not detect
unexpected
Detects only non-
target
microorganisms
JOE- Vol 32, No.2, Feb2006 24

• Random amplified polymorphic DNA (RAPD) analysis and pulse-
field gel electrophoresis (PFGE) are techniques that have been
utilized to determine variations in DNA sequences and have been
employed in determining various E. faecalis subtypes
• In fact, the Bacteriology Collection of the ATCC (American Type
Culture Collection) currently lists 69 isolates of E. faecalis that are
commercially available
• These isolates each have a different ATCC number and designation.
The biosafety level ranges from 1 to 2 and growth conditions differ
among the subtypes.
• Sources for these isolates include sour milk (ATCC number 376™),
meat involved in food poisoning (ATCC number 7080™), and the
root canal of a pulp less tooth (ATCC number 4083™)
25

Attention has been turned towards Enterococci since the
1970s when they were recognized as major nosocomial
pathogens causing bacteremia, endocarditis, bacterial
meningitis, urinary tract, and various other infections.
Sources of the bacteria in these infections have been
reported as originating from the hands of health care
workers, from clinical instruments, or from patient to
patient
26

Studies show E. faecalis is able to translocate from the root
canal system to the submandibular lymph nodes of germ-
free mice, suggesting this route of infection may play a role
in the pathogenesis of opportunistic infections in patients
Enterococcal urinary tract and soft tissue infections are
generally treated with single drug therapy, often with
penicillin or vancomycin
JOE- Vol 32, No.2, Feb2006 27

PREVALENCE IN SECONDARY ROOT
CANAL INFECTIONS
E.faecalis is a normal
inhabitant of the oral cavity.
Its increased in oral rinse samples from patients
receiving initial endodontic treatment, those
midway through treatment, and patients
receiving endodontic retreatment when
compared to those with no endodontic history
28

E. faecalis is associated with different forms of
periradicular disease including primary
endodontic infections and persistent infections
It is found in 4 to 40% of primary endodontic
infections
JOE- Vol 32, No.2, Feb2006 29

Failed root canal treatment cases are nine
times more likely to contain E. faecalis than
primary endodontic infections
In some cases, E. faecalis has been found as the
only organism (pure culture) present in root
filled teeth with periradicular lesions
JOE- Vol 32, No.2, Feb2006 30

Polymerase chain reaction (PCR) is currently a
more predictable method for detection of E.
faecalis
This method proves to be faster, more sensitive,
and more accurate than culturing methods
JOE- Vol 32, No.2, Feb2006 31

It involve in vitro replication of DNA, therefore it is
also called as ‘genetic xeroxing’method.Multiple
copies of specific region of DNA are made by
repeated cycles of heating & cooling.
32
Polymerase chain reaction (PCR)
NISHA GARG 2ND EDITION PAGE NO 55

Identify the microorganisms qualitatively not quantitaively
Detect only target microorganisms
Difficult in microorganism with thick wall like fungi
Possibility of false positive and negative results
33
Disadvantage of Polymerase chain reaction (PCR)

An optical spectroscopy-based method has also
been studied as a way to detect E. faecalis activity
.
It is possible that this detection system could be
used chair side to rapidly monitor the presence or
absence of E. faecalis in the root canal system
JOE- Vol 32, No.2, Feb2006 34

SL .NO SURVIVAL AND VIRULENCE FACTORS OF E. FAECALIS
1 Endures prolonged periods of nutritional deprivation
2 Binds to dentin and proficiently invades dentinal tubules
3 Alters host responses
4 Suppresses the action of lymphocytes
5 Possesses lytic enzymes, cytolysin, aggregation substance,
pheromones, and lipoteichoic acid
6 Utilizes serum as a nutritional source
7 Resists intracanal medicaments (i.e. Ca(OH)2)
-Maintains pH homeostasis
-Properties of dentin lessen the effect of calcium
hydroxide
8 Competes with other cells
9 Forms a biofilm
35

SURVIVAL AND VIRULENCE FACTORS
E. faecalis possesses certain virulence factors including lytic
enzymes, cytolysin, aggregation substance, pheromones, and
ipoteichoic acid
It adhere to host cells, express proteins that allow it to
compete with other bacterial cells, and alter host responses
E. faecalis is able to suppress the action of lymphocytes,
potentially contributing to endodontic failure
JOE- Vol 32, No.2, Feb2006 36

JOE- Vol 32, No.2, Feb2006 37
It is also able to share these virulence traits among
species, further contributing to its survival and ability
to cause disease
E. faecalis is less dependent upon virulence factors,
it relies more upon its ability to survive and persist
as a pathogen in the root canals of teeth
It possesses serine protease, gelatinase, and
collagen-binding protein (Ace), which help it bind to
dentin

JOE- Vol 32, No.2, Feb2006 38
It is small enough to proficiently invade and live
within dentinal tubules
Serum, which originates from alveolar bone and
the periodontal ligament, also helps E. faecalis
bind to type I collagen
E. faecalis is able to form a biofilm that helps it resist
destruction by enabling the bacteria to become 1000
times more resistant to phagocytosis, antibodies, and
antimicrobials than non biofilm producing organisms

Overview of bacterial biofilms
Biofilm is made of microbial
growth where dynamic
communities of interacting sessile
cell are irreversible attached to a
solid substratum, as well as each
other and embedded in a self-
made matrix of extracellular
polymeric substances
Ingle’s 6th edition pg no 268 39

In the past, bacteriological studies
were concluded on free-floating
bacterial cells (planktonic state),
ignoring the importance of the
sessile bacterial cells (biofilm state)
40Ingle’s 6th edition pg no 268

Biofilms can be
formed wherever
there is a flow of
fluid, microorganisms
and a solid surface
JOE- Vol 32, No.2, Feb2006 41

E. faecalis can form calcified biofilm in
tough environmental condition within
the root canals.
Biofilm formation on tissues and
biomaterials surfaces can lead to biofilm-
mediated infections, which are difficult to
treat as a result of the increased
antimicrobial resistance of biofilm bacteria
42
Influence of various herbal irrigants as a final rinse on the adherence of E.faecalos by fluroscence conofocal laser
scanning microscope rosaline et.al journal of conservative dentistry /vol 16/jul-aug 2013/4

Literature has shown that Azadiracta
indica (neem)has antimicrobial and
theraputic effects suggesting its
potential to be used as an endodontic
irrigant.
43

Murray et.al also
suggested that
Morinda
Citrifolia(MC) juice
can be formulated
for use as an
intracanal irrigant
44

All showed relatively lesser adherence of E. Faecalis
to dentin.
Hence the medicinal and antimicrobial properties of
the AI(NEEM) can be a alternative to NaOCl as a
final root canal irrigants
45

NaOCl was highly effective in
eliminating E. faecalis grown in biofilm.
46
Comparative Evaluation of Endodontic Irrigants against Enterococcus faecalis Biofilms Thomas
R. Dunavant et.al JOE —Volume 32, Number 6, June 2006

Quick review on Calcium Hydroxide
Is the most commonly used intracanal medicament
Calcium hydroxide releases hydroxyl ions in aqueous solutions, resulting in a
high alkaline environment where most bacteria cannot survive
Is antimicrobial by raising the pH of the root canal environment
Dissolves tissue

JOE- Vol 32, No.2, Feb2006 48
Calcium hydroxide, a commonly used intra-canal
medicament, has been shown to be ineffective at
killing E. faecalis on its own, especially when a high
pH is not maintained

pH needed to kill E. Faecalis
At pH of 10.5 to 11.0, growth of E. faecalis was inhibited
• McHugh et al, 2004
pH can only reach up to 10.3 because of the buffering effect of dentin.
pH gradient decreases deeper in the dentinal tubules
11.5 was necessary to eradicate

Reasons have been proposed to explain why E. faecalis is able to
survive intra-canal treatment with calcium hydroxide:
a) E. faecalis passively maintains pH homeostasis. This occurs
as a result of ions penetrating the cell membrane as well as
the cytoplasm’s buffering capacity.
b) E. faecalis has a proton pump that provides an additional
means of maintaining pH homeostasis. This is accomplished
by “pumping” protons into the cell to lower the internal ph.
c) At a pH of 11.5 or greater, E. faecalis is unable to survive
JOE- Vol 32, No.2, Feb2006 50

METHODS OF ERADICATION
JOE- Vol 32, No.2, Feb2006 51

Good aseptic technique, pretreatment chlorhexidine rinse, disinfection of tooth and
rubber dam, disinfection of gutta-percha with sodium hypochlorite
Adequate instrumentation (increase apical preparation size)
Canal Irrigants 6% sodium hypochlorite 17% EDTA 2% chlorhexidine
Intracanal Medicaments 2% chlorhexidine gel or 2% chlorhexidine gel +
calcium hydroxide
Consider AH Plus or Grossman’s sealer A well sealed coronal restoration
is essential
52
Steps to eliminate E. faecalis during endodontic retreatment (2 appointments).

E. faecalis can gain entry into the root
canal system during treatment,
between appointments, or even after
the treatment has been completed.
Therefore, it is important to consider
treatment regimens aimed at
eliminating or preventing the
infection of E. faecalis during each
of these phases.
JOE- Vol 32, No.2, Feb2006
53

JOE- Vol 32, No.2, Feb2006 54
Preparing the apical portion of
the root canal to a larger
instrument size will help eliminate
intra-canal microorganisms by
reaching areas not normally
accessible by smaller master
apical files

JOE- Vol 32, No.2, Feb2006 55
In addition, larger apical preparation
sizes facilitate removal of the innermost
(pulpal) dentin.
This provides the potential to remove
intra-tubular bacteria and open the
dentinal tubules to allow antimicrobials
to penetrate more effectively.

Three percent to full
strength sodium
hypochlorite, if used in
adequate amounts and
exchanged regularly, has the
capability to destroy E.
faecalis in the root canal .
Sodium hypochlorite is an
effective irrigant for all
presentations of E. faecalis
including its existence as a
biofilm
JOE- Vol 32, No.2, Feb2006 56

JOE- Vol 32, No.2, Feb2006 57
EDTA has little antibacterial
activity, but is important in
its ability to remove the
inorganic portion of the
smear layer thus allowing
other irrigants access to the
dentinal tubules
A 10% citric acid solution
will remove the smear layer
and, like EDTA, has little
effect against E. faecalis.

58
A 10% citric acid
solution will remove the
smear layer and, like
EDTA, has little effect
against E. faecalis.
MTAD, a new root
canal irrigant
consisting of a mixture
of a tetracycline
isomer, an acid, and a
detergent has shown
success in its ability to
destroy E. faecalis
The effects of
MTAD are
enhanced when
1.3% sodium
hypochlorite is
used as an irrigant
during
instrumentation

JOE- Vol 32, No.2, Feb2006 59
A 10% citric acid
solution will remove
the smear layer and,
like EDTA, has little
effect against E.
faecalis.
MTAD, a new root
canal irrigant
consisting of a mixture
of a tetracycline
isomer, an acid, and a
detergent has shown
success in its ability to
destroy E. faecalis
The effects of
MTAD are
enhanced when
1.3% sodium
hypochlorite is
used as an irrigant
during
instrumentation

MTAD was developed as a final rinse to disinfect
the root canal system and remove the smear layer
NaOCl (1.3%) is used as an intracanal irrigant
before placing 1 ml of MTAD in a canal for 5
minutes
and rinsing it with an additional 4 ml of MTAD as
the final rinse
It appears to be superior to CHX in antimicrobial
activity
ndodoNtics: Colleagues for Excellence
60
SEM of dentinal tubules after
removal of the smear layer by MTAD

61
Chlorhexidine, in a 2% gel or
liquid concentration, is
effective at reducing or
completely eliminating E.
faecalis from the root canal
space and dentinal tubules
A 2-min rinse of 2% chlorhexidine
liquid can be used to remove E.
faecalis from the superficial layers
of dentinal tubules up to 100 um
2% percent chlorhexidine
gel is effective at
completely eliminating E.
faecalis from dentinal
tubules for up to 15 days

JOE- Vol 32, No.2, Feb2006 62
It is questionable as to whether 0.12%
chlorhexidine is more effective
than calcium hydroxide.???
Some studies suggest it is more effective,
yet neither will completely eradicate
E. faecalis .
.
Another study suggests 10% calcium hydroxide
alone is more effective When heated to 46°C,
both 0.12% chlorhexidine and 10% calcium
hydroxide have greater antimicrobial effects
against E. faecalis than at normal body
temperature
Other irrigants that may be effective at eliminating E. faecalis
include ozonated water and stannous fluoride. Ozonated water
has been shown to have the same antimicrobial efficacy as 2.5% sodium
hypochlorite . Stannous fluoride demonstrated greater antimicrobial
effectiveness against E. faecalis than calcium hydroxide.

JOE- Vol 32, No.2, Feb2006 63
Combinations of irrigants to eliminate
E. faecalis have also been studied.
In one study, a combination of calcium hydroxide
mixed with camphorated paramonochlorophenol
completely eliminated E. faecalis within dentinal tubules
Metapex, a silicone oil-based calcium hydroxide paste containing
38% iodoform, more effectively disinfected dentinal tubules
infected with E. faecalis than calcium hydroxide alone

JOE- Vol 32, No.2, Feb2006 64
The antimicrobial activity against E. faecalis
of various sealers has also been studied
Zinc -oxide eugenol based sealer, has been shown
to exhibit the greatest antimicrobial activity
against E. faecalis when compared to other
sealers

JOE- Vol 32, No.2, Feb2006 65
AH Plus epoxy-resin based sealer and zinc
oxide-eugenol based sealer both exhibit good
antibacterial effects against E. faecalis
AH Plus and Grossman’s sealer are effective in
killing E. faecalis within infected dentinal tubules

At the University of Toronto a
different approach was tried—
sealing the canals with two
experimental glass-ionomer sealers,
one containing an antimicrobial
substance.
The first sealer proved effective in
preventing the “penetration of E.
faecalis” probably because of the
natural release of fluoride. The
experimental sealer with the added
antibacterial “needs more study.”
Ingle’s 6th edition page no 652 66

SMEAR LAYER REMOVAL
EDTA [ethylene diamine tetraacetic
acid] removes inorganic portion of
smear layer allowing access of
irrigants within dentinal tubules, but
has no action against E. faecalis.
10% Citric acid removes smear layer
but less effectively. 0.1% sodium
benzoate & Citric acid can kill E.
faecalis.

68
hlorhexidine & sodium hypochlorite
should not be used together.
Chlorhexidine must be used as
inter-appointment irrigant.
Irrigants do not penetrate to more
than 100 – 150 microns. Therefore the
mesh of dentinal tubules harboring E.
faecalis is impossible to reach.

OTHER IRRIGANTS
Ozonated water & stannous
fluoride has been shown to be
effective at eliminating E. faecalis.
69

JOE- Vol 32, No.2, Feb2006 70
Based on these studies it can be concluded
that a combination of adequate
instrumentation, and appropriate use of
irrigants, medicaments, and sealer will
optimize the chances of eradicating E. faecalis
during retreatment of failed root canal cases.

71
Having the
patient rinse
with
chlorhexidine
before
treatment
disinfecting
the tooth
rubber dam
with
chlorhexidine
or sodium
hypochlorite
disinfecting
gutta-percha
points with
sodium
hypochlorite
before
insertion in
the canal
Other
possibilities
may include
using an
obturating
system that
can provide a
more effective
seal. Newer
obturation
systems such
as Epiphany
Additional steps should be taken to prevent E. faecalis from
re-entering the root canal space. These include:

Enterococcus faecalis is known to colonize dentinal
tubules, isthmus, rami, lateral & accessory canals. As
shown by the LCSM (Laser Confocal Scanning Microscopy)
& SEM (Scanning Electron Microscopy) analysis
Enterococcus faecalis penetrates the dentinal tubules to
the depth of 1483.33 μm (nutrient rich aerobic condition)
1166.66 μm (nutrient rich anaerobic condition) 620 μm
(nutrient deprived anaerobic condition).
It is present as “mushroom shaped” micro
colonies
72

Presence of
medicaments
like calcium
hydroxide
Low pH and
high
temperature
Prolonged
periods of
starvation &
utilize tissue
fluid that flow
from periodontal
ligament
73
It can survive in :

Persist in
poor nutrient
environment
of root canal
treated tooth
Stay alive in
presence of
irrigation like
sodium
hypochlorite
Convert into
viable but
non-
cultivable
state
Form biofilm
in medicated
canal
74NISHA GARG 2ND EDITION PAGE NO 53

75
Penetrate and
utilize fluid
present in
dentinal tubules
Acquire gene
encoding
resistance
combined with
natural
resistance to
antibiotics
Establish
monoinfections
in medicated
root canals

Clinical & radiological features of failure
Types of failure Clinical features Radiological features
Potential
failure
 Sporadic or vague symptoms, usually
not reproducible
 Feeling of pressure or tightness
 Slight discomfort when chewing or
pressing tooth with finger or tongue
 Overlapping symptoms of sinusitis in
the region of treated teeth
 Occasional need of analgesics to
alleviate discomfort
No change in periapical
radiolucenecy or slight evidence of
healing
The periodontal ligament is not
normal
Evident space between filling & root
canal walls
Filling material/cement extending
beyond the anatomic apex
Established
failure
Persistent symptoms
Reccurent sinus tract, swelling or pain
Pain on percussion
Unable to chew with the tooth
The periapical radiolucency has not changed or has
enlarged
The appearance of new periapical or lateral
radiolucency
Absence of formation of new lamina dura
Evident space in the root canal that was not filled
Excessive overfilling
Essentials of endodonticss by Vimal sikri
page no 541
76

Microorganisms and Flare -ups
n endodontic flare-up is defined
by the American Association of
endodontics(AAE) as
“an acute exacerbation of an
asymptomatic pulpal and /or
periapical pathosis after the
initiation or continuation of root
canal treatment”
Ingle ‘s 6th edition pg no 266 77

Flare-ups are unpredictable
events with with reported
prevalance varying from
1.4% to 19%
The most likely pre-disposing
clinical condition for its
occurrence appears to be
asymptomatic necrotic pulp
with periapical lesions
78Ingle ‘s 6th edition pg no 266

CHAIR-SIDE MONITORS
Monitoring chair-side bacterial
activity provides advantage for
the clinician & beneficial for
the treatment outcome.
79

Polymerase
Chain Reaction
Optical spectroscopy
Detects chair side presence or absence of E.
faecalis. Optical spectroscopy in conjunction
with specific enzyme synthetic chromogenic
substrate-based medium allows the early
detection of E. faecalis activity quantitatively
and qualitatively, without the need for
additional laboratory based culturing and
plating for cell counting.
80

Studies indicate that the prevalence of E. faecalis is low in primary endodontic
infections and high in persistent infections.
E. faecalis is also more commonly associated with asymptomatic cases than with
symptomatic ones.
Although E. faecalis possesses several virulence factors, its ability to cause
periradicular disease stems rom its ability to survive the effects of root canal
treatment and persist as a pathogen in the root canals and dentinal tubules of teeth.
81
Conclusion

82
Our challenge as endodontic specialists is to implement methods to effectively
eliminate this microorganism during and after root canal treatment.
Currently, use of good aseptic technique, increased apical preparation sizes, and
inclusion of full strength sodium hypochlorite and 2% chlorhexidine irrigants are
the most effective methods to eliminate E. faecalis.
In the changing face of dental care, continued research on E. faecalis and its
elimination from the dental apparatus may well define the future of the
endodontic specialty

REFERENCES
Enterococcus faecalis – the root canalsurvivor and ‘star’ in posttreatment disease ISABELLE PORTENIER,
TUOMOS M.T. WALTIMO & MARKUS HAAPASALO Endodontic Topics 2003, 6, 135–159
Comparative Evaluation of Endodontic Irrigants against Enterococcus faecalis Biofilms Thomas R. Dunavant
et.al JOE —Volume 32, Number 6, June 2006
Enterococcus faecalis; clinical significance & treatment considerations ENDODONTOLOGY by VIBHA HEGDE
Influence of various herbal irrigants as a final rinse on the adherence of E.faecalos by fluroscence conofocal
laser scanning microscope rosaline et.al journal of conservative dentistry /vol 16/jul-aug 2013/4
Enterococcus faecalis Adhesin, Ace, Mediates Attachment to Particulate Dentin William J. Kowalski et.al
JOE—Volume 32, Number 7, July 2006
83

JOE- Vol 32, No.2, Feb2006 84
 Ingle’s 6th edition
 Pathways of pulp by cohen
 Nisha garg 2nd edition
 Essentials of endodonticss by Vimal sikri
 Endodontic microbiology by ashraf F.Faoud
REFERENCES

E. faecalis Role in Root Canal Treatment Failure

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